HEALTH SCIENCES LIBRARY
OF THE
UNIVERSITY OF NORTH CAROLINA
AT CHAPEL HILL
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in 2011 witli funding from
Nortli Carolina History of Health Digital Collection, an LSTA-funded NC ECHO digitization grant project
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North Carolina Medical Journal
Owned and Published by
NORTH CAROLINA MEDICAL SOCIETY
Under the Direction of Its
EDITORIAL BOARD
*WiLLiAM M. Nicholson, M.D.
Durham, Chairman
John S. Rhodes, M.D.
Raleigh, Associate Editor
Rose Pully, M.D.
Kinston
Charles W. Styron, M.D.
Raleigh
Robert W. Prichard, M.D.
Winston-Salem
Louis deS. Shaffner, M.D.
Winston-Salem
George Johnson, Jr., M.D.
Chapel Hill
John H. Felts, M.D.
Winston-Salem, Editor
Mr. William N. Hilliard
Raleigh, Business Manager
Volume 35
January-December, 1974
00 South Hawthorne Road
EDITORIAL OFFICE
Winston-Salem, N. C. 27103
ill North Boulevard
' Deceased
'.CEMBER 1974, NCMJ
Press of
Edwards & Broughton Company
P. O. Box 27286
Raleigh, N.C. 27611
761
£a™S£S£ESLIBRARY
Official Journal of the NORTH CAROLINA MEDICAL SOCIETY
January, 1974, Vol. 35, No. 1
JORTH CAROLINA
Medical Journal
THIS ISSUE: Carolinas' Camp for Diabetic Children. II. Descriptive Features of a Camper Population with Emphasis on
implications, Jay S. Skyler, M.D., George J. Ellis, III, M.D., and Carl H. Bivens, M.D.; Primary Medical Care and Group
actice in North Carolina, John Allcott, M.D., Donald L. Madison, M.D. and Cecil G. Sheps, M.D.; Initial Care for Lacera-
ins of Flexor Tendons of the Hand, Robert B. Winslow, M.D., and A. Griswold Bevin, M.D.
Announcing . . .
U-lOO Iletin®
(Insulin, Lilly)
(100 units of Insulin per cc.)
This is a concentration suitable for most
Insulin-dependent diabetics.
U-100 Iletin promises significant patient
benefits from standardized, simplified,
and convenient Insulin therapy. It is
available in six formulations.
Note: A U-100 syringe must be
used with U-100 Iletin.
cS^
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Indianapolis, Indiana 46206
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ft TOcc. ^
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Leadership in Diabetes Research
for Half a Century
m
Additional information
available to the profession on request.
974 LEADERSHIP CONFERENCE
February 1-2— Raleigh
1974 ANNUAL SESSIONS
May 18-22— Pinehurst
1974 COMMinEE CONCLAVE
September 25-28— Southern Pines
This psychoneurotic
often respond!
Before prescribing, please con-
sult complete product information,
a summary of which follows:
Indications: Tension and anx-
iety states; somatic complaints
which are concomitants of emo-
tional factors ; psychoneurotic states
manifested by tension, anxiety, ap-
prehension, fatigue, depressive
symptoms or agitation ; symptomatic
relief of acute agitation, tremor, de-
lirium tremens and hallucinosis due
to acute alcohol withdrawal ; ad-
junctively in skeletal muscle spasm
due to reflex spasm to local pathol-
ogy, spasticity caused by upper
motor neuron disorders, athetosis,
stiff-man syndrome, convulsive dis-
orders (not for sole therapy).
Contraindicated: Known hyper-
sensitivity to the drug. Children
under 6 months of age. Acute narrow-
angle glaucoma ; may be used in pa-
tients with open angle glaucoma
who are receiving appropriate
therapy.
Warnings: Not of value in psy-
chotic patients. Caution against
hazardous occupations 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 anticonvulsant
medication ; abrupt withdrawal ni
be associated with temporary in-
crease in frequency and 'or severi
of seizures. Advise against simul-
taneous ingestion of alcohol and
other CXS depressants. Withdraw
symptoms ( similar to those with
barbiturates and alcohol) have
occurred following abrupt discon-
tinuance (convulsions, tremor, ab-'
dominal andmusclecramps, vomit I
and sweating). Keep addiction-pri
individuals under careful surveil-
lance because of their predisposit
to habituation and dependence. In
pregnancy, lactation or women of
childbearing age, weigh potential
benefit against possible hazard.
w.
hen you determine that the
denressive symptoms are associated
V ) ch or secondary to predominant
a. xiety in the psychoneurotic
patient, consider Valium (diazepam)
in addition to reassurance and
counseling, for the psychotherapeutic
support it provides. As anxiety is
'^ relieved, the depressive symptoms
referable to it are also often relieved
or reduced.
The beneficial effect of Valium is
usually pronounced and rapid.
Improvement generally becomes
evident within a few days, although
)
some patients may require a longer
period. Moreover, Valium (diazepam)
is generally well tolerated. Side
effects most commonly reported are
drowsiness, ataxia and fatigue. Caution
your patients against engaging in
hazardous occupations or driving.
Frequently, the patient's symptoms
are greatly intensified at bedtime.
In such situations, VaUum offers an
additional advantage: adding an h.s.
dose to the b.i.d. or t.i.d. schedule
can relieve the anxiety and thus
may encourage a more restful
night's sleep.
symptom complex
O \klilim' (diazepam)
r Precautions: If combined with
ler psychotropics or anticonvul-
■nts, consider carefully pharma-
iogy of agents employed ; drugs
ch as phenothiazines, narcotics,
xbiturates, MAO inhibitors and
ler antidepressants may poten-
te its action. Usual precautions
riicated in patients severely de-
lessed, or with latent depression,
[with suicidal tendencies. Observe
ual precautions in impaired renal
or hepatic function. Limit dosage to
smallest effective amount in elderly
and debilitated to preclude ataxia
or oversedation.
Side Effects: Drowsiness, con-
fusion, diplopia, hypotension,
changes in libido, nausea, fatigue,
depression, dysarthria, jaundice,
skin rash, ataxia, constipation, head-
ache, incontinence, changes in sali-
vation, slurred speech, tremor,
vertigo, urinary retention, blurred
vision. Paradoxical reactions such
as acute h\'perexcited states, anx-
iety, hallucinations, increased mus-
cle spasticity, insomnia, rage, sleep
disturbances, stimulation have been
reported; should these occur, dis-
continue drug. Isolated reports of
neutropenia, jaundice ; periodic
blood counts and liver function tests
advisable during long-term therapy.
ROCHE
Roche Laboratories
Division ot Hoftmann-La Roche Inc
Nulley. N J 07110
VSllUm 2-mg, 5-mg, lo-mg tablets
(diazepam)
ALCOHOLISM
DRUG ADDICTION
And Other Drug Dependency Conditions
Willingway Hospital
A unique original program of recovery with a different approach.
For information or to admit patients contact:
John Mooney, Jr., M.D.
Medical Director
WILLINGWAY HOSPITAL
311 Jones Mill Road
P. 0. Box 508, Statesboro, Georgia 30458
(912) 764-6236
Member Georgia Hospital Association
Dorothy R. Mooney
Administrator
" I'm sorry,
Doctor!
You're not
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Have you ever stopped to consider the effect on
yourself and your family if this were ever to
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the expenses of day-to-day living can quickly
use up the money it has taken you years of
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especially designed for younger doctors, is avail-
able for members of the North Carolina Medical
Society.
This plan can help see to it that your family's
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upon the plan you select and qualify for, bene-
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NORTH CAROLINA
MEDICAL JOURNAL
Pithlished Monthly as the Official Organ of
The North Carolina
Medical Society
January, 1974, Vol. 35, No. 1
EDITORIAL BOARD
Robert W. Prichard, M.D.
Winston-Salem
EDITOR
John S. Rhodes. M.D.
Raleigh
ASSOCIATE EDITOR
Miss Louise MacMillan
Winston-Salem
ASSISTANT EDITOR
Mr. William N. Hilliard
Raleigh
BUSINESS MANAGER
W. McN. Nicholson, M.D.
Durham
CHAIRMAN
Louis deS. Shaffner, M.D.
Winston-Salem
Rose Pully, M.D.
Kinston
William J.
Cromartie, M.D.
Chapel Hill
Charles W. Styron, M.D.
Raleigh
NORTH CAROLINA MEDICAL JOUR-
NAL. 300 S. Hawthorne Rd.. Winston-Salem,
N. C. 27103, is owned and published by The
North CaroHna Medical Society under the di-
rection of its Editorial Board. Copyright ©
The North Carolina Medical Society 1973.
Address manuscripts and communications re-
garding editorial matter to this Winston-
Salem address. Questions relating to sub-
scription rates, advertising, etc., should be
addressed to the Business Manager, Bo;;
27167, Raleigh, N. C. 27611. All adver-
tisements are accepted subject to the ap-
proval of a screening committee of the State
Medical Journal Advertising Bureau. 1010
Lake Street. Oak Park. Illinois 60301.
and or by a Committee of the Editorial
Board of the North Carolina Medical Journal
in respect to strictly local advertising. In-
structions to authors appear in the January
and July issues. Annual Subscription, $5.00.
Single copies, $1.00. Publication office;
Edwards cSc Broughton Co.. P. O. Box 272S6.
Raleigh, N. C. 27611. Second-class postage
paid at Raleigh, North Carolina 27611.
President's Newsletter , 17
Original Articles
Carolinas' Camp for Diabetic Children. II. Descriptive
Features of a Camper Population With Emphasis
on Complications 29
Jav S. Skyler. M.D.. George J. Ellis. III. M.D.. and
Carl H. Bivens, M.D.
Primary Medical Care and Group Practice in
North Carolina 33
John .Alleott, M.D., Donald L. Madison, M.D., and
CeeilG. Sheps, M.D.
Initial Care for Lacerations of Flexor Tendons of the Hand 38
Robert B. Winslow. M.D., and .A. Griswold Bevin. M.D.
Editorial
Suggestions for Authors.
41
44
Emergency Medical Services
Historical Background of the AMA Committee on
Community Emergency Services
William E. Bumette,
abstracted by George Johnson. Jr., M.D.
COM.MITTEES & ORGANIZATIONS
Committee on Health Care Delivery 44
Committee on Hospital and Professional Relations 44
Bulletin Board
What? When? Where? 45
News Notes from the University of North Carolina Division
of Health Affairs 47
News Notes from the Duke University Medical Center 47
News Notes from the Bowman Gray School of Medicine of
Wake Forest University 51
News Note 52
Month in Washington 53
Book Reviews 56
In Memoriam 58
Classified Ads 59
Index to Advertisers 60
Contents listed in Current Contents /Clinical Practice
What's your ticker
done for you lately?
While the stock market is sinking fast, real
estate investments continue a steady growth
upward. The Wallace Corporation, one of
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You may invest on an individual or group
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If your present investments are causing
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Contact our Vice President of Finance,
Mr. M. D Deason
^▼The Wallace Corporation
Jefferson-First Union Tower
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Phone 704/334-4681
What's an your
patient's face...
may be more imj^ortant than
his chief complaint
11
0
Patient ET* seen on
3/29/67 shows typical
lesions of moderately
severe keratoses. Note
residual scarring on
ridge of nose from pre-
vious cr> osurgical and
electrosurgical
procedures.
\
t^
I
\: \
-••i*^^^
x-^
Patient RT* seen on
6/ 12/67, sc\en weeks
after discontinuation
of 5^r FU cream. Re-
action has subsided.
Residual scarring not
seen except that due
to prior surgery. In-
flammation has cleared
and face is clear of
kcratotic lesions.
*Data on file,
Hoffmann -La Roche
Inc., Nutley, N.J
he lesions on his face
re solar/actinic—
D-called ^^senile'' keratoses...
nd they may be premalignant.
)lar, actinic or senile keratoses
3se lesions may be called Ijy se%'eral names, but they
lally can be identified by the following characteris-
:. The typical lesion is flat or slightly elevated, of a
wnish or reddish color, papular, dry, rough, adherent
1 sharply defined. They commonly occur as multiple
ons, chiefly on the exposed portions of the skin.
quence of therapy—
lectivity of response
er several da>'s of therapy with Efudex- (fluorouracil),
thema may begin to appear in the area of the lesions;
reaction usually reaches its height of unsightliness
1 discomfort within two weeks, declining after dis-
tinuation of therapy. This reaction occurs in affected
as. Since the response is so predictable, lesions that
not respond should be biopsied.
c:ceptable results
atment with Efudex pro\ides highly favorable cos-
'ic results. Incidence of scarring is low. This is par-
larly important with multiple facial lesions. Efudex
uld be applied with care near the eyes, nose and mouth.
Before prescribing, please consult complete product
information, a summary of which follows:
Indications: Multiple actinic or solar keratoses.
Contraindications: Patients with known hypersensitivity
to any of its components.
Warnings: If occlusive dressing used, may increase in-
flamniator>- reactions in adjacent normal skin. Avoid pro-
longed exposure to ultra\'iolct ra>s. Safe use in pregnancy
not established.
Precautions: If applied with fingers, wash hands immedi-
atel\'. Appl\- witli care near eyes, nose and mouth. Lesions
failing to respond or recurring should be biopsied.
Adverse Reactions: Local— pain, pruritus, hyperpigmen-
tation and burning at application site most frequent; also
dermatitis, scarring, soreness and tenderness. Also re-
ported—insonuiia, stomatitis, suppvuation, scaling, swell-
ing, irritability, medicinal taste, photosensitivity,
lacrimation, lcukoc>tosis, thrombocNtopenia, toxic
granulation and cosinopliilia.
Dosage and .'Vdministration: Apply sufficient quantity to
co\er lesion twice daily with nonmctal applicator or suit-
able glove. Usual duration of therap\' is 2 to 4 weeks.
How Supplied: Solution, lO-ml drop dispensers— contain-
ing 2^r or .5'"r fluorouracil on a weiglit/wcight basis,
compounded with propylene ghcol, tris(h\drox>mcthyl)-
aminomcthanc.h\drox>propyl cellulose, parabens (methyl
and prop\ 1) and disodium cdetate.
Cream. 25-Gm tubes— containing .5^r fluorouracil in a
vanishing cream base consisting of white petrolatum,
stear\l alcohol, prop\lene glycol, pol>sorbate 60 and
parabens (methyl and prop>l).
<\ Roche Laboratories
ROCHE ? Division of Hoffmann-
/ Nutley, N J 07110
La Roche Inc.
his patient's lesions were resolved with
Efudex
Huorouracil/Roche'
5%cream/solution...a Roche exclusive
NORTH CAROLINA
MEDICAL SOCIETY'S
DISABILITY INSURANCE PLAN
NOW PAYS UP TO
$500
WEEKLY INCOME
f.
($2,166.00 per mo.)
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 .1^
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-
renewable to age 60. This is an ing payment of all claims!
exclusive and most important
feature.
J. L. & J. SLADE CRUMPTON, INC.
(). Drawer 1 767— Durham. 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 Adniinij>trators for:
NORTH CAROLINA MEDICAL SOCIETY • NORTH CAROLINA DENTAL SOCIETY • NORTH CAROLINA SOCIETY OF ENGI- \fX
NEERS • NORTH CAROLINA CHAPTER OF ARCHITECTS • NORTH CAROLINA ASSOCIATION OF C.P.A.'S AND BAR GROUPS
i
Officers
1973-1974
NORTH CAROLINA MEDICAL
SOCIETY
esident George G. Gilbert, M.D.
1 Doctors Park, Asheville 28801
esident-Elect Frank R. Reynolds. M.D.
1613 Dock St., Wilmington 28401
rst Vice-President D. E. Ward, Jr., M.D.
2604 N. Elm St., Lumberton 28358
cond Vice-President (Vacant)
cretary E. Harvey Estes. Jr., M.D.
Duke Univ. Med. Ctr., Durham 27710 (1976)
eaker James E. Davis, M.D.
1200 Broad St., Durham 27705
ce-Speaker Chalmers R. Carr, M.D.
1822 Brunswick Ave., Charlotte 28207
st-President John Glasson, M.D.
306 S. Gregson St., Durham 27701
;ecutive Director William N. Milliard
222 N. Person St., Raleigh 27611
Councilors and Vice-Councilors
I -St District Edward G. Bond, M.D.
Chowan Medical Center, Edenton 27932 (1974)
ce-Councilor Joseph A. Gill, M.D.
1202 Carolina Ave., Elizabeth City 27909 (1974)
:ond District Joseph Benjamin Warren, M.D.
Box 1465, New Bern 28560 ( 1976 )
ce-Coiincilor Charles P. Nicholson, Jr., M.D.
3108 Arendell St., Morehead City 28557 (1976)
lird District E. Thomas Marshburn, Jr., M.D.
1515 Doctors Circle, Wilmington 28401 ( 1976)
•e-CouncUor Edward L. Boyette, M.D.
Chinquapin 28521
urth District Harry H. Weathers, M.D.
:entral Medical Clinic, Roanoke Rapids 27870 (1974)
e-Councilor Robert H. Shackleford, M.D.
115 W. Main St.. Mt. Olive 28365 (1974)
i(/i District Albert Stewart. Jr., M.D.
114 Broadfoot Ave., Fayetteville 28305 (1975)
e-Councilor August M. Oelrich, M.D.
Box 1169, Sanford 27330 (1975)
f/i District John W. Watson, M.D.
104 New College St., Oxford 27565 (1974)
e Councilor J. Kempton Jones, M.D.
1001 S. Hamilton Rd., Chapel Hill 27514 (1974)
I UARY 1974, NCMJ
Seventh District JESSE Caldwell. Jr., M.D.
1 14 W. Third Ave., Gastonia 28052 (1975)
Vice-Councilor _ William Thomas Raby, M.D.
1012 Kings Drive, Charlotte 28207 (1975)
Eighth District Ernest B. Spangler, M.D.
3811 Henderson Rd., Greensboro 27410 (1976)
Vice Councilor James F. Reinhardt, M.D.
Cone Hospital, Greensboro 27402 (1976)
Ninth District Verne H. Blackwelder, M.D.
Box 431, Lenoir 28645 (1976)
Vice-Councilor Jack C. Evans, M.D.
244 Fairview Dr., Lexington 27292 (1976)
Tenth District Kenneth Edward Cosgrove, M.D.
510 7th Ave., W., Hendersonville 28739 (1975)
Vice-Councilor Otis Bentley Michael, M.D.
Suite 208, Doctors BIdg., Asheville 28801 (1975)
Section Chairmen — 1973-1974
Fainilx Phxsicians A. M. Alderman, Jr., M.D.
233 Bryan Bldg., Raleigh 27605
Internal Medicine Lawrence M. Cutchin, M.D.
600 St. Patrick St., Tarboro 27886
Ophthalmology and Otolaryngology
Patrick D. Kenan, M.D.
Duke Medical Center, Durham 27710
Surgery WiLLlAM B. McCuTCHEON, Jr., M.D.
1830 Hillandale Road, Durham 27705
Pediatrics William W. Farley, M.D.
1300 St. Mary's St., Raleigh 27605
Obstetrics and Gynecology Robert G. Brame, M.D.
Duke Hospital, Durham 27710
Public Health and Education John J. Wright, M.D.
Box 1267, Chapel Hill 27514
Neurology and Psychiatry Robert W. Gibson, Jr., M.D.
Radiologv Stuart Wynn Gibbs, M.D.
Box 1495, Gastonia 28052
Pathology James Arthur Maher, M.D.
Wayne County Hospital, Goldsboro 27530
Anesthesiology Merel H. Harmel, M.D.
Duke Univ. Med. Ctr., Durham 27710
Orthopaedics
Dermatology Royal G. Jennings, M.D.
624 Quaker Lane, High Point 27262
Urology Vernon H. Youngblood, M.D.
1421 Highway 20 North, Concord 28025
Student AMA Chapters (SAM A)
1
Synthroid
(sodium levothyroxine)
the smooth road
to thyroid replacement
therapy.
Synthroid is r4.
It provides your patients with
nhat is needed for eoniplete
th>roid replaeeinent therapy.
Indications: SYNTHROID (sodium levothyroxine)
IS specific replacement therapy for diminished
or absent thyroid function resulting from pri-
mary or secondary atrophy of the gland, con-
genital defect, surgery, excessive radiation, or
antithyroid drugs. Indications for SYNTHROID
(sodium levothyroxine) Tablets include myxe-
dema, hypothyroidism without myxedema, hypo-
thyroidism in pregnancy, pediatric and geriatric
hypothyroidism, hypopituitary hypothyroidism,
simple (nontoxic) goiter, and reproductive dis-
orders associated with hypothyroidism. SYN-
THROID (sodium levothyroxine) for Injection is
indicated for intravenous use in myxedematous
coma and other thyroid dysfunctions where
rapid replacement of the hormone is required.
The injection is also indicated for intramuscular
use in cases where the oral route is suspect or
contraindicated due to existing conditions or to
absorption defects, and when a rapid onset of
effect is not desired.
Free Tab-Minder sample
packages available
from Flint Professional
Services Department.
Precautions: As with other thyroid preparations,
an overdosage of SYNTHROID (sodium levothy-
roxine) may cause diarrhea or cramps, nervous-
ness, tremors, tachycardia, vomiting and
continued weight loss. These effects may begin
after four or five days or may not become appar-
ent for one to three weeks. Patients receiving
the drug should be observed closely for signs of
thyrotoxicosis. If indications of overdosage ap-
pear, discontinue medication for 2-6 days, then
resume at a lower dosage level. In patients with
diabetes mellitus, careful observations should
be made for changes in insulin or other antidia-
betic drug dosage requirements. If hypothyroid-
ism is accompanied by adrenal insufficiency,
such as Addison's Disease (chronic adrenocor-
tical insufficiency), Simmonds's Disease (pan-
hypopituitarism) or Cushing's syndrome
(hyperadrenalism), these dysfunctions must be
corrected prior to and during SYNTHROID (so-
dium levothyroxine) administration. The drug
should be administered with caution to pa iM
with cardiovascular disease; developmi
chest pains or other aggravations of card
cular disease requires a reduction in dosac
Contraindications: Thyrotoxicosis, acute mj
dial infarction. Side effects: The effects of
THROID (sodium levothyroxine) therapy are I-
in being manifested. Side effects, when th ~
occur, are secondary to increased rates of :
metabolism; sweating, heart palpitations ■
or without pain, leg cramps, and weight \,r
Diarrhea, vomiting, and nervousness have I;
been observed. Myxedematous patients \ ]
heart disease have died from abrupt incr 4;
in dosage of thyroid drugs. Careful obserwy:-
of the patient during the beginning of anwffinj
roid therapy will alert the physician to arij'
toward effects.
foil
paiie
rare*
It has been shown that Synthroid (T4)
converts to T3 at the cellular level
to supply metabolic needs, i' ^
1
Synthroid is T4.
^ Because T4 converts to T3 at the cellular
level, it provides full thyroid replacement
at maintenance doses. ^-^
O T4 hormone content is controlled
by chemical assay.
I Synthroid \s assayed chemically;
no biologic test is necessary to
measure potency.
«J Synthroid pTO\'\des predictable
results when used with current
thyroid function tests.
O Synthroid \s the most prescribed
brand name of thyroid in the U. S.
and Canada.
/ Sodium levothyroxine in Synthroid
tablets is chemically pure. It does not
contain any animal gland parts.
8
■-!>
When stored properly, Synthroidhas a
longer shelf life than desiccated thyroids.
y On a daily basis, Synthroid is cost
competitive with other thyroid
products.
The smooth road to
thyroid replacement therapy.
Synthroid
Mum levothynKine)
Id jiost cases with side effects, a reduction of
,p^ (3 followed by a more gradual adjustment
Q' id will result in a more accurate indication
js tpatient's dosage requirements without the
-ance of side effects.
His te and Administration: The activity of
i rmg. SYNTHROID (sodium levothyroxine)
liT is equivalent to approximately one grain
'I, U.S. P. Administer SYNTHROID tablets
i? ingle daily dose. In hypothyroidism with-
t i /xedema, the usual initial adult dose is
. ' |. daily, and may be increased by 0.1 mg.
31: BO days until proper metabolic balance is
d. Clinical evaluation should be made
,ly and PBI measurements about every 90
'^inal maintenance dosage will usually
rom 0.2-0.4 mg. daily. In adult myxedema,
dose should be 0.025 mg. daily. The
dose may be increased to 0.05 mg. after two
weel<s and to 0.1 mg. at the end of a second two
weei<s. The daily dose may be further increased
at two-month intervals by 0.1 mg. until the opti-
mum maintenance dose is reached (0.1-1.0 mg.
daily).
Supplied: Tablets: 0.025 mg., 0.05 mg., 0.1 mg.,
0.15 mg., 0.2 mg., 0.3 mg., 0.5 mg., scored and
color-coded, in bottles of 100, 500, and 1000. In-
jection: 500 meg. lyophilized active ingredient
and 10 mg. of Mannitol, U.S. P., in 10 ml. single-
dose vial, with 5 ml. vial of Sodium Chloride In-
jection, U.S. P., as a diluent. SYNTHROID
(sodium levothyroxine) for injection may be ad-
ministered intravenously utilizing 200-400 meg.
of a solution containing 100 meg. per ml. If sig-
nificant improvement is not shown the following
day, a repeat injection of 100-200 meg. may be
given.
1. Braverman, L. E., Ingbar, S. H., and Sterling,
K.: Conversion of Thyroxine (T4) to Triiodothyro-
nine (Tj) in Athyreotic Human Subjects, J. Clin.
Invest. 49:855-64, 1970.
2. Surl<s, M. I., Schadlow, A. R., and Oppen-
heimer, J. H.: A New Radioimmunoassay for
Plasma L-Triiodothyronine: Measurements In
Thyroid Disease and in Patients Maintained on
Hormonal Replacement. J. Clin. Invest. 5i:3104-
13, 1972.
FLINT LABORATORIES
DIVISION OF TRAVENOL LABORATORIES. INC
Deerfield. Illmois 60015
Basics in the treatment of urinary tract infection
Short-term therapy is no shortcut
Enter any opening
and find way to centf
of maze. Only
-one entrance will get
you there.
The case for adequate length of therapy
In the insidious, common and often stubborn urinary
tract infections, duration of therapy is not standardized.
Because renal damage in many patients is believed to re-
sult from repeated urinary tract infections in childhood,
one pediatrician has stated that a rational approach to
treatment includes more than a perfunctory prescription
of an antibacterial agent. ^
The first 48 hours and after. . .
To ensure adequate therapy, one expert^ proceeds as
follows: an initial culture and one after 48 hours. If the an-
tibacterial used has been effective, the urine will be clear
of pathogens after 24 to 48 hours. However, urine should
be recultured and any persistence of original pathogens in-
dicates that another drug be used. On the other hand, if
urine is found to be sterile, the same drug is continued for
two weeks. Then urine is recultured starting a week after
the last drug dose, and cultures are continued monthly for
three months, then every three months tor a year, and fi-
nally, every four months for several years. ^
Another authority^ notes that initial short-term ther-
apy without careful follow-up can lead to trouble, as re-
flected by the high relapse rate. He treats an initial urinary
tract infection with a sulfa drug after taking a urine culture.
If Escherichia coli is found — and it is in 70 to 80 percent of
cases — he continues full dosage for 21 days. Five to 10
days after cessation of therapy, he recultures and takes a
colony count. If urine is sterile, he recultures at three and
six months.
Measurement of success "Itssi
For success in the treatment of urinary tract infectii ,„,
the urine must be kept free of bacteria for prolonged per
ods until the focus of infection in the tissue has been era
cated.3 This may take months or years when the infectioi p^^
is chronic or persistent. Criteria for successful therapy w
a drug are regarded as absence of symptoms and absen( '■^■
of pyuria and bacteriuria.3 One authority defines signifia
bacteriuria as a count of at least 100.000/ ml of the sami
organism in two consecutive clean-voided urine samples
The nature of the infection and the length
of therapy
Long-term follow-up is essential, a clinician who
treats recurrent infections for one to two years points ou!
Persistent, symptomless bacteriuria usually calls for urc
logic procedures to find the site of infection, because ai
underlying abnormality predisposing to urinary tract inff ^
tion must be detected and corrected — otherwise therapj
futile. 5 Upper urinary tract infection generally requires
longer therapy than infection of the lower urinary tract.
In acute, simple, first infections of a symptomatic
type, the pathogens are nearly always E. coli or Proteus
mlrabilis.^
sool
Ur,
Iter
urif
IIUS
ephi
3!e"
References: 1. Normand, I. C. S,: Practitioner. 204:91, 1970. 2. Ki
E, H.: Hosp, Med.. 4:73, 1968. 3. Lampe, W. T. II: / Am. Geriatr.
Soc. J6:798, 1968. 4. Petersdorf, R. G., and Turck, M.-. GP. 32:{
130, 1965 5. Benner, E. J.: Med. Times, 98:(2) 95, 1970
I'
Vi
The case for Gantanol (sulfamethoxazole)
s susceptible organisms most often
!cated
fjantanol" (sulfamethoxazole) is effective against
;ly susceptible strains of E. coli and Proteus mirabilis
•,o of Klebsiella- Aerobacter, Staphylococcus aureus
iiss frequently, Proteus vu/gar/s — pathogens apt to be
tin the mixed bacterial flora of recurrent and chronic
.ift|3 and/or pyelonephritis.
■cf'jpt antibacterial blood/urine levels
fter the Initial 2-Gm adult dose, therapeutic
urine levels are usually reached in from 2 to 3
then maintained with either of the two dosage
of Gantanol — tablets or suspension. And, Gantanol
,:G((losage means up to 12 hours of antibacterial
„i1|/, obviating the patient's having to disturb his sleep
].< ; medication. More severe infections may require
'J ,osage.
•5 'effective in certain nonobstructed
;,r jiic and recurrent urinary' tract infections
;;■ Dionobstructed chronic and recurrent cystitis or
•;;l jephritis develops more commonly in the elderly and
) ated. and response to Gantanol (sulfamethoxazole)
f 1 1 highly satisfactory. The usual precautions in
'fi -jimide therapy should be observed, including
:;i :j;nance of adequate fluid intake, frequent c.b.c.'s
i ' nalyses with microscopic examination.
Make the therapy suit the infection
In most urinary tract infections the b.i.d. schedule
will usually suffice, but therapy must be maintained long
enough to ensure eradication of pathogens. Mounting
evidence in current medical literature suggests a minimum
of 14 days of continuous therapy. - Adequate treatment
fora sufficient time may also help prevent possible kidney
damage. Gantanol is generally well tolerated with relative
freedom from complications. The most common side
effects include nausea, vomiting and diarrhea. Prescribe
Gantanol tablets or the pleasant-tasting suspension.
*Data on file, Hoffmann-La Roche Inc., Nutley, N.J.
In nonobstructed cystitis
due to susceptible organisms
Gantanol b.ld.
sulfamethoxazole
Basic Therapy
^mieN
Roche Laboratories
Division of Hoffmann-La Roche Inc
Nutley. N J 07110
Please see following page for summary of product information.
Before prescribing, please consult
complete product information, a
summary of which follows;
Indications: Acute, recurrent or
chronic nonobstructed urinary tract infec-
tions (primarily pyelonephritis, pyelitis
and cystitis) due to susceptible orga-
nisms Note: Carefully coordinate in vitro
sulfonamide sensitivity tests with bacte-
riologic and clinical response; add amino-
benzoic acid to follow-up culture media.
The increasing frequency of resistant
organisms limits the usefulness of anti-
bacterlals including sulfonamides, espe-
cially in chronic or recurrent urinary
tract infections. Measure sulfonamide
blood levels as variations may occur;
20 mg/ 100 ml should be maximum total
level.
Contraindications: Sulfonamide
hypersensitivity: pregnancy at term and
during nursing period; infants less than
two months of age
Warnings: Safety during pregnancy
has not been established. Sulfonamides
should not be used for group A beta-
hemolytic streptococcal infections and
will not eradicate or prevent sequelae
(rheumatic fever, glomerulonephritis) of
such infections. Deaths from hypersensi-
tivity reactions, agranulocytosis, aplastic
anemia and other blood dyscrasias have
been reported and early clinical signs
(sore throat, fever, pallor, purpura or
jaundice) may indicate serious blood
disorders. Frequent CBC and urinalysis
with microscopic examination are recom-
mended during sulfonamide therapy.
Insufficient data on children under six
with chronic renal disease.
Precautions: Use cautiously in
patients with impaired renal or hepatic
function, severe allergy, bronchial
asthma; in glucose-6-phosphate
dehydrogenase-deficient individuals in
whom dose-related hemolysis may occur.
Maintain adequate fluid intake to prevent
crystalluria and stone formation.
Adverse Reactions: Blood dyscra-
sias (agranulocytosis, aplastic anemia,
thrombocytopenia, leukopenia, hemo-
lytic anemia, purpura, hypoprothrombi-
nemia and methemoglobinemia); allergic
reactions (erythema multiforme, skin
eruptions, epidermal necrolysis, urti-
caria, serum sickness, pruritus, exfoliative
dermatitis, anaphylactoid reactions,
periorbital edema, conjunctival and
scleral injection, photosensitization.
arthralgia and allergic myocarditis);
gastrointestinal reactions (nausea, eme-
sis, abdominal pains, hepatitis, diarrhea,
anorexia, pancreatitis and stomatitis);
CNS reactions (headache, peripheral
neuritis, mental depression, convulsions,
ataxia, hallucinations, tinnitus, vertigo
and insomnia); miscellaneous reactions
(drug fever, chills, toxic nephrosis with
oliguria and anuria, periarteritis nod
and L.E. phenomenon). Due to certa
chemical similarities with some goit
gens, diuretics (acetazolamide,thiaz
and oral hypoglycemic agents, sulfo
mides have caused rare instances of
goiter production, diuresis and hypog
cemia as well as thyroid malignanciei
rats following long-term administrati
Cross-sensitivity with these agents mi
exist.
Dosage: Systemic sulfonamides
contraindicated in infants under 2
months of age (except adjunctively v*
pyrimethamine in congenital toxoplas
mosis).
Usual adult dosage: 2 Gm (4 ta|jj(l
teasp.) initially, then 1 Gm b.i.d. or t
depending on severity of infection.
Usual child's dosage: 0.5 Gm (1
or teasp.)/ 20 lbs of body weight initi;
then 0,25 Gm/ 20 lbs b.i.d. Maximurr
dose should not exceed 75 mg/ kg/ 2fl!8
hrs.
Supplied: Tablets, 0.5 Gm sulfa
methoxazole; Suspension, 0.5 Gm su
methoxazole/ teaspoonful.
JKI!
tot
III
ROCHE
Roche Laboratories
Division ot Hotlmann-La Roc
Nutley N J 07110
to
da
tlO'
It
ira
ftl
the
iuc
lOV
)iir
lur
lep
In nonobstructed cystitis due to susceptible organisms
Gantanol(sulfamethoxazole) B.I.D.
Basic Therapy
I Ml
lit
i;k(
:k(
le;
:ei
PRESIDENTS NEWSLETTER
MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA
1974 may be a Happy New Year and we wish the same to all of you. We can be
acre certain, what with energy crises, political turmoil, continuing inflation,
Eind many medical bills in our upcoming state legislation, that it is sure going
CO be a hectic New Year in the practice of medicine.
^o. 8
January 9, 1974
At the Clinical Convention of the AMA at the Disneyland Hotel in California,
;is usual, your North Carolina Delegation actively covered and participated in the
ieliberation for your benefit. The biggest consumer of time, interest, and change
In AMA policy was — you guess it — PSRO. From all over the country and after
Living with the potentials of this law, the groundswell of opinion was loud and
:lear. The AMA and all its members should work for its repeal. In a very well
thought out statement which passed the House of Delegates, this goal was expressed,
[n spite of this very worthy goal, it was equally clear, from a point of view of
>ractical politics, that the chances of repeal in the Congress are very slim.
Chis should in no way dim or diminish our zeal in trying to get it repealed. We
therefore strongly urge you to write your congressman in favor of the bill intro-
luced by Congressman Rarick of Louisiana for repeal of PSRO. Please stress,
lowever, that we in organized medicine are still strongly and constantly pushing
)ur efforts for "peer review" to keep our own house clean but that this PSRO
mreaucracy is not the way.
One of the constructive suggestions is now quoted from the AMA amendment to
Leport EE paragraph number 3:
i "That the Association suggests that each hospital medical staff, working
j with the local medical society, continue to develop its own peer review,
I based upon principles of sound medical practice and documentable objective
i criteria, so as to certify that objective review of quality and utilization
, does take place; to make these review procedures sufficiently strong as to
I be unassailable by any outside party or parties; and that the local and
state medical societies take all legal steps to resist the intrusion of any
third party into the practice of medicine."
i Meanwhile the federal juggernaut roles on, and on December 20th published
:n the Federal Register were the long awaited PSRO geographical boundaries. To
lave verbal description, the PSRO geographical boundaries were outlined in the
Jecember 24, 1973, issue of the American Medical News, revealing the Secretary
)f HEW's decision for the four PSRO's in North Carolina. In accordance with
the action of the House of Delegates and the wishes of the Board of Directors of
the Peer Review Foundation, an objection to these designations will be filed
fiefore January 19, 1974, and our request for a statewide designation will be
renewed. The presidents of each county society have been asked to send to head-
i.uarters office a letter supporting our protest and renewed request for a state-
Jide PSRO designation, which request I sincerely hope will have a 100% response.
f*/
I
A second most crucial concern of the AMA is its ongoing fight with the Cost
of Living Council to do away with the Phase IV discrimination against the private
practicing physician. The AMA has filed an official protest in the form of a
petition with the Cost of Living Council. This is the first step and is a
prerequisite to the filing of legal action by the AMA (or any other Medical
Society) on behalf of the medical profession against the Cost of Living Council.
Mentioned in previous "Newsletters" has been our deep concern over the sur-
prisingly widespread practice of physicians' employees, with their employers
sanction, making the medical decision for prescription refills and even new pre-
scriptions. This very sloppy and shady practice has brought about a most produc-
tive meeting of your State Society Pharmacy Committee along with officers of
the State Pharmaceutical Association. As a result of this meeting, the joint
effort is being launched by our two organizations and we implore your cooperation.
Each pharmacist in the state will receive enough copies of a form which has been
compiled, along with a covering letter from me in behalf of the Medical Society.
The pharmacist by this device will be urged to send one form to his regular doctor
prescribers. Each of you will be receiving these forms which will tell your
druggist a number of things about your office so as to upgrade not only the
quality of prescription writing but also make it possible for the pharmacist to
follow your personal prescription routine. Perhaps most important is the blank
for you to sign your name exactly as you do on a prescription. Prescription
forging and theft of prescription pads is becoming alarmingly widespread.
One more plea. We are cooperating through an ad hoc committee with the State
Department of Mental Health and have formed an ad hoc committee. The goal of this
ad hoc committee is an effort to upgrade the quality and financial return for full
and part-time physicians in our statewide mental health institutions. This
includes not only psychiatrists but also surgeons, pediatricians, internists,
family physicians. In behalf of this committee, we want to know how many of you
would be willing to work on a part-time basis in these institutions and how much
money do you feel you should receive for a day's service? Put another way, how
much compensation would make such an effort attractive to you? I urge all of
you who may be interested to write the Chairman of this ad hoc conmiittee who is
also Chairman of our State Society Mental Health Committee, Dr. Philip Nelson,
Medical Pavilion, Greenville, N. C. 27834.
To the many members of the Society who have written the Governor concerning
the appointment of a Chiropractor to the Board of the North Carolina Division of
Health Services (formerly State Board of Health), please accept my thanks for
doing so and for your interest and participation in affairs of concern to the
Society.
*
4
Happy New Year!
Sincerely yours,
George G. Gilbert, M.D.
President
in
i
conditions
The Gl tract in spasm is commonly a "gas trap."
Sidonna*' is formulated to releaseentrapped
gas, as well as to provide antispasmodic/ seda-
tive effects.
In addition to the traditional combination of
belladonna alkaloidsand butabarbital (warning:
may be habit forming.), Sidonna contains si-
methicone—a non-systemic defoaming agent
that "lyses" gas bubbles on contact.
Sidonna has the ability to relieve Gl spasm,
pain and gas in the irritable bowel syndrome,
spastic colon, pylorospasm, gastroenteritis, gas-
tritis, nausea, nervous indigestion, or gastric and duodenal ulcer.
Sidonna can calm Gl spasm... control anxiety... and release entrapped Gl gas from
the system.
Sidonna can do more for your "gasspastic" patient. Try him on 1 or 2 tablets
before meals and at bedtime.
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 buta-
barbital sodium N.F. 16 mg. (Warning: May be habit forming.)
can do more
Contraindications: Anticholinergics should not be used in patients with glaucoma, known prostatic hypertrophy, or
pyloric obstruction. Urinary retention may indicate the presence of prostatic hypertrophy. If it occurs, the dose should
be reduced or the drug withdrawn. Also contraindicated in patients with known hypersensitivity to one of the components.
Side Effects: Dryness of the mouth, blurred vision, dysuria, skin rash, constipation or drowsiness may occur.
1^
Reed & Carnrick/ Kenilworth, New Jersey 07033
fTlondolQ Center
A private multi-disciplinary 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 mod-
alities are used. The services consist o
individual, couple, group and family psycho
therapies; sexual and marriage counseling
pastoral counseling; vocational guidance am
rehabilitation; alcohol and drug counseling
psychological testing, chemotherapy, elec
trotherapy and other somatic therapy sei
vices.
Blue Cross participating hospital
Richard B. Boren, M.D.
Psychiatrist-in-Chief
Ali Jarrahi, M.D., M.S.P.H.
Psychiatrist
For Information Call Collect (919) 724-9236 or Write:
741 Highland Avenue • Winston-Salem, N. C. 27101
si^.. Towards Wholeness
-w*...:
iUt
seii!
Acar nearly killed me.
The bills would have
done the same?^
"One morning an out-of-control car
crashed mine, head-on. Both my arms and
i . legs were shattered, and my head was badly
hurt.
"I spent three months in the
hospital, and six weeks in a
convalescent home.
"That was a year and
a half ago, and I'm just
getting back to normal
life.
"My Blue Cross
and Blue Shield
coverage paid some
$20,000 worth of bills for me.
I don't know what I'd have
done without it."
Twenty-thousand dollars
worth of bills sure makes you appreciate
Blue Cross and Blue Shield coverage.
But unless you're rich, you could get
swamped for a lot less.
You never know when you're on a
collision course with fate.
Blue Cross
rAfH tw^l Blue Shield
of North Carolina
40 years of helping people.
Mrs. Virgin laMasscy
This advertisement appeared in North Carolina newspapers.
•aeg. Mark Blue Cross Assn S'Reguieted Service Mark or ihe National Associai-on o( Blue Shield Plans
li
TREATMENT AND LEARNING CENTER For
ALCOHOL RELATED PROBLEMS
FELLOWSHIP HALI
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
Individual counseling
Group Therapy
Nature Trail
indoor Outdoor Recreation
Recognized by:
Biue Cross & Blue Shieid • Life Assurance Co. of Carolina
• Pilot Life Ins. Co. • Aetna Life & Casualty
• John Hancock Mutual Life Ins. Co. • Kemper Ins.
• Metropolitan Life Ins. Co. • United Benefit Life Ins. Co.
• Security Life & Trust Co.
Member of:
• N. C. Hospital Association
• The Alcoholic & Drug Problems
Assn. of North America
• American Hospital Association
FOR ADMITTANCE CALL
JAMIE CARRAWAY
EXECUTIVE DIRECTOR
919-621.3381
FELLOWSHIP HALL
p. 0. BOX 6928 • GREENSBORO, N. C. 27405
Located off U.S. Hwy. No. 29 at Hicone Road Exit,
6V2 miles nortti of downtown Greensboro, N. C.
Convenient to 1-85, 1-40, U.S. 421, U.S. 220,
and thie Greensboro Regional Airport.
INC.
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 v^ith emphasis on
reality therapv-
Medicai examination
admission.
Modern, motel-like accom-
modations with private bath
and individual temperature
control.
A therapeutic nature trail
to encourage physical er- j
ercise, and arouse objec-
tive interest in the miracle
of nature.
FELLOWSHIP HALL WILL ARRANGE CONNECTION WITH COMMERCIAL TRANSPORTATION.
JlCATIONS: The^peufTcaf/^'us'ed-^i'an adjunct'O appropriate systemic
^•««* / ," therapy for topical infections, primary or secondary, due to susceptible
'^ . *J» w'organtems, as^in: • infected bums, skin grSfts, surgfeal incisions, otitis e)rtemai 'j
> J I *>• primary pyodermas (impetigo, ecthyma, sycosis vulgaris, paronychia)
" * •'secondarily infected dermatoses (eczema, herpes, and seborrheic dermatitis)
•■ • traumatic lesions, inflamed or suppurating as aresult 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
s, wounds accidentally incurred, its use may prevent the development of infection and
•f"** . * permit wound healing.
CONTRAINDICATIONS: Not for use in the external earcaiial if the eardrum is perforated.
This product is contraindicated in those individuals who have shown hypersensitivity
f » to any of the components.
PRECAUTION: As with other antibiotic preparations, prolonged use may result in
, overgrowth of nonsusceptible organismsand/orfungi. Appropriate measures should betaken
If this occurs. Articles in the current medical literature indicate an increase in the prevalence
of persons allergic to neomycin. The possibility of such a reaction should be borne in mind.
Complete literature available on request from Professional Services Dept. PML.
EOSPOREV' Ointment
mimiN B-BAOTRACIN-NEi
"f
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
q.s. In tubes of 1 oz. and Vz oz. and Vzz oz. (approx.) foil packets.
rWf /Burroughs Wellcome Co.
I fl / Research Triangle Park
WeHcoms/ North Carolina 27709
More than sleep
your choice of sleep medication
is wisely based on more than
sleep-inducing potential
3IOeP W iXn Chronic tolerance studies have confirmed the relative safety of D.
I I . f 1 Cflurazepam HCI); no depression of cardiac or respiratory ft
|^0|Q'[|\/0 SaTetV was noted in patientsadministered recommended or higher
-' for as long as 90 consecutive nights.
In most instances when adverse reactions were reported, they were mild, infrequent and seld
quired discontinuance of therapy Morning "hang-over" with Dalmane has been relatively infrequent
ness, drowsiness, lightheadedness and the like
sleep for 7 to 8 hoi
without need to
have been the side effects noted most frequently
particularly in the elderly and debilitated. [An
initial dose of Dalmane 15 mg should be pre-
scribed for these patients )
repeat dosage Nosee
cation has been as rigorously evaluated in the sleep research laboratory as Dalmane. Insomnia p
given one30-mg capsule of Dalmane at bedtime, on average: fell asleep within 17 minutes, had fewei
timeawakenings, spent less time awake after sleep onset, and slept for 7 to 8 hours with no need to
dosage during the night.
pp with
Dalmane has been shown to be con-
ji - . , sistently effective even during con-
nSISlGnCV secutlve nights of administration,
y with no need to increase dosage,
jmane [flurazepam HCI) is a distinctive sleep medication— a
iiazepine specifically indicated for insomnia. It is not a bar-
; or methaqualone, nor is it related chemically to any other
le hypnotic.
len your evaluation of insomnia indicates the need for a sleep
ition, consider Dalmane— a single entity nonnarcotic, non-
rate agent proved effective and relatively safe for relief of
lia.
)IDi;l
ghe
Oil
sle«
iniai
DALMANE
(flurazepam HCI)
When restful sleep
is indicated
One 30-mg capsule h.s. —usual adult dosage
( 15 mg may suffice in some patients)
One 15-mg capsule h.s. —initial dosage for elderly or
debilitated patients.
Before prescribing Dalmane (flurazepam
HCI), please consult Complete Product
Information, a summary of whicti follows:
Indications: Effective m all types of insomnia
cfiaracterized by difficulty in falling asleep,
frequent nocturnal awakenings and/or early
morning awakening: in patients witti recurring
insomnia or poor sleeping fiabits. and in acute
or chronic medical situations requiring restful
sleep Since insomnia is often transient and
intermittent, prolonged administration is
generally not necessary or recommended
Contraindications: Known hypersensitivity to
flurazepam HCI
Warnings: Caution patients about possible
combined effects with alcohol and other CNS
depressants Caution against hazardous oc-
cupations requiring complete mental alertness
(e g . operating machinery, driving) Use in
women who are or may become pregnant
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 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, 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 loint pains and GU complaints
There have also been rare occurrences of
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
hallucinations, and elevated SGOT, SGPT,
total and direct bilirubins and alkaline
phosphatase Paradoxical reactions, e g .
excitement, stimulation and hyperactivity
have also been reported in rare instances
Dosage: Individualize for maximum beneficial
effect Adults 30 mg usual dosage, 15 mg may
suffice in some patients Elderly or debilitated
patients 15 mg initially until response is
determined
Supplied: Capsules containing 1 5 mg or
30 mg flurazepam HCI
<(jocii?)
ROCHE LABORATORIES
Div, Hoffmann-La Roche Inc.
Nutley, New Jersey 07110
c
Ifs titne for action to defend the law
and regulations that protect your
patients against drug substitution.
These professional and trade organizations are unitec
in supporting antisubstitution statutes and regulatior
k'
lie
t
¥
The American Academy of Dermatofi;
The Board of Directors of the
American Academy of Family
Physicians
The Executive Board of the
American Academy of Neurology
The Committee on Drugs of the
American Academy of Pediatrics
The American College of Allergists
The Executive Committee of the
American College of Obstetricians
and Gynecologists
The Board of Regents of the
American College of Physicians IT
The Board of Trustees of the
American Dental Association
The Board of Trustees of the
American Medical Association
The American Psychiatric Associ
The Executive Committee of the
National Association of Retail
Druggists
The Board of Directors of the
Pharmaceutical Manufacturers
Association
The National Wholesale Druggists'
Association
m
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statement on Antisubstitution
ii|( .he purpose of this statement is
itio jm the support of the participat-
janizations for the laws, regula-
)nd professionaltraditionswhich
itthe unauthorized substitution
; products.
raditionally, physicians, den-
id pharmacists have worked
ratively to serve the best inter-
patients. Productive coopera-
s been achieved through
i| respect as well as a common
in for the ideals of public
This mutual respect has been
ed, in part, by joint support
e years for the adoption and
ement of laws and regulations
cally prohibiting unauthorized
ution and encouraging joint
sion and selection of the
of supply of drug products,
sic principles of medical, den-
pharmacy practice are thus
,1 and preserved in the interest
■^mt welfare.
ne antisubstitution laws have
itructed enhancement of the
sional status of pharmacy any
lan they have in and of them-
^uaranteed absolute protec-
m unsafe drugs, or freed
ans, dentists and pharmacists
eir responsibilities to patients,
actical matter, however, such
d regulations encourage inter-
ional communications regard-
g product selection and assure
ofession the opportunity to
2 fully its expertise in drug
;:o the advantage of patients.
Sysicians and dentists should
d to increase the frequency
ularity of their contacts with
cists in selection of quality
Dducts, recognizing that
JiOl
Laws and Regulations
economies to patients can be im-
proved through such communica-
tion, taking into account the patients'
needs. The pharmacist's knowledge
of the chemical characteristics of
drugs, their mode of action, toxic
properties and other characteristics
that assist in making drug selection
decisions should be utilized to the
fullest extent practicable by physi-
cians and dentists in servingtheir
patients.
Since drug product selection
entails knowledge derived from
clinical experience, the physician's
and dentist's roles in product selec-
tion remain primary and do not per-
mit delegation of decisions requiring
medical and dental judgments. A
broader role in therapy will evolve
for pharmacists as improved under-
standing and cooperation among the
professions continue to grow.
There has been no evidence that
there are convincing reasons to
modify or repeal existing laws and
regulations prohibiting the unauthor-
ized substitution of another drug
product for the one specified by a
prescriber. It is our belief that such
laws and regulations merit the joint
support of the medical, dental and
pharmaceutical professions and the
pharmaceutical industry.
Add your opinion to the weight
of other professionals and send it to
your state assemblyman or legislator.
Pharmaceutical Manufacturers Association
1155 Fifteenth Street, N.W. , Washington, D. C. 20005
P'M'A I
^ftE
%^^ ^,
^1 i^
|tfiiw»»-'
Not too little, not too much...
but just right!
"Just riizht" amounts of Ilosone Liquid 250
can be dispensed easily from the pint bottle in any quantity
you specify to meet your patients" precise needs—
without regard to package size.
ready- mixed
ILOSONE LIQUID 250
ERYTHROMYCIN ESTOLATE
(equivalent to 250 mg eryftiromycin per 5-ml teaspoonful)
AilililiiDUil infiirniinicn civiiihihlc Ic ihc profession on rcqiicM.
DISTA
Disia Products Company
Division ot Ell Lilly and Company
Indianapolis, Indiana 46206
Carolinas' Camp for Diabetic Children
Descriptive Features of a Camper Population
With Emphasis on Complications
Jay S. Skvler, M.D., George J. Ellis, III, M.D., and Carl H. Bivens, M.D.
N our companion paper, we described the organi-
. zation, operation, and objectives of Carolinas'
imp for Diabetic Children that evolved over our
ist five years' experience. Access to a large number
children vi'ith diabetes mellitus allowed us to make
'Servations about the spectrum of the illness. This
per describes some of these observations about the
mper population and the medical problems oc-
rring during one camp session. Our observations,
lich show that there is a significant incidence of
mplications of diabetes in these children, may have
plications relevant to the large group of patients
ih juvenile-onset diabetes living in the Carolinas.
lus, these findings are important for all physicians
'O care for patients with diabetes.
POPULATION
One-hundred thirteen campers and junior counse-
s with diabetes mellitus attending camp during
1972 season represent the study population.
ere were 49 boys and 64 girls, their ages ranging
m 7 to 18 years (mean, 11.5; median, 11) (Ta-
t 1). Eighty-seven (78.8 percent) had known posi-
; family histories of diabetes mellitus. The dura-
1 of diabetes varied from newly discovered to 1 1
;rs with a mean of 3.9 years (Table 2). Eleven
1 diabetes eight years or longer. The mean age
onset of diabetes was 7.5 years with a range of 1
16 years (Table 3).
om the Departments of Medicine and Community Health Science,
D ; University Medical Center. Durham. North Carolina, and Caro-
Camp for Diabetic Children Pisgah Forest. North Carolina.
JARY 1974, NCMJ
METHODS
Our defined data base, in addition to a question-
naire answered by parents (available on request),
included a limited physical examination (Figure 1).
Campers with questionable retinal disease and all
campers with duration of diabetes eight years or
longer had fundus photographs taken, through dilated
pupils, using a hand-held Kowa RC fundus camera.
Neuropathy was evaluated by determining, in tripli-
Table 1
Age and Sex Distribution of Campers and Junior
Counselors with Diabetes
Age (years)
Boys
Girls
Total
7 8 9 10 11 12 13 14 15 16 17 18
168693545200
08847 18 556111
1 14 16 10 16 21 10 9 11 3 1 1
Table 2
Duration of Diabetes in Campers and Junior Counselors
Duration (years) <1 1 2 3 4 5 6 7 8 9 10 11
Number of
individuals 5 14 19 16 15 17 10 6 6 1 2 2
Table 3
Age of Onset of Diabetes in Campers and Junior
Counselors
Age at onset
(years) <! 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Number of
individuals 0 2 2 6 7 14 9 20 11 14 7 13 2 2 3 0 1
29
CAMPER
Height _
CCOC Physical Examination Form
Date
Weight
BP
R/L Arm
Skin: Lipoatrophy Lipohypertrophy Other changes Normal
Sites:
Description:
HEENT: Eyes: EOM: Full No Pupils: React No
Fundi: Discs: Sharp No Macula: Clear No
Hemorrhages Exudates Microaneurysms IRMA
Other
Ears: Drums Clear No Not visualized
Pharynx: Clear Injected
Thyroid: Normal Enlarged description ^_^_
Nodes: No Yes Site description
CHEST: Clear No Description
CARDIAC: Gallop: No Sj S3 Click
Murmur: No Systolic Diastolic grade /vi
location
Description
ABDOMEN: Masses: No Yes Location
Supine Sitting
Organomegaly: No Yes Location
Other:
EXTREMITIES: Normal Abnormal How?
NEUROLOGIC: Ankle jerks: Right— Intact No
Lett— Intact No
Vibration: Right great toe — Intact No
Left great toe — Intact No
Other:
Exammer
Figure 1
cate, the vibratory perception threshold of both in-
dex fingers and both great toes, using a Model PVD
Bio-Thesiometer ( Bio-Medical Instrument Com-
pany, Newburg, Ohio), and by measuring Achilles
reflex time (interval between time of stimulus and
time of half-relaxation) using a Burdick FM-1 Photo-
motograph. Height and weight percentiles were de-
termined using standard anthropometric charts. -
Data on insulin administration and urine testing
were derived from questionnaires answered by camp-
ers" parents the first day of camp and from staff
observations during camp.
Data on camp illness and hypoglycemic symptoms
were obtained from camp medical records. When a
hypoglycemic reaction was treated, a card indicating
the symptoms and treatment was completed. Some of
the reactions were documented using Dextrostix
(Ames Company) read with an Ames Reflectometer.
All other reactions were considered hypoglycemic
if the symptoms were reversed after glucose feeding,
or in two episodes, after glucagon injection.
Fasting samples for blood lipids were collected
from each camper one morning during the middle of
the camp period. Serum was separated and frozen
for later anaKsis of cholesterol and trislvceride.
RESULTS
Nutrition and growth
Eight campers (five girls and three boys) wen
obese, and none was underweight. Nine boys (11
percent) and three girls (5 percent) ranked belov
the third percentile in height. The distribution o
heights is summarized in Table 4.
Complications
No camper had an elevated blood pressure or ab
sent Achilles reflex. All Achilles reflex times wer
normal, with the range being 213 to 380 msec
mean 289. Four patients had high vibratory percep
tion thresholds in at least three of the digits testec
Ten others had high thresholds in one or two of th
digits tested. Table 5 summarizes the skin and ey "
problems found in the camper population. All camp
ers with cataracts had visual impairment.
fi
Cholesterol and triglyceride determinations ftj;
Cholesterol levels ranged from 110 to 327 mg/c
with a mean of 196. Nineteen patients had valus''^
greater than 230, the upper range of normal for thi >*
age group, according to Fredrickson.-* Triglycerid fjii
levels ranged from 33 to 240 mg/dl with a mean c k
72. Three patients had values greater than 140, th
upper range of normal in this age group.-'
TabI
e4
Distribut
on
of H
eights
Percentile
Girls
Boys
<3
3
9
3-10
7
3
10-25
11
6
15-50
15
10
50-75
17
10
75-90
7
8
90-97
3
2
>97
1
1
12
10
17
25
27
15
5
2
Table 5
Skin Problems in Campers with Diabetes
Lipodystrophy
Lipoatrophy only 24
Lipohypertrophy only 16
Both lipoatrophy and lipodystrophy 3
No lipodystrophy
Necrobiosis lipoidica diabeticorum
Pretibial patches
Eye Problems in Campers with Diabetes
Diabetic retinopathy
Microaneurysms, intraretinal micro-
vascular abnormalities 3
Hemorrhages 1
Exudates 0
Proliferative changes 0
Cataracts
Ptosis
Retinal pigment spots
MJe
l)po
I Ms
14
ht
ipeti
nil;
ivi
Bl
Jliil
01 fi
30
Vol. 35, Nc. i.-:]
W! I
)ffi
Table 6
Insulin Administration and Urine Testing
Draw
Insulin
Pre- End of
Camp Camp
Administer
Insulin
Pre- End of
Camp Camp
Check
Urine
Pre- End of
Camp Camp
d alone 64 111
53
107
90
112
d with help 11 2
11
5
10
1
.unselor 38 0
49
1
13
0
Table 7
Number of Hypoglycemic Episodes per Camper*
iber of reactions
iber of campers
0 12 3
39 27 22 11
9 13
1 1
le camper was excluded from data because of multiple atypi-
"reactions" with repeatedly normal or high blood glucose.
ulin administration and urine testing
:*rior to admission to camp, 101 of the 113 camp-
\used disposable syringes and needles, nine used
s syringes with disposable needles, and three used
I) jis syringes with reusable needles.
^able 6 summarizes the progress campers made
ing the camp session in learning to draw and mea-
■; insulin, to administer their insulin, and to test
r urine for glucose. All campers listed as pen-
ning these tasks "alone" at the end of camp
lonstrated to the satisfaction of the medical staff
i they were using the proper techniques.
joglycemia
i
'here were 187 episodes of hypoglycemia in 73
'pers. Forty-six individuals had more than one
ode of hypoglycemia (Table 7). Thirty-four of
114 repeat episodes (as well as four initial
odes) were documented by Dextrostix.
hypoglycemic reactions were characterized by
bus combinations of symptoms (Table 8), with
'■ 14 of the episodes having a single symptom,
ikness was the most common symptom. Most
ipers who had more than one reaction also had a
irring group of symptoms, although there was
t variability of the symptom complex from
per to camper. The exception to these generali-
ins usually was seen when a camper had a reac-
or reactions at night in which he was unrespon-
to light and/or was aroused with difficulty.
:r camp illness
ampers had a total of 201 medical problems (Ta-
)), excluding hypoglycemia, of which some re-
;d multiple infirmary visits. The most severe
lems were two fractures. Although there
'£ four instances of severe hyperglycemia, no
Ders had frank ketoacidosis.
i^J lARV 1974, NCMJ
DISCUSSION
The population of campers probably constitutes
a representative sample of young juvenile diabetics
in the Carolinas. Of interest arc several findings. For
the group of boys in this sample the high percentage
(18.4 percent) with heights below the third percen-
Table 8
Incidence of Hypoglycemic Symptoms (187 episodes)
Symptom
Number of
Occurrences
Weakness
124
Trembling
86
Hunger
Sweating
Headache
Pallor
72
51
30
27
Crying/moaning
Tachycardia
27
21
Dizziness
19
Abdominal pain
18
Inability to arouse
Unresponsiveness to light
Belligerence, resistiveness uncooperativeness
Drowsiness
16
12
12
10
Resistance to food
9
Diplopia
6
"Nervousness"
6
Disorientation
4
Incoherence
4
Unconsciousness
2
Chest pain
2
Thirst
2
Homesickness
2
Hypothermia (documented)
2
Cold, clammy appearance
Irritability
2
Passivity/quietness
Hiccups
Fasciculations
Nightmare
Table 9
Camp Illness (excluding hypoglycemia)
Illness
Number of
Incidences
Minor injuries (bruises, cuts, blisters, splinters
62
Sore throats
23
Sprains, strains, muscle soreness
21
Bee stings and insect bites
16
Stomach ache
15
Skin problems
14
Poison ivy oak
7
Rash
6
Sunburn
1
Headache
12
Earache
11
Homesickness
7
Colds, nasal stuffiness
5
Hyperglycemia
4
Anorexia, nausea, vomiting (not related to
diabetic control)
4
Anorexia
2
Nausea
2
Vomiting
1
Eye Problems
4
Conjunctivitis
2
Sty
2
Fractures
2
Toothache
1
Total
201
31
tile suggests a significant incidence of growth retarda-
tion. Since insulin is necessary for protein synthesis,
and thus for growth, it would not be surprising to see
growth retardation in patients who continually re-
ceived inadequate amounts of insulin. Unfortunately,
we have no data on the long-term degree of diabetic
control in our population and can offer no explana-
tion for the sex difference in growth retardation.
We were struck by the number of campers who
already demonstrated diabetic complications and
lipid abnormalities. Two of the three patients with
evidence of retinopathy also had elevated triglycer-
ides, and one had elevated cholesterol as well. Four
of the five campers with cataracts also had elevated
cholesterol levels, and two had associated neuro-
pathy; all five had some history of very poor control,
observed especially during the period immediately be-
fore their admission to camp. Cataracts are to be ex-
pected if the mechanism of their production in ju-
venile diabetics is related to hyperglycemia and to
subsequent increased activity of aldose reductase
within the lens. The resulting accumulation of sorbi-
tol (a nondiffusable sugar alcohol) would cause os-
motic changes and eventuate in degenerative changes
including cataract formation.^ There is some evi-
dence that neuropathy, as well, may be related to this
mechanism.'
With the evidence that a large number of campers
were able to assume responsibility for their own in-
sulin administration and urine testing, we think that
primary physicians should be encouraged to develop
such capabilities in diabetic patients of all ages. Be-
cause many campers, upon returning home, ap-
parently revert to previous habits of permitting el-
ders to administer insulin and/or to check urine, the
education process must include relatives as well as
patients. Since the children can learn the procedures
during a two-week exposure, with encouragement
from physicians and parents it should be possible for
them to continue to exercise their new skills at home.
Assumption of such responsibility is especially im-
portant for the child's maturation process and for the
fostering of independence and self-discipline. Each
person with diabetes should realize that it is his ci:
dition; its course in large part will depend on i
rigorousness with which he applies himself to
management.
Hypoglycemia is quite common at camp, presu
ably because of the increased activity and freedi
from psychological stress. The large number of t
ferent symptoms and the varying presentations in
cate that physician and patient must be keenly al
to hypoglycemia, especially in a setting (e.g.,
creased activity) where it is more likely to occ
The other camp illnesses, except for hyperglycem
might be expected at any summer camp.
SUMMARY
The data indicate to us that insulin deficien
as evidenced by growth retarda'Jon, cataracts, a
elevated blood lipids, is not uncommon in a popu
tion of children with diabetes in the Carolinas.
we are to prevent more severe problems from occ
ring in later life, perhaps we must direct more ca
ful attention to the adequacy of insulin replacemi
and to the consistency of diabetic control from i
onset of diabetes.
ti:
.\cknowledgment
Supported by the Greenville Unit of the Soi
Carolina Diabetes Association, the North Carol
Diabetes Association, the Duke University Juver
Diabetes Research Fund, the Walter Kempner Foi
dation, the North Carolina Regional Medical P
gram, and grant 5-Tl-AM 5074 from the Natio
Institutes of Arthritis, Metabolic and Digest
Diseases.
References
1. Skyler JS. Ellis GJ III. Delcher HK: Carolinas' camp
diabetic children: I. Report ot first five years of operatfe;
NC Med J .14; 935-938. 1973.
2. Vickers VS. Stuart HC: Anthropometry in the pediatrici ^
office: norms for selected body measurements based on stu
of children of North European stock. J Pediatr 22: 155-170. 1
3. Fredrickson DS. Levy HI: In The Met.ibolic Basis of Inher
Disease. 3rd edition. Stanburv JB. W vngaarden JB, Fredricl
DS (eds). New "lork: McGrav.-Hill. 1972, p 546.
4. Van Hevnineen R: Formation of polvols by the lens of the
with 'suiiar' cataract. Nature 184: 194-195, 1959.
5. Gabbay KH. O'Sullivan JB: The sorbitol pathway: enzyme
calization and content in normal and diabetic nerve and
Diabetes 17: 239-243. 196S.
!l.
»
The various accidents of drowning, strangling, and apparent deaths, by blows, falls, hunger,
cold, etc., likewise furnish opportunities of trying such ( resuscitative efforts). Those, perhaps,
who to appearance are killed by lightning, or by a violent agitation of the passions, as fear. joy.
surprise, and such-like, might also be frequently recovered by the use of proper means, as blow-
Prcvciilion ami Cure of Discuses by Rci;iinen am! Simple Medicines, elc. Ricliard Folwell. 1799,
Prevention ami Cure of Disea.res hv Regimen and Simple Medicines, etc.. Richard Foheell. 1799.
pp. 425-426.
32
Vol. .l.s, Ni
pi
3i
estu
Primary Medical Care and Group Practice
in North Carolina
John Allcott, M.D., Donald L. Madison, M.D., and Cecil G. Sheps, M.D.*
:Sc
'iro, I-
liive ,;
rFt
\'ati( ),
fees
^ ROUP medical practice has become a significant
pattern for the delivery of health care. The origi-
1 Mayo Clinic model was perhaps the most in-
^lential organizational form of group practice dur-
g the first half of this century. However, in recent
ars the multispecialty regional referral group has
^en overshadowed, in terms of growth, by at least
o newer forms. One of these is the multispecialty
oup organized to deliver primary care, which may
' either fee-for-service (open to the general popula-
im), or prepaid (open only to those members of
t population who have elected to enroll in an in-
m prance plan which provides benefits in the form of
Alii irvices from the group.) The other newer form and
one which is showing the greatest growth cur-
itly is the single specialty group. Several national
(rveys have documented the growth and characteris-
s of these forms of practice.'-''
In many communities throughout the country,
3up practice occupies the dominant position in the
livery of primary medical care. There has been
nsiderable speculation that the presumed advan-
;es of the group format make group practice a de-
able means for achieving proposed national goals
regard to medical care. Evidence for the strength
this idea may be found by examining the several
:ional health care financing proposals currently be-
c the United States Congress. The majority of
m contains provisions which, in one way or an-
ler, recognize the group practice format as a pre-
red model for the delivery of health services.
0> J I,
'■I
i! li >.
and
l\l '
"om the Department of Family Medicine, University of North
:)lina School of Medicine, Chapel Hill (Dr. Sheps and Dr.
lison).
■om the Department of Social Medicine, Montefiore Hospital
Medical Center, Bronx, New York.
Vice Chancellor for Health Sciences, University of Norlh Caro-
Chapel Hill, N. C. 27514.
UARY 1974, NCMJ
There has also been much recent discussion of the
problem of assuring the population access to health
care at the primary level. The decline in numbers
of general practitioners and the strong trend toward
specialization have prompted the promotion of sev-
eral possible solutions. Most of these have, in one
way or another, centered on the production of more
or a different type of medical manpower. There have
been fewer examinations of the possible effect
of alternative types of practice arrangements on ac-
cess to primary care.*' '
A survey was undertaken in one state. North Caro-
lina, to document the role of group medical practice
in the delivery of primary medical care.
DEFINITIONS AND METHODS
Three terms which were central to the survey
should be defined at the outset.
Primary medical care
For purposes of this survey, we have defined pri-
mary medical care as the range of ambulatory services
provided or coordinated by a patient's personal phy-
sician, continuing over time, for the broad scope of
medical and health maintenance needs. The practice
of primary medical care is thus contrasted with other
types of medical practice such as the episodic care
typically provided in emergency rooms and industrial
clinics, and specialty consultant services which make
up the bulk of practice for many physicians and
clinics. In past years the prototype provider of pri-
mary medical care was the "old family doctor." To-
day, the generalist, internist, pediatrician, and obste-
trician-gynecologist are the most frequently identified
"primary physicians." However, any physician may
serve this role, given only that (s)he serves as the
33
continuing entry point into a health care system for
patients.
Group medical practice
In this sur\'ey we have used the definition of the
American Medical Association for group medical
practice:
The application of medical services by three or more
physicians formally organized to provide medical consulta-
tion, diagnosis, and/or treatment through the joint use of
equipment and personnel and with the income from medi-
cal practice distributed in accordance with methods pre-
viously determined by the group. s
Multispecialty groups are groups providing services
in at least two specialties. Single specialty groups
provide services in only one specialty. General prac-
tice groups are a special type of single specialty
group composed exclusively of general practitioners.
Primary care group
We define a primary care group as a group medical
practice having a potential for major involvement
in primary medical care. For purposes of the survey
we include within this definition single specialty in-
ternal medicine, pediatrics, and general practice
groups; and multispecialty groups which include in-
ternists, pediatricians and/or generalists, but not
single specialty obstetrics or surgical groups. We
recognize that there is much anecdotal evidence sug-
gesting the significant role that these last mentioned
specialists may fill in delivering primary care; how-
ever, this function is a limited one for most obstetri-
cian-gynecologists, and is clearly thought of as a sec-
ondary function by most surgeons.
In strict keeping with the AMA definition of group
practice, the survey did not cover certain other non-
private organizational pattern? based on the group
format, such as the clinics of teaching hospitals, fac-
ulty practice arrangements, federally funded compre-
hensive health care programs, student health services
of colleges and universities, and other institutional
(including military related) health care programs.
Most of these programs, however, would no doubt
otherwise meet our definition of a primary care
group.
Methods
Using as a basic source the AMA's Listing of
Group Practice in the United States, 1967/' a list by
county of location of all group practice organizations
in North Carolina was sent to all district public health
officers in the state for confirmation and additions.
The University of North Carolina (Chapel Hill) col-
lection of current telephone directories was then
searched for additional listings of possible group
practices. From these sources 165 medical practices
were identified as possible group practice organiza-
tions. Subsequent follow-up revealed that 143 organi-
zations conformed to the ,AMA definition of group
practice.
A survey questionnaire was mailed during the f;i
and winter of 1970-1971 to 90 internal medicir
pediatric, general practice and multispecialty groii
practices. The questionnaire requested informatit
on the origin, composition, and specialty staffing i
the group; its non-physician employees, formal a
filiations with other organizations, plans for staff e;
pansion, patient referral source, practice volume, ar
proportionate primary care activity, night and eme
gency coverage, (primary) laboratory and radiolog
procedures, patient records, and performanc
evaluation activity.
Nineteen of the 90 groups receiving questionnain
were subsequently determined not to be true primai
care group practices. The questionnaire was returnc
by 61 of the 71 true primary medical care groi
practices in North Carolina, or 85 percent. Questioi
naires were obtained from 23 of 26 internal medicin
16 of 18 pediatric. 12 of 14 general practice, and 1
of 13 multispecialty groups. The nonresponders wei
telephoned to obtain information on the physicia
staffing pattern, year of origin and legal structui
of the group. Seventeen of the 71 primary medic
care groups were composed of five or more phys
cians, and 12 of these were visited to obtain furths
information.
FINDINGS OF THE SURVEY '
Number and type of group practice organizations
As of June. 1971, there were 143 independei
group medical practices in North Carolina. An add
tional 12 associations of three or more physiciar
who practiced together were found, but could not t
considered true group practices. The distribution (
the groups bv specialty staffing pattern is shown i
Table 1.
Growtli of primary care group practice
Of the 71 primary care groups, four (three mult
specialty and one pediatric) originated before 1931
The number of primary care group practices has a|
proximately doubled each decade since 1930 i
Table 1
Group Practices in North Carolina, 1971 by Spec
Staffing and by Primary Care Potential
Specialty Type
Major potential for primary care
Multispecialty
Internal medicine
Pediatrics
General practice
Other single specialty
Obstetrics-gynecology
Surgical (general, thoracic, urology, orthopedics,
ENT. opthalmology, neuro)
Other (radiology, pathology, psychiatry, dermatology,
neurology, subspecialties of internal medicine)
TOTAL
1
laity
Numb.
13-
25.
H,
14-
n
143
34
Vol. 35, No.i
ijown in Table 2. In the last decade internal medi-
ne and general practice groups have been primarily
iponsible for the growth rate.
Table 2
^cade of Origin of Primary Care Groups, by Type of Group
Table 4
Decade of 0
rigin
'e of Group
1921-
1930
1931-
1940
1941-
1950
1951-
1960
1961-
1970
Unknown
Total
i^rnal
ledicine
_
_
3
7
13
3
26
'iatrics
1
1
2
7
5
2
18
eral
'actice
_
_
2
2
9
1
14
•tispecialty
3
2
1
2
1
4
13
EAL
4
3
8
18
28
j/IULATIVE
4
7
15
33
61
10
71
! oup size
'\lmost half of the primary care group practices
a lude three physicians, the minimum size necessary
conformance with the AMA definition of a group
dical practice. The single specialty groups as con-
ited with multispecialty groups are, as expected,
iributed much more toward smaller group size.
J distribution by specialty and size of all North
'rolina groups is shown in Table 3.
Table 3
Group Practices in North Carolina, 1971,
>i by Specialty and Size
[ Specialty
Group
Size
Total
!
3
4 5
or More
Groups
r potential for
imary care
f\/lultlspecialty
Internal medicine
0
1
12
13
15
8
3
26
^diatrics
10
7
1
18
general practice
9
4
1
14
Sub-total
34
20
17
71
r single specialty
Obstetrics-gynecology
13
3
1
17
liurgical
21
9
6
36
jDther
8
7
4
19
1 Sub-total
42
19
11
72
TOTAL
75
39
28
143
I* kiber of physicians in primary care group practice
here were 359 physicians practicing in groups
^i, major potential for primary care as of June,
S 1. The "primary physician specialists" — inter-
ir, pediatricians, and generalists — accounted for
8 or 80 percent of the total. The other specialists
n , of course, uniformly located in multispecialty
r ps, where they comprised 46 percent of multi-
P'ialty group physician manpower. The distribu-
c by specialty and type of group is shown in
"£ e4.
'I icians in primary care groups and total N. C.
.lysician resources
1 the last year for which reliable figures are
V able, 1968, there were some 2,938 physicians in
Primary and Other Physicians in Primary Care
Group Practice by Specialty
Physician
Specialty
Single
Specialty
and General
Practice
Groups
Multispecialty
Groups
Total
Internal medicine
96
43
139
Pediatrics
65
11
76
General practice
48
26
74
other specialists
—
70
70
TOTAL
209
150
359
active private practice in North Carolina, available
for patient care.' About 20 percent of these physi-
cians are in group practice and 12 percent are in
primary care groups. Table 5 shows the distribution
of physicians by specialty in primary care groups as
compared to all North Carolina physicians.
Table 5
Number and Percent of All North Carolina Physicians
in Primary Care Group Practice, by Specialty
Total Number
Number in
Percent in
in Private
Primary
Primary
Practice,
Care Groups,
Care Group
Specialty
1966
1971
Practice
Internal medicine
458
139
30
Pediatrics
208
76
37
General practice
1054
74
7
Other specialists
1218
70*
6
TOTAL
2938
359
12
■ An additional 252 non-primary physician specialists were in sin-
gle specialty group practice; hence the number of all group
practice physicians was 611, or 20 percent of total physicians
in private practice.
About one third of all active private practice in-
ternists and pediatricians and one fifteenth of general
practitioners are in organized groups. General prac-
tice, it appears, remains the domain of the solo prac-
titioner and two-physician partnership.
Proportionate volume of primary medical care
Almost three fourths of the internal medicine,
pediatric and general practice groups estimate 80 per-
cent or more of their office practice to be primary
medical care. In contrast, more than half of the mul-
tispecialty groups expect less than 80 percent of their
practice to be primary care activity. Presumably this
difference is because some of the multispecialty
groups prefer to emphasize a consultant role in their
communities. Table 6 presents the distribution of es-
timated primary care activity in primary care groups.
Planned expansion of physician staff
The impact of group practice as a source of medi-
cal care for the population can increase in two ways:
UivRY 1974. NCMJ
35
Table 6
Estimated Percent of Primary Care Service
Activity, by Specialty
Estimated Percent of Primary
Care Activity
Specialty Type
and Number of Groups 0-19% 20-39'''o 40-59% GO-79% 80-100%
Multispecialty (9) 1
Internal medrcine (23) —
Pediatrics (15) —
General practice (9) —
TOTAL (56)* 1
1
2
1
4
2
2
2
17
-
1
2
12
-
—
2
7
3
5
7
40
■ Five of the 61 groups returning questionnaires did not respond
to this question.
by the formation of new groups and by the expansion
of existing ones. Most of the large nationally known
group practice organizations began with relatively
small physician staffs and grew actively by recruiting
more physicians as additional demand for medical
service was felt by the group. Table 7 presents infor-
mation on planned recruitment of additional physi-
cians by existing primary care group practices within
two years from the time of the survey. The majority
of primary care groups plan recruitment of one or
more additional physicians. There is a trend toward
more planned expansion with increasing group size.
Table 7
Planned Physician Staff Expansion by Specialty
and Size of Groups
No. of
Groups
Planning Percent
Physician No. New Planning
No. staff Physicians Additional
Specialty Type Groups Expansion Sought Physicians
Multispecialty
10
6
14
60%
Internal medicine
23
13
17
55%
Pediatrics
16
6
6
37%
General practice
12
6
6
50%
Current Group Size
3
29
13
14
45%
4
16
8
11
50%
5 or more
16
10
18
63%
TOTAL
61
31
43
5or„
Use of allied health personnel
Primary care groups employ a broad range of
allied health personnel for professional, business,
laboratory, and custodial purposes. A ratio of 2.63
allied health personnel per physician was found
in this survey. This ratio is very similar to the 2.51
allied health personnel per physician reported in the
1969 AM.A survey of all group practices in the
United States.
Several types of allied health workers require
special note. These personnel are variously known
as physician surrogates or physician extenders, and
they have a potentially large role in the delivery of
primary medical care. Physician surrogates include
the family or pediatric nurse practitioner, the physi-
cian assistant or associate, the pediatric associa
and the nurse midwife. Nine primary care grou
indicated that they used physician surrogates at t
time of the survey. Three of these were pediat
groups employing pediatric nurse practitione
Family nurse practitioners are used by one gene;
practice group and two multispecialty groups. Ti
internal medicine groups and one general practi
group stated that they employed physician assistan
Another five groups indicated that they were consi
ering the recruitment of one of these several typ
of surrogates.
Extramural service affiliations
About one third of primary care groups have fc
mal arrangements with other organizations for t
provision of medical care. The majority of these ;
filiations are with local public health departmei
for medical staffing of pediatric, prenatal, fam
planning, and other public health clinics. In additic
several groups have contracts to provide medical ca
in colleges, boarding schools, summer camps a
prisons.
Availability of primary care groups to new patients
There are wide \ariations in the degree to whi
primary care group practices are available to new p
tients. Adult non-emergency patients without a
pointments (walk-ins) would have considerab
more difficulty being seen in an internal medicii
group than in a general practice group. Thirty-fr
percent of the 23 internal medicine groups and ;
nine of the general practice groups stated that th(
could see new patients without appointments durij
regular office hours. Forty-seven percent of the pec
atrics groups were able to see new patients witho
appointments during their regular hours; however, ;
but one of them were accessible to new patients
the evening. It is noted, however, that many intern
medicine groups wrote on the questionnaire that tli.
participate in a rotation schedule for emergeiv'
room coverage at one or more local hospitals.
Standardized clinical procedures
One of the potentials of group practice is achiev
ment of efficiency, and perhaps quality, through sta)
dardized procedures. Primary medical care groui
were asked if they followed a standard set of labor'
tory and x-ray diagnostic procedures for all iit
patients and patients who present for a rouiin
physical examination. The results are summarizJ
in Table 8. t
The discriminating factor in having or not ha\it
an agreed upon set of laboratory and x-ray prcxf
dures is not immediately apparent; however, the m.
jority of internal medicine and pediatric groups i
have some standardized procedures. While no mulii
specialty group reported such procedures, it is qui"
possible that the internists, pediatricians and/or ge*,
eralists as a subset of the entire group might hak
36
Vol. 35, No
J
Table 8
Groups with Standardized Laboratory and
X-ray Procedures for New Patients
Type of Group
Itispecialty 10
;rnal medicine 24
. iatrics 15
'eral practice 11
j'AL 58*
Iiiree of the 61 groups returning did not respond to this ques-
,in.
^
Do
Do Not
Have
Have
0
10
IS
6
10
5
4
7
32
26
ndard procedures in effect for the evaluation of
V patients.
Icord filing system
One manifestation of a primary care group's orien-
■on toward an individual versus family centered
ictice is its method of filing charts. Table 9 sum-
rizes the information on the system of filing pa-
'iit charts used by the primary care groups.
^^ediatric groups appear to be much more likely to
their patient records by family, while maintenance
ndividuality of practice within an organized group
an apparent objective of three general practice
ups as indicated by the record filing system they
ifi
Table 9
Record Filing System Used by Primary Care Groups
/pe of Group and
Number
ispecialty
(8)
rnal medicine (23)
tries
iral practice
(15)
(12)
58*
By
Individual
21
6
7
42
By
Family
2
9
2
13
By
Physician
■ee of the 61 groups returning questionnaires did not respond
his question.
jformance assessment in office practice
phere has been considerable discussion and in-
st regarding quality review. This focus is currently
tered in the federal financing programs. Medicare
1 Medicaid. Various peer review methods have
li; been a standard part of hospital practice in,
: example, death conferences, tissue committees,
), more recently, with utilization review commit-
To ascertain the current practice of primary
i; groups in regard to performance review, they
2 asked about the practice of regular formal re-
' of the quality of patient care in their ambula-
practice. The results are summarized in Table
idthough the questionnaire specifically requested
jxmation on the existence of a formal review pro-
cure, a few groups responded that they had '"in-
,|pal" procedures; these responses are not tabu-
l in the "has formal review" column in Table 10.
formal procedures ranged from "daily review.
Table 10
Regular Method for Evaluation of Performance
in Ambulatory Practice
Type of Group
and
Number
Multispecialty
(10)
Internal medicine
(23)
Pediatrics
(16)
General practice
(12)
TOTAL
61
Has
Formal
Review
1
3
Has No
Formal
Review
9
20
16
12
57
especially for inpatients," to a written evaluation
by one group member of randomly drawn charts of
other group physicians.
SUMMARY
A survey was undertaken in North Carolina to
document the role of group medical practice in the
delivery of primary medical care. Approximately 20
percent of all privately practicing physicians in North
Carolina are organized in 143 independent group
practices. Twelve percent of private physicians are in
71 primary care groups, defined as group medical
practice having a potential for major involvement
in primary medical care. These accounted for about
one third of active privately practicing internists and
pediatricians in the state and about one fifteenth of
general practitioners.
Primary care group practice in North Carolina had
its origin during the 1920s. The number of primary
care groups has increased approximately 100 percent
during each decade since then. Three quarters of
the groups with a potential for primary medical care
estimate 80 percent or more of their practice volume
to be primary medical care activity.
As an organizational form for the delivery of medi-
cal care, group medical practice is increasing in North
Carolina as it is also in the nation. Groups having
a physician staffing pattern that suggests a potential
for major involvement in primary care at present con-
stitute a majority of all medical groups in North
Carolina. It is considered likely that group practice
will play an even more significant role in the delivery
of primary care in the future.
ACKNOWLEDGMENT
This research was supported hy the Health Services Re-
search Center of the University of North Carolina throuoh
Research Grant HS 00239 from the National Center tor
Health Services Research and Development, Department of
Health. Education, and Welfare.
References
1. Pomrinse SC, Goldstein MS: The 1959 survev of groiap practice.
Am J Public Health 51: 671-681. 1961.
2. Balfe BE, McNamara ME: Survey of Medical Groups in the
United States, American Medical Association, 1965.
3. Todd C. McNamara ME: Medical Groups in the U.S., 1969,
Center for Health Services Research and Development, American
Medical Association, 1971.
4. Madison DL: The structure of American health care services.
Public Admin Review 31: 518-527. 1971.
5. Bodcnheimer Thomas: Patterns of American ambulatory care.
Inquiry, Vol. 7, Sept.. 1970. pp. 26-37.
6. American Medical Association, Listing of Group Practices in the
United States. 2nd Edition, American Medical Association, Chi-
cago, 1967. * This reference, although out of date now, is still the
only available complete listing of medical groups.
7. "Biennial Report." Research and Evaluation Division. North Caro-
lina Regional Medical Program I96S.
*ARY 1974. NCMJ
37
Initial Care for Lacerations of Flexor Tendons
of the Hand
Robert B. Winslow, M.D., and A. Griswold Bevin, M.D.
CURGERY of the hand has become increasingly
sophisticated since Bunnell^ formalized it in his
well-known textbook, first published in 1944. Since
that time, great contributions have been made by
surgeons from many different specialties — especially
plastic, orthopedic, and general surgery. Bunnell
taught that the area of the digital theca or flexor
tendon sheath was "no man's land." He recom-
mended that no primary reconstruction be attempted
(instead only cleansing the wound and closing the
skin) when the flexor tendons within this area were
lacerated; a second stage tendon graft, in which both
anastomoses were placed outside "no man's land,"
was to be carried out after the wound healed. How-
ever, owing to refinement in techniques, improved
understanding of tendon physiology and wound heal-
ing, and the development of hand rehabilitation cen-
ters, this sound dictum has become modified.
Today, all major hand surgery requiring primary
reconstruction is performed under tourniquet isch-
emia, in a formal operating room with excellent light-
ing and instruments, under anesthesia, and with the
aid of experienced assistants. Two-, four-, and ten-
power magnification is often utilized for suturing and
for the most accurate realignment of tissues. Atrau-
matic technique is a sine qua noii. as is the use of
either removable or very fine, nonreactive, strong
sutures. Excellent postoperative care must be avail-
able— frequent follow-up and accessibility to closely
supervised, occupational and physical therapy pro-
grams. Such care must be available on a daily basis,
if needed. Long-term follow-up is equally essential
From the Division of Plastic and Reconstructive Surgery and Sur-
gery of the Hand, and The Hand Rehabilitation Center. Department
of Surgery. University of North Carohna School of Medicine and
the North Carohn.i Memorial Hospital. Chapel Hill, North Carolina.
since it may help the patient toward acceptable func
tion and because it will provide the surgeon wit)
additional information about his work.
The work of Boyes,-' ■" Peacock,"'- ^ Verdan,
and others, as well as our own, carried out unde
the conditions mentioned, leads us to advocate thi
primary repair of flexor tendon lacerations (even h
Bunnell's "no man's land") in selected cases. Thus
the term "some man's land" evolved."
Although every eminent hand surgeon seems ti
have his own slightly varied criteria for selectin;
patients as candidates for primary repair, none rec
ommends primary tenorrhaphy for all flexor tendoi
lacerations. The selection of patients who qualify io
primary repair depends on several factors: the pa
tient's age, the nature of the injury, the location o
the wound, the structures involved, the occupation o
the patient, the initial care already given, and th
capability of the surgeon and the facilities at his dis
posal. It is not important that the surgeon be a plastic
orthopedic, or general surgeon; but it is essentif
that he be well-trained in surgery of the hand. If h-
lacks familiarity with the anatomy and surgery of th
hand, the surgeon, regardless of his talent, shoub
not undertake this kind of surgery. Furthermore, eve
under the most ideal conditions, not all patients cat
or should, be treated by definitive primary repaii
The most successful results in primary repair hav
been possible because of the surgeon's intimat
knowledge of the anatomy of the hand and his ex
perience in the field. Primary repair, be it anastc
mosis or graft, can be successful. It can insure bette
and more reliable results — with less scarring, e%:
pense, and disability — than other approaches used i
ideal wounds. An ideal wound is clean, less than si
to eisht hours old, and has onlv one or two tendon'
38
Vol. 35, No. >
berated within it. It occurs in a young patient who
IS supple, clean hands, and no apparent mitigating
sease or deformity. The priorities of wound care
:tate that before any consideration can be given to
:xor tendon reconstruction, the wound must be
;aned, accompanying fractures reduced and stabi-
ed, nerves repaired, and adequate skin cover ob-
ned. In certain circumstances, however, dirty
junds can be made clean by debridement or by ac-
lal wound excision. Inadequate or damaged local
isue can best be replaced by grafts or cross-finger
ps. Although six to eight hours may be sufficient,
th antibiotic coverage and splinting, primary repair
n be delayed for twelve to twenty-four hours. ^
lamson" even recommends waiting five days to
] rform deferred primary repair on a scheduled,
( ctive basis. He claims that the results are com-
Irable to more aggressive, earlier approaches. In
:se undertakings, poor results are infrequent and
asters are rare.
If primary or deferred primary flexor tendon re-
c_istruction cannot be safely accomplished, such
\ 11 known alternatives as secondary tenorrhaphy
,8 1 free tendon grafting can be performed. Less well
ipwn, but advantageous, is the (now accepted)
s ondary scar resection with construction of pulleys,
a 1 the insertion of a Silastic® rod.^"'* After ap-
P|)ximately three months, tendon continuity may be
r established through the scar-free tunnel formed
a'und the rod. This can be done by either the tra-
d onal free graft or the two-stage tenoplasty tech-
n'ue. '■'•■'*' Neither is performed until protective
5' sation has been restored, adequate joint supple-
n s has been gained, and sufficient skin cover has
b n provided. According to BCyes,'-' only the sur-
g'n who can perform this surgery is qualified to
piform the initial surgery.
->Jew techniques, materials, and approaches are
;i tinually being sought and evaluated. New de-
/' )pments that seem worthwhile are disseminated,
^jiough primary repair in flexor tendon injuries is
^[Dmmended when feasible (rather than simple
djure of the skin wound), not every hand surgeon
lijuld perform primary repair. The occasional hand
■:i ;eon — who is not well acquainted with current
;(;Cepts, who is caught at night between busy of-
jy hospital days, who has inadequate help and less
ideal operating facilities, who is without magni-
don, and who is without the desire or facilities
compulsive, prolonged postoperative care —
it: lid not repair all flexor tendons primarily. Un-
it these circumstances, the best treatment is to clean
hjA'ound and close the skin.
</hether to perform some kind of primary repair,
)il/hether to close the skin and perform secondary
& nstruction later, is a crucial decision. Primary
etir, if successful, results in the shortest duration
>f isability, the least expense, and the least scar-
ii) Often, however, failure to adhere to the basic
t
principles mentioned results in an unsatisfactory
outcome; it then becomes necessary to implement
complex secondary reconstructive procedures which
are time-consuming and expensive, and which proba-
bly will be less satisfactory than an initially well
planned and performed deferred or secondary pro-
cedure. Thus, even under the best of circumstances,
the experienced hand surgeon must exercise caution
in deciding whether to perform primary repair. Al-
though Chase-" has acknowledged the theoretical,
actual, and documented advantages of primary re-
pair, he still recommends skin closure and secondary
reconstruction.
Considerable exposure to the results of primary
flexor tendon surgery is afforded by the Hand Re-
habilitation Center of the University of North Caro-
lina School of Medicine at Chapel Hill. Those pa-
tients whose simple and uncomplicated postoperative
course has resulted in a prompt return of acceptable
function are not referred to us. We see patients
with delayed healing, wound infections, disrupted
anastomoses, poor function caused by stiff joints, or
adherent anastomoses. Thus, in our experience, we
have had an opportunity to care for many patients
who have had unsatisfactory results, as well as many
patients who have had primary complex injuries. We
have seen examples of nerves anastomosed to ten-
dons; nerves anastomosed by a Bunnell woven suture
of silk; finger tenorrhaphies done by using mattress
sutures of 2-0 silk; primary tenorrhaphies in which
adjacent lacerated nerve(s) were left unrepaired;
primary neurorrhaphies and tenorrhaphies performed
in uncleaned wounds; dressings covered by a cast
and left unchanged for as long as four or six weeks;
active motion begun at one week, without protec-
tion; tenorrhaphies in the distal finger, done with
cotton sutures; and anastomoses wrapped in Silas-
tic?' sheet. These experiences are not unique;
Boyes'" reported five instances of "board certified''
surgeons using segments of the median nerve for a
free tendon graft. In each case cited there has been a
disastrous result, requiring prolonged therapy and
further surgery which might well have been avoided
by adhering to the principles stressed herein.
The surgeon — especially the hand surgeon — is
not compelled to perform primary tendon repair
within eight hours of injury. Owing to advanced
transportation in this state, a patient can be taken,
within a few hours (by helicopter, if necessary), to
an adequate center with special facilities for hand
surgery. Within four to eight hours, a patient can be
taken to such a center by routine modes of travel.
Hopefully, those centers which arc not adequately
equipped to give comprehensive care to flexor tendon
injuries will recognize the advantages (to themselves,
as well as to their patients) of sending the victim to
the nearest hand surgeon, regardless of time and
distance. Primary repair — the best treatment in care-
fully selected patients — can then be performed in a
A.ARY 1974, NCMJ
39
manner and under conditions that justify its use.
Under less than ideal conditions, primary tendon re-
pair is unjustified.
References
1. Bunnell S: Surgery of the Hand. 1st edition. Philadelphia,
Pennsylvania: J B Lippincott, l'?44.
2. Boves JH: Flexor-tendon grafts in the fingers and thumbs: an
evaluation of end results. J Bone Joint Surg 32A: 4S9-499, 1950.
3. Boyes JH. Stark HH; Flexor-tendon grafts in the fingers and
thumb; a studv of factors influencing results in lOIX) cases.
J Bone Joint Surg 53A: 1332-1342. 1971.
4. Peacock EE Jr. Hartrampf CR: The repair of flexor tendons
in the hand. Int Abst Surg 113: 411-432, 1961.
5. Peacock EE Jr: Some technical aspects and results of flexor
tendon repair. Surgery 58: 330-342, 1965.
6. Verdan CE: Half a century of flexor-tendon surgery — Current
status and changing philosophies. J Bone Joint Surg 54A:
472-491. 1972.
7. Kleinert HE. Kutz JE, Ashbell TS. et al: Primary repair of
lacerated flexor tendons in "no man's land." J Bone Joint
Surg 4yA: 577. 1967.
8. Harrison SH: Delayed primary flexor tendon grafts of the fingers:
a comparison of results with primarv and secondary tendon grafts.
Plast Rcconstr Surg 43:366-372, 1969.
9. Adamson JE: Technique of flexor tendon repair. Presented at the
Annual Meeting, Southeastern Society of Plastic and Reconstructive
Surgeons, Williamsburg, Virginia. 1972.
10. Carroll RE: Formation of tendon sheath by silicone rod impl;
Dow Corning Bull 6:5. 1964.
11. Conway H, Smith JW, Elliott MP: Studies on the revasculan
tion of tendons grafted by the sihcone rod technique. Pj
Reconstr Surg 46:582-587, 1970.
12. Gaisford JC, Hanna DC, Richardson GS: Tendon graftii
a suggested technique. Plast Reconstr Surg 38: 302-308. 1966.
n. Hunter J: Artificial tendons — early development and applicati
Am J Surg 109: 325-328. 1965.
14. Hunter JM, Salisbury RE: Use of gliding artificial impla
to produce tendon sheaths: techniques and results in childi
Plast Reconstr Surg 45:564-572. 1970.
15. Paneva-Holevitch E: Two-stage plasty in flexor tendon injur
of fingers with digital synovial sheath, 1. Acta Chir Plast (Pral
7: 112-124. 1965.
16. Paneva-Holevitch E: Two-stage tenoplasty in injury of the fie
tendons of the hand. J Bone Joint Surg 51 A: 21-32, 1969.
17. Chong JK. Cramer LM. Culf NK.: Combined two-stage te
plasty with silicone rods for multiple flexor tendon injuries
"no-man's-land." J Trauma 12:104-121, 1972.
18. Kessler FB: Use of a pediclcd tendon transfer with a silicone :
in comphcated secondary fle.xor tendon repairs. Plast Recor
Surg 49: 439-443. 1972.
19. Boyes JH : The great flexor tendon controversy. In Symposi
on the Hand, Stanford University. 1970. Cramer LM, Chase
(eds). Proceedings of the Symposium of the Educational Fo
dation of the American Society of Plastic and Reconstruct
Surgeons. Vol 3. St. Louis. Mosby, 1971.
20. Chase RA: Surgery of the hand. N Engl J Med 287:1174-1!
1972.
No part of the practice of medicine is of greater importance, or merits more the attention of
the physician, as many lives are lost, and numbers ruin their health, by cold bathing, and an
imprudent use of mineral waters. — William Buchan: Domestic Medicine, or a Treatise on the
Prevention ami Cure of Diseases hx Regimen and Simple Medicines, etc., Richard Folwell, 1799,
p. 426.
40
Vol. 35, Nc
Editorials
SUGGESTIONS FOR AUTHORS
The North Carolina Medical Journal wel-
mes original contributions to its scientific pages,
^pecting only that they be under review solely by
Jis Journal at a given time, and that they follow a
kv simple guidelines. The ouidelincs are as follows:
1. Subject Matter
Educational articles, especially those in which particular
Mications to the practice of medicine in North Carolina
developed, are one of the main objectives of this
JRNAL.
\rticles reporting original work by North Carolina phy-
ans are invited, whether the work is done in a clinic, a
oratory, or both. The editor and his consultants will
iluate the work by the usual criteria, including a proper
;ussion of previous work, control observations, and sta-
ical tests where indicated.
listorical articles, especially those dealing with local his-
y, are considered of real value and interest.
2. Manuscripts
^n original and a carbon copy of the manuscript should
6 submitted, one for review by the editorial staff, the other
referees. The manuscript should be typed on standard-
paper, double-spaced, with wide margins (one inch on
;l side).
3. Bibliographic References
eferences to books and articles should be indicated by
^ecutive numerals throughout the te.xt and then typed,
ble-spaced, on a separate page at the end of the manu-
script. 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 infor-
mation necessary to locate them easily. The North Caro-
lina Medical Journal follows the form used in the journals
of the American Medical Association and the Imlcx Mci/iciis,
giving the author's surname and initials, title of the article,
name of the periodical, volume, inclusive page numbers, and
the date of publication. It is believed that this style makes if
easier for the reader to judge whether 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 ob-
tain 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 Publica-
tions Division of the American Medical Association, John H.
Talbot, M.D., director. All manuscripts are subject to edi-
torial 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 Medical Journal.
Without a proper discrimination with regard to the disease and constitution of the patient,
the most powerful medicine is more likely to do harm than good. The same physician, who,
by cold bathing, cured .'\ugustus, by an imprudent use of the same medicine, killed his heir. This
induced the Roman senate to make laws for regulating the baths, and preventing the numerous
evils which arose from an imprudent and promiscuous use of those elegant and fashionable
pieces of luxury. — William Biiclnin: Domestic Medicine, or a Treatise on the Prevention and
Cure of Diseases by Regimen and Simple Medicines, etc.. Richard Folwell. 1799. p. 426.
ARY 1974, NCMJ
41
!'
^//
^^Jn&
The irritations of
day are often
cted in his gut.
The causes of irritable colon and the diarrhea;
symptoms that often accompany it can be as di;
verse as the systemic and emotional irritation)
man is faced with daily.
Although the mucoid nature of stools and th<
occurrence of diarrheal episodes coincident witr
times of emotional stress may be valuable clue!
to the functional nature of the disorder, irritabh
colon must often be diagnosed by exclusion
Such diagnostic exploration takes time. Discov
ery of the nature of any emotional problems maj
take more. During that time, Lomotil" is an idei
agent for controlling diarrheal symptoms.
Lomotil tablets are small, easy to carry a
easy to take. They act promptly and effectively
Secondary effects are relatively infrequent and
once the first force of the diarrhea is controlled
maintenance is frequently effective on as littl<
as one fourth of the initial dosage.
These same characteristics make Lomot^
useful in controlling the diarrhea associated wit
gastroenteritis, antibiotic therapy and acut|
infections.
]
;>'.,
/
^omotil
TABLETS/LIQUID
:ach tablet and each 5 ml. of liquid contain:
■ diphenoxylate hydrochloride ... 2.5 mg.
(Warning: May be habit forming)
atropine sulfate 0.025 mg.
Ikes care of the gut issue
"(irritable colon
IMPORTANT INFORMATION: This is a Sched-
ule V substance by Federal law: diphenoxylate
HCI is chemically related to meperidine. In
case ol overdosage or individual hypersensitiv-
ity, reactions similar (o those alter meperidine
or morphine overdosage may occur: treatment
is similar to that lor meperidine or morphine
intoxication (prolonged and carelul monitor-
ing). Respiratory depression may recur in spile
ol an initial response to Nalline'^' /nalorphine
HCI) or may be evidenced as late as 30 hours
alter ingestion. LOMOTIL IS NOT AN INNOC-
UOUS DRUG AND DOSAGE RECOMMENDA-
TIONS SHOULD BE STRICTLY ADHERED TO
ESPECIALLY IN CHILDREN. THIS MEDICA-
TION SHOULD BE KEPT OUT OF REACH OF
CHILDREN.
Indications: Lomotil is effective as adjunctive ther-
apy in tfie management of diarrfiea.
Contraindications: In cfiildren less ttian 2 years, due
to ttie decreased safety margin in younger age
groups, and in patients wtio are jaundiced or hyper-
sensitive to diphenoxylate HCI or atropine.
Warnings: Use with caution in young children, be-
cause of variable response, and with extreme cau-
tion in patients with cirrhosis and other advanced
hepatic disease or abnormal liver function tests,
because of possible hepatic coma. Diphenoxylate
HCI may potentiate the action of barbiturates, tran-
quilizers and alcohol. In theory, the concurrent use
with monoamine oxidase inhibitors could precipitate
hypertensive crisis.
Usage in pregnancy: Weigh the potential benefits
against possible risl<s before using during preg-
nancy, lactation or in women of childbearing age.
Diphenoxylate HCI and atropine are secreted in the
breast milk of nursing mothers.
Precautions: Addiction (dependency) to diphenoxy-
late HCi is theoretically possible at high dosage. Do
not exceed recommended dosages. Administer with
caution to patients receiving addicting drugs or
known to be addiction prone or having a history of
drug abuse. The subtherapeutic amount of atropine is
added to discourage deliberate overdosage; strictly
observe contraindications, warnings and precautions
for atropine; use with caution in children since signs
ofatropinism may occur even with the recommended
dosage.
Adverse reactions: Atropine effects include dryness
of skin and mucous membranes, flushing and urinary
retention. Other side effects with Lomotil include
nausea, sedation, vomiting, swelling of the gums,
abdominal discomfort, respiratory depression, numb-
ness of the extremities, headache, dizziness, depres-
sion, malaise, drowsiness, coma, lethargy, anorexia,
restlessness, euphoria, pruritus, angioneurotic
edema, giant urticaria and paralytic ileus.
Dosage and administration: Lomotil is contraindi-
cated in children less than 2 years old. Use only
Lomotil liquid for children 2 to 12 years old. For
ages 2 to 5 years, 4 ml. (2 mg.) t.i.d.; 5 to 8 years, 4
ml. (2 mg.) q.i.d.; 8 to 12 years, 4 ml. (2 mg.) 5
times daily; adults, two tablets (5 mg.) t.i.d. to two
tablets (5 mg.) q.i.d. or two regular teaspoonfuls
(10 ml., 5 mg.) q.i.d. Maintenance dosage may be as
low as one fourth of the initial dosage, tvlake down-
ward dosage adjustment as soon as initial symptoms
are controlled.
Overdosage.- Keep the medication out of the reach
of children since accidental overdosage may cause
severe, even fatal, respiratory depression. Signs of
overdosage include flushing, lethargy or coma, hy-
potonic reflexes, nystagmus, pinpoint pupils, tachy-
cardia and respiratory depression which may occur
12 to 30 hours after overdose. Evacuate stomach by
lavage, establish a patent airway and, when neces-
sary, assist respiration mechanically. Use a narcotic
antagonist in severe respiratory depression. Obser-
vation should extend over at least 48 hours.
Dosage torms: Tablets, 2.5 mg. of diphenoxylate
HCI with 0.025 mg. of atropine sulfate. Liquid, 2.5
mg. of diphenoxylate HCI and 0.025 mg. of atropine
sulfate per 5 ml. A plastic dropper calibrated in in-
crements of Vz ml. (total capacity, 2 ml.) accom-
panies each 2-oz. bottle of Lomotil liquid.
SEARLE
Searle & Co.
San Juan, Puerto Rico 00936
Address medical inquiries to:
G. D. Searle & Co.. H/Iedical Department
Box 5110, Chicago, Illinois 60680
Emergency
Medical
Services
HISTORICAL BACKGROUND OF THE AMA
COMMITTEE ON COMMUNITY EMERGENCY
SERVICES
William E. Burnette, Secretary
AMA Committee on Community Emergency
Services
In May of 1970, the Board of Trustees estab-
lished the AMA Committee on Community Emer-
gency Services to 1 ) maintain effective liaison with
state medical societies in the area of EMS, 2) de-
velop disaster programs, and 3) maintain liaison with
the government.
Since its inception, it has been very active in
emergency medical services and has had a major role
in attempts to implement Federal legislation on emer-
gency medical services. In November 1971, the com-
mittee submitted a report with their ideas for im-
proving emergency medical services: 1 ) All medical
societies should assign a high priority to EMS. 2 )
Special emphasis on EMS in rural areas. 3) W(
equipped and staffed emergency vehicles. 4) I
velopment of emergency medical service counc
5 ) The medical profession should take a leaders!
role in quality control. 6) A single Federal le
agency should be responsible.
A model disaster program is being developed
O'Hare Airport in Chicago. They have worked w
HEW on medical self-help programs. They have 1:
recommendations on a standard format for em
gency medical services telephones.
The committee is committed to serving the c(
stituent societies in their quest to improve em
gency medical services throughout the nation.
Abstracted by George Johnson, Jr., M,
From "Emergency Medicine Today." The origii
article may be obtained from the American Medi'
Association. 535 North Dearborn Street. Chica\
Illinois 60610.
Committees and
Organizations
COMMITTEE ON HEALTH CARE DELIVERY
Soutliern Pines. Sept. 28, 1973
The committee adopted the following resolution,
on motion by Dr. Patrick D. Kenan:
We propose that the primary mission of the Com-
mittee on Health Care Delivery be to concern itself
with the problems of health care accessibility.
— Patrick D. Kenan, M.D., Chairman
COVIMITTEE ON HOSPITAL AND
PROFESSIONAL RELATIONS
Southern Pines, Sept. 27. 1973
The committee adopted the following resolutions:
1 ) This committee approves in principle the re-
quest of the North Carolina Society of Internal Medi-
cine to study methods of improving medical records
and that the North Carolina Medical Society and
North Carolina Hospital Association should in cc
sultation form a committee to study and demonstn
solutions to this problem, and employ professior
consultants if necessary.
2 ) This committee recommends to the Medit
Society that it jointly with the North Carolina Hos)
tal Association prepare guidelines for commuoi
hospitals regarding professional fees for professior
services by interns and residents in training.
3 ) This committee recommends to the Medical S
ciety to take steps to obtain legal ruling regardi
the rights and hazards of physicians and hospit
employees drawing blood for alcohol determinatii
at the request of law enforcement officers and aft
obtaining same, publicize well to the medical proff
sion and hospitals as soon as possible.
— Joe M. Va.n Hoy. M.D., Chairman
44
Vol. .vs. No.
f
!-
WHAT? WHEN? WHERE?
D
In Continuing Education
Januarj 1974
:'lace" and "sponsor" are listed only where these differ
m the place and group or institution listed under "for
ormation.")
In North Carolina
January 18-19
nagement of Peptic Ulcer (Medical and Surgical Ap-
proaches), 4th Annual Surgical Symposium
ce: Babcock Auditorium
■: $100.00
'■ Information: Emery C. Miller. M.D., Associate Dean
or Continuing Education, Bowman Gray School of
(Medicine, Winston-Salem 27103
February 1-2
4 Leadership Conference, North Carolina Medical So-
iety
This conference is designed especially for new officers,
imittee members, and others who carry leadership re-
nsibility for any activities of the Society; it is open to
member of the Society.
Boe: North Carolina Medical Society Building, Raleigh
Please note change from previous location.)
Information: Mr. William N. Milliard. Executive Direc-
or, P. O. Box 27167, Raleigh 2761 1
February 13
ilgate M. lohnson Memorial Lecture
;:e: Babcock Auditorium (8:00 p.m.)
Information: Emery C. Miller, M.D., Associate Dean
ir Continuing Education, Bowman Gray School of Medi-
ne, Winston-Salem 2710.3
February 15-16
_; Annual Watts Medical and Surgical Symposium
e: Durham Hotel & Motel, Durham
Insor: Watts Hospital Medical Staff
I Information: Clarence Bailey, M.D., 1824 Hillandalc
oad, Durham 27705
February 20
iind District Medical Society Annual Meeting
e: Ramada Inn, New Bern
tific Session — 2:00 p.m.; banquet — 7:00 p.m., speaker.
«orge Gilbert, M.D., President, North Carolina Medi-
Society
Information: Zack I. Waters, M.D., 800 Hospital Drive.
ijew Bern 28560
1" March 14
Fgnant Disease Symposium on Carcinoma of the Lung
iisors: Department of Surgery and the Office of Con-
^luing Education
Information: Miss Ann Francis, Administrative As-
lant, Office of Continuing Education, School of Medi-
le, UNC, Chapel Hill 27514
March 15-16
^h Annual E. C. Hamblen Symposium in Reproductive
alogy and Family Planning. Basic themes: The Manage-
f Harv 1974, NCMJ
I
r
ment of High-Risk Obstetrics and Newer Advances in the
Treatment of Infertility
Sponsor: Department of Obstetrics and Gynecology
Tuition: $25.00; no charge for residents or students
For Information: Charles B. Hammond, M.D., P. O. Box
3143, Duke University Medical Center, Durham, N. C.
27710
March 21-23
Hematology and Oncology Post Graduate Course
Place: Duke University School of Medicine
Director: Wayne Rundles, M.D., Professor of Hematology,
Duke University.
For lnform:Uion and registration forms: American College
of Physicians, 4200 Pine Street, Philadelphia, Pennsyl-
vania 19104
March 25-27
Tutorial Postgraduate Course: Radiology of the Chest
This course is designed both for radiologists in training
and those in practice. The tutorial format and limited
registration will allow a larger than usual faculty-student
ratio and personalized instruction to those enrolled. Guest
faculty have been chosen both for their excellence in their
respective topics, and for their effective use of the tutorial
approach. During one hour tutorial sessions 12 registrants
will join one faculty member in a separate quiet room
with a bank of viewboxes for organized film reading-dis-
cussions, with 10-12 case presentations on a basic subject
or two. Registrants are invited to bring interesting cases
for consultation with the "experts."
Place: Durham Hotel-Motel, Durham
Credit: 21 hours AMA "Category One" accreditation
Fee: $200.00
For Information: Robert McLelland. M.D., Department of
Radiology, Box 3808, Duke University Medical Center,
Durham 27710
March 26-28
Cardiac Arrhythmia Course
Place: Duke Hospital Orthopedic Clinic, Room 1367
For Information: Galen Wagner, M.D., Box 3327, Duke
University Medical Center, Durham 27710
March 28
Wilson Memorial Hospital Symposium on Obesity. Nutrition
& Physical Fitness
Sponsors: Wilson County Medical Society and the North
Carolina Academy of Family Physicians
For Information: Gloria Graham, M.D., Wilson Memorial
Hospital, Wilson 27893
April 1-2
Postgraduate Course: Obstetrics and Gynecology
Place: Babcock .Auditorium
For Information: Emery C. Miller. M.D.. Associate Dean
for Continuing Education, Bowman Gray School of
Medicine, Winston-Salem 27103
April 27
Craven-Pamlico Annual Medical Society Symposium
Place: Ramada Inn, New Bern
For Information: Zack I. Waters, M.D.. 800 Hospital Drive,
New Bern 28560
May 4-5
Principles of Practical Oxygen Therapy
Sponsors: Department of .Anesthesiology in cooperation
with the Office of Continuing Education
For Information: Miss ,-\nn Francis, Administrative As-
sistant, Office of Continuinc Education, School of Medi-
cine, UNC, Chapel Hill 275 r4
45
May 14-16
The Neuro-endocrinology Symposium; Neurobiology of
CNS — Hormone Interaction
Place: UNC Student Union Building. Great Hall
Sponsors: UNC Neurobiology Program and Laboratories
for Reproductive Biology
For Information: Miss Ann Francis, Administrative As-
sistant. Office of Continuinu Education. UNC School of
Medicine. Chapel Hill 275 14
May IS
Ethel Nash Day Program
Place: Cline Auditorium. Time: 1:00-5:30 p.m.
Sponsor: Department of Obstetrics and Gynecology
For Information: .Miss .Ann Francis. Administrative As-
sistant. Office of Continuing Education. UNC School of
Medicine. Chapel Hill 27514
May 29-30
Hypertension: Critical Problems — 25th Annual Meeting and
Scientific Sessions. North Carolina Heart Association
Place: Hyatt House and Convention Center. Winston-Salem
Designed especially for nurses and physicians
For Information: North Carolina Heart .Association. 1 Heart
Circle. Chapel Hill 27514
In Contiguous States
January 18-19
The Tennessee Regional Meeting of the .American College
of Physicians
Place: Holiday Inn Vanderbilt. Nashville
Sponsor: .American College of Ph\sicians
For Information: Gerald I. Plitman. M.D.. 17.14 Madison
.Avenue, Memphis. Tennessee 38104
January 21-22
E.xtending the Scope of Nursing Practice
For Information: Medical University of South Carolina,
Division of Continuing Education. 800 Barre Street. Char-
leston. S. C. 29401
January 21-24
The Alton D. Brashear Postgraduate Course in Head and
Neck Anatomy
The primary teaching method of this course is the dis-
section of the head and neck. Fresh specimens (unpre-
served) are used to be as life-like as possible. Individual
surgical approaches and manipulations are welcomed. Lec-
tures and demonstrations will augment the laboratory dis-
sections.
On Friday, January 25 the laboratory will be open and
specimens will be available if special individual dissection
is desired. All members of the staff of the department
of anatomy will be available for consultation and assistance.
Registration: Tuition $175.00; $90.00 for students in resi-
dency programs. Class size limited to 32; applications
processed in order received. Course open to any indivi-
dual who holds one of the following degrees: M.D.,
D.D.S.. D.M.D..Ph.D. or equivalent.
Sponsors; Department of .Anatomy in cooperation with the
Department of Continuing Education. Schools of Medi-
cine and Dentistry.
For Information: Dr. Hugo R. Seibel. Department of
Anatomy. Medical College of Virginia, Bo.x 906 — MCV
Station. Richmond. Virginia 23298
February 3-9
Fifth .Annual Family Practice Refresher Course
Place: Mills Hyatt House Hotel
Registration open through January 21; enrollment limited
to 100.
Tuition: $140.00, payable in advance on or before January
21.
For Information; Dr. Vince Moseley. Director. Division of
Continuing Education. .Medical University of South Caro-
lina. 80 Barre Street. Charleston. S. C. 29401
February 7-8
27th .Annual Stoneburner Lecture Series: Clinical .Advances
in Medical and Surgical Neurology
Place: Baruch Auditorium (Egyptian Building)
46
Sponsors: Department of Continuing Education and tht
Division of Neurosurgery
Credit: 13',2 hours .AAFP applied for; AMA accreditation
Fee: $95.00
For Information: David B. Walthall. III. M.D.. Director
Department of Continuing Education. Medical College o:
Virginia. Bo.x 91. MCV Station, Richmond, Virgini.
23298
February 21-23
.Annual Meeting of the Virginia Chapter of the .Americar
Academy of Pediatrics
Place: Colonial Williamsburg
Program: Friday night banquet guest speaker — Dr. James B
Gillespie. President. .American .Academy of Pediatrics
Friday and Saturday scientific sessions include: Nev
Trends in .Management of Respiratory Distress; Supportivi
Therapy for the Child with Inborn Error of Metabo
lism: Non-Bacterial Respiratory Tract Infections; Suddei
Infant Death Syndrome: Viral Vaccines; Adaptation ii
School of the Child with Borderline Cerebral Handi
caps.
For Information: James H. Stallings. Jr., M.D.. 6503 Nortl
29th Street. .Arlington. Virginia 22213.
March 7-9
Sports Medicine Problems in .All Age Groups
Place: Page .Auditorium. Duke University. Durham. N. C.
Sponsor: .American .Academv of Orthopaedic Surgeons
Fee: $150.00; residents $50. (')0
For Information: The .American .Academy of Orthopaedii
Surgeons. 430 North Michigan .Avenue. Chicago, Illinoi
60611 I
March 10-14 !
Postgraduate Course in Gastrointestinal Radiology
Place: Williamsburg Conference Center. Williamsburg. Vir
ginia
Sponsors: Department of Radiology and the Department o
Continuing Medical Education
Fee: $175.00; $75.00 for residents
For Information: Department of Continuing Education
Medical College of Virginia, Box 91. MCV Station. Rich
mond. Virginia 23298
April 16
Fourth Annual Charles W. Thomas Lecture
Place: George Ben Johnston .Auditorium
Sponsor: Division of Connective Tissue Diseases
For Information: Department of Continuing Education
Medical College of Virginia. Box 91. MCV Station, Rich
mond, Virginia 23298
April 20-24
"Selection of Materials for Reconstructive Surgery," th
Sixth International Biomaterials Symposium
Designed to bring together clinicians in orthopedics, era
surgery, plastic and reconstructive surgery with leadin,
researchers in biomaterials, biomechanics, biophysics am
experimental surgery
Place: Clemson University. Clemson. South Carolina
For Information: Dr. Samuel F. Hulbert. Dean of Engl
neering. Tulane University, New Orleans, Louisiana 7011
May 6-9
The Treatment of Coronary Syndromes
Place: Atlanta. Georgia ,
For Information: Miss Mary Anne Mclnerny. Directoi
Department of Continuing Education Programs. Americal
Colleee of Cardiology. 9650 Rockville Pike. Bethesdi]
Maryland 20014
Items submitted for listinc should he sent to: WHAT'
WHEN? WHERE':'. P. O. Box 8248. Durham. N. C. 2770,
by the 10th of the month prior to the month in whic
they are to appear.
Vol. 35. No. i
i.jws Notes from the —
UNIVERSITY OF NORTH CAROLINA
DIVISION OF HEALTH AFFAIRS
'inis Newton, assistant director for Continuing
cation in Health Sciences, has been elected to the
3ring committee of the Continuing Education for
Professions Section of the AduU Education As-
siation of the U.S.A.
^he major concern of the section this year is the
ijications of mandatory continuing education for
•orofessions.
* * *
r. J. Wilbert Edgerton has been elected to head
inational professional organizations. He is presi-
of Division 27, American Psychological As-
ition, and chairman of the Mental Health Sec-
American Public Health Association.
iivision 27 is composed of community psycholo-
nhroughout the world.
Igerton is professor in the departments of psy-
ry and psychology.
' * * *
-. R. W. Penick, a 1968 graduate of the UNC
ol of Public Health, received the Sidney S. Chip-
a. Award Nov. 16 at ceremonies in Carrington
a;on the Chapel Hill campus. Dr. Penick, director
ijblic health at the Greenville-Pickens District
;h Department in South Carolina, was cited for
J"ork in developing one of the most outstanding
|,riunity health programs in the country.
'We. Chipman Award was established in 1970 to
J nize the contributions of Dr. Sidney S. Chip-
t founder of the UNC Department of Maternal
rhild Health in 1950 and chairman until 1967.
•ecipient of the award must be a graduate of the
|am who has made outstanding contributions in
j^ld of maternal and child health.
* * :;:
[1 t. C. Arden Miller of the UNC School of Public
h has been elected president-elect of the 50,-
aember American Public Health Association
lA).
I Miller was elected by the governing council
Jeilj: Association's annual meeting in San Fran-
llltl !
professor of Maternal and Child Health, Dr.
is former vice chancellor for health sciences at
He is also a pediatrician and former dean and
f' 3t of the University of Kansas Medical Center.
C Miller is the second national president to
: ; from the UNC School of Public Health in the
^lll i*yo years. Dr. Margaret Dolan, former profes-
:' fd chairman of the department of public health
'■ ' g, was president in 1972-73.
S DV 1974, NCMJ
Dr. Kenneth M. Brinkhous stepped down as chair-
man of the UNC School of Medicine's Department
of Pathology in October. He had held the position
since 1946. He became an Alumni Distinguished
Professor of Pathology in 1961.
Dr. Brinkhous was cited for his outstanding con-
tributions to biomedical research, his service to medi-
cine, his training of medical students and his leader-
ship in developing national and international re-
search programs.
Barbara B. Germino was promoted to associate
professor in the School of Nursing. Charles Harper
was promoted to associate professor in the School of
Public Health.
* * :K
Dr. Ralph H. Boatman, administrative dean of
the UNC Office of Allied Health Sciences, has been
elected secretary of the American Society of Allied
Health Professions ( ASAHP).
Boatman is immediate past chairman of the
ASAHP's Council on Baccalaureate and Higher De-
grees. The Society changed its name and reorganized
its councils at its November meeting. Previously it
was the Association of Schools of Allied Health Pro-
fessions.
News Notes from the —
DUKE UNIVERSITY MEDICAL CENTER
Duke and Cabarrus Memorial Hospital in Con-
cord are engaged in a joint new program aimed at
improving and expanding health care for the people
served by the hospital and providing continuing edu-
cation for doctors on the hospital staff.
The one-year affiliation may lead to a broader
long-term arrangement. This could include the chan-
neling of Duke interns, residents and fourth-year
medical students, particularly those interested in
family practice, through a period of training under
senior physicians at Cabarrus.
About 15 doctors from Duke's departments of
medicine, surgery, pediatrics and obstetrics-gyne-
cology have been commuting to Concord weekly for
one- or two-day visits.
While the primary focus during the initial year is
to provide continuing education for the Cabarrus
staff, Duke hopes the affiliation will provide the basis
for future training of young doctors and senior medi-
cal students in a community hospital setting and per-
haps lead to affiliations between Duke and other hos-
pitals in the state.
* * :|:
Dr. Daniel C. Tosteson, chairman of physiology
and pharmacology, is the new chairman of the As-
sociation of American Medical Colleges (AAMC).
47
r
Tostcson is the first representative of the AAMC's
Council of Academic Societies to be chosen chair-
man, the organization's highest elective office. He
said he believes the development shows that the
AAMC is mo\ing to represent more effectively all
segments of academic medicine, including the pro-
fessional educators who comprise faculties of schools
of medicine.
A Harvard graduate (M.D. "49), Tosteson has
been department chairman at Duke since 1961. In
1971 he was named James B. Duke Professor of
Physiology.
^ * -r=
Dr. Joseph C. Farmer, Jr., assistant professor of
surgery, and Dr. David F. Paulson, assistant profes-
sor of urologic surgery and director of urologic re-
search, were inducted as new Fellows of the Ameri-
can College of Surgeons at the 59th Annual Clinical
Congress in Chicago.
A researcher at Duke has been awarded a March
of Dimes grant to study some of the genetic and bio-
chemical aspects of connective tissue diseases.
The one-year, $16,500 grant has been given to Dr.
Byron D. McLees. assistant professor of medicine,
under a program designed to enable young scientists
to start their own research projects on birth defects.
* ^ *
At a special ceremony. Duke's Orthopaedic Out-
patient Clinic was renamed for Dr. Lenox D. Baker,
retired Duke surgeon who served as North Carolina's
first Secretary of Human Resources.
Baker, who was Duke's first medical student and
the first doctor to graduate after completing a full
four-year course, was chief of orthopaedic surgery
from 1937-67 and was instrumental in establishing
and operating the N. C. Cerebral Palsy Hospital
which also has been renamed for him.
* :^ ;|;
In another special ceremony. Dr. Ewald D. Basse,
chairman of psychiatry at Duke for 20 years, was
honored with a dinner and scientific program, which
included presentation of a portrait of Busse to the
medical center.
Dr. Hiroshi Nagaya, assistant professor of medi-
cine, and Dr. C. E. Buckley III, associate professor
of medicine, assistant professor of microbiology and
immunology, and director of the Allergy-Immu-
nology Laboratory, attended the International Con-
gress of Rheumatology in Kyoto, Japan, and the
fnternatienal Congress of Allergology in Tokyo.
:■: * :=:
About 100 doctors from throughout the state at-
tended the joint annual meeting of the N. C. Society
of Internal Medicine and the regional chapter of the
American College of Physicians at Duke in Decem-
ber.
The subject for a day-long scientific program was
Rondomycii
(methacycline HCI)
CONTRAINDICATIONS: Hypersensttivity to any of Ihe tetracyclines
WARNINGS: Tetracyctme usage during tootti development (last halt of pregnancy tc
years) may cause permanent tooth discoloration (yellow-gray-brown). which is
common during long-term use but has occurred after reoealed short-term cc
Enamel hypoplasia has also been reported Tetracyclines should not be used in Iti
group unless other drugs are not likely to be effective or are contraindi
Usage in pregnancy. (See above WARNINGS about use during tooth develop'
Animal studies indicate tfiat tetracyclines cross the placenta and can be toxic to t
velopmg ietus (often related to retardation of skeletal development). Embryotoxici
also been noted m animals treated early m pregnancy
Usage in newborns, infants, and children. (See above WARNINGS about use i
tooth development )
All tetracyclines form a stable calcium complex in any bone-formmg tissue A dei
m fibula growth rate observed m prematures given oral tetracycline 25 mg/kg e
hours was reversible when drug was discontinued
Tetracyclines are present in milk of lactatmg women takmg tetracyclines
To avoid excess systemic accumulation and liver toxicity m patients with impaire:
function, reduce usual total dosage and, it therapy is prolonged, consider serum le
terminations of drug The anti-anabolic action of tetracyclines may increase BUN
not a problem m normal renal function, in patients with significantly impaired fur
higher tetracycline serum levels may lead to azotemia, hyperphosphatemia, and ac:
Photosensitivity manifested by exaggerated sunburn reaction has occurred with
cyclmes Patients apt to be exposed to direct sunlight or ultraviolet light should he
vised, and treatment should be discontinued at first evidence of skm erythema
PRECAUTIONS: If superinfection occurs due to overgrowth of nonsusceptible orgar
including fungi, discontinue antibiotic and start appropriate therapy
In venereal disease, when coexistent syphilis is suspected, perlorm darkfteld i
nation before therapy, and serologically test lor syphilis monthly tor at least four mc
Tetracyclines have been shown to depress plasma prothrombin activity, patients .
ticoagulant therapy may require downward adjustment of their anticoagulant dosagi
In long-term therapy, perform periodic organ system evaluations (including i
renal, hepatic)
Treat all Group A beta-hemolytic streptococcal infections for at least 10 days
Since bacteriostatic drugs may mterlere with the bactericidal action of penicillin,
giving tetracycline with penicillin
ADVERSE REACTIONS: Gastrointestinal (oral and parenteral forms) anorexia, n;
vomiting, diarrhea, glossitis, dysphagia, enterocolitis, inflammatory lesions (with i
lal overgrowth) m the anogemtal region
Skin: maculopapular and erythematous rashes, exfoliative dermatitis (uncommom.
tcspnsitivity IS discussed above (See WARNINGS)
Renal toxicity, rise m BUN, apparently dose related (See WARNINGS)
Hypersensitivity: urticaria, angioneurotic edema, anaphylaxis, anaphylactoid pui
pericarditis, exacerbation of systemic lupus erythematosus
Bulging fontanels, reported m young infants after full therapeutic dosage, have'
peared rapidly when drug was discontinued.
Blood: hemolytic anemia, thrombocytopenia, neutropenia, eosmophiha
Over prolonged periods, tetracyclines have been reported to produce brown-bin
croscopic discoloration ol thyroid glands, no abnormalities of thyroid function studi
known to occur
USUAL DOSAGE: Adults-600 mg daily, divided into two or four equally spaced (
f^ore severe infections an initial dose ot 300 mg followed by 150 mg every six ho
300 mg every 12 hours Gonorrhea In uncomplicated gonorrhea, when penicillir i
traindicated, Rondomycm' (methacycline HCI) may be used for treating both malf
females m the following clinical dosage schedule 900 mg inilially, lollowed by 3(
q I d for a total of 5 4 grams
For treatment of syphilis, when penicillin is contraindicated. a total of 18 to 24 gi
■Rondomycm (methacycline HCi) m equally divided doses over a period of 10-lJi
should be given Close follow-up, including laboratory tests, is recommended. \\
Eaton Agent pneumonia 900 mg daily for six days |j
Children -3 to 6 mg/lb/day divided into two to four equally spaced doses
Therapy should be continued for at least 24-48 hours after symptoms and fevej
subsided
Concomitant therapy: Antacids containing aluminum, calcium or magnesium irra;
sorption and are contramdicated Food and some dairy products also interfere Gi^i
one hour before or two hours after meals Pediatric oral dosage forms should i
given with milk formulas and should be given at least one hour prior to feeding
In patients with renal impairment (see WARNINGS), total dosage should be dea
by reducing recommended individual doses or by extending time intervals Dt
doses
In streptococcal infections, a therapeutic dose should be given lor at least 10 daif
SUPPLIED: ■Rondomycm' (methacycline HOD 150 mg and 300 mg capsules, synj
taming 75 mg/5 cc methacycline Hl^l
Before prescribing, consult package circular or latest FOR information.
ifWi WALLACE PHARIVIACEUTICALS
' - ' CRANBURY, NEWJERSEY08512
Pet
©.
4S
Vol. 35, N.
I
i«1 t
(
1
II
1
ill
fl ■(
es
When the focus is on bronchitis due to
susceptible strains of H. influenzae and pneumococci^
RondomyGin 300.e
[metihacycline HCI] ^^^^^'^^
Delivers from the very first dose:
show that after the first dose serum levels rapidly rise above
minimum in vitro inhibitory concentrations
*Since many strains are known to be resistant, routine sensitivity testing is recommended.
medicine, has been elected president-elect of the For-
syth County Medical Society. Dr. James F. Toole,
professor and chairman of the Department of Neu-
rology, has been elected vice chairman of the society.
Dr. C. Douglas Maynard, professor of radiology,
has been elected a delegate to the North Carolina
Medical Society. The Forsyth County Medical So-
ciety's current president is Dr. M. Frank Sohmer, Jr.,
clinical instructor in medicine at the Bowman Gray
School of Medicine.
^ * ,-!:
Dr. David R. Mace, professor of family sociology,
spoke on various aspects of marriage and family
during a month of speaking engagements throughout
the United States. His topics included, "The De-
velopment of Interpersonal Potential in Married
Couples," "A New Preventative Approach to Marital
Disharmony," "Our Professional Responsibility for
the Prevention of Marriage and Family Breakdown,"
"Marriage — Its Present Status and Future Pros-
pects," "Marriage Enrichment — Its Procedures and
Potentials," "Help Families to Help Themselves and
Each Other" and "A Prevention to Malfunctioning
Families Through Marriage Enrichment."
* * *
Dr. George Podgorny, clinical instructor in sur-
gery, was a panel member on emergency care at the
Ontario Medical Society meeting on emergency medi-
cal care Oct. 5 in Toronto, and represented the
North Carolina chapter of the American College oj
Emergency Physicians at the annual college assemblj
in Dallas.
Dr. James F. Toole, professor and chairman d
the Department of Neurology, spoke on "Evolutioii
of Concepts of Ethical Standards" on Nov. 5 to the
Council on Academic Societies of the American As-
sociation of Medical Colleges in Washington, D. C
NEW FDA PROPOSAL ON X-RAY
EQUIPMENT
The Food and Drug Administration proposed ac-
tion on Dec. 3, 1973 ( 1 ) to require that equipmeni
manufactured after the August 1, 1974, effective date
of the diagnostic x-ray standard shall contain onh
parts certified for compliance and (2) to promote the
upgrading of existing equipment to meet the stan-
dard's performance requirements for patient protec-
tion.
The proposals were published in the Federa
Register December 3, as an addition to polic;
provisions of Radiation Control for Health and
Safety Act regulations. The addition would replace
policies proposed last February 28. These would have
included the requirement that used x-ray equipmen.
refurbished, rebuilt, or reassembled and sold afte:
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.
Accredited by the Joint Commission on Accreditation and
Certified for Medicare
James Asa Shield, M.D.
James Asa Shield, Jr., M.D.
Catherine T. Ray, M.D.
Weir M. Tucker, M.D.
George S. Fultz, Jr., M.D.
Graenum R. Schiff, M.D.
52
Vol. 35, Ni
gust 1, 1974, would have to comply with the stan-
c 'd for new equipment.
^DA's proposed new policy declaration would pre-
V it the assembly and installation of new systems
h 'ing a combination of components that meet the
s ndard and those that do not. The regulations, as
p' sently written, could be interpreted as permitting
o'tified and uncertified components to be combined
d ing the assembly of a new system. Such a mix-
ti ; might not have the public health advantages
0 an x-ray system composed entirely of certified
c riponents.
The upgrading of existing equipment would be
a ieved under two other provisions of the new
p icy proposal. One would require that an x-ray
s;'cm made before August 1, 1974, but repaired or
rrJificd by installation of a certified component,
v\ lid thereafter have to use only certified replace-
nit components. The other provision would pro-
b.- 1 the assembly of uncertified components into
ems moved, reassembled, and sold after August 1,
1979 — five years after the standard became effec-
tive. Components not made under the standard would
have to be replaced in such reassembled systems.
The five-year grace period for application of the
standard to used diagnostic x-ray equipment would
allow time for adequate inventories of certified com-
ponents to be produced. The period, furthermore, is
compatible with medical profession estimates of the
usual time it would take certified equipment to move
from hospital radiology departments and other high
workload facilities into used x-ray machine markets.
During the five years allowed for relocating and
selling equipment with uncertified components, FDA,
in order to protect the public health, could take ac-
tion against any equipment found to be defective.
The February 28 proposal was opposed by State
and local radiation protection agencies as well as
physician organizations and individual doctors. Many
of the agencies reported that components complying
with the standard could not be used with some of
the x-ray systems subject to their registration.
Month in
Washington
ivio more major national health insurance pro-
3( lis have been thrown into the Congressional
i( per, bringing the total to eight with at least two
Ti e waiting in the wings, including that of the Ad-
Ti istration.
hairman Harley O. Staggers (D-W. Va.) of the
tI se Commerce Committee has introduced his own
IE 3nal health insurance proposal (NHI), saying
le ings will be held on his bill in the coming
,'e .
he second new NHI proposal came from Senate
^( ublican leader Hugh Scott (R-Pa.) and Charles
'e y (R-Ill.).
aggers' National Comprehensive Health Benefits
\( of 1973 would provide comprehensive health
:a benefits and complete protection against the
0 ; of catastrophic illness to all. It would be fi-
la ed by a combination of contributions from em-
)1< ers, the federal government and individuals,
ci d to income. The federal funds are for health
ns -ance and catastrophic illness benefits for the
)0 and near-poor.
le introduction came shortly before hearings on
^I by the Commerce Subcommittee on Public
ii th and Environment.
is the first major NHI proposal to be referred
'^
,RY 1974, NCMJ
to the Interstate and Foreign Commerce Committee
rather than the Committee on Ways and Means, Stag-
gers noted, adding that it is the first NHI proposal
by a chairman of a major committee in the House.
Major features of the proposal, as described by
Staggers:
— a strong role for state governments in the de-
velopment and administration of the program;
— incentives for the creation and use of Health
Maintenance Organizations;
— a six-year transitional period for orderly de-
velopment;
— the use of existing private health insurance car-
riers for administration of the insurance pro-
visions;
— and the fact that the program builds on, rather
than federalizing, the existing health care sys-
tem.
The bill provides that newly created State Health
Commissions (SHC's) would be responsible for the
actual administration of much of the program, in-
cluding standard setting and quality control, assisting
in the development of Health Maintenance Organiza-
tions (HMO's), and administration of some of the in-
surance provisions. Existing private health insurance
carriers would be used to underwrite most of the
53
legislation's insurance benefits. The development and
use of HMO's would be encouraged through addi-
tional direct developmental assistance and through a
ten percent federal subsidy of HMO premiums.
Within two years of enactment all aged, low in-
come and unemployed individuals and families,
would be provided coverage for basic health services.
Within four years of enactment, all individuals and
families would be provided coverage for basic health
services and the costs of catastrophic illness. Within
seven years of enactment, all individuals and families
would be provided coverage for comprehensive
health care benefits and the costs of catastrophic ill-
ness.
Senator Scott said his two-part "Health Rights
Act" would provide for in-patient protection for all
persons suffering major illness, and would set up an
out-patient health maintenance insurance plan. It
would replace both the medicare and medicaid pro-
grams now in effect. Scott added that he believed
his bill was "must legislation" for this session of Con-
gress "because its goal is to serve every American at
a critical time."
Under the Scott-Percy Health Rights Act, both the
in-patient and out-patient plans would be admin-
istered by insurance carriers or other public or private
agencies on a regional basis, under contract with the
newly created Office of Health Care within the De-
partment of Health, Education and Welfare.
The in-patient, "major illness" protection differs
from traditional catastrophic plans by covering all
costs above each family's health cost ceiling, which
is determined by a formula taking into account both
family income and family size. Money for the plan
would be financed in part through the present health
insurance portion of Social Security payroll taxes
and in part through general revenues.
The out-patient plan would be financed in part
through family premium payments which would be
supplemented in whole or part with federal payments
for low-income families. Employers could arrange
to finance all or part of their employees' premiums.
The Act would also establish a two-year, Presiden-
tially appointed "Health Delivery Committee" to
study the current and long-range needs for medical
personnel and facilities. It would make recommenda-
tions to the President and Congress.
* * sH
The American Medical Association has asked the
Congress to reject proposed legislation that would
restrict the Food and Drug Administration's authori-
ty over food supplements.
In testimony before the House Commerce Sub-
committee en Health and Environment, C. E. Butter-
worth, Jr., MD, Chairman of the AMA's Council on
Foods and Nutrition, said the FDA's actions "are
based upon sound scientific evidence and are clearly
in the public interest."
Under new FDA regulations, U. S. government
recommended daily allowances (RDA's) have be.
established that permit the inclusion of 19 essenti
vitamins and/or minerals in products to be marketi
as dietary supplements. The RDA's are based (
those formed by the National Academy of Scienc
and reflect the most current scientific judgments i
the subject," said Dr. Butterworth.
Ingredients with no recognized nutritional vali
would be excluded from dietary supplements.
"There is no scientifically acceptable evidence
support the use of bioflavonoids, rutin, inositol ai
other similar ingredients," said the witness. "It is o
opinion also that the quantities of vitamins includi
in mixtures for dietary supplementation should fu
nish daily an amount which approximately fulfi
but does not greatly exceed the recommended c
etary allowances," Dr. Butterworth testified. Incl
sion of excessive amounts of fat-soluble vitamins
and D can be harmful, and "is scientifically unwa
ranted and potentially dangerous," he said.
Dr. Butterworth said: "It clearly would not be
the public interest to enact legislation virtually elin
nating the authority of the Secretary (HEW)
control the kinds and amounts of ingredients in t)
dietary supplements and other foods for dietary us
The current regulations promote safety, and provii
full information to consumers about such produci
and this information will enable them to make d
cisions based on scientifically acquired data."
* * *
Legislation liberalizing tax treatment of retireme
savings by the self-employed seems to be movii
closer to congressional enactment in the next Sessio
The House Ways and Means Committee has te
tatively approved the Senate provision allowing se
employed people such as lawyers, dentists and ph
sicians to claim tax deductions on 57,500 a year,
15 percent of income, for sums placed in quahfii
pension plans. This compares with the previo
Keogh hmit of $2,500 or 10 percent of income.
The threat of a strict limitation on pension t
deferments in corporations, including profession
ser\ice corporations, appears to have diminishe
The Ways and Means Committee in general a,
cepted the principle in the Senate bill of a $75,01
annual limit on retirement benefit plans (so-call
defined benefit plans) and on others (defined co
tribution plans which included profit-sharing, mon
purchase, etc. ) of a retirement benefit not to exce,
100 percent of the high three years of avera,
compensation. Jj
Ways and Means must still take a final vote a.'
also work out with the House Education and Lat
committee an agreement on the form the over
legislation — a sweeping pension reform measure
will take when presented on the House floor. I
feated in Ways and Means was a move by lab i
an arch enemy of the Keogh provision, to reduce i
tax deferral to a maximum of $5,000 per year|
54
Vol. 35, No
President Nixon is correct in his statement that
Tie temperatures in the mid-60s are, in some ways,
filthier than temperatures in the mid-70s, accord-
L to William Barclay, MD, Assistant Executive
\ e President for Scientific Affairs, American Medi-
c Association.
'Heating the interior of homes and offices during
(3^ winter removes moisture from the air. The higher
tl temperature, the dryer the air. Air with little
q isture aggravates bronchial and other respiratory
p'iblems. It can contribute to dry throat and nose,
c ighs and dry skin.
"'The respiratory system doesn't cope well with the
S; den changes in temperature. Moving from an
3 rly warm room into outside cold affects the body
1 ersely, causing coughs and respiratory problems.
Y: body adjusts to temperature changes gradually.
V' feel the cold more acutely on the first cold day
ii'the fall than in January. We do not adapt well
;< ibrupt temperature changes.
'There are no major health advantages inherent
ceeping inside temperatures somewhat lower, but
re arc minor advantages that add to comfort and
1 being during the winter."
f * * *
"resident Nixon has signed into law a three-year,
15 million bill to help set up emergency medical
:s around the nation.
"he bill authorizes grants and contracts for feasi-
".y studies, planning, establishment, operation and
■"ansion of emergency medical systems (EMS) as
'I as research and training. Rep. Tim Lee Carter,,
'>, (R-Ky.) said in House debate it would assist
fmunities throughout the nation to develop and
Wove their emergency medical services systems
' "contribute directly to saving tens of thousands
;ves each year."
''resident Nixon had criticized the bill in a veto
!ier this year, contending that existing federal and
e programs are adequate to handle the problem.
' veto led to a major confrontation with Con-
.s last September in which the Administration
\ when the House failed by a narrow margin to
iter the required two-thirds vote.
rhe bill increases from 50 percent to 75 percent
F federal share of grants for emergency programs
u' earmarks 20 percent of grants for rural areas.
- he Administration's prime objection to the earlier
ri'was an amendment ordering that all public health
e ice hospitals be kept open. The EMS law does
u contain this provision. However the PHS hospi-
a were kept alive by a rider to a military appropria-
ii'S bill that was subsequently signed into law.
he White House has said that it plans to desig-
i; enough radio frequencies for emergency medical
c ice to serve the entire country.
Clay T. Whitehead, director of the White House's
Office of Telecommunications Policy, says this will
be a vital first step in giving American communities
the kind of integrated emergency medical services
they need to save thousands of lives a year among
persons stricken by heart attacks and strokes or in-
jured in accidents. Many such persons now die be-
cause they do not get adequate emergency care be-
fore they reach a hospital.
Estimates of the number of lives that could be
saved each year if all regions of the country had
adequate emergency care systems range from 60,-
000 to more than 100,000.
Mr. Whitehead noted that a few cities already
had efficient systems including two-way communica-
tion between ambulance and hospital and radio
equipment for sending vital data on the patient's con-
dition from the scene of the emergency to doctors
at a hospital. For most American communities, he
said, such arrangements are still nothing more than
science fiction.
Dr. Charles C. Edwards, Assistant Secretary for
Health in the Department of Health, Education and
Welfare, said the department was putting a high
priority on efforts to develop an efficient emergency
medical system throughout the United States. How
much of the effort should be Federal and how much
locally initiated is under study, he said.
The Administration plan calls for allocating 38
radio frequencies for emergency medical use through-
out the United States. Mr. Whitehead said 22 were al-
ready available, but on a much less standardized
basis. Some of the others are now used by the De-
partment of Defense and other Federal agencies.
Still others are used for highway callboxes, ski patrols
and the like. A few are not allocated.
* * *
The American Medical Association has awarded a
plaque to David Kindig, MD, in recognition of his
"outstanding and dedicated service in implementing
the goals and objectives of the National Health Ser-
vice Corps (NHSC)."
Dr. Kindig played a key part in launching the
NHSC program of sending PHS physicians into phy-
sician-shortage areas where help is requested by the
local and state medical societies. In receiving the
award, the youthful physician said the cooperation
of the AMA and of the nation's local and state
medical societies has "been unique and made the pro-
gram a success."
Presenting the award, at a Washington, D. C,
lunch Richard Palmer, MD, vice chairman of the
AMA Board of Trustees, said the AMA has been
firmly behind the NHSC program. He pointed to the
AMA's "project USA" program in which the AMA
provides physicians to spell PHS physicians who
are on vacation or ill.
A ARY 1974, NCMJ
55
Book Reviews
Standard First Aid and Personal Safet)'. The American
National Red Cross, First Edition. 268 pages. Price
SI. 95, Garden City, New 'lork: Doubleday & Co., Inc.,
1973.
Advanced First Aid & Emergency Care. The American
National Red Cross. First Edition, 318 pages. Price
S:.5U, Garden City, New York: Doubleday & Co., Inc.,
1973.
Dr. Warren Cole was chairman of the Ad Hoc
Committee of the Division of Medical Sciences, Na-
tional Academy of Sciences, which gave authorita-
tive advice and guidance for 1973 editions of these
American National Red Cross textbooks for use in
their popular First Aid instruction program.
The books are up to date in content, concisely
written and presented, appropriately illustrated with
colored drawings, and thoroughly practical in ap-
proach.
The standard \'olume is written in outline style,
which may make learning easier for the beginning
first aid student, and puts emphasis on prevention of
accidents.
The advanced volume was prepared for policemen,
firemen, ambulance attendants, and others whose
jobs make them responsible for giving emergency
care. It includes more instructions on use of equip-
ment readily available to them, such as half-ring
spHnts and stretchers, techniques of methods of ex-
tricating victims from automobiles and closed spaces,
and a chapter on emergency childbirth.
Otherwise the general contents, instructions, and
illustrations are the same, covering wounds, shock,
respiratory emergencies and resuscitation, poison-
ings, drugs, fractures, splints, dressings, and transpor-
tation.
Perhaps the conduct of an advanced course dif-
fers enough from that of the standard course to justify
the printing of separate texts with almost identical
contents. In my opinion the advanced volume is not
too advanced for a beginning first-aider, and I would
recommend this one for all. Each volume, however.
is complete in itself, and can serve admirably as
home text and reference on this important subjei
for anyone, whether he takes a formal course c
not.
Louis Shaffner, M.[
Review of Medical Physiology. 6th Edition. 577 pages.
W. F. Ganong, M. D., Los Altos, California: Lange
Medical Publications, 1973.
Every two years Ganong's Review of Media
Pliysiology is revised, partially reset, re-covered aa
released for use by freshmen medical students as
short text and practicing physicians as an outline n
view of physiological processes. The current 6th ed
tion has been changed very little from the 5th ed
tion. which was altered only slightly from the 4th ed
tion, etc. Although certain sections have been uf
dated such as the discussions on cyclic AMP an
Calcitonin, the text and illustrations remain largd
as they were in previous editions. I
In the past, this book has been used primarily a
an introductory text for the first-year course in medi
cal physiology. As such it does not present an
subject in detail (e.g. the two short paragraphs o
the prostaglandins ) and has omitted all controvers)
By not representing all views of current debate, th
text tends to appear somewhat dogmatic.
Future use of this book as a medical student tej
may be limited by its classical physiology orientatio:
and its assumption of a prior working knowledg
of anatomy and biochemistry. With the present cor
curricula emphasizing the time integration of all basi
science material, the utility of this type of text i
diminished in these arenas. It is. however, recoa
mended to practicing physicians and others whc
having studied physiology under the old block sys
tem. desire a superificial review outline of medica
physiology.
Philip M. Hutchins. Ph.D
56
Vol. 35. No.
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In iEpttwriam
Glenn Raymer Frye, M.D.
Glenn Raymer Frye was born on a farm in Ire-
dell County, N. C. on April 29, 1894, to Eli David-
son Frye and Mary Jane Raymer Frye. He was die
youngest of twelve children of whom a brother, Hal
Frye," and a sister, Mrs. J. Watt Summers, are still
living.
He attended the local schools and entered Lenoir
Rhyne College in 1913, graduating in 1917, with an
A.B. Degree. While a student there, he was a winner
of the Junior Oratorical Debate Medal, President of
the student body and of the senior class, business
manager of the college annual and played varsity
baseball for three years.
In 1917, he entered The University of North Caro-
lina Medical School, then a two year school, and
while there enlisted in the Students Army Training
Corps. He later entered Jefferson Medical College of
Philadelphia, graduating in 1921 with an M.D. De-
gree. In 1921-22, he interned at the Presbyterian
Hospital in Philadelphia, and on August 1, 1922, be-
gan the practice of medicine in Hickory, North
Carolina.
On November 22, 1922, he married Barbara Kath-
ryn Aderholdt. They have three wonderful daughters,
Mary Kathryn (Mrs. Samuel Hemphill), Mrs. Mar-
tha Terry, and Ruth (Mrs. Hugo Dcaton), also
eleven grandchildren.
Initially, in Hickory, Dr. Frye was associated with
Dr. Jake Shuford, s'r., who founded the Richard
Baker Hospital, a private hospital of 14 beds. In
1929, Dr. Frye became chief surgeon and five years
later purchased the hospital. Since that time there
have been numerous additions until a capacity of 1 19
beds was reached in 1968. During these years the
two names, Richard Baker Hospital and Dr.
Glenn R. Frye became synonymous. No truer word
was ever written, "An institution is but the length-
ened shadow of one man."
In 1931, Dr. Frye was admitted as a Fellow of
the American College of Surgeons, later a Fellow of
the Southeastern Surgical Congress and a Diplomat
of the American Board of Surgery. In 1948, Lenoir
Rhyne College conferred on him the Degree of Hor
orary Doctor of Laws. He served on the Board c
Trustees and in 1955, was general chairman of th
Building Campaign. He and Mrs. Frye have estat
lished a professorship in chemistry and he was hor
orary chairman of the Fund Raising Campaign.
Next to his family and his hospital, Dr. Frye love
his church. He was a member of the Holy Trinit
Lutheran Church and vice-chairman of the churc
council. In October 1948, he was elected to tb
Board of World Missions of the United Luthera
Church in America and served in this capacity fc
twenty years. He was also a delegate to two nation;
conventions of his church.
Regarding his community activities, Dr. Frye W!
a past president of the Hickory Rotary Club, Tb
Catawba County Medical Society, The Catawba Va
ley Executives Club and the Hickory Communil
Concert Association. In 1951, he was co-chairman (
The Hickory Community Chest and a past directc
of Board of Health of Catawba, Lincoln and Ale;
ander counties. The Medical Foundation of the Un
versity of N. C, The Medical Advisory Committe
of the Catawba County Chapter of the American Re
Cross and for many years he was a director of Sips
Orchard Home.
From October 15, 1940, to March 31, 1947,1
served his country by being the Chief Medical B
aminer — Selective Service, Hickor>' Township.
Dr. Frye was dean of the Hickory physicians an
on October 8th of last year ( 1972) a special obse
vance was held at Lenoir Rhyne College honorir
him for his more than 50 years of service to tl
community. The Frye Scholarship Fund at Leno
Rhyne College, endowed by the Hickory Rotai
Club and the Kiwanis Club was established at thi
time.
Since then it was business as usual for Dr. Fn
up until shortly before September 1 when, after
brief illness, he died September 9, 1973, in tl
hospital where he had been associated for more thi
half a century.
Catawba County Medical Society
58
Vol. 35. No.
(I's WANTED— One or two to follow a retired GP who
tracticed here for sixty years. His records available. Small
own, good public and private schools. Financial assistance
'ivailable. Call or write D. G. King, Box 147, Red Springs,
i<i. C. 28377. Telephone 919-843-4431.
COASTAL COMMUNITY experiencing resort and indus-
trial growth needs family practitioner, internist, obstetri-
cian, and pediatrician. Contact Gene Wallin, M.D., South-
port, N. C. 28461 (919) 457-6214.
SAINT ALBANS
PSYCHIATRIC HOSPITAL
Radford, Virginia
STAFF:
William D. Keck, M.D.
Morgan E. Scott, M.D.
David S. Sprague, M.D.
Delano W. Bolter, M.D.
Edward E. Cole, M.D.
Terkild Vinding, M.D.
James P. King, M.D. (Emeritus)
Clinical Psychology:
Thomos C. Camp, Ph.D.
Carl McGraw, Ph.D.
Don Phillips, Administrator
George K. White
Asst. Administrator
/ jARY 1974, NCMJ
59
Index to
Advertisers
Burroughs Wellcome 23
Crumpton, J. L. & J. Slade. Inc 8
Fellowship Hall 22
Flint Laboratories 10. II
Golden-Brabham Insurance Agency 12
Lilly. Eli & Company Cover 1, 28
Mandale Center 20
McNeil Laboratories 13
Mutual of Omaha 3
N. C. Blue Cross & Blue Shield, Inc 21
Ortega Pharmaceutical Company, Inc 57
Pharmaceutical Manufacturers Association 26, 27
Poythress, William P. & Company
Reed & Carnrick '
Roche Laboratories Cover 2, 1, 6, 7, 1
15, 16, 24, 25, Cover 3,
Saint Albans Psychiatric Hospital
Sealy of the Carolinas, Inc
Searle. G. D. & Company 42,
Tucker Hospital
Wallace Corporation
Wallace Pharmaceuticals 48,
Willingway, Inc
Winchester Surgical Supply Company
Winchester-Ritch Surgical Company '
WINCHESTER
"CAROLINAS' HOUSE OF SERVICE"
Winchester Surgical Supply Company
200 South Torrence St. Charlotte, N. C. 28201
Phone No. 704-372-2240
Winchester-Ritch Surgical Company
421 West Smith St. Greensboro, N. C. 27401
Phone No. 919-272-5655
Serring the MEDICAL PROFESSIO^ of ^ORTH CAROLINA
and SOITH 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.
60
Vol. 35, No.
Before prescribing, please consult
plete product information, a summary
hich follows:
Indications: Relief of anxiety and
ion occurring alone or accompanying
)us disease states.
Contraindications: Patients with known
irsensitivity to the drug.
Warnings: Caution patients about
ibie combined effects with alcohol and
r CNS depressants. As with all
-acting drugs, caution patients
ist hazardous occupations requiring
Diete mental alertness (e.g., oper-
; machinery, driving) . Though physi-
nd psychological dependence have
y been reported on recommended
s, use caution in administering to
;tion-prone individuals or those who
t increase dosage; withdrawal symp-
, (including convulsions), following
intinuation of the drug and similar
ose seen with barbiturates, have been
'ted. Use of any drug in pregnancy,
tion, or in women of childbearing
equires that its potential benefits
sighed against its possible hazards.
^Precautions: In the elderly and de-
tted, and in children over six, limit to
est effective dosage (initially 10
r less per day) to preclude ataxia or
edation, increasing gradually as
=d and tolerated. Not recommended
Idren under six. Though generally
A .'commended, if combination therapy
t ither psychotropics seems indicated,
u ully consider individual pharmaco-
'g'effects, particularly in use of poten-
S g drugs such as MAO inhibitors
K ihenothiazines. Observe usual precau-
in presence of impaired renal
□atic function. Paradoxical reac-
(e.g., excitement, stimulation and
rage) have been reported in psychi-
patients and hyperactive aggressive
li en. Employ usual precautions in treat-
e of anxiety states with evidence of
If iding depression; suicidal tendencies
a )e present and protective measures
K sary. Variable effects on blood
la ilation have been reported very rarely
f ients receiving the drug and oral
it 'agulants; causal relationship has
it en established clinically.
Adverse Reactions: Drowsiness,
a) and confusion may occur, espe-
cially in the elderly and debilitated.
These are reversible in most instances
by proper dosage adjustment, but are
also occasionally observed at the lower
dosage ranges. In a few instances syn-
cope has been reported. Also encoun-
tered are isolated instances of skin
eruptions, edema, minor menstrual
irregularities, nausea and constipation,
extrapyramidal symptoms, increased
and decreased libido— all infrequent and
generally controlled with dosage reduc-
tion; changes in EEG patterns (low-
voltage fast activity) may appear during
and after treatment; blood dyscrasias
(including agranulocytosis), 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 q.i.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?' (chlordiazepoxide
HCI) Capsules, 5 mg, 10 mg and 25 mg
—bottles of 100 and 500; Tel-E-DoseS'
packages of 1000. Libritabs?' (chlordiaz-
epoxide) Tablets, 5 mg, 10 mg and 25 mg
-bottles of 100 and 500. With respect to
clinical activity, capsules and tablets are
indistinguishable.
ROCHE
Roche Laboratories
Division of Hoffmann-La Rocfle Inc.
Nutley. N J 07110
J
to help reduce clinically significant anxiety and
thereby help improve patient receptivity
Lll^l Iwl I I severe anxiety
(chlordiazepoxide HCI)
Please see following page.
Symptom of excessive anxiety:
The patient may have difficulty in accepting medical counsel.
Clinical experience has shown
that some unduly anxious patients
may tend to deny or minimize their
illness and therefore resist seeking
or following medical advice. Through tient, thereby encouraging physicia
its antianxiety action, adjunctive patient rapport and, on occasion,
Librium (chlordiazepoxide HCI) can making it easier for the patient to
oftencalm the emotionally tense pa- accept medical counsel.
Please see reverse side
for summary of product information.
for relief of excessive anxiety
Librium 10-mg capsules'
(chlordiazepoxide HCI)
HEALTH SCIENCES LIBRARY
Official Journal of the NORTH CAROLINA MEDICAL SOCIETY D
n February, 1974, Vol. 35, No. 2
WORTH CAROLINA
Medical Journal
THIS ISSUE: Medical and Surgical Complications of Therapeutic Termination of Pregnancy, David A. Evans, M.D.,
id John P. Gusdon, M.D.; The Tail is Wagging the Dog, Bernard A. Wansker, M.D.; A Community of Care, Peter James
^e
Announcing . . .
U-100 Iletin® (Insulin, iniy)
(100 units of Insulin per cc.)
This is a concentration suitable for most
Insulin-dependent diabetics.
U-100 Iletin promises significant patient
benefits from standardized, simplified,
and convenient Insulin therapy. It is
available in six formulations.
Note: A U-100 syringe must be
used with U-100 Iletin.
IIP
r I I
ULTRA!
ILETIN
insuun:
suspbw
EXTENDS
U-100
-*\
10 cc,
SEMIlf
ILETIN
INSUWi|
pRQMf
^^
Eli Lilly and Company
Indianapolis, Indiana 46206
Leadership in Diabetes Research
for Half a Century
Additional information
available to the profession on request.
'^"
1974 ANNUAL SESSIONS
May 18-22— Pinehurst
1974 COMMIHEE CONCLAVE
September 25-28— Southern Pines
1975 LEADERSHIP CONFERENCE
Jan. 31-Feb. 1— Pinehurst
U
I
This psychoneuroti
often respond
Before prescribing, please con-
sult complete product information,
a summary of which follows:
Indications: Teiisidti and anx-
iety states; somatic complaints
which are concomitants of emo-
tional factors ; psychoneurotic states
manifested by tension, anxiety, ap-
prehension, fatigue, depressive
symptoms or agitation ; symptomatic
relief of acute agitation, tremor, de-
lirium tremens and hallucinosis due
to acute alcohol withdrawal ; ad-
junctively in skeletal muscle spasm
due to reflex spasm to local pathol-
ogy, spasticity caused by upper
motor neuron disorders, athetosis,
stiff-man syndrome, convulsive dis-
orders (not fur sole therapy).
Contraindicated: Known hyper-
sensitivity to the drug. Children
under 6 months of age. Acute narrow
angle glaucoma ; may be used in pa-
tients with open angle glaucoma
who are receiving appropriate
therapy.
Warnings: Not of value in psy-
chotic patients. Caution against
hazardous occupations 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 anticonvulsant
medication ; abrupt withdraw;
be associated with temporary if
crease in frequency and 'or se^i
of seizures. Advise against sin
taneous ingestion of alcohol ail
other CNS depressants. Withdi
symptoms ( similar to those wii
barbiturates and alcohol) haV'
occurred following abrupt disii
tinuance (convulsions, tremori
dominal and muscle c ramps, vo.i
and sweating). Keep addiction):
individuals under careful suru
lance because of their predis]i!i
to habituation and dependent 1 1
pregnancy, lactation or womcio
childbearing age, weigh poten' 1
benefit against possible hazai-
The Rx that says
^ "Relax"
BUTISOL Sodium provides highly predictable sedative effect:
minor dosage adjustments are usually all that's needed to
produce the desired degree of sedation. (With 3 dosage forms
and 4 strengths to make adjustments easy.)
BUTISOL Sodium offers prompt, smooth, relatively non-
cumulative action: begins to work within 30 minutes. ..yet,
because of its Intermediate rate of metabolism, generally has
neither a "roller-coaster " nor a "hangover" effect.
BUTISOL Sodium is remarkably well tolerated:
a 30-year safety record assures you that there is little likelihood
of unexpected reactions.
BUTISOL Sodium saves your patients money:
costs less than half as much as most commonly prescribed
sedative tranquilizers.'
These are four good reasons for prescribing BUTISOL
Sodium for the many patients who need to have the pace set
just a little slower. Its gentle daytime sedative action is often
all that's needed to help the usually well-adjusted patient
cope with temporary stress.
'Based on surveys of average daily prescription costs
Butisol
(SODIUM BUTABARBITAL)
SODIUM'
IMcNEIL]
jfeNeil Laboratories, Inc., Fort Washington, Pa. 19034
/
© McN 1971
Contraindications: Sensitivity or idiosyncracy to barbiturates; history of
manifest or latent porphyria or marked liver impairment; respirator/ disease
with dyspnea or obstruction; history of addiction to sedative/hypnotic drugs;
uncontrolled pain, to avoid because of possible excitement.
Precautions: Exercise caution in: moderate to severe hepatic disease;
anticoagulant therapy, because of possible increased metabolism of coumarin
anticoagulants; withdraw/al in drug dependence or the taking of excessive
doses over a long period, to avoid vuithdrawal symptoms; elderly or debilitated
patients, to avoid possible marked excitement or depression; use with alcohol
or other CNS depressants, because of combined effects.
Adverse Reactions: Slight hangover, drowsiness, lethargy, headache, skin
eruptions, nausea and vomiting, hypersensitivity reactions (especially in those
with asthma, urticaria, angioneurotic edema, or similar conditions).
Usual Adult Dosage: For daytime sedation, 15 mg. to 30 mg. t.i.d. orq.i.d.
For hypnosis, 50 mg. to 100 mg.
Available as: Tablets, 15 mg,, 30 mg,, 50 mg,, 100 mg,; Elixir, 30 mg. per 5 cc.
(alcohol 7%). BUTICAPS® [Capsules BUTISOL SODIUfVl (sodium
bulabarbital)] 15 mg,, 30 mg,, 50 mg,, 100 mg.
NORTH CAROLINA
MEDICAL JOURNA
Published Monthly as the Official Organ
The North Carolir
Medical Socie
February, 1974, Vol. 35, No. !
EDITORIAL BOARD
Robert W. Prichard, M.D.
Winston-Salem
EDITOR
John S. Rhodes, M.D.
Raleigh
ASSOCIATE EDITOR
Miss Louise MacMillan
Winston-Salem
ASSISTANT EDITOR
Mr. William N. Milliard
Raleigh
BUSINESS MANAGER
W. McN. Nicholson, M.D.
Durham
CHAIRMAN
Louis deS. Shaffner, M.D.
Winston-Salem
Rose Pully, M.D.
Kinston
William J.
Cromartie, M.D.
Chapel Hill
Charles W. Styron, M.D.
Raleigh
NORTH CAROLINA MEDICAL JOUR-
NAL, 300 S. Hawthorne Rd., Winston-Salem,
N. C. 27103. is owned and published by The
Nonh Carolina Medical Society under the di-
rection of its Editorial Board. Copyright ©
The North Carolina Medical Society 1974.
Address manuscripts and communications re-
garding editorial matter to tiiis Winston-
Salem address. Questions relating to sub-
scription rates, advertising, etc.. should be
addressed to the Business Manager. Box
27157, Raleigh, N. C. 27611. All adver-
tisements are accepted subject to the ap-
proval of a screening committee of the State
Medical Journal Advertising Bureau. 1010
Lake Street, Oak Park, Ilhnois 60301.
and or by a Committee of the Editorial
Board of the North Carolina Medical Journal
in respect to strictly local advertising. In-
structions to authors appear in the January
and July issues. Annual Subscription, $5.00.
Single copies, $1.00. Publication office;
Edwards & Broughton Co.. P. O. Box 27286.
Raleigh, N. C. 27611. Second-class postage
paid at Raleigh, North Carolina 27611.
President's Newsletter ''
Original Articles
Medical and Surgical Complications of Therapeutic
Termination of Pregnancy 7
David A. Evans, M.D., and John P. Gusdon, M.D.
The Tail is Wagging the Dog l
Bernard A. Wansker, M.D.
A Community of Care 5
Peter James Lee
Editorial
How to Know What is Going On 9
Emergency Medical Services
Categorization of Hospital Emergency Departments.
How it was Done in Ohio
Maurice A. Schnitker, M.D.
Abstrated by George Johnson, Jr., M.D.
10
Com.mittees & Organizations
Committee on Chronic Illness, TB and Heart Disease lO
Committee on Peer Review ;iO
Bulletin Board
What? When? Where? )2
News Notes from the Bowman Gray School of Medicine of
Wake Forest University M
News Notes from the University of North Carolina Division
of Health Affairs )9
News Notes from the Duke University Medical Center..
News Notes
.. 10
.. iO
Month in Washington ,2
Book Review , 9
In Memoriam 20
Classified Ads 23
Inde.x to Advertisers 24
Contents listed in Current Contents /Clinical Practice
PRESIDENT'S NEWSLETTER
MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA
No. 9
February 8, 1974
I
e moves and counter moves on the PSRO front are coming in such bewildering
speed that it is hard to keep up. I will enumerate just a few high spots:
(1) Out of the blue in mid-January, the Secretary of HEW, Mr. Weinberger,
put out a proposed regulation making pre-hospital admission approval
for all Medicare and Medicaid patients mandatory by thirty days after
publication in the Federal Register.
(2) On January 25th, the President of the American Medical Association,
Dr. Russell B. Roth, in a press release announced that the American
Medical Association will take Secretary Weinberger to court if he
doesn't cancel this ridiculous regulation.
(3) On January 23rd, Dr. Frank Sohmer, President of our North Carolina
Medical Peer Review Foundation, Inc., Congressman Richardson Preyer,
Mr. John Anderson and Mr. Henry Mitchell, our Legal Counsel, personally
delivered North Carolina's official protest against four PSRO's for
the State. Coincidentally, great credit and thanks go to Congressman
Richardson Preyer for his untiring efforts in our behalf and great
cooperation in helping present our case to Dr. Henry Simmons, the head
of the PSRO office. They reported cordial but a non- rewarding recep-
tion. However, in the same press release mentioned above. Dr. Ross
announced that the AMA will go to court with all states wanting to
protest the geographic boundary decisions. Along with Mr. Bill Billiard,
our Executive Director, on January 25th, I attended a meeting with
representatives of nearly all the rebelling states where tentative
agreement was reached to join together in a common suit with the help
of the AMA.
(4) Copies of our protest with a covering letter from me went to all of
the North Carolina delegation in Washington and they have nearly all
responded with notes of cooperation.
[n the meantime back home in North Carolina, the political winds are slowly reach-
ing gale proportions. Now is the time to get down to bedrock. The President of
Che New York State Medical Society asked his legislators why doctors do so poorly
In the political arena. The answer was unanimous, "You doctors don't contribute
:o our campaign. Put your money where your mouth is.". In addition to money
Tou should also let the state legislator of your choice know that you not only
rontributed to his campaign but that you are also willing to ring doorbells and
rark at the precinct level in his behalf. This is the only way we will ever
Improve our political effectiveness. All such activity should also be accompanied
by membership in both the national AMPAC organization as well as the North Carolina
MedPac organization.
In this hectic environment, our State Medical Society's Legislative Committee with
its Chairman, Dr. David Bruton; our attorney, Mr. John Anderson; and our Legisla-
tive Staff Representative, Steve Morrisette, are working feveriously staying on
top of the bills, committee meetings, and actions of the state legislature
related to health. Governor Holshouser's State of the State Message emphasized
the importance of upcoming health legislation, and we were very pleased that he
came out loud and clear in supporting the Board of Governors of the Greater
University in their AHEC program. The stand your Governor has taken on these
matters is in basic agreement with that of the State Medical Society. It will be
sheer tragedy for the future of medical education in this state if politicians
succeed in getting higher education back into partisian politics.
The annual State Medical Society Leadership Conference was for the first time held
in Raleigh on the 1st and 2nd of February. This use of our new headquarters
building along with the provocative program arranged and provided by our Public
Relations Committee proved to be a great success, so much so that it was decided
to use the same format in 1975.
This was indeed an eventful weekend, for not only did the Board of North Carolina
Peer Review Foundation, Inc., have a meeting but also as has been the custom fol-
lowing the Leadership Conference, so did your Executive Council.
The shock waves stemming from these meetings were so numerous and of such ampli-
tude that space in this Newsletter forbids enumeration. Suffice it to say, that
the shocks will be reaching you in the relatively near future.
Like all other institutions these days, our society is having to tighten its finaq
cial belt. Currently, you get this Newsletter twice — once in the mailing with
the Public Relations Bulletin and once as a page in the State Medical Journal.
I would like opinions as to the wisdom of distributing it only once and if so by
eliminating which method of getting it to you.
Sincerely yours,
George G. Gilbert, M.D.
President
I
Medical and Surgical Complications of
Therapeutic Termination of Pregnancy
David A. Evans, M.D.* and John P. Gusdon, M.D.
.P'ROM January 1970 to October
ll 1971, therapeutic termination of
I I jregnancy was performed upon ap-
jroximateiy 550 patients at the
Vorth Carolina Baptist Hospital. Of
hese patients' records, 536 were ex-
ensively reviewed to determine the
extent of our complications with
hese procedures. Recent reports
rem other institutions have shown
,:n overall morbidity rate, in com-
t- *ined first and second trimester ter-
1 ninations, to be nearly 13.5 percent.
lowever, these same reports showed
, hat, in their large series, the major
omplications of all stages of termi-
lation were a surprisingly low 1.7
lercent.*
, Our own data, analyzed for all
i omplications (major and minor),
dther compiled from the record
r communicated by the patients
t their follow-up examinations,
aowed an overall complication rate
.'f 20 percent. If one carefully ex-
lludes all minor complications, the
ite drops to 11.7 percent. Table 1
ives the total breakdown according
!> procedure, trimester, and compli-
Pitions (major or minor).
There was a nearly equal division
Read before the Annual Session, North Caro-
la Medical Society. Pinehurst, May 19-23, 1973.
From the Department of Obstetrics and Gyne-
logy, the Bowman Gray School of Medicine
Wake Forest University, Winston-Salem,
. C. 27103.
•Present address: Monroe Women's Clinic
onroe, N. C. 28110.
between clinic and private patients.
Two hundred and forty-one patients
were managed by the resident staff,
and 295 were managed by the at-
tending physicians.
MATERIALS AND METHODS
Therapeutic abortion medical
records from January 1970 to Oc-
tober 1971 were obtained from the
North Carolina Baptist Hospital
in Winston-Salem, North Carolina.
Each chart was reviewed completely,
and pertinent data were analyzed.
Major complications of the first
trimester included: (a) hemorrhage
of greater than 500 ml of blood;
(b) infection with febrile morbidity
(defined as a temperature above
100.4 F which persists for more than
24 hours); and (c) uterine perfora-
tion.
Complications of the second tri-
mester included hemorrhage, infec-
tion, and failure of the primary in-
duction, requiring a second proce-
dure (in cases of saline-induced
abortion).
In the category of major compli-
cations, we have included patients
who were readmitted to the hospital
for observation, as well as patients
who required a second procedure.
RESULTS
Table 1 is a composite of all tri-
mesters and all procedures. It shows
the differential between all compli-
cations and major complications.
Table 2 shows the complications
Table 1
Complications of Therapeutic Termination of Pregnancy
North Carolina Baptist Hospital
Jan
uary 1970 - October 1971
536 CASES
*
Trimester
Procedure
Number
of
Cases
An CompI
Number
ications
Percent
Major Com
Number
plications
Percent
First
D & C — Suction
346
39
11.3
18
5.2
Second
Saline
127
36
28.3
27
21.3
Hysterotomy and
tubal ligation
63
32
50.8
18
28.5
TOTAL
All Procedures
241 Clinic.
536
107
20.0
63
11.7
* 295 private.
EBRUARY 1974, NCMJ
87
Table 2
Complications of D and C— Suction Abortions
North Carolina Baptist Hospital Study
January 1970 - October 1971
346 CASES*
Complication Category
Postpartum bleeding
Infection
Perforation
TOTAL
All Complications
Number Percent
Major Complications
Number Percent
13
3.8
10
2.9
18
5.2
0
0.0
8
2.3
8
2.3
39
11.3
18
5.2
' 222 private, 124 clinic.
of D and C suction abortions in 346
cases. Of these cases, 3.8 percent
were complicated by some type of
postpartum bleeding; however, ex-
cluding all cases except those having
an estimated blood loss greater than
500 ml, only 2.9 percent (10 cases)
had bleeding complications of the
first trimester.
In the original survey, 18 patients
(5.2 percent of the total) had some
type of infection or febrile mor-
bidity, indicated by at least one tem-
perature elevation. All of these cases
were excluded from the category of
major complications since the dura-
tion of febrile reaction apparently
did not exceed 24 hours. The dura-
tion of febrile reaction was ex-
tremely difficult to determine be-
cause of the nature of the procedure
used; nearly all charts showed that
these patients received antibiotics at
the first sign of temperature eleva-
tion.
In eight cases, uterine perforation
was suspected and confirmed by the
operator; these, of course, were
placed in the major complication
category. Five of these patients were
treated by observation only, and no
subsequent complications developed
as a result of the perforation. Three
patients were explored because of
suspected intra-abdominal hemor-
rhage: Of these patients, two re-
quired hysterectomies to control
blood loss, but the third patient re-
quired only evacuation of the re-
maining contents of the uterus and
repair of the posterior uterine wall.
In the first trimester group, three
patients required blood transfusions
because of excessive hemorrhage.
We have excluded one case from the
major complications category be-
cause of the non-specific nature of
the case. The patient, in this case,
underwent a suction curettage for
removal of the fetal parts and pla-
centa. She was subsequently seen in
the emergency room, approximately
one week later, where she expelled
an additional fetus and placenta
from an obvious twin gestation
which had been missed at the time of
the original procedure.
Table 3 outlines our complica-
tions with saline abortions. Of 127
patients, 27 developed major com-
plications. Significant hemorrhage
occurred in 1 1 patients, ten of whom
required a curettage to complete the
evacuation of a retained placenta or
fetal parts. Two patients required
transfusions. Major febrile mor-
bidity occurred in 13 patients (10.2
percent of the saline cases). There
were three cases of failed saline in-
duction which required a second in-
jection. After a second injection, one
patient aborted spontaneously with-
out any further complications. The
second patient failed to abort and
was given oxytocin; her posterior
lower uterine segment ruptured be
cause of sacculation beneath the cer
vix with consequent expulsion of th(
contents of the uterus into the va
gina. This patient was taken to th^
delivery room where inspectioi
showed a 3 cm vertical laceratioi
which required suturing by the at
tending physician. The patient ex
perienced no further morbidity ii
her postpartum course. The thir(
case of failed saline induction re
quired re-injection; after the patier
failed to respond to re-injection an
became morbid with fever, she wa
taken to the operating room wher
a hysterotomy was performed.
Three patients required readmit
sion to the hospital for treatment c
postpartum bleeding, but these wei
not counted doubly since they ai
included in the postpartum hemo
rhage section of the report. No casi
of disseminated intravascular ci
agulopathy occurred.
Table 4 outlines the complicatioi
of hysterotomy/tubal ligation abo
tions. Although some authors ha'
excluded this procedure from thi"
complications statistics, because :
the double nature of the surgery, v,
felt that the procedure should be i-
eluded since sterilization is onlyi
minor portion of the surgery. We t-
lieved that sterilization per se shoil
not add morbidity to the major p^•
tion of the procedure (abortion /
hysterotomy).
According to our criteria, of 3
cases in this category, 18 paties
developed major complicatio;.
Surgical hemorrhage, represent g
greater than 500 ml of blood lc>,
was present in four cases of whh
only one required a transfusii.
Table 3
Complications of Saline Abortion
North Carolina Baptist Hospital Study
January 1970- October 1971
127 CASES*
All Com
plications
Major Complications
Number
Percent
Number
Percent
Postpartum bleeding
11
8.7
11
8.7
Infection
23
18.1
13
10.2
Failed
3
2.4
3
2.4
TOTAL
37
29.2
27
21.3
' 67 private. 60 clinic.
88
Vol. 35. N. 2
Table 4
Complications of Hysterotomy— Tubal Ligation Abortion
North Carolina Baptist Hospital Study
January 1970 - October 1971
63 CASES*
All Complications
Number Percent
Major Complications
Number Percent
Surgical hemorrhage
Infection
TOTAL
5
27
32
7.9
42.8
50.7
4
14
18
6.3
22.2
28.5
* 6 private, 57 clinic.
rjVgain, infection was difficult to
,.,.valuate in terms of febrile mor-
idity and treatment. Most of the 27
t^i^atients listed under the category of
).ll complications with possible infec-
;..,ous course were placed on a regi-
j.^ien of antibiotics shortly after the
Kuiitial temperature spike. However,
jjijidged strictly from the criteria out-
j-jned, 14 patients were within the
itegory of persistent temperature
jcijCvation above 100.4 F, despite an-
((jbiotic therapy; therefore, they were
(ijijitegorized as cases with major com-
lj,i[ications, representing 22.2 percent
.J,,:' the total.
i.i[i We believe that the final figure —
,;;!? complications in 63 cases; a
5I1 .implication rate of 28.5 percent —
Acobably represented less than the
i,j,,|tual morbidity in this series. Al-
f Aough two patients were readmitted
Qjlji the hospital and treated for one
j- the above complications, we did
(jjj it count them twice.
3(j(iJ5 Table 5 shows the procedures
jjidtjed and the clinical status of pa-
ijjijnts who received a concomitant
jlijl'rilization with their therapeutic
Jjfortions. Six private patients and
iieii
57 clinic patients were sterilized at
the time hysterotomies were done.
Nine private patients and 20 clinic
patients had tubal ligations at the
time of the first trimester abortion
which was performed by dilatation
and curettage, or suction. The total
was 29 first trimester sterilizations.
Two private patients and four clinic
patients were sterilized by an ab-
dominal tubal ligation after saline
abortion. Ninety-eight patients were
sterilized concomitant with thera-
peutic abortion in the total series of
536 cases, the sterilization rate being
18.3 percent. In the sterilization se-
ries, the patients showed no signifi-
cant increase in morbidity.
DISCUSSION
We feel that the outcomes de-
scribed in our data are primarily re-
lated to the type of procedure per-
formed and to the gestation stage of
the patient. In our first trimester ter-
minations series, of the total 346 pa-
tients, an overwhelming majority of
240 cases (70 percent) were within
the gestational age group of eight to
ten weeks at the time of termination.
Table 5
Therapeutic Pregnancy Termination
North Carolina Baptist Hospital Study
January 1970- October 1971
STERILIZATION RECORD*
1
Clinical Status
Icedure Private Clinic
Total
Number
of Patients
Sterilized
Number of
Patients
Undergoing
Procedure
■terotomy 6 57
63
63
inal uterine evacuation 9 20
29
346
ne injection 2 4
6
127
al number of patients sterilized 17 81
procedures)
98
—
erilization rate, 18.3%.
iRUARY 1974. NCMJ
Sixty patients were thought to be be-
tween ten and 12 weeks' gestation,
representing approximately 17 per-
cent of the total group. Approxi-
mately two percent (eight patients)
were found to be over 12 weeks'
gestation at the time of the surgical
intervention. The remaining 1 1 per-
cent were at less than eight weeks'
gestation at the time of termination.
It is probably unfair to judge our
own complication rate by compari-
son to Tietze's' report on prelimi-
nary data. His original statistics ap-
pear to be an underestimation — 1.8
percent major complications in pa-
tients within the New York area,
with terminations between 1 1 and
12 weeks' gestation, including 3,212
patients — since in his study of com-
plications in the first trimester ges-
tational age group, the New York
patients with follow-up reported a
10.9 percent complication rate, ap-
proximating our own percentage of
1 1.3 percent. A recent series, includ-
ing 6,201 patients from California,
reports that a complication rate of
2.7 percent occurred in termination
between five and six weeks' gesta-
tion. Complications rose to nearly
six percent for terminations between
seven and ten weeks, and again
sharply to 12.9 percent for termina-
tions between 11 and 12 weeks. -
Another study from Great Britain''
is difficult to analyze in terms com-
parable to those of our own and the
California study, but it should be
mentioned to reinforce our opinion
regarding the high complication rate
of abortion after the first trimester.
In a series of 1,317 cases, over half
of the patients were past the first
trimester at the time of termination,
and the total complication rate was
16.8 percent.
Stewart and Goldstein- reported a
complication rate of 23.4 percent in
combined morbidity statistics on ter-
minations between 13 and 14 weeks'
gestation and combined morbidity
of 25 percent between 15 and 16
weeks' gestation. The use of intra-
amniotic hypertonic saline for thera-
peutic abortion after 12 weeks" ges-
tation has caused recent controversy
and a wide variation of complication
statistics, varying from 47.6 per-
89
cent* to less than five percent,^
have been cited. A more recent
study, from the Beth Israel Medical
Center in New York,'' shows that 23
percent of their patients who re-
ceived a saline injection required a
second procedure to terminate the
pregnancy.
Although large series on termina-
tion by hysterotomy are difficult to
find in the literature, Stallworthy et
al" from Great Britain have suffi-
cient data to compare with our own.
Stallworthy reported on 1,182 pa-
tients, 70 of whose pregnancies were
terminated by hysterotomy. In this
study, ten patients experienced a
blood loss of greater than 500 ml
(14.5 percent), and an additional
30 patients had febrile reactions of
greater than 100.4 F persisting for
longer than 24 hours (43 percent).
It is also interesting to note, from
this same series, that of 290 patients
undergoing vacuum aspiration and/
or dilatation and curettage at less
than ten weeks' gestation, ten per-
cent experienced hemorrhage greater
than 500 ml and 16.5 percent ex-
perienced febrile reaction greater
than 100.4 F which persisted for
longer than 24 hours. It is, at times,
difficult to compare others' studies
with one's own data, and it may be
unfair to judge the quality of care
without further knowledge regarding
the experience of the surgeons,
methodology, and sterile technique.
We feel that our experience and
the experiences of our colleagues in
eastern Europe, the Soviet Union.
Japan, Scandinavia, Great Britain,
and in the United States document
the fact that the medical and/or sur-
gical interruption of pregnancy is not
•References 2. 4. 5, 6. 7. 8, 9. 11, 12.
without risk.* Although complica-
tion rates were recently reported
(15) in the New York area to be
3.8 per 1,000 for abortions per-
formed in the first trimester of preg-
nancy, and 23.7 per 1,000 for those
performed beyond the first trimester,
12 deaths were reported following
legal termination of pregnancy from
July 1, 1970, to December 31, 1971.
During the same period, the legal
abortion had some apparent posi-
tive effect upon maternal health
in New York, in that the maternal
mortality rate has declined 37 per-
cent from 1970 to 1971, reaching
an all time low of 2.9 deaths per
10,000 live births. In the state of
California,- since the inception of
the therapeutic abortion law of
1967, there have been five reported
deaths attributed directly to abortion
legally performed, with an incidence
rate of five per 90,000, or approxi-
mately five to six per 100,000 abor-
tions. According to these statistics,
three of the California deaths oc-
curred either during uterine evacua-
tion, or shortly after termination of
pregnancy by uterine evacuation by
means of a curettage; the other two
deaths occurred in patients under-
going saline mid-trimester abortion.
We are fortunate to be able to re-
port that there were no fatalities in
our series.
Because of our lack of experience
with long term latent effects of
therapeutic abortion, in this paper
we have considered only the imme-
diate medical and surgical complica-
tions of therapeutic termination of
pregnancy. A positive correlation
between previous abortion and pla-
centa previa, abruptio placentae,
cervical incompetence, prolonged la-
bor, and endometriosis has been re-
ported in Czechoslovakia.*"
The patient's decision to term
nate pregnancy, by any means, a[
parently only rarely involves a coi
sideration of serious risks to her lili
We believe, however, as a result c
the data which we have presentei
and that of other authors, that then
peutic abortion beyond ten to 1
weeks' gestational age is not witho
a major increase in serious compl
cations. It is, therefore, our recor
mendation that, if at all possible, tl
procedure should be performed b
fore the tenth week of gestation, ai.
certainly no later than the twelfi
week. If therapeutic abortion is i
be considered after the twelfth we:
of gestation, the increased ric
of major complications of mid-t-
mester termination should also :
considered.
References
1. Tielze C. Lewil S: Leyal abortions: cy
medical complications. Fam Plann Pers :t
3: ^14. 1971.
2. Stewart GK, Goldstein P: Medical and t-
cical complications of therapeutic aborli.s.
bbstet Gynecol 40: 5.19-550, 1972.
^. Sood SV: Some operative and postopcr :e
h.tzards of Iec-1 termination of preen v
Br Med J 4: 270-27.1. 1971.
4. Wattatsuma T: Intra-amniotic injectiorol
saline for therapeutic abortion. Am J Oiet
Gynecol 9.1: 743-745, 1965.
5. Olsen CE. Nielsen HB. Osterjiaard E: ■ n-
plications to therapeutic abortions. Int J y-
necol Obsiet 8: 823-829. 1970.
6. Berk H. Ullman J, Berger J: Expence
and complications with the use of hypcrliic
inlra-amniotic saline solution. Surg G>ixl
Obstct 133: 955-958, 1971.
7. Stallworthy JA. Moolpaoker AS, Walsl J:
Legal abortion: a critical assessment i;ils
risks Lancet 2: 1245-1249, 1971.
8. Vojta M: A critical view of vacuunss-
piration: a new method for the termin on
of pregnancy, Obsiet Gynecol 30: 234,
1967.
9. Vlodov E: The vacuum aspiration miiod
for interruption of earlv pregnancy, /l J
Ohstet Gynecol 99: 202-207. 1967.
Hi. Mehlan KH: Tlie socialist countries irEu-
rope. In Family Planning and Popu ion
Programs: A Review of World Devop-
menis. Berelson et al teds). Chicago. Ini-
vcrsity of Chicago Press, 1966, pp 207-:i.
11. Arthure H: Morbidity and mortality of lor-
tions. Lancet 2: 310-311, 1971. (Letter t.Ihe
Editor.)
12. Legal abortion, the New "^"ork story Ion-
temp obgyn 1: 21-23. 1973. (Edil^al.;
Nor are examples wanting, either in ancient or modern times, of the baneful consequences
which have arisen from an injudicious application of the warm hath; but as warm baths are
not so common in this country, and are seldom used but under the direction of a physician. I
shall not enlarge on that part of the subject. — William Biichan: Domestic Medicine, or a Treatise
on the Prevention and Cure of Diseases hv Rei'imen and Simple Medicines, etc.. Richard Fol-
well. I799.P.427.
90
Vol. 35, o.l
The Tail Is Wagging the Dog
Bernard A. Wansker, M.D.*
IS
'"'HE purpose of this article is to
r discuss the North Carolina
Ijedical Society's concern with
1 alth care costs and to tell about
ffiil; activities of the Society regard-
^ s ; physicians' fees and insurance.
aji'j wish to consider particularly the
a,,<(iestion of "reasonable and custo-
"hry charges" and "peer review."
Ejme of the material herein has been
° iapted from a testimony which was
;^|;sented to the Joint Subcommittee
6*i Health Care Costs of the North
\A';?rolina General Assembly on Oc-
'"W)er 17, 1973; other portions are
iuAjpted from various writings of the
tivhor. Smce this article docs en-
,jLnpass a substantial amount of
t)' j r.terial reflecting the author's per-
,6ii,ial views, it should not, except
'Jijindicated, be considered official
'll'/icy of either the Insurance Indus-
iivA Committee or of the North Caro-
"K Medical Society. On the other
«nd, it probably reflects little with
I lich either would disagree.
jifhe North Carolina Medical So-
j ;y enjoys excellent rapport with
health insurance carriers in this
:e. We often disagree, but we do
as gentlemen, and we communi-
i freely and frankly. The Insur-
e Industry Committee operates a
Chairman, Insurance Industry Commiltee.
h Carolina Medical Society,
quest for reprints to Suite 400. Metroyiew
linB, 191X) Randolph Road, Charlotte, North
Una 28207.
retrospective peer review service,
the Claims Review Service. A
spokesman for the insurance carriers
has characterized the service we per-
form as follows: "We arc fortunate
in North Carolina in having one of
the best peer review arrangements in
the United States — the North Caro-
lina Claims Review Service." In
turn, the cooperation, communica-
tion, and liaison which the Medical
Society has enjoyed with the insur-
ance carriers has made such an ar-
rangement possible and productive.
Further refinements which are an-
ticipated by the activation of the
North Carolina Medical Peer Re-
view Foundation should markedly
increase the quality of the decisions
that are reached.
THE CLAIMS REVIEW
SERVICE
The function of this service is to
advise the commercial insurance
carriers and the Part B Medicare
carriers of their responsibilities to
their insureds under the terms of the
insurance contract or of the Medi-
care program (Part B Medicare
deals with physicians' fees — not hos-
pital bills).
Specifically, the Claims Review
Service is asked to give an opinion
regarding the carrier's responsibility
for reimbursement of professional
charges and/or for an opinion as to
•RUARY 1974, NCMJ
the necessity of the services ren-
dered.
Confusion apparently exists in re-
gard to the concept of a "reason-
able" charge as it applies to insur-
ance contracts and as it applies to
a private relationship between a phy-
sician and his patient. They are not
necessarily the same.
Reasonableness, as beauty, is in
the eye of the beholder. How does
one define it? How does one deter-
mine it? To place a dollar value on
a medical service is no easier than
answering the question, "How long
is a piece of string?" A fee which
seems quite reasonable to a physi-
cian (and probably to his patient)
may not be considered reasonable to
(a) Medicare (b) Medicaid (c)
CHAMPUS (d) Workmen's Com-
pensation (e) Veteran's Administra-
tion (f) Vocational Rehabilitation,
or (g) private carriers. At the same
time, one or more of these agencies
might consider the fee reasonable,
whereas one or more might consider
it unreasonable.
DEFINITIONS
The "prevailing charge" as de-
fined by the American Medical As-
sociation and by the United States
Government is as follows:
American Medical Association
Usual charge: that made at least 50
percent of the time by a specific
91
doctor for a specific service.
Customarj' charge: that charge made
by most physicians of similar
training and experience in the
same geographic area.
Reasonable charge: a charge meet-
ing the definition of both Ususal
and Customary.
U.S. Government (Medicare)
Customary charge: that made at
least 50 percent of the time by a
specific doctor for a specific ser-
vice.
Prevailing charge: that charge which
will cover 75 percent of the
charges (not 75 per cent of a
charge) made by physicians of
similar training and experience
but not necessarily in a geo-
graphic area.
Reasonable charge: a charge meet-
ing the definition of both Custom-
ary and Prevailing.
Thus, whereas specific differences
exist (and they are of the utmost
importance), usual = customary,
and customary = prevailing. I think
it is much simpler to ignore the ques-
tion of "usual" since we are talk-
ing about the physician's "regular"
charge, for both the AMA and the
Government.
Let us enlarge upon our new
friend PREVAILING. Let us con-
sider the fee charged for a specific
service by a physician. How does
Medicare, for example, find out
what is prevailing? Here's how: Let
us say that for a given period of
time, from a specific area, and from
surgeons alone. Medicare accumu-
lates actual charges submitted for
the specific service. Now let us as-
sume that they have accumulated
100 actual charges which they ar-
range from lowest to highest. Medi-
care counts the first 75 actual
charges and calls this the 75th per-
centile (not percent). This 75th per-
centile covers 75 percent of the
charges submitted (not 75 percent
of a charge). As an example, the
charge screen might look this way:
Actual charges submitted: $50.00
Number of charges submitted: 10
Actual charges submitted —
Number of charges submitted: —
In this example, 75 percent of the
charges submitted are $75.00 or
less. Hence, any charge of $75.00
or less will be considered by Medi-
care to be prevailing, and therefore,
reasonable. It is entirely possible
that a higher percentile could still
have $75.00 as its highest figure. As
a matter of fact, if all the submitted
charges had been $75.00, even the
100th percentile would have had
$75.00 as the highest figure.
Who, then, establishes the range
of fees submitted? Who, then, es-
tablishes the individual physician's
profile; i.e., the fees he charges for
various services? Not the insurance
companies; not Government agen-
cies. The physician does.
In my opinion, this prevailing
charge concept is the single most im-
portant change in insurance carrier
(private or Government ) reimburse-
ment to date, and it portends signifi-
cant influences upon private fec-for-
service medicine. I want to empha-
size that Medicare no longer uses
relative values in determining its
payments. Certainly, with its enor-
mous data bank, no longer a secret,
i.e., since a court test has been won
against the Government (and the
Government failed to appeal), the
public is now entitled to physician
profiles (not of individual physi-
cians, but of specialties). I doubt
that John Q. Public would be able
to make much out of a few hundred
pounds of computerized data, but
you may rest assured that every in-
surance company in America that is
large enough to rent a computer will
soon have this data and will no
longer use relative values.
Hopefully private insurance com-
panies will use a more satisfactory
(to physicians) percentile. Initially,
Medicare started at the 83rd per-
centile; private carriers have been
known to be in the low 90s; but an
additional factor must also be ap-
preciated— Medicare is required to
establish certain areas which often
are not geographic. For example, in
a given state, the larger cities may be
$55.00 $60.00
5 10
$65.00
10
$80.00
5
$85.00 $90.00
0 15
$70.00 $ 75.00
10 30
$95.00 $100.00
0 5
grouped together; then the medium
sized cities; then the smaller com-
munities. And, a medical school f-
self might be designated as an aix
Other states might conceivably «
divided geographically as east, ci-
tral, and west.
Private insurance companies -e
under no such compunction; tby
may elect any area, geographic)!
not, and any percentile they cho>e.
How, then, can anyone tell whfe
prevailing?
Relative value studies
Rarely does one find that rela n
value studies are accurately refeiui
to. Most of the time they are refei:d
to as relative value schedules. Tire
is a great difference; it is not a nit-
ter of semantics. A study is a stiy,
a guide, a teaching document. A
schedule is a schedule, a list, a le-
less "cookbook" designed foi a
clerk to utilize. Already, insur:ice
carriers are ignoring the indivii.al
specialty relative value studies in
those instances in which rehive
values are still being used) whenier
and wherever such individual ^/S
unit values are higher than the sne
service coded under the Califoiia
1969 RVS. To think that insur;ce
payments are going to be incre;ed
merely because a unit valu^ is
changed is a misplaced hope. 1 en
if the price commission would ; )»
it, the insurance carriers are gng
to pay according to their prevang
data. Their major medical contibts
call for the payment of reason}le
and customary charges and the do
not call for specific unit vaes
which are multiplied by conveion
factors.
It seems that having prev.mg
levels of charges for services, a-le-
fined by the Current Proce^ra:
Terminology (CPT-73) and )b-
tained under ground rules aciplr
able to all parties concerned, i:;he
only way to preserve, as far as os-
sible, the fee-for-service coivpt
and it seems that it is the niv
way to avoid a fee schedule \uci
is not reflective of individual iit-
ferences and regional variat'ns.,
A relative value study, whereti
roneously used as a schedule K-j
quires the use of a fixed convcioo;
factor in each of the various ec-
tions; it does not permit, nor aLim-
92
Vol. 35. )■
I'odate, the flexibility reflected in an
individual's profile. A profile which
Hs varied in this fashion accurately
ijflects the personal modifications
at the physician has elected to
li ake, consciously or not, in a rela-
te value study. Again, each indi-
Jlual physician has already estab-
iKhed his own charge pattern (pro-
ti). No one else did it for him.
jMassive confusion and inequities
(n, will, and must be avoided by
!; use of the concept "prevailing"
l^iher than relative value "sched-
e';s" which are developed by each
ifficiaJty and subspecialty organiza-
|n that wishes to do so (and which
'Hers from the California 1969-
''"l73 relative value studies). The
'I'lifornia studies do not separate,
'« atsoever, the various specialties
'i^i sub-specialties. Therefore, sig-
'flicant differences in unit values re-
tX, depending upon which sched-
'l' one wishes to utilize. Hence,
-rre is, as previously indicated, a
■'i*'iflict already existing within the
t'ltive value family; the California
•fdy is still the standard. In my
"finion, the sooner relative value
"'jyies are relegated to the status of
''f des, especially for physicians who
"V new in practice, the better it will
Hor all concerned. Let us waste
J 11^ more time on them — they are on
■Mt way out.
irli
ARRIER RESPONSIBILITY
FOR PAYMENT
lb; science of medicine
V"he problem of benefit deter-
t^ation in major medical insurance
I es since the insurance contract
:.a''ally restricts liability to reason-
\.|l6' and customary charges. When
• hfee exceeds the carrier's prevail-
j-.tl charge, the matter is brought to
ibClaims Review Service. What do
:i' consider and what do we have
.'Hable to consider? We can, and
' do, obtain the hospital record
;,.| .isting of the patient's history
jkli physical examination, order
::i«ts, progress notes, pertinent
r I- ratory data, operative notes, and
\'!:M discharge summary. We also
clider any additional information
J litted by the carrier or by the
riOil''ician; the nature of the medical
lOt.ii'or surgical problem presented
and what the physician did about it;
the uniqueness (if present) of the
situation, and we give due allowance
for that; and the submitted charge
as compared to the prevailing range
of charges determined by the carrier.
Finally, after we take a vote, we
give the carrier a figure which we
feel represents a fair judgment as to
the carrier's responsibility to its in-
sured; that is, its responsibility for
defraying the costs of the science of
medicine for its insured. We do not
give an opinion as to the value of
the art of medicine furnished, and we
do not consider such a determina-
tion to be the responsibility of any
carrier.
The art of medicine
In the consideration of "reason-
able" as it applies to the private re-
lationship between a physician and
his patient, many factors in addition
to the science of medicine must be
considered. These usually do not ap-
pear as part of the medical records.
One must consider the individuality
of the physician and his practice;
the type and scope of services he
renders; the facilities he has pro-
vided and his availability to utilize
them; the time and energy he spent
before, during, and after the services
were rendered; the special consid-
erations demanded by the patient
and/or his family; the agony or de-
light in handling the patient; the
study, contemplation, consultation,
and teaching involved; the physi-
cian's cost in time, facilities, and
expense in rendering the service; and
the relationship developed with the
patient and/or the family, as it
plainly reflects the art of medicine.
There are no standard patients.
There are no standard physicians.
And, the longer one practices medi-
cine, one sees fewer and fewer stan-
dard diseases.
Do any two physicians actually
render an identical service? It is
nearly impossible, in most instances,
to determine whether or not a pri-
vate fee is, or is not, reasonable in
the context of a private contract. As
far as the patient is concerned, a far
different view of "reasonable" exists.
Did the service afford relief to the
patient? If not, in his opinion, it
wasn't worth much; on the other
hand, if the service brought relief,
it's nearly priceless. Physicians
whose fees are substantially higher
than that which prevails in their
community, and whose fees are un-
accompanied by the art of medicine,
soon find that this situation will
create a backlash of turbulence
which is quite difficult to tolerate.
Such a physician would soon have
no practice.
The Claims Review Service finds
it regularly compatible to give a
carrier a determination of what is, in
the opinion of the Claims Review
Service, a reasonable fee in the con-
text of the carrier's allowable ex-
pense or liability under the terms of
the insurance contract with its in-
sured; at the same time, it recognizes
that prevailing fees are not to be
equated with reasonable fees. It is
entirely possible for a physician to
charge a fee which we think is
greater than the carrier's liability;
and yet it can, and does, fall into a
range in which it would not merit
further study or review. Was the fee
agreed upon in advance? If so, it
was reasonable and no more can be
said; the matter would be closed. It
would be a solidly agreed-to con-
tract. Fees are regularly discussed in
advance, and often the conversation
is initiated by the patient or by the
family.
THE PHYSICIAN/ PATIENT
RELATIONSHIP
It has been stated that "there
is an unwillingness, based on ethical
grounds, for any medical society to
directly intervene in the patient/
physician relationship, including the
freedom of a physician to set his
own fees"; and that "peer re-
view cannot be complete and of di-
rect benefit to the public unless the
medical profession is willing to pro-
tect the patient against excessive
charges." On behalf of the North
Carolina Medical Society, the record
must be corrected and our position
must be re-emphasized; A charge is
not necessarily excessive simply be-
cause it is not prevailing. And, the
small fraction of claims, reflecting
charges that are higher than prevail-
ing, belays the question of protecting
'I UARY 1974, NCMJ
93
the patient against excessive charges.
Insurance carriers regularly equate
"prevaiUng" with "reasonable""; that
"prevailing" and "reasonable"" are
synonymous is not necessarily ac-
curate.
Further, private insurance com-
panies are now using data which
they accumulated to determine pre-
vailing levels of charges. We, as phy-
sicians, have no information as to
the amount of data used, the timeli-
ness of the data, the areas consid-
ered, the breakdown or lack of
breakdown by specialty, or the per-
centile. I can think of no more press-
ing a need than to have an organi-
zation which is not the arm of medi-
cine, not the arm of insurance, and
not the arm of Government, to ac-
cumulate data in order to determine
prevailing levels of charges. First,
we all would have to agree on the
following: What areas are to be
used? What specialties? What time
limit? What percentile? Then, who is
to do the work of compiling the
data? Who is to pay for it? My sug-
gestion is that the non-profit North
Carolina Medical Peer Review
Foundation, Inc. have the responsi-
bility as part of its accumulation of
PSRO data. Private carriers could
well do the funding.
Nonetheless, we do intervene to
protect the patient from "excessive""
charges. Every county medical so-
ciety in this state has a Grievance or
Mediation Committee. And, prop-
erly, it is "at home"" that such prob-
lems are best handled, whether aris-
ing via an insurance claim or via a
direct complaint from a bill sub-
mitted to a patient. If the matter
cannot be resolved at this level, the
problem is referred to the Commit-
tee on Mediation of the North Caro-
lina Medical Society. This Commit-
tee is composed of the last five past-
presidents of our State Society. It
has very strong investigative and
persuasive powers. In isolated in-
stances, its findings are referred to
the Board of Medical Examiners of
i The Blue Shield Commillee handled 275 lo
30U cjses in the past fiscal year.
t Neither sla\crv nor involtintary servitude, ex-
cept as a punishment for .i crime whcreol the
parly shall have been duly convicted, shall exist
within the L^nitcd Slates, or any place suhicct
to their jurisdiction.
the State of North Carolina.
Again, carefully place in your
mind that these are very unusual
circumstances. The largest private
health insurance carrier in the na-
tion reported that, nationally, it was
experiencing only five percent of all
charges above its prevailing levels.
In North Carolina the percentage is
thought to be considerably less. The
Claims Review Service reviews
fewer than 100 casesT annually, and
many of them are not for fee ad-
judication, but are submitted for rea-
sons such as utilization or liability
for a service or facility. And what
happens to the cases that are sub-
mitted for fee adjudication? Some
are sustained as being acceptable;
others are moderately reduced; and
the rest are reduced substantially.
By and large, our review system is
an acknowledged success. The whole
commotion of protecting the public
from excessive charges by physicians
is certainly not reflective of the facts
of the matter.
FEE CONTROLS
It might seem that it has been sug-
gested that physicians should be held
to prevailing levels of charges in
those instances in which major medi-
cal contracts call for reimbursement
on that basis. If this were done, there
would exist a maximum fee schedule
which would become a minimum as
soon as the knowledge became dis-
seminated. Do not forget that many
charges are less than the specific
percentile which a particular carrier
may choose as its cut-off point. Car-
riers do not voluntarily elevate the
submitted charge to the cut-off per-
centile if it falls below it.
It may well be, in the future, that
physician reimbursement will be
handled on a capitation basis; or on
a fixed fee schedule such as manda-
tory indemnity schedules would
provide; or limited by the prevailing
level of charges. The philosophy of
these concepts is being widely de-
bated, as are Government controls
on all segments of society in general.
Nonetheless, a decline in initiative,
a reduction in quality, and a stagna-
tion of the medical mind can be ex-
pected if any of these measures is
adopted. As long as all purvey:;
of personal services are protect]
by the 13th Amendment to our C':-
stitution,:i: no one will have the rijl
to tell anyone that he must perfc i
a personal service for another, aij
price determined by a third paj
and not mutually agreed upon. S
physician does have the right ]
charge that amount which he 1-
lieves his services to be worth. 3
does anyone else. This is the t ■
for-service concept which is inhernt
in a free enterprise system, 'h
North Carolina Medical Sociy
does not set fees. Even if it wisld
to do so, the antitrust statutes wod
prohibit such action. Yet this d'S
not mean that the North Carol a
Medical Society advocates recklis
abandon in setting fees. Quite ie
contrary, members are urged to \y
carefully consider their charges n
order that the fees be commensur:e
with the services rendered.
The North Carolina Medical >
ciety agrees that organized medicie
would be ill advised to defend le
right of any physician to m:e
charges which are considered by r-
ganized medicine to be unreasi-
able. since it would be a reflecim
upon the entire profession. Jt
again, the problem of charges whh
are obviously unreasonable or exis-
sive, by anyone"s definition, is ic-
traordinarily rare.
Federal policy
One cannot fail to observe ai
the physician's prerogative to cole;
the difference between the prevaiag
charge and his own usual fee hasot:
been attacked by the Feilal
Government. The right to acce]ioi
not to accept assignment uie:
Medicare has been kept invio ;e
When a physician does not ac pi
assignment of the Medicare ])'•
ment, he has every right underlie
law to collect the full charge bm
the patient. If he does accept as^ji-
ment, he must accept the MediiRf
(prevailing charge) determin.oni
as his full charge. It would seenin-
appropriate for other agencii
carriers to advance the suggc
of mandatory prevailing fees .ei:
the Federal Government, witlilsi
94
Vol. 35,
^ lUge data bank, has not seen fit to
*io so. I firmly believe that Part B
.viedicare in North Carolina would
■ igree that physicians do not present
':nuch of a problem in the area of
ees, and even less in the area of
^verutilization.
WHAT CAN THE
CARRIERS DO?
A viable private health insurance
jidustry is an obvious necessity if a
iliirivate system of health care de-
"very is to be maintained. However,
ti: controlled system of fee reimburse-
i i;ient would not be palatable to or-
, anized medicine generally; and this
Lrrangement would be unsuitable
ijpecifically in the event that all pri-
:!uate insurance carriers became
; lerely fiscal agents of the Govem-
' /lent. Demands upon the nation's
i -rivate health carriers to insure any-
„ [ling and everything in full — a
ractice which does extreme vio-
; , nee to the concept of insurance it-
I ,j;lf — can be achieved only at an
(§ In 1972, physicians' fees rose 2.4 percent,
cordinn to Government licures.
incalculable cost. Yet, the carriers
yield to this demand and they expect
physicians to keep "impossible"
costs "in line." There is no question
that health insurance premiums are
regarded as part of health care costs.
No one is more aware of that than
practicing physicians. Time after
time we hear complaints about high
premiums and poor benefits. One of
the ways the private carriers can
help is by examining the ratio of
premium income to insurance car-
rier expenditures for accident and
health insurance policies. The per-
cent that is returned in benefits to
policyholders possibly should be
held to a prevailing range. In any
event, insurance carriers are not in
business for entirely altruistic rea-
sons.
CONCLUSIONS
The problem of reasonable health
care costs is of vital concern to the
North Carolina Medical Society. We
pledge our best efforts in achieving
the delivery of health care to the
public we serve at the least possible
cost, commensurate with quality.
Reasonable costs are not necessarily
equivalent to prevailing costs: costs
in excess of prevailing are not neces-
sarily excessive. Physicians are still
under Phase II-III of the Cost of
Living Council. Therefore, their fees
cannot rise more than 2.5 percent§
per year, and then only if costs are
not offset by productivity. Hence,
by law, physicians must hold the line
on fees while at the same time they
must absorb costs of an inflationary
tide which is estimated to be climb-
ing at a rate of three and one-half
times the 2.5 percent ceiling. It
seems that organized medicine is get-
ting a bad "rap" from those who
have been unable to distinguish the
difference between rising institu-
tional costs and rising professional
charges. It's the apples and oranges
problem.
Physicians' fees should be fair;
they should not be wagged by a tail
called "prevailing," "usual," "cus-
tomary," "reasonable," "relative
value," or what have you. The
North Carolina Medical Society sin-
cerely believes that the physicians of
this state and of this nation are hold-
ing the line on health care costs. We
urge others to do the same.
ve
a i
i
Ffi
til
i i
set:
#
ees
The cold bath recommends itself in a variety of cases, and is peculiarly beneficial to the
inhabitants of populous cities, who indulge in idleness, and lead sedentary lives. In persons of
this description, the action of the solids is always too weak, which induces a languid circula-
tion, a crude indigested mass of humours, and obstructions in the capillary vessels and glandular
system. Cold water, from its gravity as well as its tonic power, is well calculated either to ob-
viate or remove these symptoms. It accelerates the motion of the blood, promotes the different
secretions, and gives permanent vigour to the solids. But all these important purposes will he
more efficiently answered by the application of salt water. This ought to be preferred on account
of its superior gravity, and for its greater power of stimulating the skin, which promotes the
perspiration, and prevents the patient from catching cold. — William Biichan: Domestic Medi-
cine, or a Treatise on the Prevention and Cure of Diseases hv Regimen and Simple Medicines,
etc., Richard Folwell, 1799, p. 427.
3RUARY 1974, NCMJ
95
A Community of Care
Peter James Lee*
Wf HAT is to follow came origi-
nally as an interlude in a two-
day symposium on malignant dis-
ease, and the papers which emerged
from those sessions have already ap-
peared in the Journal. The two
days were highly technical examina-
tions of difficult and complex sub-
jects. The interlude was a symbol
in which the context of the issues
was resolved, a symbol of the rela-
tionship between what you do in
your work and how your work re-
lates to the community. As a layman
in a gathering of specialists, I repre-
sented the larger context — a shifting
one — in which medical care is ad-
ministered.
I represent some other things. 1
am a priest — a holdover from an
age when the priest was the com-
munity's dominant symbol of care
and the surgeon was the barber with
a knife. Priesthood, in many ways,
is a bad word. For many people it
means an elite caste, a fraternity of
mystery, and too frequently, a
brotherhood that stands for care but
which often represents authority di-
rected toward self-preservation. In
this secular age, for better or for
worse, the priesthood of which I am
Ad.ipted from an address delivered at Ihe Sixth
Annual S>mposium on Malitinant Disease. IJni-
versity of North Carolina School of Medicine.
Chapel Hill, North Carolina. April e. 1972.
• Rector of the Chapel of the Cross. Chapel
Hill. North Carolina 27514.
a part has been driven (or has fled)
to the sidelines. Although physicians
are not called priests, I suggest that
for the great masses of the popula-
tion you represent many of the attri-
butes of priesthood — an elite caste;
a fraternity of mystery; and, sadly,
because a minority can create an un-
fair image, the medical community
sometimes represents a moral au-
thority directed toward self-preser-
vation. Speaking for a priesthood
that has lost much, yet weathered the
storm, welcome aboard! But that's
history for me and prophesy for you.
I invite you to explore the wider
context in which care is exercised.
As a priest I am a symbol, however
inadequate, of a tradition of care.
You, the medical community, are
the people who now maintain that
tradition.
"Care" is a word I use to suggest
the range of actions by which so-
ciety copes with persons who are
sick: it may be the obscure probings
of a research physician who never
sees a patient; or it may be the direct
relationship of a physician, nurse, or
chaplain, to the patient and his
family. Care may be the political ac-
tivity of citizens who are concerned
with increasing public responsibility
for medical research and delivery of
medical treatment to all citizens, re-
gardless of their economic condition.
Not too many years ago, and even
now in some places, the term "hel{
ing professions" was used to dt
scribe physicians, clergymen, soci;
workers, and others who could f
under that umbrella. I suggest th;
that term is obsolete. The sophist
cation of our social system requiri
the use of an incredible variety <
professions to make any systc
work. Lawyers, accountants, air coi
ditioning engineers, and even vent
ing machine operators are essenti
in the contemporary medical cent,
if the complicated, multi-faceted sy
tem is to work effectively and rel
lively free of frustration. Care is
word which we can no longer use
describe actions by those unusual
gifted, committed, and skilled peop
who relate to suffering individu,
on a one-to-one basis.
The exercise of care is no long
the exclusive province of the pric
the physician, the hospital, or i
helping professions. In a period
transition, care has become broail
than the professions; so broad th;
in this time of transition, the concc
of care may lose its significance,
society assigns to no one the speci '
tasks of caring, then in a hum:
context of assistance to the si.
does care give way to a technii
pathological process by which tl-
cases are treated and persons ■
no red?
In my experiences with a ran: |
96
Vol. 35, Nn!
of people both inside and outside of
hospitals, I have seen the hopeful
young couple with a healthy child;
the elderly, terminally ill husband
whose wife never leaves his bedside;
the family member who, in the midst
ijof Hfe, is told of his fatal malig-
nancy. Through all of my experi-
ences, I have realized that care —
that sustaining, affirming expression
of competent action and genuine
:oncern — takes place through a
variety of channels and in many
ivays. There is no specialist of care
n this transitional age, no one per-
son who, in fact or in symbol, pro-
/ides the primary sustaining support.
What we need, I think, is a com-
nunity of care that recognizes a
tyle of relating to the sick which
-ranscends, but includes, the tradi-
ional personal style of the helper
0 the person in need of help.
' y The concept of a community of
"are removes the luxury in the as-
I I'ignment of care to the specialists,
, nd it requires a rediscovery of the
: ommon bond of human concern
nd feeling among all people who
'' 3uch the lives of the sick. This con-
cpt, that the entire context of
.lerapy, research, and support for
' je sick must bear the responsibility
_', J. thoughtful and sensitive care, also
■\pnors the technical specialists'
ork as an essential component in
le community of care. Too often
le essential work of the unseen re-
^farcher, administrator, technician,
'id others is considered to be a
, iipportmg service only. It is also too
'' ten thought that those persons who
e responsible for direct patient
re have a greater responsibility for
; nsitivity to patients as human be-
'' 'gs. I am suggesting that the entire
' 'ucture of the development and de-
ery of medical services needs to
.icover its identity as a community
. care.
The image of the "family doctor"
11 kindles hope among the sick.
- ; itics of the medical profession
j Id up this symbol as the ideal of
. ,,re. The development of renewed
I erest in family medicine demon-
ates its power. However, in the
' Tiplexity of contemporary medi-
; 1 e, the family doctor, as the help-
ing professions, is a fundamentally
obsolete symbol. We have lost the
"family doctor," and the "helping
professions" is more a slogan than a
reality. With that loss, attention to
the sick has become a bureaucracy
of technique in the absence of a
community of care. Nevertheless,
the deeper power expressed in these
concepts is still an essential ingredi-
ent for humane and considerate at-
tention to the sick. That power is a
message to the patient that he is re-
spected in his human dignity and
honored as an individual with par-
ticular physical, emotional, and
spiritual needs.
I have been astonished by the dig-
nity and maturity of terminally ill
patients, especially that of children
in the face of death. Being with such
a person in his last hours, as he
slips toward that darkness which
eventually we all encounter, is an
experience that should summon the
best resources of humility and re-
spect at our command. Too often
we do not summon such resources,
but instead take flight from our hu-
manity into the frenzied attention to
technique. No one is at fault. Our
symbols are inadequate.
Recovery of appropriate symbols
cannot mean a return to the idealis-
tic notion of one-to-one therapy be-
tween a family doctor and a patient
whom the doctor has known since
infancy. We need to develop new
symbols for future medical care so
that the power of humane concern is
enhanced in the most sophisticated
and complex systems.
I propose that attention to the
state of our community could be a
first step toward the development of
appropriate symbols. We need to
transform mindless bureaucracies
into sensitive communities — com-
monwealths in which all the people
making up the medical community
share a common concern. Whatever
the diversity of their own technical
skills, all people in the medical com-
munity should realize that they
share, by the virtue of their hu-
manity, common strengths in sus-
taining life, in nourishing hope, and
in honoring the dignity of all per-
sons.
The transformation of bureau-
cratic medical techniques into com-
munities of care introduces a note
of imprecision into disciplines that
must be rigorous in their precision.
But human life, by definition, is in-
definite and imprecise and not easily
categorized. The exceptions to the
necessary disciplines teach us less
about the inadequacy of our rules
than about the diversity of people.
A community of care honors that
diversity among patients as indi-
viduals who need different sorts of
support and attention, and who re-
quire different disciplines. The ter-
minally ill, for example, are rich in
their diversity. Some are already
spiritually dead. Others, in their dy-
ing, discover resources of life they
never knew before. All people de-
serve the dignity of a community of
care in which to die, rather than
the insensitivity of a bureaucracy
that holds their dying bodies in cus-
tody while their ignored spirits ra-
diate life.
How to provide a community of
care is another question, but perhaps
the task is surprisingly simple, for
the development of a community of
care needs first the nourishment of
our gifts as persons, then our talents
as professionals.
The development of such a com-
munity obviously requires attention
to the personal dimension of pa-
tients" needs. But it also requires so-
ciety's respect for those persons who
work together in the medical com-
munity — respect for their hu-
manity, as well as respect for their
skills. Finally, the development of a
community of care requires broad
attention to the political and eco-
nomic structures of a society that
can easily crush the individual hu-
man spirit unless persons are re-
garded as individuals and not simply
as statistics. We need a recognition
of the diversity among people, an
honoring of the depths of human
life, and an acceptance of life's limits
and mystery.
My presentation and the contri-
bution of the specialists at the sym-
posium on malignant diseases were
directed to the simplicity and to the
iRUARY 1974, NCMJ
97
profundity of every single human
life — to honor that life, to release its
energies, to respect its ending when
the time comes, and to respect our
common bonds with that life. These
are the central tasks of any com-
munity of care. The individual hu-
man life is the beginning and the end
of our work, regardless of our re-
ligious and philosophical traditions.
James Agee, that perceptive
Southern writer who understood the
caring of one person for another, de-
scribed the dignity of human life
that provides the impetus for care:
All that each person is, and experi-
ences, and shall never experience, in body
and mind, all these things are differing
expressions of himself and of one root,
and are identical: and not one of these
things nor one of these persons is ever
quite to be duplicated, nor replaced, nor
has it ever quite had precedent: but each
is a new and incommunicably tender life,
wounded in every breath and almost as
hardly killed as easily wounded: sustain-
ing, for a while, without defense, tht
enormous assaults of the universe.'
A community of care recognizes
the strengths of the world's assaults,
but the community of persons who
care is ultimately victorious in iti
affirmation that life — the indi-
vidual human life — is what mat-
ters; and finally, it is all that matters.
References
t. Agee J. Evans W: Let us Now Praise Fa-
mous Men. Boston: Houghton Mifflin, 1941
(reprinted. 1960).
In what is called a plethoric state, or too great a fulness of the body, it is likewise dangerous
to use the cold bath, without due preparation. In this case, there is great danger of bursting a
blood-vessel, or occasioning an inflammation of the brain, or some of the viscera. This precau-
tion is the more necessary to citizens, as most of them live full, and are of a gross habit. Yet,
what is very remarkable, these people resort in crowds every season to the seaside, and plunge in
the water without the least consideration. No doubt they often escape with impunity; but does
this give a sanction to the practice? Persons of this description ought by no means to bathe,
unless the body has been previously prepared by suitable evacuation. — William Biichan: Do-
mestic Medicine, or a Treatise on the Prevention and Cure of Diseases by Regimen and Sim-
ple Medicines, etc., Richard Folwell. 1799, p. 42S.
98
Vol. 35. No2
Editorials
I
HOW TO KNOW
WHAT IS GOING ON
With continuing education becoming a requirement
for membership in the North CaroHna Medical So-
ciety, it is important to make sure that many and
varied continuing education opportunities exist for
: our members, and that physicians know when and
1 where these opportunities are available. County medi-
cal societies, specialty groups, medical schools,
' volunteer health associations and others join to offer
i a continuous string of courses, lectures, seminars and
j; symposia. Each month the North Carolina Medi-
I CAL Journal tells you about many of these which
I will take place in North Carolina and our adjoining
I states.
"WHAT? WHEN? WHERE? In Continuing Edu-
i cation," which was mentioned in the "President's
1 Newsletter" for October, appears each month in the
"Bulletin Board" section of the Journal. Continu-
ling Education opportunities which will take place
I during the next five and one-half months are listed,
usually with topic, place, sponsor(s), and where to
write for additional information. Credit available,
, registration, fees and other items of special interest
are given when these are known and considered per-
tinent.
The column is organized in two sections, "In North
Carolina" and "In Contiguous States." The latter, of
course, includes Georgia, Tennessee, South Carolina
'and Virginia. In many instances a doctor in North
Carolina is closer to a good meeting in a bordering
(State than to one in his own state.
The listing period covers from the 15th of the
month, the date when the Journal usually is mailed,
through the following five months. An item is carried
during this entire five and one-half month span if it is
received in time. Items for listing must be received
by the 10th of the month prior to the month in which
they will appear.
WHAT? WHEN? WHERE? is available to help
publicize any activity which has educational potential
for physicians in North Carolina, and/or for those
who work directly with these physicians, if the meet-
ing is within the geographic area specified above,
and if it is "open," rather than restricted to an "in
house" group, such as a board of trustees, school
faculty, committee, or the medical staff of one hos-
pital.
The Journal welcomes any opportunity to in-
crease the listing of learning opportunities which are
available to its readers, and of which they otherwise
might not be aware.
To request listing for a learning activity, or if you
would like a copy of "Information for Contributors"
and a form on which to submit information for an
activity you would like listed, write to WHAT?
WHEN? WHERE?, P. O. Box 8248, Durham, North
Carolina 27704.
To find out where the action is in continuing medi-
cal education read "WHAT? WHEN? WHERE?"
each month, in the North Carolina Medical
Journal.
Ron W. Davis, Ed.D.
'ebruary 1974, NCMJ
99
Emergency
Medical
Services
CATEGORIZATION OF
HOSPITAL EMERGENCY DEPARTMENTS
HOW IT WAS DONE IN OHIO
Maurice A. Schnitker, M.D.
Clinical Professor of Medicine
Medical College of Ohio at Toledo
Forty-two hospitals in northwestern Ohio were
studied and categorized by a team of physicians. The
four categories of the National Research Council and
the National Academy of Science were used; Type
I, Major Emergency Facility; Type II, Basic Emer-
gency Facility; Type III, Standby Emergency Fa-
cility; Type IV, Referral Emergency Facility.
At the time of the initial study, there were no
Type I installations in northwestern Ohio. Because
of the study, within a year, 13 of the surveyed hospi-
tals had improved their status. The team chose to
categorize a hospital rather than having the hospital
categorize itself. They thought this was a wise move.
To help in the upgrading of the hospitals, training
programs for nurses in the intensive care unit, coro-
nary care unit, and courses to train technicians for
operating rooms, laboratories and ambulance services
were set up at the Medical College of Ohio. The city
of Toledo adopted training requirements for ambu-
lance technicians and set up a monitoring service.
The author thought this program was a step for-
ward in improving emergency medicine.
Abstracted by George Johnson, Jr., M.D.
From "Emergency Medicine Today." The original
article may be obtained from the American Medical
Association, 535 North Dearborn Street, Chicago.
Illinois 60610.
Committees and
Organizations
I
COMMITTEE ON PEER REVIEW
September 28, 1973
The following motions were approved, in effect;
That the committee serve as a coordinating body
to meet at frequent intervals with the review com-
mittees involved with claims review to coordinate the
problems. The committee would make certain educa-
tional efforts as are deemed necessary in the particu-
lar cases. If they cannot correct the problem, they
would refer it as a profile to the Mediation Com-
mittee for whatever action they deem necessary.
That the committee recommend to the Executive
Council that a study in conjunction with the licens-
ing board be undertaken to establish authority for the
Executive Council of the Society to take punitive
action in those cases deemed necessary by the Media-
tion Committee. — M. Frank Sohmer, Jr., M.D.,
Chair/jian.
COMMITTEE ON CHRONIC ILLNESS,
TB AND HEART DISEASE
September 26, 1973
Whereas in 1972 reports were made to public
health authorities of 996 new active cases of tubercu-
losis with 60 percent being over the age of 45 ani'
70 percent being male, 130 reactivations of tuber-
culosis and 113 deaths attributed to tuberculosis ir
North Carolina,
And Whereas in 1972 North Carolina had th.
twelfth highest new active tuberculosis case rate i-
the nation (19.1 per 100,000 population compare,
to US rate of 15.8 per 100,000), the committee rec
ommended to the Executive Council that the follow
ing be done;
1. A renewed effort to identify and bring to trea:
ment cases and potential cases of tuberculosis amor;
the population;
100
Vol. 35. No.
2. That where treatment is indicated every attempt
be made to select, with appropriate consultation and
laboratory investigation as necessary, an adequate
regimen of anti-tuberculosis drug therapy for a mini-
mum of two years of uninterrupted treatment in the
case of active or probably active disease;
3. That the initial phase of treatment of active cases
covering the period of possible infectiousness should
in most cases take place in a hospital having the nec-
essary medical, laboratory and supporting facilities
for full evaluation and formulation of optimum
drug therapy plans, and
4. That responsibility for supervising the carrying
out of treatment at home and epidemiological investi-
gation of cases including the reporting of new cases
be actively shared with public health authorities.
The tuberculin skin test was recommended as the
initial screening procedure of choice in tuberculosis
case finding.
The committee also decided to re-submit to the
Executive Council their recommendation on the pre-
ventive use of Isoniazid, in effect:
The committee endorses the preventive use of
Isoniazid in those situations where, in the opinion of
the individual's physician, or one or more physicians,
experienced in tuberculosis, such would be in the best
interest of the health of the individual, his family or
community from the point of view of preventing
further spread of infection. Those included may fall
into one of the following groups:
1. Infants and young children with a history of
household exposure to an infectious case of tubercu-
losis;
2. Recent close household older child and adult
contact of an infectious case of tuberculosis who have
significant tuberculin hypersensitivity;
3. Previously untreated children 20 years of age
and under who have significant tuberculin hyper-
sensitivity;
4. Known recent tuberculin converters of any age
who have significant tuberculin hypersensitivity;
5. Certain medical situations involving uncon-
trolled diabetes mellitus, silicosis and those with pep-
tic ulcer about to undergo gastrectomy where the pa-
tient has significant tuberculin hypersensitivity and
for those who are placed on corticosteroid therapy;
6. Certain previously untreated or inadequately
treated, inactive or quiescent cases of tuberculosis;
7. The committee recommends in each situation
that the risk of known side effects of Isoniazid be
evaluated against the possible advantage to the indi-
vidual and community before deciding to institute
therapy, and that when Isoniazid is prescribed,
periodic (monthly) inquiries be made of patients re-
ceiving it in order to detect occurrence of any ad-
verse side effects as early as possible.
The committee reviewed and approved the "Re-
ferral and Treatment" form (DHS-1500) of the De-
partment of Human Resources, Division of Health
Services, as was presented, and recommended the fol-
lowing to the Executive Council:
That the Society continue to endorse home health
services and recommend the development and exten-
sion of home care to areas not having these services
at the present time.
The committee also discussed the desirability of
having a medical director for long-term facilities, as
well as the guidelines of what the director should do
with the following recommendations to the Executive
Council:
That the Society endorse the principle that long
term care facilities in North Carolina employ the ser-
vices of a physician to serve as medical director.
That the Society endorse the "Guidelines for a
Medical Director in a Long Term Care Facility" as
adopted by the AMA and that copies of these
"Guidelines" be forwarded to the N. C. Department
of Human Resources and to the N. C. Health Fa-
cilities Association with the recommendation that
these respective agencies and organizations take
similar action of endorsement. — Dirk Verhoeff,
M.D., Chairman
Elfl
ate c
sisi J
3tei?»
Another class of patients, who stand peculiarly in need of the bracing qualities of cold water,
is the nervous. This includes a great number of the male, and almost all the female inhabitants
of great cities. — William Biicluin: Domestic Medicine, or a Treatise on the Prevention and Cure
of Diseases by Regimen and Simple Medicines, etc. Richard Folwell, 1799, p. 428.
•EBRUARY 1974. NCMJ
101
Bulletin Board
In Continuing Education
Februan' 1974
("Place" and "sponsor" are listed only where these dif-
fer from the place and group or institution listed under
"for information." )
In North Carolina
February 15-16
31st Annual Watts Medical and Surgical Symposium
Place: Durham Hotel & Motel, Durham
Sponsor: Watts Hospital Medical Staff
For Information: Clarence Bailey, M.D.. 1824 Hillandale
Road, Durham 27705
February 20
Second District Medical Society Annual Meeting
Place: Ramada Inn, New Bern
Scientific Session — 2:00 p.m.; banquet — 7:00 p.m., speaker,
George Gilbert, M.D., President, North Carolina Medi-
cal Society
For Information: Zack J. Waters. M.D., 800 Hospital Drive,
New Bern 28560
February 20 & 27
First District Medical Society Symposium — the last of a
series of seven meetings
February 20 — Current Concepts in Diabetes, and Review
of Thyroid Disease
February 27 — Medicare and Medicaid; Physician Profile;
this also is "Ladies Night"
Sponsors: First District Medical Society; Division of Health
Affairs. ECU; in cooperation with .Albemarle Human Re-
sources Development System and the North Carolina
Regional Medical Program
Place: Queen Anne's Restaurant, Edenton
Time: 4:00-9:00 p.m.. including two scientific sessions and
dinner
For Information: Miss Patricia Garton, P. O. Bo.x 589.
Edenton 27932
March 6-7
Gastrointestinal Endoscopy: Diagnostic & Therapeutic .Ap-
plications
Sponsor: Division of Gastroenterology, U.N.C. School of
Medicine
Speakers will include: Hiromi Shinya, M.D., Beth Israel
Hospital, New York, and Col. H. Worth Boyce, Jr.. M.C..
President, .American Society for Gastrointestinal Endos-
cop\, plus speakers from Bowman Gray, Duke and U.N.C.
School of Medicine. The program will utilize workshops,
lectures and demonstrations
Eligibility: Enrollment limited
Fee: $75
For Information: Oscar L. Sapp III. M.D.,
for Continuing Education, School of
Chapel Hill 27514
March U-IS
(With a follow-up meeting on May 17th)
Practical Approaches to Diabetic Care
Place: Carrington Hall
Associate Dean
Medicine, UNC,
102
Eligibility: Open to all registered nurses
Fee: $150.00; James M. Johnston awards available to cover
up to $ 1 40.00 of the tuition, on the basis of need
For Information: Patricia Lawrence, R.N., UNC-CH School
of Nursing, Chapel Hill 27514
March 14
Malignant Disease Symposium on Carcinoma of the Lung
Sponsors: Department of Surgery and the Office of Con-
tinuing Education
For Information: Miss Ann Francis. Administrative As-
sistant, Office of Continuing Education, School of Medi-
cine, UNC, Chapel Hill 27514
March 15-16
Tenth Annual E. C. Hamblen Symposium in Reproductive
Biology and Family Planning. Basic themes: The Manage-
ment of High-Risk Obstetrics and Newer Advances in the
Treatment of Infertility
Sponsor: Department of Obstetrics and Gynecology
Tuition: $25.00; no charge for residents or students
For Information: Charles B. Hammond. M.D., P. O. Box
3143, Duke University Medical Center. Durham 27710
March 21-23
Hematology and Oncology Post Graduate Course
Place: Duke University School of Medicine
Director: Wayne Rundles, M.D.. Professor of Hematology.
Duke University.
For Information and registration forms: American College
of Physicians, 4200 Pine Street. Philadelphia, Pennsvl
vania 19104
.March 25-27
Tutorial Postgraduate Course: Radiology of the Chesi
This course is designed both for radiologists in trainin.
and those in practice. The tutorial format and limiteJ
registration will allow a larger than usual faculty-studeni
ratio and personalized instruction to those enrolled. Gue^
faculty have been chosen both for their excellence in then
respective topics, and for their effective use of the tutori.;
approach. During one hour tutorial sessions 12 registrant
will join one faculty member in a separate quiet roon
with a hank of viewboxes for organized film reading-di-
cussions. with 10-12 case presentations on a basic subjet
or two. Registrants are invited to bring interesting case
for consultation with the "experts."
Place: Durham Hotel & Motel, Durham
Credit: 2! hours AMA "Category One" accreditation
Fee: $200.00
For Information: Robert McLelland, M.D., Department o
Radiolocv, Box 3808, Duke University Medical Center
Durham 27710
March 26-28
Cardiac Arrhythmia Course
Place: Duke Hospital Orthopedic Clinic. Room 1367
For Information: Galen Wagner, M.D.. Box 3327, Duk
University Medical Center, Durham 27710
March 28
Wilson Memorial Hospital Symposium on Obesity, Nuti:
tion & Physical Fitness
Sponsors: Wilson County Medical Society and the Nort
Carolina .Academy of Family Physicians
For Information: Gloria Graham. M.D., Wilson Memor:.
Hospital, Wilson 27893
Vol. 35, No.
April 1-2
Postgraduate Course: Obstetrics and Gynecology
Place: Babcock Auditorium
For Information: Emery C. Miller, M D., Associate Dean
for Continuing Education, Bowman Gray School of
Medicine, Winston-Salem 27103
April 27
iCraven-Pamlico Annual Medical Society Symposium
Place: Ramada Inn, New Bern
For Information: Zack J. Waters, M.D., 800 Hospital Drive.
New Bern 28560
May 4-5
Principles of Practical Oxygen Therapy
Sponsors: Department of Anesthesiology in cooperation with
the Office of Continuing Education
For Information: Miss Ann Francis. Administrative As-
sistant, Office of Continuing Education, School of Medi-
cine, UNC, Chapel Hill 275 1 4
May 8-9
fBreath of Spring '74 — Respiratory Care Symposium
Place: Babcock Auditorium
\i .,PoT Information: Emery C. Miller, M.D., Associate Dean
« . for Continuing Education. Bowman Gray School of Medi-
cine. Winston-Salem 27103
|{ May 14-16
J jThe Neuro-endocrinology Symposium: Neurobiology of
■; . CNS — Hormone Interaction
i, j>lace: UNC Student Union Building. Great Hall
sponsors: UNC Neurobiology Program and Laboratories
for Reproductive Biology
-or Information: Miss Ann Francis. Administrative As-
j( (, sistant. Office of Continuing Education, UNC School of
; Medicine. Chapel Hill 27514
May 15
Ethel Nash Day Program
' Place: Clinic Auditorium Time: 1 :00-5:30 p.m.
K (iponsor: Department of Obstetrics and Gynecology
-or Information: Miss Ann Francis. Administrative As-
( 1 sistant. Office of Continuing Education. UNC School of
,,;„ Medicine. Chapel Hill 27514
May 16-18
-, Jasic Mechanisms in Hypertension
.. ,'lace: Babcock Auditorium
,,, .ponsor: American Heart Association Basic Science Council
.; I'or Information: Emery C. Miller. M.D.. Associate Dean
-; .. for Continuing Education. Bowman Gray School of Medi-
.; '. cine, Winston-Salem 27103
, May 28-31
m n'ourth postgraduate course in Head & Neck Anatomy
Cv :iiponsors: Department of Anatomy, School of Medicine, in
ifcj.i" cooperation with the Division of Continuing Education.
»i' East Carolina University
ee: $125.00; students in residency programs $75.00
ligibility: Open to holders of any of following degrees:
M.D., D.D.S., D.M.D.. Ph.D.
redit: Approved for 28 hrs. AAFP elective hours: CE
.:: I units also given by Division of Continuing Education.
col: £ ECU
or Information: Head & Neck Anatomy Course. ECU Di-
vision of Continuing Education, P. O. Box 2727. Green-
ville 27834
May 29-30
Di fiypertension: Critical Problems — 25th Annual Meeting and
Scientific Sessions, North Carolina Heart Association
ace: Hyatt House and Convention Center, Winston-Salem
esigned especially for nurses and physicians
v.. t)3r Information: North Carolina Heart Association, 1 Heart
Circle, Chapel Hill 27514
^ ^ June 12-15
;0 :i;urology for Practicing Physicians
ace: Babcock Auditorium
Sponsor: American College of Physicians
Fee: Members, residents and research fellows $120; non-
members $175; associates $60.
For Information: Emery C. Miller. M.D., Associate Dean
for Continuing Education, Bowman Gray School of Medi-
cine, Winston-Salem 27103
July 29-August 2
2nd Annual Beach Workshop: Selected Topics in General
Internal Medicine
Sponsors: Bowman Gray. Duke and UNC Schools of Medi-
cine, in conjunction with the Medical University of South
Carolina
Place: St. Johns Inn. Myrtle Beach. South Carolina
Fee: $100
For Information: Emery C. Miller. M.D.. Associate Dean
for Continuing Education. Bowman Gray School of Medi-
cine. Winston-Salem 27103
In Contiguous States
February 21-23
Annual Meeting of the Virginia Chapter of the American
Academy of Pediatrics
Place: Colonial Williamsburg
Program: Friday night banquet guest speaker — Dr. James B.
Gillespie. President. American Academy of Pediatrics.
Friday and Saturday scientific sessions include: New
Trends in Management of Respiratory Distress; Suppor-
tive Therapy for the Child with Inborn Error of Metabo-
lism; Non-Bacterial Respiratory Tract Infections; Sudden
Infant Death Syndrome; Viral Vaccines; Adaption in
School of the Child with Borderline Cerebral Handicaps.
For Information: James H. Stallings. Jr.. M.D.. 6503 North
29th Street. Arlington. Virginia 22213.
March 7-9
Sports Medicine Problems in All Age Groups
Place: Page Auditorium. Duke University. Durham
ANESTHESIOLOGY
PLACEMENT
SERVICE
For Locations in North Carolina desir-
ing the services of an anesthesiologist and
for anesthesiologists wishing to locate or
reloiate in North Carolina
CONTACT:
Placement Service
N. C. Society of Anesthesiologists
Department of Anesthesiology
North Carolina Memorial Hospital
Chapel Hill, North Carolina 27514
iBRUARY 1974. NCMJ
103
Sponsor: American Academy of Orthopaedic Surgeons
Fee- $150.00; residents $50.00 ^^ , r
For Information: The American Academy of Orthopaedic
Surgeons, 430 North Michigan Avenue, Chicago, lUinois
606"i 1
March 10-14
Postgraduate Course in Gastrointestinal Radiology
Place: Williamsburg Conference Center, Williamsburg, Vir-
Sp^mors: Department of Radiology and the Department
of Continuine Medical Education
Fee- $17vOO: $"75.00 for residents
For Information: Department of Continuing Education.
Medical College of Virginia. Bo.x 91. MCV Station, Rich-
mond, Virginia 23298
April 5-6
AMA-Southeast Regional Mental Health Conference
Place: Marriott Hotel, .Atlanta, Georgia
Sponsors: AMA Council on Mental Health and the com-
mittees responsible for mental health in the state medical
associations of Florida, Georgia, Kentucky, North Caro-
lina. South Carolina and Tennessee
For' Information: Philip G. Nelson, M.D.. Medical Pavilion.
Greenville 27834
April 16
Fourth Annual Charles W. Thomas Lecture
Place: Georce Ben Johnston .Auditorium
Sponsor: Division of Connective Tissue Diseases
For Information: Department of Continuing Education,
Medical College of Virginia, Bo.x 91, MCV Station, Rich-
mond, Virginia 23298
April 20-24
"Selection of Materials for Reconstructive Surgery," the
Sixth International Biomaterials Symposium
Designed to bring together clinicians in orthopedics, oral
surgery, plastic and reconstructive surgery with leading
researchers in biomaterials, biomechanics, biophysics and
experimental surgery
Place- Clemson Universitv, Clemson. South Carolina
For Information: Dr. Samuel F, Hulbert. Dean of Eiigi-
neering, Tulane University, New Orleans, Louisiana 70118
May 6-9
The Treatment of Coronarv S\ndromes
Place- Roval Coach Motor Hotel, Atlanta. Georgia
Sponsors- 'American Heart Association Council on Clinical
Cardiology and the Department of Medicine of Emory
University School of Medicine
For Information: Miss Mary Anne Mclnerny. Director, De-
partment of Continuing Education Programs, American
College of Cardioloay, 9650 Rockville Pike. Bethesda.
Marvland 20014
Items submitted for listing should be sent to: WH.AT?
WHEN' WHERE', P. O. Box 8248, Durham, NC, 27704,
by the 1 0th of the month prior to the month in which
they are to appear.
News Notes from the—
BOWMAN GRAY SCHOOL
OF MEDICINE
WAKE FOREST UNIVERSITY
One associate professor and five assistant profes-
sors are among those newly appointed to thie faculty
of the Bowman Gray School of Medicine.
Dr, Nitya R. Ghatak, associate professor of patho-
logy, is a native of India and holds the M.B.B.S.
degree from Nilratan Sircar Medical College of the
104
Rondomycin
(methacycline HCI)
CONTRAINDICATIONS: Hypersensitivity to any of the tetracyclines
WARNINGS: Teliacycline usage during tooin development (last nail ol pregnancy to eig ■
years) may cause permanent lootli Oiscoloralion (ycllow-gray-orowni, wtiicn is mc
common during long-ierm use t)ul nas occurred alter repealed short-term course,
Enamel hypoplasia has also been reported Tetracyclines should not be used in tliis ag
group unless oltier drugs are not likely to be elfeclive or are contraindicaled
Usage in pregnancy. (See above WARNINGS about use during tooth developmen
Animal studies indicate thai tetracyclines cross me placenta and can be toxic lo the c:
veloping lelus loHen related lo retardation ol skeletal develdpment) Embryotoxicity r
also been noted m animals Ireated early in pregnancy
Usage in newborns, infants, and ctiildren. iSee above WARNINGS aboul use dur
tooth development 1
All tetracyclines lotm a stable calcium complex m any bone-lorming tissue A decree ,
in libJia growth rate observed m prematures given oral lelracycline 25 mg/kg ever,
hours was reversible when drug was discontinued
Tetracyclines are present m milk ol laclatmg women taking tetracyclines
To avoid excess systemic accumulation and liver toxicity in patients with impaired re
tunclion reduce usual total dosage and il therapy is prolonged consider serum level
terminations ol drug The anti-anabolic action ol tetracyclines may increase BUN V.'
not a problem in normal renal function, m patients with signilicantly impaired tunct
higher tetracycline serum levels may lead to azotemia, hyperphosphatemia, and acido;
Photosensitivity manilesled by exaggerated sunburn reaction has occurred with tei
cyclines Patients apt to be exposed to direct sunlight or ultraviolet light should be so -
vised and treatment should be discontinued at lirst evidence ol skm ervthema
PRECAUTIONS- It supetinlection occurs due to overgrowth ol nonsusceptible organis-
inciuding lungi. discontinue antibiotic and start appropriate therapy
In venereal disease when coexistent syphilis is suspected, perform darklield exa
nation belore therapy, and serologically lest lor syphilis monthly lor at least lour mom-
Tetracyclines have been shown to depress plasma prothrombin activity patients on
ticoagulant therapy may require downward adjustment ol their anticoagulant dosage
In long-term therapy, perloim periodic organ system evaluations (including blo^
renal, hepatic)
Treat all Group A beta-hemolytic streptococcal infections for at least 10 days
Since bacteriostatic drugs may interfere with the bactericidal action ol penicillin av
giving tetracycline with penicillin
ADVERSE REACTIONS: Gastrointestinal (oral and parenteral lorms) anorexia, naus
vomiting, diarrhea glossitis dysphagia enlerncolitis. intlammatory lesions (with mc
lal overgrowth) in the anogenital region
Skin: maculopapular and erythematous rashes, exiolialive dermatitis (uncommon) P
tosensitivity IS discussed above (See WARNINGS)
Renal toxicity rise in BUN apparently dose related (See WARNINGS)
Hypersensitivity; urticaria, angioneurotic edema, anaphylaxis, anaphylactoid purp.
ppricardilis exacerbation ol systemic lupus erythematosus
' Bulging lontanels reported m young inlanls alter lull therapeutic dosage, have di: i
peared rapidly when drug was discontinued
Blood- hemolytic anemia, thrombocytopenia, neutropenia, eosinophilia
Over prolonged periods, tetracyclines have been reported lo produce brown-black
croscopic discoloration ol thyroid glands, no abnormalities ol thyroid lunction studies
known to occur „,..«.< h.,
USUAL DOSAGE- Adulls-600 mg daily divided into two or lour equally spaced do -
More severe mlections an initial dose ot 300 mg followed by 150 mg every six hou-
300 mg every 12 hours Gonorrhea In uncomplicated gonorrhea, when penicillin is
traindicaled Rondomycin (methacyclme HCI) may be used for treating both males
temales in the lollowmg clinical dosage schedule 900 mg initially, lollowed by 300
q 1 d lot a total ol 5 4 grams
For treatment ot syphilis, when penicillin is contraindicaled, a total ol « >o 24 gram:
■Rondomycin- (methacycline HCI) in equally divided doses over a period ol 10-15 0=
should be given Close loliow-up, including laboratory tests, is recommended '
Eaton Agent pneumonia 900 mg daily lor six days
Children - 3 to 6 mg,'lb,'day divided into two to lour equally spaced doses
Therapy should be continued lor at least 24-48 hours alter symptoms and lever hi
cincomilani therapy: Antacids containing aluminum, calcium or magnesium impair i
sorption and are contramdicated Food and some dairy products also interfere I3ive fli
one hour belore or two hours alter meals Pediatric oral dosage lorms should not
given with milk lormuias and should be given at least one hour prior to feeding
In patients with renal impairment (see WARNINGS!, total dosage should be decrea!
by reducing recommended individual doses or by extending time intervals betv/i
°m slieplococcal mlections a therapeutic dose should be given lor at least 10 days.
SUPPLIED: Rondomycin (methacycline HCI) 150 mg and 300 mg capsules, syrup c
taming 75 mg:5 cc methacycline HCl
Belore prescribing, consull package circular or lalesi PDR inlormalion,
iTfi WALLACE PHARMACEUTICALS
^^ * CRANBUBY.NE)A/ JERSEY 08512
Rev
Vol. 35, Nt
Oniversity of Calcutta. He was an intern and resident
n internal medicine at the Nilratan Sircar Medical
;!ollege and was a rotating intern at Griffin Hospital,
Darby, Conn. He took residency training in pathology
It Montefiore Hospital and Medical Center in New
Iifork City, where he was also a trainee in neuro-
)athology.
Before joining the Bowman Gray faculty, he was
m associate neuropathologist at Montefiore Hospital
ind Medical Center and an assistant professor of
)athology at the Albert Einstein College of Medi-
:ine.
Also receiving appointments were Dr. Jerome J.
Cunningham, assistant professor of radiology (uro-
iiiadiology) ; Dr. Jack L. Mason, assistant professor
■'i the medical school's allied health program; Dr.
':)ixon M. Moody, assistant professor of radiology
;neuroradiology); Dr. Darwin W. Peterson, assis-
ant professor of physiology; and Dr. Roger F.
Jffarker, assistant professor of physiology and phar-
lacology.
Also, Daniel R. Beerman, instructor in pediatrics
;■ social work).
* * *
Dr. Felda Hightower, professor of surgery, has
een elected treasurer of the Southern Surgical Asso-
ation for the 10th year. Dr. Hightower also is serv-
; i,ig his 10th year as editor of Transactions of the
'irgical Association.
; 1 * * *
Dr. Hugh B. Lofland, professor of pathology, has
';en elected to a three-year term on the Executive
: Jommittee of the Council on Arteriosclerosis, Ameri-
' in Heart Association.
l< 1^ ^ ^
; J Dr. Richard B. Patterson, associate professor of
,;diatrics, has been appointed to the Governor's
ommission on Sickle Cell Syndrome.
Dr. Lawrence R. DeChatelet, associate professor
biochemistry, chaired a session on "Structure,
jnction and Biochemical Activities of RE Cells" at
e 10th annual meeting of the Reticuloendothelial
'iciety, Dec. 5-8 in Williamsburg, Va. He also pre-
nted a paper entitled "Superoxide Dismutase
• OD) Activity in Phagocytic Cells" during the
;eting.
* * *
^Dr. Frank C. Greiss, Jr., professor and chairman of
:; Department of Obstetrics and Gynecology, was
airman of the Section on Obstetrics at the Southern
:dical Association meeting in San Antonio, Tex.
• was moderator for a panel on "Sexual Function
iring Pregnancy" during the meeting.
* * *
Dr. Henry S. Miller, Jr., professor of medicine, pre-
i ited a paper entitled "Effect of Exercise on Circu-
1 ion" during the 25th annual meeting of the Ameri-
I 1 Heart Association in Atlantic City, N. J.
Dr. B. Moseley Waite, associate professor of bio-
chemistry, presented a seminar entitled "Heparin
Stimulated Release of Phospholipase AT' to the De-
partment of Nutrition at the Harvard School of Pub-
lic Health in November.
News Notes from the —
UNIVERSITY OF NORTH CAROLINA
DIVISION OF HEALTH AFFAIRS
The following appointments have been made in
the School of Medicine:
David L. Ingram, assistant professor. Department
of Pediatrics, has been associated with The Children's
Hospital Medical Center and Beth Israel Hospital.
He holds the A.B. from Harvard University and M.D.
from Yale University.
Anthony Cole, visiting instructor. Department of
Family Medicine, is a native of England and received
his medical training at King Edward VI School and
St. Mary's Hospital, University of London.
Frances C. Driver, instructor. Department of Psy-
chiatry, and assistant director. Day Hospital, holds
the B.S. from Montana State University and the
M.D. from the University of Rochester. She spent
the last three years as a resident at N. C. Memorial
Hospital.
School of Dentistry:
Harold B. Wise, assistant professor. Department
of Operative Dentistry, has been in private practice in
Fort Worth, Texas for the past four years. He re-
ceived his undergraduate degree from Texas Chris-
tian University and his dental training at Baylor
University College of Dentistry.
School of Nursing:
Margaret E. Campbell, assistant professor, comes
to UNC from UNC-Greensboro, and received her
B.S. and M.S. in nursing from the University here.
* * *
A research fellowship has been established in the
UNC Department of Parasitology in Chapel Hill by
Becton, Dickinson and Co. of the Research Triangle
Park, N. C.
The $20,000 award will support a doctor of public
health candidate in laboratory practice for the three
year program. The first fellowship will be announced
in 1974.
^ ^ ^
Dr. Bernard G. Greenberg, dean of the UNC
School of Public Health and Kenan Professor of Bio-
statistics here, has been elected to the Council of the
Institute of Medicine, National Academy of Sciences.
The Council is the governing body of the Institute
of Medicine and consists of 21 members chosen from
among the current membership of 215. Organized in
1971 under the National Academy of Sciences, the
muARY 1974, NCMJ
109
Institute is concerned with the protection and ad-
vancement of the health and medical professions and
sciences, and the promotion of biomedical research
and development.
The Council of the Institute of Medicine meets
every two months to guide the work of the Institute
and to plan its program and policy in conjunction
with the Governing Board of the National Research
Council.
Richard Shachtman. biostatistician in the School
of Public Health, has been awarded a $32,820 Na-
tional Institutes of Health grant to study the long-
term complications of induced abortions.
Shachtman is analyzing data collected on 948
women whose first pregnancies were either carried
to term or terminated by legal abortions. He will
study the relationships between abortions and future
pregnancies. In his research he will use a Markov
Chain, a statistical technique which treats data in
chronological fashion in order to test whether certain
biological factors are dependent on other biological
happenings.
Shachtman said that they hope to provide a de-
scription of these interrelationships, a tool for predic-
tion and answers to some questions concerning the
risks of abortions.
* =j= ^
Dr. Bernard G. Greenberg, dean of the UNC
School of Public Health, was a consultant to the
World Health Organization in Geneva during the
beginning of December. The sessions Greenberg at-
tended were part of a conference on family planning
statistics.
* * *
The following resignations have been announced
in the School of Medicine;
Howard D. Stowe, associate professor. Department
of Pathology, resigned to accept a position in Au-
burn, Alabama.
Jean L. Gueriguian, assistant professor. Depart-
ment of Pharmacology, resigned to accept a position
at the University of Minnesota at Duluth.
News Notes from the —
DUKE UNIVERSITY MEDICAL CENTER
Ten seniors and six juniors in the School of Medi-
cine have been elected to memberships in Alpha
Omega Alpha, the honorary medical fraternity. Pres-
entations of certificates and keys were made at the
Pound Sterling Restaurant in Durham on Tuesday,
Nov. 13, at the organization's annual banquet.
In addition, a faculty membership was conferred
on Dr. D. Bernard Amos, James B. Duke Professor
and director of the Division of Immunology, and
alumni memberships were presented to Dr. Niche
las G. Georgiade, professor of plastic, maxillofaci;
and oral surgery. Dr. Raymond W. Postlethwai
professor of general and thoracic surgery, and D
A. Jack Tannebaum, an internist in private practit
in Greensboro.
Professor Guido Calabresi, who holds the Job"
Thomas Smith chair at Yale Law School, was gue
speaker at the banquet as Visiting Professor of Leg
Medicine.
Alpha Omega Alpha is composed of medical sti
dents who have demonstrated leadership and ac
demic promise of future achievement and alumr
faculty or honorary members who have distinguisht
themselves in medical teaching, research or practice.
■ Seniors elected were:
Robert Woodward Downs of Greenville, S. C
Isabelle Faeder, James William Mold and Richa
Alan Hopkins of Durham; William Elwood Garr^
Jr. of Roxboro; Arthur Garson Jr. of New Yv
City; Robert Woodrow Gilbert Jr. of Elko, G.
Phyllis Carolyn Leppert of Ridgewood, N. J.; Ste\i
Andrew Paris of Roscindale, Mass.; and John Glci
Scottof Tillar, Ark.
Juniors elected were Michael Joseph Borowitz
Bronx, N. Y.; Michael John Jobin of Sommervil
N. J.; Donald Norman Kapsch of Boca Raton, Fl;
Robert William Novak of Berea, Ohio; Harry Rissl'
Phillips III of Spartanburg, S. C; and Stanley Glei
Rockson of New York City. jl
* jH +
Dennis E. Klima, administrator of the Eye Cenf
and assistant director of the hospital since Septemb"
of 1971, has resigned to accept the post of assista
administrator of Memorial Hospital in Easton. Md,
C. J. "Cy"" Rodio, former unit administrator
the medical unit and manager of the Medical Oi
patient Clinic, has been named to succeed Klin
as assistant administrative director of the hospil
and administrator of the Eye Center.
Wallace E. Jarboe, director of Hospital Planni!
Studies since February 1971, has been named din-
tor of the newly established Hospital Project Manai-
ment Office (HPMO).
The new office will centralize all activities, frd
planning through construction to occupation, f
Duke's new $91 million hospital.
Jarboe's appointment was formalized with the U-
versity Board of Trustees' authorization of fundi;
for the office. At the same time the trustees approv!
retention of an architectural firm for the hospil
project.
In addition to Jarboe and three administrative m-
port people, the office will have four other staff j-
sitions, known as assistant directors for administ-
tion, finance, architecture and engineering.
Larry Nelson, currently architect for the Medil
Center Planning Office, will become the assistant -
110
Vol. 35, No^
What^ in the future
for mental health care and how
will it affect you?
Your guides into the future: many prominent experts including
Drs. Ewald Busse and J.M. Stubblebine Topics you'll cover:
the role of private and public sectors in mental health care;
PSROs; health insurance coverage; therapeutic trends; and
service capabilities of state and local facilities.
Do plan to attend this enlightening first conference sponsored
by the American Medical Association Council on Mental Health
and the State Association committees responsible for mental
health in the states of Florida, Georgia, Kentucky, North
Carolina, South Carolina, and Tennessee. Co-sponsors are
the Southern Regional Education Board, District Branches of
the Amencan Psychiatric Association and the State Chapters
of the American Academy of Physicians in the above six states.
Acceptable for 8 credit hours in Category 1 for the Physician's
Recognition Award of the AMA and approved for 8 prescribed
hours by the AAFP.
Register Now!
AMA-Southeast Regional Mental Health Conference
Marriott Hotel / Atlanta, Georgia
April 5-6, 1974
Return to: Dept. of Mental Health; AMA; 535 N.
Dearborn St.; Chicago, III. 60610
n Yes.. .please send me details on the AMA-South-
eastern Regional Mental Health Conference in
Atlanta, April 5-6.
D Registration fee of $25 enclosed. (Make check
payable to AMA)
n I w/ill pay at conference.
Name
Address
Affiliation
City/State/Zip.
rector for architecture. Appointments to the other
positions have not been announced.
Immediately prior to coming to Duke, Jarboe was
a senior medical planner and a vice president of
Georgetown Consultants, a Washington consulting
firm specializing in health-care management and fa-
cility planning. Prior to that he was an Air Force
officer whose 30-ycar career was largely in hospital
and health-care administration.
For five years he was chief of the facilities division,
office of the Air Force Surgeon General, during
which time he was responsible for planning, program-
ming and justifying medical facilities world-wide to
the Air Staff, Department of Defense, Bureau of the
Budget and the Congress.
Norma L. Harris, nurse clinician on the Renal
Transplantation Team, has been nominated by the
N. C. State Nurses' Association for the first Ameri-
can Nurses' Association Honorary Nurse Practitioner
Award. The award winner will be announced in June.
In support of Miss Harris' nomination, 27 doctors,
nurses and patients who have worked with or been
cared for by her over the years have written a stack
of testimonial letters telling of her kindness, concern,
inspiration and extreme competence.
A new breathing mixture for deep sea divr
which could allow men to tap the vast oil resouie
of the ocean floor beyond the continental shelf a
been successfully tested in the hyperbaric chanie
here.
The mixture may allow men to dive to gre.:e
depths than ever before, get there faster and arv
in much better physical and mental condition tha
now possible.
The last in the series of experimental dives a
completed earlier this month, with four men di^n
to 1,000 feet in only 33 minutes — the fastest C'U
pression time to that depth ever used — breathing h
new mixture of helium, oxygen and nitrogen.
They arrived at that simulated depth in the Ig
pressure chamber with none of the usual loss of n r
tal and physical capacity that afflicts divers breh
ing the traditional helium-oxygen mixture, and fe-
returned to surface pressure in a little over 96 hots
This compares to the usual 14-day decompres:oi,
period used by the U. S. Navy for dives to 1,01.
feet.
"To get men down to that depth in only 33 iri
utes and to end up with men who are functiiia
and capable is really quite remarkable and will'e
open the search for new depths to which man ai
go" said Dr. Peter B. Bennett, professor of anestlsi
ology and director of the project.
Month in
Washington
Little noticed amid congressional confusion in
attempting to deal with the energy crisis was the pas-
sage of a major health bill shortly before adjourn-
ment. The bill provides $375 million over five years
to support the development of Health Maintenance
Organizations (HMO's) across the country.
If signed into law by the President, the HMO legis-
lation will go far in determining both consumer and
provider acceptance of pre-paid group health care.
Despite a substantial flow of federal dollars into the
experimental program, HMO's are not expected to
encounter easy sailing. Ardent supporters of the pro-
gram admit the trial period will be a rough one and
caution against over optimism.
The speculation is that the President will sign the
bill inasmuch as the money provided is not far over
what the Administration originally requested, though
the bill is much broader in scope than the President
wished.
Two key provisions of the $805 million bill first
112
approved by the Senate earlier this year were del
or watered-down in conference enough to makcffi
measure more palatable to the administration, ffi
would have authorized federal subsidization of H(C
premium costs for people who couldn't afford a o|
part of the cost. The other controversial Senate %i
tion would have created an independent Commisca
on Quality Health Care Assurance to supervisete
HMO program. The compromise bill vests thi.^re-
sponsibility with the Assistant Secretary of HEW'oi
Health.
To qualify for federal aid, HMO's must nu
long list of federal standards of minimum ben.ts.
stay open 24 hours a day, provide open enrollnnt
and conform to numerous other requirements n
duccments are provided to attract people from ,io
and rural areas.
The Senate provision authorizing grants to i
HMO's in meeting operating deficits during the i :
three years of operation was knocked out of the w
Vol. 35, h. 1
i
loan fund was retained to aid HMO's
m
„il, but a
[/meeting "a portion of initial operating costs in
j[,;ess of gross revenues."
Co-payments were barred under tfic Senate bill.
j;,wever the conference agreed to allow HMO's to
jijirge nominal co-payments, but not to the extent
ijjjy could be considered a barrier to seeking treat-
nt. The conference committee said the co-pay-
;,nts are aimed at enabling an HMO "to market
Ij,; benefit package at a competitive price."
cj.rhe final bill requires larger employers to offer
ijjrkers an HMO option when existing contracts for
'"ilth insurance expire provided that a qualified
^ 10 is operating in the area.
fjrhe bill does not provide a specific number of
[f^lO's, but the bill's legislative history indicates the
Ijngress had in mind around 100 programs.
koo * * *
««Xep. John Rarick (D., La.), principal congres-
1' lal sponsor of legislation to repeal the Professional
ndards Review Organization (PSRO) program,
iiTi dispatched a letter to all members of the House
:ibiing their support.
■Un his letter, Rarick said PSRO "is the hottest con-
in'versy facing medical doctors and their patients.
sllltj American Medical Association's prestigious
I use of Delegates yesterday voted to seek congres-
laal repeal of this controversial peer-review law
i goes into effect on January 1, 1974."
larick quoted AMA President-elect Malcolm C.
3d, MD, as calling PSRO ". . . the greatest threat
che private practice of medicine of any piece of
slation ever passed by congress."
The PSRO section of Medicare was added by the
ate and was never adequately debated, the law-
yer said. "The House did not even hold public
rings on this issue."
karick cited the Wall Street Journal's statement
li'PSRO — that points out that "the controversial
slation is laced with pointed references to 'new
'gations imposed on' medical practitioners. It re-
jj'es physicians to open their private files and hos-
1 records to outside inspectors. Strong financial
*btions are provided for physicians who fail to com-
r\'is
1E«:
wit]
enii
Larick wrote that he is concerned over the effect
he legislation on private medical practice in this
itry. "I am convinced that the medical profcs-
has done an outstanding job of policing its own
ession and establishing a high code of ethics,
'imply does not make sense to bog down the medi-
profession with further government intervention
threatens the relationship between doctor and
*ent."
,, I; he first round of congressional hearings on Na-
i,:|ijil Health Insurance (NHI) concluded following
.1.1, eek of testimony from experts in the health-
: lomic field who laid a general philosophical foun-
dation for full-scale legislative sessions early in the
new year.
The hearings by the House Health Subcommittee
were the opening gun in what promises to be a busy
1974 in congress on the issue of an NHI bill.
The Subcommittee, headed by Rep. Paul Rogers
( D., Fla. ) , has charted six weeks of further testimony
in January and February that will consider specific
legislative proposals. The House Ways and Means
Committee also is slated to explore NHI sometime
next year. Senate sessions are expected to open during
the winter or spring by both Senate Finance and
Senate Labor and Public Welfare Committees.
The next major development in the field will be
the formal disclosure of the details of the Administra-
tion's new plan, expected to be unveiled in President
Nixon's January State of the Union speech to con-
gress and probably in a special message to congress
on health.
The new Administration plan will be more liberal
than the previous one, but it will continue to be based
on the principle of requiring employers to furnish
comprehensive health insurance to their workers. The
major changes are a broad catastrophic provision tied
to income and federal subsidization of premiums for
all poor people. Medicare and Medicaid, apparently,
would lose their separate identities and become part
of the new program under the jurisdiction of the
Public Health Service.
According to Budget Director Roy Ash, NHI
should be kept to a size that will avoid creating more
demands for health services than can be met with
existing resources. Otherwise, he said in an interview
with the New York Times, there is a danger that the
sole accomplishment would be an increase in the
prices of health sen/ices.
Many of the witnesses before Roger's Subcom-
mittee predicted that a financing mechanism for NHI
without other provisions would add to inflation of
health care costs without much impact, if any, on the
health of Americans. Other experts questioned
whether any type of NHI would improve health, con-
tending that environment, life styles, poverty, etc.,
are to blame for poor health conditions.
The closest approach to a consensus was that too
much hope should not be placed in an NHI program
to solve the health care problems of the nation.
One of the final witnesses, Robert J. Myers, former
Chief Actuary of the Social Security Administration,
denied there has been any crisis in health care costs,
asserting that health has simply been caught up in
the "general price and wage inflation resulting from
the Viet Nam war, plus the more rapid wage increases
of hospital personnel . . . plus the historical trend
of medical care costs rising more rapidly than the
general price level. . . ."
Myers said there is "far too much" first dollar
coverage in private health insurance and not enough
catastrophic coverage. Catastrophic, he said, "is
/UARY 1974, NCMJ
113
sorely needed by most Americans" and should vary
with income and assets.
"I am convinced that cost-sharing provisions,
properly designed can have a beneficial effect in pre-
venting overutilization without being an unjust eco-
nomic barrier that will result in preventing the in-
sured from receiving necessary medical care. . . .""
Under a sv/eeping NHI such as proposed by Sen.
Edward Kennedy (D., Mass.), and labor "the pro-
viders of services might rebel if the financial screws
on them are tightened too rapidly or too much, or
the beneficiaries might rebel if they are regimented
or controlled too much as to their desires for medical
services," Myers told the subcommittee.
Herbert Dencnberg, Pennsylvania Commissioner
of Insurance, asked for strict cost and quality con-
trols in any NHI program. "Pumping more dollars
into a health care system with serious structural short-
comings will aggravate present problems."
Earl Brian, MD, California Secretary of Health,
stressed that the cooperation of organized medicine
and other health providers is necessary for an NHI
program to work. Otherwise, the nation's health care
system will deteriorate, he said. As many responsi-
bilities as possible should be left to the providers,
according to Dr. Brian. He cited the cooperation of
organized health groups in California despite state
controls that have "alienated the health care com-
munity." The demand for medical care will always
exceed the dollars available, he said, so any program
must contain restrictions which relate it to the free
market system. The present concern over Profes-
sional Standards Review Organizations is only a har-
binger of what would happen if a bureaucratic NHI
were enacted and demonstrates the "imprudence of
permanent government controls," he asserted.
Sen. Edward Kennedy's Health Subcommittee
hearings on the drug industry lived up to their ex-
plosive expectations with HEW Secretary Casper
Weinberger throwing the first bomb by announcing
that the Administration would propose a cost-saving
drug plan for Medicare and Medicaid patients under
which reimbursement would be limited to "the lowest
cost at which the drug is generally available."
Estimating the savings at $25 to $60 million
a year, the HEW proposal was a blow to the phar-
maceutical industry which viewed it as a step toward
generic prescribing and a setback to the brand name
concept. Congress would have to approve the pro-
posal, however.
Under questioning from subcommittee members,
Weinberger was vague about how the program would
work, but emphasized that physicians would remain
free to prescribe as they choose. Sen. Kennedy
praised the proposal. Sen. Gaylord Nelson (D. Wis.)
said the HEW recommendation "must be only the
first step in a massive intrusion by the federal govern-
ment into the prescribing habits of physicians."
114
PRESCRIBING INFORMATION
Antiminth (pyrantel pamoate) Oral
Suspension
Actions, .\ntiminth (pyrantel pamo-
ate) has demonstrated anthelmintic
activity against Enterobius 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. 13|ig/ml.) are reached in 1-3
hours. Quantities greater than 507o
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 SGOT 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: .\ntiminth Oral
Suspension (50 mg. of p\rantel 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 bodv weight. (One teaspoonful
= 5cc.)
.Antiminth (pyrantel pamoate)
Oral Suspension may be adminis-
tered without regard to ingestion of
food or time of day: and purging is
not necessar)' prior to, during, or
after therapy. It may be taken with
milk or fruit juices. Because of lim-
ited data on repeated doses, no rec-
ommendations can be made.
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.
ROeRIG<®
A division o1 Plizer Pharmaceuticals
New York. New York 10017
i)RNSBLnZED
A single dose of Antiminth
( 1 cc. per 10 lbs. of body
weight, 1 tsp,/50 lbs.— max-
imum dose, 4 tsp=20 cc)
offers highly effective control
of both pmworms and
roundworms.
Antiminth has been shown
to be extremely well tolerated
by children and adults alike
m clmical 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 Rizer Pharmaceuticals
New York. New York 10017
Hnwonns,ix>iindworms controlled
with a single, non-staining dose of
ANTIMINTH
(pyrantel pamoate)
^n file at Roerig.
equivalent to 50 n"vg. pNraiitel/iTvl
ORAL SUSPENSION
Please see prescribing information on facing page.
a
The first day's session featured charges that drug
companies are monopolistic, keep prices jacked high,
and spend huge amounts on advertising. Physicians
were described as inept and too generous prescrib-
ers of drugs influenced inordinately by advertising
and drug detail men. It was implied that 100 deaths
a day due to adverse drug reactions were the fault
of the drug industry and the prescribing physicians.
Sen. Gaylord Nelson (D., Wis.), a subcommittee
member, urged that prescription drug advertising be
banned and trade names eliminated. Consumer advo-
cate Ralph Nader agreed and recommended patent
restriction.
In an opening statement, Kennedy said the hear-
ings are designed to "search for legislative solutions
to the problems surrounding the way drugs are de-
veloped, marketed and used in this country." He said
"Too many physicians are prescribing too many drugs
on the basis of too little information . . . such irra-
tional prescribing is a product of physician ignorance,
not malice. . . ."
Kennedy's subcommittee had never before asserted
broad jurisdiction in the drug field. The hearings were
viewed as a stake-out to this aspect of health and
government, and also as a bow to Nelson who has
been investigating the drug industry for years and is
its strongest critic on Capitol Hill. Nelson is a new
member of the Kennedy subcommittee. His previous
forum was a Senate small business subcommittee.
James H. Sammons, MD, Chairman of the Boarc
of the American Medical Association, told the sub
committee that in the heat of controversy it shoulcj
be emphasized that "Today there are a large numbe
of drug preparations available through a complex de
livery system replete with checks and balances pro
vided by industry, the Food and Drug Administra
tion, physicians, pharmacists, and in some instance
allied health personnel."
Dr. Sammons continued, "It is not surprising thj
this complex and important system carries with i
complex problems that different groups within th
system perceive differently . . . simple solutions fo
the management of our problems are not realistic."
The AMA official said the reduction in funding ic
research investigators could have an adverse effei
on development of improved drugs. The complexit
of FDA procedures "is becoming self-defeating an
some new approaches are required if we are to b
able to provide new and useful therapeutic agents t
alleviate existing maladies."
Whatever is done. Dr. Sammons said, "the ph\
sician must be able to prescribe the drug in dosas
and strength deemed appropriate for his patient. . . .
"Where appropriate, we believe the physiciay
should prescribe the least expensive product," D
Sammons testified. "But the generic name on the bo
tie is not a guarantee of equivalence, nor for th;
matter does a generic prescription even guarantee
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; GO P.M. - 8:00 P.M. daily.
Accredited by the Joint Commission on Accreditation and
Certified for Medicare
James Asa Shield, M.D.
James Asa Shield, Jr., M.D.
Catherine T. Ray, M.D.
Weir M. Tucker, M.D.
George S. Fultz, Jr., M.D.
GrAENUM R. SCHIFF, M.D.
116
Vol. 35, No.
Under Phase IV Cost of Living Council regulations, physicians
must maintain a schedule showing prices in effect on December 28,
1973, for services which comprise 90% of their revenues, and the
subsequent changes and dates. "A conspicuous and easily' readable
sign" must be posted stating the availability and location of the price
schedule.
PHASE IV REQUIRES A SIGN BE POSTED.
FOR YOUR CONVENIENCE WE
OFFER THE SIGN BELOW
CLIP AND POST IN
YOUR OFFICE
To my patients . . .
Q
UJ
H-
H-
O
a
o
z
o
o
n Compliance with Cost
of Living Council regulations,
a schedule of my fees
is available at this office
upon request
(Signature)
Member, North Carolina Medical Society
the patient that he will receive the least expensive
product.'"
C. Joseph Stetler, President of (ne Pharmaceutical
Manufacturers Association, testified that, "What the
secretary is proposing represents an extraordinarily
radical approach to health care, one which may give
the appearance of providing first class medical care
at less cost, but which will either require Medicare
and Medicaid beneficiaries to accept inferior products
or force them to pay the cost of first class medicines
from their own household budgets."
Stetler said the proposal might have some merit
if therapeutic equivalence of drugs could be assured,
"but the published evidence is almost entirely on the
other side. Reports of the clinical inequivalence of
drugs sold under the same generic name are increas-
ing as are quality control failures."
On another tack, Stetler said new drug discoveries
have been a major contributor to improving health
care, and that drug prices have held stable in a period
of soaring inflation.
But, he warned, .'\merica is falling behind foreign
competitors in the rate of pharmaceutical innovation,
adding that the industry's pattern of discovery of new
drugs and the stable prices of medicines are threat-
ened by proposals to reduce incentives for drug pro-
ducers to continue their massive research programs.
"Price setting, dilution of patent rights, or a gov-
ernment takeover of research and development or
promotional activities," suggested by some, would be
self-defeating and lead to higher prices and lower pro-
ductivity, Stetler said.
Although the industry's dollar investment in re-
search is continuing to climb, Stetler testified thati
fewer American pharmaceutical firms are sponsoring
such activities due, in part, to the tangle of govern-
ment delays and regulations.
In his slashing testimony. Sen. Nelson said thi.-
AMA "has cooperated in creating confusion" and ha
been "disastrous in this field because the custodian
of health care in this country are the guide to u
on what good medical practice is." The AMA "ha:
done more damage to the good practice of drug
prescribing than if it did not exist at all," Nelson
said. The AMA's drug manual was "degraded" due
to pressure from drug companies . . . "For mone^l
It is as simple as that," he asserted.
Nader accused the industry of "price gouging and
Facility, program and environment
allows the individual to maintain
or regain respect and recover with
dignity.
Medical examination upon admis-
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Modern, motel-like accommodations
with private bath and individual
temperature control.
FELLOWSHIP HALL
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FOR ADMITTANCE CALL
JAMIE CARRAWAY
EXECUTIVE DIRECTOR
919-621-3381
Recognized by:
Blue Cross & Blue Shield • Life Assurance Co. of Carolina
• Pilot Life Ins Co. • Aetna Life & Casualty
• John HancocK Mutual Life Ins. Co. • Kemper Ini.
• Metropolitan Life Ins. Co. • United Benefit Life Ins, Co.
• Security Life & Trust Co
FELLOWSHIP HALL mc
p. 0. BOX 6928 • GREENSBORO, N. C. 27405
Member of:
• N. C. Hospital Association
• The Alcoholic & Drug Problems
Aun. of North America
• American Hospital AaaoclatlOH
FOR MEDICAL INFORMATION CAL
J. W. WELBORN, JR., M.D.
MEDICAL DIRECTOR
919-275-6328
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 HALL WILL ARRANGE CONNECTION WITH COMMERCIAL TRANSPORTATION..
118
Vol. 35. No.
": causing serious harm to tens of thousands of people
that is unparallclled history."
The hearings will resume later this winter and con-
tinue through to summer.
* * *
The Administration has moved to set clear fuel
priorities in the health field as Congress was warned
by health leaders that emergency care, drugs and de-
cvices and hospital care could be severely affected un-
dess sufficient fuel is made available this winter.
I Immediately following a hastily scheduled one-day
Ihearing before the Senate Health Subcommittee, Wil-
liam E. Simon, head of the Federal Energy Office,
isaid the pharmaceutical industry will get all the fuel
<it needs for production and research in order to main-
tain adequate supplies of essential drugs and medical
usupplies.
w A spokesman for the American Medical Associa-
fition testified there is a critical need to make special
' (provisions for an adequate supply of motor fuel to
imeet the needs of medicine. J. Cuthbert Owens, MD,
/a member of the AMA's Commission on Emergency
Medical Services, said, "Physicians, nurses, life sup-
iport personnel, rescue workers, and ambulances and
other emergency motor vehicles must have a suf-
ficient and continuous supply of gasoline to insure the
provision of prompt care for the ill and injured. In
addition, adequate fuel must be available to health
care institutions, as well as to suppliers of necessary
medical equipment and supplies."
Leo J. Gehrig, MD, Vice President of the Ameri-
can Hospital Association, said there is no federal
natural gas allocation program for health care institu-
tions.
"This substantial area of potential energy shortages
significantly magnifies the effect of shortages of other
fossil fuels on hospitals," Dr. Gehrig told the subcom-
mittee. The proposed regulations published on De-
cember 13, 1973, providing for mandatory allocation
of middle distillates, allow hospitals only 100 per cent
of their 1972 base period volume, he pointed out.
"With increasing natural gas interruptions there is
need for hospitals to receive 100 per cent of current
fuel requirements," Dr. Gehrig said.
"The hospitals of this country must be provided
the priority and supply of energy sources to permit
them to deliver vital services to patients," Gehrig
said.
Book Review
The Power and the Frailty. By Jean Hamburger. 140
pages. Price, $4.95. New York:MacMillan Publishing
Company, 1973.
; Such is his reputation as a nephrologist that when
•Professor Hamburger addresses himself to other as-
pects of the human condition he deserves our careful
attention. In The Power and the Frailty he has offered
IS his view as a physician and biologist of the revolu-
lionary ferment brought to our daily lives by the ac-
telerating application of new knowledge, a process
vhich he sees as forcing on the physician a new role
IS diagnostician and therapist for the ills of a society
inable to assimilate the offerings of modern science,
i'erhaps the most appealing part of his book is its
itle, illuminating as it does the contrast between the
weakness of individuals and the limitless might pos-
lessed by nations which, whether as governments of
{he one or of the many, seem to be having increasing
jlifficulty determining to whom their ultimate respon-
iibihty is due. Hamburger would have us, if I read
lim aright, accept his prescription that a redefinition
f our scientific and humanistic aims and purposes
bllowed by a reorientation in our actions, all de-
jigned to impress on man the need to be rational,
tSEBRUARY 1974, NCMJ
provides an adequate blueprint. To direct this new
regime there must be developed a new managerial
class enlightened in and by biology and beyond the
profit motive and, presumably, the pleasure princi-
ple as well. Yet this speaks for an elite, altruistic
granted, almost supernaturally determined class, for
how could self-selection create such a remarkable as-
sembly? As the Watergate hearings, in recess as this
is written, so trenchantly ask "who is to police the
policemen?"
This is not to question Professor Hamburger's in-
tense concern for man's future, else he could not
exhibit such hope and faith, but to try to cast his
assumptions in historical perspective. For when elites
gain power they usually do so in league with the
masses who hope for a better world and for a healing
of their frailties. Yet true believers, as Eric Hoffer
has so nicely argued, possess an almost infinite capa-
city for and acceptance of betrayal by the elite
it has chosen as its leaders for those in office usually
become enchanted by power and rendered helpless
by strength.
What antidote can be offered to good intentions
wedded to potentially totalitarian theories? Kind
119
words? Vigilance? Hardly. Rather should we as
physicians exercise that same constructive skepticism
which allows compassion for patients but prevents
expectations greater than we or they can realize and
maintain continued awareness that fixed stars fade
and new trails usually appear when we most need
them and have the greatest difficulty recognizing
them.
If the medical reader really wishes to appreciate
his place in this world of science he would be better
advised to read Alfred North Whitehead's Science
and the Modern World which appeared in 1925,
before the atom, before DNA and before Watergate
and which provides a remarkable synthesis of what
has gone before. For unless we know how our for-
bears coped with the crises of their day, as horrifying
and overwhelming to them as ours to us, how can
we improve our chances of recognizing and taking
the right road today?
John H. Felts, M.D.
BASICS OF BIOAVAILABILITY AND
DESCRIPTION OF UPJOHN SINGLE-DOSE
STUDY DESIGN
This Upjohn booklet is concerned with the descrip-
tion of a certain application of bioavailability test-
ing. The application discussed is that in which single-
dose drug blood concentrations of two or more drug
formulations of the same parent drug are compared.
The authors wrote this booklet with the idea that
there was a need for simplifying the principles and
applications of comparative bioavailability testing,
and with special interest in bioequivalence testing.
This is meant to be an introduction to the basics of
bioavailability and might be of interest to our read- I
ers.
Included in this publication is a reference list of
297 articles relating to the comparative bioavailability
of different drugs, as well as references to related
review articles and editorials.
Copies are available upon request from The Up-
john Company, Kalamazoo, Michigan.
George M. BuIIard, M.D.
George Minson BuUard, M.D., was born in Rose-
boro. North Carolina on June 10, 1922, the son of a
dentist. He attended public school in Roseboro and
then entered the United States Army during Worid
War II as a foot soldier. He was captured by the
German Army in the Battle of the Bulge and held
as a POW until the end of hostilities. His death oc-
curred on June 7. 1973.
Following the war he graduated from Elon Col-
lege and the Medical College of Virginia. He interned
at Wilmington General Hospital.
He practiced medicine in Mebane. North Carolina
for twenty years diligently and faithfully caring for a
large practice. He was revered by his patients and
respected by the medical community.
George Bullard used his compassion, loyalty, deep
feeling and dedication to do his part in many basic
programs and services in Alamance County. As a
member of the Alamance County Board of Educa-
tion, he gave much of his spare time in making a
valuable contribution to the progress of the Alamance
County School System during a difficult transitional
period. He served as a Trustee for Elon College with
devotion and vigor. He was very active in affairs of
his church, serving in many capacities. He was an
accomplished organist who enjoyed and encouraged
good music in the community, serving as a church
organist and frequently participating in special music
events. For many years he served as organist-director
for the presentation of Handel's "Messiah," per-
formed by the Mebane Community Choir.
George Bullard was a man of varied responsi-
bilities and interests whose lifetime of contributions
will long survive him.
Alamance-Casvv'ell County Medical Society
The name J. Street Brewer inadvertently ap-
peared under "In Memoriam" in the Index to
Volume 33.
120
Vol. 35. No.
HEALTH SCIENCES LIBRARY
March 1974, Vol. 35, No. 3
yORTH CAROJJA
! Medical Journah^^:?^:^^^^^^---::
U- C;:SrLHlu NORTH CAROUNA
ChTp^L H,a, NORTH CAROLINA
THIS ISSUE: State Mental Hospital Referrals: Patient Abandonment by Local Medical Resources, Keith R. Edwards,
D., Gerald T. Gowitt, P.A., and Robert L Rollins, Jr., M.D.; Folk Medicine in North Carolina, Leonldas Betts; Experi-
ice With a Skin Cancer Detection Clinic at a State Fair, Elizabeth P. Kanof, M.D.
U-100 Iletin® (InsuUn, Lilly)
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This is a concentration suitable for most
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U-100 Iletin promises significant patient
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Note: A U-100 syringe must be
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tl-IM
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11974 ANNUAL SESSIONS
» May 18-22— Pinehurst
1974 COMMIHEE CONCLAVE
September 25-28— Southern Pines
Additional information
available to tiie profession on request.
1975 LEADERSHIP CONFERENCE
Jan. 31-Feb. 1— Pinehurst
If/
j-^--:
^ -r' 'i
This psychoneuroti
often respoiK
Before prescribinjj, please con-
sult complete product information,
a summary of which folh)\vs:
Indications: Tetisidii and anx-
iety states; somatic complaints
which are concomitants of emo-
tional factors ; psychoneurotic states
manifested by tension, anxiety, ap-
prehension, fatigue, depressive
symptoms or agitation ; symptomatic
relief of acute agitation, tremor, de-
lirium tremens and hallucinosis due
to acute alcohol withdrawal ; ad-
junctively in skeletal muscle spasm
due to reflex spasm to local pathol-
ogy, spasticity caused by upper
motor neuron disorders, athetosis,
stiff-man syndrome, convulsive dis-
orders (not for sole therapy).
Contraindicated: Known hyper-
sensitivity to the drug. Children
under 6 months of age. Acute narrow
angle glaucoma ; may be used in pa-
tients with open angle glaucoma
who are receiving appropriate
therapy.
Warnings: Not of value in psy-
chiitic patients. Caution against
hazardous occupations 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 anticonvulsant
medication ; abrupt withdraws
be associated with temporary iil
crease in frequency and'orsevi
of seizures. Advise against sim-
taneous ingestiim of alcohol an
other CNS depressants. Withdiva
symptoms (similar to those wit
barbiturates and alcohol) have
occurred following abrupt disci-
tinuance (convulsions, tremor, '•
dominal and muscle cramps, voitln
and sweating). Keep addiction-'O"
individuals under careful survl-
lance because of their predisiictio
to habituation and dependencen ,
pregnancy, lactation or womenE |
childbearing age, weigh potenti I
benefit against possible hazard "^
The Rx that says
•^^ "Relax"
BUTISOL Sodium provides highly predictable sedative effect:
minor dosage adjustments are usually all that's needed to
produce the desired degree of sedation. (With 3 dosage forms
and 4 strengths to make adjustments easy.)
BUTISOL Sodium offers prompt, smooth, relatively non-
cumulative action: begins to work within 30 minutes... yet,
because of its intermediate rate of metabolism, generally has
neither a "roller-coaster " nor a "hangover" effect.
BUTISOL Sodium is remarkably well tolerated:
a 30-year safety record assures you that there is little likelihooc
of unexpected reactions.
BUTISOL Sodium saves your patients money:
costs less than half as much as most commonly prescribed
sedative tranquilizers.*
These are four good reasons for prescribing BUTISOL
Sodium for the many patients who need to have the pace set
|ust a little slower. Its gentle daytime sedative action is often
all that's needed to help the usually well-adjusted patient
cope with temporary stress.
'Based on surveys of average daily prescription costs.
Butisol
(SODIUM BUTABARBITAL)
SODIUM'
|McNEIL )
pNeil Laboratories, Inc., Fort Washington, Pa. 19034
© r^cN 1971
Contraindications: Sensitivity or idiosyncracy to barbiturates; history of
manifest or latent porphyria or marked liver impairment: respiratory disease
with dyspnea or obstruction; history of addiction to sedative/hypnotic drugs;
uncontrolled pain, to avoid because of possible excitement.
Precautions: Exercise caution in; moderate to severe hepatic disease;
anticoagulant therapy, because of possible increased metabolism of coumarin
anticoagulants; withdrawal in drug dependence or the taking of excessive
doses over a long period, to avoid withdrawal symptoms; elderly or debilitated
patients, to avoid possible marked excitement or depression; use with alcohol
or other CNS depressants, because of combined effects.
Adverse Reactions: Slight hangover, drowsiness, lethargy, headache, skin
eruptions, nausea and vomiting, hypersensitivity reactions (especially in those
with asthma, urticaria, angioneurotic edema, or similar conditions).
Usual Adult Dosage: For daytime sedation, 15 mg. to 30 mg. t.i.d. orq.i.d.
For hypnosis, 50 mg. to 100 mg.
Available as: Tablets, 15 mg., 30 mg., 50 mg., 100 mg.; Elixir, 30 mg. per 5 cc.
(alcohol 7%). BUTICAPS® [Capsules BUTISOL SODIUM (sodium
butabarbital)] 15 mg., 30 mg., 50 mg,, 100 mg.
NORTH CAROLINA
MEDICAL JOURNAL
Published Monthly as the Official Organ of
The North Carolina
Medical Society
March 1974, Vol. 35, No. 3
EDITORIAL BOARD
Robert W. Prichard, M.D.
Winston-Salem
EDITOR
John S. Rhodes, M.D.
Raleigh
ASSOCIATE EDITOR
Ms. Martha van Noppen
Winston-Salem
ACTING ASSISTANT EDITOR
Mr. William N. Billiard
Raleigh
BUSINESS MANAGER
W. McN. Nicholson, M.D.
Durham
CHAIRMAN
Louis deS. Shaffner, M.D.
Winston-Salem
Rose Pully, M.D.
Kinston
William J. Cromartie, M.D.
Chapel Hill
Charles W. Styron, M.D.
Raleigh
NORTH CAROLINA MEDICAL JOUR-
NAL, 300 S. Hawthorne Rd., Winston-Salem,
N. C. 27103, is owned and published by The
North Carolina Medical Society under the di-
rection of its Editorial Board. Copyright ©
The North Carolina Medical Society 1974.
Address manuscripts and communications re-
garding editorial matter to this Winston-
Salem address. Questions relating to sub-
scription rates, advertising, etc., should be
addressed to the Business Manager, Box
27167, Raleigh, N. C. 27611. All adver-
tisements are accepted subject to the ap-
proval of a screening committee of the State
Medical Journal Advertisinj; Bureau, 711
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. In-
structions to authors appear in the January
and July issues. Annual Subscription, $5.00.
Single copies, $1.00. Publication office:
Edwards & Broughton Co , P. O. Box 27286,
Raleigh, N. C. 27611. Second-class postage
paid at Raleigh, North Carolina 27611.
President's Newsletter 137
Original Articles
State Mental Hospital Referrals: Patient Abandonment
by Local Medical Resources 151
Keith R. Edwards, M.D., Gerald T. Gowitt, P.A., and
Robert L. Rollins, Jr., M.D.
Folk Medicine in North Carolina 156
Leonidas Belts
Experience With a Skin Cancer Detection Clinic at a
State Fair 159
Elizabeth P. Kanof, M.D.
Editorials
The 1974 Midwinter Executive Council Meeting 162
Folk. Medicine 162
Prescription PSRO 167
Preliminary Program North Carolina
Medical Society 168
Emergency Medical Services
Activities of the Public Health Service in Emergency
Medical Services 174
Robert van Hoek, M.D.
Abstracted by Edward H. Wagner, M.D.
Committees & Organizations
Report to the North Carolina Medical Society Committee
Liaison to the Pharmaceutical Association 177
Committee Advisory to Crippled Children's Program 177
Committee to Work with the N. C. Industrial Commission.. 177
Bulletin Board
New Members of the State Society 179
What? When? Where? 180
News Notes from the Duke University Medical Center 182
News Notes from the Bowman Gray School of Medicine of
Wake Forest University 184
News Notes from the University of North Carolina
Division of Health Affairs 186
American Board of Dermatology 187
A New Medical Foundation 187
North Carolina Society of Internal Medicine 187
News Note 187
Pre-PSRO Educational Seminars 187
Month in Washington 188
Book Review 190
In Memoriam 191
Classified Ads 193
Index to Advertisers 194
Contents listed in Current Contents /Clinical Practice
PRESIDENT'S NEWSLETTER
MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA
I No. 10
March 8, 1974
AMERICAN CANCER SOCIETY — In general the vast amount of my time is spent in
acting and reacting to bad news, controversies, the rotten apples in our barrel,
and threats from all corners to our independence. It is therefore a refreshing
pleasure to help publicize something wonderful and wholesome. One of the honors
of my office is to be on the Board of Directors of the N. C. Division of the
iAmerican Cancer Society. They are justifiably proud of one of their extremely
valuable rehabilitation services. They are however disappointed that so few
doctors know about these services or do not take advantage of them. Three post-
operative groups of patient volunteers have been trained to help new victims of
the same malignancies; namely (1) the postoperative laryngectomy patient, (2) the
postoperative mastectomy patient, and (3) the postoperative patient with all kinds
of "ostomies". These volunteers who have been through exactly the same crisis are
itralned to help meet the patient's physical, psychological, and cosmetic needs.
:'By so doing, their service is invaluable to the referring doctor, not only in the
(physical training of the patients but by changing a depressed, ill adjusted
ipatient into a hopeful useful individual. The whole point is that these ser-
vices have to be initiated solely by the referring physician — you are the access
to this vital program. There are six regularly scheduled laryngectomy speech
Iclasses spread about the state. The 216 "reach to recovery" postoperative
mastectomy volunteers are available in 34 counties. There are 10 ostomy organiza-
tions distributed over the state. The availability of these services for your
' patients are as near as your telephone and local American Cancer Society office
or the office in Raleigh whose phone number is area code 919-834-8463.
WAIVER OF LIABILITY ~ Now to less appetizing news. Believe it or not the
Jrudential people who administer Part B of Medicare are really our friends and
want to help us digest the nauseating regulations they have to administer. The
case in point is yet another section of the old horror public law 92-603, Section
^13. It provides for "waiver of patient liability on assigned claims for certain
services and supplied denied as not covered". The explanation for this is sum-
parized in a Medicare bulletin sent to you in January. If you didn't throw
it away and can't understand it, join the club. The main point of this section
>f the law is that in certain complicated circumstances you may be left holding
i:he bag for a Medicare Part B claim if you accept assignment. So, this is yet
mother crucial reason for not accepting assignment and our Prudential Part B
larrier joins me in this recommendation.
iIHEAPEST DRUGS — If you follow medical news at all, you have heard that Secretary
f HEW Weinberger has proposed that Medicare and Medicaid reimburse patients for
nly the lowest priced drugs unless the doctor can justify a higher priced one.
''his further manifestation of the climate in Washington has led to the following
uote from an editorial in the February issue of the magazine "Private Practice".
Can you imagine the time and effort it would take to justify all of a doctor's
ctions each day? It now appears that a doctor will have to justify why he saw
I patient, why he got a laboratory test, why he made the diagnosis he did, why
he hospitalized the patient, why he kept the patient in the hospital for a certain
number of days, why he performed surgery, why he chose a certain course of
treatment — and now — why he prescribed each kind of drug. He must also justify
his charges." This is as succinct a summary of our frustrations as I have read
anywhere. The ethical drug firms and their representatives are really on the hot
seat along with us .
COLC — For those of you who did not read or have not seen the February 18th issue
of the AMA. News, you'll be happy to know that the AMA has gone to the District
Court in Washington, D. C. , with a suit against the Cost of Living Council for
its maintenance of the health field under Phase IV. It is most heartening to
have the AMA come out swinging in our behalf. This is where your pocketbook is
involved and you may certainly site this action if you hear the query "What's the
AMA Done for Me Lately?".
PROFESSIONAL INSURANCE — As to what your State Society has been doing for you
lately and has been doing as far as your pocketbook goes, recent experience with
your professional insurance carriers leads to this very crucial and sound advice
to help you stay out of court. To illustrate, an action against one of our mem-
bers was recently thrown out of litigation on a basis of just one sentence
written in the patient's office record. Hint: Make your office records (the
average doctor does better with hospital records) intelligible and complete with
pertinent details.
GASOLINE — As of this writing, gasoline for doctors is in a state of confusion.
It is hoped that by the time you read this, we may have already gotten equitable
treatment for you at both the national and local level. Here again, the AMA has
initiated strong pressure on Mr. Simon and we are doing likewise here in North
Carolina but so far to no avail.
THE TAIL IS WAGGING THE DOG — Required reading is in the February issue of the
NORTH CAROLINA MEDICAL JOURNAL, the article written by Dr. Bernard Wansker, "The
Tail is Wagging the Dog". This is the most concise and clear presentation of both
definitions and delineations of the many complications of our third party inter-
mediaries.
NEWSLETTER — Many thanks to all of you who responded to the request in my last
Newsletter as to its distribution. So far the opinions are about 10 to 1 in favor
of enclosing it with the Public Relations Bulletin. This leads me to restate the
standing invitation to comment on anything and everything else that we report.
Sincerely yours,
George G. Gilbert, M.D.
President
state Mental Hospital Referrals:
Patient Abandonment by
Local Medical Resources
Keith R. Edwards, M.D., Gerald T. Gowitt, P.A.,* and Robert L. Rollins, Jr., M.D.
'HE medical profession is in an
"' era of increasing awareness of
p ients" rights. Health care is often
V A'ed as a right rather than a privi-
le '.. Consumers are asking elected
n resentatives, as well as the medi-
c profession, to increase availa-
b :y of medical care to the indigent
pi'Ulation.' Problems of medical
e cs in relation to transplantation
0 Drgans, human experimentation,
b nedical research, human fertili-
z; on, and the creation of life have
ajjcared in the medical litera-
ti -.--''
1 mental hospitals, patients'
ri ts are increasing and practices of
di irimination toward psychiatric
p; ents are decreasing.*- ^ Discrimi-
n; on by the medical profession
aj-nst psychiatric patients who are
01 ide of mental institutions has re-
cced little comment.
sychiatric and alcoholic patients
he ng multiple state hospital ad-
m ions often present special prob-
le: for the physician. Acutely psy-
1 m the Department of Medicine, Boston
Cil -lospital, Boston, Massachusetts (Dr. Ed-
wa ).
lysician's Assistant.
■ perintendent and Director of Forensic
Sei ES. Dorothea Dix Hospital, Raleigh, North
Ca na 27611.
1 tint requests to Dr. Rollins.
chotic or inebriated patients may not
give a reliable history. Their physical
signs and symptoms may be over-
looked, and commitment to a state
mental hospital for treatment of an
acute psychosis or "organic brain
syndrome" may result from the pa-
tient's "label" as a "mental patient."
Most referrals to a state hospital are
appropriate and they primarily in-
volve mental illness. However, any
physician should first rule out an ac-
tive organic disease process, espe-
cially in medically high risk patients
such as those who have histories of
mental illness or inebriation and who
cannot, or will not, normally attend
to physical problems. An alcoholic
with a high fever or a middle-aged or
elderly patient with an acute psycho-
sis is usually medically ill; yet many
such patients are sent to a state men-
tal hospital — especially those who
have histories of past state hospital
admissions.
The following case reports are ex-
amples, not at all atypical, of the
extreme degree to which a physician
may overlook or neglect an impend-
ing or an active medical emergency,
especially if the patient has been la-
beled because of a history of pre-
vious mental illness.
CASE REPORTS
Casel
A 46-year-old man had a ten-
year history of alcoholism and one
previous uneventful admission to the
state hospital inebriate ward. Ac-
cording to his wife, he had last been
drinking heavily two weeks prior to
admission. He had been in his usual
state of health (inebriation) until
one week prior to admission, when
the onset of an upper respiratory in-
fection and cough productive of a
purulent sputum was noted. On the
day of admission the patient became
unconscious, without aura, and was
taken to a local emergency room.
The emergency room note records
a blood pressure of 170/70. There
is no record of other vital signs or of
a physical examination. At the emer-
gency room the patient apparently
had a major motor seizure and was
treated with diazepam and sodium
bicarbonate, administered intraven-
ously, in addition to oxygen. Postic-
tally, appearing confused and deliri-
ous, he was given chlordiazepoxide,
administered intramuscularly, and
was referred to the inebriate ward
for the treatment of alcoholism.
At this time, a physical examina-
M H 1974, NCMJ
151
tion revealed severe respiratory dis-
tress in the obtunded, cyanotic male.
His recorded blood pressure was
100/60, pulse rate 150- and regular,
respirations 50, and his temperature
105 F rectally. Positive chest find-
ings included diffuse wheezes, rhon-
chi, and rales most pronounced on
the right side of the chest.
A cardiac examination showed a
summation gallop and an aortic flow
murmur. The abdomen was without
bowel sounds, tenderness, or or-
ganomegaly. Clubbing and cyanosis
of the extremities were present. Neu-
rologic examination revealed obtun-
dation and withdrawal response to
deep pain and hypoactive deep ten-
don reflexes; no pathologic reflexes
were present.
The hematocrit reading was 42
percent, a white blood cell (WBC)
count was 1.500. A repeat WBC was
600. A differential cell count, with
only ten cells counted, showed four
pol_\morphonuclear (PMN) cells,
five bands and one metamyelocyte.
The sodium was 114 mEq/L, po-
tassium 2.5 mEq L, and chloride
85 mEq L. The PO, was 42 mmHg,
PCOj was 24 mmHg, and pH was
7.50 while the patient received nasal
oxygen. A chest X-ray showed
pneumonia in the right lower lobe.
Gram stain of the patient's sputum
re\ealed many PMN cells, many
gram positi\'e diplocci, and some
negative rods. Cultures of sputum,
urine, blood, and cerebrospinal fluid
were taken.
The patient was given gentamicin,
penicillin, and cephalothin, injected
intravenously, in addition to vita-
mins, folate, hydrocortisone succi-
nate, a cooling blanket, nasotracheal
suction, and postural drainage. Hy-
poxia was transiently improved in a
50 percent oxygen tent with eleva-
tion of PO.. to 55 mmHg. 1 he pa-
tient became progressively hypoten-
sive and was poorly responsive to
pressor agents. Subsequently, oxy-
genation deteriorated and he re-
quired ventilation on an Emerson
respirator. The patient became an-
uric and died 26 hours after admis-
sion.
Post mortem cultures of sputum
and blood revealed erowth of E. coli
and D. pneumoniae. Autopsy re-
vealed pneumonia of the middle and
lower lobes of the right lung, bron-
chopneumonia of the middle and
lower lobes of the right lung, and fi-
bropurulent exudate of the right
lung. Also revealed were moderate
fatty changes of the liver and passive
hyperemia of the kidneys.
Case 2
A 53-year-old man had been
drinking one to two pints of bonded
alcohol every day for the past thirty
years. A history obtained from his
wife indicated that he had been in
good physical health until one month
prior to admission when he noted
the symptoms of progressive weak-
ness, fever, and a cough productive
of purulent, blood streaked sputum.
Two weeks prior to admission the
patient became too weak to work,
and on the day of admission he was
unable to rise from his bed. A local
physician prescribed a medication
and referred the patient to a local
hospital.
At the local hospital the emer-
gency room recorded a blood pres-
sure of 100/60, pulse rate 100, res-
pirations 26, and a temperature of
100.6 F. The lungs were described
as clear. The patient was given 10
mg diazepam, administered intra-
muscularly, and ha\ing been given a
diagnosis of "impending D.T.'s'" he
was referred to the mental health
clinic. He was subsequently referred
to the state hospital inebriate ward
and was said to be suffering from
acute and chronic alcoholism.
A physical examination on ad-
mission revealed a blood pressure of
120 60, pulse rate 150, respirations
40, and a temperature of 105 F rec-
tally. The patient appeared to be
markedly tachypneic and diaphoret-
ic. The chest examination showed
diffuse rales, most evident o\er the
right mid-lung area. The liver was
palpable 4 cm below the right costal
margin. Lethargy, without focal
signs, was noted on neurologic ex-
amination.
The initial hematocrit reading was
36 percent and a white cell count
was 3.000. A differential cell count
showed predominantly PMN cells
with a marked shift to the left. Bled
chemistries were within normal lii-
its except for a blood urea nitrojn
(BUN) of 46 mg percent and a CI,
of 15 mEq 'L. A stool guaiac tst
was positive. A test for blood al)-
hol level was negative. Chest X-iy
demonstrated a right, middle, lA
lower lobe infiltrate. Sputum gm
stain showed many PMN cells, gm
positive cocci in pairs, and grift
negative rods.
After sputum, blood, and una
cultures were obtained, the patijt
was started on a medical progra
which included gentamicin, ceph;>i
thin, acetaminophen, SSKI, vitaiin'
supplements, antacids, postiali
drainage, and an oxygen tent. Int(L
percent headbag the initial PO d£
47 nmiHg was raised to 66 mm s.
On the morning after admisMm
the patient was confused. That af r-
noon he had a transient fall n
blood pressure and respirations c
a spontaneous return of all \j
signs when he was in the su| it
position. On the evening of le
second day in the hospital the i-
tient had increased congestion c ;i
the right lung. Immediately a;r
ha\ ing been given nasotracheal ;
tioning. he had cardiovascular ai _-:
and respiratory arrest; subseqia[
resuscitati\e attempts were un-c-
cessful.
Autopsy revealed extensi%e ;-
lateral, acute pneumonitis. The '
weight of the lungs was 3,150
Post mortem blood and lung cul;
yielded no growth. The liver wa-
peremic with a diffuse patten j:
finely nodular cirrhosis. The ut '
of the liver was 3,220 gm.
Case 3
An SO-year-old man had a k
standing history of episodic ex
sive drinking and three previous
eventful admissions to the state 1
pital inebriate ward. On the last
mission four years ago, he was
toxicated with bromides, but
completely recovered.
A history obtained from his fa:
indicated that the patient had
used alcohol or taken exec
medication for at least two } u
prior to his final hospital admis
15;
Vol. 35. N i
^iiree days before the admission,
IJImptoms of an upper respiratory
'ji'ection and severe vomiting were
Rted. On the morning of admission
■'; patient became confused and de-
ij^ious. He was taken to a local
■l-iergency room where he was re-
^rted to be well oriented. The phys-
?iiil examination at the emergency
iiDm was unremarkable except for
?''iittered rhonchi throughout the
;st. The emergency room staff's
«":ipressions of the patient's con-
iiiaon were that he had bronchitis
^i possible alcoholism. No labora-
toy tests were ordered. The patient
lEis given a prescription for tetracy-
stinie and he was referred to the mcn-
Icr health clinic. From there he was
O.i'erred to the inebriate ward where
mil was given a tentative diagnosis
>'broniidc intoxication.
■The patient presented as a lethar-
- and confused elderly male. His
od pressure was 120/70, pulse
I 84 and regular, respirations 22,
I temperature 97.6 F. The physi-
examination was unremarkable.
; mental status examination
"'pwed markedly slowed thought
'cesses and disorientation. A neu-
)gical examination showed only
'ressed deep tendon reflexes.
'1 'initially, a sodium was 110
q/L, potassium 4.0 mEq/L,
mde 76 mEq/L and COj was 16
q/L. The urinalysis result was
i''lmal. Spot urine sodium was 0.0.
: blood urea nitrogen (BUN)
\ 10 mg percent and a creatinine
^-.rance was 1.15 mg percent. A
ji:t|i> for bromide level was negative.
MVip-.ma Cortisols were within normal
I'he patient was given parenteral
lum chloride replacement which
fdly improNCd his mental status,
(lording to psychiatric evaluation,
jpatient had mild senile dementia
was ready for discharge on the
Ijji.inth day of his hospitalization.
al>:
m:\
,i*
m
I 64-year-old woman with adult
st diabetes was reported by her
trring physician to be without
ahiatric problems and in good
;icai health until three months
iC to admission. At that time she
had an acute myocardial infarction
and was admitted to a local hospital.
The course of her illness was com-
plicated by pulmonary embolism
and difficulty in diabetic control.
The patient became confused and
disoriented, showing inappropriate
behavior which persisted after the
acute episode. She was treated with
a regimen of digoxin 0.25 mg daily,
20 units NPH insulin each morning,
and chlorpromazine as needed.
Eleven days prior to admission
the patient was again sent to a local
hospital because of complaints of
dyspnea and anxiety. Bradycardia
and bigeminal rhythm were noted on
admission. In the hospital, several
electrocardiograms (ECG) demon-
strated a junctional rhythm and a
steadily declining cardiac rate. The
patient was treated with atropine
and meperidine administered intra-
muscularly, as well as nasal oxygen.
Her mental status continued to de-
teriorate and she was referred to the
state hospital psychiatric ward with
a tentative diagnosis of chronic un-
differentiated schizophrenia.
Her blood pressure on admission
was 98/50, temperature 99.4 F, res-
pirations 16, and pulse rate 44 and
irregular. The patient, confused and
disoriented, was unable to give a his-
tory. The fundi showed microaneu-
rysms and hard exudates. The neck
veins were distended to the mandib-
ular angle at 30 degrees. There was
a soft bruit over the right carotid ar-
tery. The chest examination showed
moist rales in the left base, but was
otherwise clear. Cardiac examina-
tion revealed an irregular rhythm
without murmurs or gallops. There
was no peripheral edema. The ab-
dominal examination was unremark-
able. No focal neurologic signs were
present.
Laboratory studies included a
hematocrit reading of 30 percent
and a WBC count of 6.900 with a
normal differential. Blood chemis-
tries were within normal limits, with
the exception of a glucose of 130
mg percent and a BUN of 42 mg
percent. Urinalysis showed 1 + pro-
tein and 50 to 60 WBC per high
powered field. Chest X-ray showed
cardiomegaly and pulmonary con-
3;;fi;H 1974. NCMJ
gestion. The serum digitalis level
was 0.4 ng ml. ECG showed an ir-
regular junctional rhythm with fre-
quent premature ventricular de-
polarizations and periods of bigem-
iny at a rate of 42 to 48. There was
evidence that the patient had had an
anterior myocardial infarction at an
undetermined age.
The patient was transferred to the
intensive care unit and placed on a
cardiac monitor. Atropine, adminis-
tered intravenously, produced no
change in cardiac rhythm. Because
pacemaker facilities were not avail-
able at the state institution, the pa-
tient was transferred to a nearby
hospital where a transvenous pace-
maker was inserted. She developed
intractable heart failure and died 72
hours after transfer.
Case 5
A 39-year-old man had been ad-
mitted, three years ago, to the state
hospital inebriate ward where he un-
derwent uneventful detoxification
from alcohol. Three months prior to
his final admission he began drink-
ing one to two pints of bonded alco-
hol each day. However, he claimed
to be in his usual state of good
health until two days before admis-
sion when he noted the onset of se-
vere, penetrating, midepigastric pain
which persisted without relief. Be-
sides bilious and bloody vomiting,
the patient had melena. a cough pro-
ductive of purulent sputum, pleuritic
chest pain, and fever.
He was taken to a local hospital
by his regional alcoholism counselor
who described him as being in "too
much pain to walk." The emergency
room made no record of the patient's
complaints, although they described
him as smelling strongly of alco-
hol. However, the patient, the al-
coholism counselor, and the family
denied that the patient had con-
sumed any alcohol for 48 hours
prior to the time he was admitted to
the local hospital. Vital signs noted a
blood pressure of 130/100 and a
rectal temperature of 96 F. The re-
sult of the chest examination was
normal and the abdominal examina-
tion records note only an enlarged
liver. The patient was given 75 mg
153
chlordiazepoxide, administered in-
tramuscularly, and he was referred
to our inebriate ward for the treat-
ment of acute and chronic alco-
holism..
Physical examination on admis-
sion showed a diaphoretic male with
intense abdominal pain. A blood
pressure was 120/90, temperature
100.4 F, pulse rate 136, and respira-
tions 24. The abdomen was rigid
and exquisitely tender with rebound
present. Bowel sounds were dimin-
ished. The size of the liver was nor-
mal. There was no costovertebral
angle or back tenderness. The initial
diagnosis was acute pancreatitis.
Laboratory data included a hema-
tocrit reading of 36 percent and a
WBC count of 9,300 with a slight
shift to the left. Blood glucose was
225 mg percent and BUN was 29
mg percent. Calcium was 7.0 mg
percent and phosphorus 2.2 mg
percent. Glutamic oxalacetic tran-
saminase (SGOT) was 192 mg
percent and amylase 432 mg per-
cent. Chest X-ray was normal. Ab-
dominal flat plate demonstrated an
ileus. The sputum was "Quellung
positive.""
After blood, sputum, and urine
cultures were obtained, a medical
program of intravenous fluids,
cephalothin, diazepam, meperidine,
acetominophen suppositories, and
frequent nasogastric suction was ad-
ministered to the patient. Oral
chlorccystogram was normal. The
patient had an uncomplicated course
and recovery, with amylase return-
ing to normal after nine days of his
hospitalization.
Case 6
A 52-year-old black man, having
a twenty-year history of hyperten-
sion and cigarette smoking, was
healthy until 1969 when he had a
cerebrovascular accident with result-
ing left hemiparesis. The patient be-
gan having seizures with a right cere-
bral focus several months later. His
seizures were controlled with pheno-
barbital and diphenylhydantoin. The
patient had one previous state hos-
pital admission in April of 1970 for
transient confusion secondary to
"organic brain syndrome." He lived
154
at home and functioned in the care
of his wife until the day prior to
admission when he became con-
fused, combative, and aphasic. He
was taken to a local emergency
room. His wife was told that the pa-
tient had a "near stroke," and he
was sent home. Later the same even-
ing, the patient returned to the emer-
gency room with aphasia and in-
creasing confusion and combative-
ness. He was referred to the state
hospital with "possible psychosis"" as
the only diagnosis on the commit-
ment papers. No record of a physi-
cal examination or laboratory data
was available.
On admission to the state hospi-
tal, the patient"s confusion and
aphasia were resolved. The patient
appeared oriented and cooperative,
his chief complaint being of recent
inability to talk, weakness in the left
side, and mild chest pain. The pulse
was irregular. An electrocardiogram
demonstrated acute anterior myo-
cardial infarction, frequent multifo-
cal premature ventricular depoliriza-
tions, and periods of bigeminy. The
patient was transferred to the inten-
sive care unit where he received
lidocaine intravenously, procaina-
mide orally, oxygen, and later,
digoxin and diuretics for congestive
heart failure. Neurological examina-
tion revealed sensory and motor
deficit and hyperreflexia on the
left side. An electroencephalogram
showed random slowing. Electro-
cardiogram and serum enzyme
changes after the acute episode con-
firmed the diagnosis of an an-
terior myocardial infarction. It was
thought that the patient"s aphasia
and confusion were caused by a
transient cerebral ischemic attack.
Lipid panel showed a type IV hy-
perlipoproteinemia.
The patient had a successful con-
valescence without further complica-
tions. He was oriented and coopera-
tive and showed no evidence of
psychosis during his entire hospitali-
zation.
DISCUSSION
These six patients, referred from
emergency rooms or from physi-
cians" offices, were sent to the state
hospital with no record of compi
cated diagnostic problems or occ
diseases. Yet each of these patier
had a life-threatening disease in ti
acute phase.
Case reports 1 and 2 were repo
of patients who died during the fi
day after admission to the psychi;
trie hospital. One may only spec
late whether the delay in treatme
after the transfer from an emergen
room, commitment proceedings, a
re-evalution after admission wov
have made any difference in the fa
course of the disease. However, t
issue is whether a non-former p;
chiatric patient would have receiv
the same treatment as a patient hi
ing a history of psychiatric tre,
ment.
Case report 3 concerns an 8
year-old man who was sent from
emergency room to the state hosj
tal without having had a compl
physical examination or laborat(
studies done. His diagnosis of 1(
sodium psychosis was made, af
admission, from the minimal routi
laboratory studies.
Case report 4 concerns a 64-ye;
old woman having a three-mor
history of confusion which be^
acutely after a myocardial infa
tion. The patient had no previc
history of mental illness. Having h
no neurological studies done, the f
tient was referred to the state hos
tal with a single handwritten n
from the physician stating that s
had schizophrenia. On admissic
the patient was found to have an
regular bradycardia and a low bio
pressure. Her "mental conditio
was probably the result of a ce
brovascular accident of cardiogci
origin. She was hardly a candid;
for a psychiatric hospital.
In case report 5, the patient hac
high fever and peritoneal signs a
was referred from an emerger
room. The referring diagnosis a
subsequent commitment presumal
had been based solely on the pre
lem of alcoholism. The physi
examination and serum amyli
levels confirmed the diagnosis
acute pancreatitis.
Case report 6 concerns a pati
who had a clear history of aci
Vol. 35, Not
hasia and confusion. One cannot
i;ow whether the patient's irregular
Ijlse and chest pain were as promi-
iat in the emergency room as they
j re on admission to the state hospi-
i(, but an acute cerebral ischemic
ilfack is usually not considered to
iji a primary psychiatric problem.
lijlhe five most common physical
i^jOrders associated with alcoholism
delirium tremens, "blackouts"
I convulsions, liver damage,
ipheral neuritis, and stomach dis-
jjtlers. The alcoholic patients who
re presented here had fewer
(Hmonly occurring disorders. That
more significant disease might
e been present should have been
E^stioned. Chronic alcoholics often
not give reliable histories and
/ are not noted to be cooperative
ients. However, the physician
it examine himself, as well as the
P jent, in reference to his attitudes
ard the patient. When the physi-
1 has failed to communicate with
; I patient, he often describes the
„ |ient as being "uncooperative" or
reliable." Regarded as such, the
.lent sometimes is sent as quickly
.•ossible to the state hospital, re-
.lless of concomitant physical di-
,e.
jhese cases are not presented to
icize the medical care provided
particular region, nor to criti-
^any group for practicing inferior
icine. The referrals discussed
J from a too divergent, otherwise
jpetent, group of hospitals and
...icians to suggest that these phy-
■ns are incompetent. These cases
sent the effects of a basic dis-
-linatory attitude toward patients
^ have psychiatric or alcoholic
I'oses. One patient aptly ex-
ed the following attitude:
P :c you're a (state mental hospi-
tl patient, you're branded." An-
tl ■ stated, "Once a psych patient.
19i
se; I
* \
ap <
& 't
ai
liK
always a psych patient. That's how
they (physicians) feel about you."
There are several ways to limit
these inappropriate, end-of-the-line
physician referrals for patients who
are abandoned by their appropriate
local medical resources. One ap-
proach for the improvement of
health care for "undesirable" poten-
tial or for former mental hospital
patients is to restrict mental hospi-
talization policies. The current de-
bate on voluntary mental hospitali-
zation has been reviewed recent-
ly.'-- '■■' The status of involuntary
hospitalization for people having
mental illness has been questioned
and suggested revisions have been
proposed which include shortened
observation periods in the commit-
ment process, expansion of patients'
civil liberties and right-to-treatment,
a legal aide system for mental pa-
tients, and a patient advocate pro-
gram.'^ Both voluntary and invol-
untary hospitalization is subject to
indiscriminate application. It is ap-
parent that former hospital patients,
particularly those with past inebriate
admissions, are sometimes given a
choice between jail and voluntary
commitment.
Significant revisions of mental
hospitalization laws are needed be-
fore abuse of patients" rights to
proper physical and mental care can
be corrected.
SUMMARY
The medical profession is becom-
ing increasingly aware of patients"
rights, particularly in the field of
mental health. This report has in-
cluded an account of six patients,
having a primary referring diagno-
sis of mental illness, who were trans-
ferred by various physicians to state
mental hospitals. On admission to
the state hospital each patient had a
life-threatening physical condition
which required intensive medical
care. It is our contention that in-
appropriate referrals to state mental
hospitals are sometimes made when
patients are confused or when they
present a management problem,
even if overwhelming physical dis-
ease is the cause of their mental
status changes. Those patients hav-
ing histories of state hospital admis-
sions are at risk to be disregarded
by their local medical resources and
to be sent to a state mental hospital,
regardless of concomitant physical
illness. They have been "labeled" by
their past histories of hospitalization
in mental institutions. Disposition
may reflect this label rather than an
objective review of the presenting
symptoms.
ACKNOWLEDGMENT
We are indebted to Dr. H. W. Glas-
cock. Jr., and Dr. P. P. Lara for their
helpful suggestions, and to Mrs. Cynthia
Gowitt and Mrs. Jo McCullen for their
help in preparation of the manuscript.
References
1. Callaham JJ: Poor people and the medical-
care crisis. (Editorial.) N Engl J Med 286:
126.1-1 :«. 1972.
2. Elkinlon JR: The literature of ethical
problems m medicine — Part .1. Ann Intern
Med 73: X63-S7I), 1971).
3. \\'ilbur DL: The heritajje of Hippocrates.
J.AMA 208: S41)-S4t. 1969.
4. Leake Cl^: Theories of ethics and medical
pr.iclice. JAMA 20.H: 842-H47. 1969.
5. Roth RB: Medicine's ethical responsibil-
ities. JAMA 215: 1956-195S. 1971.
6. Schroeder OC Jr: Ethical problems in medi-
cal practice. Postiirad Med 51: 59-61. 1972.
7. Kass LR: Babies by means of in vitro
fertilization: unethical experiments on the
unborn? N Enul J Med 285: 1174-1179,
1971.
8. Patch YD: Blacklisting mental hospital pa-
tients. Hosp Community Psychiatry 21:
269-271. 1970.
9. Suchotliff LC. Sleinfcld GJ, Tolchin G: The
struggle for patients' rights in a state hos-
pital. Ment Hyg 54: 230-240. 1970.
10. Tomsovic M: Hospitalized alcoholic pa-
tients: 1. A two-year study of medical, so-
cial and psychological characteristics. Hosp
Community Psychiatry 19: 197-203. 1968.
11. Silberslein EB: Implications of "Unco-
operative." (Letter to the Editor.) N Engl
J Med 283: 1413. 1970.
12. Szasz TS: Voluntary mental hospitalization:
an unacknowledged practice of medical
fraud. N Engl J Med 287: 277-278. 1972.
13. McGarry AL. Greenblatt M: Conditional
voluntary mental-hospital admission. N Engl
J Med 287: 279-280. 1972.
14. Rollins RL Jr: Suggested revisions of North
Carolina's laws on involuntary hospitaliza-
tion for mental illness. NC Med J 33:
1019-1022. 1972.
Where cold bathing is practiced, there ought likewise to be tepid baths for (gradual transi-
tion). Indeed, it is the practice of some countries to throw cold water over the patient as soon
as he comes out of the warm bath; but though this may not injure a Russian peasant, we dare
not recommend it to the inhabitants of this country. The ancient Greeks and Romans, we are
told, when covered with sweat and dust, used to plunge into rivers, without receiving the small-
est injury. They might often escape danger from this imprudent conduct, yet it was certainly
contrary to sound reason. — IVilliain Biichaiu Domestic Medicine, or a Treatise on the Preven-
Ycnlion and Cure of Diseases bv Regitnen and Simple Medicines, etc.. Richard Fohvell. 1799.
p. 428.
1H 1974, NCMJ
155
Folk Medicine in North Carolina
Leonidas Betts*
"IKJ HILE I was studying at
* ' Duke, I made the acquaintance
of a student, the son of a prominent
Charlotte surgeon, who arranged his
dormitory-room furniture in an un-
orthodox manner. Since I am in-
nately curious about almost every-
thing, I persisted in my inquiries
about the position of his bed. Worn
down at last, he finally gave me an
answer which was at first shy but
became defensive in the telling. "It
has to do with health," he said.
"Health? Are you trying to keep
from sleeping in a draft?" I pursued.
"Hell, no! Don't you know you'll
go crazy if you sleep in moonlight?"
he said. I laughed until I realized
how serious he was. The old ideas
persisting — "lunacy," "moon-mad-
ness." And he was a physician's son.
I inquired no more.
In the early days of its study, folk-
lore was viewed as the "remains" of
past culture, curious relics, beliefs,
and practices surviving from days
gone by. The modern folklorist.
however, sees folklore as an on-go-
ing body, its content dying gradually
at one end and growing at the other.
Today folklore is defined as the ma-
terials of any culture that are trans-
mitted by oral means or by example,
that are traditional within any group.
An address to the Raleigh Academy of
Medicine. October 26. 1«72.
• Editor. Sank Carolina Folklore Journal-
Requests for reprints to the Department of
Enghsh. P. O. Box 5308, Winston Hall. North
Carolina State University. Raleigh, N. C. 27607.
that are generally anonymous, and
that become formularized. Thus, by
definition, e\eryone has folklore.
The old mountain woman singing a
"ballet" on the front porch of her
log cabin is no more unique a source
of folklore than the urban housewife
or the insurance executive or the
physician. Every socialized in-
dividual belongs to several groups
distinguished by age, occupation,
ethnicity, region, and various combi-
nations of these; and he shares with
his groups the baggage of their tradi-
tional lore.
The study of folklore has three
phases: collection, classification,
and analysis. Collection, under-
standably, has beea the most suc-
cessful of these. Vast quantities of
materials have been gathered
throughout the United States. With-
out doubt, the finest state accumu-
lation is the Frank C. Brown Col-
lection of North Carolina Folklore,
running to seven thick volumes, pub-
lished by Duke University Press.
Classification, too, has made signifi-
cant progress, and standardized pro-
cedures have been developed to en-
able the collector to arrange his find-
ings into some formalized pattern
for the purposes of comparison and
cross-reference. However, analysis is
still in its infancy, with psychiatrists,
sociologists, anthropologists, and
English professors vying for supre-
macy. Increasingly, folklorists are
attempting to view folklore in s:
as part and parcel of a societal pi
cess.
My keenest interest in folklc
study is in the area of superstitio;
or, euphemistically, "popular I
liefs." Two volumes of the Bro'
Collection are devoted to the si
ject, with a total of more than 8,0
entries. In addition. Profess
Joseph D. Clark has published so:
2,000 items in the journal No
Carolina Folklore J
Superstitions do not readily yi
to education. Studies over the ye
have shown no decrease in tb
prevalence. In 1950 an Indiana
thropologist, with college students
subjects, made a study of super
tions using highly sophisticated
tistical methods. He discovered t
students are as superstitious as tJ
ever were, that women are more
perstitious than men, and that, vn^
intriguing, the more educated e
parents, the more superstitious e
children. Further, urban studes
proved to be as superstitious i
those from rural areas. There 6
folklorists who claim that everyp-
di\ idual harbors some kind of sufj
stitious belief within himself. -
If we look at medical pract:!
and their relation to superstition!
popular belief, we find a curious d
complex situation. Scientific mi-
cine and folk medicine exist side)
side, each contributing to the e^•
156
Vol. 35, Nl
nee of the other, often in tension,
xasionally in harmony, the materia
edica of one sporadically passing
to the other in a kind of begrudg-
g comradeship. What passes out of
vor in legitimate medicine may
!id its way into the repertory of
e folk healer. Physicians in the
' venteenth century held firmly to
e "doctrine of signatures" which
oposed that the colors and forms
herbs signified their usefulness in
;ating diseases or affected ana-
tnical features with similar colors
d forms. In folk medicine the doc-
ne ultimately accreted application
mineral elements. That red beads
)rn about the neck prevent nose-
;ed is a belief recorded in North
irolina and in other areas through-
t the United States.-'
On the other hand, folk cures can
q readily pass into recognized medi-
1. practice. An issue of The News
)i Observer' carried a United
lisss International release concem-
; a report to the American
iillege of Surgeons, by Dr. Paul
iverstein of the Army Institute
'^.Surgical Research, that pigskin is
£; effective as cadaver skin in the
t iitment of burns. (I must admit to
Sriie ignorance here: application of
c lavcr skin sounds like something
f/m dark times, when moss from a
J.iged man's skull was valued as a
pent curative.) In any case, for
•Ctintless years the application of
fiih hog meat has been a standard
•tjitment for burns among the coun-
t[''olk. And now, at last, its discov-
6: by science! These days are beset
V 1 media releases about acupunc-
tv:. And, according to a Tinie^
D]jazine report, faith healing is be-
;ii! seriously studied by medical re-
si>rchers.
'oik cures are generally divided
ir- two, sometimes ill-defined,
v^cties: the magicoreligious and
11" rational or herbal type. My ex-
:p' ences with the faith healing,
p :ly magicoreligious variety are
•U'ted.
-lowever, many common folk
cii:s have strong elements of the
:ili' icoreligious in them. For ex-
ar'le, I have met a number of
: pi 5le who firmly beheve that
■ M CH 1974, NCMJ
bleeding can be stopped by repeat-
ing applications of Ezckial 16:6
three times. And one of my best in-
formants told me of a foolproof pre-
ventive for whooping cough, a pro-
cedure with absolutely no rational
basis: "Take a live minnow and let
him gape in a baby's mouth three
times, and the baby won't have
whooping cough."
Most folk cures consist of con-
coctions of roots, bark, leaves, na-
tural minerals, and purchased
chemicals which seem, on the sur-
face, to be posited on some sys-
tematic, reality oriented world-
view, although these too may con-
tain some element of irrationality.
One informant showed me a pine
grove on her farm that had provided
her for many years with both pur-
gatives and cures for diarrhea. The
inner bark of the tree works both
ways, she explained: "If you cut up,
that white bark'U clog up loose
bowels, but if you cut down, it's a
mighty potent laxative. I used it both
ways on all my children whiles they
were growin' up."
Under the heading "Folk Medi-
cine," the Brown Collection'' alone
contains 2,290 items gathered from
North Carolina sources. The pre-
ponderance of these were assembled
during the period 1910-1940, and a
look at them can reveal something
about what the canon of folk medi-
cine has been at some point in time
past. Obviously, many folk remedies
have passed away, even in memory,
as new folklore is created. My field
studies seem to indicate a continuous
deterioration of old-time folk medi-
cine from generation to generation.
Even the elderly many times remem-
ber folk cures but they no longer use
them.
It is interesting to examine some
of the Brown entries, not only as a
revelation of a view of the nature of
things significantly different from
our own, but as a source of amuse-
ment. The following is a sampling of
some of the more picturesque beliefs
in the collection:
If you take a pound of shot and boil it
in water for several hours, and then drink
two swallows of the water, you will be
cured of boils and never be troubled with
them again. (956)
For chapped lips, kiss the middle rail
of a five-railed fence. (1017)
'When younguns have got chicken pox
you lay 'em down on the floor and shoos
the chickens out over 'em. Hit'll break
'em out in two hours. Why the day the
baby got 'em I se'd the fust bump comin'
and I shood the old Dominnecker over
her and she was all pimpled out in a
hour.' (1019)
If a child has chicken pox, grease him
with chicken grease, and put him naked
in the chicken house. ( 1021 )
For severe constipation, cook a pack-
age of fine-cut tobacco in a quart of
boiling water and strain. Use a pint as
an enema, and if necessary repeat with
a second pint. This may slightly inebriate
the patient, but the effect will soon pass.
(II«5)
Pour whiskey on roaches to stop con-
vulsions, ( 1 197)
There is a bone in the penis of the
raccoon similar in shape to the letter
'J.' The old 'coon hunters of the neigh-
borhood used to tell the younger set that
if this bone should be worn about the
neck or carried in the pocket, the carrier
would never have cramp. (12311
Bite off the dog's tail to prevent in-
fection from dog bite. ( 1 292 )
To cure headache, take a live frog and
bind it to your head, and let it stay
there till it dies. (1584)
If you have the hiccoughs, think of a
fox with no tail. (1633)
For yellow jaundice, catch nine lice
off someone's head and eat them. ( 1756)
For rheumatism, fill a can with angle-
worms, let it stand in the sun all day,
and rub the oil in the stiff joints. ( 1697)''
My field collecting has yielded a
number of folk remedies not found
in Brown nor in Clark's items. My
best informant, Mrs. Hattie Holt,
a country woman in her seventies,
swears by snow water for the treat-
ment of burns: "Gather up snow
from the first snowfall in March,
melt it and put it in glass jars for the
rest of the year. There's an acid in it
that'll take out fire. I don't know
why you have to have March snow,
but other kinds of snow won't
work." (She was gracious enough to
give me a jar of the miraculous
water, which I am saving for future
use). About croup, she told me, "It
don't sound reasonable, but it does
work, 'cause I've tried it lots of
times. Stand the croupy younguns
out in the yard, no matter if there's
snow on the ground. It'll cure croup,
for sure." And Mrs. Holt has told
me on good authority that standing
barefoot on the ground will cure
"nerves." "I do it all the time," she
said. (Psychiatrists, take note.) For
teething babies, she observed, "I
know this 'un to be so. Kill a rabbit
and get his brains out hot. Rub it on
157
i
the baby"s gums. It'll help. I din"t
ever do it. but 1 knowed them that
did do it."
One striking characteristic of folk
medicine that becomes readily ap-
parent to the collector is that fre-
quently the more nauseating the
remedy, the more effective its
powers. Pity the poor child with
measles. Teas brewed from chicken
manure, goat dung, rabbit "pills,"
or sheep sorrel were (and may still
be) prescribed. One of my infor-
mants stated, without qualification,
that the best cure for toothache is a
poultice of warm cow manure placed
on — of all spots — the elbow. The
ubiquitous and vile-smelling asafeti-
da is still around. As you probably
know, asafetida is generally worn in
a small cloth bag around the neck as
a method of warding off colds and
sundry disorders. However, its
makers list it as a carminative and a
placebo. (I wonder what asafetida-
wearers think those terms mean.)
On one occasion an informant re-
marked to me, "Sometimes I think
younguns got well so they wouldn't
have to be dosed with some of these
cures." Maybe so.
There are folk terms for disor-
ders, although most conditions re-
main unlabeled and are simply de-
scribed by symptoms. Disease names
include "golly marbus," "nniUy
grubs," "humors in the blood,"
"spring disease," "high-galloping
poots," "scrofus," and "courage
bumps.'"* Many are corruptions
of current medical terminology:
"roaches of the li\'er," "phosphate
gland trouble," and "sinus of the
stomach," as well as one case of
"double pneumonia of the lungs and
kidneys.'"' An informant related to
me that she had been to the hospital
to get "bluccoats" put in her blood.
And another told me that a certain
home remedy was "good for chil-
dren as well as adulterers."
In the course of my investigation,
carried on primarily in rural eastern
North Carolina, I have sat in the
parlors of fine country houses, on
land continuously in family posses-
sion since the eighteenth century —
my informants articulate, well-tra-
velled, and educated; and I have
perched precariously on plank-bot-
tom chairs in hovels of unimaginable
squalor, expecting at any moment an
attack from some awesome kind of
vermin, while I collected bits and
pieces of the unwritten traditions of
the past and the present. All levels
of society have yielded their lore.
But as I stated previously, most
traditional folk medicine in the
countryside exists more in memory
than in usage. When I am told of
the effectiveness of a certain
remedy, often told with a personal
testimonial, I inquire about its pres-
ent day use. The answers I receive
are generally apologetic: "You can't
get pussley no more. It's stopped
growin" 'round here"; "Since the
younguns have growed up, I don't
have no need for these old cures."
"I'm taking some pills the doctor
ga\'e me. They work pretty good."
"I go to the drugstore and get store-
boughten medicine."
Even so, a few folk remedies per-
sist; but more and more, they are
yielding to increasing medical avail-
ability and perhaps, in some cases,
to the promises made by the adver-
tising media. Why use ginseng to
promote sexual potency, when there
is Ultra-Brite which gives one sex
appeal? Why stand barefoot on
the ground when one feels nervous,
when there is Compoz? Why make
the children drink rusty water to
put iron in their blood, when there
are Chcwable Chocks for Kids? Why
use Virginia creeper tea for consti-
pation, when there arc scores of pre-
pared laxatives, including a particu-
lar brand which improves one's at-
titude toward incorrigible grandchil-
dren and which cleanses the bowels
as well?
In spite of whatever advances
medical science will make, an ele-
ment of society will first try a
home remedy, then go to the drug-
store for a patent medicine, and fi-
nally consult a physician, if all else
fails.
There are parallels. One morning
as I sat in my internist's examining
room, enduring one of those inter-
minable periods of waiting and feel-
ing depressed and helpless, as I
always feel in a doctor's office, I
became rather desperate to fii
something to take my mind off wli
I was convinced was a terminal i
ness. I spied a paper entitled "Trei
ment of Warts"'" under the gla
top of an equipment case. Not ha-
ing had warts, I was nonethek
curious about their treatment, just i
case I ever developed one, if I si-
vived my illness. The paper c-
scribed the procedure in three par,
First came "The Therapy of Inspii-
tion," which included this sugg(-
tion: "Flat warts or digitol [s|
warts that are not spreading, pa:
with mercurochrome or other
ganic materials. . . or other color
hocus pocus and apply it with
vigorous personality." Second cat
"The Therapy of Desperation," w
six seemingly scientific possibiliti
The list ended with "The Thera
of Panic": "Refer the patient to
dermatologist." With an emh,
rassed laugh, I knew that my terr
nal illness had miraculously disi
pea red.
One last example of folk-healir
(The best informants readily g:
testimonials about the efficacy
their methods.) One old lady t(
me her pokeberry "wine" was a h
proof cure for arthritis. "I knew
woman," she related, "that was
crutches. I took her some of
pokeberry wine, and the next tim
seen her, she "us totin' water to 1
chickens, two buckets at the tim
Her recipe was as follows: Takf
gallon jar and fill it with ripe pol
berries. Then pour whiskey into 1
jar right up to the top. Drink
needed. O happy arthritic. . . .
References
1 Clark JO: North Carolina popular
liefs and superstitions. North Carolina F
lore. XVni: .1-66. 1970.
2. Briin\.inJ JH; The Studv of Amer?
Folklore, New York: WW Norton
Co. 196S, p 181.
3. Hand W (cd): The Frank C Brown '
k-Ltion of North Carolina Folklore,
\T. Durham, North Carolina: Duke I
versitv Press, 1952-1964. p 241.
4. The ,V.-«.v tiiid Ohsericr. Raleigh. Oct(
5. 1972. p .W.
5. Tuiu-. October 16. 1972. pp 73-74.
6. Hand W led): The Frank C Brown i
lection ol North Carolina Folklore, Vol
Durham, North Carolina: Duke Univei
Press, 1952-1964, pp 76-.157.
7. Hand W (edi: The Frank C Brown
lection of North Carolina Folklore, Vol
!3urham. North Carolina: Duke Uni
sitv Press, 1952-1964. pp l.U-254.
8. Beits I Folk speech from Kipling. N'
Carolina Folklore. XIV: .17-4I>, 1966. ^l*-
9. Leonidas Belts collection. North Carol
State University. Raleigh- (Unpublished )
10, Photocopy of t\ped page, courtesy ol '
liam J Senter, MD, Raleigh, North C'
lina. (No source or ilate available.)
158
Vol. 3.5. Nt'
»3
Experience With a Skin Cancer Detection Clinic
at a State Fair
Elizabeth P. Kanof, M.D.
KIN cancer detection clinics are
not new. Weary^ reported his ex-
ience witli a number of annual
.lies in a rural community in Vir-
^ lia. These clinics were held on
lurdays. The best attendance was
iorded in the spring or fall when
clinics were held in conjunction
h events which brought farmers
3 town. Adequate publicity via
\ news media was extremely help-
I in attracting community resi-
ks.
Patients who presented them-
s' /es for examination in the study
r ntioned were not restricted as to
a . They were routinely screened
fy lesions in the oral cavity and
c y light-exposed areas of the body
(om the clavicle up, and from the
caws down). Examination of
o'er areas was included only upon
tl, patient's request. Of 548 patients
eimined, 1 1 8 had been referred for
tiiitment. Approximately ten pa-
llets were examined per hour, per
pisician. The gratifying results of
tl ;e clinics yielded an overall de-
teHon rate of 21.6 percent prema-
li ant or malignant lesions in the
p; ulation examined.
_ y sented at the Annual Session, North Caro-
lii^ Medical Society, Pinehurst, North Caro-
Ui May 20, 1973.
wint requests to 1300 St. Marv's Street.
R gh, N. C. 27605.
In Weary's study, patients in
whom significant malignant or pre-
malignant lesions were found re-
ceived adequate follow-up care.
Their private physicians were noti-
fied by mail. Subsequently, a volun-
teer from the American Cancer So-
ciety, after conferring with the phy-
sician regarding his preference for
disposition of the problem, encour-
aged the patient to follow through
with treatment. It was stressed be-
forehand that, although the clinic
was free, the patient would be re-
sponsible for the fee to the physician
who undertook treatment. No diffi-
culty was encountered in securing
dermatologists to volunteer their
time to the clinic.
.Approximately 50 percent of all
patients screened in these clinics re-
ceived information regarding ade-
quate sunlight protection. It was
learned that the vast majority of
people examined did not wear hats
or sunscreening preparations during
the summer months. An instruction
sheet of appropriate measures, such
as using umbrellas while operating
tractors, and a list of appropriate
sunscreens were distributed to these
patients.
The cost of the screening clinic
was minimal — $23.26 per clinic, in-
cluding the cost of all promotional
activities.
It is not surprising that the yield
of significant lesions in a skin cancer
detection clinic was higher in Vir-
ginia than in New York City.- As
noted by A. Kopf, M.D. (written
communication, 1972), during a
Cancer Detection Week held in No-
vember 1971, sponsored jointly by
New York University Medical Cen-
ter, BellevLie Hospital and the New
York City Division of the American
Cancer Society, 643 patients were
examined. Four of these patients
(0.62 percent) had malignant skin
lesions, and 15 (2.33 percent) had
possible malignant lesions.
In October, 1972, the National
Program for Dermatology, in coop-
eration with the North Carolina
State Board of Health, the American
Cancer Society, and the North Caro-
lina Medical Society, undertook a
similar project at the North Caro-
lina State Fair. The main objective
was educational: to increase the
public's awareness of the relation-
ship between excessive sunlight ex-
posure and skin cancer.-''- * The de-
tection of significant lesions was
used to emphasize this educational
effort. Six hundred thousand peo-
ple visited the Fair during a ten day
period. The booth was open seven
hours daily, for nine days. During
those nine days, 11,750 people
studied the posters, and they were
N' CH 1974. NCMJ
159
given booklets about skin can-
cer,''' " as well as a sample bottle of
a medically accepted topical sun-
screen.
Each of the nine sessions, with
one attending dermatologist per ses-
sion, lasted three and one-half
hours. Three auxiliary volunteers
(per examination session) were pro-
vided by the North Carolina State
Board of Health and the Auxiliary
of the Wake County Medical So-
ciety. During the hours when a phy-
sician was not present, at least one
volunteer was in attendance to dis-
tribute pamphlets and samples and
to answer questions. A total of nine
dermatologists took part in the
clinic.
The educational posters and the
booth occupied an area of 200
square feet, divided as follows: a
reception area in which volunteers
assisted people with the question-
naire form (Figure 1); an exami-
nation area divided into two sec-
tions by a partition; and an exit
area where a volunteer, after distrib-
uting booklets and sunscreen sam-
ples to patients following their ex-
aminations, discussed with the pa-
tients their decision regarding treat-
ment. Those patients from remote
areas, or who were obviously indi-
gent, were referred to their county
health department.
In this study, the patient was
given the ultimate responsibility for
confirmatory biopsy and subsequent
treatment. The physicians in the
state were alerted beforehand via the
secretaries of all county medical so-
cieties, and by the society news bul-
letin. Because a large number of
people from widely different geo-
graphic areas of the state were seen,
the individuals' family physicians
were not notified in writing (Table
1).
During the nine sessions, 418
Table 1
Geographic Distribution of Persons
Examined
Residents of North Carolina
Western Section
Piedmont Section
Eastern Section
Out of State
Percent
3.7
74.3
18.3
3.7
people, 21 years of age or older,
were examined, averaging 46 pa-
tients per session. Lesions of such
significance as to warrant referral
were found in 158 (37.8 percent)
people. Patients having significant
oral lesions were referred to an oral
cancer detection clinic being held
simultaneously. On the light-ex-
posed areas (face, neck, chest, back,
and upper extremities), the most
frequent lesions found in the 158
persons referred for treatment were
solar keratosis (19.6 percent), basal
cell carcinoma (3.6 percent), and
nevus with questionable malignant
change (3,3 percent). A variety of
other malignant and premalignant
lesions were also detected (Table
2).
SKIN CANCER DETECTION CL
Informality was helpful in -
couraging participation. The nu-
ber of people waiting for examir.-
tion significantly increased wli
Table 2
Summary of Experience
Number
260
158
82
16
14
5
Patients not referred
Patients referred
Multiple actinic keratosis
Basal cell carcinoma
Suspicious nevi
Squamous cell carcinoma
Melanotic freckle 3
Multicentric superficial
BCE vs. Bowen's 3
Leukoplakia 2
Malignant melanoma 1
Cutaneous horn 1
Recurrence BCE or Bowen's 1
Pigmented BCE vs.
^flo'^nnma 1
Miscellaneous 53
Total numoer of patients
examined 418
Percjf^
6
3
1
101
z
o
z
o
I-
u
UJ
z
o
K
u
UJ
z
o
O
z
o
I-
u
INIC REGISTRATION FORM
Please fill in Sections I, II, and III
Date:
Name
jj Address
UJ
en Occupat1on_
Age White Non-White Sex
Telephone
Number of Years
Hours
Estimated average daily time spent outdoors, May - September?
History of skin cancer? Yes^ No^
History of skin cancer in other members of family? Father Mother Si
History of X-Ray treatment for acne or other skin conditions? Yes No
Do you use arsenic-containing insecticides or spray? Yes No
Do you regularly come in contact with tar or creosote? Yes No
Color of hair (original color)? Blond Red^ Brown_
Color of eyes? Blue^ Green Brown^ Other
Complexion -- Freckled Ruddy Darl^ Pale
Do you regularly wear a hat with
Do you regularly use c
■ Siblings_
Black
)rim in summer? Yes^
screening preparation? Yes
_ No_
No
In winter
Have moles rapidly enlarged or darkened recently? Yes No_
Are there any places on your skin which are sore and will not heal? Yes No_
Do you have any sore or irritated places in the mouth? Yes No
Do you smoke cigarettes? Yes No_
Do you smoke a pipe? Yes No_
Do you smoke cigars? Yes No_
Do you chew tobacco? Yes No
Do you wear dentures? Yes No
Additional pertinent historical facts
Examination :
Face
Refer
Not Pe'
Ears
Mouth
Neck
Palms
Dorsum of hands and forearms
Trunk or other sites if indicated
Follow-up: 1. Refer to family doctor
2. Refer to other doctor or dentist_
3. Refer to health department
4. Other:
state Fair Exhibit
National Program for Dermatology
N. C. State Board of Health
1972
N. C. Division, American Cancer Society
Fig. 1
160
Vol. 35, No.
■A
lite coats were shed, when the
iLiuiysician appeared in the reception
ii:i;a from time to time evidently en-
tiiying himself, and when volunteers
I assured those who were hesitant
-at no procedures were entailed.
The response of the news media
IS gratifying. All major newspa-
irs, television, and radio networks
vered the event. Personal inter-
|,;ws with participating physicians
Te held prior to the sessions and
lile the booth was in progress.
The major expense of $200 for
; booth rental was covered by the
nerican Cancer Society. The de-
ji and erection of the booth, print-
> of the patient questionnaire
II ifms, and the notification of the
_ unty medical societies were
|ided by the North Carolina State
iiard of Health.
iSeveral problems were encoun-
" led during the study. Some confu-
n arose regarding the division of
ponsibilities among the large
_ ^mber of volunteers. In order to
. .Dre effectively answer patients'
sstions, volunteers should have
i;n more adequately briefed by the
."matologists. The examining areas
\ re makeshift, providing inade-
( ite light and ventilation, and no
J imbing.
^fter the Fair ended, a question-
i.re was sent to all physician volun-
teers requesting their anonymous,
frank appraisal of the project. All
expressed the opinion that the proj-
ect was worthwhile. According to
Robert Gilgore, M.D. and Mrs. Ger-
trude Price (written communica-
tions, 1972), two physicians volun-
teered to conduct similar clinics in
other counties and they submitted
plans to the National Program for
Dermatology in the hope of coor-
dinating efforts.
The public openly expressed their
appreciation for the efforts of all
people involved in the project.
Young adults appeared to be im-
pressed with the information at
hand, and many indicated their
awareness, for the first time, that
skin problems in the future could be
minimized or avoided. Colleagues
in other fields expressed their inter-
est and support. And, we enjoyed
the strengthening of friendships and
closer professional ties, as well as
the gratification derived from a job
well done.
SUMMARY
Nine skin cancer detection clinics
were held at the 1972 North Caro-
lina State Fair. The primary objec-
tive was educational; i.e., to increase
the public's awareness of the rela-
tionship between excessive sunlight
exposure and skin cancer.
Eleven thousand seven hundred
people received educational ma-
terial. The light-exposed areas of
418 patients were examined; 37.8
percent of this group were referred
for further diagnostic work and
treatment.
Acknowledgments
The author wishes to acknowledge the
assistance of the following people: Mrs
Harriet Flint, Program Director, North
Carolina Division of the American Can-
cer Society and Miss Grace H. Daniel,
Chief, Health Education Section; Mrs.
Jane Gauntz, Artist-Illustrator, Dental
Health Division, and Dr. Isa Grant,
Chief, Chronic Disease Section of the
North Carolina State Board of Health.
Appreciation is expressed to the phy-
sicians participating: Drs. Edward Bur-
ton, Robert Gilgore, Frank Houston,
Mendel Jordan, W. Stacy Miller, Frances
Pascher, Vade G. Rhoades, and Harry
Scott.
Appreciation is also expressed to the
following pharmaceutical companies:
Dome Laboratories, Owen Laboratories,
Inc.. Person and Covey, Inc., Texas
Pharmacal Company, Westwood Phar-
maceuticals, and Lydia O'Leary Cos-
metics.
References
1. Weary PE: A two-year experience with a
series of rural skin and oral detection clin-
ics. JAMA 217: 1862-IS63, 1971.
2. Lynch FW. Lehmann FC, Pipkin JL: A con-
trast of cutaneous cancer as observed in
Texas and in Minnesota. Arch Dermatol
79: 27.'i-28.1, 1959.
.1. Mackee BS, McGovern VJ: The mechanism
of solar carcinogenesis. Arch Dermatol 78;
218-244. 1958.
4. Howell JB: The sunlight factor in aging and
skin cancer. Arch Dermatol 82: 865-869,
I960.
5. Yoti, Your Dermatologist and Cancer of the
Skin, The American Academy of Derma-
tology, Portland, Oregon.
6. Sense in tfie Sun, The American Cancer So-
ciety, New York. New York.
Galen says, that immersion in cold water is fit only for the young of lions and bears; and
recommends warm bathing, as conducive to the growth and strength of infants. How egregiously
do the greatest men err whenever they lose sight of facts, and substitute reasoning in physic in
place of observation and experience! — H-'/Wiu/d Bttchaii: Domestic Medicine, or a Treatise on
the Prevention and Ctire of Diseases by Regimen and Simple Medicines, etc., Richard Folwell,
1799, p. 429.
^ CH 1974, NCMI
161
Editorials
THE 1974 MIDWINTER EXECUTIVE
COUNCIL MEETING
Gas shortages notwithstanding, the Council met as
usual and for the third time in the new Society build-
ing, which looks better all the time, especially since
it is paid for. Dr. Tilghman Herring, who guards
the Society's finances with a zeal which should satisfy
any Society member familiar with his actions, an-
nounced that while 1973 was a good year as evi-
denced by the paying off of the building, 1974
is likely to be a very tight year for meeting the
budget. The way in which our committees try to avoid
spending their projected budgets is an example for all
of us.
Much of the time was occupied with the Legisla-
tive Committee's reports, and what is said here will
of necessity be old, for with the Legislature in session
things happen fast. A bill requiring reporting of
wounds seen in out-patient practice was opposed last
year by the Society, and will likely not get out of
committee this year. It is expected that a great deal
of useful change will be brought about in the pro-
cedures affecting mental institution admission and re-
tention practices, helping patients, families, and phy-
sicians. These changes are the result of experience
with the recently changed regulations, and physician
reaction to them, as well as the comments of institu-
tional authorities. Legislation is pending which would
allow the state to set up a uniform accounting pro-
cedure for various medical facilities so that cost
analyses could be done; no rate enforcement authority
is included. Another bill would require third party
payors to establish their fee profiles on a statewide,
not regional, basis. This apparently reflects the feeling
of some physicians in rural areas that they are un-
justly receiving less for a given procedure than an-
other physician in an urban area. Apparently the net
result of the fee schedule would be to lower fees
for some urban physicians with little, if any, increase
in fees in rural areas. The Council opposed this legis-
lation. The Council went on record as disapproving
a proposal to eliminate coordination of health bene-
fits; opposition was based on the fact that this move
would result in what might well be presented to the
public as an increase in health care costs, including
physicians' fees, when it was no such thing. This
would occur because under the new legislation pa-
tients would collect the full sum available under all
their medical policies for whate\er illness they had.
Since they might well have to pay only a part of t^
money to the people and places involved in the
treatment, not all the money paid them would be gt
ing for health care. Under present plans peop
usually do not collect more than they owe. The Coui
cil also opposed a bill requiring a reasonable su
picion of criminality before a medical examiner cou
order an autopsy. The state medical examiner feel
and the Council concurred, that often no such susp
cion exists prior to the autopsy. In the legal med
cine field also is a bill which would make the prese
blood alcohol level of 0.1 percent prima facie e\
dence of driving under the influence of alcohol, thi
permitting no courtroom argument over that matti
and removing a decision as to whether or not, d
termined from the jury's deliberations, the driver w:
intoxicated. It was suggested that members wl
might want to demonstrate just how a person wii
the 0. 1 percent level feels may be assisted by loc
law enforcement officers at times. One member wl
witnessed such a demonstration was most impressc
by the amount of liquor drunk before the people
volved reached the legal blood level. There is a po
sibility that a bill will be introduced to make mand
tory the wearing of seat belts, with stiff penalties
one is stopped and found not in compliance. The
have been dramatic decreases in fatalities in a Sou
American country which has such a law.
The State Board of Medical Examiner's Dr. W:
kerson reported that no applications have been r
ceived from solo nurse practitioners, but that there
interest on the part of specially trained hospital-bas(
nurses, e.g., in coronary care units, in some spec^
certification. Thus far no mechanism exists for su(
certification. Dr. Wilkerson pointed out that un
censed foreign medical graduates cannot work
physician's assistants, as some have tried to do.
The large number of other matters which were di
cussed will either by now have reached the met
bership through other channels, or represent ongoii
problems on which nothing newsworthy has dew
oped. One of the long discussions concerned prima
care physicians, and a position paper, to be discuss
by the House of Delegates, is to appear in the JOU
NAL before they meet.
FOLK MEDICINE
Since Eve cured Adam of his delusions of imnu
tality by administering natural food, man has requir.
162
Vol. 35. No
I rich and varied store of beliefs to help him preserve
limself from the ever present threat of the unknown.
^d as the unknown has changed, so has the body of
ommon beliefs, certainly true but unverifiable, called
olklore. As Betts intimates in this issue of the
OURNAL, yesterday's scientific medicine has been
bsorbcd into the medical underground of the pres-
nt, and even today's medical indications may be al-
;red to allow authoritative self-treatment, as wit-
essed by the emergence of Vitamins E and C as
■iianaceas. If we were concerned with other disci-
'ilines, it would be legitimate to suggest that cultural
ig, that delayed admission of new knowledge to the
'/orld of everyday, has been overwhelmed by the
iixplosion in medical science in recent decades to the
aoint that intellectual indigestion and fragmentation
'ave set in. What would be more logical, then, than
> incorporate the more apparent and simpler data
-f modern medicine into that incompletely codified
./stem of folklore which offers perpetual testimony
;> our wishful thinking and suppressed belief in
nagic?
i! If we look to the 18th century, called The Age of
'. eason, we find that John Wesley, faced with a simi-
rly exploding world, not only got the Methodist
; hurch going but wrote a home medical advisor en-
*tled "Primitive Physic" which passed through 19
i.litions in the following century and a 20th edition
; this century. Wesley incorporated Indian remedies,
' e advice of "the great Sydenham" and many old
fives' tales, into a cheap book in order to help the
oor save money and to keep the apothecary and the
nysician from getting too rich a profit from his fol-
"wers. And Wesley's advice was usually as good as,
'- not better than, that of his medical contemporaries
iho by our lights often practiced a miserable brand
therapeutics, based on ignorance and arbitrary
dgment. This of course confirms that one of the ele-
ments of folklore is a measure of hard practicality,
c accumulation of centuries of experience. Since
n have left botanicals for chemical synthesis, this
; ritage becomes medical history-and we forget per-
' ps that digitalis was elevated to the' therapeutic
crerage from such company.
I Yet it behooves us not to forget this past because
'^ find that some of our patients, seeking to expand
eir senses, have taken to experimenting with nature,
seating, to their chagrin, the often lethal trials of our
icestors. Such recent practices may be confirmed by
reports of cyanide poisoning from eating cherry pits,
atropinism from eating fruit borne by a jimson weed
• — tomato graft, and the recurring reports of mush-
room poisoning.
So we must be discriminating in our amusement,
perceptive in our reading, and thankful that some
people are interested in what contributes to the
laity's notions of medicine and drugs.
John H. Felts, M.D.
Reading List
Thompson CJS: Mystic Mandralie. New Hyde Parti, New Yori<:
University Books, 1968.
Wesley J: Primitive Physic. London; Epworth Press, 1960.
King LS: The Medical World of the Eighteenth Century. Chicago:
University of Chicago Press. 195S.
Gibbons E: Stalliing the Wild Asparagus. New York: David
McKay Co Inc. 1962.
Gibbons E: Stalking the Healthful Herbs. New York: David Mc-
Kay Co Inc. 1966.
PRESCRIPTION PSRO
Several members of the North Carolina Medical
Society are actively involved with pharmacists on lo-
cal peer review committees in reviewing drugs pur-
chased by recipients who are eligible under the North
Carolina Medicaid program. The peer review, ad-
ministered by PAID Prescriptions, is being done on a
professional, confidential basis.
These committees work with computer-generated
drug profiles that contain a six-month history of all
prescriptions purchased by the Medicaid recipient.
The computer records each patient's drug purchases
and these records are sent to the practitioner.
This peer review of prescription drugs under
Medicaid has been well received and has had a posi-
tive impact on both the quality of drug therapy and
on the economy of the program.
On September 27, 1973, PAID Prescriptions re-
ported to the North Carolina Medical Society Com-
mittee Liaison to the Pharmaceutical Association on
the operations of the peer review program in connec-
tion with the administration of the prescription drug
benefits under the Title XIX Medicaid program. The
committee felt that this information was of such im-
portance that it should be brought to the attention
of the Medical Society members. The report appears
in this issue of the Journal and is recommended
for your reading.
Charles W. Byrd, M.D., Chairman
Committee Liaison to North Carolina
Pharmaceutical Association, North
Carolina Medical Society
M
When cold bathing occasions chillness, loss of appetite, listlessness. pain of the breast or
bowels, a prostration of strength, or violent head-aches, it ought to be discontinued. — Willium
Buchan: Domestic Medicine, or a Treatise on the Prevention and Cure of Diseases by Regimen
and Simple Medicines, etc., Richard Folwell, 1799, p. 429.
ji tecH 1974, NCMJ
167
Program
Preliminary
PROGRAM
NORTH CAROLINA MEDICAL SOCIETY
May 18-22, 1974
PINEHURST HOTEL
Pinehurst, North Carolina
Sunday, May 19, 1974
2:00 p.m.— OPENING SESSION — HOUSE OF
DELEGATES— Cardinal Ballroom
Monday, May 20, 1974
7:00 a.m.— MEMORIAL SERVICE/PRAYER
BREAKFAST— Crystal Room
2:00 p.m.— REFERENCE COMMITTEES meet
I — Cardinal Ballroom
II — Pine Room
7:00 p.m.— MEDPAC DINNER— Cardinal Ball-
room
(Everyone invited to attend)
9:30 p.m. Cardinal Ballroom
•SEX AFTER SUPPER"
How to help doctors keep their wives and marriages
happy
John B. Reckless, M.D.
Tuesday, May 21, 1974
2:00 p.m.— Second Session— HOUSE OF DELE-
GATES— Cardinal Ballroom
7:00 p.m.— PRESIDENT'S DINNER —
Main Dining Room
9:00 p.m.— PRESIDENTS BALL —
Cardinal Ballroom
GENERAL SESSIONS
FIRST GENERAL SESSION
Monday, May 20, 1974 Cardinal Ballroom
9:00 a.m. — 12:30 p.m.
Convene Session
Presiding; George G. Gilbert, M.D., President,
Ashevillc
Invocation:
Surgical Session
CONTEMPORARY SURGICAL MANAGEMENT
Department of Surgery, University of North
Carolina. School of Medicine, Chapel Hill,
North Carolina
MODERATOR: Colin G. Thomas, Jr., M.D.
Professor and Chairman
Department of Surgery
9:00 a.m.— OPENING REMARKS —
Christopher C. Fordham. Ill, M.D., Deai
University of North Carolina School of Medicine
9:15 a.m.— CANCER OF THE LUNG
Gordon F. Murray, M.D.,
Assistant Professor of Surgery
Division of Cardiovascular and
Thoracic Surgery
9:30 a.m.— PAIN CONTROL — Microneuro
surgery
Frederic I. Fagelman, M.D.
Assistant Professor, Division o
Neurosurgery
9:45 a.m.— IMPROVED NUTRITION — PAR
ENTERAL ALIMENTATION
AND ELEMENTAL DIET
Robert D. Croom, III, M.D.,
Assistant Professor, General Surger
10:00 a.m.— SURGICAL RESTORATION OF
THE VOICE
W. Paul Biggers, M.D., Associate
Professor. Surgery, Otolaryngology
10:15 a.m.— TREATMENT ^ OF THE BURI
INJURY
A. G. Bevin, Jr., M.D., Associat
Professor, Plastic Surgery
10:30-10:45 a.m.— BREAK
10:45 a.m.— NEW DEVELOPMENTS IN OR
THOPAEDICS
Edwin T. Preston, M.D., Assistar
Professor, Surgery, Orthopaedics
11 00 a.m.— IMMUNOLOGICAL ADVANCES
IN UROLOGICAL TUMORS
Andrew T. Cole, M.D.,
Assistant Professor, Surgery, Uro
ogy
11:15 a.m.— NON-INVASIVE ESTIMATES O;
PERIPHERAL BLOOD FLOW
Noel B. McDevitt, M.D.,
Assistant Professor, Vascular Sui
gery
168
Vol. 35. No
1:30 a.m.— END STAGE RENAL DISEASE —
ROLE OF COMMUNITY HOS-
PITAL
Stanley R. Mandel, M.D.,
Associate Professor, Vascular Sur-
gery
2:00 Noon—
\WARDING OF DOOR PRIZES
ADJOURN
j SECOND GENERAL SESSION
Tuesday, May 21, 1974 Cardinal Ballroom
1 9:00 a.m. — 12:30 p.m.
Convene Session
Presiding: D. E. Ward, Jr., M.D., First Vice Presi-
dent, Lumberton
fledical Session
1 Bowman Gray Day
Department of Medicine, Bowman Gray School
j of Medicine, Winston-Salem, North CaroHna
9:00 a.m.— WHATS NEW AT BOWMAN GRAY
Richard Janevvay, M.D.. Dean
Bowman Gray School of Medicine
9:10 a.m.— INTRODUCTION
Joseph E. Johnson, M.D.,
Professor and Chairman
■ Department of Medicine
9:20 a.m.— THE PROBLEM OF HYPERTEN-
SION: AN OVERVIEW
Robert N. Headley, M.D.,
Associate Professor of Medicine
iJ:45 a.m.— HYPERTENSION AND THE
HEART
John H. Edmonds, Jr., M.D.,
Professor of Medicine
):05 a.m.— HYPERTENSION AND CEREBRO-
VASCULAR ACCriDENT
Richard Janeway, M.D., Dean
20 a.m.— BREAK
):35 a.m.— RENIN, ALDOSTERONE AND
THE KIDNEY
Vardaman Buckalew, M.D.,
Professor of Medicine
(:00 a.m.— PHEOCHROMOCYTOMA
John S. Kaufmann, M.D., Assistant
Professor, Medicine and Pharma-
cology
:30 a.m.— THERAPY OF HYPERTENSION
John H. Felts, M.D.,
Professor of Medicine
*::00 Noon— Address: George G. Gilbert, M.D.,
I President, Asheville
;VARDING OF DOOR PRIZES
;DJOURN
' THIRD GENERAL SESSION
Mnesday, May 22, 1974 Cardinal Ballroom
9:00 a.m. -12:30 p.m.
taCH 1974, NCMJ
B
I
r
Convene Session
Presiding: George G. Gilbert, M.D., President
Asheville
SOCIO-ECONOMIC SESSION
MODERATOR: Josephine E. Newell, M.D., Bailey
9:00 a.m.— CONJOINT SESSION — NORTH
CAROLINA DIVISION OF
HEALTH SERVICES AND
NORTH CAROLINA MEDI-
CAL SOCIETY
Jacob Koomen, M.D., Director,
Raleigh
9:30 a.m.— PAST MISTAKES — FUTURE EX-
PECTATIONS— HOW TO
PLAY THE SECOND HALF
Edward R. Annis, M.D.,
Physicians Planning Service Corpo-
ration, New York, New York
10:30 a.m.— Address: Russell B. Roth, M.D., Presi-
dent, American Medical As-
sociation, Erie, Pennsylvania
11:15 a.m. — Address: Frank R. Reynolds, M.D.,
President, North Carolina
Medical Society
1 1:45 a.m. — Awarding of Prizes.
ADJOURN SINE DIE
SECTION ON ANESTHESIOLOGY
Saturday, May 18. 1974 HMS Bounty
9:00 a.m. -11:30 a.m.
Chainncm: Merel H. Harmel, M.D., Durham
SECTION ON NEUROLOGY & PSYCHIATRY
Saturday, May 18, 1974 Pine Room
9:00 a.m. -12:00 Noon
ChainiHin: Robert W. Gibson, M.D., Morganton
12:30 p.m.
Dutch Luncheon and Business Meeting
Crystal Room
# # #
SECTION ON PATHOLOGY
Saturday, May 18, 1974 Ballroom, Holly Inn
9:00 a.m.-5:00 p.m.
Chairnuin: James A. Mahcr, M.D., Goldsboro
LIVER BIOPSY INTERPRETATION
Joseph W. Grisham, M.D., Professor and Chairman
Department of Pathology, Univ. of North Carolina
School of Medicine. Chapel Hill
RECENT DEVELOPMENTS IN CLINICAL LAB-
ORATORY STANDARDS —
Development of Consensus Standards Analogous to
Industry — a recent phenomenon
Robert W. Prichard, M.D., Professor and Chair-
man, Department of Pathology, Bowman Gray
School of Medicine, Winston-Salcm
CLINICAL AND STATISTICAL INTERPRETA-
TION OF ELECTROIMMUNO ASSAY IN
169
IDENTIFICATION OF BODY FLUID PRO-
TEIN ABNORMALITIES
Florian Mcnninger, M.D., Mason Research
Institute. Worcester, Massachusetts
BUSINESS MEETING— North Carolina State Pa-
thology Society
Election of Officers, Delegate and Alternate Delegate
for the Section for 1974-75
ADJOURN
# # #
SECTION ON ORTHOPAEDICS
and
NORTH CAROLINA ORTHOPAEDIC
ASSOCIATION
Saturday. May 18, 1974 Pine Room
Cliainnan: Robert J. Burleson, M.D., Ashcville
12:30 p.m. — Executive Committee Meeting of
North Carolina Orthopaedic Asso-
ciation
1:00 p.m. — Lunch — (On your own)
2:00 p.m. — North Carolina Orthopaedic Associa-
tion. Spring Meeting
3:00 p.m. — Section on Orthopaedics Meeting
4:00 p.m. — Adjournment
# # it
SECTION ON RADIOLOGY
Saturday, May IS. 1974 Cardinal Ballroom
1:30 p.m. — 5:00 p.m.
Cliairnian: Stuart W. Gibbs, M.D,. Gastonia
EVALUATION OF PATIENTS WITH SUDDEN
FLANK PAIN AND HEMATURIA WHO DO
NOT HAVE STONES
Jerome Cunningham, M.D.,
Department of Radiology, North Carolina
Baptist Hospital, Winston-Salem
RECENT AD\ANCES IN NUCLEAR MEDICINE
RENOGRAPHY
Edward V. Staab. M.D.. Professor of Radiology
and Director of Nuclear Medicine Division,
Department of Radiology. N. C. Memorial
Hospital. Chapel Hill
INTERMISSION
RENAL SHUNTS AND THE TRUETA PHE-
NOMENON IN MAN
Milton Elkin. M.D.. Professor of Radiology,
Albert Einstein College of Medicine, Bronx,
New York
OPPORTUNISTIC PULMONARY INFECTIONS
Arvin Ri^:-!inson, M.D., Department of
Radiology, Duke University Medical Center,
Durham
BUSINESS SESSION— Election of Officers, Dele-
gate and Alternate Delegate
for 1974-75
ADJOURN
170
SECTION ON DERMATOLOGY
Saturday, May 18, 1974
6:30 p.m.— SOCIAL HOUR— Poolside
7:30 p.m. — DINNER and Entertainment —
Cardinal Ballrooi
# # #
SCIENTIFIC SESSION
Sunday, May 19, 1974 Crystal Rooir]
9:00 a.m.-12:00 Noon
SYMPOSIUM ON CONTACT DERMATITIS
Guest Speaker: Alexander Fisher, M.D.
Clinical Professor of Dermatolog-
New York University
Business Session: Election of Officers, Delegate an('
Alternate Delegate for 1974-75
# # #
SECTION ON FAMILY PHYSICIANS
Sunday. Mav 19, 1974 Pine Roo:
9:00 a.m.-12:00 Noon
Cliainnan: A. M. ,A,lderman. Jr.. M.D., Raleigl-
and
BOARD OF DIRECTORS Meeting— North Can
lina Academy of Family Physicians
^ ^ 44-
-tf- t^ -f*
SECTION ON SURGERY
Monday, May 20, 1974 London Gr
7:30 a.m.
Cliairnian: Wm. B. McCutcheon, Jr.. M.D., Durha
Breakfast Meeting —
Election of Officers, Delegate and Alterna
Delegate for year 1974-75
SECTION ON OBSTETRICS & GYNECOLOG
Monday, May 20, 1974 Pine Roo
8:00 a.m.-9:00 a.m.
Cliairnian: Robert G. Brame. M.D., Durham
BUSINESS MEETING— Election of Officers. Del
gate and Alternate Del
gates for 1974-75
# # #
SECTION ON PUBLIC HEALTH
AND EDUCATION
Mondav. Mav 20. 1974 TV Lounge, Holly Ii
2:00 p.m.
Cliairnian: John J. Wright, M.D,. Chapel Hill
Program Chairman: Isa C. Grant, M.D., Ralei]
NUTRITION EVALUATION PROJECT
Joseph C. Edozien. M.D.. Professor and
Head of Nutrition
School of Public Health. Chapel Hill
BUSINESS MEETING— Section on Public Health
Education and North Carolina Academy of
Preventive Medicine
Election of Officers. Delegate and Alternate
Delegate for 1974-75
Vol. 35, No.
SECTION ON PEDIATRICS
nday, May 20, 1974 Crystal Room
2:00 p.m.-4:30 p.m.
'Chairman: William W. Farley, M.D., Raleigh
""'rogram Chairman: Ronald P. Kruegcr, M.D.,
li Durham
'JROLOGIC PROBLEMS OF CHILDHOOD
MMON URINARY TRACT MALFORMA-
TIONS OF CHILDHOOD
,, Patrick Currie, M.D., Division of Urology
! Bowman Gray School of Medicine, Winston-
] Salem
lisiCO-URETERAL REFLUX: ETIOLOGY,
pNIFICANCE AND MANAGEMENT
lit John Weinerth, M.D., Division of Urology
) Duke University School of Medicine, Durham
)::URRENT URINARY TRACT INFECTIONS
!i William G. Conley, M.D., Department of
A Pediatrics, University of North Carolina School
[ of Medicine, Chapel Hill
TIBACTERIAL THERAPY OF URINARY
ACT INFECTIONS
Catherine Wilfert, M.D., Department of
Pediatrics, Duke University School of Medicine,
Durham
NAGEMENT OF THE CHILD WITH AD-
MCED RENAL DAMAGE
C. Richard Morris, M.D., Department of
Pediatrics, University of North Carolina School
of Medicine, Chapel Hill
LIOLOGIC EVALUATION OFTHEGENITO-
(NARY TRACT IN CHILDREN
Herman Grossman, M.D., Department of
Radiology, Duke University School of Medicine,
Durham
JND TABLE DISCUSSION AND QUESTIONS
lo|»)M THE AUDIENCE: UROLOGIC PROB-
>1S OF CHILDHOOD—
Drs. Currie, Weinerth, Conley, Wilfert, Morris
and Grossman
p. iness Session: Election of Officers, Delegate and
Alternate Delegate for the year
1974-75
s program will he of interest to General Practi-
lers as well as Pediatricians)
# # #
! SECTION ON OPHTHALMOLOGY &
OTOLARYNGOLOGY
;day. May 20, 1974 Ballroom, Holly Inn
2:00 p.m.-4:30 p.m.
irman: E. Randolph Wilkerson, Jr., M.D.,
Charlotte
0 p.m. — Scientific papers — by Ophthalmolo-
gists
iO p.m.— BUSINESS MEETING —
Discuss establishing:
a) Section on Ophthalmology
b) Section on Otolaryngology
'<H 1974, NCMJ
aii
:k;>:
OOi
i
Election of Officers, Delegate and
Alternate Delegate for each Section
for 1974-75
3 : 30 p.m. — Scientific papers — by Otolaryngologists
# # #
ORGANIZATIONAL MEETING FOR
NEUROSURGERY
Tuesday, May 21, 1974 Parlor No. 129
(East Wing)
9:00 a.m.
Chairman: Ira M. Hardy, 111, M.D., Greenville
# # #
SECTION ON UROLOGY
Tuesday, May 21, 1974 Pine Room
10:00 a.m.
Cliairnian: Vernon H. Youngblood, M.D., Concord
POSTGRADUATE AND AUDIO-VISUAL
PROGRAM
ONE HUNDRED TWENTIETH ANNUAL
SESSION
Pinehurst, North Carolina
G. Patrick Henderson, Jr.. M.D., Chairman.
Pinehurst
Morning Session
Monday, May 20, 1974
9:00 a.m. -12:00 Noon HMS Bounty
Moderator: Thornton R. Cleek, M.D., Asheboro
9:00 a.m.— CHARLIE
Emphasizes the importance that
drinking and flying do not mix.
Charlie's judgment and his life
are changed by alcohol, even a
small bit of alcohol.
9:25 a.m.— DIAGNOSIS AND TREATMENT
OF RENOVASCULAR HYPER-
TENSION
Approximately 5% of those who
have elevated blood pressure
have surgical correctable lesions.
The vigorous and intensive medi-
cal and neurological investigation
acquired to find these patients
with potentially curable hyperten-
sions is carefully and thoroughly
illustrated.
9:55 a.m.— LAPAROSCOPY
Diagnostic and Therapeutic opera-
tive technique has come into its
own since the advent of fiber
optics. An over-view of the pro-
cedure, including instrumentation,
operative team, and technique is
presented.
10:20 a.m.— FIRE UNDER CONTROL
Brief review of hazards of fire in
171
everyday living and specifically in
manned space flight.
10:35 a.m.— ALL IT TAKES IS ONCE
Even the best pilots can be dis-
tracted in flight by pre-occupation
with personal problems. Mental
distraction is a serious problem
in flight. How five psychological
problems frequently encountered
by general aviation pilots — affects
of their performance is adequate-
ly presented.
11:05 a.m.— UNCOVERING DEPRESSION IN
THE ANXIOUS PATIENT
Intended to reinforce the importance
of stop, look and listen, in actual
practice. Encourage a physician
to take time to explore possibility
of a hidden depression in every
patient who presents with obvious
an.xietv.
11:35 a.m.— RX FOR HEALTH CARE
Correlates the root causes for health
crises and the proposal for deal-
ing with these concerns.
# # #
Afternoon Session
Monday. May 20. 1974
2:00 p.m.-5:00 p.m. HMS Bounty
Moderator: John L. Monroe, M.D., Pinehurst
2:00 p.m.— THE ROLE OF THE PRACTICING
PHYSICIAN IN THE INVESTI-
GATION OF A SUDDEN, UN-
USUAL, UNNATURAL OR
SUSPICIOUS DEATH
Slides from the office of R. Page
Hudson, Jr., M.D., Chief Medieval
Examiner, State of North Caro-
lina, Chapel Hill.
3:00 p.m.— THE NOSE AND PARANASAL
SINUSES
The gross anatomy and physiology
of the now and paranasal sinuses
are emphasized. Causes of chronic
ma.xillary sinusitis, atrophic rhini-
tis, polyposis, septum deviation,
foreign body, and carcinoma are
diagnosed and discussed.
3:30 p.m. THE TREATMENT OF DEAFNESS
A presentation of experimental and
clinical observations on which the
use of prosthetic appliances in the
tympanic cavity is based.
4:05 p.m.— CAN WE HAVE A LITTLE QUIET,
PLEASE?
This is an illustration how govern-
ment and industry are cooperating
to reduce aircraft smoke emissions
and noise, particularly around air-
ports, and describes technical 3
provements that have been n(
to jet engines and sound ab:i
ment procedures.
4:25 p.m.— OTOSCOPY IN INFLAMMATK
An illustration of the tymp
membrane pathology, from
acute and chronic catarrhal
ditions to the adhesive proce
Chronicities are analyzed and
cussed.
# # #
Morning Session
Tuesday, May 21, 1974
9:00 a.m.-12:00 Noon HMS Bo
Moderator: John C. Grier, Jr., M.D., Pinehi
9:00 a.m.— THREE TIMES A DAY
One out of every four Ameri
in the 55 to 62 age group will
fer coronary, diet being on^
the chief causes. Up to 70";^
our population should take s
to lower the cholesterol level
evidence through research.
9:30 a.m.— ESCAPE FROM ADDICTION
A comprehensive and organized
ture of chemical dependence
straight forward unemotional
ter. A broad view of addictio
it relates to alcohol, narcotics
other drugs.
10:05 a.m.— THE MEDICAL WITNESS
An illustration to help the physi
make an effective transition f
medical examining room to
court room. The film uses
examples to dramatize the i
and wrong way to give mc
testimony. Gives special empl
to proper preparation.
10:40 a.m.— SPRINGBOARD TO SPACE
,^n illustration how astroni
chemistry, physics, mathem;
engineering, medicine and t
academic areas will pioneer
way to creativity and comprei
sion in conquering the unknc
11:00 a.m.— URETHRAL CATHETERIZAT
OF MALE AND FEMALE
The various purposes for, and ni
ods of urethral catheterization
discussed as are the types
composition of catheters. Pr
dures for catheterization are c
fullv illustrated.
11:20 a.m.— OUAL'iTY ASSURANCE P
GRAM
An illustration of the PSRO Sys
Tell exactly what the PJ(
172
Vol. 35,
System is, exactly how it is in-
tended to work.
# # #
^rnoon Session
sday, May 21, 1974
f] p.m.-5:00 p.m. HMS BOUNTY
krator: Paul McB. Aberncthy, M.D., Burlington
)0 p.m.— RECOGNIZING GLAUCOMA
This film reviews the different
types of glaucoma and demon-
strates how glaucoma can be
recognized by measurement of in-
traocular pressure.
50 p.m.— THE MANAGEMENT OF SEVERE
BURNS IN CHILDREN
This demonstrates the treatment
upon arrival of one patient in the
emergency room immediately fol-
lowing a burn accident. Treatment
Ito
n.
is followed through the successful
completion of grafting.
3:00 p.m.— THE MAN WHO DIDN'T WALK
Dramatizes one of the most contro-
versial issues in the entire catalog
of medico-legal problem . . . trau-
matic neurosis.
3:40 p.m.— A MATTER OF FACT
An innocent man is nearly indicted
for murder. Illustrates the neces-
sity for alert and keen observation
on the part of any doctor who
establishes the cause of death.
4:15 p.m.— MEDITATIONS ON HUNTING
More than 20-million American
hunters take to the field each year.
This film is an intellectual and cul-
tural justification for hunting to-
day.
'program and environment
ie individual to maintain
respect and recover witti
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
Recognized by:
Blue Cross & Blue Shield • Life Assurance Co. of Carolina
• Pilot Life Ins Co. • Aetna Life & Casualty
• John Hancock Mutual Life Ins. Co. • Kemper Ins.
• Metropolitan Life Ins. Co. • United Benefit Life Ins. Co,
• Security Life & Trust Co.
Member of:
• N. C. Hospital Association
• The Alcoholic & Drug Problems
Assn. of North America
• American Hospital Association
FOR ADMIHANCE CALL
JAMIE CARRAWAY
EXECUTIVE DIRECTOR
919-621-3381
FELLOWSHIP HALL
p. 0. BOX 6928 • GREENSBORO, N. C. 27405
Inc.
FOR IVIEDICAL INFORMATION CALL
J. W. WELBORN, JR., M.D.
MEDICAL DIRECTOR
919-275-6328
otel-like accommodations
ite bath and individual
I e control.
Located off U.S. Hwy. No. 29 at Hicone Road Exit,
6V2 miles north of downtown Greensboro, N. C.
)S «
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..
I 1974, NCMJ
173
Emergency
Medical
Services
ACTIVITIES OF THE PUBLIC HEALTH
SERVICE IN EMERGENCY MEDICAL
SERVICES
Robert van Hoek, M.D., Acting Director
Bureau of Health Services Research and Evaluation
Health Resources Administration
Department of Health, Education and Welfare
In 1972, President Nixon directed HEW to utilize
existing knowledge and management concepts to up-
grade emergency medical services. The task focused
on increasing the rapidity with which the accident
victim could enter an effective emergency care net-
work. The components of such a system include the
extension of services into areas where on-site medical
help is unavailable, improved communication sys-
tems, recruitment and training of supportive para-
medical personnel, and more effective transportation
of patients.
This led to the formation of an Emergency Medi-
cal Services program (EMS) which has provided
technical assistance to local areas, collected and dis-
tributed information, and established seven demon-
stration systems intended to improve local services
and to evaluate new approaches.
1. Illinois — expansion of statewide traimia treat-
ment system into a state-wide emergency medical
system. Plans include radio networks between hospi-
tals and ground and air vehicles, physician-monitored
ambulance systems, and regional central emergency
medical control centers.
2. Arkansas — organization and planning of a co-
ordinated EMS system among the state's districts.
Specific objectives are training of paramedicals and
ambulance drivers, a radio network, and an am-
bulance system.
3. Jacksonville, Florida — expansion of a city-ori-
ented EMS unit to surrounding rural counties by up-
grading local ambulance services, hospital ERs, i
training of all law enforcement officers and firemer
4. San Diego. Imperial, Riverside counties, C
fornia — coordination of separate EMS systems int
single entity with a radio network, training progra
for ambulance attendants, park rangers, and peo
in remote areas, and other specific programs.
5. Seven Ohio counties — establishment of a co-
erative EMS system. Novel features include train
programs in the community college system and &
cational programs to acquaint citizens with the 5
vices.
6. Baltimore. Maryland — implementation of a
dio-telephone network to facilitate transport of
tims to the most appropriate medical facility.
7. Arizona — establishment by the Dept. of Pul
Safety of a model communications system includ
training interstate truck drivers equipped with po'
ble radios to report accidents.
In addition, an interdepartmental EMS comr
tee has been formed involving multiple agencies to
ordinate federal EMS activities. The AdministraU
has requested $15 million for FY 1974 for EM«3
support the demonstrations and provide technical •
sistance and consultation to local areas. The fun,
if appropriated, will be administered by the Bum
of Health Services Research and Evaluation, Hc;li
Resources Administration. Department of Hc:li
Education and Welfare,
Abstracted bv Edward H. Wagner, M.D
From "Emergency Medicine Today," AM A Ce
mission on Emergency Medical Services. Volunu
No. 12. John M. Howard. M.D., Editor. Origi
article can be obtained from tlie American Med
Association. 535 North Dearborn Street, Chict^^
Illinois 60610.
Strong stimulants applied to the stomach and bowels for a length of time, must tend to weaken
and destroy their energy; and what stimulants are more active than salt and sulphur, especially
when these substances are intimately combined, and carried through the system b>, the penetrat-
ing meduim of water'.' These bowels must be strong indeed, which can withstand the daily opera-
tion of such active principles for months together, and not be injured. This is the plan pursued
by most of those who drink the purging mmeral waters, and whose circumstances will permit
them to continue long enough at those fashionable places of resort. — William Biuhnn: Domestic
McdKiiic. or a TreaUsc on the Prevention and Cure of Diseases by Regimen and Simple Medi-
cines, etc. Richard Folwell, 1799, p. 431.
174
Vol. 35, N^
Committees and
Organizations
Report to the
t NORTH CAROLINA MEDICAL SOCIETY
COMMITTEE
LIAISON TO THE PHARMACEUTICAL
ASSOCIATION
September 27, 1973
PAID Prescriptions is a non-profit corporation
iCializing in prescription drug claims processing
i pharmacy program administration. On December
1972, PAID Prescriptions entered into a contract
|h the North Carolina Department of Social Scr-
ips to administer the prescription drug benefits
.|ler the Title XIX Medicaid program,
pne of the requirements of this contract called for
IID to administer a program of drug utilization
,(iew based on the successful peer review program
it PAID had administered for Medicaid recipients
California under a contract with the San Joaquin
indation for Medical Care.
f,:^or the purpose of peer review, North Carolina
w divided into four geographic regions, each having
a roximately 75,000 eligible Medicaid recipients.
S, pharmacists and one physician were selected for
n.nbership on each of the four committees to meet
0|e a month in their respective areas.
; ,'rior to implementation, representatives from
P][D Prescriptions met individually with the Chair-
Jlji and Commissioner of this committee. They also
It with key Medical Society members and staff at
tl: r headquarters in Raleigh. President Glasson sug-
'g(ed that a centrally located county in each region
ie :t a physician for membership on the local com-
iiDlee. At this meeting, form letters were designed
fcr communicating information to the physicians.
Tse letters were written with special tact and pro-
'.'e':onalism. A simple reply form, designed to allow
iiohysician to quickly report the necessary informa-
i( has been a major factor in the success of our
M ;ram. The importance of receiving this informa-
nt' ifrom the practitioner cannot be overemphasized.
he core of the drug utilization review program is
hi computer-generated patient drug profile. These
n iles are generated automatically each month if
h patient's drug utilization exceeds the following
IE meters within that month:
Twelve or more prescriptions.
$70.00 or more total drug cost.
Four or more prescriptions in one therapeutic
;a ',ory.
4. Four or more physicians.
5. Three or more pharmacies.
6. The same drug purchased in more than one
pharmacy, on the same day.
These parameters are not necessarily indicative of
problems, but they have been found to identify a
high incidence of problems.
A patient profile contains a six-month history of
drug purchases. These profiles arc reviewed by the
peer review committees at their regular meetings. If
either the dispensing or utilization shown on the pro-
file cannot be explained, a copy of the patient's pro-
file, along with a letter requesting additional informa-
tion that can be added to the patient's profile, is sent
to the practitioner. In the instances of large numbers
of patients visiting more than one physician and one
pharmacy, our greatest asset is the computer-gener-
ated drug profiles with which we furnish the physi-
cians and pharmacies involved. This information is
completely confidential. Both pharmacist and physi-
cian are identified by numbers that are unknown even
to the peer review committee at the time of the re-
view.
Problems in the program have been in one of three
areas:
1. Frequent dispensing of small quantities of main-
tenance medication.
2. Apparent overutilization of medication by the
patient.
3. Apparent overutilization involving more than
one pharmacy or physician. (One case involved nine
physicians and seven pharmacies within a calendar
month).
Abuse in any of these three areas increases pro-
gram expenditures. Therefore, a reduction in drug
cost is usually consistent with either an improvement
in program economy or in patient drug therapy. For
this reason, we measure the effect of the peer review
by comparing the cost per day, of the drug under re-
view, on a "before and after" basis.
Comparisons have been completed for the first two
months" meetings in each of the four regions. The
results are as follows:
RESULTS OF TWO-MONTH COMPARISON
Number
Profiles reviewed 6,500
Profiles selected for further action 585
Profiles compared 458 (78%)
■A- H 1974, NCMJ
177
Letters to pharmacists
Replies from pliarmacists
Letters to physicians
Replies from physicians
814
610 (75%)
278
162 (58%)
Drugs considered (for 458 patients) 896
Drugs with decrease in utilization
following review 708 (79%)
Drugs with increase in utilization
following review 173 (19%)
Drugs unchanged following review 15 (2%)
* ^: * •^^^
Total reduction in cost of drug per
day (for 458 patients) $196.25
Average reduction in cost of drug
per day per patient $ .43
In order for us to fully understand the potential
of these savings to the program, we have projected
these savings for a period of twelve months (365
days) :
$0.43 per day x 365 days = $156.40 per patient,
per year
We can assume that this average savings will hold
true for each of the 585 patients reviewed:
$156.40 per patient, per year x 585 patients re-
viewed = $91,495.00 potential reduction in drug cost
per year resulting from two months of peer review.
The results from these first two months have bei
most impressive. We have received many replies fra
physicians thanking us for the information they ha
received, as well as many compliments on this ty
of review.
ACKNOWLEDGMENT
On behalf of PAID Prescriptions. I would like to {
press my sincere appreciation to the North Carolina Me
cal Society and its members for the cooperation and
sistance they have given us in the peer review program.
Frank F. Yarborough, Director
PAID Prescriptions
P.O.Box 18964
Raleigh, N. C. 27609
COMMITTEE ADVISORY TO CRIPPLED
CHILDREN'S PROGRAM
Southern Pines, Sept. 26, 1973
The chairman reported that the committee had :
ceived a request from the State Board of Health i
assistance in developing a protocol for the evaluati
of an institution which had made application to ;
ceive benefits under the Crippled Children's Progra
It was the consensus of the committee that:
The State Board of Health should draft cert;
criteria and guidelines, noting number of physicic
as well as specialties, and set forth certain crite
FV — -■■ ■ - Jf
Westbrook
Psychiatric Hospital, Inc.
Richmond, Virginia
FOUNDED 1911
PSYCHIATRY NEUROLOGY
REX BLANKINSHIP, M.D. GERALD W. ATKINSON, M.D.
Chairman, Advisory Group Associate in Neurology
JOHN R. SAUNDERS, M.D. HUGH HOWELL, M.D.
Medical Director Associate in Neurology
THOMAS F. COATES, JR., M.D.
Assistant Medical Director CHILD PSYCHIATRY
OWEN W. BRODIE, M.D. GILBERT SILVERMAN, M.D.
Associate in Psychiatry Associate in Child Psychiatry
M. M. VITOLS, M.D.
Associate in Psychiatry ADMINISTRATION
WESLEY E. McENTIRE, M.D. H. R. WOODALL
Associate in Psychiatry Administrator
BOBBY W. NELSON, M.D.
Associate in Psychiatry
F M
■ I
ti
:
178
Vol. 35, Nd
th which an institurion could be measured in order
receive certification for payment.
— Robert G. Underdal, M.D., Chairman
COMMITTEE TO WORK WITH THE
N. C. INDUSTRIAL COMMISSION
Southern Pines, Sept. 27, 1973
'Following a discussion concerning efforts of the
mmittee and the Industrial Commission to adopt
policy of basing payment for physicians" services in
Workmen's Compensation cases on the "usual, cus-
tomary, and reasonable concept," and the fact that
the Workmen's Compensation Fee Schedule was up-
dated in 1971 and again in 1973, a motion was made
to the effect that:
This committee recommends that the Industrial
Commission update the Workmen's Compensation
Fee Schedule again in May of 1975 and every two
years thereafter.
— Ernest B. Spangler, M.D.. Chairman
Bulletin Board
\
t
NEW MEMBERS
of the State Society
.brook. Everett Harold. Jr. (Student). 1301 Brookstown
.venue, .Apt. 301, Winston-Salem 27103
B ughten. Robert .Allen (Student). 1720 Grace St., Win-
on-Salem 27103
B'ch, Patrick Glenn (Student), 3830-D Huntins^reen Lane.
i/inston-Salem 27106
CUes. Peter George (Intern-Resident). 3803 Tremont Dr.,
|iurham 2770.^
CIrch. Karolen Ruth (Student). 817 S. Hawthorne Rd..
/inston-Salem 27103
(ton, Calvin Porter, Jr., M.D. (CDS), Doctors' Pk,
jite ."^12. .Asheville 28801
iry. Jimmie Ray. M.D. (GP) (Former Member). Stan-
yville Shopping Center. Route 1. Rural Hall 27045
iwic. Rick Edmund (Student), 1505 Woods Rd.. .Apt.
)3, Winston-Salem 27106
Dbn, Sevvell Hinton. Jr.. M.D. (CDS). 1016 Prof. Village.
Ireensboro 27401
D|;on. Ellen Maurine (Student), 2029 Elizabeth Ave..
inston-Salem 27103
Elards. Joel Lynn (Student), 2046 Queen St., Winston-
Mem 27103
F; Stephen Mart (Student), 4670 Elk Valley Court,
inston-Salem 27103
Glo. Peter Paul, M.D. (D), 120 Randomwood Lane,
sw Bern 28560
Gifin, Adrian Mark (Student), 660 Brent St.. Winston-
lem 27103
xk, Seymour Leon, M.D. (P), 500 Laurel Hill Road,
lapel Hill 27514
ler, Robert Norment, Jr. (Student), 624 W. End Blvd..
3t. 6, Winston-Salem 27101
y, Grant Fletcher (Student), 2021 Elizabeth Ave..
inston-Salem 27103
, Elzie Franklin, Jr. (Intern-Resident), Windsor Circle,
lapel Hill 27514
i, Albert Connor, III, M.D. (IMl, 3812 Canterbury
I., Wilmington 28401
I', David Fulmer (Student), 337 Crafton St., Apt. 2,
inston-Salem
M' :h 1974, NCMJ
Lang, Delano Roosevelt, Jr., M.D. (GP), 705 E. Sunset
Ave.. Ahoskie 27910
Lewis. Clifford Thomas. Jr.. M.D. (IM). 913 Hood Dr.,
Wilmington 28401
Norton, Michael (Student), 3830-A Huntingreen Lane,
Winston-Salem 27106
Olson, Maynard, Robert (Student), 1930 Gaston St., Win-
ston-Salem 27103
Pierce. Charles Grainger (Student). 411 N. Columbia St.,
Chapel Hill 27514
Plemmons, Ronald Lawrence (Student), P. O. Box 5922,
Winston-Salem 27103
Powell. James Bobbitt. M.D. (PTH), 810 W. Davis St..
Burlington 27215
Prokos. Craig Philip (Student). 2520 Preston Ave.. Durham
27705
Reeves. Michael Leo (Student). 438 S. Hawthorne Rd..
Apt. B.. Winston-Salem 27104
Roach. John Grover. Ill (Student). 1950 Hinshaw Ave.,
Winston-Salem 27104
Rock. John Aubrey. M.D. (Intern-Resident), Bo.\ 2984,
Duke Med. Center. Durham 27710
Sanders. Fredrick Douglas (Student), 1266 Tredwell Dr.,
Winston-Salem 27103
Scholl, George Kenneth, Jr.. M.D. (U), 100 Manning Dr..
Charlotte 28209
Shanahan, Eugene. M.D. (GP), 125 N. Main St.. Spring
Lake
Suarez. Jaime. M.D. (Intern-Resident), Station B.. Box 7441,
Raleich 27611
Thakur. Veda Nand. M.D, (ORS), 14th and Chesnut St.,
Lumberton 28358
Thomas. John Barham Raaland, M.D.. 644 Fenimore St.,
Wmston-Salem 27103
Vogler. James Brevard, III (Student), 1403 Pilot View St.,
Apt. D. Winston-Salem 27103
Walker. John Barrett. Ill (Student). 1900 Queen St., Apt.
B-7. Winston-Salem 27103
Whitesides. John Harvey. M.D. (OBG). 1509 Elizabeth
Ave.. Charlotte 28204
Williamson. Warren Eicon, M.D. (GS), P. O. Box 1171,
Lumberton 28358
Woodall, Hal Breeden (Student), 2863 Hermitage Dr.,
Winston-Salem 27103
Yopp, James Dennic, Jr., M.D. (IM). 3010 Maplewood Dr.,
Suite 122. Winston-Salem 27103
Yount, James Alvin. M.D. (IM), 3535 Randolph Road,
Charlotte 28211
179
^
WHAT? WHEN? WHERE?
March 1974
("Place" and "sponsor" are listed only where these differ
from the place and group or institution listed under "for
information.")
In North Carolina
March 15-16
Tenth Annual E. C. Hamblen Symposium in Reproductive
Biolog> and Family Planning. Basic themes: The Man-
agement of High-Risk Obstetrics and Newer Advances in
the Treatment of Infertility
Sponsor: Department of Obstetrics and Gynecology
Tuition: 52.*!. 00; no charge for residents or students
For Information: Charles B. Hammond. M.D., P. O. Box
3143, Duke University Medical Center. Durham 27710
March 21-23
Hematology and Oncology Post Graduate Course
Place: Duke University School of Medicine
Director: Wayne Rundles, M.D., Professor of Hematology,
Duke University
For Information and registration forms: American College
of Ph\sicians, 42(10 Pine Street. Philadelphia, Pennsyl-
vania 19104
March 25-27
Tutorial Postgraduate Course: Radiology of the Chest
This course is designed both for radiologists in training
and those in practice. The tutorial format and limited
registration will allow a larger than usual faculty-student
ratio and personalized instruction to those enrolled. Guest
faculty have been chosen both for their excellence in their
respective topics, and for their effective use of the tutorial
approach. During one hour tutorial sessions 12 registrants
will join one faculty member in a separate quiet room
with a bank of viewboxes for organized film reading-dis-
cussions, with 10-12 case presentations on a basic subject
or two. Registrants are invited to bring interesting cases
for consultation with the "experts."
Place: Durham Hotel-Motel, Durham
Credit: 21 hours AM.\ "Category One" accreditation
Fee: 5200.00
For Information: Robert McLelland. M.D.. Department of
Radioloev, Box 3S08, Duke University Medical Center,
Durham 27710
March 26-28
Cardiac Arrhythmia Course
Place: Duke Hospital Orthopedic Clinic, Room 1367
For Information: Galen Wagner. M.D.. Box 3327, Duke
University Medical Center. Durham 27710
March 28
"The Fit and the Fat — Our Overweight, Coronary Prone
Society," The 9th Wilson Memorial Hospital Postgraduate
Symposium
Sponsors: Wilson County Medical Society and the North
Carolina .Academy of Family Physicians
Credit: The Continuing Education Programs of Wilson Me-
morial Hospital are fully accredited by the Council on
Medical Education of the .'^MA. and are acceptable for
credit toward the AM.A Physician's Recognition .Award.
Credit from the .AAFP has been requested.
For Information: Gloria Graham, M.D., Wilson Memorial
Hospital, Wilson 27839
April 1-2
Postgraduate Course: Obstetrics and Gynecology
Place: Babcock .Auditorium
For Information: Emery C. Miller. M.D.. Associate Dean
for Continuing Education. Bowman Gray School of
Medicine, Winston-Salem 27103
April 5-6
-AM.A-Southeast Regional Mental Health Conference
Place: Marriott Hotel, Atlanta, Georgia
Sponsors: AMA Council on Mental Health and the com-
180
mittees responsible for mental health in the state med
associations of Florida, Georgia, Kentucky, North C;|
Una, South Carolina and Tennessee
Fee: $25.00
For Information: Philip G. Nelson, NTD.. Medical Pavili
Greenville 27834
April 8-9
Anglo-American Conference on Continuing Medical E
cation
Sponsors: The Royal Society of Medicine Foundation, 1
New York: The Royal Society of Medicine. London
University of North Carolina School of Medicine
Program: In addition to speakers of national promine
and from abroad, tours of points of interest will be (
ducted for ladies, and a number of social events are bi
arranged for delegates and their spouses.
Fee: Delegates, SI 00; delegate and spouse, Sl.'iO
For information: Office of Continuing Education, 119 ^
Nider Buildmc, UNC School of Medicine, Chapel
27514
April 20
Present Concepts On Knee Problems
Place: Royal Villa Hotel. Raleigh
Sponsor: American .Academy of Orthopaedic Surgt
(Produced b> The Committee on Adult Musculoske
Diseases )
Fee: $40; residents $20. Registration limited to 100.
Credit: .Approved for five prescribed hours by A.AFP
For information: Thomas B. Dameron, Jr,, M.D., P.
Box 10707, Raleigh 27605
April 24-25
Third .Annual Cancer Symposium
Place: Downtown Holida\ Inn. Raleigh
Sponsors: North Carolina Central Cancer Registry; N
Carolina Regional Medical Program; .American Ca
Society, North Carolina Division
For information: Corv Menees, Cancer Program Man,
P. O. Box 2091, Raleigh 27602
April 26-28
Annual Meeting of the .American Association of Me(
Assistants. North Carolina State Society
Place: Hilton Motel. Winston-Salem
Program: Keynote Speaker. George G. Gilbert. ^
President. North Carolina Medical Society. Mr.
Silver of Conomikes .Associates will present a pro
on managing the patient, the office, and the physi
Phvsicians and their assistants are urged to attend.
Fee: $30
For information: Mrs. June .Aysse. 911 Hay Street, f
Box 3514, Fayetteville 28305
April 27
Craven-Pamlico .Annual Medical Society Symposium
Place: Ramada Inn, New Bern
For Information: Zack J. Waters, M.D., 800 Hospital D
New Bern 28560
May 1
Diabetic Complications: .Are They Preventable'!', a one
symposium
Place: The Governor's Inn, Research Triangle Park
Sponsors: North Carolina Diabetes Association and the
partment of Medicine. Duke University Medical C
Fee: $15
For Information: Jerome M. Feldman, M.D.. Box '
Duke University Medical Center, Durham 27710
May 4-5
Principles of Practical Oxygen Therapy, which had
scheduled for this date, has been postponed until
For Information: Miss Ann Francis, .Administrative
sistant. Office of Continuing Education. School of !*
cine, UNC. Chapel Hill 27514
May 9-10
Breath of Spring '74 — Respiratory Care Symposium
Place: Babcock Auditorium
For Information: Emery C. Miller, M.D., Associate
Vol. 35, ^'
OFFICIAL CALL
HOUSE OF DELEGATES
pursuant to the Bylaws, Chapter IV, Section 1:
HOUSE OF DELEGATES
Meetings scheduled
Notice to: Delegates, Alternate Delegates. Officials
of the ]\orth Carolina Medieal Society, and Presidents
and Secretaries of countv medical societies.
Sessions of the HOUSE OF DELEGATES will convene in
the Cardinal Ballroom. The Carolina. Pinehurst, North
Carolina, at the following times:
'&
Sunday, May 19. 1974 — 2:00 p.m. — Opening Session
Tuesday, May 31, 1974 — 3:00 p.m. — Second Session
THE CREDENTIALS COMMITTEE will be present to receive dele-
gate registration for certification beginning at 1:30 p.m., Sunday,
May 19. 1974. just inside the entrance of the Cardinal Ballroom.
REFERENCE COMMITTEE
HEARINGS
erence Committee hearings are scheduled for Monday, May 20, 1974. at 2:00 p.m.
George G. Gilbert, M.D., President
James E. Davis, ^LD.. Speaker
E. Harvey Estes, Jr.. M.D., Secretary
William N. Hilliard. Executive Director
„ vH 1974. NCMJ 181
for Continuing Education, Bosnian Gray Schocil of
Medicine. Winston-Salem 27103
May 14-16
The Neuro-endocrinology Symposium: Neurobiology of
CNS — Hormone Interaction
Place: UNC Student Union Building, Great Hall
Sponsors: UNC Neurobiology Program and Laboratories
for Reproductive Biology
For Information: Miss Ann Francis, Administrative As-
sistant, Office of Continuing Education, UNC School of
Medicme, Chapel Hill 275 14^
May 15
Ethel Nash Day Program
Place: Clinic Auditorium. Time: 1 :t1l)-5: 30 p.m.
Sponsor: Department of Obstetrics :md Gynecology
For Information: Miss Ann Francis, .Administrative As-
sistant. Office of Continuine Education, UNC School of
Medicine. Chapel Hill 27514^
May 16-18
Basic Mechanisms in H\pci tension
Place: Babcock Auditorium
Sponsor: American Heart .Association Basic Science Council
For Information: Emery C. .Miller, M.D., Associate Dean
for Continuing Education, Bowman Gray School of Medi-
cine, Winsion-Salem 271(13
.May 18-22
120th Annual Session of the North Carolina Medical So-
ciety: General Session on Scientific Subjects and Specialty
Section Meetings
Place: Pinehurst Hotel and Countr\ Club
For Information: Mr. William N. Hilliard. Fxecuti\e Di-
rector, P. O. Box 27167, Raleigh 2751 I
May 28-31
Fourth postgr.iduate course in Head & Neck .Anatomy
Sponsors: Department of .Anatomy, School of Medicine, in
cooperation with the Division of Continuing Education,
East Carolina University
Fee: $12.'!.U0; students in residency programs $75.00
Eliaibilitv: Open to holders of any of followinc decrees:
M.D., D.D.S., D.M.D., Ph.D.
Credit: .Approved for 2S hrs. .A.AFP elective hours: CE units
also given b\ Division of Continuing Education, ECU
For Information: Head & Neck .Anatomy Course. ECU Di-
vision of Continuing Education, P. O. Box 2727, Green-
ville 27834
Maj 29-30
Hypertension: C ritical Problems — 2.sth .Annu.il Meeting and
Scientific Sessions, North Carolina Heart .Association
Place: Hyatt House and Convention Center, Winston-Salem
Designed especially for nurses and physicians
For Information: North Carolina Heart .Association, I Heart
Circle, Chapel Hill 27.sl4
June 12-15
Neurology for Practicing Physicians
Place: Babcock .Auditorium
Sponsor: .American College of Physicians
Fee: Members, residents and research fellows SI 20: non-
members $175; associates $60
For Information: Emery C. Miller, M.D.. .Associate Dean
for Continuing Education, Bowman Gray School of Medi-
cine, Winston-Salem 27103
June 20-22
Mountain Top .-\ssembly
Place: Wavnesville Country Club, Wavnesville
For Information: R. Stuart Roberson,' M.D., P. O. Box 307.
Ha/cKvood 2873M
July 29-.\ugust 2
2nd Annual Beach Workshop: Selected Topics in General
Internal Medicine
Sponsors: Bowman Gray, Duke and UNC Schools of
Medicine, in conjunction with the .Medical University of
South Carolina
Place: St. Johns Inn, Myrtle Beach, South Carolina
Fee: $100
For Information: Emery C . Miller, M.D , .Associate Dean
182
for Continuing Education, Bowman Gray School
Medicine. Winston-Salem 27103
Loan Materials .Available
A packet of materials to help you Train Your Own A
tant is available to members on a loan basis from Med
Society headquarters. It includes a color TV tape cassL
practice forms for planning and evaluation, and TV
evaluation report forms. For more information write
Gene Sauls, North Carolina Medical Society, P, O.
27167, Raleigh 27611.
In Continuous States
April 2-4
Institute on Dietetic Department .Administration
Place: Sheraton-Nashville Hotel, Nashville, Tennessee
Fee: $72
For Information: .American Hospital .Association, 840 Nc
Lake Shore Dri\e. Chicago, Illinois 6061 1
April 16
Fourth Annual Charles W. Thomas Lecture
Place: George Ben Johnston Auditorium
Sponsor: Division of Connective Tissue Diseases
For Information: Department of Continuing Educat
Medical College of Virginia, Box 91. MCV Stat
Richmond, Virginia 2324iS
April 20-24
"Selection of Materials for Reconstructive Surgery,"
Sixth International Biomaterials Symposium
Designed to bring together clinicians in orthopedics,
surgers, plastic and reconstructive surgery with leai
researchers in biomaterials, biomechanics, biophysics
experimental surgery
Place: C lemson University, Clemson. South Carolina
For Information: Dr. Samuel F. Hulbert. Dean of I
neering. TuUme University. New Orleans, Louisiana 7i
.May 6-9
The Tre.itment of Coronary Syndromes
Place: Ro\al Co.ich Motor Hotel, Atlanta, Georgia
Sponsors: .Americ:in Heart .Association Council on Cli
Cardiology and the Department of .Medicine of Ei
University School of .Medicine
For Informtition: Miss Mary .Anne Mclnerny. Dire
Dep.irtment of Continuine Education Programs, .Amer
College of Cardiolocy, 9650 Rockville Pike, Beth^
Maryland 20014
Items submitted for listing should be sent to: WH
WHEN' WHERE', P. O. Bo\ 8248. Durham, N. C. 2"
b\ the loth of the month prior to the month in which
are to appear.
News Notes from the —
DUKE UNIVERSITY MEDICAL CENTER
The Duke Medical Center hti.s adopted a coi!
dress tind grdcMiiinc for its employees, with partis
emphasis on those vsho are directly involved in
tient care.
The "dress code," as it is called, was designe
ptirt to eretite a better professional atmosphei
Dtike.
But it also is aimed at helping ptitients, visitors
Dtike employees thcmseKes more clearly ide
physicians and other health professionals, and tc
Vol. 35, ^
ployees a greater pride in their own appearance
i 1 personal identity.
The code is part of a patient-oriented program
, ich has been unfolding at the medical center over
^1 past year. Other innovations include preparation
1 distribution to all hospital patients of a "Patient's
i of Rights."
\lso under construction now is a patient discharge
t. Patients unable to leave the hospital at normal
;harge time, possibly because of transportation
'icultics with their families, may wait in this lounge
a. This will free their beds on the ward so that in-
ning patients may be admitted and taken to their
iims more quickly.
^j,rhe over-all program is being developed and
; ded by the Committee on Patient Services and Per-
nel Relations, chaired by a neurosurgeon, Dr.
■hard Kramer.
* * *
., jiighteen faculty members have been promoted,
.uding Dr. Blaine S. Nashold Jr., who was pro-
ted to a professor of neurosurgery.
:leven have been promoted to associate professor-
■)s. They are Dr. Nels C. Anderson, physiology;
rren P. Bird, medical literature; Dr. Per-Otto Ha-
, experimental surgery; Dr. Dale T. Johnson,
Ileal psychology; Dr. William B. Kremer, medi-
;; Dr. Melvyn Lieberman, physiology; Dr.
I Stephen Mahaley, Jr., neurosurgery; Drs.
Lome M. Mendcll and Elliott Mills, physiology; Dr.
David W. Schomberg, obstetrics and gynecology; and
Dr. Frances K. Widmann, pathology.
Promoted to assistant professorships arc Drs.
J. Gordon Burch, Walter E. Davis and Peter Gebel,
medicine; Dr. Richard F. Kay, anatomy; Dr. Allen
David Roses, medicine; and Dr. Timothy L. Strick-
ler, anatomy.
# * *
Dr. William J. Kane, a practicing family physician
from Hamilton, N. Y., has been appointed director
of the Duke-Watts Family Practice Residency Train-
ing Program to succeed Dr. Lyndon K. Jordan who
resigned in September.
Kane's primary goal will be to continue to develop
a sound educational program for the training of
family physicians utilizing the resources at Duke,
Watts and the Family Medicine Center, formerly
called Durham Health Care.
He said he believes the residency program must
become a viable model for the undergraduate medical
students, and the program should have an important
impact in the primary health care of people in the
area and in the state.
The Pennsylvania native is a 1972 graduate of the
University of Rochester and Highland Hospital (New
York) residency program, one of the oldest in the
nation for training family physicians. He received his
board certification in family practice in August,
)ir. >
itit 11
\\H
TUCKER HOSPITAL, Inc.
CO J
i\
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.
Accredited by the Joint Commission on Accreditation and
Certified for Medicare
James Asa Shield, M.D.
James Asa Shield, Jr., M.D.
Catherine T. Ray, M.D.
Weir M. Tucker, M.D.
George S. Fultz, Jr., M.D.
Graenum R. Schiff, M.D.
id II '.
<CH 1974, NCMJ
183
1972, and he is a 1969 graduate of the Temple
University School of Medicine.
* * *
The Center for the Study of Aging and Human
Development has created two new posts for associate
directors in a move that reflects the expanding scope
of the center's programs.
Dr. George Maddox, director of the center, an-
nounced that Dr. Walter Obrist, professor of medical
psychology, has been named associate director for
research development and Dr. Eric Pfeiffer, professor
of psychiatry and project director of Older Americans
Resources and Services (OARS), has been named as-
sociate director for programs.
* * *
Dr. David C. Sabiston, chairman of the Depart-
ment of Surgery, is the new editor of the Annals
of Surgery, the nation's foremost journal of surgical
science, and he also is the new president of the
Southern Surgical Association.
* * *
Appointed to assistant professorships are Dr.
James E. Hall, physiology; Dr. Edward W. Holmes,
medicine; Dr. Robert David Nebes, medical psy-
chology; and Dr. John L. Sullivan, psychiatry.
Hall received his B.A. degree in 1963 from Po-
mona College in Claremont, Calif. He obtained his
M.A. and Ph.D. degrees in physics from the Uni-
versity of California in Riverside.
ANESTHESIOLOGY
PLACEMENT
SERVICE
For Locations in North Carolina df^sir-
iiig the services of an anesthesiologist and
for anesthesiologists wisliiiig to locate or
relocate in North Carolina
CONTACT:
Placement Service
N. C. Society of Anesthesiologists
Department of Anesthesiology
North Carolina Memorial Hospital
Chapel Hill, North Carolina 27514
Following military service, Hall joined the Dii
staff in 1970 as a postdoctoral research fellow woi
ing under Drs. Carver Mead in electrical sciences £
Max Delbruck in biology.
A native of Winona, Miss., Holmes came to Di
in 1970 as a resident in medicine. He received
B.S. degree from Washingon and Lee University
Lexington, Va., and M.D. from the University
Pennsylvania School of Medicine in Philadelphia.
Prior to his recent appointment. Holmes served
chief medical resident at Duke.
A 1965 graduate of Tufts University in Medfc
Mass., Nebes received his Ph.D. degree in psyc
biology at the California Institute of Technology
Pasadena in 1971.
He came to Duke in 1970 as a postdoctoral fell
in the Neurosciences Research Program and fr
1971-72 served as a psychologist at the Durham \
erans Administration Hospital.
Sullivan received his A.B. degree from Duke
1965 and his M.D. from Johns Hopkins School
Medicine in Baltimore, Md., in 1969. He serve(
straight medical internship at Johns Hopkins Ho:
tal and was a resident in psychiatry at the Univer
of California, San Diego School of Medicine in
Jolla.
Prior to his appointment at Duke, Sullivan \
course lecturer and director of the Psychopharr
cology Clinic in the Department of Psychiatry at
University of California.
News Notes from the—
BOWMAN GRAY SCHOOL
OF MEDICINE
WAKE FOREST UNIVERSITY
Three undergraduate colleges are participal
with Bowman Gray in a program through wl
highly qualified students may gain early acceptanci
the medical school.
The participating schools are Davidson Colk
Wake Forest University and Swarthmore Colh
The program will allow qualified premedical studf
to be accepted by Bowman Gray at the end of il
sophomore year. If the students continue to perfc
satisfactorily during their last two years of unc
graduate work, they will be admitted to the med
school.
* * «
Dr. Maxwell M. Wintrobe, Distinguished Profei
of Internal Medicine at the University of Utah M
cal Center, was a visiting professor Feb. 13 at B
man Gray.
He presented the third annual Wingate M. John
184
Vol. 35, N'
iijemorial Lecture. His topic was "The Inert Parti-
K-,; — The Story of Discovery."
; The visiting professorship was estabhshed as a liv-
y memorial to the late Dr. Wingate M. Johnson,
rmer professor of medicine at Bowman Gray.
Dr. Wintrobe is internationally prominent as a re-
archer and a clinician, particularly for his work in
matology.
He is a past president of the Association of Ameri-
n Physicians, the American Society of Hematology,
d the Association of Professors of Medicine.
Di(
''!(
HI
lb,
"Four prominent North Carolinians have been ap-
■^■'linted to the Board of Visitors of the Bowman Gray
^hool of Medicine.
They are: Mrs. Smith Bagley, WinstoruSalem
'"usewife and civic leader; Richard T. Chatham of
"kin, president of Chatham Manufacturing Co.;
Roger Soles of Greensboro, president of Jeffer-
a-Pilot Corp. and Jefferson Standard Life Insur-
ce Co.; and J. Paul Sticht of Winston-Salem, presi-
mt and chief executive officer of R. J. Reynolds
vtfedustries. Inc.
eiDr. Jack W. Strandhoy, assistant professor of
larmacology, has been awarded a $10,000 grant by
; Pharmaceutical Manufacturers Association Foun-
tion.
ji ]The grant will support Dr. Strandhoy's research
|tdies on the kidney.
!Dr. Strandhoy is studying the role of prostaglandin
ikidney function.
"Management of Peptic Ulcer" was the topic for
the fourth annual Surgical Symposium which was held
Jan. 1 8 at the Bowman Gray School of Medicine.
The two-day symposium featured two visiting pro-
fessors and seventeen members of the Bowman Gray
faculty.
The visiting professors were Dr. John L. Sawyers,
professor of surgery and chief of surgical service at
Vanderbilt University Medical Center, and Dr. Gra-
ham Jefferies, professor and chairman of the Depart-
ment of Medicine at the Milton S. Hershey Medical
Center.
Dr. Donald M. Hayes, professor and chairman of
the Department of Community Medicine, recently
was elected to the Board of Directors of the North
Carolina Health Council.
The council is a coordinating, planning and action
agency for voluntary and governmental health pro-
grams in the state.
* * *
Dr. John S. Kaufmann, assistant professor of medi-
cine and pharmacology, is a recipient of the Pharma-
ceutical Manufacturers Association Foundation Fac-
ulty Development Award in the field of clinical
pharmacology. He recently was elected to member-
ship in the American Society for Clinical Pharma-
cology and Therapeutics.
Dr. Clark E. Vincent, professor of sociology, has
been selected to serve on the editorial board of the
Journal of Sex and Marital Therapy.
"WHEN YOUR BACK FEELS GOOD YOU'LL FEEL GOOD"
lEALY POSTUREPEDIC
u
The Unique Back Support System
A very firm, luxury quilted Posture-
pedic. Coils are specially positioned
to concentrate firmness where body
weight is concentrated. Exclusive tor-
sion bar foundation for more firm-
ness. "Pillow-puff quilts filled with
double thickness of Sealyfoam®*.
QUEEN SIZE 60x80" 2-piece set $339.95
KING SIZE 76x80" 3-piece set $449.95
$11095 ,$19095
llVfea.pc. size l^rf*-fea.p.
"No morning backache from sleeping on a loo-soft
mattress.
urethane j
185
physicians and administrative representatives of
NCMPRF, Inc. in conjunction with county medical
societies and hospital staffs. The intent and provi-
sions of the PSRO law will be discussed. Recent
developments in Washington and the current situa-
tion in North Carolina will be discussed. These
seminars will be presented throughout the State in
approximately 10-12 locations, in conjunction with
various county medical societies. Plans are now be-
ing finalized as to specific dates and locations q
these seminars which will be held through June 3C
1974.
The Foundation has convened a committee rej)
resenting all specialty disciplines to review existin'
peer review methodologies and to establish norms c
medical care. It will identify the process and criten
that will be most appropriate to North Carolina
;J
Month in
Washington
The American Medical Association has branded as
"wrong medically, wrong morallv, and wrong legally"
the Health, Education, and Welfare Department's
proposed regulation requiring prc-hospital-admission
certification for Medicare and Medicaid patients.
In what appeared as an ending to a "deliberate
effort on the part of the AMA over the past four or
five years to cooperate with HEW," the Association
announced that if the pre-admission certification
regulation and the Professional Standards Review Or-
ganizations area designations were placed into effect,
HEW Secretary Caspar Weinberger would be taken
into court.
AMA President Russell B. Roth, M.D. and Board
Chairman James H. Sammons, M.D. at a press con-
ference in Chicago made the following statement:
"We are here today to serve notice on Secretary
Weinberger that if he proceeds with two proposed
actions, we are going to take him to court.
"Earlier this month, the Secretary of the Depart-
ment of Health, Education, and Welfare issued a set
of proposed regulations that would require pre-ad-
mission certification for Medicare and Medicaid. If
adopted as proposed they would require that every
Medicare and Medicaid patient be cleared by a Utili-
zation Review Committee before admission to a hos-
pital. The only exception would be emergency cases.
"These regulations are a direct threat to the medi-
cal care of the 35 million or so patients who are
served by Medicare and Medicaid. For most of them,
the withholding of Medicare or Medicaid hospital
benefits will mean that the individual will he denied
188
hospitalization because they have no other means
pay for their care.
"Furthermore, such decisions would not be ma'
on the basis of an examination of the patient by ph
sicians. Rather, they would be paper decisions. T'
verdict would be rendered on the basis of what t
patient's doctor put down on the record. It is like
that, as a practical matter in many instances, the c
cision would not be made by a committee of phy
cians or even a single physician but by an admitti
nurse or other hospital administrative personnel.
"Any such denial of medical care represents
clear violation of both the spirit and the letter of t
Medicare-Medicaid law. Congress clearly establish
the programs to provide medical care for the elde
and the poor. What the Congress has given, the Si
retary now seeks to take away. The Secretary has
authority under the guise of regulations to amend t
law and reduce benefits. He has no moral or le;
right or authority to do so. Indeed, his action is
illegal as it is reprehensible. The Medicare-Medic;
law provides for pre-admission certification by
patient's physician and for post-admission review
hospital utilization review committees. The Congr
did not intend that a committee substitute a paj
decision for the judgement of a patient's physici
The Secretary's proposal is a direct and clear vie
tion of Section 1801 of the Medicare-Medicaid 1:
"We intend to fight Mr. Weinberger on this, i
proposed regulations are wrong medically, wr<
morally, and wrong legally. We are here to s
notice on the Secretary that if he persists in putti
■"
Vol. 35, NiJ
le regulations into effect, the AMA will seek an in-
-inction on that very same day to stop him.
"We would welcome support from all interested
jrties, such as senior citizen organizations and con-
imer groups. We would hope they would join in our
;tion. But with them or without them, we will be in
)urt on the day those regulations are promulgated.
" "While we are in a suing mood, let me mention that
e are also going to take on Mr. Weinberger in
tiother area.
; "This involves his gerrymandering of the PSRO
istrict. Without getting too involved, let me say for
ose of you who don't know, PSRO stands for Pro-
ssional Standards Review Organizations. These are
pposed to be groups of doctors set up to review the
lality and medical necessity of care given under
c edicare and Medicaid.
"The AMA originally opposed PSRO. But once it
came law, we decided that if such review was going
! be done it would be better for all concerned it if
pre done by physicians.
'"We decided to cooperate with HEW in the imple-
i^ntation of the law. I can tell you, we've had very
jtle cooperation in return.
"Peer review — the concept on which PSRO is
ised — was invented by the medical profession and
IS in existence long before the government ever
■lard of the idea. There are many excellent and func-
ning peer review programs now in effect in this
jUntry, and we asked the Secretary to set up the
!JR0 designated areas (regional units) so as not to
sturb them.
"This plea apparently fell on deaf cars. I won't
] zard a guess as to the reason behind the Secretary's
: ;a designations. I don't think there were any. I
ink the decision was simply capricious and arbi-
ijry.
"Our Board of Trustees has voted to join with any
< our state organizations who want to go to court to
n^et the area designation in their state. Our prelimi-
1,7 indications are that seven or eight may do so.
[ 'Let me say in closing that over the past four or
1 ; years we have made a deliberate effort to coop-
£jte with HEW in implementing government pro-
|[jims for the benefit of the people. 1 think for a
N'iie there was good communication and good coop-
t tion.
'That day apparently has passed. Of late we've
i 1 nothing but rebuff after rebuff. We've now been
I, with no recourse but to fight in our own best in-
t ;sts and, we believe, in the best interests of our
iT'ents."
«r
Iks
^'hysician fees in 1974 have been ordered held to a
r per cent increase by the Cost of Living Council.
Despite strong arguments from physician groups
Ending the AMA for an exemption from all wage
price controls for the medical profession, the
nncil refused to step back from its November pro-
il llal to impose the four per cent ceiling.
s
■.CH 1974, NCMJ
As in November regulations, physicians under
Phase IV will be permitted an annual aggregate fee
increase of four per cent. A ten per cent maximum
fee increase is allowed for specific charge items; fees
under $ 1 0 can be raised by $ I .
The limits are effective as of the first of this year.
They remain legally in effect until April 30 by which
time Congress must authorize an extension of the
President's power to impose wage-price controls or
they will expire. There is growing sentiment in the
Senate and the House to terminate the program.
The regulations in the health field have been under
court attack. Nursing homes have won a preliminary
legal battle in their suit against the Phase III controls.
The American Hospital Association has threatened
to challenge the controls in court.
Hospitals were restricted to a 7.5 per cent increase
per in-patient stay, with adjustments for volume
changes.
Under the final regulations, all physicians must
maintain a schedule showing prices in effect on De-
cember 28, 1973, which comprises 90 per cent of
their revenues, and the subsequent changes and dates.
"A conspicuous and easily readable sign" must be
posted stating the availability and location of the
price schedule. The requirement applies whether or
not fees have been increased.
The Council said that physicians and medical labo-
ratories that have not raised charges as allowed in
the past will be allowed to apply the unused portion
of increase up to a maximum of five per cent.
* * *
President Nixon is enthusiastically endorsing the
Health Maintenance Organizations program effort
getting underway at the HEW Department, according
to federal health officials.
The government is "going all out" to implement
the new law "as rapidly as possible," Charles Ed-
wards, M.D.. Assistant HEW Secretary for Health,
said.
Proposed regulations to carry out the HMO pro-
gram will be issued by the end of March.
At a briefing of health reporters. Dr. Edwards an-
nounced that the director of the HMO program is
Frank Scubold who has been serving as Deputy Di-
rector of the old HMO office as well as Associate
Director of the Bureau of Community Health. Scu-
bold, 51, is a Ph.D. chemist who came to HEW in
1971 after a career in the aerospace industry in
California during which time he became increasingly
involved in space medicine and medical systems
management work.
With respect to the new HMO law that authorizes
$375 million over the next five years. Dr. Edwards
said that for the first time the government is going
to be making changes in the economic base of health
care delivery in this country. The HMO concept at-
tains added importance, he told reporters, as the Ad-
189
ministration and Congress move on national health
insurance proposals.
* * «
Health outlays last fiscal year for the nation
reached S94.1 billion, an 11 per cent increase, the
lowest rate in several years. The proportion of total
health spending to the Gross National Product re-
mained at the 1972 level — 7.7 per cent. Per capita
expenditures rose S41 to $441, including private and
government spending.
The Social Security Administration's preliminary
figures for the fiscal year that ended last July showed
per capita private spending on health of $265 and
government spending of SI 76 per person for the year.
The ratio of public \ersus private health spending
continued the trend of two decades toward more gov-
ernment spending. The ratio for fiscal 1973 was 60.1
per cent private and 39.9 per cent public. In 1928.
the corresponding ratio was 86.7 per cent and 13.3
per cent.
Of the S94 billion total. S36 billion went for hos-
pital care, $18 billion for physicians" services, com-
pared with $32.6 billion and SI 6.6 billion the previ-
ous year.
Federal spending was estimated at $24.6 billion,
up almost $2 billion; state and local, $12.9 billion,
up more than $ 1 .5 billion.
E.xpenses for prepayment and administration,
largely private health insurance e.xpenses, rose from
$2.4 billion in fiscal 1972 to $3.3 billion in fiscal
1973.
The American Medical Association recognizes
that supplemental printed information given to the
patient by the pharmacist at the physician's discretion
would be valuable for certain classes of drugs.
However, the AMA stated at a Washintgon, D. C,
conference on patient drug information that the
preparation and distribution of such informational
material pose a number of problems.
"Patients differ in their diaig requirements wiih
respect to dose, duration of therapy and adjunci
medication. They also differ in therapeutic respons
adverse side effects and toxic reactions. The info
mation in a "patient package insert' might be helpf j
to some patients but might confuse, frighten or evei
harm other patients."
The meeting of medical, drug and consumers' rep
resentatives was told by an AMA spokesman that tb
usefulness of a patient package insert should be ex
plored for a limited number of drugs. The AMA, th
Food and Drug .-Xdministration and the manufacture
could cooperate in preparing informational materia
on a limited number of drugs, selected because the'
are used over a long period of time or have a big
incidence of interaction with other drugs.
The acceptance of such material by patients an
physicians and the impact it might have on the wa
in which patients used drugs should be assessed bt
fore encompassing a large number of therapeuti
agents in the program, according to the AMA.
The FDA has been considering steps to broade
the package insert to assure it reaches patients fc
many drugs.
Dr. John Zapp. D.D.S., Deputy Assistant Secrt
tary for Legislation of the HEW Department is rf
signing to join the Washington office of the AMA i
Director of the Department of Congressional Reli
tions.
Dr. Zapp has been at HEW since 1969. He held
variety of posts including Deputy Assistant Secretai
for Health Manpower. The 41 -year-old official h;
been in%olved with health legislation for several yea
and has served as federal representative to the AM/
American Medical Colleges Liaison Committee c
Medical Education.
Dr. Zapp will replace William Colley as the he<
of AMA's Congressional Relations Department.
Book Review
Speech and Reason: Language Disorder in Mental
Disease. By Wilfred .^bse, M.D., and a translation of
The Lite of Spcixh b\ Philipp Wecener. .'^lO pages.
Price. SI 2.00. Charlottesville: The University of Vir-
ginia Press, 1971.
Those of us who were fortunate enough to enjoy
the colleagueship of Dr. Abse. when he was Clinical
Director of Dorothea Dix Hospital and later Pro-
190
fessor of Psychiatry at the University of North Car
lina, will not be surprised to see the publication
this scholarly work. Wilfred Abse has always brouE
an intense interest in psychoanalytic formulation a'
a broad knowledge of language and literature to be
on his clinical studies of patients. His own skills
a gifted speaker and writer are matched with a spec
fascination in man's capacity, or incapacity, for co:
Vol. 35, No
'unication. In particular, Abse is intrigued by the
gures of speech which are used in communication,
id his earher writings on hysteria and other topics
cive illustrated this as well as his own capacity to use
?e English language elegantly.
Abse points out that the study of language is ncces-
rily grounded in social psychology. As a student of
■eud's works, with all their contributions to lan-
^lage theory, he is impressed with the fact that a con-
jinporary of Freud, Philipp Wegener, shared many
teas with the founder of psychoanalysis. Whether or
)it Freud and Wegener knew each other's work is
riknown. Abse illustrates the value of Wegener's
[jas in the elucidation of problems of hysteria. A
japter on hysteria and metaphor touches on medical
id psychoanalytic history and illustrates with clini-
jl material how metaphoric statements convey af-
Ctive communication. Thus, the metaphor cannot
3 perceived merely as having an ornamental func-
iin. The book proceeds to discuss emendation and
jtaphor, thought, imagery, symbolism, dreams,
Jiizophrenia and development of language in a
ies of interwoven and carefully constructed chap-
's.
All of the above described writing contains much
ginal scholarship as well as a constructive review
d synthesis of other experts. Abse presents this
tion of the book as an introduction to the first
jglish translation of Wegener's The Life of Speech
• ginally published in 1885. Although this reviewer
ind the latter of interest, he obtained the greater
ijellectual stimulation from Abse's own original
titribution. This is perhaps understandable in that
[isychiatrist with Abse's gifts is bound to appeal to a
}iow professional.
(The second half of this book undoubtedly fills a
need, and many professional groups are well served
with this translation with which Abse obtained com-
petent scholarly assistance within the University of
Virginia, where he is now Professor of Psychiatry. I
found Wegener's work interesting but the flow of
reading was interrupted by the frequent parenthetical
insertions of the original German phrases. However,
no doubt these insertions may be valuable for the
linguistics expert who is seeking some fine point of
nuance. Wegener perceives words as being first
learned as a means to achieve definite ends. Thus
the child starts communicating with one-word sen-
tences, for example with the word "milk" meaning
"give me some milk." Thereafter, language develops
into more complex forms through the processes of
emendation and metaphorical extension. Syntactical
forms of speech arise from emendation whereas ab-
stract reference and generality come from metaphori-
cal extension. Indeed, abstract language, according to
Wegener, is "faded metaphor,"
Abse shows how the metaphor can carry such an
impact because of its unconscious associations. He
also demonstrates how in psychopathology the meta-
phor can become a physical symptom. Thus, this
whole volume has something of significance for a
wide spectrum of professionals ranging from the psy-
chologist, psychiatrist and behavioral scientist to the
communication theorist and language expert. As
Abse points out, many of today's political and social
problems are compounded by the lack of effective
communication. Thus, this scholarly study of lan-
guage, communication, and thinking is pertinent to
the understanding of normal man as well as the
psychiatrically disturbed.
John A. Ewing, M.D.
Eugene Ramsey Hardin. M.D.
Ve are meeting once more to pay a tribute of re-
ct to the memory of one of our comrades, who
lurching through the span of years has fallen by the
j'side and now sleeps the everlasting sleep. He is
)l Eugene Ramsey Hardin, pioneer physician and
cd public health official, who passed away Novem-
|ll 8. 1973 after a short illness.
t is a fundamental fact that we are born to die,
) in the plan and providence of God the opportu-
is given every man to so live in service to, and
,, 1 fCH 1974. NCMJ
-
fellowship with, his comrades that the memory of his
good deeds will follow him long after the dark por-
tals of the grave have claimed their own.
Dr. Hardin was born in Appling, Georgia on De-
cember 6. 1888. He graduated from Harlem High
School in 1905 and attended Sacred Heart Col-
lege from 1905 to 1907. In 1911 he received his M.D.
degree from the University of Georgia Medical
School. He served as an intern in Lamar General
Hospital, Augusta, Georgia. At the end of this
service he was appointed intern in Wilard Parker Hos-
191
pital, the largest contagious disease hospital in New
York City.
In 1915 he accepted the position of Health Officer
of Sampson County, N. C. From August 1917 to Au-
gust 1919 he served with the Army Medical Corps,
and on September 1, 1919 he began his work as
Health Officer for Robeson County.
During his career he received many honors and
achieved many goals. Dr. Hardin's interest in public
health work was keen, tireless, and constructive. He
kept in close touch with advancing public health
thoughts and practices. He was always alert to what
medical organizations, especially those in his own
state, were saying and thinking about public health
work. In legislative years it was his custom to ob-
serve and work for pending legislation concerning
improved public health laws.
Upon his retirement in 1969, after 50 years
head of the oldest rural county health department i
the nation, he was praised at a testimonial dinner to
his unselfish work in making Robeson County a bet
ter and safer place to live. Dr. Hardin once said, "
have always felt that next to religion, public healt
is the most important service one can give his fellow
man."
Resolved, that this resolution and a copy be ir
corporated in the minutes of the Robeson Count
Medical Society, a copy be mailed to each membc
of the bereaved family, a copy be sent to The Robt
sonian. and the North Carolina Medical Jouf
NAL.
Robeson County Medical Society
The internal ube of water, as a medicine, is no less an object of the physician's attention than
the external. Pure elementary water is. indeed, the most inoffensive of all liquors, and constitutes
a principal part of the food of every animal. But this element is often impregnated with sub-
stances of a very active and penetrating nature; and of such an insidious quality, that, while they
promote certain secretions, and even alleviate some disagreeable symptoms, they weaken the
powers of life, undermine the constitution, and lay the foundation of worse diseases than those
which they were emplo\ed to remove. Of this, every practitioner must have seen instances; and
physicians of eminence have more than once declared, that they have known more diseases oc-
casioned than removed by the use of mineral waters. This doubtless, has proceeded from the
abuse of these powerful medicines, which evinces the necessity of using them with caution. —
William Buchaii: Domestic Medicine, or a Treatise on the Prevention and Cure of Diseases by
Regimen and Simple Medicines, etc., Richard Folwell, 1799, p. 430.
192
Vol. 35, No
HEALTH SCIENCES LIBRARY
KTH CAROLINA
ilORTH CAROLINA
le Official Journal of the NORTH CAROLINA MEDICAL SOCIETY D D
April 1974, Vol. 35, No. 4
Medical Journal
THIS ISSUE: Poisons that Killed: An Analysis of 300 Cases, Abdullah Fatteh, M.D., Ph.D., LLB., and Bill Hayes, B.S.;
le Role of Gastroesophageal Reflux in Nocturnal Asthma in Children, Susan C. Dees, M.D.; Need for More and Better
stributed Primary Care Physicians in North Carolina, Committee on Community Medical Care, North Carolina Medi-
I Society
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relief of acute agitation, tremor, de-
lirium tremens and hallucinosis due
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Warnings: Not "f value in psy-
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mal seizures may require increased
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taneous ingestion of alcohol an(
other CXS depressants. Withdr:a
symptoms ( similar to those witl
barbiturates and alcohol ) have
occurred following abrupt discf
tinuance (convulsions, tremor, i-
dominal and muscle cramps, vnnin
and sweating). Keep addiction-iU
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to habituation and dependence,
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benefit against possible hazard.,.
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1 or 2 tabJets every 4 to 6 hours is
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2 fabJets on retiring ivilJ J<eep residunJ
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complete voiding and lessens frequency
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^
NORTH CAROLINA
MEDICAL JOURNAL
Published Monthly as the Official Organ of
The North Carolina
Medical Society
April 1974, Vol. 35, No. 4
EDITORIAL BOARD
Robert W. Prichard. M.D.
Winston-Salem
EDITOR
John S. Rhodes. M.D.
Raleigh
.ASSOCIATE EDITOR
Ms. Martha van Noppen
Winston-Salem
ACTING ASSISTANT EDITOR
Mr. William N. Hilliard
Raleigh
BUSINESS MANAGER
W. McN. Nicholson, M.D.
Durham
CHAIRMAN
Louis deS. Shaffner, M.D.
Winston-Salem
Rose Pully. M.D.
Kinston
William J. Cromartie. M.D.
Chapel Hill
Charles W. Styron, M.D.
Raleigh
NORTH CAROLINA MEDICAL JOUR-
NAL, 300 S, Hawthorne Rd.. Winston-Salem,
N. C. 27103. is owned and published by The
North Carolina Medical Society under the di-
rection of its Editorial Board. Copyright ©
The North Carolina Medical Society 1974.
Address manuscripts and communications re-
garding editorial matter to this Winston-
Salem address. Questions relating to sub-
scription rates, advertising, etc.. should be
addressed to the Business Manager, Box
27167. Raleigh, N. C. 27611. All adver-
tisements are accepted subject to the ap-
proval of a screening committee of the State
Medical Journal .^dvertisinii Bureau. 711
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. In-
structions to authors appear in the January
and July issues. Annual Subscription, $5.00.
Single copies. Sl.Ot). Publication office;
Edwards & Broughton Co.. P. O. Box 27286.
Raleigh. N. C. 27611. Secoiui-clais postage
paid ar Raleinh. North Carolina 2761 1 .
President's Newsletter 221
Original .Articles
Poisons that Killed: An .Analysis of 300 Cases
Abdullah Fatteh. M.D.. Ph.o!. LL.B.. and Bill Hayes. B.S.
The Role of Gastroesophageal Reflux in Nocturnal
Asthma in Children
Susan C. Decs. M.D.
Need for More and Better Distributed Primary Care
Physicians in North Carolina
Committee on Communit_\ Medical Care. North CaroHna
Medical Society
Editorials
Louise Fant MacMillan..-
Drugs. Regulation and Progress
The North Carolina Regional Medical Program..
Right Physician at the Right Time...
227
230
234
238
238
239
239
240
EMERGENCi Medical Services
A "New Role" for the Emergenev Department Nurse.
Ruth M.Miller. R.N.
Abstracted by Marv C. Davison. R.N.
COM.MITTEES & ORGANIZATIONS
Ad Hoc Committee to Study and Recommend a Salary or
Increase in .Allowances for the President 245
Bleletin Bo^rd
New Members of the State Society
Whaf:* When'? Where'?
News Notes from the University of North Carolina
Division of Health .Affairs
News Notes from the Duke University Medical Center
News Notes from the Bowman Gray School of Medicine of
Wake Forest University
AMA Council on Constitution and Bylaws
News Notes
MoNiH IN Washington
Book Remews
In Memoriam
Classified Ads
Index to Advertisers
245
246
250
251
252
254
255
255
25^^
260
261
262
Contents listed in Current Ci>nients Clinical Practice
^€^^
im PRESIDENTS NEWSLETTER
MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA
^#^;#
11
April 5, 1974
SRO — It would be nice to have one month pass without necessary bulletins as to
SRO. It is even certain that by the time this reaches you, more events will have
ranspired than have as of this writing. Even though the major action of PSRO in
lis state will be centered with the Peer Review Foundation which is a separate
titity from the Medical Society, it still involves all of us. The recent gross
fivelopments are as follows: _
1. Having lost our battle for a single statewide PSRO, the final area desig-
nations were published in the FEDERAL REGISTER March 18. At least they
followed the recommendations of our Peer Review Foundation for realistic
and logical "patient flow" areas as compared to the original capricious
four that were suggested by HEW. We end up with eight areas and the
boundaries may be obtained either from our Headquarters Office or the
Peer Review Foundation office which now has a separate space in our Head-
quarters Building. The number of hospitals in each area varies from
eight to twenty-seven and the number of physicians from 363 to 1,012.
2. Well, you ask, what comes next? Now, HEW announces that they are ready
to receive applications from organizations (formed by HEW guidelines)
in each PSRO area. Two types of applications may be submitted:
(1) "planning contracts" and (2) "conditional designation contracts".
Outside of each individual PSRO area, a third type of contract called
"statewide PSRO support center contracts" may be filed. So, as far as
we are concerned, our North Carolina Peer Review Foundation is eligible
for the last type and it is applying to HEW to be so designated. However,
obviously none of our eight areas have had time to get together and form
a professional association, be legally incorporated as a non-profit
organization as they require, and then submit a plan for a formal peer
review system under HEW guidelines. Now believe it or not, these bureau-
cratic bunglers have set a deadline for all applications from every PSRO
area to be submitted by April 15th for planning contracts and April 30th
for the conditional designation contract type.
3. Well, what else you ask? Within a proper amount of time to be prepared
and practical and despite "the bunglers," our Peer Review Foundation will
be getting to you with all the detailed help possible and as soon as pos-
sible. This effort is being financed by the North Carolina Regional
Medical Program to the tune of over $50,000.
A. In the meantime and involving very intense concentrated activity all over
the country, I'd simply report that the rebellion against PSRO is growing
as is congressional awareness of the movement. The rebellion is taking
two forms : (1) an all out fight for repeal (recently adopted as policy
by both the Illinois and Georgia Medical Societies) and (2) introduction
of eleven carefully thought out major amendments of the law which the AMA
^
has proposed for congressional action. Needless to say, ourownHouse of
Delegates will be reassessing our own position at our May meeting.
C.O.L.C. — Now for some good news! By action last week of the Senate Banking
Committee, it appears that the Cost of Living Council will be phased out as of
April 30th. Should this come to pass, a colossal sigh of relief will come from the
entire health field. Wonderful as is this outlook, let me be one of the first to
warn you, with your newly returned freedom, don't go wild with your fee increases.
Be reasonable, because our bureaucratic enemies of the private practice of medicine
like nothing better than to throw high medical fee statistics at us.
POLITICS — As you well know, there is a strong sentiment in the wake of Watergate
to throw out all of the "so and sos" in Washington. Cynical as we have every reason
to be, we must get down to intense, practical politics for the upcoming congressional
and senatorial primaries and the fall election. Whomever we vote into office will
determine what type of national health insurance we may have along with all our
other concerns. So, evaluate your candidate, find out where he stands, and if he
is with us not only support him personally but also through your membership in the
North Carolina Political Action Committee.
MEMBERSHIP SURVEY — By the time you receive this newsletter, you will have already
gotten in the mail a survey postcard asking for your help and advice on whether you
would prefer to continue holding the Annual State Medical Society Meeting in May
or hold it in September. You are also being asked to indicate a preference for towns
which now appear to have adequate facilities for holding the Annual Meeting, along
with any other meeting suggestions you may care to make. We need your opinion, so
please complete and return the card promptly to the Medical Society Headquarters.
This is but one of the ways in which the Officers and Staff of the Society are trying
to provide the kind of Annual Meeting you and the other members most desire.
PRESIDENT'S NEWSLETTER — In the future, after the April issue, a duplication of the
President's Newsletter will not appear in the North Carolina Medical Journal. This
action is being taken in the interest of economy and wisest possible use of your
membership dues dollars.
DRUG AUTHORITY — I'll close with another pleasant note. Many of you have responde(
to requested data for the North Carolina Drug Authority and their analysis of drug
abuse in this state. Mr. F. E. Epps, the Director, with Mr. Moody B. Drum have
requested that I pass on their thanks for your contributions which have been most
helpful.
Hold on to your hats until the next time!
Sincerely yours,
George G. Gilbert, M.D.
President
3
Poisons That Killed: An Analysis of 300 Cases
Abdullah Fatteh, M.D., Ph.D., LL.B. and Bill Hayes, B.S.
N 1969 a total of 44,864 people
died in North Carolina; of these
< iths, 177 were caused by poison-
( > agents.' A study of deaths re-
sting from poisons in North Caro-
1 1 had not been undertaken in re-
c It years. Therefore, it seemed ap-
p ipriate to carry out such a study.
Te purpose of this study is to ana-
1 z 300 cases of poisoning in North
{ rolina in 1970 and to determine
t distribution of poisoning cases in
c "erent age, sex, and race groups
ail to recognize the frequency of
dliths caused by various agents. We
b )e that the analysis will help to
s gest the means to reduce the
n hber of deaths from poisoning,
e ecially the number of accidental
d'ths.
lATERIAL AND ANALYSIS
Ve made a random selection of
3 } cases of poisoning that occurred
iri>Jorth Carolina in 1970. The se-
le ions included only the cases in-
vi'igated by the Office of the Chief
^^ iical Examiner in the counties
w re the Medical Examiner system
)m the Office of the Chief Medical Ex-
ar iT and East Carolina University Medical
Sc )1. Greenville. North Carolina (Dr. Fat-
te.' and the University of North Carolina
M :al School. Chapel Hill, North Carolina
(p Hayes).
ledical student.
irint requests to Dr. Fatteh. Professor of
r£ >logy. East Carolina University, Greenville.
N' 1 Carolina 27834.
was operative. The information on
the cases was obtained from the case
files maintained in the Office of the
Chief Medical Examiner in Chapel
Hill. Only the cases clearly thought
to be deaths from poisoning were
included. Borderline cases were ex-
cluded. Of the 300 cases studied,
evidence of poisoning in 267 cases
was confirmed by toxicological stud-
ies. In the remaining 33 cases the
overwhelming circumstantial and in-
vestigative evidence of poisoning
justified inclusion of the cases in this
study.
Table 1 shows the distribution of
273 of the cases with respect to the
fatal agents. In addition, single fa-
talities were caused by each of the
following 17 single agents: strych-
nine, imipramine (Tofranil®) kero-
sene, sulphuric acid, furniture pol-
ish, varnish remover, ethylene glycol
(antifreeze), paraldehyde, pentazo-
cine (Talwin®), chlorprothixene
(Taractan®), ethchlorvynol ( Placi-
dyl®), methapyrilene (Sominex),
ethylene di-bromide (Fumi-sol),
bromide, alkali (Plunge), zinc, and
phosphate. Ten single deaths were
caused by each of the following com-
binations: glutethimidc (Doriden®)
and thioridazine hydrochloride (Mel-
laril®); chlorpheniramine (Corici-
din®) and paraldehyde; doxepin hy-
drochloride (Sinequan®) and alco-
hol; propoxyphene (Darvon®) and
meprobamate; propoxyphene and
barbiturate; morphine and pheno-
thiazine; paraldehyde and thi-
oridazine hydrochloride; barbiturate
and chlordiazepoxide hydrochloride
(Librium®); carbon monoxide with
alcohol and barbiturate; and mor-
phine with codeine and glutethimide.
Of the 134 cases of alcohol poi-
soning, 122 were caused by ethanol
intake alone and six were caused by
the other volatiles of which iso-
propyl alcohol, N-propyl alcohol,
and methanol were a few. Six more
Table 1
Distributi
on of Cases with Reference
to Fatal Agents
Number
of
Fatal Agent
Deaths
Alcohol and/
or other volatiles
134
Carbon monoxide
51
Barbiturates
32
Morphine
21
{2 more in
combination
with other
drugs
Arsenic
10
Salicylates
8
Meprobamate
2
Darvon
3
Digitalis
2
Lead
2
Parathion
2
Mellaril
2
Ammonia
2
Freon
2
A L 1974, NCMJ
227
cases resulted from a combination of
ethanol and other volatiles. In the 32
i cases of barbiturate poisoning, there
( were nine cases in which a signifi-
■■' cant level of alcohol was also found.
i In view of the fatal concentrations
\ of barbiturates, these were classified
] as barbiturate deaths. Similarly, in
; two cases of morphine poisoning
and in eight cases of carbon monox-
] ide deaths, alcohol was present, al-
though alcohol was not the primary
cause of death.
In the cases studied, 218 were
men and 82 were women. There
were 188 Caucasians, 109 Negroes,
and three Indians. The age distribu-
tion of the cases can be found in
■ Table 2.
Table 2
Distribution
of Cases with Reference
to Age
Age
in
Years
Number
of
Deaths
Under 10
5
11-20
30
21-30
40
31-40
54
41-50
82
Over 50
79
Unknown
10
Total 300
Deaths from poisoning were ei-
ther accidents, suicides, or homi-
cides. We were unable to determine
whether 26 deaths from poisoning
were accidental, suicidal, or homici-
dal. Hence, the manner of death in
these cases was carried as "undeter-
mined." In the group of 300 cases,
202 (67 percent) were accidental
deaths, 69 (23 percent) were sui-
cides, and three (one percent) were
homicides. In the three homicides
the fatal agent was arsenic.
DISCUSSION
It is clear from the analysis of
the sample that alcohol is a leading
killer among all poisons; 44.7 per-
cent of all poisoning deaths were
caused by alcohol. The figures for
the previous years show that in
North Carolina 17 people died of
acute alcohol poisoning in 196S; 21
people died of acute alcohol poison-
ing in 1969.- By comparison, these
figures are much lower than the
1970 figure. In the past, and in cer-
tain parts of the state at present, the
designations of the cause of death in
persons with fatal concentrations of
alcohol have been varied. Many a
case has been signed out as a natural
death. There is a great variation in
the willingness to accept acute alco-
hol poisoning per se as a valid cause
of death. It would appear, therefore,
that the figures for the years 1968
and 1969 are gross underestimates.
The 1970 figure does not necessarily
reflect a true increase in the inci-
dence of deaths from alcohol. We
feel that the efforts of the Office of
the Chief Medical E.xaminer, in the
direction of better investigation and
accurate labeling of the cause of
death in such cases, is the factor
contributing to the apparent increase
in the incidence of such deaths.
Nearly all deaths from acute alco-
hol poisoning are accidental. Many
people are not aware that alcohol in
excess is poisonous and can kill. We
hope that this study will serve not
only to crystallize the fact that
many people die accidentally from
alcohol poisoning, but also that it
will have some impact on the inci-
dence of deaths from alcohol poi-
soning.
It appears that alcohol kills pri-
marily the middle-aged and the el-
derly. In this study, 90 percent of
the deaths from alcohol poisoning
occurred in people over the age of
30, many of whom were chronic
alcoholics. Thirty-eight percent of
deaths occurred in the 41- to 50-
year-old age group. In our sample,
deaths from alcohol in men outnum-
bered those in women 3:1.
Inhalation of carbon monoxide
results in the loss of several lives
each year. This gas caused 5 1 deaths
in the group under study. A sur-
prisingly high proportion of these,
25 of 51, were accidental deaths,
the remaining 26 being suicides. In
two cases the manner of death was
unknown. It must be stressed that
most accidental deaths from the in-
halation of carbon monoxide are
preventable. For instance, 16 of the
25 accidental deaths occurred in au-
tomobiles which had improper ven-
tilation or faulty exhaust systems, or
both. An awareness of the dangi
of such situations could reduce,
not eliminate, these tragedies.
Barbiturates continue to be wid
ly used as suicidal agents, as can
seen in the present series. Tweni
two of the 32 deaths were suicide
the manner of death in eight of t
remaining ten cases being "undeti
mined." Only two of the deal
were accidental; these were the i
suits of the combined use of barl
turates and alcohol.
Morphine deaths occurred in
narrow subset of the population, i
the 23 deaths attributed to nn
phine, two were in combination w
alcohol. The remaining 21 deal
were caused by morphine alone. .
were men; 21 were between the a;
of 16 and 31. Of the 23 deaths
tributed to morphine, 21 of the \
tims were Negroes. Most of the \
tims appeared to be addicts, as
dicated by their histories or by i
presence of old, as well as fre
needle marks on their bodies. M;
times needles were found in
veins or near the bodies, and otl
items such as syringes, toumiqui
bottle caps, and spoons were fou
in the victims' possession. The e
dence in all cases indicated ti
these deaths were accidental.
North Carolina no deaths from m
phine poisoning were reported
1968 and only one death attribu
to it is known to have occurred
1969.- Therefore, the dramatic
crease in the number of fatalii
from morphine in 1970 should b
cause for concern.
Only three deaths from arse
poisoning were reported in 1968
North Carolina and four were
ported in 1969.- The occurrence
ten cases of arsenic poisoning i:
group of 300 poisonings reflects
increase in the incidence. E'
though arsenic is an age-old poi;
and one that is easily detecta
long after death, it appears to
in fashion again as a homici
agent. The increase in the cases
arsenic poisoning may be parti:
only an apparent increase owing
improved investigation and del
tion of such cases as a result of
introduction of the medical ex;
228
Vol. }5. Nifl
er system. Accidental and suicidal
f;aths may not pose a significant
oblem in the investigation and de-
;tion of deaths from arsenic poi-
ning. However, the examiner
ould have a high index of suspi-
lion to detect homicides from ar-
Inic poisoning.
11 In the consideration of prevention
1! deaths from poisoning, suicides
ise a very complex problem, and
; best preventive efforts may yield
irely recognizable results. On the
ler hand, the prevention of acci-
ntal deaths is much easier. The
ures in this study, showing that
]i|iier two-thirds of the cases were ac-
(Jental, reflect a need for action. A
[ge number of these accidental
aths were caused by excessive use
alcohol and inhalation of carbon
B )noxide. The prevention of such
iuaths can be accomplished, to a
degree, through education of the
public. The problem of accidental
deaths appears to be of great signifi-
cance in North Carolina. In this
state the ratio of accidents to sui-
cides, as reflected in the analysis, is
3:1, whereas the national figures for
1966 and 1967 show that suicidal
poisonings outnumbered accidents
almost 2: 1.' '
SUMMARY
An analysis of 300 fatalities from
poisons in North Carolina in 1970,
with respect to age, sex, race, and
fatal agents is presented. The signifi-
cant facts that emerged are that al-
cohol is a leading killer and that
deaths from drug addiction are on
the increase. It is suggested that the
increase in the incidence of deaths
from alcohol, arsenic, and drugs of
addiction may be partially an appar-
ent increase, owing to better meth-
ods of investigation resulting from
the expanding functions of the medi-
cal examiner system. The salient
features that became clear from this
study are the high incidence of acci-
dental deaths from poisoning in this
state and the importance of the pre-
vention of deaths resulting from
poisons.
ACKNOWLEDGMENTS
The authors wish to extend sincere
thanks to Dr. Page Hudson and Dr. Ar-
thur McBay for their advice and coopera-
tion.
References
1. North C.irolma Vital Statistics. 1969, pp
K5-87.
2. Tessenear C: Personal communication,
1970; Office of Vital Statistics. State of
North Carolina.
.1. Vital Statistics of the US. 1967, Vol II-
Mortality, pp 84-K6, Part A. Section I. US
Public IHealth Service. US Department of
Health, Education, and Welfare.
4. Vital Statistics of the US, 1966, Vol II-
Mortality. pp X2-X6. Part A, Section I, US
Public Health Service. US Department of
Health, Education, and Welfare.
fit 3
Oil
1' I
fall
le i
II,
al.
nn
■id I
ribi J
tra^
ilic ;
italij
ildlJ
ari II
m
/eti
tent !•
IBgl t
led!
:, [
il
;kc1 J.
file
casi
nait '
id
■al e! «
I would not only caution patients who drink the purging mineral waters overnight to avoid
heavy suppers, but also from eating heavy meals at any time. The stimulus of water, impregnated
with salts, seems to create a false appetite. I have seen a delicate person, after drinking the Har-
rowgate waters of a morning, eat a breakfast sufficient to have served two ploughmen, devour a
plentiful dinner of flesh and fish, and, to crown all, eat such a supper as might have satisfied a
hungry porter, — tVilliciin Biichan: Domestic Mcilicinc. or ii Treaiisc on the Prevention and
Cure of Diseases by Ret;imen and Simple Medicines, etc.. Richard Folwell, 1799. p. 432.
i!,»
L 1974. NCMJ
I
229
The Role of Gastroesophageal Reflux
in Nocturnal Asthma in Children
Susan C. Dees, M.D.
A LL of us who treat patients hav-
■^^ ing asthma are familiar with the
repeated complaints that the asth-
matic attacks are more severe at
night than in the daytime and that
the attacks are often preceded by
severe bouts of coughing which sud-
denly awaken the patient from
sleep. ^ Several explanations have
been offered as to why these noctur-
nal attacks occur. It has been sug-
gested that when the patient lies
down, the vital capacity and chest
mobility are reduced sufficiently to
impede normal air exchange, par-
ticularly in a patient whose pul-
monary function may be already
slightly reduced; thus dyspnea, hy-
poventilation, and asthma result. -
It is further suggested that secretions
accumulate more readily in the
respiratory tree when the patient is
in the horizontal, supine, or prone
position than when he is upright;
therefore, in sleep, especially deep
sleep, the patient, being unaware of
the secretions, clears his airway less
often or less effectively. Experience
with problems of bronchial toilet in
unconscious or paralyzed patients
Read before the Pediatrics Section.
Carolina Medical Society. May 22. 1M73,
hurst. North Carolina.
From the Department of Pediatrics,
Uni\ersitv Medical Center, Durham.
Carolina 27710,
230
North
Pme-
Duke
North
has been used to substantiate this
theor}'.'^
Other investigators have sug-
gested that the vagotonia induced by
sleep may be sufficient to cause an
increase in airway constriction. ■'■ ''
Excessive fatigue is sometimes re-
sponsible for asthma. Some obser-
vers feel that dreams may serve as
unconscious trigger mechanisms for
asthma.'''
It as been proposed that the in-
timate contact with the most prolific
source of house and feather dust and
mold in bedroom furnishings is the
key to nighttime asthma. The cool,
damp evening air, a sudden fall in
temperature, or a rise in humidity
can induce bronchoconstriction
under experimental conditions and
possibly contributes to nighttime
asthma attacks. For the pollen-sen-
sitive patient, the shower of pollen
fall-out shortly before dawn may be
the extra challenge needed to pro-
duce symptoms. In other patients,
the nighttime symptoms may repre-
sent merely a longer reaction time to
an allergen contact which occurred a
few hours before the attack — possi-
bly a reaction to some food taken at
the evening meal."
.Another possible cause for noc-
turnal asthma is a gastroesophageal
reflux in the presence of an overre-
active airway. After eating a full or
partial meal, many people have g
troesophageal reflux when they ;
lying down, bending, or sitting. I
tients with hiatal hernia frequen
have reflux of stomach conter
they are prone to aspirate and
have recurrent pneumonia and brr
chitis.'' For many years thoracic s
geons have suggested that ref
may occur without hiatal hernia a
may cause this same type of p-
monary disease.'-'
Whether nocturnal asthma in si
a setting is a result of aspiration
the stomach contents, moment
change in intrathoracic press
secondary to reflux, stretching £
distention of the esophagus, or va
stimulation has not been establish
Belsey,'" Kennedy," Overhol
Klotz,'-* and others have repor
that nocturnal asthma frequently '
curs in persons who have this vai
tion from the usual esophageal fu
tion. Without invoking possi
mechanisms relating to gastroe
phageal reflux, previous generatii
of physicians customarily adm
ished their asthmatic patients
quently to eat small meals and
to go to bed soon after eat
a meal.'"* Indeed, many asthma
have discovered for themselves t
this schedule for eating is helpfu
procuring an untroubled nig!
sleep.
Vol. 35. N(
-'^
Jsing the so-called water siphon
, for several years we have done
oentgenographic study of the
)hagus and stomach of asthmatic
ents. This study was carried out
L means of documenting the ten-
zy to gastroesophageal reflux in
ly asthmatics whose symptoms of
:re nocturnal asthma, paroxysms
oughing, or recurrent pneumoni-
; bronchitis, or atelectasis sug-
ed that more than the usual al-
ens might be trigger mecha-
is. The water siphon test was
proposed by de Carvalho'"'
51) who, at the completion of a
/entional barium gastrointestinal
y, instructed the patient, while in
ipine position, to drink 100 to
i ml of water and to roll to the
t approximately 45 degrees. The
;r clears the esophagus of
um; if reflux is present,
um erupts back up the esopha-
' I often as high as, or higher than,
lortic arch.
insman'" describes a positive
fls one in which, after the patient
drunk the water, there is a mo-
tary delay, then a brief peaking
;ndng of the barium-filled fun-
of the stomach and a dramatic
g of the lower esophagus, often
fie aortic arch. Rolling the pa-
slightly backward and forward,
,,iving the patient breathe deeply,
also help to stimulate reflux
In 1,000 consecutive upper
Vointestinal studies, 40.5 per-
of all patients showed reflux,
ital of nine percent of the entire
s had demonstrable hiatal her-
4 Jof these, 79 percent had reflux,
patients' ages ranged from one
;
ilii (
a;'
«
Jli
It ^'
bi
ver 80 years; the greatest inci-
e of reflux was in patients who
f between the ages of 41 and 71.
Jail patients who had hiatal her-
;ouId be made to reflux. The
iiasis of this study was exclu-
on the technique and the gas-
testinal tract; no mention was
of associated pulmonary
|»toms in these patients,
similar study by Crummy,"
only 15 to 30 ml of water, pro-
|ii results similar to those of
inan^''; ten percent of the pa-
I who were examined had reflux
JSt
1
:1«
and 69.6 percent of those patients
having pyrosis had reflux.
Our observations of patients who
were selected from an asthmatic
population have been sporadic.
Therefore, the frequent finding of
reflux does not indicate its true in-
cidence or significance in either
asthmatics in general or in normal
children. Because reflux commonly
occurs at all ages, it is considered a
"normal" event. Dr. Arvin Robinson
of the Duke University Medical
Center Radiology Department is do-
ing a systematic review of reflux in
children with asthma, and other
chronic chest diseases; his study in-
cludes, too, those children without
chest disease who are having ga
trointesrinal radiography for diges-
tive problems. The study should
soon give us a more realistic idea of
the incidence of reflux in patients
who have chest disease and in those
who do not. Robinson's preliminary
flgures show 17 of 30 asthmatics
who have reflux, in contrast to one
of 16 children who have gastrointes-
tinal complaints.
Regardless of whether gastroeso-
phageal reflux is a common physio-
logic phenomenon, our notable ex-
amples of impressive reflux seem to
be associated with several recogniz-
able patterns of nocturnal asthma.
The child, in most instances, eats
bedtime snacks, large or late din-
ners, or takes large amounts of li-
quid with the evening meal or be-
fore going to bed. A child who goes
to bed seemingly well or with very
little respiratory difficulty often has
attacks that occur with clocklike
regularity, night after night. In the
most frequently occurring pattern,
the attack begins one to two hours
after the patient has lain down, and
it is ushered in by sudden paroxys-
mal coughing and wheezing. In a less
frequently occurring pattern, the at-
tacks begin at midnight and last un-
til 4:00 a.m. In yet another pattern,
the attack begins when the patient
arises in the morning, usually while
he is dressing. Body positions which
often elicit reflux are sudden bend-
ing, stooping, or straining. Fre-
quently, the nocturnal attacks are
much more severe than those the
child has during the daytime hours.
Each child is likely to have his own
stereotyped pattern of reactions.
Those children who have demon-
strable reflux often have repeated
episodes of severe resistant pneu-
monia, bronchitis, or atelectasis. We
have not been able to elicit many
gastrointestinal complaints from
these patients, in contrast to adults
in these instances, since children
seldom describe "heartburn" or sub-
sternal burning. Very few were per-
sistent vomiters, and few had anemia
or malnutrition which is seen in pa-
tients who have hiatal hernia; rarely
did we find hiatal hernia in any of
these children. Parents have volun-
teered that they or other family
members have hiatal hernias for
which they have been using the
medical program. We have not been
able to ascertain whether there is a
developmental or hereditary rela-
tionship between gastroesophageal
reflux and hiatal hernia, but this
point might bear systematic study.
None of our patients with reflux
has had surgical correction of the
condition. Belsey,"* Nissen,^^
Vos,-" and Davis and Fugat-'
have reported successful results in
children who had severe respiratory
disease and reflux. The objective of
the surgery is to restore competence
to the lower esophageal sphincter as
a valve. The surgery is accomplished
by a plicating procedure, either
transthoracically (Belsey)'" or by
the intraabdominal approach (Nis-
sen),'-' restoring the angle of His
but preserving the integrity of the
vagus nerve.
We have used the simple medical
program of elevating the head of the
bed on six- to eight-inch blocks,
restricting fluid intake to less than
four ounces at a light evening meal,
and prohibiting food and fluid in-
take after the evening meal. We have
recommended that the evening meal
be taken at least three hours before
the patient retires. We have not rec-
ommended antacids for these chil-
dren, although antacids have been
advised for patients who have pyro-
sis or esophagitis. Some of the fol-
lowing case reports bear testimony
to the almost immediate cessation of
Pi 1974, NCMJ
231
nocturnal symptoms when food in-
take is restricted and the bed is ele-
vated. This medical program has
been effective even when the pa-
tients' symptoms have persisted for
several years.
CASE REPORTS
Case 1
A girl who had a small sliding
hiatal hernia and a history of severe
episodes of nocturnal coughing and
alarming asthma was admitted to the
hospital for study several years ago.
.After admission, she had an episode
of respiratory and cardiac arrest
during her typical, nocturnal cough-
asthma attack, from which she was
successfully resuscitated. Since her
hospitalization, the medical program
to prevent reflux has controlled her
nocturnal symptoms.
Case 2
Another child, aged seven, had
to be taken, as often as four or five
times a week, to her local hospital
emergency room for the treatment
of severe asthma. For months these
visits were made prior to the dis-
covery of significant reflux to the
cervical esophagus. From the first
night after the patient's bed was
elevated and the fluid intake was
restricted, she slept through the
night without coughing or asthma;
before any other treatment was in-
stituted, her sleep was undisturbed
for the first time in months. In the
ten months that she has adhered to
the medical program to prevent re-
flux, the patient has had only three
or four nocturnal attacks, all of
which, in retrospect, could be attrib-
uted to nocturnal dietary indiscre-
tions. Since she has taken the usual
environmental precautions, the pa-
tient's daytime and seasonal allergic
symptoms have improved, although
to a less dramatic degree.
Case 3
A seven-year-old boy who had
multiple allergies gave a similar his-
tory of severe nocturnal asthma at-
tacks. He enjoyed relative freedom
from attacks during the daytime, ex-
cept for sporadic attacks during sev-
eral days of the pollen season or
after he was exposed to animals.
This case serves as an illustration
232
Fifj. la. Initial barium swallow of water
siphon test.
that the water siphon test does not
always indicate reflux. One year
ago, the results of a water siphon
test were negative after a small
amount of barium was administered
to the patient when his stomach was
empty. However, considering the
child's history of nocturnal asthma
and his recent, nearly fatal episode
of status asthmaticus which began
abruptly several hours after he went
to bed, we strongly suspected aspira-
tion as a possible trigger for attacks.
The water siphon test, repeated
while the patient had a full stomach,
showed massive reflux (Figures la
and lb).
Several authors have reported on
the variabilitv in the test re-
FiK. lb. Reflux after drinking watt
reclining position. Barium reflux
thoracic outlet.
sponse. -'-■ -■■' The first patient ci
in this paper had a repeat roui
gastrointestinal series done fourd'
after the first study; the hiatal hci
was not demonstrated. This va
bility underscores the point that
physician should not rule out p(
ble reflux in the presence of nega
results from radiologic studies, [
ticularly when the patient's hist
strongly suggests reflux.
Case 4
An infant had vomiting, recun
pneumonia, wheezing, and esc
agitis. He also had a hiatal hei
which was successfully repaired
cently. The infant has progre;
well since surgery, although he
Fig. 2a. Hiatal hernia, esophagitis and re-
current pneumonia. Chest showing in-
filtrate in right middle lobe and at left
hiluni. Increased density behind the heart
caused by esophagus distended with food.
Fig. 2b. Barium swallow postoperati*
pair of diaphragmatic hernia shol
stricturcd lower esophagus and pur
filled stomach.
Vol. 35,
istent lower esophageal stenosis
mdary to csophagitis (Figures
md2b).
he literature provides descrip-
3 of various tests that evaluate
rocsophageal reflux and amplify
ographic studies. The following
jialized diagnostic tests are used
:astrocntcrologists and surgeons:
hagoscopy; comparative mea-
ments of pH of the esophagus,
/e and at the lower esophageal
ncter, just within the cardia of
stomach; measurements of intra-
ihageal gastric pressure at these
s-*; perfusion of the esophagus
one-tenth normal HCl to re-
uce symptoms of pyrosis; and,
Radiography after the patient
I swallowed neutral and acid
jim.-"' Obviously, these tests
. far more readily applied to
jts and older children than to un-
jcrative infants or young chil-
". We have not done any of the
j;oing studies to evaluate gas-
ophageal reflux in our patients.
most instances, when the set-
S of nocturnal asthma suggests
B; oesophageal reflux, the physi-
a; is justified in instituting the
iHcal program for the control of
!f;>c, as a therapeutic trial, having
0' only the radiologic barium
r siphon test. In our preoccupa-
tion with the newest specific phar-
macologic agents and immuno-
therapy for asthma, we often neglect
simple hygienic measures, familiar
to previous generations of physi-
cians, which can greatly diminish
symptoms and make our patients
more comfortable.
SUMMARY
Gastroesophageal reflux, among
various other causes, may serve as
a trigger mechanism for nocturnal
asthma. A characteristic history of
sudden onset of nocturnal attacks
is usually elicited from patients in
whom reflux is present. In many in-
stances reflux of gastric contents is
demonstrable by barium water
siphon roentgenography of the
eosphagus.
References
1. Jamar JM (ed): International Textbook of
Allergy. Springfield: CC Thomas, 1959, pp
243-244.
Coniroc JH: Physiology of Respiration:
An Introductory Text. Chicago: Year Book
Medical Publishers. 1965, pp 17-27.
3. Comroe JH: Physiology of Respiration:
An Introductory Text. Chicago: Year Book
Medical Publishers. 1965. pp 220-230.
Comroe JH: Physiology of Respiration:
An Introductory Text. Chicago: Year Book
Medical Publishers. 1965. pp 75-85.
Eppinger H, Hess L: Vagotonia: A Clinical
Study in Vegetative Neurology, ed 2. Ner-
vous and Mental Disease Monograph Series.
No 20. Krauss WG and Jelliffe SE (trans-
lators). New >'ork: the Nervous and Mental
Disease Publishing Company. 1915.
6. McGovern JP, Knight 3A.: Allergy and
Human Emotions. Springfield: CC Thomas.
1967, pp 22-24.
7. Tuft L, Mueller HL: Allergy in Children.
Philadelphia: WB Saunders, 1970, pp 306-
377.
8. Davis MV: Relationship between pulmonary
disease, hiatal hernia, and gastroesophageal
reflux. NY Slate J Med 72: 935-938, 1972.
9. Hicbert CA. Bclsey R: Incompetency of the
gastric cardia without radiologic evidence
of hiatal hernia. J Thorac Cardiovasc Surg
42; 352-362. 1961.
10. Belsey R: The pulmonary complications of
oesophageal disease. Br J Dis Chest 54:
342-348, 1960.
11. Kennedy JH: "Silent" gastroesophageal re-
flux: an important but little known cause of
pulmon;irv complications. Dis Chest 42:
42-15, 1962.
12. Overholt RH, Vorhees RJ: Esophageal re-
flux as a trigger in asthma. Dis Chest 49:
464-466. 1966.
13. Klolz SD, Moeller RK : Hiatal hernia and
intractable bronchial asthma. Ann Allergv
29: 325-32K, 1971.
14. Bray GW: Recent Advances in Allergy.
Philadelphia: P Blackiston's Son & Co,
1931, pp 255-256.
15. Carvalho M de: Chirurgie du syndrome
hiato-oesophagicn (communication preal-
able). Arch Fr mal I'app dig 40: 280-293.
1951.
16. Linsman JF: Gastroesophageal reflux elic-
ited while drinking water — (water siphon-
age test). Am J Roentgenol Radium Ther
NucI Med 94: 325-332. 1965.
17. Crummy AB: The water test in the evalua-
tion of gastroesophageal reflux. Radiology
87: 501-504, 1966.
18. Skmner DB. Belsey RHR, Hendrix FR,
Zuidema GD ( eds ) : Gastroeosphageal Re-
flux and Hiatal Hernia. Boston: Little
Brown, 1972. pp 133-161.
19. Nissen R: Gastropexy and "fundoplication"
in surgical treatment of hiatal hernia. Am J
Dig Dis 6: 954-961, 1961.
20. Vos A, Boerema I: Surgical treatment of
gastroesophageal reflux in infants and chil-
dren: long-term results in 28 cases. J Pediatr
Surg 6: lOI-llI, 1971,
21. Davis MV, Fugat J: Application of the
Belsey hiatal hernia repair to infants and
children with recurrent bronchitis, bron-
chiolitis, and pneumonitis due to regurgi-
tation and aspiration. Ann Thorac Surg 3:
99-110. 1967.
22. Edwards DA: Medical thoughts on the
"hiatus hernia-reflux syndrome." Trans Med
Soc Lond 86: 147-153, 1970.
23. Ellis FH Jr: Gastroesophageal reflux: in-
dications for fundoplication. Surg Clin North
Am 51 : 575-588. 1971.
24. Butterfield DG. Struthers JE, Shovalter
JP: A test of gastroesophageal sphincter
competence: the common cavity test. Am
J Dig Dis 17: 415-422. 1972.
25. Benz LJ. Hootkin LA, Margulies S, et al:
A comparison of clinical measurements of
gastroesophageal reflux. Gastroenterology
62: 1-5. 1972.
When I speak of drinking a glass of the water over night, I must beg leave to caution those
who follow this plan against eating heavy suppers. The late Dr. Daultry of New York, who
was the first that brought the Harrowgate waters into repute, used to advise his patients to drink
a glass before they went to bed: the consequence of which was, that having eat a flesh supper,
and the water operating in the night, they were often tormented with gripes, and obliged to call
for medical assistance — William Bucimn: Domestic Medicine, or a Treatise on the Prevention
and Cure of Diseases by Regimen and Simple Medicines, etc.. Richard Fohvell. 1799. p. 431.
II
'I'l 1974, NCMJ
233
Need for More and Better Distributed Primary
Care Physicians in North Carolina
Committee on Community Medical Care. North Carolina Medical Society
"T" HE North Carolina Medical So-
ciety is vitally concerned with
every aspect of the medical care of
the people of North Carolina. Of
particular concern are the de-
ficiencies in the delivery of primary
medical care to the people of North
Carolina in rural and less urbanized
areas of the state.'
In keeping with the leadership
that has become expected of the
North Carolina Medical Society and
as evidence that our present medical
care system is concerned and re-
sponsive, the following position pa-
per has been prepared on the need
for more and better distributed pri-
mary care physicians. The Commit-
tee on Community Medical Care is
comprised predominantly of pri-
mary care physicians who, by inter-
est and practice characteristics, are
knowledgeable of the problems in-
volved.
PROBLEM DESCRIPTION
Distribution
It is desirable that physician ser-
vices in North Carolina be evenly
accessible to the population in all
geographic settings in relation to de-
mand. Until now, such accessibility
has not been possible because phy-
sician distribution, as that of many
Reprim requests to J. Kempton Jones. M.D..
1001 S. Hamilton Rd.. Chapel Hill. N. C. 27514.
234
segments of the population, has been
markedly influenced by economic
and social conditions and by
urban and rural dynamics. Such
factors include the prevalence of
po\erty. age, and accidents, and
the availability of communication,
transportation, educational, cultural,
and recreational resources.- The re-
sult has been a dramatically dispro-
portionate concentration of physi-
cians in various population areas.
Primary medical care
Of equal importance is the prob-
lem of having the right physician in
the right place at the right time. The
distribution of physicians by medi-
cal specialty is comparable in im-
portance to the total number of phy-
sicians and their geographic dis-
tribution.
Health care manpower is a special
and acute problem in North Caro-
lina, particularly with respect to pri-
mary care which includes the full
spectrum of basic services needed to
maintain and restore health. Pri-
mary care services are called for in
80 to 90 percent of all patient needs.
Yet the predominance of the effort
is focused on the other 10 to 20
percent — training specialists and
subspecialists who are increasingly
less trained for handling the prob-
lems of primary care.-
The modern personal physician
considers the expanded health d
team and diverse community
sources as an extension of hims(
This type of team can be the m
efficient and flexible means of ass
ing comprehensive primary hea
care made available to the rich
poor in rural or urban settings. -
Part of the dilemma of und
served areas is that there has i
been an advocate with responsibiJ
for allocating health care manpov
for primary and rural health ca
Until recently medical schools hi
not been accountable for produc
the numbers and kinds of physicii
that society needs. The types of c
cational programs offered have
to a migration of medical manpoy
from rural areas to more uri
areas where the more sophistics
facilities have been located. Tl
efforts, quite understandably, h.
been directed toward develop
programs that would attract fedt
monies available at the time whi
unfortunately, were mostly it
marked, until recently, through gr
ernment designation for other t^ ;
primary care services. -
Financing rural care is a most
ficult problem. Actual cost per i^
of service is frequently higher ■.
rural areas, especially if an attei ,■;
is made to provide a broad sf ■;
trum of health care. Many n
areas are unable to support evej ,
Vol. 35, N^ ; :
Idimentary public health care sys-
m, let alone one directed toward
oviding comprehensive care. The
lancial incentives are often inade-
k ate, and discriminatory reim-
rsement practices by third party
yors for rural physicians com-
lund the problem. -
SUPPORTING DATA
K)graphic distribution
The geographic distribution of
] ysicians by population in North
< rolina is as follows: In rural
] irth Carolina there are 1,737 peo-
1 to each physician; there are 760
japle to each physician in urban
I rth Carolina. In rural North
( rolina there are 2.3 times more
I jple per physician than in urban
I as of the state.''
In the six most populated counties
L North Carolina, the population/
f /sician ratio is 859:1. The popu-
Ii on/physician ratio is 2,396:1 in
t six least populated counties.^
( iduating physicians
between 1958 and 1972 North
Colina had a total of 2,983 phy-
s;;an graduates.'' Bowman Gray
S|Ool of Medicine had 776 (26
p,:ent); Duke University Medical
S ool had 1,226 (41 percent); and
tl University of North Carolina
Sjool of Medicine had 981 (33
p,-ent).
fi, ention rates
'detention of North Carolina
mUical school graduates for prac-
tiii' in North Carolina allows three
yc "s for placement." Because of in-
ie ship, residency, and military ob-
;li}»:ions, there is frequently a time
la^of five to seven years between
; ch'time of graduation and establish-
n t in practice. From 1955 to
.J5U, the number of physicians who
:?r uated from North Carolina
n ical schools was 1,869; of these,
-M; percent had settled in North
" )Unaasof 1967.
I he retention rates for each of the
C' ols are as follows: Bowman
3: / School of Medicine — 37 per-
;e , Duke University Medical
->c ol — 29 percent; University of
North Carolina School of Medicine
— 56 percent.
Primary care physicians in North
Carolina
Of the 1,869 graduates from
North Carolina Medical schools be-
tween 1955 and 1964, four hundred
and two (22 percent) were practic-
ing in North Carolina in the primary
medical care specialties by the year
1972 7 jj,g breakdown from the
three schools is as follows: Bowman
Gray School of Medicine — 22 per-
cent of 493 graduates; Duke Uni-
versity Medical School — 13 percent
of 782 graduates; University of
North Carolina School of Medicine
— 32 percent of 594 graduates.
Of the 5,964 non-federal physi-
cians practicing in North Carolina in
1971, 45 percent (2,583) were in
the primary medical care specialties:
19 percent were in family medicine;
13 percent were in internal medi-
cine; six percent were in pediatrics;
and seven percent were in obstetrics-
gynecology.''
Training programs for primary care
specialties in North Carolina
In 1972 there were 703 residents
in training in North Carolina, of
whom 27 percent were in training in
the primary care specialties.''
Relationships can be seen be-
tween the 45 percent of non-federal
physicians practicing in North Caro-
lina in the primary medical care
specialties in 1971, the 27 percent
of total residents in training in North
Carolina in primary medical care
specialties in 1972, and the recently
adopted AMA goal that at least 50
percent of all medical graduates en-
ter residency training in the primary
care specialties in the coming years.
PREVIOUS STUDY REPORTS
The North Carolina Medical So-
ciety has long been interested in pro-
moting realistic solutions to meet the
problems of medical manpower, as
evidenced by two reports in 1972 re-
garding "Medical Students and
Medical Manpower" by the Joint
Conference Committee, and the
"Recommendations from the Con-
ference on Access to Health Care"
by the Public Relations Committee.
Recommendations regarding these
problems, including the need for
more medical school graduates in
North Carolina, have been made in
the "Report of the Statewide Plan
for Medical Education in North
Carolina" by a panel of medical
consultants to the Board of Gover-
nors of the University of North
Carolina. The UNC Board of Gov-
ernors has prepared Recommenda-
tions Consistent with the Report of
the Panel of Medical Consultants on
a Statewide Plan for Medical Edu-
cation in North Carolina. Separate
recommendations have been pre-
pared by the Medical Manpower
Commission of the North Carolina
State Legislature which call for the
graduation of an increased number
of physicians in North Carolina and
the addition of a second year to the
ECU Medical School.
RECOMMENDATIONS
Alleviating maldistribution
The scholarship or loan funds ad-
ministered through the North Caro-
lina Department of Human Re-
sources to support medical educa-
tion, with forgiveness of indebted-
ness if the student ultimately prac-
tices for a short length of time in
rural areas, should be continued and
enlarged.'"
Medical school admission and re-
cruitment criteria should be altered
in favor of those factors in the ap-
plicant's background which might
encourage him to practice in an un-
derserved area. Medical students
should be more oriented to the needs
of medically deprived areas."
Admission committees to medical
schools should include as full active
members independent primary care
physicians. Since this service can be
very time consuming for a busy
practitioner, reimbursement for time
spent should be provided. '-
In the selection criteria for schol-
arship recipients in the proposed
scholarship program for under-
graduate medical students, to be im-
plemented by the Board of Gover-
nors of UNC for financially disad-
vantaged students, high priority
should be given those applicants
Af , 1974, NCMJ
235
who express an interest in entering a
primary care specialty and serving in
an underserved area.''
The Resident Physician-Preceptor
Field Training Program for Primary
Care - Family Practice Residents,
being iinplemented by the North
Carolina Department of Human
Resources, should be supported
and expanded. This program pro-
vides opportunities for primary care
residents to receive part of their
training in rural communities with
selected medical practitioners.'^
The statewide network for decen-
tralization and coordination of
medical and health professional edu-
cation through development of Area
Health Education Centers in North
Carolina should be encouraged. The
decentralization of undergraduate
and graduate medical education
through the greater use of commun-
ity hospitals for intern and residency
training will also be beneficial.''
Expansion of transportation and
communication capabilities between
rural areas and larger medical cen-
ters, presently in the planning stage
by the Emergency Medical Services
Network, should be accomplished,
making adequate provision for ap-
propriate reimbursement for medi-
cal services to be provided. Such re-
imbursement will be vital to the suc-
cess of this program.'"'
The enhanced use of allied health
professionals to increase the pro-
ductivity of physicians, particulariy
those in rural areas, can be a bene-
ficial influence. A program to help
accomplish this, although not in it-
self a substitute for increased pro-
duction of primary care physicians,
is being implemented by the North
Carolina Medical Society.'"
The proposal to establish a net-
work of primary medical care clinics
throughout the state, as a coopera-
tive endeavor between the commu-
nity and the state, with supervision
and backup by physicians and hos-
pitals in nearby towns and cities, is
an experimental program that de-
serves continuing support and guid-
ance by the North Carolina Medical
Society. The support of backup phy-
sician coverage will be vital to its
success.''
Consideration should be given,
with assistance from the interested
agencies available, to expanding the
function of the North Carolina
Medical Society's Physician Place-
ment Service to include development
of demographic profile data on com-
munities seeking a physician and ac-
tive contact with physicians on be-
half of such communities."*
New physicians moving into un-
derserved areas should be allowed
fee reimbursement for services pro-
vided, similar to those in other
areas, and should not be limited for
reimbursement to previously exist-
ing regional, prevailing fee sched-
ules. These new reimbursement al-
lowances should be included in de-
termining prevailing fee sched-
ules.'''
Efforts such as job fairs, similar
to the 1973 Student Physician Com-
munity Fair by the North Carolina
Academy of Family Physicians, to
bring physicians and rural leaders
together should be supported and
encouraged. Advance planning by
representatives of parties involved
and widespread publicity are impor-
tant for the success of these pro-
grams."' -"
Correlating medical education with
function
In the development of new cur-
ricula for medical students, fur-
ther relevance should be sought
by increased emphasis on perfor-
mance criteria including task analy-
sis and team concepts." There
should be greater interrelationship
of training programs for medical and
allied health professionals. Core
courses in geographic proximity of
the training programs to areas of
need, as that envisioned in the ex-
panded AHEC program, is one way
to accomplish this."
The professional associations
should provide programs to interest
medical students in selecting pri-
mary care specialty, such as that
provided by the North Carolina
Family Practice Club of Medical
Students.-".
Attractive credit-bearing electives
in community primary medical care.
using practicing physician precep
tors (not limited to the AHEC af
filiated community hospitals men
tioned in the preceding recommer
dation) should be developed so tha
as a goal. 25 percent of senior med
cal students' available elective timi
can be spent in rotations off unive;
sity medical center campuses. Fu
reimbursement of student transloc:
tion expenses and appropriate pn
ceptor reimbursement should 1
provided. Utilization of model medi
cal practices, with physician pr
ceptors who successfully demo: I
strate for medical students how u ■
derserved areas can effectively I
served, should be given highest pi
ority."' -'
To promote appropriate orient
tion as the programs of the medic
schools move further into commu
ities. it is recommended to t
Chairman of the Board of Go\t
nors of UNC that a practicing ph
sician. named by the North Caroli
Medical Society, be added as an
officio member of the propos
health subcommittee of the Comin
tee on Educational Planning, P'
icies and Programs of that Board
Increased funding should be pi
vided for primary care physici
training in North Carolina. T
might include grants to departme
for graduates after four years
practice in North Carolina as f
mary care physicians. --'
The general requirements for
residency programs, as enfon
through the .\MA Medical Speci;
Review Teams, should be broader
and supervised to assure increa:
emphasis on the exposure of ho
officers to meaningful experiencesi
health and medical service outs
the university medical center; ori
tation to the social and econoi-
aspects of medical practice sho
be included.--'
It is important, in keeping wit
recently adopted AMA goal, tha
least 50 percent of all med
graduates enter residency trainini
the primary care specialties in
coming years. -^
Health care deliverj systems
The Office of Comprehend
Health Planning in the North Ci!
276
Vol. 35, Nl
|i Department of Administration
_'i the responsibility of planning to
. T,et the health needs of the people
-i North Carolina. Inadequate pri-
r ry care services have been idcnti-
f 1 as a major health problem; yet,
t re are no primary care practicing
f sicians on the Comprehensive
i-ilth Planning Advisory Com-
D^ tee. There should be at least five
p.cticing physicians on this Com-
n'tee.-''
bounty medical societies, as far as
p,sible, should consider taking on
a, population frame of reference"
ii vhich physicians accept not only
a individual responsibility to indi-
V jal patients but also cooperate by
e; blishing responsibility to the
gi,,graphic areas.-" The regional ap-
P[ach for underserved areas, using
siJlite clinics which are staffed by
ill Ith care teams composed of an
a],'d health professional under phy-
>i,m supervision, is being imple-
ir, ited in North Carolina.' '
ridditional studies should be un-
Ji.aken to determine newer meth-
3<i of transportation to bring the
ii Jy to areas of existing health ser-
t'forts underway by the Emer-
ge .y Medical Services Program to
x ralize the provision of emer-
it-:y medical services in the com-
n-iity and to eliminate duplicate
X ing of emergency rooms in hos-
)i s which are close together are
Btortant. Efforts should be con-
ir;;d to find more efficient and less
xjy ways to provide non-emer-
^ly, unscheduled care than by use
'f.ispital emergency rooms. ^'^
Coimunity responsibility
here is an urgent need today for
il,:ns in communities to examine
hi, medical services" strengths and
le iencies. The people must estab-
is^ he means for planning to assure
'PjUum quality and continuity of
0 jrehensive health services,
«. ;ing through the designated re-
i( ; of the Office of Comprehen-
sive Health Planning in cooperation
with county medical associations.
Every effort should be made on a re-
gional and geographic basis to de-
velop not only this entry point and
access to primary care, but also the
necessary secondary care in rural
areas and backup tertiary care in
strategically located medical centers.
It is important for each community
health planning committee with
leadership from community physi-
cians to establish long term goals to
be accomplished in a stepwise fash-
ion.-' These goals should be as
follows:
To make quality health care
available for all people in the re-
gion: (1) Start with improvements
in the area's transportation system
to bring people to available physi-
cians and hospitals in the region;
(2) Secure cooperation of commun-
ity colleges to train medical and den-
tal assistants; (3) Contract with
health departments to provide pub-
lic health nurses; (4) Develop plans
for providing new medical/dental
clinics to help in recruitment of
health personnel; (5) Seek to enlist
the cooperation of medical and den-
tal societies to provide added ser-
vices; (6) Contract with local hos-
pitals to establish emergency ser-
vices; and (7) Establish improved
ambulance services with better
training and equipment for ambu-
lance attendants,-"
To improve the family's ability to
handle health problems: (1 ) Health
education courses in schools for
adults and children should be im-
proved; (2) First aid courses for
each family should be emphasized;
(3) Self-help courses should be
taught; and (4) Rural safety and ac-
cident prevention programs should
be made available.-'
References
1. Forsyth Countv Medical Soclelv Resolii-
Hon to the 197.1 NC Medical Societv
House of Delegates . . . referred to the
Executive Council for consideration.
2, Rural Heallli Cure Needs, address by Len
Ungues Andrus. M D. Professor and Chair-
man of Depanment of Familv Practice.
School of Medicine. University of Calif, 12-
3. Uislrihulion of Physicians in the Unilecl
Stales. 1971. AMA. Chicago, 1972. ("Rural"
refers to AMA county classifications 1-4;
"urban" refers to classification 5-9. The US
figures refer to the US. excluding North
Carolina. )
4. Population figures from 1970 Census of
Population, Advance Report PC (Vl)-35,
US Heparlment of Commerce. 1970. (Total
physicians, non-federal, from Roster of Reg-
istered Physicians in the State of North
Carolina.) Board of Medical Examiners
ol the State of North Carolina. March 1.
1972. (Six most populous counties were
Cumberland. Forsyth, Gaston. Guilford,
Mecklenburg, and Wake. Six least populous
were Tyrrell, Clay, Camden. Hyde. Gra-
ham, and Currituck.)
5. Report of the Committee to Study the Re-
quest of East Carolina University for a
Second Year of Medical Education. Report
to the UNC Board of Governors. Decem-
ber 29. 1972. p 67. Supplemented by tele-
phone communications viith medical schools
for graduates 195S-1960.
6 Medical School Alumni, 1967. AMA Chi-
cago. 1968. pp 528-5,10.
7. Derived from computer analysis of 1972
AMA Master File computer tape for North
Carolina by Division of Education and Re-
search in Community Medical Care, UNC
School of Medicine.
8. Health Resources Statistics, Health Man-
power and Health Facilities. 1972-1973. US
Department of Health. Education, and Wel-
fare, 1973. pp 192, 196, 197.
9. Telephone survey of Sept 1, 1972, resi-
dency positions filled, by Division of Edu-
cation and Research in Community Medi-
cal Care, University of North Carolina at
Chapel Hill, 1973.
10. A Stalevide Plan for Medical Education
in North Carolina — Report of the Panel of
Medical Consultants to the Board of Gov-
ernors of the University of North Caro-
lina (9 21 73).
1 1 Expandini; the Supply of Health Services
ill the 1970s. Report of the National Con-
gress on Health Manpower, sponsored by
The Council on Health Manpower of the
AMA (10 22-24-70).
12. Actions of NC Medical Society House of
Delegates, May 1973.
13. Recommended Actions Consistent with the
Report of the Panel of Medical Consul-
tants on a Statewide plan for Medical Edu-
cation in North Carolina, UNC Board of
Governors.
14. Senate Bill 301, General Assembly of North
Carolina, 1973 Session.
15. Statement by Stale Emergency Medical
Services Advisory Council. NC Department
of Human Resources (9 20 73).
16. Outline of Proceedings — Conference on Ac-
cess to Health Care. By NC Medical So-
ciety and NC Regional Medical Program
(9 9-10 73).
17. NC Medical Societv E.xecutive Council
110 73).
18. Priorities for Increasing Availability of
Health Services in Rural Areas — AMA
House of Delegates. 6 72.
19. Written communication to LH Fountain
from RM Ball, Commissioner for Social Se-
curity, US Department of HEW. 3. 22, 73.
(Resource information only.)
20. Written communication from Dr. Alleson M
Alderman, President. NC Academy of
Family Practice (12 10 73).
21. Medical school expands off campus. .Ameri-
can Medical News. 10, 1/73. ("For each of
the past four years, more than 50 per-
cent of the senior medical students time
was spent in rotations off the Indinapohs
campus" — University of Indiana).
22. Senate Bill 858. General Assembly of NC,
1973 Session.
23. AMA Council on Medical Education. Es-
sentials of .Approved Residences, p 351.
24. AMA House of Delegates. June. 1973.
25. Membership Comprehensive Health Plan-
ning Advisory Committee. NC Department
of Administration.
26. Fenderson DA: Special Communications —
Health manpower development and rural
services. JAMA 225: 1627-1631, 1973,
27. Guidelines: Community Organization for
Health Services in Rural Areas. AMA
Council on Rural Health (4 16 '71 ).
. 1974, NCMJ
I
237
Editorials
LOUISE FANT MacMILLAN
For almost a quarter of a century the day-to-day
work of getting out the editorial matter of this
Journal has been done by Louise MacMillan.
Authors and others in contact with the Journal
knew her as a very bright, well-read, experienced
woman who epitomized Southern gentility. Few knew
that she was paraplegic from birth, fewer still that
until her 62nd year she rarely missed a day of work,
justifying her own description of herself as "an able-
bodied paraplegic." On March 2, 1973 she died, a
victim of chronic active lupoid hepatitis, a disease
she faced with her characteristic resolution and care
for those who worried about her.
Miss MacMillan's life has special meaning for
physicians, aside from her work with the Journal,
for medical situations currently hotly debated (N
Engl J Med 289:890, 1973 and N Engl J Med 240:
518, 1974) find illustration in her life. ^
Although born with spina bifida and paraplegia,
she was bom into a family with great intellectual and
spiritual resources — the MacMillans who are so am-
ply represented in North Carolina medicine, the
Johnsons. Memorys, Fants, and others of profes-
sional and literary acclaim in this state and elsewhere.
Her father, a Baptist minister, many times literally
carried Louise and saw to it that she mixed in
the activities of the extended family, to the extent
that she and they could manage. Thus she swam
and played with her innumerable relatives of suit-
able age and grew to adulthood with great psycho-
logical strength. Many alumni of the Baptist or-
phanage in Thomasville remember with fondness
Louise's work with the children and young people of
that institution. At one time or another she was a
teacher, editor, and counselor, succeeding her father
as editor of Charity and Children, the statewide
Baptist publication dealing with their orphanages.
She found much time for service outside her work,
being a deacon of the Wake Forest Baptist Church
and president of the North Carolina Paraplegic Asso-
ciation, and active in both organizations until the last
few months of her life. In 1963 she was designated
"Handicapped Person of the Year," an honor fitly
given. Although it could be said that wc are all handi-
capped in some way. few people overcome a major
handicap as well as Miss MacMillan did.
The Journal, and especially Miss MacMillan"s
family, will miss her knowledge, judgment, and good
238
manners. The friends of her younger days think th^
her father will carry her into Heaven in his arms; th?
are both surely there.
DRUGS. RP:GULATI0N AND PROGRESS
In testimony before the Health Subcommittee c
the Senate Committee on Health and Welfare Decen
ber 19, 1973, HEW Secretary Casper Weinbergc
revealed a plan to limit reimbursement for druj
under Medicare and Medicaid to the least cost]
drugs available in the absence of demonstrated di
ference in therapeutic effect. Ostensibly, this pn
posal was designed to achieve economy in drug cos
under these programs.
Testifying at a hearing before the same Committf
on February 1, 1974, Joseph Stetler, formerly
member of the AMA Staff and now president of tl
Pharmaceutical Manufacturers Association, proper
urged a careful evaluation of this proposed reguli
tion to determine whether it would: (1) achiei
economies in these government programs; (2) inte
fere with the professional judgment of physicians ai
pharmacists: (3) assist or penalize beneficiaries; ai
(4) encourage, rather than retard, continued effoi
by pharmaceutical companies to improve dn
quality and develop new products.
It is recognized that all drug products are not
equal quality. In 1967, then Secretary of HEW Gat
ner estimated that the cost of establishing adequ£
facilities for scientific and clinical testing of all dru
by the Food and Drug Administration would
proach S75 million, while Secretary Weinberger pr ;;
jects a saving of only $28 million to be achievjcJ
through his proposal. There is a question as
whether the FD.A should replace the manufacture
efforts in quality control or rather should complemf Sf
such existing facilities. i;-
The proposed regulation places in question 1 'm,
expertise of physicians and pharmacists. Freedom: i^^
the physician to exercise his judgment in the care jj
patients is at stake. Furthermore, any different rd
in cost not reimbursed under the Secretary's propoi id
would be borne by beneficiaries to their disadvanta; f";
A portion of the cost of drugs is necessarily a ' \^
flection of the outlay for quality testing and prodi \\[
tion of new drugs. Physicians and pharmacists ! :s>
fully aware of significant progress incident to int njj(
vative and effective effort on the part of pharmaceiftfc,
Vol. 35. NcJ
Iff
manufacturers, particularly during the past three
ades, in the control of pneumonia, tuberculosis,
p iomyelitis, and many other diseases. Regulatory
B asures must be carefully designed to avoid retard-
future progress.
J.S. R.
THE NORTH CAROLINA REGIONAL
MEDICAL PROGRAM
['\s Executive Director of the North Carolina Re-
g'lal Medical Program, I would like to thank our
n ly physician friends for their loyalty and support
d ing the past few years. 1 am not naive enough to
b' eve that every physician in our state has fully
a;-ed with the concepts and activities of the pro-
g;,3Ti. However, speaking in generalities, the support
hi been extremely gratifying. Without our close
3:perative relationship with the North Carolina
N-iical Society we could not have survivied.
iis many of you are aware, this past year has been
I: fficult and trying one for Regional Medical Pro-
|i;ns throughout the nation. The threatened phase-
3trof the program in February 1973 markedly cur-
a d our activities for the first six months of that
/tic Owing to the efforts of many friends throughout
:bi state and nation, both the Senate and House of
i resentatives, by overwhelming majorities, voted
ajune 1973 to extend the Regional Medical Pro-
'^-fls (as well as 12 other health programs) for
irher year— to July 1, 1974. On June 18, 1973
^rident Nixon signed this bill, the Health Pro-
;r is Extension Act, into law. The President like-
vi signed a continuing resolution authorizing these
leith agencies to spend the same amount of money
is.i the previous year until the 1974 HEW Appro-
)r tion Bill was approved and signed by him.
( is true that, because of the uncertain future of
hnirogram, several key personnel of our program
t; resigned last year and accepted positions clse-
vl.e. Furthermore, the Office of Management and
k let in Washington impounded a large percentage
if e funds that had been appropriated to Regional
A-ikal Programs. In spite of these two facts, the
k>h Carolina Regional Medical Program has con-
inM to be a viable and active organization. Our
■piational projects are functioning satisfactorily,
II i new application for our overall program for the
IS' I year 1975 (July 1, 1974-June 30, 1975) is
e 5 prepared.
the past several months two events have
ctrred that are most encouraging as far as the
Ike of the program is concerned. First, in Decem-
e: 973, President Nixon signed the fiscal year 1974
t/ Appropriation Bill, thus authorizing for Re-
il Medical Programs the funds requested by
/ress. This meant that additional funds would
Ciivailable for individual Regional Medical Pro-
ngs for the remainder of this fiscal year. Sec-
ondly, in February 1974, Judge Flannery of
the Federal Court of the District of Columbia,
decreed that as a result of a suit brought
by the National Association of Regional Medical
Programs against the administration, the impounded
funds due the Regional Medical Programs for the fis-
cal years 1973 and 1974 were to be released. This
decision was a disappointment to the administration
and a boost for the Regional Medical Programs. In
simple terms, the impoundment of these funds was
ruled illegal.
It is my opinion that the release of the impounded
funds will make it possible for the North Carolina
Regional Medical Program to continue in its present
form for at least another year beginning July 1, 1974.
Recently, several bills have been introduced in Con-
gress advocating the coalition of several health
agencies including the Regional Medical Programs,
Comprehensive Health Planning and Hill-Burton.
These bills differ in minor details. They will be the
source of vigorous debate, and 1 doubt that any of
them will be passed by Congress during the present
session. We must prepare for the possibility that this
coalition will occur in the future. It will not mean the
demise of our program.
I think it is very important for the members of our
State Medical Society to realize that their Past-Presi-
dent, President, President-Elect and six physicians
appointed by the President are members of our gov-
erning group, known as the Regional Advisory
Group. They thus play an important and es-
sential role in all policy decisions that are made.
Also, the North Carolina Regional Medical Pro-
gram and the North Carolina State Medical Society
are maintaining their close cooperation in continuing
medical education.
Finally, at this time I wish to inform you that 1
have resigned my position as Executive Director of
the North Carolina Regional Medical Program ef-
fective May 1, 1974. At that time Mr. Ben Weaver,
who has been Deputy Director of the program since
March 1970, will become Executive Director. We
are indeed fortunate to have such a capable and ex-
perienced person to assume the leadership. I am
extremely indebted and grateful to you for the en-
couragement and support that you have given me
throughout these past four years.
F. M. Simmons Patterson, M.D.
RIGHT PHYSICIAN AT THE RIGHT TIME
The most pressing health issue in North Carolina
is the concern of the citizens of our state regarding
the need for more primary care physicians, as well
as for a more effective distribution of primary care
physicians.
The article, "Need for More and Better Distributed
Primary Care Physicians in North Carolina," which
appears in this issue of the Journal, is a proposed
p; 1974. NCMJ
239
position paper by the Committee on Community
Medical Care. It reviews the related problems of in-
adequate primary medical care and maldistribution
from the practitioners" vantage point, and it pro-
vides relevant data from which recommendations
have been made.
Most people hold their personal physician in high
esteem because they know him to be well informed,
compassionate, and responsive to their needs. In
keeping with tradition, it is important for organized
medicine to respond similarly to statewide health
problems.
Position papers on important issues of the day.
prepared by interested and informed committees of
the North Carolina Medical Society and approved by
the House of Delegates, are already available on a
number of topics; included are "Medical Aspects of
Sports," "Medico-Legal Code of North Carolina,"
and "Statement of Principles on Mental Health.""
In order that we continue to provide the best medi-
cal care system for the people of our state, it is im-
portant in the management of health problems that
we propose our own solutions rather than have politi-
cal solutions imposed upon us.
The proposed position paper on "Need for More
and Better Distributed Primary Care Physicians in
North Carolina"" is commended to your attention.
John L. McCain, M.D.
Emergency
Medical
Services
A 'NEW ROLE" FOR THE EMERGENCY
DEPARTMENT NURSE
Ruth y\. Miller. R.N. President
Emergency Department Nurses Association
Community Hospital of South Broward
Hollywood, Florida
In her article, Ms. Miller has identified a major
need for special educational programs to prepare
emergency department nurses to function in their
"new role."" The expanded role to which she refers
includes performing complex technical procedures,
teaching paraprofessional emergency personnel, and
coordinating many aspects of patient care in addition
to the "traditional"" role of the nurse. This new role
requires special skills and knowledge in "observa-
tion"' and assessment, resuscitation, and stabilization
of the acutely ill and injured.
EDNA, the nationwide Emergency Department
Nurses Association, of which Ms. Miller is president.
Rondomycii
(methacycline HCI)
CONTRAINDICATIONS: Hypersensitivity to any of the lelracyclines
WARNINGS Tetracycline usage durtng tootti development (last halt of pregnancy to
yearsi may cause permanent tootti discoloration (yeltow-gray-tjrown), whicti is nn
common during long-term use but has occurred atier repealed stiort-term coufSi
Enamel hypoplasia has also heen reported Tetracyclines stiould not be used in this
group unless oltier drugs are not likely to be effective or are contraindicab
Usage in pregnancy. (See above WARNINGS about use during tooth developmei
Animal studies indicate that tetracyclines cross the placenta and can be toxic to the
veloping fetus (oflen related to retardation of skeletal development) Embryotoxicityl
also been noted m animals treated early m pregnancy
Usage in newborns, infants, and children. (See above WARNINGS about use dur
loolh development )
All tetracyclines form a stable calcium complex in any bone-forming tissue. A decre;
m hbula growth rate observed in prematures given oral tetracycline 25 mg/kg ever
hours was reversible when drug was discontinued.
Tetracyclines are present in milk of iactating women taking tetracyclines
To avoid excess systemic accumulation and liver toxicity m patients with impaired ft
function, reduce usual total dosage and. if therapy is prolonged, consider serum level
terminations of drug The anti-anabolic action of tetracyclines may increase BUN. W
not a problem m normal renal function, tn patients with significantly impaired fundi
higher tetracycline serum levels may lead to azotemia, hyperphosphatemia, and acitloi
Photosensitivity manifested by exaggerated sunburn reaction has occurred with ip
cyclines Patients apt 10 be exposed to direct sunlight or ultraviolet light should be so
vised and treatment should be discontinued al first evidence of skm erythema
PRECAUTIONS. If supermlection occurs due to overgrowth of nonsusceplible organist
including fungi, discontinue antibiotic and start appropriate therapy
In venereal disease when coexistent syphilis is suspected perform darkfield exaj
nation before therapy, and serologically lest (or syphilis monthly for at least tour monl
Tetracyclines have been shown to depress plasma prothrombin activity, pahents on
ticoagulant therapy may require downward ad|ustment of their anticoagulant dosage.
In long-term therapy, perform periodic organ system evaluations (including bifl;
renal, hepatic)
Treat all Group A beta-hemolytic streptococcal infections for at least 10 days
Since bacteriostatic drugs may interfere with the bactericidal action of penicillin, a\t
giving tetracycline with penicillin
ADVERSE REACTIONS. Gastrointestinal (oral and parenteral forms) anorexia, nau/
vomiting, diarrhea, glossitis dysphagia, enterocolitis, inflammatory lesions (with rric;
lal overgrowth) m the anogenital region '\
Skin: maculopapular and erythematous rashes, exfoliative dermatitis (uncommon) Pj
tosensitivity is discussed above (See WARNINGS) '
Renal toxicity rise m BUN. apparently dose related (See WARNINGS)
Hypersensitivity: urticaria, angioneurotic edema, anaphylaxis, anaphylactoid purpi
pericarditis, exacerbation of systemic lupus erythematosus
Bulging fontanels, reported in young infants after full therapeutic dosage, have di:
peared rapidly when drug was discontinued
Blood hemolytic anemia, thrombocytopenia, neutropenia, eosmophilia
Over prolonged periods, tetracyclines have been reported to produce brown-bia ::k
croscopic discoloration of thyroid glands, no abnormalities of thyroid function sIuC e?
known to occur
USUAL DOSAGE: Adults-600 mg daily, divided into two or four equally spaced .:o
More severe infections an initial dose of 300 mg followed by 150 mg every six hour ,
300 mg every 12 hours Gonorrhea In uncomplicated gonorrhea, when penicillin isi I
framdicated, Rondomycm (methacycline HCI) may be used for treating both males |
females m the following clinical dosage schedule 900 mg initially, followed by 300
q I d for a total of 5 4 grams
For treatment of syphilis, when penicillin is contramdicated, a total of 18 to 24 grin
Rondomycm' (methacycline HCI) m equally divided doses over a period of 10-15 1
should be given Close follow-up. including laboratory tests is recommended
Eaton Agent pneumonia 900 mg daily for six days
Children- 3 to 6 mg/lb. day divided into two to tour equally spaced doses
Therapy should be continued for at least 24-48 hours after symptoms and feverll
subsided
Concomitant therapy; Antacids containing aluminum, calcium or magnesium impaii
sorption and are contramdicated Food and some dairy products also interfere Give
one hour before or two hours after meals Pediatric oral dosage forms should nc '
given with milk formulas and should be given al least one hour pnor to feeding
In patients with renal impairment (see WARNINGS), total dosage should be deae
by reducing recommended individual doses or by extending time intervals teh
doses
fn streptococcal infections, a therapeuhc dose should be gtven for at least 10 days,;
SUPPLIED: Rondomycm (methacycline HCI) 150 mg and 300 mg capsules, syr^p'
\An nq 75 mg/5 cc methacycline HCI,
GJ
J:^
Before prescribing, consult package circular or latest PDR inlormation
illL WALLACE PHARMACEUTICALS
' - ' CRANBUBY. NEW JERSEY 08512
»K(
240
Vol. 35, Ncj
i promoting the development of educational pro-
j ms and national standards for emergency depart-
I nt nurses. This effort is consistent with EDNA's
i ted belief that "it is the responsibility of hospital
ninistrations and nurses alike to assure that only
:quately trained and oriented personnel work in
e'ergency departments. Ms. Miller asserts that edu-
c ional programs to provide initial training for these
f sonnel and structured continuing education pro-
r is are essential to attaining this goal. She main-
t IS that increased public awareness of emergency
medical services has placed the emergency depart-
ment nurse in a very visible position from which the
nurse has a new opportunity as well as a "new role."
Abstracted by Mary C. Davison, R.N.
From "Emergency Medicine Today," AM A Com-
mission on Emergency Medical Services, Volume 3,
No. I , John M. Howard, Editor. Original article can
be obtained from the American Medical Association,
535 North Dearborn Street, Chicago, Illinois 60610.
Committees and
Organizations
AD HOC COMMITTEE TO STUDY AND
JRECOMMEND A SALARY OR INCREASE
«IN ALLOWANCES FOR THE PRESIDENT
Southern Pines, Sept. 29, 1973
This Committee was appointed by President John
sson at the direction of the House of Delegates
a'he annual meeting in May 1973. After a lengthy
d ;ussion, the Committee submitted the following
si ement to the Executive Council:
=Ve recommend that the Society continue to pay
n'nbursable expenses attendant to the President
ir'uding necessary travel, housing, food, communi-
cations, and out-of-pocket secretarial expenses; and
that, in addition, the Society pay a per diem at the
rate of $25 per day for days, or parts of days, spent
by the President outside of the home town on Society
business.
We further recommend, in alleviating the burden
of assuming the Presidency, that the President-elect
and the immediate past-President be reimbursed for
their travel and living expenses when, by virtue of
their office, they are involved in official Medical So-
ciety functions. — George W. Paschal, Jr., M.D.,
Chairman
Bulletin Board
NEW MEMBERS
of the State Society
«iad, Wahaj Din, MD (N), 521 Beaumont Dr., Fay-
teville 28304
A in, Henry Vann, MD (IM), Box 551, Pinehurst Med.
J., Pinehurst 28374
A'jck, Perry Wm., Jr., MD (IM), 1896 Remount Rd.,
istonia 28052
B? 1, Haynes Wallace, MD (PTH), 1200 N. Elm St.,
reensboro 27401
Bi es, Robert Paul, MD (Intern-Resident), Box 3371,
ake Med. Ctr., Durham 27710
Bi n, Joseph James, MD (FP), 146 E. McLelland Ave.,
ooresville 28115
A L 1974, NCMJ
//
Bethea, Wm. Thaddeus. Jr., MD (OM), Rt. 4, Turnpike
Rd., Box 223-W, Laurinburg 28352
Boehmke, Fred Edward. MD (Intern-Resident), 4315 Morn-
ingside Dr., Winston-Salem 27106
Browning, Frank Ward, MD (OPH), 1629 Owen Dr., Fay-
etteville 28304
Chung, Joseph Y., MD (GS), Fleming Avenue, Marion
27858
Clark, Perry Belton, MD (OBG), 3890 Sturbridge, Win-
ston-Salem 27103
Cole, BueJ] Carlton, MD (SO), Wake Forest Surgical Cen-
ter, S. Allen Road, Wake Forest 27587
Crane, Larry Martin MD (Intern-Resident), 2312 Oriole
Dr., Durham 27705
Crook, John Newman. MD (GS), 486 Crestside, SE, Con-
cord 28025
Elliston. Erwin Bruce, MD (Intern-Resident), 1426 Cole-
wood Dr., Durham 27705
Francis, Edwin Howard, MD, Moore Memorial Hospital,
Pinehurst 28374
245
Hulk, Robert Vernon, Jr., MD (OTO). Suite 10-A Murchi-
son Bldg., Wilmington 28401
Garside, Wm. Blake. MD (PL), 3924 Browning Place, Ra-
leigh 27609
Gibson, Robert Wylie, MD (P), 15 Staff Circle. Morgan-
ton 28655
Glass, Frederick Wm., MD (GS), Bowman Gray School of
Med., Winston-Salem 27103
Gomez, Raul Fernando, MD (IM). Bordeaux Center, Owen
Dr., Fayetteville 28304
Hermann, Arlene Martone. MD (GP), 110 Doctors Bldg..
Franklin 28734
Hermann. James Howard, MD (GP). 110 Doctors Bldg.,
Franklin 28734
Jones, Thaddeus Leroy. MD (PTH), 5835 Beckett Court,
Charlotte 28211
Lane, Robert Earl, MD (GP), 304 S. Granville St.. Eden-
ton 27932
Lopez, Clemenceau DeJesus. MD (GP), Gooden St., Eliza-
bethtown 28337
McNiel, Jesse Neal. MD (P), 2281 Lakeview Terrace,
Burlington 27215
Metzerott, Kirk Oliver, MD (AN). P. O. Bo.x 2554. Char-
lotte Mem. Hospital, Charlotte 28201
Mullins, Patrick S., MD, HI Fairway Road, Morehead
City 28557
Murray, Gordon F., MD (GS), UNC Cardiovascular Sur-
gery, Chapel Hill 27514
Nebel, Edward Joseph. MD (ORS). 5108 Pine Tree Lane.
New Bern 28560
Nixon, Wm. Preston. Jr.. MD (Intern-Resident), 3249 Duke
Homestead Rd., Durham 27701
Osldahl, Rocer Harold, MD (Intern-Resident), Box 3955.
Duke Medical Ctr.. Durham 27710
Pena, Horacio, MD (GP), P. O. Box 308, Clarkton, N. C.
Phillips, Bruce Alton, Jr., MD (IM), P. O. Box 86, Eliza-
bethtown 28337
ANESTHESIOLOGY
PLACEMENT
SERVICE
For Locations in North Carolina desir-
iiii; the services of an anestliesiolo^ist and
lor anesthesiologists wishino; to locate or
relocate in North Carolina
CO ^^ TACT:
Placement Service
N. C. Society of Anesthesiologists
Department of Anesthesiology
North Carolina Memorial Hospital
Chapel Hill, North Carolina 27514
Pratt, Laura Wmstead. MD (FP). P. O. Box 725. Bamr
Elk 28604
Palmaren. Einar Alexander, MD (OTO), 224 S. New Hie
Rd., Gastonia 28052
Procter, James Thornton, MD (P), 1200 Glade St.. Vi-
ston-Salem 27101
Riddick. Joseph Henry, Jr., MD (PTH), 200 Hawthcic
Ln., Charlotte 28204
Sandridee, David Allen, MD (OBG), 5 Doctors P:t
Asheville 28801
Santos. Jose Eugenio. MD (Intern-Resident), Box 7504, a-
leigh 27611
Schiwlm. Arlen Lee, MD (D), 6608 Lynmont Dr., Clr-
lotte 28211
Slawek, David F., MD (IM), 501 6th Ave., West, Hen r-
sonville 28739
Stein, Michael Albert. MD (GS), 1300 Lexington A'..,
Thomasville 27360
Stephenson, Thomas Noel, MD (Intern-Resident), Box 3'2,
Duke Med Ctr.. Durham 27710
Stringer, Llewellyn Winn. MD (AN), 3131 Kinnamon 1..
Wmston-Salem 27103
Tavlor, Richard Allen, MD (PD). 1524 Harding Pie,
Charlotte 28204
Vaughan, Thomas June, MD (R), 632 Hertford I.,
Winston-Salem
Weaver, Phillip David, MD (R), 304 Charlotte St.. Rctji
Mount 27801
Webster. Joel Stoops, MD (CDS), 2001 Vail Aveie.
Charlotte 28207
West, George Harper. MD (IM), 1005 N. College!..
Kinston 28501
White. Jess Alexander. Jr.. MD (OBG), Rt. 3, Box 1,
Hickory 28601
WHAT? WHEN? WHERE?
In Continuing Education
April 1974
("Place" and "sponsor" are listed only where these d'er
from the place and group or institution listed under or
information." )
In North Carolina
April 18-21
Introductory and Advanced Courses in Clinical Hypisis
Place: Raniada Inn. 3920 .Arrow Drive, Raleigh, by Cib-
tree Shopping Center
Program designed to present practical principles for thoe-
ginning utilization of hypnosis in treatment for the ly-
sician, dentist and clinical psychologist, with special ini-
cal h\ pnotherapy seminars for advanced students.
Fee: .-\SCH members S50: non-members S125; special «■
sideration given to students of medicine, dentistry jod
psychology.
Credit: 21 hours AM A Category I accreditation; AFP
credit applied for.
For Information: Mr. F. D. Nowlin, Executive Secrery,
The .American Society of Clinical Hypnosis. 800 Waslil
ton Axe. S.E.. Minneapolis. Minnesota 55414.
April 20
Present Concepts on Knee Problems
Place: Royal Villa Hotel. Raleigh
Sponsor: .American Academy of Orthopaedic Surgeons (re-
duced by The Committee on Adult Musculoskttal
Diseases)
Fee: $40; residents $20. Registration limited to 100.
Credit: Approved for five prescribed hours by AAFP
For Information: Thomas B. Dameron, Jr., M.D., fO
Box 10707, Raleigh 27605
246
Vol. 35, "^ ^
. April 24-25
ird Annual Cancer Symposium
ice: Downtown Holiday Inn, Raleigh
'onsors: North Carolina Central Cancer Registry; North
Carolina Regional Medical Program; American Cancer
Society. North Carolina Division
r Information: Cory Menees, Cancer Program Manager,
^P. O. Box 2091, Raleigh 27602
April 26-28
inual Meeting of the American Association of Medical
Assistants, North Carolina State Society
■ :iice: Hilton Inn, Winston-Salem
jgram: Keynote speaker, George G. Gilbert, M.D., Presi-
jJent, North Carolina Medical Society. Mr. Mike Silver
jf Conomikes Associates will present a program on man-
iging the patient, the office, and the physician. Physi-
;ians and their assistants are urged to attend.
s: $30
r Information: Mrs. June Aysse, 911 Hay Street. P. O.
Box 3514, Fayetteville 28305
l! April 27
iaven-Pamlico Annual Medical Society Symposium
■ ^ice: Ramada Inn, New Bern
r Information: Zack J. Waters, M.D., 800 Hospital Drive,
iMew Bern 28560
May 1
: j'ibetic Complications: Are They Preventable?, a one day
symposium.
. j.ce: The Governor's Inn. Research Triangle Park
, msors: North Carolina Diabetes Association and the
Department of Medicine, Duke University Medical Center
ly. $15
r Information: Jerome M. Feldman, M.D., Box 2963.
,3uke University Medical Center, Durham 27710
May 1 and May 2
.'S and MAP Medical Audit Seminars
1 ces: May I — Moose Lodge, Greenville; May 2 — Holi-
lay Inn West, Winston-Salem
Tmsors: The Commission on Professional and Hospital
\ctivities in cooperation with North Carolina Medical
■ iociety, North Carolina Hospital Association, North
Carolina Chapter of the Hospital Financial Management
sXssociation, North Carolina Blue Cross and Blue Shield,
'ind The Duke Endowment Program: The program will
mphasize in formal presentation and laboratory session
he effective and efficient use of the PAS system to do
nedical audit studies and utilization review,
i 1 ^: $35; seminars open to physicians, hospital trustees and
i isdministrators, health record analysts, medical record ad-
ninistrators, and health organization representatives.
J' Information: CPHA. 1968 Green Road. .Ann Arbor,
^lichigan 48105
May 4-5
1 iciples of Practical Oxygen Therapy, which had been
icheduled for this date, has been postponed until later.
, }|. Information: Miss Ann Francis, Administrative As-
,. jistant. Office of Continuing Education, School of Medi-
rine, UNC, Chapel Hill 275 r4
S May 6-8
- Itjlications of PSRO for Hospital Management
I :e: Key Bridge Marriott, Arlington, Virginia
I : ACHA affiliates $225; non-affiliates $275
I Information: American College of Hospital Admin-
• trators, 840 North Lake Shore Drive, Chicago, Illinois
:0611
May 6-24
( e of the Patient — Valvular Heart Disease and Cardio-
lyopathies
I : $200
I Information: Laurice Ferris, R.N., Continuing Educa-
'on, UNC School of Nursing, Chapel Hill 27514
May 8-9
;, i 1th of Spring '74 — Respiratory Care Symposium
'' I :e: Bahcock Auditorium
"I Information: Emery C. Miller, M.D., Associate Dean
for Continuing Education, Bowman Gray School of
Medicine, Winston-Salem 27103
May 9-10
Hospital-Health Insurance Institute
Place: Wilmington Hilton. Wilmington
Program designed for personnel responsible for handling
hospital and medical claims in the hospital, physician's
office and insurance company health claims office.
Fee: $20
For Information: Mr. Al Rinne, North Carolina Hospital
Association, P. O. Box 10937, Raleigh 27605
May 14-16
The Neuro-endocrinology Symposium: Neurobiology of
CNS — Hormone Interaction
Place: UNC Student Union Building. Great Hall
Sponsors: UNC Neurobiology Program and Laboratories for
Reproductive Biology
For Information: Miss Ann Francis, Administrative As-
sistant, Office of Continuing Education, UNC School
of Medicine, Chapel Hill 27514
May 15
Ethel Nash Day Program
Place: Clinic Auditorium. Time: 1 :00-5:30 p.m.
Sponsor: Department of Obstetrics and Gynecology
For Information: Miss Ann Francis. Administrative As-
sistant, Office of Continuing Education, UNC School of
Medicine, Chapel Hill 27514
May 16-18
Basic Mechanisms in Hypertension
Place: Babcock Auditorium
Sponsor: American Heart Association Basic Science Council
For Information: Emery C. Miller. M.D.. Associate Dean
for Continuing Education, Bowman Gray School of
Medicine, Winston-Salem 27103
May 1 8-22
120th Annual Session of the North Carolina Medical So-
ciety; General Session on Scientific Subjects and Specialty
Section Meetings
Place: Pinehurst Hotel and Country Club
For Information: Mr. William N. Hilliard. Executive Di-
rector, P. O. Box 27167. Raleigh 2761 1
May 20-21 and May 23-24
Nursing Evaluation and Documentation
Place: Royal Villa, Raleigh. May 20-21; Downtowner East,
Charlotte. May 23-24
Intended Participants: Hospital nursing personnel
Fee: $75
For Information: Mr. Jay Camp. North Carolina Hospital
Association, P. O. Box 10937. Raleigh 27605
May 28-31
Fourth postgraduate course in Head & Neck Anatomy
Sponsors: Department of Anatomy, School of Medicine, in
cooperation with the Division of Continuing Education,
East Carolina University
Eligibility; Open to holders of any of following degrees:
M.D.. D.D.S.. D.M.D.. Ph.D.
Fee: $125; students in residency programs $75
Credit: Approved for 28 hrs. AAFP elective hours: CE
units also given by Division of Continuing Education,
ECU
For Information: Head & Neck Anatomy Course. ECU
Division of Continuing Education, P. O. Box 2727.
Greenville 27834
May 29-30
Hypertension: Critical Problems — 25th Annual Meeting and
Scientific Sessions. North Carolina Heart Association
Place: Hyatt House and Convention Center. Winston-Salem
Designed especially for nurses and physicians
For Information: North Carolina Heart Association. I Heart
Circle. Chapel Hill 27514
June 12-15
Neurology for Practicing Physicians, originally scheduled
/ IL 1974, NCMJ
247
by the Bowman Gray School of Medicine for this date,
has been cancelled.
June 20-22
Mountain Top Assembly
Place: Waynesville Country Club, WaynesviUe
For Information: R. Stuart Roberson, M.D., P. O. Box
307, Hazlewood 28738
July 8-13
16th Annual Duke Medical Post Graduate Course
Place- Atlantis Lodge. Atlantic Beach, North Carolina
P o/ram: designed primarily for the generahst but w.th st^f-
ficient variation to appeal to the interest of the internist
and the pediatrician. Conferences and lectures w, be
given in the morning; afternoons and evenings will be
left free for recreational activities.
Fee: $85, payable in advance. Course limited to 7? par-
Credit'-'^T 'certificate of attendance will be given. Program
is acceptable for 30 accredited hours by AAFP.
For Information: W. M. Nicholson M.D., P- O. Box 3088,
Duke University Medical Center, Durham 27710.
July 29-August 2
^nd Annual Beach Workshop: Selected Topics in General
Sponr'' Bowmln^Gray, Duke and UNC Schools of Medi,
cine, in conjunction with the Medical University of South
Carolina , ^ , _ ,.
Place: St. Johns Inn. Myrtle Beach, South Carolina
For' Information: Emery C. Miller, M.D., Associate Dean
for Continuing Education, Bowman Gray School of Medi-
cine. Winston-Salem 27103
September 20-21
1974 Walter L. Thomas Symposium on Gynecologic Malig-
nancy and Surgery ,. . ,, • , J
Program- The two day symposium will be clinically oriented
w'^ith the main emphasis on "Ovarian Cancer" and "Dit-
ficult Office Gynecology." Invited guest speakers include
Dr. J. Donald Woodruff. Baltimore, Maryland; Dr. Her-
bert Buchsbaum. Iowa City. Iowa; and Dr. J. Taylor
Wharton, Houston, Texas.
Credit: AAFP credit applied for.
For Information: W. T. Creasman, M.D., Director of Gyne-
cologic Oncology. P. O. Box 2079, Duke University Medi-
cal Center, Durham 27710
Loan Materials Available
A packet of materials to help you Train Your Ow^n As-
sistant is available to members on a loan basis from Medical
Society headquarters. It includes a color TV tape cassette,
practice forms for planning and evaluation, and IV tape
evaluation report forms. For more information write Mr.
Gene Sauls, North Carolina Medical Society, P. O. Box
27167. Raleigh 27611.
In Contiguous States
April 16
Fourth Annual Charles W. Thomas Lecture
Place- George Ben Johnston Auditorium
Sponsor- Division of Connective Tissue Diseases
For Information: Department of Continuing Educa ion.
Medical College of Virginia. Box 91, MCV Station.
Richmond, Virginia 23298
April 20-24
"Selection of Materials for Reconstructive Surgery," the
Sixth International Biomaterials Symposium
Desicned to brine together clinicians in orthopedics, oral
surgery plastic and reconstructive surgery with leading
researchers in biomaterials, biomechanics, biophysics and
experimental surgery
Place- Clemson University, Clemson, South Carolina
For Information: Dr. Samuel F. Hulbert. Dean of Eiigi-
neerinc Tulane University. New Orleans. Louisiana 70118
248
■h
PRESCRIBING INFORMATIC',
Antiminth (pyrantel pamoate) Ol
Suspension
Actions. .Antiminth (pyrantel p;ri.
ate) has demonstrated anthelmirc
activity against Enterobius vern.ii^
laris (pinworm) and Ascaris lun.ii-
coides (roundworm). The antheliri-
tic action is probably due to e
neuromuscular blocking propert.f
the drug. ,
.\ntiminth is partially absorM
after an oral dose. Plasma levelilf
unchanged drug are low. Peak k^ls
(0.05-0. iS^ig/ ml.) are reached in IS
hours. Quantities greater than it
of administered drug are excreteqn
feces as the unchanged form, wheris
only 7% or less of the dose is foijd
in urine as the unchanged forniif
the drug and its metabolites.
Indications. For the treatmentf
ascariasis (roundworm infection) rd
enterobiasis (pinworm infection
Warnings. Usage in Pregnancy: ^
production studies have been ]r-
formed in animals and there waso
e\idence of propensity for harno
the fetus. The relevance to the t
man is not known.
There is no experience in pg-
nant women who have received is
drug.
Precautions. Minor transient elt
tions of SCOT have occurred ia
small percentage of patients. Tlie-
fore, this drug should be used
caution in patients with pre-exis ig
liver dysfunction.
Adverse Reactions. The most e-
quently encountered adverse ruc-
tions are related to the gastroii-s
tinal system.
Gastrointestinal and hepatic re-
tions: anorexia, nausea, vomit g,
gastralgia. abdominal cramps, ci-
rhea and tenesmus, transient ela-
tion of SCOT
CNS reactions: headache, dfei-
ness, drowsiness, and insomnia, 'ir
reactions: rashes.
Dosage and .administration.
dreri and Adults: .\ntiminth i
Suspension (50 mg. of pvrantel !■ :
ml.) should be administered i '
single dose of 1 1 mg. of pyrantel |se
per kg. of body weight (or 5 mg. .):
maximum total dose I gram, pii
corresponds to a simplified dufce
regimen of 1 cc. of Antiminth ptfflD
lb. of body weight. (One teasponul
= 5 cc.)
Antiminth (pyrantel pamn e
Oral Suspension may be adrUfis
tered without regard to ingestiool
food or time of ciay: and purgii b
not necessary prior to, durinajOi
after therapy. It may be taken (ih
milk or fruit juices. Because ol m-
ited data on repeated doses, noec-
ommendations can be made.
How Supplied. .Antiminth is 3ul-
able as a pleasant tasting car.iel-
flavored suspension which con ins
the equivalent of 50 mg. pyr;tel
base per ml., supplied in 60 ccot-
ties.
ROeRIG<0
A division of Rizer Pharmaceuticals
New York, New York 10017
WORMS BLnZED
A single dose of Antiminth
( 1 cc^ per 10 lbs. of body
weight, 1 tsp./50 lbs.— max-
imum dose, 4 tsp.=20 cc.)
offers highly effective control
of both pmworms and
roundworms.
Antiminth has been shown
to be extremely well tolerated
by children and adults alike
m cKnical studies* Pleasantly
caramel-flavored, it is
non-staining to teeth and oral
mucosa on ingestion...
doesn't stain stools, hnen or
clothing.
One prescnption can
economically treat the entire
family
ROGRIG <0
A division of Pfizer Pharmaceuticals
New York, New York 10017
1Hnwonns,roundwonns controlled
^ith a single, non-staining dose of
ANTIMINTH
(pyrantel pamoate)
Iff 1
, pt n
1 on file at Fioerig.
I
equivalent to r50 n"\g pNraiitel/iTvl.
ORAL SUSPENSION
Please see prescribing information on facing page.
..jt
May 6-9
The Recognition and Management of Coronary Syndromes
Place: Royal Coach Motor Hotel. Atlanta, Georgia
Sponsors: American Heart Association Council on Clinical
Cardiology and the Department of Medicine of Emory
University School of Medicine
For Information: Miss Mary Anne Mclnerny. Director.
Department of Continuing Education Programs, American
College of Cardiology, 9650 Rockville Pike, Bethesda,
Maryland 20014
Items submitted for listinc should he sent to: WHAT?
WHEN' WHERE?. P. O"; Box S248, Durham NC 27704.
by the lUth of the month prior to the month in which
they are to appear.
News Notes from the—
UNIVERSITY OF NORTH CAROLINA
DIVISION OF HEALTH AFFAIRS
Dr. William E. Easterling, Jr., is the new chief of
staff at the North Carolina Memorial Hospital and
an assistant dean of the UNC School of Medicine. He
succeeds Dr. William J. Cromartie, who has served
as chief of staff since 1969. Dr. Cromartie will con-
tinue as associate dean for clinical sciences in the
School of Medicine.
Dr. Carl M. Shy has been named director of the
UNC Institute for Environmental Studies. He is
former director of the Human Studies Laboratory of
the Environmental Protection Agency (EPA) in
Research Triangle Park. Dr. Shy holds the medical
degree from Marquette University and the master's
and doctor's degrees in public health from the Uni-
versity of Michigan.
Responsible to Dr. Cecil G. Sheps, UNC vice
chancellor for health sciences, the Institute will co-
ordinate and fund research which will focus on en-
vironmental needs of North Carolina.
The UNC School of Medicine is one of eight medi-
cal schools in the United States and Canada selected
for the Robert Woods Johnson Clinical Scholars'
Program. The program is designed to develop doctors
skilled in finding better ways to deliver health ser-
vices, especially in the area of primary care.
UNC will be funded from 1974 to 1977. The
$727,000 grant will provide for two-year support and
training of 18 scholars. Si.x scholars will be named
each year.
The Johnson Foundation hopes the program will
find out hov^" doctors can be more effective in treat-
ing patients. It also wants to know what doctors can
do to measure the costs and benefits derived from
different kinds of health care systems.
William F. Vann, Jr., chairman of the Council (
Students of the American Association of Dent
Schools, is the winner of the 1974 Morehead Fellov_
ship in Dentistry at UNC.
A graduate of Auburn University, Vann is a foun
year student in the School of Dentistry at the Uri
versity of Alabama. He is president of the dentist:
student government association. Last year he was
member of the editorial board of "Dental Studei
News," the publication of the American Associati«
of Dental Schools.
At UNC he will pursue postdoctoral studies
pedodontics, the treatment of children. The Moi!
head Dental Fellowship is valued at S5,000 pi
tuition and fees to cover expenses during two ye3
of study in the UNC School of Dentistry.
Dr. Paul A. Obrist, Department of Psychiati
was elected President-elect of the Society for Psych
physiological Research (SPR) at their thirteen
annual meeting held in Galveston, Te.xas on Octob:
25-28, 1973.
The SPR is an international, interdisciplin
group of researchers with a current membership f
700; their bi-monthly journal is Psychophysiolc).
The general thrust of the research is aimed at the -
terrelationships between behavioral and biologid
events both at a basic and clinical level. Illustrative f
the clinical application of the research are the ci-
rent efforts using biofeedback techniques to modjff
visceral events such as electrical abnormalities of I:
heart and blood pressure.
I
Dr. Colin G. Thomas, chairman of the Departnut
of Surgery, UNC School of Medicine, spoke i
"Small Intestinal ,\tresia — The Critical Role oil
Functioning Anastomosis" on Dec. 3-5 to the Soii-
ern Surgical Association in Hot Springs, Virgir..
Also attending the meeting from the Department^
Surgery were Drs. Stanley R. Mandel, James '.
Newsome and Georee Johnson, Jr.
I
The Psychoanalytic Clinic of the UNC Departnut
of Psychiatry has been established for the evaulatn
of persons potentially interested in psychoanahc
treatment, to be a source of information about sih
treatment, and to assist in arrangements for it.
It is staffed by students and faculty of the U>"-
Duke Psychoanalytic Training Program, with M-
Miller, M.D, as director. The Clinic operations '11
be under the direction of Roger F. Spencer, M).
Fees will be assessed according to individual mcas,
and no one will be excluded on financial grounds. 1)-
cation of the central appointments secretary is: Ron
237, Old Nurses Dorm, UNC Department of F/-
chiatry, telephone number: 966-4224.
250
Vol. 35. N'4
I-
^News Notes from the —
DUKE UNIVERSITY MEDICAL CENTER
i Two distinguished economists at Duke have been
swarded a National Science Foundation grant to
^udy the effects of the trend toward zero population
growth on the nation's economy.
The two are Dr. Joseph J. Spengler, James B.
|)uke professor emeritus of economics, and Dr.
juanita M. Kreps, also a James B. Duke professor
jf economics. One of Spengler's primary interests
^tT the past 40 years has been problems of popula-
(on and resources, and Kreps is a widely known spe-
ialist in the economics of aging.
1 The $67,000 grant is from Research Applied to
Rational Needs (RANN), a section of the National
jcience Foundation. The two economists will be
forking as research investigators in the Center for
jie Study of Aging and Human Development.
1 Dr. George Maddox, director of the center, said
emographers have forecast that the nation is moving
joward a stable population in which the number of
girths will equal the number of deaths. Throughout
ae history of the United States, the birth rate has far
Outstripped the death rate.
■ As the birth rate decreases, the proportion of el-
erly people in our population grows, Maddox said,
^o one yet knows what percentage of the population
jill be in the elderly age bracket when we reach zero
opulation growth, he said.
This will be one of the questions Spengler and
reps will address. Another area deals with the eco-
itDmic implications of the emerging age structure of
sie population.
:K * *
ij The National Institute of Allergy and Infectious
liseases (NIAID) is creating an Asthma and Aller-
|c Disease Center here.
jThe Duke project, one of a national network of 17
toters, will be headed by Dr. Rebecca H. Buckley,
"isociate professor of both pediatrics and immu-
3logy.
>< NIAID will provide $127,206 to support the cen-
t'-Er's research for three years. Scientists in the project
:: Jill study the basic mechanisms involved in allergy.
The study will focus on mechanisms leading to in-
eased production of immunoglobulin E (IgE) anti-
I 'idles.
' I The researchers will study facets of immunity in
lergic people as well as in other persons with high
':E levels who are also very susceptible to infections
■ ^ an effort to find out what leads to the increased
>; nthesis of IgE. The goal is to find a means of treat-
i hnt which will "turn off the increased production.
' NIAID is an arm of the Department of Health,
lucation and Welfare.
' «IL 1974, NCMJ
Energy conserving efforts begun here in the fall
have resulted in a substantial savings in both money
and the amount of electricity used.
The reduction of lighting in non-essential areas is
expected to save the medical center $14,979 yearly.
In addition, the shutting off of certain large air han-
dling units where there are no employees after 6 p.m.
should save another $14,040 over the next 12
months.
* * *
Harbor Branch Foundation of Florida has awarded
the medical center a $300,000 grant for a program of
simulated dives in the hyperbaric chamber aimed at
working out a new set of decompression timetables
for divers.
Dr. Peter B. Bennett, professor of anesthesiology
and biomedical engineering, is the principal investi-
gator on the project.
The program will run 12 to 18 months with a total
of 100 to 120 dives. It will evaluate decompression
times of 30, 45. and 60 minutes from depths of 450
to 650 feet.
Experienced divers from Oceanecring Interna-
tional, Inc. of Houston, a commercial diving firm,
will take part in the project. Harbor Branch and
Oceanecring will also provide technical support for
the project.
Bennett said the study is being undertaken be-
cause decompression tables now in use do not always
prevent decompression sickness or "bends," espe-
cially at the deeper depths.
The exploration for offshore oil requires divers to
operate from oil rigs. As the depth of their operation
has increased, so have the decompression dangers to
the divers.
The decompression tables and knowledge obtained
from this study will be generally available to all div-
ing organizations, and Bennett said it is hoped that
this will greatly improve the safety and health of
working divers.
^ ^ *
The model family practice clinic operated by the
medical center and Watts Hospital will move into
expanded offices soon to provide training for more
family doctors and offer medical care to larger num-
bers of Durham residents.
Dr. William J. Kane, who became director of the
Duke/Watts Family Practice Residency Training
Program Jan. 1, said the new office at 719 Broad St.
will have 14 to 16 examining rooms. The present
clinic at 1010 Broad St. has only four examining
rooms.
The name of the model clinic has been changed
from Durham Health Care to the Family Medicine
Center.
Kane said there are now 10 residents in the three-
year training program, and eight first year residents
will be added in July. In July of 1975 another first-
year class of eight will be added, he said, and from
251
then the program will be stabilized at a level of 24
trainees.
"We are probably serving about 2,000 area resi-
dents right now," Kane said. "In a year or two when
we have a full complement of residents we hope to
be providing primary medical care for about 8,000
people."
The clinic operates like a private group medical
practice. Each resident spends certain hours in the
clinic and is assigned a certain number of families as
his private patients. Patients call for appointments
just as they would at a private physician's office. The
rest of the time the residents spend rotating through
various services at Duke and Watts hospitals.
* * *
For the past 20 years, thousands of elderly patients
from Europe. Asia, Africa and the United States have
flocked to clinics in Bucharest and Constanza, a re-
sort city on the Black Sea, to receive treatments with
a controversial Romanian "youth drug" — Gerovital
H3.
Now researchers at Duke are conducting one of
the first double-blind clinical trials of Gerovital
(GH3) in the United States to determine whether it
is effective in treating mental depression among the
aged.
The study is designed specifically to test the drug
for mild to moderate depression, even though
Romanian scientists have claimed that by taking the
drug the elderly patient can overcome the effects of
everything from arthritis and angina pectoris to
senility.
The principal investigator on the project is Dr.
William W. K. Zung, professor of psychiatry, who
is widely known for his research on depression.
Last June Zung visitied Professor Ana Asian, di-
rector of the Geriatrics Institute in Bucharest and
developer of GH3 therapy, to see how the drug is
used there.
Dr. Asian visited Duke and spoke about her drug
at Department of Psychiatry Ground Rounds
Feb. 14.
News Notes from the —
BOWMAN GRAY SCHOOL
OF MEDICINE
WAKE FOREST UNIVERSITY
Dr. Jimmy L. Simon, deputy chairman of pedia-
trics at the University of Texas Medical Branch in
Galveston, has been appointed professor and chair-
man of the Department of Pediatrics at the Bowman
Gray School of Medicine.
He succeeds Dr. Weston M. Kelsey, who asked to
be relieved of the chairmanship in order to return to
252
NEW ! Patient Therapy Packs
Because many patients tend to
stop treatment prematurely, the
full course of b.i d. therapy is
now specially packaged to
encourage patients to complete
the full course of therapy.
CANDEPTIN Vaginal Ointment
Therapy Pack— two 75 gm. tubes
CANDEPTIN Vagelettes
Therapy Pack-2% vaginal capsules
CANDEPTIN Vaginal Tablet
Therapy Pack-2% vaginal tablets
RrjeT Siitnniur>
Description: Candeptin (Candicidin) Vagina]
Ointment contains a dispersion of Candicidin
powder equivalent to 0.6 mg. per gm. or 0.06%
Candicidin activity in U.S.P petrolatum. 3 mg.
of Candicidin is contained in 5 gm. of oint-
ment or one applicatorful. Candeptin Vaginal
Tablets contain Candicidin powder equivalent
to 3 mg. (0.3%) Candicidin activity dispersed
in starch, lactose and magnesium stearate.
Candeptin Vagelettes Vaginal Capsules
contain 3 mg. of Candicidin activity dispersed
in 5 gm. U.S.P petrolatum.
Action: Candeptin Vaginal Ointment, Vaginal
Tablets, and Vagelettes Vaginal Capsules
possess anti-monilial activity-
Indications: Vaginitis due to Candida albicans
and other Candida species.
Contraindications: Contraindicated for pa-
tients known to be sensitive to any of its com-
ponents. During pregnancy manual Tablet or
Vagelettes Capsule insertion may be pre-
ferred since the use of the ointment applicator
or tablet inserter may be contraindicated.
Caution: During treatment it is recommended
that the patient refrain from sexual inter-
course or the husband wear a condom to
avoid re infection.
Adverse Reaction: Clinical reports of sensiti-
zation or temporary irritation with Candeptin
Vaginal Ointment. Vaginal Tablets or
Vagelettes Vaginal Capsules have been ex-
tremely rare.
Dosage: One vaginal applicatorful of
Candeptin Ointment or one Vaginal Tablet
or one Vagelettes Vaginal Capsule is in-
serted high in the vagina twice a day, in the
morning and at bedtime, for 14 days. Treat-
ment may be repeated if symptoms persist or
reappear.
Available Dosage Forms: Candeptin Vaginal
Ointment is supplied in a Patient Therapy
Pack, containing two 75 gm, tubes with two
applicators for the full course of treatment.
Candeptin Vaginal Tablets are packaged in
boxes of 28. in foil with inserter — enough
for a full course of treatment. Candeptin
Vagelettes Vaginal Capsules arc packaged in
a Patient Therapy Pack, containing
28 Candeptin Vagelettes Vaginal Capsules
(2 boxes of 14), for the full course of treat-
ment. Store under refrigeration to insure full
potency.
Federal law prohibits dispensing without pre-
scription.
References:
I. Melgcs. F, J,: Obstet, Gynecol, 24:921. Dec.
1964, 2. Cameron. P F: Pr.ictitioner 202:695,
May 1969. 3. Olsen, J, R,: Journal-Lancet 85:
287, July 1965, 4. Giorlando. S, W, : OB/GYN
Digest /.?:32, Sept, 1971, 5. Decker, A,: Case
Reports on file. Medical Department. Julius
Schmid. 6. Fricdel, H, J ; Md, State Med. J.
/.':36. Feb. 1966, 7. Roberts. C, L, and Sulli-
van, J, J: Calif, Med,/ Oi: 109, Aug, 1965, 8, Gior-
lando, S, W, Torres, J, F and Muscillo, G,: Am.
J, Obstet, Gynecol, 90:370, Oct. 1, 1964.
9. Abruzzi, W. A.: Western Med .5:62. Feb,
1964
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^
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full-time teaching and patient care. Dr. Kelsey has
headed the department for the past 20 years.
Dr. Simon, who is best known for his work in am-
bulatory pediatric care, cystic fibrosis and medical
education, joined the faculty of the University of
Texas Medical Branch in 1966 as associate pro-
fessor and deputy chairman of the department.
Earlier he served on the faculty of the University of
Oklahoma School of Medicine.
He holds the A.B. degree from the University of
California at Berkeley and the M.D. degree from the
University of California School of Medicine in San
Francisco. He took postdoctoral training at the Uni-
versity of California Hospital, the Grace-New Haven
Hospital (New Haven, Conn. ) and Children's Hospi-
tal (Boston).
* * :|i
A joint medical center administrative board of the
Bowman Gray School of Medicine and North Caro-
lina Baptist Hospital was established recently at the
medical center.
The 17-member board has delegated to it by the
boards of trustees of the hospital and Wake Forest
University responsibility for overall supervision of
the medical center. A primary function of the admin-
istrative board will be to formulate general policies
of the medical center and to provide planning for its
future needs and development.
The chairmen of the two boards of trustees, in a
joint statement, said that the need for the new or-
ganizational structure was evident in view of the
medical center's rapid expansion, the growing com-
plexities in managing an academic medical center,
and the increased demands being placed on the in-
stitutions.
They emphasized that the corporate autonomy and
operational integrity of both institutions will be main-
tained and the establishment of the administrative
board will not interfere with nor infringe upon the
duties of the trustees of the hospital or the university.
The new board consists of eight representatives of
the trustees of Wake Forest University, eight repre-
sentatives of the trustees of Baptist Hospital, and a
member of the professional staff of the medical cen-
ter.
* * *
Four piedmont North Carolina leaders have been
named to the Board of Visitors of the medical school.
They are Mrs. Smith Bagley, Winston-Salem house-
wife and civic leader; Richard T. Chatham of Elkin,
president of Chatham Manufacturing Co.; W. Roger
Soles of Greensboro, president of Jefferson-Pilot Co.;
and J. Paul Sticht of Winston-Salem, president and
chief operating officer of R. J. Reynolds Industries,
Inc.
^ 'fi iifi
Dr. Irving B. Elkins, a third-year resident in
urology, has won first place in the Clinical Research
Division of the Montague Boyd Prize Essay Conte
The contest is sponsored by the Southeastern Sectn
of the American Urological Association.
The award, which carries a $350 prize, was prs
entcd for his essay on "Surgical Anatomy of t
Human Kidney."
^ * ^
The Comprehensive Stroke Program of the mci
cal school has been awarded a $150,000 grant frc
the Kate Bitting Reynolds Health Care Trust. It v
allow the program to continue its work for the ni
three years.
The grant will enable the program to continue
foUowup of stroke patients in the 20 counties whi
the program operates, to help finance a cooperat
effort with the North Carolina Heart Association a;
fighting stroke, and to train doctors and nurses fm
small communities in North Carolina to recogne
stroke earlier and to provide the latest therapy ,d
rehabilitation to stroke victims.
* * *
Dr. B. Lionel Tniscott, professor of anatomy,
been elected to the Executive Committee of
Stroke Council of the American Heart Associat
as a Member-at-Large.
^ '^ ^
Dr. L. Earl Watts, associate professor of medici
has been inducted as a fellow in the American C
lege of Cardiology.
AMA COUNCIL ON CONSTITUTION
AND BYLAWS
The Council on Constitution and Bylaws of
American Medical Association is investigating a f
posal to grant to national medical specialty socio"
direct representation in the AMA House of Dj-
gates. The first objective is to determine whether s;h
representation would be in the best interest of ^
AMA. I
In resolving the first issue, the Council is appit
ing to the members of all state medical socieis,
AMA delegates, and members of medical specity
societies to share their opinions with regard to if
following;
What effect would direct representation oi
medical specialty societies have on — the FederaM
concept upon which AMA is based; the Scieni
Assembly of the AMA; the membership of all he
medical societies involved (the AMA, state, coiuy.
and medical specialty societies); and, the acti\ ,es
and influence in the community of the state 3C
county medical societies?
Further questions may be suggested, from th^fl-
put, to conclude a thorough study. Responses sbiild
be addressed to; Council on Constitution and ly-
laws, American Medical Association, 535 Nlth
Dearborn Street. Chicago, Illinois 60610.
2.^4
Vol. 35, K*
II t NEW AUDIOVISUAL PRESENTATION ON
4 CURRENT PROCEDURAL TERMINOLOGY
Computer Systems in Medicme has made avail-
"le a new audiovisual presentation on the 3rd
ition of "Current Procedural Terminology." This
lund and slide resource is useful in familiarizing
ysicians with the benefits of CPT-3 usage in their
^ctice.
iFor further information write to: Computer Sys-
311S in Medicine, Division of Medical Practice,
nerican Medical Association, 535 North Dearborn
jreet, Chicago, Illinois 60610.
a
TENNIS TOURNAMENT AT 1974 ANNUAL
MEETING OF THE NORTH CAROLINA
MEDICAL SOCIETY
The North Carolina State Medical Meeting in
Pinehurst, N. C. May 18-22, 1974, will hold a tennis
tournament having equal billing with the usual golf
tournament. Depending on the number of entries,
the program will include open men's singles, men's
doubles, senior men's singles, and men's doubles;
women's singles, women's doubles and mixed
doubles. Each person will be permitted to enter no
more than three events.
Inquiries and notification of class entries should
be addressed to: Claude A. Frazier, M.D., 4-C Doc-
tor's Park, Asheville, N. C. 28801.
Month in
Washington
diii
The American Medical Association has announced
i filing of a law suit against the Cost of Living
Duncil to seek an end to all economic controls on
bdicine.
»At a news conference in the AMA-Washington
f'ice, the organization disclosed that it is seeking an
junction against the Phase IV regulations on phy-
dans and hospitals. It charged that the rules are
.onfiscatory, arbitrary and capricious," that they
jlate the "generally fair and equitable" standard es-
plished by Congress and that they violate the fifth
■lendment of the U.S. Constitution.
tAnnouncement of the legal action was made by
assell B. Roth, M.D., President of the AMA, and
"•^fnes H. Sammons, M.D., Chairman of the AMA
^lard of Trustees.
'In its complaint stating its legal action, the AMA
tinted out that the Phase IV regulations represent
"attempt to mold the health care delivery system
comport with the CLC's concepts for health care"
te !'d are specifically designed "to curb the quantity
« id quality of health care services as an integral part
the legislative program to induce Congress to
cdiiact national health insurance."
tfP'The AMA asked that the court declare these
>ase IV regulations invalid and enjoin the Cost of
ving Council from enforcing them.
tin his statement. Dr. Roth said the AMA was fil-
■ssljl; in U.S. District Court, District of Columbia, a
t seeking an injunction against the Cost of Living
; ijltuncil. "We are asking the court to declare invalid
Phase IV regulations as applied to physicians
|8iL 1974, NCMJ
and hospitals on the grounds that they are confis-
catory, arbitrary, capricious and discriminatory.
"We further believe that they violate the very law
on which they are based in that they do not conform
to the 'generally fair and equitable' standard written
into the law by the Congress.
"Finally, we believe that they violate the most
fundamental law of the land — the Constitution of the
United States, in that they confiscate the property
of physicians and hospitals without due process of
law, a clear infringement of the fifth amendment.
"Those are the legal tenets on which we are basing
our case. We are convinced that they are valid and
sound and that they will prevail in the courts.
"But while we proceed on legal grounds, I think
it is important to point our that we believe the issues
involved are far broader than mere legalisms and that
they cast their shadows far beyond the limited scope
of Phase IV.
"They are issues of principle and they have pro-
found implications for the future of health care in this
country.
". . . It is patently unfair and unreasonable for the
services of some working people — namely us physi-
cians— to be subject to severe price controls while
permitting other working people to function in a free
market. That is not fair play; it is an act of dis-
crimination.
"It is patently unfair to apply a revenue margin
limitation to physicians in private practice so that
they are penalized if they work longer hours and see
more patients. That is not fair play; it is an act of
255
capriciousness — not to mention that it is also short-
sighted as hell.
"It is patently unfair when physicians are subject
to controls but chiropractors and naturopaths are
not . . . when ophthalmologists are subject to con-
trols but optometrists and opticians are not . . . when
psychiatrists are subject to controls but clinical psy-
chologists and psychiatric social workers are not.
That is not fair play; rather it is an act so arbitrary
as to be vindictive.
"Any one of these would be good and sufficient
reason to end the controls, in and of itself. For a law
that is applied arbitrarily, capriciously and vindic-
tively is a bad law and ought to be abolished.
"But there are even more compelling reasons why
the controls should be abolished — not just from
health care but from the entire economy.
"Perhaps the best reason for getting rid of them
is that they just don't work. . . ."
Dr. Sammons" statement noted that the AM.'\ did
not stand alone in its call for an end to all controls.
"No less a person than C. Jackson Grayson — chair-
man of the Price Commission during Phase II —
has adopted the same stance," Dr. Sanmions said,
adding "he has been echoed by the Wall Street Jour-
nal and others."
"In the face of this advice and the e\idence that
controls don't work, why does the Cost of Living
Council persist in continuing the controls?
"CLC officials have made no secret of the fact
that they intend to control far more than costs in the
health care field through their regulations, The press
release from the CLC announcing Phase IV estab-
lished these goals:
" 'reduce the inflationary rate of increase in the
cost of hospital stay;
" 'provide economic incentives for the substitution
of less expensive ambulatory care in place of inpa-
tient hospital care where possible;
" 'maximize internal flexibility and incentives for
health care managers to improve productivity;
" 'be responsive to cost saving innovations, such as
health maintenance organizations and prospective
reimbursement plans. . . ."
"Further, to enforce the last of these goals, the
Phase IV regulations were drawn to confer outright
favoritism on physicians under contract with an
HMO. They have been exempted from the revenue
margin limitation that is applied to physicians in pri-
vate practice.
"This is not economic stabilization. This is not in-
flation control.
"This is nothing less than a blatant attempt by the
social schemers at CLC to impose their will on the
physicians and patients of America.
"What right have they to tell us how to practice
medicine?
"What right have they to tell the American people
where and how thev shall receive their medical care?
"These are not economic controls . . . they a
political controls. We intend to fight them right do.'
the line. , . ,
"We recognize how appealing it is to try — throuj.
controls — to keep the lid on at least some costs durii;.
this period of astronomical inflation. We certain'
recognize and are sensitive to the plight of the gro:
majority of wage earners who have been caught i
this terrible squeeze. We have tried to do our sha;
to keep costs down.
"Since the beginning of Phase I in August 19''
physicians' fees have risen but 7.3 per cent while :
cost of living generally has risen by 13.3 per ce:
and legal fees, by contrast, have risen by 26 per ceni
"We have cooperated — the figures prove that. B:
now the time has come to call a halt.
"For the simple trutb is that unless the contii,
are removed — and soon — the quality of henh
care — particularly in the hospitals — is going to sufti.
". . . And that is precisely what is going to happi
very soon if the controls continue.
"We believe the .American people had better knc?
and understand that."
I
One day after the AMA filed its suit against tl
Cost of Li\ing Council, President Nixon reaffirml
the Administration's intention to keep cost contr.j
on hospitals and physicians until a national heal
insurance program is approved.
In a second message on health submitted to C^:-
gress, the President also emphasized a shift in poll/
on health education from operating subsidies i
direct assistance to students. Nixon said "The t-
tion's total supply of health professionals is beco-
ing sufficient to meet our needs during the mt
decade. In fact, oversupply in the aggregate coil
possibly become a problem."
On controlling health costs, the President sa,
"We must avoid the cost inflation which foUowl
the introduction of Medicare and Medicaid. Cr
health insurance proposal would call for states 3
oversee the operation of insurance carriers and est;-
lish sound procedure for cost control. Until these r
other controls are in place, 1 recommend that a
present authorities to control health care costs e
continued. 1 am asking the Congress for such ;-
thority." Inflationary pressures are still strong in e
medical field, he said, "so that we must maint i
federal controls until other measures are adopted i-
der comprehensive health insurance."
* * *
Shortly after an .\MA delegation met separa: y
with President Nixon and Health, Education, ji
Welfare Department Secretary Casper Weinberg,
the latter announced he would drop the hotly ci-
tested proposed regulations that would have requiid
pre-admission certification for the hospitalization if
Medicare and Medicaid patients.
The President had assured the .AM.A delega^ n
256
Vol. 35. N
yfrlier in the day that serious consideration would
given to changing the controversial pre-admis-
n certification plan.
[oiljrhose visiting the President were Russell Roth,
lu -jD., AMA President; James Sammons, M.D.,
tii jairman of the AMA Board of Trustees; Malcolm
a ^dd, M.D., AMA President-elect; Ernest B. How-
]i, M.D., AMA Executive Vice President, and Jo-
;1 j»h Miller, Assistant Executive Vice President.
JDther topics discussed by the President and the
/lA group included the Administration's plan for
tewide fee schedules in its national health in-
t iance proposal and area designations for Profes-
:et [flial Standards Review Organizations (PSRO's).
: jfhe AMA delegation told the President of their
s jng opposition to the pre-admission certification
::[^n as an unwarranted interference with medical and
;ij;pital judgments; contended that continuation of
/If controls on physicians would be unfair and puni-
■■■ly, declared that fee schedules in an NHI program
i uld be government regimentation; and suggested
, t-t the PSRO program needed regrouping and a new
1 ft after encountering stiff resistance from physician
[ ups and much controversy and confusion.
The Chief Executive, according to participants,
J rmly received the delegation and declared that he
..( ; aware of the problems physicians face in the
_ a,a of expanded federal supervision. President
\on indicated that serious consideration would be
given to changing the requirement of area or state-
wide fee schedules in his NHI plan. He stressed that
he wished to avoid saddling physicians with un-
necessary paperwork that would take time away from
patient care.
The President also talked of his desire that high
level quality care be maintained. Physicians should
work for patients and not the federal government,
he told the delegation. He outlined his NHI program
and his opposition to a bill of the scope of the
Labor-Kennedy plan.
Conceding that the Administration's programs
might well be amended by Congress, he invited the
AMA to recommend changes in the NHI program.
* * *
The federal government will spend more than $26
billion next fiscal year on civilian health programs if
the Administration's proposed budget is approved
by Congress.
The budget reflects the Administration's desire to
hold health spending in the fiscal year that begins
July 1 to about the level Congress approved for the
current fiscal year, considerably more than requested.
The exception is an unavoidable $3 billion hike in
Medicare and Medicaid outlays.
The new health budget is almost $8 billion over
the spending in the fiscal year 1973 that ended last
June.
HEW Secretary Caspar Weinberger conceded that
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Graenum R. Schiff, M.D.
;jit 1974, NCMJ
257
the budget reflects "in a number of ways the results
of that give and take" involved in the battle with Con-
gress last year over HEW appropriations.
No funds are sought for the Administration's new
national health insurance program, even if Congress
acted this year, Weinberger noted, and it would take
another year or longer to gear up for the program
which carries a S5.8 billion price tag.
The budget emphasized two controversial HEW
programs of special interest to the medical prces-
sion. To carry out the Health Maintenance Orgij-
zation (HMO) program, $65 million was recn-
mended for the remainder of this fiscal year, aa
S65 million for next year. The Professional Stand:ds
Review Organization (PSRO) program was mi
down for $34 million through the remainder of he
current fiscal year; $58 million, next year.
Those who wish for the cure of an obstinate malady from the mineral waters, oupht to take
them in such a manner as hardly to produce any effect whatever on the bowels. With this view
a half-pint glass may be drank at bed-time, and the same quantity an hour before breakfast,
dinner, and supper. The dose, however, must vary according to circumstances. Even the quantity
mentioned above will purge some persons, while others will drink twice as much withoui being
in the least moved by it. Its operation on the bowels is the only standard for using the water as
an alterative. — William Biiclian: Domestic Mcilicinc. or a Treatise on the Prevention and Cure
of Diseases by Regimen and Simple Medicines, etc., Richard Folwell, 1799, p. 431 .
Facility, program and environment
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Located off U.S. Hwy. No. 29 at Hicone Road Exit
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Convenient to 1-85, 1-40, U.S. 421, U.S. ;),
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FELLOWSHIP HALL WILL ARRANGE CONNECTION WITH COMMERCIAL TRANSPORTATION.
258
Vol. 35.
rat
Book Reviews
iCurrent Diagnosis and Treatment. By Marcus Krupp,
M.D. and Milton J. Chatton, M.D. Price, $12.00. Los
\ltos, California: Lange Medical Publications, 1973.
.This most recent edition of Current Diagnosis and
eatment is, once again, larger and more expensive
iin its predecessor. Despite the shortcomings al-
^ys present in condensed surveys of vast and varied
itbooks of medicine, this paperback does serve
'3 authors' stated purposes. "It is not intended to be
fed as a te.xtbook of medicine. . . is intended to serve
b practicing physician as a useful desk reference on
dely accepted technics currently available for diag-
fsis and treatment"" — these general aims are met
imost instances.
The text is characterized by a huge array of speci-
' disease entities and each is headed by a succinct
inmary of "essentials of diagnosis." References are
mtiful and generally up-to-date. The format of the
ct is largely founded on a pathologic basis; thus,
; interested physician or student, or both, must
:ve made a reasonably accurate prior diagnosis if
! is to use this book as a clinical "practice" aid.
iie book serves as a basis of review and should be
(warding for the physician and student undertaking
ch a project. Many of the contributors have
ide significant contributions to other Lange publi-
tions, and discussions of therapy often closely simu-
:e, if not duplicate, discussions in some of these
;.g. Review of Medical Pharmacology). The text
buld not be considered an "emergency" type of
Iference, but rather a handy source to check the es-
htial diagnostic and therapeutic aims for a given
ndition.
* ''Despite these stated drawbacks, the amount of in-
[,.,:rmation per dollar spent, represented by this text,
1 1 difficult to surpass. Perhaps its greatest strength
m I
,1 t
■.r.\l
IB w
If I
« I
ill I
H I
- 1
li
lies in the fact that it is rewritten yearly and in a
meaningful manner.
John S. Kaufmann, M.D., Ph.D.
Annual Review of Allergy, 1972. Claude A. Frazier,
M.D., (ed). Price. $12.00. Flushing, New York: Medi-
cal Examination Publishing Company. Inc., 1973.
The purpose of the Annual Review of Allergy,
according to the editor's preface, "is to bring together
in one volume the most important. . . recent ad-
vances" in this field from the previous year. There is
a need for such a book, particularly for the practicing
allergist, because of the explosion of new knowledge
in the areas of allergy and clinical immunology.
In order to serve this purpose, the book should be
short, the writing style should be succinct, and the
sections should not overlap. A standard format, uti-
lized in all chapters, would be desirable and duplica-
tion should be eliminated by the editor. The format
used in Section IV is excellent and could well be
adapted to other sections. Suggested section headings
for future volumes are: Basic Mechanisms in Al-
lergic Disease, Asthma, Non-Asthmatic Allergic
Lung Disease, Ocular Allergy, ENT Allergy, Allergic
Skin Diseases, Insect Allergy. Drug Allergy, Aero-
biology, Treatment with Pharmacologic Agents (in-
cluding steroids). Immunotherapy (including the
current status of bacterial vaccines) and Rehabilita-
tion (including psychological factors). Despite its
defects (excessive length, lack of a standard format,
and overlapping of subject headings with resulting
repetition), this book is a step in the right direction.
The chapter on Aerobiology was of particular in-
terest to this reviewer.
Carolyn C. Huntley, M.D.
The instruments of medicine will always be multiplied in proportion to men"s ignorance of the
nature and cause of diseases: when these are sufficiently understood, the method of cure will be
simple and obvious. — William Biiclian: Doineslic Medicine, or a Treatise on llie Prevention and
Cure of Diseases by Regimen and Simple Medicines, etc.. Richard Folwell. 1799. p. 437.
PIL 1974, NCMJ
159
Weldon Parten Chandler, M.D.
Wcldon Parten Chandler died on April 11, 1973
after a long illness. He was 57 years old.
A native of Asheville and Buncombe County, he
practiced in Weaverville, N. C. from 1946 until his
retirement several years ago because of illness.
He was educated in the Asheville public schools.
Mars Hill College, Wake Forest College, and received
his M.D. Degree from the University of Maryland in
1940. His internship was at Baptist Hospital, Win-
ston-Salem, N. C.
He was a member of the Buncombe County Medi-
cal Society, Madison County Medical Society, and the
North Carolina State Medical Society. He was also
a member of Phi-Rho Sigma Fraternity, Lions Club,
and Masons.
Weldon was distinguished by his skill as a doctor
and compassionate concern for his patients" welfare,
overriding any concern for himself. He was greatly
loved and respected by his patients and colleagues.
Whereas, Dr. Chandler was a skilled and dedi-
cated physician, much loved and respected, be it
Resolved, That a copy of this resolution be sent to
his widow, Athylene Briggs Chandler, a copy to be
incorporated in the minutes of the Buncombe County
Medical Society and a copy forwarded to the North
Carolina Medical Society for publication in the
State Journal.
Buncombe County Medical Society
Edgar Witherly Lyda, M.D.
Ed Lyda died June 11, 1973 at the age of 52.
He practiced obstetrics and gynecology for many
years in Asheville, until recently becoming As-
sistant Director of the Buncombe County Health
Department. In the latter position he was active in
Family Planning Programs
He was an Asheville native, a graduate of Mars
Hill College, Wake Forest College, and Bowman
Gray School of Medicine, graduating from the latter
in 1944. His internship was at the Baptist Hospital,
Winston-Salem, N. C, and three years in residency
in St. Louis.
He was a Diplomate of the American Board of Ob-
stetrics and Gynecology. He served three years in the
U. S. Navy Medical Corps and attained the rank of
Lieutenant Commander.
Dr. Lyda is survived by his wife, the former Emily
Katherine Perkinson, four children and by his at
ents, Mr. and Mrs. William C. Lyda of Raleigh.
Dr. Lyda had a keen mind and was sharply ai 1}
tical. He had a warm personality and carrit
high degree of competence and dedication inttli|
practice.
Whereas, Ed Lyda has left us prematurely amhis
passing is a great loss to the profession, be it
Resolved, That this brief and paltry accouuibt
transcribed and registered in the minutes ofBii
Buncombe County Medical Society, a copy senltd
his widow and to his parents and one to the Joum
of the North Carolina Medical Society for pub:a-
tion.
Buncombe County Medical Socie i
Joseph Franklin Hamilton, Jr., M.D. |
Joe Frank Hamilton died on May 5, 1973 atii
age of 45 after a long battle with cancer. In spit ol
increasing illness, he continued to practice one-
pedics until a few months before his death.
He was associated with the Asheville Orthoplii
Associates since 1958. He was a member of the lal
and state societies and several orthopedic assiia^
tions. In addition, he was a fellow of the Amerar
Academy of Orthopedic Surgeons.
Dr. Hamilton was a native of Memphis. Here
ceived his M.D. from Tulane in 1953, and didai;
internship at Charity Hospital in New Orleans, iii
was in general surgery for a year at Baptist Hos|ta
in Memphis before joining Campbell Clinic in hf
same city where he remained for three years.
He is survived by his three children. Miss Jo Lot
Hamilton, Claude, and Joseph and by his fat;r
Dr. Joseph Franklin Hamilton, Sr. His wife, ^rs
Anne Motley Hamilton, died in 1971.
Joe Frank was a greatly respected physician. lO
only for his skill in medicine but also for his d^o
tion to his church and for his magnificent cou gi
and fortitude in the face of much personal tragedy
Whereas. Joe Frank was an outstanding plsi
eian and will be sorely missed by his colleagut ii
the Society and by his patients, be it
Resolved, That a copy of this writing be »r
warded to the Journal of North Carolina Medical o
ciety for publication, a copy to be incorporated iub
minutes of the Buncombe County Medical Soest]
and a copy sent to the bereaved family.
Buncombe County Medical Societ
260
Vol. 35. N'
JfEALTH SCIENCES LIBRARY
he Official Journal of tfie NORTH CAROLINA MEDICAL SOCIETY
May 1974, Vol. 35, No. 5
raei
^ORTH CAROLI NA
audi
iBjl
Medical Journal
™W THIS ISSUE: Congenital Neuroblastoma Presenting as Hydrops Fetalis, Archie T. Johnson, Jr., M.D. and LDCR David
;J':4albert, M.D.; The Present Status of the Physician's Assistant Program of the Bowman Gray School of Medicine, Hal T.
Wilson, M.D.; Cystosarcoma Phylloides in a Twelve-Year-Old Girl, James M. Kelsh, M.D.; Doctor, What Did You Say?
itiT-lughA. Matthews, M.D.
Simple, accurate test for glycosuria
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a summary of which follows:
Indications: Tensiiin and anx-
iety states; somatic complaints
which are concomitants of emo-
tional factors ; psychoneurotic states
manifested by tension, anxiety, ap-
prehension, fatigue, depressive
symptoms or agitation ; symptomatic
relief of acute agitation, tremor, de-
lirium tremens and hallucinosis due
to acute alcohol withdrawal ; ad-
jiinctively in skeletal muscle spasm
due to reflex spasm to local pathol-
ogy, spasticity caused by upper
motor neuron disorders, athetosis,
stiff-man syndrome, convulsive dis-
orders (not for sole therapy).
Contraindicated : Known hyper-
sensitivity to the drug. Children
under 6 months of age. Acute narrow
angle glaucoma ; may be used in pa-
tients with open angle glaucoma
who are receiving appropriate
therapy.
Warnings: Not of value in psy-
chotic patients. Caution against
hazardous occupations 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 anticonvulsant
medication; abrupt withdrawn k
be associated with temporary it
crease in frequency and/or se\ it
of seizures. Advise against sini -
taneous ingestion of alcohol an
other CNS depressants. Withdiv;
symptoms (similar to those Wit
barbiturates and alcohol ) have
occurred following abrupt disci-
tinuance (convulsions, tremor, )-
dominal and muscle cramps, vortin
and sweating). Keep addiction-'OO
individuals under careful surv'i-
lance because of their predispotio
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pregnancy, lactation or womenf
childbearing age, weigh potent i.
benefit against possible hazai d
(
N123
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while away from home. If your patient
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NORTH CAROUNi
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Puhlislied Monthly as the Official Organ
The North Carolir
Medical Socie'
May 1974, Vol. 35, No.
EDITORI.AL B0.4RD
Robert \V. Prichard. M.D.
Winston-Salem
EDI KIR
John S. Rhodes, M D.
Raleigh
ASSOCIMt; EDIIOR
Ms. Martha \an Noppen
Winston-Salem
\CTING \SSIST\NT FDl lOR
Mr. William N. Milliard
Raleigh
BUSINESS MANAGER
W. McN. Nicholson, M.D.
Durham
CH\1RM\N
Louis deS. Shaffner. M.D.
Winston-Salem
Rose Pully, M.D.
Kinston
William J. Cromartie, M.D.
Chapel Hill
Charles W. Styron, M.D.
Raleigh
NORTH CAROEINA MEDICAL JOUR-
NAL, .100 S ll.mlhornc KJ , \\ inslon-S.ilem,
N. C. :7in3, IS i.uncil ..nd published bv The
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reclion tif its [:dit(>ri.il Board. Copvri^ht r
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Address m.inuseripis .ind eommiinieations re-
izdrjini: editorial ni.illcr to this Winsion-
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addressed {o the Business Man.iyer. Box
:7167. Raleigh, N. C. 27611. All ad\er-
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in respect to strictly local advertising. In-
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paid lit Raleifih. \orlh Ctirolinn 27611.
President's Newsletter 2;
Original .Articles
Congenital Neuroblastoma Presenting as Hydrops Fetalis 2:
Archie T. Johnson, Jr,. M.D, and LDCR David Halbert.
M D.
The Present Status of the Physician's .\ssisfant Program
of the Bowman Gray School of Medicine 2!
Hal T. Wilson. M.D.
C\sfosarconia Phvlloides in a Twelve-Year-Old Girl 2'
James M. Kelsh. .M.D.
Doctor, What Did You Say? 2'
Hugh A. Matthews, M.D.
Editorial
Dr. Mvron L. Fox and Dr. Thomas More 3<
Emergency Medical Services
The Scene of an .Accident 3
George T. Wolff, M.D.
.Abstracted hy George Johnson. Jr.. M.D.
Correspondence
Louise Fant MacMillan 3
Ebcn .Alexander, Jr.. M.D.
Personal Testimonies on Medical-Ethical Issues 3
Claude A, Frazier, M,D.
Com.mittees & Organizations
Insurance Industry Committee 3
Bulletin Board
New Members of the State Society 3
What? When? Where':" 3
News Notes from the University of North Carolina
Division of Health .Affairs 3
News Notes from the Duke University Medical Center 3
News Notes from the Bowman Gray School of Medicine of
Wake Forest University 3
American Academy of .Allergy 3j
Joint Commission on Accreditation of Hospitals ^
News Note 3
Month in Washington 3
Book Reviews
In Memoriam j
Classified Ads S
Index to Advertisers :8
Contents listed in Current Contents Clinical Practice
t)
n
n
Congenital Neuroblastoma
Presenting as Hydrops Fetalis
Archie T. Johnson, Jr., M.D.* and LDCR David Halbert, M.D., MC USN t
.1-
REPORT OF A CASE
•fHE patient was a 3,000 gm in-
fant girl born to an 18-year-old
j.migravida after a 36-week gesta-
fn. The mother's blood type was
] ,, negative and her anti-Rh,, titers
( ring her uncomplicated pregnancy
] 1 been negative. Her membranes
lotured one hour prior to the de-
1 ?ry, and the amniotic fluid was
1 conium stained. There were no
5 )ntaneous respirations or heart
s inds, and immediate resuscitation
\ h endotracheal intubation was
t Tied out.
The infant appeared pale and ex-
t ncly hydropic. The placenta was
s ined with meconium and ap-
f ired to be hydropic. A grade 3/4
s tolic murmur was detected along
t left sternal border, and rales
\ e heard throughout both anterior
£ 1 posterior lung fields. The abdo-
r n was tense and edematous. The
1 r and spleen were enlarged to the
i c crest.
The patient was thought to have
i Irops fetalis, and immediate ex-
c nge transfusion was carried out
V h fresh O negative packed cells.
director. University of North Carolina
T hing Service. Waive Memorial Hospital, Ra-
il . N. C. 2761(1.
'resent address 11805 Hitchinc Post Lane.
P :ville. Maryland.
■print requests to Dr, Johnson.
The initial central venous pressure
was 25 cm of water. Initially, ap-
proximately 55 ml of blood was re-
moved and the CVP decreased to 15
cm of water. After the first exchange
transfusion, a total of 405 ml of
blood was removed and a total of
300 ml of packed cells was used as
a replacement. The CVP after the
exchange was 11 cm of water
and the hematocrit reading was 44
percent. When laboratory data be-
came available, the cord hematocrit
reading was 19 percent and the to-
tal bilirubin level was 2 mg/dl. The
baby's blood type was B negative
and the Coomb's test was negative.
The bilirubin level did not rise above
2 mg/dl during the patient's subse-
quent course. Serum electrolytes re-
mained normal, and the patient ap-
peared to improve after this proce-
dure. A flat film of the abdomen
revealed a homogeneous mass in the
right upper quadrant. During the
next 24 hours, the patient's CVP
rose to 17 cm of water and the
hematocrit value dropped to 25 per-
cent, Intermittently, phlebotomy
and replacement with packed cells
were performed. An effort was made
to keep the CVP at approximately
10 cm of water and the hematocrit
level at approximately 40 percent.
The infant was extremely acidotic
and was treated intermittently with
sodium bicarbonate.
The diagnosis remained obscure.
On the second day in the hospital
the patient had a cardiac arrest and
died.
Pathological findings
The 1,045 gm placenta measured
21 X 21 x 4 cm. The umbilical cord
was connected paracentrally and
contained two arteries and one vein.
All the cotyledons were on the ma-
ternal surface. No gross abnormali-
ties were present. Microscopically
determined, there was good vascu-
larization of the chorionic villi. The
villi were covered by a single tro-
phoblast. The capillaries contained
numerous nucleated red cells and a
few blast cells. In addition, there
were nests of uniformly round to
oval neuroblastoma cells which con-
tained hypcrchromatic nuclei and
scant pink cytoplasm (Figure 1).
The main autopsy (A-70-89)
findings were as follows: Neuroblas-
toma involving the adrenal glands,
liver, lungs, and the brain; severe
acute pulmonary hyperemia and
hyaline membrane formation.
The infant was 43 cm long and
weighed 2,879 gm. There was mod-
erate generalized edema of the scalp.
f f 1974, NCMJ
289
r^K
Fig. 1. Ntiirohlastonia cells in placental
villi. (H & K, \ 250.)
chest, genitalia, and extremities.
The abdomen was protuberant. The
massive h\er ( Figtire 2) weighed
358 gm (normal. 78 gm ) and
v\'as reddish-brown, studded with
numerotis 0.5-1 cm white no-
dules ha\ing depressed centers.
These nodules replaced approxi-
matelv SO percent of the hepatic
parench\ma. Tlie 33.3 gm (normal,
9.8 gm ) left adrenal was replaced
b\ a well-encapsulated, soft brown
mass with a smooth capsular sur-
face: it measured 4.5 x 2.5 x 4 cm.
The cut surface of this mass was
soft and reddish-brown with yellow
streaks. The 1.3 gm right adrenal
had hemoirhage in the medulla.
Except for a patent foramen ovale,
the cardiovascular system was nor-
mal. Both lungs were edematous
with slight crepitance. The spleen
weighed 6,74 gm (normal. S gm).
A small Meckel's dixerticukmi was
present. The brain weighing 400 gm
(normal. 335 gm ) was \'ery soft.
Small areas of subarachnoid hemor-
rhages were in the left frontal lobe
and a more extensi\e hemorrhage
was arotmd the brain stem.
Microscopic examination showed
the mass in the left adrenal to be
composed of large sheets and nests
of small cells which contained
large, round to oval, h_\perchroma-
tic nuclei with scant pink c_\toplasm.
The cells Were loosely arranged in a
reticular stroma. The sheet of cells
was separated by delicate, \ascular
fibrous tissue. .Areas of necrosis
were prominent (Figures 3 and 4).
Small amounts of adrenal tis-
sues were compressed toward the
peripher\ of the mass which was al-
so infiltrated by nests of tumor cells.
These tinnor cells infiltrated the
right adrenal, the pancreas, and the
li\er. The tumor cells were present
in the blood \'essels of the lungs
and biain. No infiltration of these
latter (.ugans was seen. Severe acute
passive hvperemia was present in
both lungs, kidneys, and spleen. The
lungs showed areas of hyaline mem-
brane formation.
COMMKNT
In 1S92. Ballantvne.' collected
from the literature 65 case reports
of fetal edema. .Among this series
were cases of congenital cardiac de-
fects, polvcvstic kidneys, syphilis,
and leukemia. Ballantyne recognized
that hydrops is a sequel of varying
disease processes. In 1943 Potter-
reported 1 3 cases of se\ ere hydrops
without ervthroblastosis fetalis; she
reported four other cases of fetal hy-
drops, but these presented with gross
congenital anomalies, and she made
the point that hydrops was not a spe-
cific disease but a symptom common
to several diseases.
In erythroblastosis fetalis, the
pathogenesis of hydrops fetalis is re-
lated to isoimmunization (of the Rh-
mother's anti-Rh agglutinins agair
her Rh+ infant's red cells). The
tibodies cross the placenta into t'
fetal circulation, producing a heni
lytic state. If the infant's crythropi
etic tissue cannot compensate for V
increased hemolytic rate, an int(
uterine anemia develops. Wh
anemia becomes severe, cardiac c
compensation may occur with
sultant hypoxemia, metabolic acic
sis, and massive anasarca.
Potter' has described fetal \
drops in children whose rnoth(
had toxemia, nephritis, or otl
chronic diseases. Hv drops feta
secondarv to ABO incompatibiliti
is extremelv' rare but has been i
tectcd. In the literature are scve
case re|iorls of lutein cysts of I
ovaries and one case of congeni
cvstic and adenomatoid malforn
tion o( the lung associated with 1
drops.'
In 1964 Strauss and Drisct
reported two cases of congeni
neuroblastoma involving the p
centa and presenting with hvdrc^
These authors postulate that i-
struction to the venous return bv c
huge intrtiabdominal mass and y
tumor in the hepatic and placv a
vascular channels may have plav^a
part in the pathogenesis of the -
drops. Gottschalk and .Abrani^''
have postulated a similar mechai'in
to explain the placental edema .J
fetal hvdrops associated with o r
congenital tumors causing compi-
sion of the vena cava and rcsul'g
in mechanical obstrtiction of e
venous return to the heart, "le
anemia in this case is postulateda
be caused by the invasion of tufr
cells into the erythropoietic tissue
Fi«. 2. I
enlartfid
ivtr (in situi «liicli is niassJMl)
b\ ronnd, wliiti- nodnlis.
H}i. i. Adrinal eland containing neuro-
blastoma cells, (H & K. \ 40.)
Fig. 4, Increased niaunification of adral
gland showing neuroblastoma cs.
(H & E, X 250.)
290
Vol. 35. l-
Edema occurs in most types of
evere fetal anemia, as in cases
f transplacental transfusion be-
tween monochorial twins, hemo-
lysis, chronic infections, or chronic
(jtomaternal bleeding. The cause of
;ie edema is not clear, but certainly
■bstruction to the venous return to
le right side of the heart by the
lUge liver, as shown in Figure 2, is
ijrobably a major contributing fac-
br.
SUMMARY
Hydrops fetalis is often viewed as
a specific feature of Rh incompati-
bility. However, hydrops fetalis may
be associated with conditions other
than Rh incompatibility, as is shown
in the present case in which a con-
genital neuroblastoma was the un-
derlying malady. The case is of addi-
tional general interest in that in-
volvement of the placenta by neuro-
blastoma was documented.
References
HiilUiiil.vnc J\V: The Diseases .ind l)elt)rnii-
lies of the Fetus. Rdinhiire'i: Ohver and
Hoyd, 1892.
Potter EL: Univeisal edema of the fetus
unassociateU with ervlhrobhistosis. Am J
Ohstet G.vnecol 46: 1.10-114. 1943.
Potter El.: Patltoloev of the Fetus and Infant,
ed 2. Chieago: \ear Book Medieal Publish-
ers, Inc. 1961. p 611.
Christie RW: Lutein cysts of ovaries asso-
ciated with erythroblaslotic hydrops fetalis.
Am J Clin Pathol .16: 51S-5.12. 1961.
Strauss L, Driscoll SG; Congenital neuro-
blastoma involving the placenta. Pediatrics 34:
23-31, 1964.
(iotlschalk W. Abramson D: Placental edema
and fetal hydrops: A case of congenital cystic
and adenomatoid malformation of the lung.
Obstet Gynecol 10: 626-631. 1957.
The great variety of forms into wtiich almost every article of medicine has been mantifacttired.
affords another proof of the imperfection of the medical art. A drug which is perhaps most ef-
ficacious in the simplest form in which it can be administered, has been nevertheless served up
in so many different shapes, that one would he induced to think the whole art of physic lay in
exhibiting medicine under as many different modes as possible. — Willium Biicluin: Domestic
Meclkine, or a Ticalisc on tlic Prcvcnlioii ant! Cure oj Diseases bx Reiiiineii and Simple Medi-
cines, etc.. Richard Fidwell. 1799. p. 437.
(.Y 1974, NCMJ
l
V
:9i
The Present Status of the Physician's
Assistant Program of the
Bowman Gray School of Medicine
Hal T. Wilson, M.D.^
T"" HE Physician's Assistant Pro-
gram began in North Carolina
in 1965 under the guidance of Dr.
Eugene Stead at Duke University.
Since that time few assistants have
been produced by ongoing pro-
grams. As far as can be determined,
there are 800 physician's assistants
of all types across the nation.' There
are approximately 39 approved
programs' which train "assistants to
the primary care physician" as out-
lined by the Joint Review Commit-
tee for the .American Medical Asso-
ciation.- Nearly 500 physician's as-
sistants of this type are at work.
Physician's assistants have be-
come part of the usual scene at the
Bowman Gray School of Medicine
and Medical Center. In our two-year
training program, now in its sixth
year, we have 50 students in the first
and second year classes; 38 gradu-
ates from our program are working
in physicians' offices.
Our program has produced assis-
tants to the primary care physician
(pediatricians, internists, and family
practitioners) with the exceptions of
one each to a psychiatrist, a surgeon,
and an obstetrician.
The official definition of the assis-
* Medical Director, Ph\';ician\ Ascisl.int Pro-
tzram. Division of Allifd Health Proyrams. Biiw-
man Gray School ot \tedicine of W.ikc Forest
Universitv. Winston-S.ilein, North C .irolin.i
nun.
29:
tant to the primary care ph_\sician is
as follows: "A skilled person, quali-
fied by academic and clinical train-
ing to provide patient services under
the supervision and responsibility of
a doctor of medicine."' In 1969 Dr.
Leiand Powers and Dr. Robert
Howard forecast, in a survey by the
Duke/Bowman Gray Schools of
Medicine, the professional accep-
tance of physician's assistants.' Of
the 3,800 questionnaires sent to
physicians, 2,025 were answered. Of
the physicians who replied, 1,660
(82 percent) said they were ready to
accept the concept of the physician's
assistant, and 700 indicated that
they would employ physician's assis-
tants if they could get them. Today,
graduates from both programs are
eagerly sought; they are having no
difficulty in gaining employment."'
The purpose of these programs is
to make available "physician ex-
panders" who, by providing many
clinical functions, save time for the
physician so that he can more ade-
quately serve his patients. In the
ideal situation the physician can
briefly verify the high points of the
health history and the physical ex-
amination data obtained by the phy-
sician's assistant. The physician
must agree with the assistant's iden-
tification of the patient's problems
and decide or approve all diagnostic
and treatment plans. The physiciar
assistant also may assist
counseling when appropriate.
This broad view of the role
physician's assistants is not nece
sarily the prevailing opinion. Son
physicians view the role of the phyi
clan's assistant as that of a techi
cian; others think the physiciar
assistant should have the respon:
bilily for participating in all mec
cal activities including the initi
evaluation of the patient and t
design of the treatment plan.
Our concept at Bowman Gray fc
lows the guidelines originally defini
by the National Academy of S\
cnces which depict the "Class /
physician's assistant as "one wl
corresponds with the highest level ,
allied health workers" and who
distinguished by his "ability to inl
grate and mterpret medical findiii
on the basis of general medic
knowledge and to exercise a degr
of independent judgment."'' T
physician's assistant will also "ass
in gathering the data necessary
reach decisions in implementing t
therapeutic plan for the patient."-'
Our initial dilemma concerns
cisions as to curriculum. We aw
sound evaluation of various phv
clan's assistant roles in medic
practice and suggestions from thd
who work with the graduates of d
Vol. 35, No
ling programs. Braun" of Duke
s well as others) has done task
aluations of physician's assistants
, office activities. Here, too, at
iiwman Gray, evaluations have
en initiated. Those North Carolina
ysicians who employ our physi-
in's assistants seem to be cxceed-
jly tolerant of our incursions into
j;ir offices and our efforts to mea-
e the results of the working re-
lionship with physician's assis-
its. However, the number of prac-
;es evaluated is still insufficient to
Ip us in curriculum design. An-
ler dilemma for the curriculum
Signer arises in regard to the utili-
;ion of physician's assistants in
:dical practice.
We hope the physician's assistant
0 graduates from our program
~ "1 be a first-class data base gath-
r: He does a complete history
len necessary; his information is
jent; he has the ability to under-
nd both the organic and nonor-
lic problems as well as the envi-
:imental, social, and economic
Ss ctors involved in a patient's illness
1 problems. To obtain an ade-
.ci :kte and viable history, the physi-
3n's assistant must use some de-
F lie of clinical judgment. We concur
B \h. the American Medical As-
* Nation's description: "Instruction
mid be sufficiently comprehen-
; so as to provide the graduate
Ih an understanding of mental and
tli 'Vsical disease ... to provide . . .
''»hnical capabilities, behavioral
tracteristics and jiulgiiient iieces-
^' V to perform in a professional
'iiacity all of his assignments."-'
i/iewing our responsibilities in the
igram, we emphasize various
acities that wo consider neccs-
j/ for good patient evaluation (in-
ying clinical judgment) rather
,1 follow a purely task-oriented
gram which would prepare one
llnly for the work of a technician.
course we recognize that the phy-
^an's assistant who does tasks of a
' ijinical nature is also saving the
,ot
teif'
saij
lin!
sician s time,
li'urthermorc, consideration of the
ii,«
1,1 iDwing occupational guidelines
f fortified us in our belief —
II' 1974. NCMJ
A physician's assistant will be able
to do the following:
1. Elicit a detailed and accurate
history, perform an appropriate phy-
sical examination, and record and
present pertinent data in a meaning-
ful manner.
2. Perform or choose the required
routine laboratory evaluations.
3. Immunize, suture, and handle
other routine therapeutic proce-
dures.
4. Instruct and counsel regarding
both physical and mental health.
5. Assist in hospital rounds, write
progress notes, transcribe orders,
and prepare case summaries.
6. Assist in the delivery of ser-
vices to patients in all settings.
7. Perform independently the
evaluation and treatment in emer-
gencies.
8. Be aware of community facili-
ties and resources.-'
We think it is important that clini-
cal judgment be involved in many
of the physician's assistant's respon-
sibilities as a physician expander.
We are concerned with his ability
to learn and to apply basic informa-
tion about the body, in health and in
illness, so that the assistant can con-
ceptualize the patient's particular
situation as the story unfolds. With
the physician's approval, the physi-
cian's assistant may handle all the
talk, touch, and task activities neces-
sary to problem delineation; he also
may use general knowledge specifi-
cally applied to the patient in coun-
seling activity.
In the first year, our physician's
assistant trainees receive a basic sci-
ence continuum which is coordi-
nated internally and linked to clini-
cal topics which have two predomi-
nating overtones. These units
demonstrate basic physiological and
pathophysiological modules and rep-
resent the most frequently encount-
ered complaints and symptom com-
plexes confronted in primary medi-
cal care. We rely on the hospital
setting for basic exposure to exam-
ples of system function and failure;
the outpatient situation provides ex-
perience with the more frequently
seen clinical entities.
The concern of utilizing the phy-
sician's assistants in medical prac-
tice relates to the busy practicing
physician, his confidence in the
abilities of his assistant, and his own
sense of responsibility. Finally, the
degree of independence the physi-
cian allows his assistant is entirely
the decision of the employing phy-
sician. The most time-consuming ac-
tivity in primary care is listening to
and examining the patient to pro-
duce a careful delineation of his
problems. The site of our emphasis
should be at this point in primary
care activity. Principles of treatment
procedures will be learned, but ap-
plication will vary with the physician
and practice concerned.
Independent function of the phy-
sician's assistant is likely to occur
under many circumstances. Accord-
ing to Estes, "This type of assistant
should be allowed to perform in set-
tings apart from the direct supervi-
sion of the physician provided the
limits of his autonomous activity are
clearly defined. . . . The physician
need not be present at each activity
of the assistant nor be specifically
consulted before each delegated task
is performed."^ Considering these
circumstances, we have asked our-
selves: What should physician's as-
sistants try to learn? How much of
the natural history of disease and
basic pathophysiology should be
presented? We believe the answer to
these questions is: Of the most fre-
quently encountered problems in
primary care, they should learn as
much as possible.'-'- '"
We have included in our nine-
month basic science continuum early
patient encounters and the pharma-
cology of the chief therapeutic
agents. We have not concentrated
on routine "cookbook" diagnoses,
standing orders, or routine therapies.
During his rotation in the hospital
and outpatient department during
a one-year period, the student is
asked to demonstrate that he has
learned the natural history of pre-
dominant clinical entities in primary
medical care and to compile coun-
seling data for indicated clinical
problems. Finally, he is tested and
evaluated in two 6 to 8 week pre-
293
M.D. DECISIONS
Further def ini tion?
Treatment?
DISEASE
PREVENTION
HOST
ILLNESS
Counse ling as to:
P rognos i s
Rationale of
Act ion
TREATMENT
■J'
OUTCOME
P. A. DECISIONS
_What problens are present?
Counseling as to details
of action.
Elucidation of rationale.
Kit;. '• After Feinstcin'
ceptorships with practicing primary
plnsicians.
Bearing in mind tiic "dangers of
a little knowledge" and the authori-
tative certainty of some people who
ha\e a superficial acquaintanceship
with medicine, our concern is that
the student should be exposed to the
extent and complexity of the data
needed and should be taught the
steps in interrogatiiMi necessary to
identify problems and make medical
decisions. He must develop a sense
of humility in the face of the task
and a clear and honest recognition
of his limitations in knowledge and
ability.
According to Feinstcin,' ' clinical
judgment is composed of valid evi-
dence, logical analysis, and demon-
strable proof. The physician's assis-
tant who is best qualified to save
time for the physician goes as far
along the continuum of problem de-
lineation as possible. When an ill-
ness begins with an interaction be-
tween the disease and the host, the
physician's assistant must take an
accurate and sensiti\e %iew of the
patient's social and economic situa-
tion as the assistant continues the
thorough investigation of the pa-
tient's symptoms and signs to that
final aniysis of data and discernment
of problems (Figure I >." Resolu-
tion of the dilemmas in our educa-
tional effort can come only from
continuing evaluation of our stu-
dents' performance and repeated re-
structuring of the curriculum. Per-
haps schools of allied health will al-
low more opportunity for a true
identification of better ways of
learning medical knowledge and re-
defining course content. The system
should include process evaluations
such as testing the assistant's ability
to learn that which saves the physi-
cian time and increases the numb
of units of health care performed
enhances office economy and patic
satisfaction. However, the ultim;
test invoKes the quality of medic
care that is maintained or iniprov
with the addition of the physiciai
assistant to medical practice. A
the objectives of accessibility
care, continuity of care, optimi
medical diagnosis and treatment,
eluding preventive and rehabilitati
aeti\ ities, being carried out in suci
way as to produce more effect
medical service?
The challenge of measurement
such end objectives has seldom be
met in medical care activities. 1
Osier Peterson study.'' emanati
from the University of North Ca
lina Medical Center nearly 20 ye
ago, and its companion study, i
Canadian Clute Report,'" painst
ingly e\aluate practice activities
primary physicians' offices. E\
there, medical care processes w
evaluated in the practices of onl;
few physicians. I belie\e it is po!
ble that the new organizational sit
tion exemplified by the schools of
lied health, with their limited c(
straints and shorter courses, c
bring about definitive and excit
studies of pedagogy in medicine 2
its relation to the effectiveness of
tient care.
References
I Hejlth EdiicalKin Nmsk-iler. Oclobcr
: Council on Medici EdvK.iUcin Jninl Ku-
Committee. Amcnc.m McdK.tl Assnct.Jl
Appro\Ld Educ.ition.il Proi;r.ims. Thi-
Mst.int to the Pnni.irs C.irc Physiii
mimcOLzr.iphed public.ilion. December 19
3. American Mcdic.il As'^ociation: Hssenlial
an Appro\ed Education Program for the
sistant to the Primary Care- Physician,
cemhcr 1^"!,
4. Pov^ers L- North (. arolin.t Physicians"
terest in Ph\sici.ins Assisi.ints, ( Letter
the Editor! NC Mtd J 1 1 : 4M-465, 1"?
5. Job Oilers Si^.imp C.radu.itcs of Dl'
M D Aide Prefer. im Intern. il Medicine
Diaenostic Nev^s, \ ol 1, No .s. p 21, f
IQ^O. I Editorial.)
6. National Academs of Sciences. Ad t
Panel on Ne^v Members of the Physic
Health Team; Report of Ph\sicians A
tants. Ma\ 14711
7. Braun JA. Hoi'.ard KH. Pond> LR «
Ph\sician Associate. 1 .isk Anal.vsis i-
\ember I. 1471.
.s. Estes EH: .Adsantaees and limitati.
medical assistants J .Am tier Soc 1^
10.S7. I')6S
i*. Peterson OL. et al: The doctor an if
medical communitN. J Med Ediic .11. N -
Part :. Chapter \ I. 44-1113. 14-'i6.
Ill, Clute KF: The General Practilionc .^
Studv of Medical Education and Prad .i"
Onlano and No\a Scotia. Toronto: I n r-
sit> of Toronto Press. 196.3.
n Feinstein AR Clinical Judgment. Balli i"
Willi.ims ,1. Wilkins. 14h^.
244
Vol. .V"!.
i
Cystosarcoma Phylloides in a
Twelve-Year-Old Girl
James M. Kelsh, M.I).. F.A.C.S.
I
OME confusion in terminology
I is foLmd in the literature per-
ifning to breast tumors in adoles-
iit girls. The giant fibroadenoma
[ithis age group presents a problem
iboth clinical esaluation and surgi-
approach to anyone not familiar
h the characteristics of this tu-
jr. It is not necessary to stress that
radical procedure on a young girl
ould be avoided, if at all possible,
cording to Hines and Geurkink.
liant fibroadenoma is the most
,mmon cause of massive enlarge-
,int of one breast in the young fe-
jle patient and cystosarcoma phyl-
ies the second most common.""'
jverthcless, these tumors are infre-
Ipnt in children, and the very few
t rapidlv achieve sreat size are
.irming to the patient and often the
[Ending physician.
iEight cases of cystosarcoma phyl-
•ies in girls aged 1 3 years or less
:'e been reported by the Mayo
inic-; two of them (Simpson and
|tin) were from the Mayo
iinic itself. Simpson and Lynn do
attempt to distinguish between
l,nt fibroadenoma and benign cys-
ft'arcoma phylloides in adolescents.
Li —
t om the Tarboro Clinic. Tarboro, N. C.
I I 1 print requests to Merrie Meade. Tarbort*.
'> '. 27886.
>' ' 1974, NCMJ
I
Recently a case of cystosarcoma
phylloides in a 12-year-old girl was
encountered at the Tarboro Clinic.
CASE REPORT
A 12-year-old Negro girl was re-
ferred to the Tarboro Clinic with the
chief complaint of massive enlarge-
ment of the left breast over a two-
month period. Normal dexelopment
began one year before admission,
and there was no discrepancy in size
at that time. Although the left breast
began to enlarge two months prior
to her clinic visit, the patient dates
the sudden increase in size to a blow
she received on the school grounds
two weeks previously. She denied
feeling any pain in the breast, but
complained of a sensation of numb-
ness.
The menarche had not yet oc-
curred in this patient; the medical
and family history were otherwise
unremarkable.
The physical examination dis-
closed no abnormalities, with the ex-
ception of the enlargement of the left
breast. The right breast was compa-
tible with normal development in a
12-year-old girl. The left breast ap-
peared massively swollen and tense
(Figure 1 ). A well defined nonfixed
mass measurinc about six inches in
diameter was palpated and gase the
impression of a solid structure. On
attempted transillumination it failed
to permit the passage of light. Sev-
eral superficial veins were present
in the overlying skin. There was no
evidence of lymphadenopathy. Pel-
vic examination revealed a virginal
introitus, with normal distribution of
pLibic hair.
Laboratory salues were as fol-
lows: hemoglobin, 12 gm; hemato-
crit, 36 percent; white blood cell
Fis. 1
:95
count, 4,800 with a normal differen-
tial. The urine was normal and a
VDRL test was nonreactive.
A chest roentgenogram was inter-
preted as unremarkable except for
the obviously enlarged left breast.
Mammography revealed the right
breast to be normal. The left breast
appeared as a homogeneous increase
in density, with no radiologic find-
ings that could rule out malignancy.
The radiologist's diagnostic possi-
bilities included ( 1 ) diffuse inflam-
matory carcinoma or sarcoma, or
both, and (2 ) giant adenofibroma.
Hospital course
The patient was taken to the op-
erating room on the fifth day after
admission and given general anes-
thesia. A generous transverse cir-
eumlinear incision was made over
the mass in the inframammary re-
gion of the left breast. The tumor
was disclosed as a well encapsulated
firm mass which was easily enucle-
ated by finger dissection once the
proper plane was found. The frozen
section was compatible with a giant
fibroadenoma.
Pathology
G'ro.ss examination: The spheroi-
dal tumor mass measured 11 cm in
diameter and was completely en-
closed by a thin, grayish-tan capsule.
As the specimen was cut, the gray,
firm surface bulged slightly, and no
focal changes were present.
Microscopic examimuion: The
tumor mass was enclosed bv a thin
Fig. 2
fibrous capsule, and the follicular
architecture was obliterated. The
fibrous stroma was composed of
stellate and spindle-shaped fibro-
blasts exhibiting no pleomorphism
or mitotic figures. The ducts were
slightly dilated and were lined by a
double layer of epithelial cells (Fig-
ure 2 I .
DISCUSSION
Giant fibroadenoma or benign
cystosarcoma phylloides may be
bilateral and can start, as in this
case, prior to the menarche. The
course is marked by rapid, painless
enlargement; the mass is firm but
usually freely movable. Benign vir-
ginal hypertrophy of the breast can
also be unilateral or bilateral, but
no distinct tumor is palpable, and
there is no thinning or tenseness
the skin over the breast. Neither a
there enlarged veins.'' ■''
It should be noted that virgir
hypertrophy is the least comm^
cause of unilateral breast enlarj
ment. Although carcinoma of t
breast is extremely rare in the you
female, it does occur. In 1943
Cholnoky reported a case in a 1
year-old girl.''
There is some conflict of opini
concerning the pathological d
ferentiation of giant fibroadenoi
and benign cystosarcoma phylloid
Some authorities feel that the s;
and rapid growth of the tumor
sufficient to classify it as cystos;
coma phylloides; others believe tl
the two lesions are better dist
guished on the basis of increas
pleomorphism and cellularity
stromal elements. In either case,
the lesion is benign it usually q
be easih removed by simple er
cleation, preferabh' through an
framammary incision; if it is
moved early enough, the result;
cosmetic defect can be slight to nc
existent.
References
1. Hine' JR. Geurkink RE: Giant bre,ist tui
in the adolescent. Am J Surt; \m . «10-1
1965.
2. Simpson TE. Van Der\oort RL Jr. Lynn I
Gijnr fibroadenoma (benijin cystosarti
ph\ Hordes): Report of case in 13-year
tirl. Suritery 65: ,14l-.14:, 1969.
3. Farrou JH. Ashikari H: Breast lesions
vounj: j:irls. Surp Clin North Am 49: 261-
1969.
4. Daniel W .A Jr. Mathews MD: Tumors of
breast in adolescent females. Pediatrics
743-749. ig6X.
5. Ashikari R. Farrow JH. OHara J: Fibr<
enomas in the breast of ju\eniles.
Gynecol Obstet 132: 259-262. 1971.
6. de Cholnok\ T: Mammary cancer in yo
Suri; Gynecol Obstet 77: 55-60. 1943.
Different forms of medicine, no dotiht have their use; but they otight never to be wantonly
increased. They are by no means so necessary as is generally imagined. .\ few grains of powdered
rhubarb, jalap, or ipecacuanha, will actually perform all that can be done by the different prepa-
rations of these roots, and may also be exhibited in as safe and agreeable a manner. The same
observation holds with regard to the Peruvian bark, and many other samples of which the prepa-
rations are very numerous. — William Biuluui: Donusiu Medicine, or a Treatise on ilie Pre-
vention anil Cure of Diseases bv Revinien mnt Simple MeJieiites. etc.. Richard Fu/ui'//. 7 799.
p. 437.
296
Vol. 3.S. N(
«
Doctor, What Did You Say?
Hugh A. Matthews, M.D.*
■ T a seminar on the Western
^ Carolina University campus, a
lysician spoke before a group of
0 lay people. After an appropri-
i but spicy introduction, the in-
Tiist had the industrial workers
d businessmen in the palm of his
ind. Very soon thereafter, he had
it his audience to obvious bore-
)>m or sleep.
.'The physician presiding at the
(Jeting, although thoroughly enjoy-
1 the address, began listing medi-
i terms that the physician lecturer
ii^is using. At the end of the address,
i terms had been jotted down on a
ascription pad. Fifty of them were
,:anged in a multiple choice exami-
tion designed to test only general
derstanding. Fine distinctions
ire not required to arrive at cor-
:t answers. The choices were re-
'wed, and in some instances ai-
led, by a medical secretary in the
•erest of assuring clarity and
oiding trickery.
IThe multiple choice examination
IS evolved was given to 41 gradu-
. students in the School of Educa-
n and Psychology. All were col-
'f e graduates and many were in
' ir second year of postgraduate
' rk leading to master's degrees.
Director of Health Affajrs. Western Caro-
1 University. Cullowhee. North Carohna
■ 3.
These students were on a par with
graduate students across the nation
in their respective fields. Each
ranked at or above the median level
of the national Graduate Records
Examination (GRE) required for
admission to the graduate school.
Some had GRE scores higher than
the usual requirements for medical
school admission.
The examination given to these
graduate students was the following;
Hepatic referred to
A. fever blisters
B. the liver
C. need for sympathy
Apneic meant
A. breathless
B. an opening
C. apologetic
Hemiparesis indicated
A. slight paralysis on one side
B. half-wittedness
C. a type of anemia
Hypoxia meant
A. a false or nonfunctioning or-
gan
B. an injection of air
C. a state of decreased oxygen in
tissue
Cyanotic implied
A. a bluish color
B. a confused state
C. poisoning with cyanide
I.V. referred to
A. inverting a blood vessel
B. a valve to the heart
C. injecting a substance into a
vein
Clonic indicated
A. rapid contraction and relaxa-
tion of muscles
B. constant spasm of muscle
C. a procedure to empty the
bowels
Fibrillation implied
A. growth of muscle fibers
B. very rapid twitching of the
heart
C. compulsion to misrepresent
Tonic indicated
A. a disturbance in hearing
B. a normal sense of tone
C. a continuous contraction of a
muscle
Edema referred to
A. retention of fluid in tissue
B. a skin disease
C. a loss of epidermis
Pronate indicated
A. turning the arms so that the
tops of the hands are forward
B. turning the arms so that the
palms of the hands are for-
ward
C. extending the arms laterally
V 1974. NCMJ
297
Stenosis meant
A. a stretching
B. a narrowing
C. a scarring
Viscous referred to
A. a fluid in the eye
B. a free flowing liquid
C. a sticky, slow flowing liquid
Plethoric had reference to
A. a sluggish person
B. an excess of body fluids
C. an emotional attachment
Hypoglycemia indicated
A. an alteration in blood sugar
B. a weak gl\cerin solution
C. a depressed mood
Uremic related to
A. an excess of wastes in the
blood
B. a bladder infection
C. too many red blood cells
Cirrhosis meant
A. yellow skin
B. scarring of an organ
C. a circular skin lesion
Febrile had reference to
A. old age
B. abnormal heart rhythm
C. elevated temperature
Petechiae meant
A. severe itching
B. pin point to pin head size
hemorrhages
C. a small opening at the corner
of the eye
Svncope referred to
A. rhythm of the heart
B. a bout of fainting
C. combining two or more drugs
Cer\ical os indicated
A. a pelvic bone
B. the collar bone
C. the opening to the uterus
Epistaxis meant
A. bleeding from the nose
B. a top layer of skin
C. dramatic flow of blood
Arrhythmia indicated
A. stoppage of the heart
B. jumping leg muscle
C. irregular heart beat
Bradycardia implied
A. a narrow opening
B. a slow heart action
C. a scarring of muscle
Pulmonary had reference to
A. pumping action
B. the lungs
C. pulse beat
Cardia pointed to
A. the opening to the stomach
B. a valve in the heart
C. a li\er defect
Infarction meant
A. breaking a medical rule
B. death of tissue
C. narrowing of a blood vessel
Cilia referred to
A. a state of stupidity
B. hairs in lung tubes
C. indecisiveness
Cicatrix implied
A. a scar left by a healed wound
B. a round lesion
C. an indefinite time period or
year
Dialysis indicated
A. breaking up scars
B. passing of a substance through
a membrane
C. dividing one lesion from an-
other
Hirsute made reference to
A. an excessive growth of hair
B. an unusually strong muscle
system
C. a primiti\e vestige
Exogenous meant
A. originating outside the body
B. flowing from one organ to an-
other
C. generating excessive fat
Neurological referred to
A. good thinking
B. mental illness
C. brain and nerves
Comatose implied
A. injury or disease to the brain
B. poor oralhygiene
C. a comic stale
Hypertension meant
A. pulled too tight
B. nervous or tense
C. abnormal blood pressure
Glucose referred to
A. an eye disease
B. a sugar solution
C. a thick liquid
Narcosis implied
A. a group of drugs
B. a mental illness
C. a stuporous state
Gavage had reference to
A. emptying the stomach
B. feeding by a stomach tube
C. rubbing the skin
Cerebral referred to
A. wax in the ear
B. a primitive medical rite
C. the brain
Fibroma meant
A. a cancerous growth
B. a benign tumor
C. a normal part of tendons
Metabolic referred to
A. poisoning by ingesting certa
heavy metals
B. chemical changes whereby n
trition is affected
C. change in the course of a
sease due to a related diseai
Endogenous referred to
A. inherited characteristics
B. origin of a process within tl
organism or one of its parts
C. generation of abnormal he
mones
Hxsteria indicated
A. a plant poisonous to hum;
beings
B. an inappropriate emotional i
action to stress
C. an infection of the uterus
H\perg]\cemia indicated
A. diabetes
B. th\roid trouble
C. excessi\e breathing
Palpitation referred to
A. examination by feeling
B. forceful pulsation of the he;
with increased rate
C. friction on one membrane
another
Barbiturates referred to
A. psychedelic drugs
B. sleeping medication
C. mood-stimulatine chemicaU
298
Vol. 35. N >'
B.
C.
arenteral indicated
A. influence of parents on off-
spring
■ B. giving medicine in the veins of
muscles
t C. overprotectiveness
poplexy meant
■ A. a complex of vessels overlying
i other vessels
an application of a medicated
mesh over a wound
a sudden loss of consciousness
due to a blockage of an artery
hrombosis indicated
A. early division of fetal cells
B. clot formation blocking a
blood vessel
C. stage in developing antibiotics
E.G.
A. brain waves
B. excess energy generation
C. electrical equipment used in
gynecology
The highest score was 72, the
west was 40, and the average was
i. Three students thought that
jepatic" referred to the need for
jmpathy, and five chose "apneic"
mean apologetic. Ten students
ought that "cyanotic" implied poi-
ining by cyanide and four students
pught that "hypoglycemia"' indi-
cted a depressed mood. Twenty-
i;ht of the 41 graduate students
rmised that "febrile" had refer-
ice to abnormal heart rhythm; only
|jr chose elevated temperature as
; answer. Eleven thought that
111
"cervical os" indicated a pelvic
bone; eight selected the collarbone,
and 22 chose the opening of the
uterus. For seven students, "infarc-
tion" meant breaking a medical rule,
and for two students, "cilia" referred
to indecisiveness. Thirty indicated
that "hysteria" referred to infection
of the uterus. Of the 41 graduate
students, none answered that "hys-
teria" indicated a plant poisonous
to human beings, and none thought
that "glucose" referred to an eye
disease.
Most physicians would find this
brief review to be indeed funny.
But who deserves to laugh? A rea-
sonable conclusion is that Robert
Burns should have thought twice be-
fore he prayed for the gift to see
ourselves as others see us. Regard-
less of whether the physician(s)
should laugh or not, the graduate
students' answers and the physi-
cians' responses appear to merit two
suggestions and one conclusion.
The first suggestion is that, in at-
tempting to communicate with pa-
tients and groups, physicians might
well strive to use the simplest pos-
sible terms. Words do not neces-
sarily communicate all that the phy-
sician, or any person, intends to
communicate. Words are but one
possible tool in the communication
process. They are but sounds which
symbolize objects, concepts, and
feelings. If the word symbol has no
meaning for the patient, the word
indeed symbolizes nothing and be-
comes merely a sound or, at worst,
a noise. If no words that have mean-
ing for the patient can be found,
the physician must find other tools
for communicating. Pictures, mod-
els, and demonstrations can serve
in some instances and assist in oth-
ers. There are yet other modalities
in communication which can assist
in giving meaning to the medical
terms which must be used.
A related suggestion is that a phy-
sician, preparing to deliver a speech
to a lay group, edit and re-edit the
paper. He then should have a lay
person edit it. The physician who
wants to be divorced from the edi-
torial work could ask his or her lay
husband or wife to read the paper.
If we should choose not to do this,
he might do well to submit the
speech for critical analysis to his
earthy, favorite patient (every phy-
sician has one).
The one and final conclusion is
that most people, including brilliant
graduate students, will never have
the interest or the time to develop
an effective medical vocabulary.
Woe be to the few lay people who
do have the time and interest to
learn the medical "lingo"! The pa-
tient whose chief complaint is,
"Doctor, I am apneic," might be
better advised to say nothing, just
pant. An expectancy more reason-
able than having lay folks develop
an extensive medical vocabulary is
that physicians return to using
"plain talk."
[IS
MiilliplyinL; ihc ingredients of a medicine, not only renders it more expensive, but also less
certain, both in its dose and operation. Nor is this all. The compound, when kept, is apt to spoil,
or acquire qualities of a different nature. When a medicine is rendered more safe, efficacious,
or agreeable, by the addition of another, they ought, no doubt, to be joined; in all other cases,
they are better Kept asunder. The combination of medicines embarrasses the physician, and
retards the progress of medical knowledge. It is impossible to ascertain the precise effect of any
one medicine, as long as it is combined with others, either of a similar or dissimilar nature. —
Williani liiiclian: Domcslic Medicine, nr a Treuli.se on the Prevention and Cure of Di.sen.se.s /iv
Re.(;iineii and .Simple Medicines, etc.. Ricliard Folwell. 1799. p. 438.
id
5]i§|Y 1974, NCMJ
299
Editorials
DR. MYRON L. FOX AND
DR. THOMAS MORE
It is to be hoped that Oscar Wilde was taken seri-
ously in his observation that Nature imitates Art.
for examples of how well he thought out the matter
are all around us. Wilde's wisdom came to mind re-
cently, upon reading the published account of Dr.
Fox's famous lecture (J Med Educ 48: 630-635.
1973). .\ group of faculty members at the Uni-
versity of Southern California hired a professional
actor who "looked distinguished and sounded au-
thoritative; pro\ided him with a sufficiently am-
biguous title. Dr. Myron L. Fox. an authority on the
application of mathematics to human behavior;
dressed him up with a fictitious but impressive cur-
riculum vitae, and presented him to a group of highly
trained educators." Dr. Fox's address on "Mathe-
matical Game Theory as Applied to Physician Educa-
tion" was well received by three separate groups of
educators, most of them in psychiatry, psychology
and related fields. One of the 55 "victims" even
claimed to have read Dr. Fox's publications. The
paper itself analyzes the whole affair in considerable
detail, and ends with some sour belching about teach-
ing and illusions of learning, going so far as to sug-
gest that hiring actors might be a good way to teach.
Wilde comes into all this when one considers how
incisively and amusingly Walker Percy covered simi-
lar ground in his 1971 masterpiece Love in the
Ruins (New York: Farrar, Straus, and Giroux, Inc.).
Surely one of the best novels of recent years, Percy's
book provides many insights and vignettes dealing
with medical matters, which is understandable since
he is a physician (and a southerner, which bears im-
portantly on many of his other views). One of the
memorable scenes of the novel is a parody of a CPC
in which Dr. Percy clearly shows, these exercises
the theatrical events they are (where still held
and the participants as actors and audience, with
the interactions one might expect and a whole
only Percy could think of. In the novel the studer
get the more vigorous putdown, as opposed to Fo
teachers: "Students are. if the truth be known, a b
lot. En masse, they're fickle as a mob, manipula
by any professor who'll stoop to it. They have, moi
over, an infinite capacity for repeating dull trut
and old lies with all the insistence of self-discove
Nothing is drearier than the ideology of students, 1
or right."
Considering that che Art involved in this editor
comes from a novel, and the Nature from Southe
California, can one safely write off lecturers and th
students as a bad lot and leave them with the pai
Pilatean cry. "Kill each other, damn you"? Hard
One could easily argue that the particular audien*.
seduced by Dr. Fox were more homogeneous a
more susceptible than the average run of medical s
dents (or people walking past the medical school
routine business). While there are exceptions, me^
cal students of the ordinary sort in most parts of t
country have been second to none in their eagerni
to detect a phony, at times immolating a few inr
cents in their zeal. Most medical school teachers .
concerned with getting accurate, up-to-date inforn
tion across to the students rather than conforming
television-actor models about whom most are
norant. Surely the alternative to having a phony c
the students (worthy only of Dr. Percy's AmeriL
Christian Proctological Society) is having an en
gctic, informed and enthusiastic teacher — not son
one so disorganized, dull and generally unattracti
that there would be no danger of confusing him w
a con man.
300
Vol. 35. No
idij
Emergency
Medical
Services
THK SCKNE OF AN ACCIDENT
Giorfif T. Wolff, M.l)., Member
Commission on Health Care Services
< The American Academy of Family Physicians
'^Because of an increasing number of accidents and
infrequency with whicli trained personnel are at
\ scene of an accident, there is an increasing need
training the public in first aid and for having
deiines to reinforce this knowledge when an acci-
it occurs. It is suggested that these guidelines be
'iched to the glove compartment door.
The major points should include FIRST, be calm,
carefully and purposefully, and seek help. \ imi-
''sal emergency telephone number would be help-
SECOND. insure an adequate airway. THIRD,
^indicated, perform closed chest heart massage.
no: II
liH
FOURTH, control bleeding if possible. FIFTH, mo-
bilize areas of which there is suspicion of fracture,
being especially cognizant of spinal fractures.
SIXTH, keep the patient warm and coxered. This
instruction should be carried out by already-function-
ing organizations and perhaps should be required as
part of our education program. Trained emergency
technicians, nurses, and doctors are not enough to do
this job.
— .Abstracted bv George Johnson, Jr., M.D.
From "Emergency Medicine Today," Commission
on Emergency Medical Services. Volume 3, No. 2,
February 1974. Original article may be obtained
from American Medical Association, 535 North
Dearborn Street. Chicai!0. Illinois 6061 0.
TUCKER HOSPITAL, Inc.
212 West Franklin Street
Richmond, Virgini.'^
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.
Accredited by the Joint Commission on Accreditation and
Certified for Medicare
James As.\ Shield. M.D.
James Asa Shield, Jr., M.D.
Catherine T. Ray, M.D.
Weir M. Tucker, M.D.
George S. Fultz, Jr., M.D.
Graenum R. Schiff, M.D.
,jl 1974, NCMJ
3n.s
Correspondence
Louise Fant MacMillan
To the Edilor:
I write this letter hoping to express my great sor-
row in the passing of Louise MaeMillan. She served
so long as the assistant editor of the North Carolina
Medical Journal and did it superbly.
We all knew her as a sensitive, extremely intelli-
gent, bright person with a fine sense of humor but
a fine judgment and unafraid to critieize when that
time eame. In spite of her handicap, being a para-
plegic for her man\ years, she scarcely recognized
any disabilit\. 1 remeniber once in discussing that
we were to ha\e a meeting of the paraplegics at
some place where there was a hindrance at the door-
way, Louise laughed this off with a statement, "Well,
any able-bodied paraplegic ought to be able to get
over that." She never thought of herself as disabled
and certainly contributed a great deal to the lives of
many people. She will be missed by all of us and par-
ticularly by those around the Bowman Gray School
of Medicine, Baptist Hospital Medical Center.
Ebi.n Alexander, Jr., M.D.
Professor of Neurosurgery
Department of Surgery
Bowman Gray School of Medicine
Winston-Salem, N.C. 27103
Personal Testimonies on Medical-Ethical Issues
To the Edilor:
I am currently editing a book on the persor
testimonies of Christian physicians and how th
view the current medical-ethical issues of today, i.
abortion, euthanasia, organ transplants, when a pi
son is officially dead, sterilization, psychosurge
semen donors, ovum donors, host mothers, revers
aging, artificial organs, genetic counseling, etc.
would be interested in hearing from any Christi
physician who would be interested in contribuli
to such a book, or who would be able to sugg
a Christian physician to write for this book. Pie;
contact me at the following address:
Claude A. Frazier, M.D.
4-C Doctor's Park
Asheville. N. C. 28801
Committees and
Organizations
INSLRANCI INDL STRY CO.MMITTEE
Charlotte, Jan. 16, 1974
Following discussion of the action taken b\ the
Committee on Sept. 26. 1973, with respect to the
support of this Committee for the continuance of
coordination of benefits clauses in all insurance con-
tracts in effect in North Carolina, it was the concen-
sus that the wording should read as follows:
With respect to all employer-employee insurai
plans in eltect in North Carolina, containing a co
dination of benefits provision, it is the opinion
this Committee that such provisions should be ma
taincd in effect in order to reduce duplication
benefit payments with the consequent effect of sic
ing the rise in the cost of medical care. — Bernard;
Wansker, M.D., Chairnum
306
Vol.. ys. Nc
Bulletin Board
NEW MEMBERS
of the State Society
ilr
3
■til
cini, John Joseph, Jr., MD (R). Scolhirnl Mem. Hosp.,
Laurinburt; 28352
rery, Frank Wahon, MD (PTH), Nash Gen. Hosp., Rocky
'iMount, 27801
Trker, Roger Wm., MD (OTO), 644 Cherry Si., States-
hville 28677
rker, Rudy Walkins, MD (OBG), 3901 Regent Road,
Durham 27705
fflJlirringer, Robert Phillips. MD (IM). 2101 Montieello Dr..
Gastonia 28052
iiion. Gerald Ray, MD (OBG), 105 Grover St., Shelby
il28150
ike, Robert .\dams, MD (ORS), Medical Bide., Gastonia
28502
(■ekelheide, Priscilla Day. MD (P), UNC Student Health
Serv., Chapel Hill 27514
•oker, John Parks. Jr., MD (R). 18 13th Ave.. NE,
Hickory 28601
iwers, Wm. Hampton. MD (ORS), 104 Kings Mt. Court,
Chapel Hill 27514
lapman, Robert A., MD (Renewal), Cannon Mem. Hosp..
Banner Elk 28607
oom, Robert DeVane, 111, MD (GS), NC Mem. Hosp.,
Chapel Hill 27514
Trie, John Lauchlin, MD (OBG), 901 Willow Dr., Chapel
f\\\\ 27514
livis. Edwin, MD (GS). 709 W. End Ave., Statesville
128677
mean, Charles Cecil. Jr.. MD (Intern-Resident), 108
iBaldwin Dr.. Durham 27705
tming. Geo. Edward, MD (.^N). Box 1519. Kinston
128501
iirrabrant. Edgar Cornelius. MD (OTO). 3614 Haworlh
Dr., Raleigh 27609
?issinger, Wm. Tuttle, MD (GS), 1350 S. Kincs Dr..
(Charlotte 28207
idbold, Ronald Lee. MD (D). 50 Ballantree Dr.. Ashe-
Iville 28803
■ant, Alfred Allison, MD (P), 1900 Randolph Rd..
Charlotte 28205
irberts, Arthur Stanley. MD (OBG), 140 E. Water St..
Statesville 28677
.rtness, John Frederick, Jr.. MD (GP). 412 Rollincwood
I Circle, Fayelteville 28305
wthorne, Henry Claiborne, Jr., MD (PD), 3208 Oleander
. Or., Wilmington 28401
rbst, Charles Arthur, Jr.. MD (GS). 407 Lake Shore
lane. Chapel Hill 27514
ihshaw, Howard Thomas. MD (IM). 1350 S. Kincs Dr..
Charlotte 28207
'fit, Ralph, MD (GP), Appalachian State Univ., Boone
JJ8607
frah, Azmi Shafiq, MD (PD), 305 Collece St., Morcanton
28655
We, Mildred Teretha, MD (P), 1900 Randolph Rd..
llCharlotte 28207
igan, Wm. Sumner, MD (D). 1350 S. Kincs Dr.. Charlotte
'8207
Wall, Francies, MD (PD). UNC Student Health Service.
Chapel Hill 27514
tee 1974, NCMJ
Maves, Charles Eugene, MD (CD). 1350 S. Kings Dr..
Charlotte 28207
McMahan. Thomas Keith, MD (IM), RFD 7, Bo.x 249, N.
Wilkesboro 28697
Moskalik. Robert Stephen (Student), 429 Northside Dr..
Chapel Hill 27514
Pena, Horacio, MD (GP), P. O. Box 308. Clarkton, NC
Phillips. Bruce Alton, Jr.. MD (IM), P. O. Box 86.
Eli7ahethtown. NC
Rogers, Noel Bruce, MD (ORS), 200 Doctors Dr.. Jackson-
ville 28540
Sessoms, Stuart McGuire, MD (IM), Duke Hospital,
Durham 27710
Shrivastav, Rajendra, MD (Intern-Resident), New Hanover
Hosp., Wilminston 28401
Staab. Edward Vincent, MD (R) 605 Churchill Dr.. Chapel
Hill 27514
Stabler, Carev Vastine. MD (IM) 3041 St. Claire Rd..
Winston-Salem 27106
Tejano. Felipe Mazon, MD (U), 2200 Sparre Dr., Kinston
28501
Tucker. Paul Chambliss. Jr.. MD (IM), 1350 S. Kings
Dr., Charlotte 28207
Vaidyanathan, Shankar Kuther, MD (GS), 1540 Garden
Terr. Apt. 305, Charlotte 28201
Wallace, Kellev. MD (PS). 1705 W. 6th St.. Greenville
27834
Wiecher. Frederick Jos.. MD (Intern-Resident). 6709 Ronda
Ave., Charlotte 28207
WHAT? WHEN? WHERE?
In Continuing Education
May 1974
("Place" and "sponsor" are listed only where these differ
from the place and group or institution listed imder "for
information."" I
In North Carolina
May 15
Ethel Nash Day Program
Place: Clinic .Auditorium; 1 :()() to 5:30 p.m.
Sponsor: Department of Obstetrics and Gynecology
For Information: Miss .*\nn Francis. Administrative Assis-
tant. Office of Continuing Education, UNC School of
Medicine. Chapel Hill 27514.
May 16-18
Basic Mechanisms in Hypertension, previously scheduled for
this date by the Bowman Gray School of Medicine, has
been cancelled.
May 18-22
120th .Annual Session of the North Carolina Medical So-
ciety; General Session on Scientific Subjects and Specialty
Section Meetings
Place: Pinehurst Hotel and Country Club
For Information: Mr. William N. Hilliard. Executive Direc-
tor. P. O. Box 27167. Raleigh 2761 1
307
Maj 20-21 and May 23-24
Nursing Fvaliiiition and Documentation
Place: Roval Villa. Raleich. Mav :0-21; Downtowner East.
Charlotte. May :?-:4
Intended Participants: Hospital nursinc personnel
Fee: $75
For Information: Mr. Jav Camp. North Carolina Hospital
Association. P. O. Box 11)937. Raleigh 276(J5
May 28-31
Fourth postgraduate course in Head & Neck .Anatomy
Sponsors: Department of .Anatomy. School of .Medicine, in
cooperation with the Division of Continuing Education.
East C arolina University
Elicibilit\ : Open to holders of any of following decrees:
iM.D . D.D S.. DM.D.. Ph.D.
Fee: SI2.s. students in residency programs $75
Credit: .Approved for 28 hrs. ,AAFP elective hours: CE
units also tiven bv Division of Contintiint; Education.
ECU
For Information: Head &l Neck Anatomy Course, ECU
Division of Continuing Education. P. O. Box 2727,
Greenville 278.34
Mav 29-30
ilcm
irt
Hypertension: Critical Problems — 25th Annual Meeting and
Scientific Sessions, North Carolina Heart Association
Place: Hvatt House and Convention Center, Winston-Sale
Designed especially for nurses and physicians
For Information: North Carolina Heart ,\ssoci,ition. 1 Hea
Circle. Chapel Hill 275 14
June 12-15
Neurology for Practicing Physicians, originally scheduled hy
the Bowman Gray School of Medicine for this dtite. has
been cancelled.
.luiH- 13-16
Seaboiird Medical Association Anntial Meeting
Place: Holiday Inn. Kill Devils Hill
For Information: Mrs. .Annette Boutvvell. P. C). Box 10387.
Raleigh 27f.(l5
June 20-22
Mountain lop .Nssenihly
Place: Wavnesville Country Club. Waynesvillc
For Information: R. Stu.irt Roherson. M.D.. P, (). Box
307. Ha/levvood 28738
Jui.v 8-13
16ih Annual Duke Medical Post Graduate Course
Place: ,\ll,intis Lodge. .■Atlantic Beach. North Carolina
Program: designed primarily for the generalist. but with
sufficient variation to appeal to the interest of the internist
and the pediatrician. Conferences and lectures will be
given in the morning; afternoons and evenings will be left
free for recreational activities.
Fee: $85. payable in advance. Course limited to 75 partici-
pants.
Credit: .A ccrtificite of .utend.ince will be given. Program
IS accept, ible for 3(1 accredited hours by .AAFP.
For Information: W. M Nictiolson. M.D.. P. O. Box 3088.
Dtike Llnivcrsity Medical C enter. Durham 27710.
July 24-Aucusl 2
2nd .Annual Beach Workshop: Selected Topics in General
Internal Medicine
Sponsors: Bowman Gray. Duke and UNC Schools of Medi-
cine, in conjunction with the Medical University of Sotith
Carolina
Place: St. Johns Inn. .Vlvrtlc lie.ich. South Carolina
Fee: $100
For Information: Emery C. Miller. .M.D., .Associate Dean
for Continuing Education. Bovvm.m Gray School of Medi-
cine. W instiin-Salem 27103
September 20-21
|y74 Walter E. Thomas Symposium t>n Gvnecologic Malig-
nancy and Surgery
Program: The two-day svmposiiini will be clmicallv oriented
with the main emphasis on "Ov.in.in Cancer" ,ind "Dif-
308
NEW ! Patient Therapy Packs
Because many patients tend to
stop treatment prematurely, the
full course of bid. therapy is
now specially packaged to
encourage patients to complete
the full course of therapy.
CANDEPTIN Vaginal Ointmeni
Therapy Pack— two 75 gm. lubes
CANDEPTIN Vagetettes
Therapy Pack— 2S vaginal capsules
CANDEPTIN Vaginal Tablet
Therapy Pack—2S vaginal tablets
Krici Summarv
Description: Candeptin (Candicidinl Vaginal
Ointment contains a dispersion of Candicidin
powder equivalent to 0.6 mg. per gm. or 0.06%
Candicidin activity in U.S.P petrolatum 3 mg.
of Candicidin is contained in 5 gm. of oint-
ment or one applicatorful Candeptin Vaginal
Tablets contain Candicidin powder equivalent
to 3 mg. (0.3%) Candicidin activity dispersed
in starch, lactose and magnesium stearate.
Candeptin Vagelettes Vaginal Capsules
contain 3 mg. of Candicidin activity dispersed
in 5 gm, U.S.P petrolatum.
Action: Candeptin Vaginal Ointment. Vaginal
Tablets, and Vagelettes Vaginal Capsules
possess anti-monilial activity.
Indications: Vaginitis due to Candida albicans
and other Candida species.
Contraindications: Contraindicated for pa-
tients known to be sensitive to any of its com-
ponents. During pregnancy manual Tablet or
Vagelettes Capsule insertion may he pre-
ferred since the use of the ointment applicator
or tablet inserter may be contraindicated.
Caution: During treatment it is recommended
that the patient refrain from sexual inter-
course or the husband wear a condom to
avoid re-infection.
Adverse Reaction: Clinical reports of sensiti-
zation or temporary irritation with Candeptin
Vaginal Ointment. Vaginal Tablets or
Vagelettes Vaginal Capsules have been ex-
tremely rare.
Dosage: One vaginal applicatorful of
Candeptin Ointment or one Vaginal Tablet
or one Vagelettes Vaginal Capsule is in-
serted high in the vagina twice a day, in the
morning and at bedtime, for 14 days. Treat-
ment may be repeated if symptoms persist or
reappear.
Available Dosage Forms: Candeptin Vaginal
Ointment is supplied in a Patient Therapy
Pack, containing two 75 gm, lubes with two
applicators for the full course of treatment.
Candeptin Vaginal Tablets are packaged in
boxes of 28. in foil with inserter — enough
for a full course of treatment, Candeptin
Vagelettes Vaginal Capsules arc packaged in
a Patient Therapy Pack, containing
28 Candeptin Vagelettes Vaginal Capsules
(2 boxes of 14). for the full course of treat-
ment. Store under refrigeration to insure full
potency.
Federal law prohibits dispensing without pre-
scription.
References:
I. Melges, F J.: Obstet. Gynecol. 24:92\, Dec.
1964. 2. Cameron, P F: Practitioner 202:695,
May 1969, 3. Olsen. J. R.: Journal-Lancet 85:
287, July 1965. 4. Giorlando. S, W.: OB/GYN
Digest /.!:32. Sept. 1971. 5. Decker. A,: Case
Reports on tile. Medical Department. Julius
Schmid. 6. Friedel. H. J,: Md. State Med. J.
/.'!:36, Feb, 1966, 7. Roberts. C L and Sulli-
van,J.J, :Calif, Med. /0i:109. Aug. 1965, S.Gior-
lando. S, W, Torres, J. F and Muscillo. G.: Am.
J Obstet, Gynecol, 90:370. (Jet. 1. 1964.
9. Ahru77i, W, A,: Western Med, .5:62, Feb.
1964
innovators in candicidin therapy
f/l SCHMID Vol 35 NoJ
L^ j LABORATORIES INC
Wmm^^ LlITlf (ALLS NEW |IRSfV07424
Gandeptin^
(eandicidin)
The highly effecrive
monilia-cide with
high cure rates
proved clinically.''
■ the only eandicidin available in three dosage forms
for complete therapeutic flexibility— even for adoles-
cent and gravid patients.
■ Symptomatic relief in many patients as early as
48-72 hours'"'; usually cures in a single 14-day course
of therapy.
■ Exact dosage assured when used as directed.
■ High patient acceptability, easy to use in all forms;
helps keep patients on the full 14-day regimen —
important in controlling recurrences.
■ Clinically proved— CANDEPTIN Vaginal Ointment
and Vaginal Tablets have more than nine years of
clinical experience.
■ Sensitivity and temporary irritation with
CANDEPTIN (eandicidin) Vaginal Ointment, Vaginal
Tablets, and VAGELETTES Vaginal Capsules have
been extremely rare.
And a dosage form for all your patients
>. . VAGELETTES
)
Vaginal Capsules
Vaginal Ointment
Vaginal Tablets
ficult Office Gynecology." Invited guest speakers include
Dr. J. Donald Woodruff. Baltimore. Mar\land; Dr.
Herbert Buchsbaum, Iowa City, Iowa; and Dr. J. Taylor
Wharton. Houston, Texas.
Credit: A.-\FP credit applied for.
For Information: W. T. Creasman, M.D.. Director of Gyne-
cologic Oncology, P. O. Box 2079. Duke University
Medical Center. Durham 277 10
News Notes from the —
UNIVERSITY OF NORTH CAROLINA
DIVISION OF HEALTH AFFAIRS
October 20-22
.Annual Joint .Meeting of the North Carolina-South Carolina
Societies of Ophthalmology and Otolaryngology
Place: .-^sheville Hilton Inn, .Ashe\ille. N. C.
Sponsor: The North Carolina Society of Ophthalmology and
Otolaryngology
For Information: Banks Anderson, Jr., M.D., Secretary-
Treastirer. P.O. Box 3802. Duke University Eye Center.
Durham 27710
October 28-November 1
Radiology Postgraduate Course
Place: Southampton Princess Hotel, Southampton. Ber-
muda
Program Chairman: Richard G. Lester, M.D., Professor and
Chairman of Radiology, Duke University Medical Center.
Guest speakers will include: Robert G. Fraser, M.D..
Professor and Chairman of Radiology. McGill University
Medical School. Montreal. Canada; John A. Evans. M.D..
Professor and Chairman of Radiology. Cornell University
.Medical College; William B. Seaman. M.D., Professor
and Chairman of Radiology. Columbia University College
of Physicians and Surgeons. New >'ork, N. Y.: Harold G.
Jacobson. M.D.. Professor and Chairman of Radiology.
.Mbert Einstein Colleee of Medicine (MHMCl. Bronx.
New York; and David H. Baker. M.D.. Director of Ra-
diology. Babies Hospital. Professor of Radiology. Colum-
bia University College of Physicians and Surgeons. New
York. N. Y. Subject matter will cover Pediatric and .Adult
Radiology of the Chest. Genitourinary Tract. Gastroin-
testinal Tract and Musculoskeletal Svstem.
Fee: S200
Credit: Twenty-three hours .A.M.A "Category One" accredita-
tion
For Information: Robert McLelland. M.D.. Department of
Radiology. Box 380S, Duke Universitv Medical Center.
Durhanf27710.
Loan Materials .Available
A packet of materials to help you Train Your Own .■\ssis-
tant is available to members on a loan basis from Medical
Society headquarters. It includes a color TV tape cassette,
practice forms for planning and evaluation, and TV tape
evaluation report forms. For more information write NIr.
Gene Sauls. North Carolina Medical Society. P. O. Box
27167. Raleigh 27611.
IN CONTIGl OL S STATES
September 30 & October 1
Tennessee Valley Medical .Assembly annual meeting
For Information: Thomas L. Buttram. M.D.. Chairman.
Tennessee Valley Medical Assembly. Whitehall Medical
Center. 960 E. Third Street. Chattanooga. Tennessee
37403
October 5-8
Southern Psychiatric .Association annual meeting
Place: The Homestead. Hot Springs. Virginia
For Information: Mrs. .Annette Boutwell. P.O. Box 10387.
Raleigh 2760.S
Items submitted for listincs should be sent to: WHAT?
WHEN? WHERE '. P. O. Box 8248. Durham. N. C. 27704.
by the 10th of the month prior to the month in which
they are to appear.
310
Paul Roger Van Ostenberg was recently appoinu
assistant professor in the Department of Denl
Ecology. UNC School of Dentistry. He received 1
B..-\. at the University of South Florida and 1
D.D.S. at the Medical College of Virginia. He com
to UNC from the University of \'irginia Hospital ai
Medical School where he was director of dental ed
cation. Child and Youth Center, and an assistant pr
fessor.
* * *
Dr. Eugene Wright has been elected president
the Research Triangle branch of the American Assl
ciation for Laboratory Animal Science. He is a clii
cal veterinarian for the UNC Medical School's
vision of Laboratory .Animal Medicine. Dr. Wrig
joined the UNC faculty in 1972 after a year on t
Texas A & M University faculty where he receiv
his D.N'.M. and M.S. degrees.
Frederic C. Shorter, professor, part-time. Depa
ment of Biostatistics. resigned Dec. 31 to accept
position with the Population Council in New Yo
City.
* * *
Joe T. Wall, Department of Operative Dentist;
UNC School of Dentistry, has been promoted to ■
sociatc professor.
Promotions to assistant professor in the U>
School of Medicine include: Jonathan R. Davidsc
psvchiatry; Hanson Y. Chuang. patholog\' and b
chemistry and nutrition: Barr\' R. Howes, physii
therapv; James A. Merchant, medicine: and Wayl
Nopanitaya, pathology.
* * *
Herbert A. Cooper, assistant professor. Depa
ments of Pathology and Pediatrics, currently is co:
pleting a residency and postdoctoral traineeship
the UNC School of Medicine. He received his B.
and M.D. degrees at the University of Kansas.
J. W. Edgerton, professor. Department of ?!
chiatry, is on leave for the entire 1974 year to assui
duties as South Central Regional Mental Hea
director. Division of Mental Health Services, N.
Department of Human Resources.
James J. Murphy, assistant professor. Departmt
of Radiology, resigned March 31 to enter privi
practice.
James L. Howard, assistant professor, Departms
of Psychiatry, resigned April 30 to accept a positi
with Btirroughs-Wellcome.
Vol. 35. No
Single-car crashes killed 1,247 drivers in North
irolina from 1970 through 1973. Of these, 851
wo-thirds) were either under the influence of alco-
il or had been drinking.
Dr. Arthur J. McBay, chief toxicologist for the of-
e of the chief medical examiner, announced these
idings upon completion of a four-year study con-
victed at UNC-Chapel Hill.
* * *
llf present trends continue. North Carolina will
end $500 million on rehabilitating alcoholics be-
leen now and the end of the century, according to
•. John A. Ewing, director of the Center of Alco-
d Studies at UNC-Chapel Hill.
^Unless something is done to prevent the dcvelop-
ent of new cases, there will be more North Carolin-
is with alcoholism in the year 2000 than the
J li'O.OOO cases we presently have, Ewing said.
ilHe made the remarks before the newly established
brth Carolina Alcoholism Research Authority of
iiich he has become the first executive secretary,
wing's message also is being delivered to all mem-
irs of the General Assembly now in session.
* + ^
Three UNC School of Medicine faculty members
; studying acupuncture and medication to deter-
^ne which lowers high blood pressure more ef-
[:tively. The study began this year when Dr. James
bods, professor of medicine, and R. A. Mueller, a
.D. in Pharmacology, set up a study to examine the
:ects of the two most commonly prescribed drugs
iren to patients with "essential" hypertension. Es-
&tial hypertension means there is no known organic
jse.
Dr. Kenneth Sugioka, chairman of the Department
4Anesthesiology, decided to investigate claims that
il'apuncture is highly effective in the treatment of hy-
ftension. "These claims have to be given credibility
■iquashed," he said.
(The three researchers have received a $36,000
,int from the National Heart and Lung Institute for
I combined study, only the second grant given in
j:U. S. for the study of acupuncture.
5 * * *
A research project which ultimately may reduce
" incidence and severity of byssinosis (biss-eh-no-
) among cotton textile workers will be conducted
Ithe School of Medicine at UNC-Chapel Hill and
i School of Textiles at North Carolina State Uni-
isity.
Often called "Monday fever," byssinosis is the only
ipiratory condition of cotton workers in which chest
atness, coughing, and wheezing have their onset on
ii first day of the working week. Symptoms usually
^appear an hour or so after leaving work, but they
y reappear on subsequent workdays after con-
ned exposure. It is believed that irreversible ob-
fictive airway disease eventually appears.
The research project is being funded by a grant
':\W< 1974, NCMJ
f/
from Cotton Incorporated. Dr. Mario C. Battigelli,
associate professor of medicine and a recognized au-
thority on byssinosis, will direct research at UNC-
Chapel Hill. Dr. Richard Gilbert, professor of textile
chemistry at NC State University, will direct the re-
search at the School of Textiles. Dr. Janet Fischer,
associate director of the microbiology laboratory at
N. C. Memorial Hospital in Chapel Hill, will conduct
bacteriological studies of the dust samples and moni-
tor use of the dust to prevent bacterial and fungal
contamination.
* * *
Dr. Berton Kaplan, an avid tennis player and a
member of the UNC School of Public Health faculty
at Chapel Hill, thinks there is a relationship between
health and the way people play outdoor games. With
tongue in cheek, he describes his ideas in "Specula-
tions on the Health Consequences of Tennis Playing
Styles," part of a forthcoming book entitled Tennis
Psychology edited by Dr. Claude Frazier. Dr. Kaplan
is a professor of epidemiology in the UNC School of
Public Health.
* ^ ij;
The professional library of the late Dr. Min-
del Cherniack Sheps, former professor in the UNC
School of Public Health's Department of Biostatistics,
has been donated to the University's Health Sciences
Library.
Myrl Ebert, chief librarian, said the gift was made
through the generosity of the late Dr. Sheps' hus-
band, Dr. Cecil G. Sheps, UNC vice chancellor for
health sciences in Chapel Hill.
The collection, given in the late Dr. Sheps'
memory, will be known as the Mindel C. Sheps Col-
lection in Biostatistics and Mathematical Demog-
raphy. It contains 400 volumes and reflects Dr.
Sheps" interests during her distinguished career.
* * *
The UNC School of Public Health began its newest
off-campus master's degree program in Asheville dur-
ing February. Dr. Bernard G. Greenberg, dean of
the school, said the program was designed in coopera-
tion with the Area Health Education Center program,
the School of Public Health, and UNC at Asheville.
Like the School of Public Health's first such pro-
gram in Raleigh, the new one will focus on health ad-
ministration. It is designed to improve health and
human services administration.
Ms. Lydia Holley of the UNC School of Public
Health will direct the Asheville program.
^ ^ ^
The UNC School of Dentistry has received a
$128,000 general research support grant from the
National Institutes of Health in Washington, D. C.
Announcement of the grant was made by Dr.
James W. Bawden, dean of the School at Chapel Hill.
This year's grant is a major increase over the $69,000
received last year, Bawden said.
The one-year grant will be used to fund support fa-
311
cilitics within the Dental Research Center as well as
oral health related research and research training,
according to Dr. Gary R. Smiley, principal inxcstiga-
tor and actins associate dean for research.
News Notes from the —
DUKE UNIVERSITY MEDICAL CENTER
Dr. James B. Sidbury. Jr., says Americans have
been taught to believe that a fat. round baby is a
healthy baby and that a healthx child must eat a set
amount of food e\ery da\. He bclie\cs that this earl\
training leads to a pattern of o\ creating which is the
main factor in childhood obesity. Sidbiuy sa\s that
SO percent of fat children end up as fat adults.
Sidbtn-y, chief of pediatric metabolism and director
of clinical research at Duke, began three \ears ago
dcxeloping a diet program for treating obese chiUlren.
The diet program begins with either a fom-ilaN
sta\ in the hospital, or a month-long stay for the
grossK obese who need medical attention while diet-
ing. Those uho must stay for a month are supported
by research funds. The most important part of the
hospital sta> is education in diet and dieting.
* * *
The Pharmaceutical Manufacturers Association
Foundation has awarded a two-year research starter
grant to Dr. X'incent W. Dennis. The $10,000 grant
will help establish a laboratory in Duke's Division of
Nephrology to study how substances are transported
across renal tubular cell membranes.
Two officials of the medical center are among the
ten winners of this year's .Awards for Distinguished
Achievement presented by Modern Mai^azine. The
two are Dr. William G. Aniyan, vice president for
health affairs and professor of surgery, and Dr.
James B. Wyngaarden, professor and chairman of the
Department o\' Medicine.
:;: * :;;
Four appointments at the medical center have been
announced b\ Universitv Provost Frederic N. Cleave-
land.
Appointed to assistant professorships are Dr.
James E. Hall, physiology; Dr. Edward W. Holmes,
medicine; Dr. Robert David Nebes, medical psy-
chology; and Dr. John L. Sullivan, psychiatry.
* * *
Twelve Duke researchers are among 36 throughout
the state who have been approved for grants-in-aid
this year by the N. C. Heart Association (NCHA).
In addition to the $S8,73S in grants-in-aid, the as-
sociation also supports senior research investigators
at the three medical schools, making current NCHA
support to state researchers SI 24.738. In addition.
Rondomycii
(methacycline HCI)
CONTRAINDICATIONS: Hypersensitivity to any of the tetracyclines
WARNINGS Tetracycline usage during lootti development (last halt ot pregnancy to eii
years) may cause permanent lootfi discoloration lyellow-gray-brown), which is ni
common during long-term use but has occurred after repealed shori-lerm cou(S>
Enamel hypoplasia has also been reported Tetracyclines should not he used in this 2
group unless other drugs are not likely to be elteclive or are contraindicsti
Usage in pregnancy. (See above WARNINGS about use dunng tooth developm^^i
Ammal studies indicate thai tetracyclines cross the placenta and can he toxic to the 1
velopmg tetus (often related lo retardation of skeletal development} Embryo toxicity t"
also been noted m animals treated early m pregnancy
Usage in newhorns. infants, and children. (See above WARNINGS about use dvt
tooth development )
All tetracyclines form a stable calcium complex in any bone-forming tissue A decre.
m libula growth rate observed m prematures given oral tetracycline 25 mg/kg everi
hours was reversible when drug was discontinued
Tetracyclines are present m milk of laclatmg women taking tetracyclines
To avoid excess systemic accumulation and liver toxicity in patients with impaired re
function, reduce usual total dosage and, it therapy 15 prolonged, consider serum level >
terminations ot drug The anti-anabolic action of tetracyclines may increase BUN. Wf
not a problem in normal renal function, m patients with significantly impaired luncin
higher tetracycline serum levels may lead lo azotemia, hyperphosphatemia, and aciflos
Photosensitivity maniiested by exaggerated sunburn reaction has occurred witfi tel
cyclmes Patients apt to be exposed to direct sunlight or ultraviolet light should be so ;
vised, and treatment should be discontinued at first evidence o( skin erythema
PRECAUTIONS: It superinfection occurs due to overgrowth of nonsusceptible oiganisi
including fungi, discontinue antibiotic and slari appropriate therapy
In venereal disease when coexistent syphilis 15 suspected perlorm darklield exai
nation before therapy, and serologically lest (or syphilis monthly lor at least four monit
Tetracyclines have been shown to depress plasma prothrombin activity, patients on i
ficoagulant therapy may require downward ad|ustment of their anticoagulant dosage
In long-term therapy, perform periodic organ system evaluations (including bio;
renal, hepatic)
Treat all Group A beta-hemolytic streptococcal infections tor at least 10 days
Since bactenostatic drugs may interlere with the bactericidal action of penicillin, z^
giving tetracycline with penicillin
ADVERSE REACTIONS: Gastrointestinal (oral and parenteral forms) anorexia, naus'
vomiting, diarrhea glossitis, dysphagia, enterocolitis, inflammatory lesions (with moi
lal overgrowth) m the anogenilal region
Skin' maculopaputar and erythematous rashes, exfoliative dermatitis (uncommon). Pi
foipn'^hvitv IS discussed above (See WARNINGS)
Renal toxicity: rise in BUN, apparently dose related (See WARNINGS)
Hypersensitivity: urlicana, angioneurotic edema, anaphylaxis, anaphylactoid purpui
pericarditis, exacerbation of systemic lupus erythematosus
Bulging fontanels, reported m young infants alter full therapeutic dosage, have disi
peared rapidly when drug was discontinued
Blood: hemolytic anemia, thrombocytopenia, neutropenia, eosmophiha
Over prolonged periods, tetracyclines have been reported to produce brown-black 1
croscopic discoloration of thyroid glands, no abnormalities of thyroid function studies,
known lo occur
USUAL DOSAGE Adults- 600 mg daily, divided into two or four equally spaced doS'
fvlore severe infections an initial dose of 300 mq lollowed by 150 mg every six hours
300 mg every 12 hours Gonorrhea In uncomplicated gonorrhea, when penicillin is C(
tramdicaled. Rondomycm (methacycline HCi) may be used tor treating both males 3
females m the following clmical dosage schedule 900 mg initially, followed by 300 1
q I d for a total of 5 4 grams
For treatment of syphilis, when pemcillm is contraindicated, a total ot 18 to 24 grams
■Rondomycm' (methacycline HCl) m equally divided doses over a period of 10-15 di
should be given Close follow-up. including laboratory tests, is recommended.
Eaton Agent pneumonia 900 mg daily for six days
Children - 3 to 6 mg/lb/day divided into two to four equally spaced doses
Therapy should be continued for at least 24-48 hours after symptoms and lever fi;
subsided
Concomitant therapy: Antacids containing aluminum, calcium or magnesium impair;
sorption and are contraindicated Food and some dairy products also interfere Give di
one hour before or two hours after meals Pediatric oral dosage forms should not
given with milk formulas and should be given at least one hour prior to feeding
In patients with renal impairment (see WARNINGS), total dosage should be decrea;
by reducing recommended individual doses or by extending time intervals betwt
doses
In streptococcal infections, a therapeutic dose should be given lor at least 10 days
SUPPLIED: Rondomycm' (methacycline HCI) 150 mg and 300 mg capsules, syrup Ci
tcimng 75 mqlb cc methacycline Hl^l
Before prescribing consult package circular or latest PDR information.
kWWi WALLACE PHARMACEUTICALS
kVi CRANBURY. NEW JERSEY 08512
Rev f
312
Vol. 35. Noj
,[ra package insert in many in-
lances. This would constitute a
1 i bstantial saving for the manu-
'cturer.
By a complete compendium,
lo not mean a volume of prohibi-
'6 size. You don't need a book
jscribing 25,000 products with
ii enormous amount of repetition,
lather, drugs should be arranged
'Class. Mutually applicable infor-
,|3tion would be provided, along
ith brief discussions pinpointing
Sferences in specific drugs of
at class. Listings would be cross-
tfjexed in a useful way.
Hher Available Documents as
urces of Information
Existing references such as
)R and the AMA Drug Evaluation
B obviously useful but they are
;omplete. Either they are not
Dss-referenced by generic name
, d do not group drugs with simi-
■^ characteristics, or they do not
l!:all the available and legally
uirketed drugs. And some of
I )se omitted may be very useful.
On the other hand, drugs made by
more than one supplier, tetracy-
cline for example, may be fully
described a dozen times in the
same book.
While perhaps PDR could be
rearranged and cross-indexed with
generics included, and while the
AMA Drug Evaluation might also
be modified and expanded, I am
not sure that the end result would
have all the attributes required for
a useful compendium. At the same
time, you would run the risk of
amassing a voluminous and un-
wieldy tome.
Should Editorial Comments
Accompany the Listings?
Subjective judgments, in my
opinion, have no place in a com-
pendium. However, if there is sub-
stantial evidence based on a sound
body of science concerning rela-
tive efficacy of several drugs, cer-
tainly that information should be
included. The committee of experts
compilingand editinga particular
section would also have to assess
and indicate instances where a
meaningful difference between
drugs is pertinent.
Sponsorship, Compilation
and Editing
Producing a book like this
would undoubtedly be difficult and
demanding. It would obviously take
a great deal of talent and exper-
tise, and would require a varied
and experienced group, ranging
from writers and editors to highly
skilled clinicians and pharmacolo-
gists. Style, format and clarity of
language would play an important
part in determining the usefulness
of the book. And it should be up-
dated periodically and completely
revised annually.
I have no opinion whether the
government or the private sector
should sponsor and/or finance the
compendium. What is most im-
portant is that the compendium be
an authoritative, objective and
useful source of information for
the doctor to have at hand as a
ready reference.
: 3uld in no way imply control over
; i practitioner's prerogatives.
ly Another Compendium?
A practicable, single-volume
mpendium cannot, nor is it
icessary to, include all drugs on
■ ; market today. From my prac-
■18 of internal medicine for some
', years, my experience as a con-
" tant, and as a faculty member
("'our or five medical schools, I
';:uld estimate that a doctor uses
( y 30 to 35 drugs regularly. The
72 Physicians' Desk Reference,
i identally, contained about
i.iQOentries.
As to whether there should be
; 3deral compendium, in my opin-
it, as stated earlier, the answer is
f ;y— there should not be one. The
I, iposal assumes that existing
(: npendia are inadequate. We're
I :sureof that at all. Whatever its
i'' perfections, the present drug
i Jrmation system in the U.S. is
( ;n, multifaceted, pluralistic and
f ensive. Good compendia exist,
i A/ell as other ample sources on
t gtherapy, ranging from journal
I rature through AMA Drug Evalu-
c )n to company materials. Not
c Dhysicians may use such
-' rces as often or as well as they
SiJld, but that is the fault of the
< O, not of the sources.
I Inany event, rather than pro-
duce another book, it makes much
more sense to work on improving
existing compendia, and perhaps
they could, as knowledge ad-
vances, include more accumulated
clinical data and experience, and
more information on drug interac-
tions and adverse reactions.
Implications of a Federal
Compendium
Take a hard look at the impli-
cations of a federal compendium.
It would have the force of law, vir-
tually dictati ng what drugs to use
and how to use them. In effect, it
would be a regulatory document
with legal or quasi-legal status,
posing medical/ legal problems
similar to those the doctor may
now encounter if and when he de-
parts from the provisions of the
package insert. A compendium
under federal aegis would tend to
restrict decisions on drug therapy
to one orthodox level — a most
dangerous trend for medicine.
New Compendium — A Medical
Option
I detect no ground swell of
initiative or support whatsoever for
a federal compendium — or, for
that matter, for a new compendium
of any type. A 1969 PMA survey
conducted by Opinion Research
Corporation found that only 15 per
cent of those physicians inter-
viewed felt a new compendium was
needed. And a large majority did
not favor the involvement of the
federal government if one were to
be created, preferring instead a
nongovernmental consortium.
Even if we come to a time
when the medical profession itself
opts for a new kind of compendium,
it should be handled and financed,
ideally,outside both government
and industry. Final review and edi-
torial authority could be delegated,
say, to specialty bodies and medi-
cal societies — but above all, not
the government.
Surely the health care system
in the United States has far more
vital matters to consider than the
extensive cost and effort that
would have to go into the prepara-
tion and maintenance of a new,
monolithic compendium, and
especially one bearing the impri-
matur of the federal government.
Opinion & Dialogue
What is your opinion, doctor? We
would welcome your comments.
The Pharmaceutical
Manufacturers Association
11 55 Fifteenth Street, N.W.
Washington, D.C. 20005
d^
the American Heart Association currently is granting
$305,312 for research to North Carolina scientists.
The Duke researchers receiving grants-in-aid this
year are: Drs. Robert M. Bell, Lee E. Lim-
bird, Lewis Thomas Williams, Walter N. Duran,
Harold C. Strauss, Harry Clark Beall, Page A. W.
Anderson, Ronald Stephen Aronson, Charles R. Hor-
res, Walter G. Wolfe, Robert W. Anderson, and Wil-
liam C. Devries.
* * *
Duke and Burroughs-Wellcome Co. will launch a
cooperative program in clinical pharmacology de-
signed to enhance the development and testing of
new drugs.
Representatives of the medical center and the
pharmaceutical company have signed a three-year,
renewable agreement setting up a Wellcome Unit in
the Division of Clinical Pharmacology at Duke.
The unit will be staffed by a group leader and
members who are full-time faculty members
of Duke. They will ha\e joint appointments
in the Pharmacology Di\ision and in one of the medi-
cal center's clinical departments. A grant from Bur-
roughs-Wellcome to the university will pay for sala-
ries and supplies for the unit.
News Notes from the —
BOWMAN GRAY SCHOOL
OF MEDICINE
WAKE FOREST UNIVERSITY
The Bowman Gray School of Medicine has re-
cei\ed a S53.I99 grant from the National Fund for
Medical Education to develop a new audiovisual
self-instructional course in radiographic anatomy.
Dr. Joseph E. Whitley, professor of radiology,
heads the program which will be a cooperative effort
between the departments of anatomy and radiology
of Bowman Gray and the State University of New
York, Downstate Medical Center, in Brooklyn.
If the program proves successful it will be made
available to other medical schools.
The two-year grant, effective July 1, is intended to
help provide more efficient teaching methods to allow
the future physician to learn what he must know to
give patients the best possible care.
While the new course will be developed primarily
for freshman anatom\ students, it may also be used
by advanced medical students, interns, and residents
who would like to re\iew the material.
Working with Dr. Whitley will be Dr. Lucy Frank
Squire, professor of radiology at the State University
of New York, Downstate Medical Center, and Dr. L
Meschan, professor and chairman of the Department
of Radiology at Bowman Gray.
They plan to ha\e a prototype of the program
318
ready this fall for use in teaching freshman anatom;
students at both institutions. The final prototype i:
scheduled to be completed next year.
The project will include the production of II
audiovisual programs with a running time of about 3(
minutes per student per session. Each student will bs
pre-tested before beginning the course.
The schedule calls for students at Downstate Medi
cal Center to receive the new course. Bowman Gra;'
students will be given the new course in addition t(
a formal 12-hour course in radiographic anatomy
These students will be tested upon completion o
the course and test scores will be compared to score
from the same test which will be given to a forme
class at Bowman Gray which received only the 12
hour course in radiographic anatomy and a forme
class at the Downstate Medical Center which receivcc
no course in radiographic anatomy.
* :;: ;^
Dr. Frederick Kremkau, research instructor ii
medicine and a research associate in neurology, ha
been appointed to the Bioacoustics Standards Com
mittee of the Acoustical Societ\ of America. He ha
been appointed to the Ultrasonics Task Force of th
National Science Foundation, and has been appointee
as a consultant to the National Science Foundatio:
for a period of one year, with an area of service i:
experimental Research and Development.
* :;; *
The North Carolina Chapter of the Arthritis Foun
dation has awarded an $875 fellowship grant to th
medical school to support a student doing arthriti
research this summer.
The research will be conducted in the school'
Rheumatology Unit under the direction of Dr. Ro
bert A. Turner Jr.. assistant professor of medicine
The student recipient of the fellowship will b
named later. * * *
Dr. Hugh B. Lofland. professor of pathology, ha
been selected to serve on the editorial board of th
Experimental and Molecular Pathologx' Journal.
Dr. Clark E. \incent, professor of sociology, spok
on "The Impact of Business-Industry on Marital an
Family Health"" March 18 during the annual mcetin
of the Southeastern Council on Famil_\ Relations i
Tuscaloosa, Ala. * * *
Dr. Paul M. James Jr., associate professor of sui
gery, has been named a representative director c
section 4-A of the Uni\ersity .Association of Emci
gency Medical Services.
Dr. James G. McCormick. research associate pre
fessor of otolaryngology, spoke on ""Sudden Hearin
Loss Due to Diving and Pre\ention with Heparin
during the First Symposium on Fluctuant Hearin
Loss, sponsored by the Department of Otolar_\r
gology and Maxillofacial Surgery of the University c
Tennessee College of Medicine.
Vol. 35. No.
t AMERICAN ACADEMY OF ALLERGY
:)r. Susan Coons Dees has been elected \ice presi-
t of the American Academy of Allergy. She is
■first woman to hold a position on the Academy's
;;utive committee.
i graduate of the Johns Hopkins University
ool of Medicine, and u member of the Duke
ilty since 1939, Dr. Dees is author of 58 articles
various subjects pertaining to allergy,
'.isted in IVho's Who in American Women and
o's Wlu) in the South, she served on the White
ise Conference on Children and Youth in 1960
' is a past-president of the N. C. Pediatric Society
the Southeastern Allergy Association.
ier professional memberships include the South-
^. Society for Pediatric Research, the American
iatric Society, the American Academy of Pediat-
the AMA, the Southern Medical Association,
the Medical Society of the State of North Caro-
ls
(er husband. Dr. John Decs, is a professor of urol-
at Duke.
JOINT COMMISSION ON
ACCREDITATION OF HOSPITALS
it its December meeting in Chicago, the Board
iTommissioners of the Joint Commission on Ac-
jlitation of Hospitals (JCAH) took action on rec-
oendations with regard to the following:
:. The process of developing a plan concerning
future organizational structure, direction, opera-
jal mechanisms of the Joint Commission, and
l;r related items.
:. Joint Commission standards: to make available
: recently approved standards for Nonhospital
ters for Ambulatory Health Care and Neighbor-
id Health Centers.
3. The governing body and medical staff relation-
ships: approval of new language to be added to the
Accreditation Manual jar Hospitals in the following
sections — "Governing Body and Management,"
"Medical Staff," and "Medical Record Services."
4. The modification of the Hospital Accreditation
Program's policies on confidentiality.
5. The JCAH policy which presently permits appli-
cation for survey by a nonaccredited hospital six
months after the date of nonaccreditation, in rela-
tion to the JCAH/CMA surveys.
6. A new budget of appro.ximutely $6,700,000
for 1974.
Details of these and other actions of the Board
will be covered in future editions of the Joint Com-
mission's newsletter Perspectives.
New Yideo Presentation Instructs In Ph>siologic
Changes Affecting Mature Women
The latest video presentation from the Ayerst
Laboratories. "Physiology and the Emotions in the
Mature Woman." is now available for viewing.
Based on the Symposium on Physiologic Bases for
Emotional Disorders in Women, at the New York
Academy of Medicine, October 16. 1972, the film
presents the diagnostic and therapeutic implications
of physiologic changes affecting women in their mid-
dle years.
The film is made with Drs. Charles W. Lloyd,
Charles E. Flowers, Jr., Robert N. Rutherford, and
Judd Marmor. It uses portions of the symposium,
office and hospital sequences, animation, and scien-
tific footage.
For more information write to Ayerst Labora-
tories, 685 Third Ave., New York, N. \'. 10017,
Attn: Averst Medical Information Service.
Month in
Washington
m
ihe American Medical Association is playing a
' ing role in an attempt to establish an American
)1 d commission that would assure a national. \ol-
ir cr supply of blood for transfiisions and medical
sr rgencies by December 31,1 975.
it a press conference in the AMA — Washington
)f e. the plan was made public by Richard E.
^ ler, M.D., now chairman of the AMA Board of
f- tees, and spokesman for the major groups in-
\^b 1974. NCMJ
I
vohed in collecting, distributing and using blood.
Other major sponsors of the proposed American
Blood Commission include the American National
Red Cross, the American Association of Blood
Banks, and the Council of Community Blood Cen-
ters.
The proposed plan is for a volunteer program con-
trolled at the local level, with medical societies play-
ing a major role. Some 150 national groups with
319
t
an interest in a safe blood supply would be mem-
bers of a commission tfiat would oversee each re-
gional program. The regional programs in turn would
guide the activities of blood banks and transfusion
facilities in their own area.
Last fall the Administration warned that if the
private sector could not reach agreement on a na-
tional program, a federally-mandated program would
be sought from the Congress. The AMA stepped in
and mediated the sharply different approaches ad-
vocated by the major blood groups.
The major difference had pitted a for-profit against
nonprofit blood supply. In the nonprofit field, the
American ,\ssociation of Blood Banks (AABB) and
the American National Red Cross have vied for the
leadership role. The nonprofit blood banks — largely
hospital units — chiefly have favored a nonreplace-
ment fee for blood as the most dramatic way of
attracting donors, whereas the Red Cross tradition-
ally has relied on strictly volunteer blood.
Under the proposed plan, the for-profits would
be out in the cold. The hope is that a nonreplace-
ment fee system will not be needed, although it would
be permitted.
The AMA-proposed plan has been published
the Federal Register in order to give interests
groups time to comment. At a later date HE'
will sponsor a conference to consider comments ai
decide a course of action.
Commenting on the proposal. Dr. Palmer told tl
news conference it "builds on the strengths of tl
pluralistic system."
"These partners in the American Blood Cor
mission can communicate the medical necessity of
dependable blood supply to the general public ha
which volunteer donors must come," he said. "Tl
systematic coordinated recruitment of volunteer do
ors called for by this plan depends on a recepti*
public attitude."
"By the end of 1975 every blood bank asso(
ated with one of the three major blood banking q
ganizations expects to be drawing 100 percent
their blood supply from volunteer donors," Dr. P;
mer said.
* * *
The .'\merican Medical Association has warn(
Congress that the legislation before it would tre
the health sector as "one vast, monolithic publ
Facility, program and environment
allows the individual to maintain
or regain respect and recover with
dignity.
Medical examination upon admis-
sion.
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FOR MEDICAL INFORMATION C/
J. W WELBORN. JR., M.D.
MEDICAL DIRECTOR
919-275-6328
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with private bath and individual
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FELLOWSHIP HALL WILL ARRANGE CONNECTION WITH COMMERCIAL TRANSPORTATION.
320
Vol. 35. No.l
jility" with the Secretary of Health, Education and
islfare "a health care czar."
[ITestifying before the Senate hciilth subcommittee
, a bill sponsored by Senator Edward M. Ken-
idy, (D-Mass.), AMA President Russell B. Roth,
(D., termed the bill "one of the gravest steps to
' proposed concerning health care delivery." The
■•asure calls for replacement of Comprehensive
(;alth Planning and Regional Medical Programs by
1) I'ornial planning system coupled with public utility
cl Illations by state health commissions under HEW
JDcrvision. "We are opposed to the creation of pub-
:n ij utility type regulatory controls and the planning
C!| jlchanisms in this and similar measures," Dr. Roth
d.
^^ ilThe bill before the Senate health subcommittee
lis for a formal system of planning coupled with
jblic utility regulation by state health commissions
fider the supervision of the HEW Department. It is
rt of a comprehensive measure, extending certain
;blic health service programs and making sweep-
|; changes in the nature of the present Compre-
lisive Health Planning and Regional Medical Pro-
lims.
I'ln our view this extreme measure is unwarranted,
■ihout justification based on either experience or
\'.d. It carries serious potential for impeding a
•leficial development of medical care," Dr. Roth
:d.
He termed the bill an "unprecedented federal in-
ivement in matters which, under our federal sys-
1, have traditionally resided in state and local
yernments.
I'We must caution against the imposition of a mas-
2 bureaucratic control of the health care system.
:e expertise within governmental bureaucracy must
'questioned. We cannot afford to institute a system
ich can stifle meaningful competition, innovation,
ii development of appropriate health care services
11 facilities. The economic forces inherent in this
jiposal could defeat the intention of this committee
t foster the developments of improvements in our
1 ilth care delivery system."
]i\ major provision of the legislation would require
t state health commissions "to determine pro-
s ictively rates used for reimbursement purposes for
I 1th services of health care providers within the
s :e and regulate all reimbursements if such health
c'e providers made on either a charge, cost, negoti-
£ d, or other basis and review such rates at least
c':e a year."
All of the authority ostensibly vested in the state
flies can ultimately rest in the HEW Secretary,
I Roth noted. He asked whether this means the
f eral government could :
—close down private health care institutions and
; federal facilities;
: — shut a municipal or state hospital; and
Y 1974. NCMJ
— regulate salaries, wages, collective bargaining
agreements of health care workers.
"Is the performance of the Secretary of HEW and
the Administration so exemplary and so unquestion-
able that he should be the ultimate repository of the
total authority over the entire health care delivery
system?" Dr. Roth asked.
The strengths of the present system which have
developed in the absence of structured planning
should not be overlooked, testified Dr. Roth.
"In our view the contemplated formal system of
planning, coupled with the public utility regulation,
cannot be justified," Dr. Roth said. "Nor should
the extreme governmentally mandated system of
planning and regulation be adopted without evi-
dence that such a plan can reasonably be expected
to succeed. We believe it is prudent to proceed on
an experimental basis so as to determine what mix
of voluntary planning together with governmentally
required planning proves to be the most effective in
specific regions of this country.
". . . In view of the potentially irreversible harm-
ful effects of the proposed system upon our health
care delivery system, we urge this committee to re-
ject any such proposal."
Dr. Roth was accompanied by James Sammons,
M.D., then chairman of the AMA Board of Trustees
and now Executive Vice-President designate.
* * ■■:■■
Congress dealt a mortal blow to the Adminis-
tration's plan to continue wage-price controls on
physicians, hospitals, and nursing homes after April
30.
The Senate Banking Committee voted 11 to 4
against a compromise plan that would give the Ad-
ministration standby authority to keep controls on
some industries after the April 30 cut-off when the
controls program expired. The Committee then
unanimously voted to kill the Administration pro-
gram to keep the lids on health while freeing the
rest of the economy.
House Banking Committee Chairman Wright Pat-
man (D-Texas), previously had predicted his panel
would not move to continue controls.
Barring an unexpected shift in Congressional sen-
timent, the control program is dead. Health provid-
ers, led by the AMA, waged a determined assault
on the Administration's program to extend controls
in health, promising legal action, and urging law-
makers to drop the entire controls apparatus.
Although Cost of Living Council Director John
Dunlop refused to concede defeat, talking bravely of
"other options . . . being explored through appropri-
ate legislative channels," most lawmakers agreed that
the Banking Committee had sounded the death
knoll to the Administration's unusually insistent drive
lo control the health segment of the economy.
Sen. John Tower (R-Texas), a member of the
Banking Committee, said most committee Senators
.121
believed that it is "time to let the marketplace be
allowed to work."
* :;: j(c
Despite a strong labor-backed move to the con-
trary, the House easily approved legislation allowing
self-employed people such as lawyers and physicians
to deduct from federal income taxes up to S7,500
a year provided it is placed in a qualified pension
plan.
The Senate had already approved the provision —
part of an overall pension reform bill — making
chances of final Congressional enactment and sign-
ing into law almost certain.
The current Keogh program limitation on tax de-
ferrals for retirement is $2,500 not to exceed 10
percent of income. The new provision allows .$7,500
not to exceed 1 5 percent of income.
Spokesmen for the provision, including the AMA,
urged lawmakers to approve on groimds that the cost
of living has increased dramatically since the Keogh
Law was last liberalized.
The legislation for the first time imposes certain
limitations on corporate retirement programs includ-
ing those for so-called professional service corpora-
tions. Tax deferrals will not be allowed on savings
that would exceed a pension that brings in more
than 75 percent of highest earnings over a three-
year period or $75,000 a year, subject to cost-of-
livine allowances in the future. A "srandfather-
elause" exempts people eligible for more than $75
()()() based on current compensation and addition;
period of employment.
* -C' *
.\ total of 203 areas have been designated fc
Professional Standards Review Organizatior
(PSRO's) by DHEW, 21 more areas than tentt
tixely proposed last December. Major change we
allowing two larger states — Georgia and Washinj
ton — to operate as single PSRO areas.
The final area designations — published in tl"
Federal Register — were handed down after a montf
long review of hundreds of comments from phy
cian groups.
"We have now reached an important milestone i
implementing the PSRO program," comment
HEW Secretary Caspar Weinberger. "Local phys
cian groups can now take the lead role in estal
lishing PSRO's for the areas we have designated
The most significant change in the final regul:
tion was naming Georgia and Washington as sing
PSRO areas. Both states have more than 5,000 ph;
sicians, and had been divided into three PSRO se
tions each. In the earlier proposed regulations, HEV
had indicated it would hew to the 2,500-3,000 ph;
sieian limit for a PSRO area. Many states and tf
AM.A had urged HEW to permit some states wit
higher ph\sician populations to serve as sing
PSRO's.
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322
Vol. 35, No.l
! Other changes included designating as a single
'ea Hawaii, American Samoa, Guam, and the Trust
irritories. These Pacific areas had been proposed
r two PSRO's.
^Increases or decreases in the number of PSRO
'sas within states accounted for the remaining
ianges. Texas was increased from 8 to 9 areas;
:ichigan from 8 to 10; Florida from 8 to 12; Cali-
'rnia from 21 to 28; and Wisconsin decreased from
to 2.
Iln addition, Illinois from 7 to 8; Indiana from
'to 7; Maryland from 5 to 7; New York from 14
' 17; North Carolina from 4 to 8; and Ohio,
pm 9 to 12.
jAll told, 31 states and territories will serve as
igle PSRO's 22 as multiple PSRO's.
,;HEW invited applications for contracts from quali-
^.'d physician organizations to plan PSRO's, to be-
1 operation of PSRO's on a conditional basis, or
■ establish statewide organizations to provide sup-
|rt services to local PSRO's.
j"We believe that PSRO's which are to be planned.
HI |erated, and controlled by private physicians can
liinificantly improve the quality of medical care ren-
Ted in institutions to beneficiaries of government
i^alth programs," said Weinberger.
[■"'For this reason, we have proposed that PSRO's
, expanded to monitor the quality of all services
ovided under the Comprehensive Health Insurance
•an which President Nixon recently submitted to
ongress."
The head of the PSRO program said the new
hltewide Support Center Plan would give large state
j'dical societies essentially what they sought in their
jht for single-state PSRO status.
: Henry Simmons, M.D., told AM NEWS that the
,^;ger states never intended to do the review and
}||indard setting on a statewide basis. According to
H'. Simmons, those states wished to provide the
lidership and support for PSRO in their states.
ow that makes a good deal of sense," the Deputy
sistant Secretary of Health said.
'"We see it (the statewide Support Center) as a
y in which state organizations can provide very
ortant leadership and very important services
ntrally, and that makes a lot of sense from our
indpoint, from the standpoint of efficiency," Dr.
jinmons said. "We see them as providing a very
Y 1974, NCMJ
1''
important role in getting the PSRO program started
in their states, using good will and leadership in
educating the profession. . . ."
The Statewide Support Center idea was one of the
major new announcements in the final PSRO area
designation rules.
Dr. Simmons was asked why Texas and other
state societies from large population states were
turned down in their bid for single PSRO area desig-
nations and why Georgia and Washington were
picked.
He said Texas is too big and diverse. "There are
too many major areas in that state which just don't
relate to one area for medical services — thus (it)
cannot be designated as a single-state area."
By contrast, according to Dr. Simmons, in both
Georgia and Washington "there is a concentration of
specialists and a majority of physicians in one par-
ticular area — in Georgia, the Atlanta area; in Wash-
ington, the Seattle-Takoma-Bremerton area."
Although present PSRO areas might be changed
in the future. Dr. Simmons indicated there was little
chance that any of the larger states would qualify
to join Georgia and Washington as single-state PSRO
areas. He said those two states, with more than 5,000
physicians each, were at "the upper limit" of physi-
cian population for a PSRO area.
Within hours after Drs. James Sammons and
Richard Palmer, representing the AMA Board of
Trustees, pressed a call upon energy czar William
Simon, with respect to the effect of gasoline short-
ages on physicians and their care of patients, Simon
wired a statement to all state governors suggesting
that they establish a special rule to assure adequate
gas for medical personnel and other essential public
services.
The statement read in part: "State and local gov-
ernments may want to consider establishing such a
procedure where long lines or early gas station clos-
ings could limit the mobility of doctors, nurses, and
other medical personnel in providing medical ser-
vices. Special accommodations also might be con-
sidered for those who provide other vital public ser-
vices."
"I urge your consideration of need for special ar-
rangement to assure gas to all those who perform
these essential public services, when it is necessary
to their work."
323
Book Reviews
Chemical and Biological Aspects of Drug Depen-
dence. S. J. Mule. Ph.D. ;ind Henrv Brill, M.D.
(edsl. 561 pages. Price S35.()0. Cle\eland. Ohio:
CRC Press, The Chemical Rubber Compan\. 1972.
This sensibly ordered collation of manuscripts by
reputable authorities deals with subject matter which
is of great concern and urgent necessity to medical
practitioners. It is clearly represented as a ■•reference
te.xt." and the editors make no claim of objectivit}
or special validity beyond what may be inferred by
the reputations of the various authors.
Certainly every physician should be as well in-
formed as possible about the effects, both beneficial
and harmful, of the chemical agents he prescribes
for his patients. Since physicians are granted the ex-
clusive right and responsibility for prescribing most
psvchotropic drugs that arc used or abused, or both,
in this countrv today, there should be sufficient prag-
matic concern on the part of physicians for retaining
this prerogative — that every care be taken to be well
informed, rational and prudent in prescribing the
psychotropic agents. This book is a valuable resource
for acquiring or updating that special knowledge
which is expected ot all prescribing physicians.
There are extensive up-to-date references at the
end of each section for those who wish to pursue
in greater depth >pecilic data or concepts. The classi-
fication of the psychotropic drugs of dependence,
as presented in this book, approaches a more rational
system for clinical applicabilitv than is to be foimd
in most textbooks.
\o\- whatever reasons, which 1 will refrain from
speculating upon here, the fields of "the psychotropic
drugs, drug abuse, addiction and dependencv"" have
remained complex and relatively obscure for manv
years, while other major medical problems have be-
come better understood, managed, or controlled,
owing to the dedicated efforts of medical scientists.
Perhaps this book represents one small step in the
right direction as it attempts to correlate and integrate
the presently existing information available on the
chemical and biological aspects of drug dependence.
I recommend to the editors and the publisher that
their next publication of urgent necessity be "The
Behaviorial and Psvchological .Aspects of Drug De-
pendence." to be compiled and edited with the same
protessional objectivity as is apparent in the presei
volume being reviewed.
\\ iLLiAM S. Pearson, M.D
Neonatolog>: Diseases of the Fetus and Infant.
RiLh.ird E. Behrm.in (edi. 698 pages. Price $39.50.
St. Louis: C. V. Mosb\ Conip,in>. 1973.
Dtuing the past ten years, much new informatio
abotit newborns h;is led to dramatic changes in the
medical care. \c<>ii(ti<>lii<^\ , a multiauthored text, fu
fills the need for a comprehensive text incorporatin
these advances. It is intended for use bv physician
nurses, and phvsicians' assistants who participate i
newborn care.
The book is divided into two parts. The first poi
tion. covering the high risk infant, resuscitation in tl\
delivery room, and birth injuries and infections,
very good in content. It provides theoretical and prac
tical guidance for many situations encountered in th
newborn period. The book will not. however, serv
as a tre:itment manual for intensive neonatal can
Sections on mechanical assistance to respiration an
parenteral nutrition contain insufficient detail for on
to use them as the onlv reference in applving thes
techniques to patients.
The second portion of the book contains chaptei
on diseases of the organ systems, metabolism, an
jaundice. Organization of these chapters varies wit
the authors" styles. 1 think the book could have bee
itnproved in having a single scheme of organizatior.
The quality of the chapters varies. For instance, th
chapter on renal disease is very useful and has sever;
illustrations, whereas the chapter on gastrointestin
disease is poorlv organized, lacks full discussion i
some entities, and has no illustrations.
In most chapters the text is not referenced, an
as a result the reader is not led directly to othe
literature on the subject. .Although some chapter
have categorized bibliographies, many are arrange
only alphabetically, an unnecessary deficiency.
The index is inadequate in that several topics dis
cussed in the text are not included in the index, an
other topics are indexed incompletely, that is, onl
line page is given although the topic appears i
several places in the text. The incomplete indexing i
324
Vol, 35. No
J erious deficiency, particularly with respect to the
t )k's use for reference purposes.
rhe entire book, could have been better illustrated,
a 1 illustrations could have been used advan-
t eously in several chapters where none are used,
f ticularly the chapter on "Diseases of the Skin."
Excellent charts of normal laboratory values and
d g doses are appended.
In summary, I would recommend this book as a
starting place for those wishing to have a knowledge
of neonatology. Although there are deficiencies in
individual chapters. Neonatology is the best single
source incorporating the modern approach to neona-
tology.
The price seems high considering the small number
of illustrations.
William A. Smithson, M.D.
In ilf mortam
Joseph Wentworth Coxe, M.D.
Qr. Joseph Co.xe. 57, was fatally injured in an
a''omobilc accident April 5, 1973. He had practiced
p chiatry in Asheville for ten years, associated with
F :hland Hospital, and was later in private prac-
t -.
A native of Roanoke, Virginia, Dr. Coxe gradu-
a 1 from the University of Virginia Medical School
h' 1942. Internship was at Roper Hospital,
C irieston, S. C. He was resident psychiatrist at
C ;stnut Lodge, Rockville, Md., Washington School
o' Psychiatry and Washington Psychoanalytic In-
s ate.
During WW II he served in the U.S. Army with
ti' rank of Lieutenant.
'"he Buncombe County Medical Society express
tl' r deep sense of loss of their fellow and extend
u'lost sympathy to the widow, the former Jane
J 'ell, and the two daughters, Susan and Sally of
tl'home.
■Vhereas. wc of the Society feel keenly the loss
o'a skillful and dedicated member by an acci-
d'.tal and untimely death, therefore be it
(ESOLXED, that a copy of this writing be made
a lart of the minutes of the Buncombe County
V'llical Society and a copy sent to the widow. Fur-
tP'-more, that a copy be forwarded to the North
C'olina Medical Society for publication in the
J RNAL of the North Carolina Medical Society.
Buncombe County Medical Society
I
Charles Darwin Thomas, M.D.
Charles Darwin Thomas, 71. died at his home
Hjxpectedly September 17, 1973. He had retired
|.971 from the Medical Directorship of Western
lilth Carolina Sanatorium.
ile was a native of Danville, Indiana, and re-
[ted his M.D. degree from the University of In-
1974, NCMJ
diana. His internship and residency were at In-
dianapolis City Hospital where, in his third year,
he was hospitalized for tuberculosis at Trudeau Sana-
torium at Saranac Lake, N. Y. Here he was both a
patient and part-time staff member from 1928-1930.
Dr. Thomas was employed by the W.N.C. Sana-
torium in 1930. He was appointed to the Staff of
the State Sanatorium at Sanatorium, N. C. in 1937.
Previously he had worked for the State as a con-
sultant and in case finding. In 1933, he skin tested
10,000 children in Buncombe County. In 1946 he
became Medical Director of W.N.C. Sanatorium.
When Streptomycin became available. Dr.
Thomas and his staff participated in one of the first
studies on its effectiveness. After resistance to the
drug developed, his research was directed to various
drug combinations. His work was an integral part of
the U.S. Public Health Service Studies at the time.
Dr. Thomas was past president of the Southern
Tuberculosis Association and of the N. C. Thoracic
Society. He was the author of many articles on tuber-
culosis.
He had the unusual satisfaction of seeing a tre-
mendous decline in the tuberculosis rate during his
career. In 1930 the mortality in North Carolina
from TB was 72 100.000 population; at his retire-
ment the mortality was 2.5 100,000.
Dr. Thomas was a most highly respected authority
in his field and was a source of countless help to
the doctors in this area and to the legion of patients
that flowed through W.N.C. Sanatorium during his
tenure. He was a warm and friendly man and will
be soreh missed by all who knew him.
He is survived by his widow, the former Doro-
thy Drake, two sons, Lt. Col. Charles D. Thomas, Jr.,
and Raymond B. Thomas, Kernersville, N. C, and a
daughter Judith Ann. Therefore, be it
Resolved that a copy of this writing be made
a part of the minutes of the Buncombe County Medi-
32.^
cal Society and a copy sent to the North Carolina
Medical Journal for publication.
Buncombe County Medical Society
William Christian McGuffin, M.D.
Dr. William C. McGuffin died at his home Oc-
tober 27, 1973 at the age of 63 years, following a
long illness.
Dr. McGuffin was born in Joliet. Illinois. He
received his M.D. degree from Loma Linda Medical
School in 1934. and he served an internship at Nash-
ville General Hospital.
He entered practice in Ashcville in 1937 and was
associated with Dr. .Alc,\ White in the practice of
obstetrics. He later confined his practice to pediatrics,
gradually abandoning obstetrics.
During WW H he sersed in the Medical Corps
at Camp Claiborne, Louisiana. He was Chief of St|
of St. Joseph's Hospital in 1958 and was a membl
of the Buncombe County Medical Society. Nor|
Carolina Medical Society, and American Medic
Association.
He is survived by his widow, the former KarJ
Reeves, a son, William T. McGuffin of Chicag
and a daughter, Mrs. Rachel Ray of Asheville.
Wliereas, he was a popular pediatrician and affel
tionately known to his patients as "Dr. Mac" ap
will be sorely missed by his associates and form
patients, therefore be it
Resolved that this account be transcribed in tl
minutes of the Buncombe County Medical Societ
a copy sent to his widow, and one to the Journ;
of the North Carolina Medical Society for publicatio
Buncombe County Medical Society
Several attempts have been made to ascertain the proportional doses for the different ages and
constitutions of patients; but, after all that can be said upon this subject, a great deal must be
left to the judgment and skill of the person who administers the medicine. The following general
proportions may be observed; but they are by no means intended for exact rules. .\ patient be-
tween twenty and fourteen may take two-thirds of the dose ordered for an adult; from fourteen
to nine, one-half; from nine to six, one-third; from six to four, one-fourth; from four to two.
one-sixth; from two to one, a tenth; and below one. a twelfth. — William Biichan: Donicslic
Medicine, or a Treatise on the Prevention unci Cure of Diseases bv Reigiincn aitil Simple Medi-
cines, etc.. Richard Folwell. 1799. p. 440.
326
Vol. 35. Ni
HEALTH SCIENCES LIBRABY
ie Official Journal of the NORTH CAROLINA MEDICAL SOCIETY
June 1974, Vol. 35, No. 6
JORTH CAROLINA
1
Medical Journal
THIS ISSUE: Variability of Prescription Drug Prices, Donald M. Hayes, M.D., and John F. Whalley, M.D.; The Etiology
Diabetic Microangiopathy. A Review of the Recent Literature, Charles W. Smith, Jr., M.D.; Recent Developments on
e Insanity Defense, R. L. Rollins, Jr., M.D.; Insect Sting Allergy in Children, Claude A. Frazier, M.D.
FLOYD W. DENNY, M. D.
SCHOOL OF MEDICINE
UNIVERSITY OF NORTH CAROLINA
CHAPEL HILL. NORTH CAROLINA
■c
Simple, accurate test for glycosuria
TES-TAPE
URINE SUGAR ANALYSIS PAPER
S&Ty
Leadership in
Diabetes Research
for Half a Century
Additional information available upon request. Eli Lilly and Company, Indianapolis, Indiana 46206
1974 COMMIHEE CONCLAVE
Jieptember 25-28— Southern Pines
1975 LEADERSHIP CONFERENCE
Jan. 31-Feb. 1— Raleigh
1975 ANNUAL SESSIONS
May 1-4— Pinehurst
Both ofte
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-
Predominant
• psychoneurotic
anxiety
Associated
• depressive
symptoms
orders, possibility of increase in freque
and/ or severity of grand mal seizuresr
require increased dosage of standard a
convulsant medication; abrupt withdrai
may be associated with temporary in-
crease in frequency and/ or severity of_
seizures. Advise against simultaneousi
gestion of alcohol and other CNS depre
sants. Withdrawal symptoms (similarfc
those with barbiturates and alcohol) hi
occurred following abrupt discontinuat
(convulsions, tremor, abdominal and r
cle cramps, vomiting and sweating). Kf
addiction-prone individuals under care
'#
*■
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.
Coniraindications : hypersensitivity to barbiturates or bella-
donna alkaloids; glaucoma, prostatic hypertrophy, pyloric
obstruction. Side Effects : 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
1
Sidonna
Each scored tablet contams: specially activated simethicone
25 mg., hyoscyamine sulfate 0.1037 mg.. atropine sulfate
0.0194 mg., hyoscine 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 working partnership
against the
pain of gas and spasm
EDITORIAL BOARD
Robert W. Prichard, M,D.
Winston-Salem
EDITOR
John S. Rhodes, M.D.
Raleigh
ASSOCIATi; EDirOR
Ms. Martha van Noppen
Winston-Salem
ACTING ASSISTANT EDITOR
Mr. Wilhani N. Hilhard
Raleigh
BUSINESS MANAGER
W. McN. Nicholson, M.D.
Durham
CH\IRMAN
Louis deS. Shaffncr, NLD.
Winston-Salem
Rose Pullv. M.D.
Kinston
George Johnson. Jr., NLD.
Chapel Hill
Charles W. St\ron, NLD.
Raleigh
NOKTU CAROLlN.Ji MEDICAL JOUR-
NAL. .100 S. Hawthorne Rd . Wmslon-Salem,
N. C. 27103, IS owned and published hy The
North Carolina Medical Society under the di-
rection of its Editorial Board. Copyright 'ti
rhe North Carolina Medical Society 1974.
Address manuscripts and communic.itions re-
garding editorial matter to this Winston-
Salem address. Questions relating to sub-
scription rates, advertising, etc.. should be
addressed to the Business Manager, Box
27167, Raleigh, N. C. 27611. All adver-
tisements are accepted subject to the ap-
proval ol a screening committee of the State
Medical Journal Advertising Bureau, 711
South Blvd., Oak Park. Illinois 60.102 and or
bv a Committee of the Editorial Board
of the North Carolina Medical Journal
in respect to strictly local advertising. In-
structions to authors appear in the January
and July issues. Annual Subscription, $5.00.
Single copies, SI. 00. Publication office:
Edwards & Broughton Co., P. O. Box 27286,
Raleigh. N. C 27611. Secnml-class postage
paid at Raleigh, Sorth Carolina 27611.
NORTH CAROLINA
MEDICAL JOURNAI
Published Monthly as the Official Organ <
The North Carolin
Medical Socie'
June 1974, Vol. 35, No
Original Articles
Variabilifv of Prescription Drug Prices
Donald M. Hayes, M.D.. anti John F. Whalley, M.D.
The Etiology of Diabetic Microangiopathy.
.\ Review of the Recent Literature
Charles W. Smith, Jr., M.D,
Recent Developments on the Insanity Defense
R. L. Rollins, Jr.. M.D.
Insect Sting .\llergy in Children
Claude A. Frazier, M.D.
Editorials
The Spring Meeting of the Executive Council
Problem-Oriented Records
Emergency Medical Services
A Mobile System of Acute Cardiac Care
Joseph Robert Anthony, M.D,
.Abstraeted by Lewis Becker, M,D.
Correspondence
Poisons That Killed
R, VV. Whitener, M.D.
Insect Bites ..
Claude A. Frazier, M.D.
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
News Notes
Month in Washington.
Book Reviews
In Memoriam
Classified Ads
Index to Advertisers
3;
3f
3;
3!
3(
3t
i
3(
3*
3i
3'
3'
3
3
3
3
3,
3|
3!
Contents listed in Current Contents/Clinical Practice
Variability of Prescription Drug Prices
Donald M. Hayes, M.D., and John F. Whalley, M.D.*
the early 1960s price differ-
nces among food stores selling
ir ar merchandise were re-
0 :d.'' - Shortly thereafter, simi-
u orice variations were found to
X for drugs.'' In these studies
Domic factors were the chief
!S s. Prices were higher in phar-
i< es which only filled prescrip-
0 and in those which were pri-
a y owned than in those operated
y 'chain" corporations selling a
i< variety of merchandise. Hast-
ij and Kunnes^ introduced
Qi icr dimension into this subject
y aving a well dressed white and
u jily dressed black college stu-
ei present prescriptions for 100
lb ts of 0.25 mg Lano.xin at 40 ur-
ai pharmacies in Kansas City,
h concluded that race and ap-
3; mce of the patient may influ-
K ' the price of a prescription,
h , non-economic variables were
i( 1 to the list of price influences.
e importance of these factors
a: denied by Braucher and Kot-
'T! who randomly sampled 36
1^ nacies in Atlanta. Each was
si i by four consumers, well
■e ;d and shabbily dressed white
Ff the Department of Community Medi-
leJ lowman Gray School of Medicine of
alt "orest University, Winston-Salem,
' , Tn in Pediatrics, University of Kentucky
2d' Center, Lexington, Kentucky.
R* nt requests to the Department of Com-
W1I Medicine, Bowman Gray School of
Jd] e of Wake Forest University, Winston-
lei >J. C. 27103 (Dr. Hayes).
and black college students, who pre-
sented prescriptions for 12 Darvon
Compound 65 pulvules. In examin-
ing the variables of race, attire, and
store type, they found a significant
price difference to occur only among
different types of stores.
This study has attempted to ex-
pand on these two earlier reports
and to clarify the influence of non-
economic variables on the price of
prescription drugs.
METHODS
This study was conducted in For-
syth County, North Carolina. Lo-
cated in the Piedmont region of the
state, it is dominated by the city of
Winston-Salem, which has a popula-
tion of approximately 150,000.*'' The
city is the long-time home of such
large companies as R. J. Reynolds
Industries and Hanes Corporation.
In recent years Western Electric
Company, Wake Forest University,
Joseph Schlitz Brewing Company,
and Westinghouse Corporation have
moved to the county. The urban
area is bordered by a beltway
created by Silas Creek Parkway and
U. S. 52. Outside this central zone
the county is rural, with occasional
suburban developments and multiple
unit apartment complexes scattered
among corn and tobacco fields.
The pharmacies chosen for the
study were selected and grouped
primarily according to their business
location and the characteristics of
their primary consumer. Represen-
tative stores were chosen from each
of the major shopping districts. They
included the downtown business
area of Winston-Salem, Model Cities
Project area, hospital pharmacies,
suburban shopping centers, subur-
ban community drug stores, and
rural community drug stores.
The differences between the vari-
ous pharmacies are described in
Table 1. If the merchandise sold in-
cluded, for example, magazines,
books, cosmetics, sports equipment,
and household goods, in addition to
prescription and over-the-counter
(o-t-c) drugs, the store was classi-
fied as "variety." The hospital phar-
macies dispense only prescription
drugs and were labeled "apothe-
cary," while the stores labeled
"drug only" also sell o-t-c medicines.
Pharmacies were classified as be-
longing to a "chain" if four or more
stores were under the same manage-
ment or if they were members of a
national chain of stores.
Consumer Population Density
(CPD) was estimated by comparing
the location of the store to the gen-
eral shopping patterns of county
residents. If the store was located in
a major business district, then the
CPD was "high." However, if the
shopper had to make special efforts
N 1974, NCMJ
351
Table 1
Attributes of Different Types of Pharmacies in this Study
Type
Merchandise
Sold
Ownership
Downtown
Variety
Cham
Model City
Drug Only
Private
Hospital Pharmacy
Apothecary
Private
Suburban
Shopping Center
Variety
Chain
Suburban
Community
Variety
Private
Rural Community
Variety
Private
Consumer
PoDulation
Density
High
High
High
High
Moderate
Low
Consumer
Income
Mixed
Low
Mixed
Mixed
High
Low
Degree
of
Competition
Categories of
Consumer Not
Seen Often
High
None
Moderate
All White M & F
High
None
High
None
Moderate
All Black M & F
Low
All Black, Radical
White M & F
to reach the pharmacy, then the
CPD was rated "low."
V'akies for consumer income were
assigned according to accepted na-
tional standards.' The degree of
competition was estimated by the lo-
cation of the store, its special appeal
to a particular consumer group, and
the mobility of the population it
served. Thus, the Model Cities phar-
macies were judged "moderate"" be-
cause they were located on the pe-
riphery of the downtown shopping
district and appealed to black con-
sumers who lived in the area.
The suburban community stores
were raised from their expected
"low" rating to "moderate"" because
their customers were highly mobile.
The category of consumer who
rarely visited a particular pharmacy
was emphasized in the last column.
Three stores were assigned to each
category except for those in the
Model Cities area and two hospital
pharmacies. One hospital located in
the Model Cities area, sold prescrip-
tion drugs only for Medicare stamps
and was excluded from the study.
A standard prescription was
written for one-hundred 0.25 mg
tablets of Lanoxin (with two refills)
by si.x physicians at the North Caro-
lina Baptist Hospital and randomly
distributed among the "consumers."
Each pharmacy was presented with
the standard prescription by a mem-
ber of each of the se\'en categories
of consumer: male, female, black,
white, well dressed, "radical," and
rural-appearing. The participants
were employed with the idea that
they would look and act naturally in
the consumer roles they were asked
to portray. Accordingly, only four
universitv students were selected.
The remainder were older adults
with various occupations, interests,
and levels of education. Should the
pharmacist question their need for
Lanoxin, all "consumers" were in-
structed to reply that their physi-
cian was treating heart disease.
Prior to the "consumer" portion
of the study, each pharmacy was
queried by telephone by a physician
who asked for the price of the stan-
dard prescription. Then each of the
12 "consumers"" visited each of the
16 pharmacies at random o\er a
three-week period, filling 192 pre-
scriptions. The purchases were made
in cash. Without specific instruc-
tions, the "consumers"" were also
asked to observe the activities of the
pharmacist and his employees during
their \isit.
RESLLTS
The \arious pharmacies are lo-
cated in Fors\th County as follows;
1, 2, and 3 are in the downtown busi-
ness area: 4 and 5 are the Model
Cities Project area; 6 and 7 are hos-
pital pharmacies; 8, 9, and 10 are
in suburban shopping centers; 11,
12, and 13 are suburban community
drug stores: and 14, 15, and 16 are
in the rural areas (Table 2).
Prescription prices are presented
in Table 2. Owing to a confusion of
names, one prescription was filled
with an estrogen preparation, and
for another prescription only 50 tab-
lets were dispensed without explana-
tion.
Seseral observations may be
made by inspecting the data. No two
consumers paid the same amount for
all 16 prescriptions. The price re-
mained identical for all consumers in
four stores, while the range was
greater than SI in four stores
several stores the telephoned pr
did not indicate what amount
consumer would be charged.
An analysis of variance emplc
ing Duncan"s New Multiple RaiJ
test was performed. No significi
difference existed among the seV
consumer groups; however, amo
pharmacies prices varied sigrt
cantly (p<0.0005). The frequer
of dispensing error was not co
puted because of the small size
the sample.
DISCUSSION
This study was designed to i
plore subtle differences in the m
economic price variables of race a
attire. The quoted telephone pr
was independent of these influenc
Another \ariable was examined
pairing male and female "ci
sumers."" Overall, the data ag
with those of Braucher and Kot
and show no evidence that race
attire influenced the price of p
scription drugs. They agree with
work of others in that between i
ferent types of stores prices for
standard prescription were marke
different.
As this study is larger than
two previously reported, it 2'
showed a wide range in prescript!'
prices occurring within a sin^
pharmacy. On a purchase of $2 '
price varied randomly by more tli
50 cents in seven stores and by*
much as $2 in two additional sto-
This variation was striking. The r
sonable explanation for this obsei-
tion was human error by the pi'
macist or his employees. Whate'
the cause, the consumer/pati'
Vol. 35, Nil
TabI
e2
Pharmacy
CONSUMER
1
2
3
4
S
6
7
8
9
10
11
12
13
14
15
16
TOTAL
ck Well Dressed
Male
Female
2,50
2.50
1.43
1.43
1.50
1.36
1.60
1.60
1.75
2.06*
1.25
1.75
2.00
2.00
1.27
1.12
1.48
1.20t
1.69
1.69
3.15
3.15
1.40
1.90
1.75
2,50
2,25
2.25
2,25
2,25
2.25
1.75
29,52
30.51
1 lical
Male
Female
2.50
2.50
1.43
1.43
1.49
1.39
2.50
2.50
1.75
1.75
2.25
2.25
2.00
2.00
1.12
1.12
1.48
1.48
1.60
1.69
3.15
3.15
1.90
1.90
1.75
2.50
2.25
2.25
2,25
2.25
2.25
2.00
31,57
32,16
1 e-Collar
Male
Female
2.50
2.60
1.43
1.43
1.39
1.36
2.50
2.61
1.75
1.75
1.50
1.65
1.40
2.00
1.27
1.27
1.48
1.48
1.69
2.25
3.15
3.15
1.90
1.90
2.50
1.75
2.25
2.25
2.00
2.00
2.00
3.00
30,71
32.45
\ te Well Dressed
Male
Female
2.50
2.50
1.43
1.43
1.25
1.39
2.50
0.60
1.75
1.75
2.25
2.25
1.50
2.00
0.75
1.27
1.48
1.48
1.69
2.25
3.15
3.15
1.90
1.90
2.00
1.75
2.25
2.25
2.00
2.25
2.00
1.75
30,40
29,97
lijical
. Male
"' Female
2.50
2.50
1.43
1.43
1.29
1.39
2.50
1.50
1.75
1.75
2.25
2.25
1.50
2.00
1.27
1.12
1.48
1.48
1.60
1.69
3.15
3.15
1.90
1.90
1.75
1.75
2.25
2.25
2.00
2.00
2.00
2.25
30,62
30,41
t e-Collar
Male
; Female
T il Paid
/'rage Paid
Flge
1 ;phone Price
2.50
2.50
30.10
2.51
0.10
2.50
1.43
1.43
17.15
1.43
0
1.43
3.25
1.48
18.54
1.55
2.00
1.39
2.50
1.60
24.51
2.04
2.01
2.00
1.75
1.75
21.31
1.76
0.31
1.75
2.00
2.25
23.90
1.99
1.00
2.25
2.00
2.00
22.40
1.87
0.60
2.00
1.27
1.12
13.97
1.16
.52
1.27
1.48
1.48
17.48
1.46
0
1.48
1.69
2.25
21.78
1.82
0.65
1.79
3.15
3.15
37.80
3.15
0
3.15
1.90
1.90
22.30
1.85
0.50
1.78
2.00
2.00
24,00
2,00
0,75
2,00
2,25
2,25
27,00
2,25
0
2,25
2.25
2.25
25.75
2.16
0.25
2.00
2.00
2.00
25.25
2.10
1.25
2.00
33,42
31.41
31.04
*; trogen Preparation
t Tablets Supplied
Supplied
v;' the loser, or winner, depending
m le direction of the error.
nere has been growing evidence
hi the consumer/patient is de-
■eoing increased awareness of his
11 ;ptibility to exploitation in the
ifcmaceutical marketplace. Con-
u.'r's Report recently highlighted
hi issue, and Richard J. Klein, '^ ^
Ci-omics editor, presented their
lb rvations to the American Phar-
i<';utical Association at its annual
Ming. In this manner the national
ih'maceutical leadership has de-
ic itrated their recognition of the
a:'amer"s discontent,
■whatever reforms the pharmacist
lict propose, the cost of a pre-
3ii tion is not determined solely by
ill The prescribing physician and
itnanufacturer also must be in-
lu ;d in the marketplace. While the
-rican Medical Association has
stated its concern over the price and
quality of drugs for several years,
a recent survey by Lowy, Lowy, and
Warner'" discouragingly showed a
"limited knowledge of the cost of
antimicrobial agents by practicing
physicians."
The "consumers" in the study un-
knowingly activated a potential
mechanism that operates to protect
the consumer/patient. Several of
the physicians writing prescriptions
for this study were questioned by
pharmacists who were aware of an
unusually high frequency of pre-
scriptions for Lano.xin. Such interac-
tion was not expected to be observed
in a medical center, although it does
occur more frequently in private
practice. The further development
of these relationships, both formally
and informally, should be en-
couraged. The quality of medical
care can be improved only by
further cooperation of various health
professionals.
References
1. Ridgewav J: Studies in groceries. New Re-
public 154; 9-10, 1966,
1. Dixon DF. McLaughlin DJ Jr: Do the ur-
ban citv poor pay more for food? Econ
Bus Bull (Temple LJniversit.v) 20: 6-12. 1969,
.1. Azarnoff DL, Hunninghake DB, Wortman
J: Prescription writing by generic name
and drug cost. J Chronic Dis 19; 1253-
1257. 1966.
4, Hastings GE, Kunnes R; Predicting pre-
scription prices, N. Engl J Med 277; 625-627
1967,
5, Braucher CL. Kolzan JA: Prescription
prices, race and attirement, J Med Assoc
Ga 60; 3n4-.107. 1971,
6, U, S, Bureau of the Census, U, S, Census
of Population; 1970, General Social and
Economic Characteristics. North Carolina,
U. S. Government Priming Office, Wash-
ington. D. C„ 1971,
7, Drug pricing and the Rx police state. Con-
sumer's Report 37: 136-140, 1972,
8, Klein RJ : The consumer's right to know,
J Am Pharm Assoc 12: 350-.361. 1972,
9, Griffenhaeen GB; Kaleidoscope of phar-
maceutical services (editorial), J Am Pharm
Assoc 12: 55, 1972,
10. Lowy DR, Lowy L, Warner RS; A survey
of ph\sician's awareness of drug costs, J
Med Educ 47; .349-,351, 1972,
'1
Medicines are often adulterated for the sake of a colour. Acrid and even poisonous substances
are, for this purpose, sometimes introduced into those medicines which ought to he most bland
and emolient. Ointment of elder, for example, is often mi.xed with verdegrife to give it a fine
green colour, v^hich entirely frustrates the intention of that mild ointment. Those who wish to
obtain genuine medicines should pay no regard to their colour. — William Biithan: Doiiiesiic
Medicine, or a Treatise on llie Prevention ami Cure of Diseases hy Regimen and Simple Medi-
cines, etc., Richard Folwell. 1799, p. 439.
-n^ 1974, NCMJ
353
^
The Etiology of Diabetic Microangiopathy-
A Review of the Recent Literature
Charles \V. Smith. Jr., IVl.D.
T N recent years many studies
have shed much light on the
theories of the etiology of dia-
betes mellitus and its associated an-
giopathy. These studies have also
raised many questions. Today 85
percent of people with diabetes mel-
litus die of the consequences of mi-
croangiopathy rather than from ke-
toacidosis, insulin shock, and other
related conditions. Further, it has
been shown that "tightly controlled"
diabetics develop vascular problems
as readily as insulin independent
diabetics.^ Thus, if control of hyper-
glycemia affects vessel involvement,
it is at best a minor improvement.
Sipcrstein- failed to demonstrate
a relationship between basement
membrane thickening and blood
glucose levels. Therefore, another
physiologic phenomenon must be at
work to cause, or to contribute to.
diabetic microangiopathy. The con-
sequent hyperglycemia may well be
only a symptom of a more basic
physiologic derangement.
The meaning of the term diabetic
angiopathy is confusing and is there-
fore a problem in the stud\ of the
disease. It is widely known that dia-
betes predisposes one to early ath-
erosclerosis, larae vessel disease, as
From ihe Univcrsitv of North t .irolin.i Si.hool
of Medicine. Ch.ipel Hill, N. C
Repnnt reciucsts to Dr. Smith, 12-B Justice
Street. Chapel Hill. N. C. 27514.
?,'^4
well as to the so-called specific small
vessel involvement which primarily
affects the arterioles. Thus, when
one refers to diabetic angiopathy
does one mean the so-called specific
small vessel lesions, or does one
mean collectively the small vessel
and large vessel involvement? In the
light of recent evidence, it is quite
possible that a single physiologic
phenomenon, contributed to by en-
vironmental factors, can account for
both types of vessel involvement.
For purposes of this review, I refer
only to small vessel disease, since
this is the only type specific for dia-
betes. The most common organ
lesions are nephropathy, retinop-
athy, iridopathy. coronary disease,
and gangrene; however, the organ
lesion most specific to diabetes mel-
litus is the nephropathy or Kimmel-
stiel-VVilson lesion of the kidney.
Diabetic neuropathy has long been
considered secondary to involvement
of the vasa nervorum, but this con-
sideration has been questioned when
nonsascular nervous anomalies were
present at the start of acute juvenile
diabetes.' ' In addition. PAS posi-
tive hyalinization of arterioles, hav-
ing the same electron micrographic
picture as the diabetic retinopathy
and the Kimmelstiel-Wilson lesions,
has been demonstrated in the
stomach, intestines, skin, striated
muscle, placenta, and the inner
ear.' Besides these morphologii
changes, demonstrations of i
creased capillary fragility and i
creased permeability of striated mi
cle capillaries to small ions, such
sodium and iodide, having be
noted.''
Clinical studies of diabetic re
nopathy have shown that at the st;
of clinical diabetes mellitus, ophth
moscopic examination results ;
normal. However, there is a positi
correlation between diabetic a
nopath\ and the duration of the d
ease since, after 15 to 25 years fr(
the onset of the disease, most }
tients showed signs of retinopati .
In 1955 Lundbaek" reported tl
four percent of the diabetic popu
tion at the start of the disease h
significant retinopathy; since most
these patients were elderly the
suits are inconclusive. Furthernio
some light and electron microsco
studies of acute juvenile onset d
betes have shown no changes in i
basement membranes of arteriol
until three to five years after [.
s\niptoms appeared."'" Siperste"
compared striated muscle caj
laries of overt diabetics, n
mals, and potential diabetics (c
spring of two diabetic parents). 1
study showed basement membr;
thickening in eight percent of n
mals. 99 percent of overt diabeti
and 53 percent of the potential "p
Vol. 35. N(^''
)ctic" group. Also, according to
th same study, there is no increase
in ascment membrane thickness in
a mdary acquired diabetes. Siper-
it 1- concludes that, since hyper-
j] cmia cannot cause this vessel in-
/( ement, microangiopathy pre-
;e 's or causes diabetes mellitus.
r . concept was supported by
< ^" who showed that children
\i ng diabetes of recent onset have
n ;ased pulse velocity secondary
0 lecreased small vessel distcnsi-
)i y. Williamson,'- however, failed
0 -'produce Sipcrstein's work, pre-
;U ably using the same methods
II materials.
it is true that microangiopathy
)i edes clinical diabetes mellitus,
vl t causes the small vessel involve-
n t? Colt'-' proposes that since
13 ?nts whose diabetes is controlled
ij tolbutamide (which stimulates
:i! in secretion) show increased
nfilence of cardiovascular death,
w in could be the cause of angiop-
iti'; he does not, however, cite any
iti ies to support this idea.
ecently several investigators
la proposed that a derangement
n Towth hormone levels is the
;a e of diabetic vessel involve-
ri :." '■"' Beaumont et al'^ and
^I'lbaek et al'" have found that
in 'th hormone plasma levels are
nr'ased by a mean of three times
hi of nondiabctics and that, instead
)f' owing the normal diurnal varia-
ic these levels fluctuate wildly
lu ig a 24-hour period. Further-
n('', these levels do not return to
10 lal when the diabetes is brought
inl r control. Additionally, a sig-
iif"nnt improvement has been dem-
in-'iatcd in many cases of diabetic
et opathy following hypophysec-
oi'.'"' Beaumont" proposes that
ly Tsecretion of growth hormone
:ar-;s levels of sorbitol to in-
tfe intraccUularly and that
he resulting osmotic load causes
chronic irritation, ultimately leading
to the basement membrane thicken-
ing seen by use of the electron
microscope; because the cell mem-
brane (except that in the liver) is
impermeable to sorbitol, growth hor-
mone plasma levels increase and re-
sult in osmotic imbalance." Since
growth hormone causes increased
use of fats for energy production
and, by feedback, causes inhibition
of enzymes of the glycolytic path-
way, the conversion of glucose to
gluccse-6-phosphate is inhibited and
results in increased cellular glucose.
This excess of glucose is shunted via
an aldose reductase to sorbitol and
leads to abnormal buildup of sorbitol
in the cells. Beaumont concludes that
"raised plasma growth hormone in
juvenile diabetes mellitus, response
to exercise in a well controlled dia-
betic, the inhibitory effects of hypo-
physectomy on the progress of
retinopathy, and the normalization
of skin capillary fragility after hypo-
physectomy points to a role for
growth hormone in diabetic angiop-
athy."" This suggestion is sup-
ported by Kinoshita'" who has
shown that diabetic neuropathy cor-
relates with levels of polyol accumu-
lation in the cells and osmotic swell-
ing of the nerve fibers. It is further
suggested that since increased sorbi-
tol in cells may cause vessel involve-
ment, inhibition of sorbitol forma-
tion by an aldose reductase inhibi-
tor, such as trimethylene glutamate,
may have clinical usefulness in the
study of microangiopathy (now un-
der study by Lundbaek) .
One can postulate that the de-
rangement in growth hormone levels
is present before clinical diabetes
mellitus and detectable angiopathy.
One can also postulate that con-
tinued insult to the cells results in
progressive thickening of the base-
ment membrane of arterioles.
Furthermore, one might assume that
if the basic lesion produces increased
growth hormone, the small and large
vessel disease may have a single
cause which works by a different
mechanism. Small vessel disease re-
sulting from osmotic insult to endo-
thelial cells, and large vessel disease
caused by prolonged increase in
plasma fatty acids could be a result
of increased levels of growth hor-
mone. Additional studies undoiibt-
edly will produce further insight
into these important questions.
References
1. Siper.stein MD: Hvperj^lycemia and diabetic
vascular disease. Calif Med 112: 59-61. 1970.
2. Siperslein MD. Unper RH. Madison LL:
Studies of muscle capillary basement mem-
branes in normal subjects, diabetic, and pre-
diabetic patients. J Clm Invest 47; 197.1-1999.
195S.
-1. Steiness I; Influence of diabetic status on
vibratory perception during ischemia. Acta
Med Scand 170: .■119-3.18. 1961.
4. Gregersen G: A study of the peripheral
nerves in diabetic subjects during ischemia.
J Neurol Neurosurg Psychiatry 31: 175-181,
1968.
5. Lundbaek K. Christensen NJ, Jensen VA.
Johansen K. et al: The pathogenesis of
diabetic angiopathy and growth hormone.
Dan Med Bull 18: 1-7. 1971.
6. Trap-Jensen J. Lassen NA: Increased capil-
l.iry diffusion capacity for small ions in
skeletal muscle in long-term diabetics.
Scand J Clin Lab Invest 21: 116-122, 1968.
7. Lundbaek K: Diabetic retinopathy in newly
diagnosed diabetes mellitus. Acta Med
Scand 152: 53-60. 1955.
8. Hansen RO: A quantitative estimate of the
peripheral glomerular basement membrane
in recent juvenile diabetes. Diabetologia 1:
97-100. 1965.
9. Hansen RO: Electron microscopic study of
glomeruli from \oung patients with short
duration of diabetes: the mesangial regions.
Diabetologia 6: 59, 1970. (Abstract)
10. Lundbaek K, in discussion: Pathogenesis of
Diabetes Mellitus: Proceedings of the
thirteenth Nobel Symposium, Stockholm,
1969. Edited by Cerasi E and Luff R.
Almqvist and Wiksell. Stockholm; Wilev &
Sons. Inc. New York. 1970. pp 97-98.
11. Katz HP. Cheitlin MD. Wasser AH, Flair
RC: Observations on the pulse wave velocity
and tissue biopsy in children with diabetes
mellitus. Johns Hopkins Med J 127: 336-343,
1970.
12. Williamson JR. Vogler NJ, Kilo C: Struc-
tural abnormalities in muscle capillary base-
ment membrane in diabetic mellitus. Acta
Diabetol Lat 8: 117-134. 1971. (Suppll
13. Colt EW; Antidiabetic drugs and athero-
genesis. Lancet 2: 1132. 1970. (Letter to
the Editor!
14. Beaumont P. Schofield PJ, Hollows FC.
et al: Growth hormone. sorbitol. and
diabetic capillary disease. Lancet 1: 579-581,
1971.
15. Lundbaek K, Christensen NJ, Jensen VA,
Johnsen K, et al; Diabetes, diabetic angiop-
athv, and growth hormone. Lancet 2: 131-
133. 1970.
16. Kinoshita JH: Pathways of glucose metabo-
lism in the lens. Invest Ophthalmol 4: 619-
628. 1965.
Take of common decoction, ten ounces; Venice turpentine, tjissolveti with the >i)lk of an egg.
half an ounce; Florence oil. one ounce. Mix them.
This diuretic clyster is proper in obstructions of the urinary passages, and in cholicky com-
plaints, proceeding from gravel. — William Biiclum: Domestic Medicine, or a Treatise on the
Preveittioii and Cure of Diseases hv Regimen anil Simple Medicines, etc., Richard Folwell, 1799,
p. 446.
|i 1974. NCMJ
355
Recent Developments on the Insanity Defense
R. L. RoIUns, Jr., M.D.*
""pHE insanity defense is ordinarily
-*- chosen only when the possibility
of conviction and the severity of the
possible penalty outweigh the disad-
vantages. This has been especially
true in North Carolina because of
the restrictions on defendants who
are acquitted on this basis. Until re-
cently the law provided that "no
person acquitted of a capital felony
on the ground of mental illness, and
committed to the (state) hospital
. . . shall be discharged therefrom
unless an act authorizing his dis-
charge be passed by the General As-
sembly. No person acquitted of a
crime of a less degree through a
capital felony and committed to the
(state) hospital . . . shall be dis-
charged therefrom except upon an
order from the Governor" (N. C.
Gen. Stat.. Sec. 122-86). .\s far as
I could ascertain, no person was ever
released from the state hospital un-
der these provisions.
A 1972 decision of the North
Carolina Supreme Court liberalized
the restrictions placed on the proba-
tionary release or discharge of those
patients acquitted as not guilty by
reason of insanitv (In re Tew, 280
N. C. 612, 1972). The 1973 Gen-
eral Assembly changed the General
Statutes to conform to this decision
(N. C. Gen. Stat., Sec. 122-86).
* Director of Forensic Services. Division of
Mental Health Services, North Carolina De-
partment of Human Resources. Raleigh. North
CaroUna 27611.
356
The 1974 General Assembly
(N. C. Gen. Stat. Sec. 122-84.1)
provided the following: that those
persons acquitted on the grounds of
mental illness must have a hearing,
and; that if the court finds that the
defendant-respondent is mentally ill
and dangerous to himself and to
others, it shall order him committed
to a psychiatric facility for not more
than 90 days. The defendant there-
after is to be treated as any other
committed patient. If the court finds
that the defendant is not mentally ill
and imminently dangerous to him-
self or to others, it shall order his
discharge. Thus, a defendant who is
found not guilty by reason of in-
sanity is to be treated as a mentally
ill person, rather than as a criminal.
In the past there may have been
some confusion between criteria of
competency to stand trial and the
test of criminal responsibility. "In
determining a defendant's capacity
to stand trial, the test is whether he
has the capacity to comprehend his
position, to understand the nature
and object of the proceedings against
him, to conduct his defense in a ra-
tional manner, and to cooperate with
his counsel to the end that any avail-
able defense may be interposed"
(State V. Propst, 274 N. C. 62, 161
S.E. 2d 560, 1968; State v. Jones,
278 N. C. 259, 179 S.E. 2d 433,
1971).
Therefore, one may be mentally
ill and still be able to meet the test
of competency. In fact, differe
levels of competency might be coi
sidered in the case of the defenda
who sits quietly in the courtroo
while his attorney enters a plea ■
guilty to breaking and entering,
opposed to a complicated incoD
tax evasion case in which the defei
dant must demonstrate a great d
gree of cooperation with his attc
ney. Also, in looking at the defei
dant's ability to cooperate wi
counsel, the defendant may be cor
petent in relation to one attomi
and incompetent in relation to a
other, depending on the skill ai
motivation of counsel. It is my fef
ing that, in most cases, it is to tl
defendant's advantage to return
court to dispose of the legal charg
as soon as possible.
The test for mental responsibili
in North Carolina is the M'Naughti
rule: "the capacity of defendant
distinguish between right and wroi ,
at the time of and in respect to tllj
matter under investigation" (Sta
V. Propst, 274 N. C.^62, 161 S.
2d 560, 1968 ). This test becomes ;j|
issue only if the defendant elects '
present the insanity defense. It ra
be to his advantage to plead n
guilty, to plead self defense, or
bargain for a lesser penalty. |
Contrary to popular belief, t '
M'Naughten rule does not restr
psNchiatric testimony, and the jud
generally allows the psychiatrist
say as much as he wishes as long
Vol. 35, Noi
relevant to the case.' It remains
the jury to determine whether the
!ndant should be held responsi-
for his actions.
1 practice, the state hospital may
immend to the solicitor that the
'ges be nol-prossed and may sug-
a treatment plan (judicial com-
nent to a state hospital or out-
ent treatment) if the hospital
aiders the patient to have a sig-
:ant mental illness. Increasing
ilvement of mental health profes-
als in consultation with law en-
ement and judiciary, in pretrial
presentence evaluations, may
provide other alternatives.
Because the insanity defense is
rarely used and since many criminal
defendants have court-appointed at-
torneys, few attorneys gain extensive
experience with the insanity defense.
Increasing use of the Public Defend-
er may result in the individual at-
torney's having more opportunity to
present the insanity defense. Rein-
statement of the death penalty in
North Carolina may also increase
the frequency of the insanity de-
fense (Amendment of N. C. Gen.
Stat., Sect. 14-17 by the 1974 Gen-
eral Assembly).
In spite of these changes, it seems
likely that the insanity defense will
remain a last resort. Few defendants
(especially those who might really
qualify) eagerly embrace the stigma
of insanity. Confinement in a men-
tal hospital is not necessarily more
appealing than incarceration in a
correctional setting. Also, one re-
ceives a definite sentence and release
date when convicted, but he must
risk the uncertainty of release if the
insanity defense is used successfully.
References
1. Goldstein AS: The Insanity Defense. New
Haven: Yale University Press. 1967.
t.l
However trifling (gargles) may appear, they are by no means without their use. They seldom
indeed cure diseases, but they often alleviate very disagreeable symptoms; as parchedness of the
mouth, foulness of the tongue and fauces, etc. they are peculiarly useful in fevers and sore
throats. In the latter, a gargle will sometimes remove the disorder; and in the former, few
things are more refreshing or agreeable to the patient, than to have his mouth frequently washed
with some soft detergent gargle.
One advantage of these medicines is, that they are easily prepared. A little barley-water and
honey may be had any where; and if to these be added as much vinegar as will give them an
agreeable sharpness, they will make a very useful gargle for softning and cleansing the mouth.
Gargles have the best effect when injected with a syring. — William Buchan: Domestic Medi-
cine or a Treatise on the Prevention and Cure of Diseases hv Rei;imen and Simple Medicines,
etc., Richard Folwell, 1799, p. 453.
V 1974, NCMJ
357
Insect Sting Allergy in Children
Claude A. Frazier, M.D.
r^HlLDREN are inquisitive, and
they often venture into close
proximity to stinging and biting in-
sects. Many children are stung each
year. Most reactions to insect stings
and bites are mild. Less often, severe
reactions occur which necessitate
prompt medical care. The impor-
tance of allergic reactions to insect
stings and bites is emphasized by
the fact that more deaths occur each
year from insect stings and bites than
from snake bites.' Therefore, an
awareness of the spectrum of symp-
toms and adverse effects of insect
stings and bites is important.
A variety of symptoms may result
from insect stings, depending upon
the amount of venom injected, the
presence or absence of hypersensiti-
vity and, to a lesser degree, the lo-
cation of the lesion. Several types of
reactions can occur: -
Normal reaction: At the time of
the sting, the patient has a sharp
pinprick sensation which lasts for
several minutes. A small red area
appears at the sting site and is gradu-
ally surrounded by a whitish zone
and a red flare. A wheal forms and,
as it subsides, gives way to irritation,
itching, and heat. All traces of the
sting usually disappear within a few
hours.
Local reacrion: This reaction is
manifest by an unusual amount or
duration of swelling, or both. Any
degree of swelling, even involvement
of an entire limb, is considered a lo-
cal reaction when it is continuous
with the sting area. The symptoms
Reprint requests to Dr. Frazier, Doctor's
Park. Building 4. Asheville, N. C. 28801.
may begin immediately, or after an
interval of time.
Superimposed infection: Unlike
bees, wasps and hornets are scaven-
gers and are likely to transmit infec-
tion with their venom. Local reac-
tions may be complicated by infec-
tion which presents as a cellulitis,
hours or days after the sting oc-
curred.
To.vic reactions: When a colony,
or swarm of bees or wasps, is dis-
turbed or threatened, numerous in-
sects may sting a single victim. Even
when no sensitivity exists, the
amount of venom injected can cause
systemic poisoning and may lead to
death. The clinical findings in these
instances include gastrointestinal
symptoms such as diarrhea and
vomiting, drowsiness, edema without
urticaria, headache, fever, and un-
consciousness.
Recovery may follow attacks, but
death is not unusual. It is estimated
that approximately 500 stings, with-
in a short time, inject a lethal dose
of poison. However, survival has
been reported following more than
2,000 stings. ■
Generalized allergic reaction:
Many varied symptoms may occur
in the sensitive child. The first symp-
tom may be a dry, hacking cough,
followed by a sense of constriction
in the throat or chest, swelling and
itching about the eyes, massive urti-
caria, sneezing, and wheezing, a
rapid pulse, a fall in blood pressure,
pallor or blushing of the skin, and a
sense of uneasiness. Generalized
papular urticaria, marked regional
adenopathy, and petechial hemor-
rhages have also been reported.
The most severe reactions consi' ■
of one or more of the foUowir'^:'
symptoms: constriction of tl
throat or chest, or both, shortness J-
breath, asthma, cyanosis, abdominis
cramps, diarrhea, nausea, vomitin'--
chills and fever, vertigo, larynge"
stridor, shock, loss of consciousnes ■
involuntary bowel or bladder 3.'-
tion, or both, and bloody, frotlli-
sputum.
Delayed reaction: It should n
always be assumed that if the rea'^:
tion can be safely controlled for ajit
proximately one hour, the danger cfi
illness is over. Some patients hav^:
delayed reactions to stings, manife
by fever, lymphadenopathy, malaisit^'
headache, urticaria, and polyarthf
tis. These symptoms usually occi
ten to 14 days after the actual stiff r
and they may occur after the fir;
sting.
Psychological reaction: Occasio
ally, in the absence of hypersensii .
vity, a person has an anxiety reait
tion from sheer fright following .ife
sting. The patient may feel faif^t:
perspire, and may have an increase :
pulse rate. It is hazardous to assuDt
that a person is having a psycholoi
cal reaction, because if hypersensit-
vity exists, death could occur befo
the proper therapy can be initiate
It is often necessary to evaluate at'^-
provide supportive therapy to p
tients with psychologic reactions u :
til an allergic reaction is excluded.
Fatal reaction: Deaths reported -^
be caused by bee stings or other Hfi..
menoptera are infrequent, probabi'i
accounting for no more than '
each year in the United States. T.
true incidence is probably h
358
Vol. 3.'!. No.
pater. Only when death results
1 m a toxic reaction to the stings by
i large number of insects, is the
< ise of death clearly evident. In
c er cases, the sting can be over-
I ked or viewed as incidental, and
t cause of death is reported as a
c onary thrombosis, heart failure,
s ick, or some other allergy with
liVngeal edema, bronchospasm, and
s ick.
Jsually the severe symptoms be-
g within two to ten minutes. Thus,
it i important for patients with hy-
p sensitivity to insect stings or bites
t( avoid potentially lethal insects.
!-• patient should be prepared to
n,L)gnize signs of early hypcrsensiti-
V reactions and be able to ad-
BCjister emergency self-treatment.
Hiiosensitization should be used
Wjn the patient has severe insect
■hjersensitivity.
c'wo groups were identified in a
re nt survey of 78 children.-* The
fii consisted of 29 children with
la ; local reactions manifest as
ai s of swelling, several inches in
di leter, usually confined to the
h£-j, foot, face, or entire limb. The
Jt;r group consisted of 49 children
i£-ng a history of one or more of
h, following symptoms; wheezing,
jr;!aria, shock, unconsciousness,
lyt'nea, angioedema, and gen-
.'r.,zed itching as a result of insect
;tii;s (Table 1).
f the total series of patients, the
ig 'ange was from two to 16 years,
rhty-seven percent were between
ivrand eight years of age. It is be-
ie:d that this age group, normally
glKSsive and inquisitive, is more
ikw to tantalize stinging insects. It
•/asiioted that 57 percent had gen-
rai-ed reactions, and the remaining
f TabI
e 1
^a' nts With Symptoms of G
Reaction*'
eneralized
vpiif Reaction
rti) ia
-h, (generalized)
igi' Jema
ffi t breathing
3Ui( and vomiting
No. of
Patients
36
33
26
12
8
2
Percentage
73
67
53
24
16
4
So of these patient;
'Hi :ing.
reported
more than
'N' 974, NCMJ
Table 2
Age
In
Relatior
to Type of Reaction'
Total
No.
Generalized Reactions
Local
Reactions
Age Group
of
No.
of
No. of
Patients
(Years)
Patients
Patients
Percent
Percent
2- 4
14
8
57
6
43
5- 8
29
17
59
12
41
9-12
23
15
65
8
35
13-16
12
9
75
3
25
Table 3
Site
5 of Stin
IS*'
Site
of
Sting
Total
No.
Generalized
Local
Patients
Reactions
(Percent)
Reactions
(Percent)
Feet
24
16-67
8-33
Head
21
12-57
9-43
Hands
14
7-50
7-50
9
4-44
5-56
Legs
Trunk
6
2
3-50
2-100
3-50
0
* Some of these
patients re
ported
more than one stin
g-
43 percent had local reactions. In
the 13 to 16 age group, 75 percent
had generalized reactions and the
other 25 percent had local reactions.
Thus, there seems to be a correla-
tion between the increase in age and
the degree of hypersensitivity (Table
2).
An analysis of the kinds of insects
responsible for these reactions re-
vealed that the honey bee and the
yellow jacket stings were the most
common. Comparisons of the sites
and types of reactions showed that
a high incidence of severe reactions
occurred in children who were stung
on the feet (Table 3). Most stings
occurred in the summer, especially
in the month of July.
Each patient or his parents were
asked how soon the reaction fol-
lowed the sting. It was reported that
most severe hypersensitivity reac-
tions occurred within thirty minutes
of the sting. This suggests that if a
severe reaction is not evident within
thirty minutes, the chances of a gen-
eralized reaction are remote.
Sixty-three percent of the children
had a history of other allergies.
These consisted of allergic rhinitis,
asthma, eczema, and conjunctivitis.
Twenty-two percent of the children
had drug allergies ( Table 4 ) .
Most of the patients estimated
that they had been stung approxi-
mately once each year. Of the 49
generalized reaction patients, 18 re-
called local reactions to the last
sting, ten had generalized reactions
to both stings, and 16 had no un-
toward reactions to any prior sting.
THE REACTION-PRONE CHILD
Is it possible to predict which
children are most likely to be stung?
If so, which type of reaction is most
likely to occur? The outstanding
characteristics and circumstances in
which the patients in this series were
stung are as follows: The sting-
prone child is a white male, between
the ages of five and eight, who is
playing in clover or near flowers,
following a heavy July shower. The
child is bare-footed and bare-headed
and is dressed in gaily colored,
coarse clothing. Sweet-smelling hair
oil keeps his wayward locks in place.
His energies are being expended in
locating a honey bee and chasing it
Table 4
Reaction in Relation to Asso
Allergy
ciated
Associated Allergy Generalized
Symptoms Reactions
Localized
Reactions
Perennial nasal allergy 9
Asthma 6
Asthma & nasal allergy 4
Hay fever i
Asthma & eczema 1
Conjunctivitis o
16
3
3
2
2
2
359
Table 5
Type of Reaction Expected'
Sex
Race
Month
Age
Type of attire
Type of insect
Site of sting
Frequency of stings
Reactions from preceding stings
Drug allergy
Personal atopic history
General
Reaction
male
white
July
teen-age
no shoes
hornet honey bee
feet
1 per year
none
possible
possible
Local
Reaction
male
white or Negro
July
pre-school
shoes
yellow jacket
arms
1 per year
local
probable
very probable
about the garden in an attempt to
catch it.
A generaHzed reaction is most
likely to occur in a teen-age male
who has a positive family history of
allergy, but who is not necessarily
atopic. He has appro.ximately one
sting each year. The patient's gener-
alized reaction is usually caused by
the same insect type, despite a his-
tory of no adverse reactions to pre-
vious stings. Thus, on a July day,
a teen-age male steps on a honey
bee or a hornet and a generalized
hypersensitivity reaction follows
(Table 5).
INSECT STING PREVENTION
The physician should have a
knowledge of insect habits and
should insure that the patient with
insect hypersensitivity is aware of
relevant information. The usual lo-
cation of insect nests is important.
Insects are more aggressive in the
vicinity of their nests. The patient
should be warned about this source
of heightened risk of exposure.
While playing or doing yardwork,
the patient having an allergy to
stings should be cautious, especially
during the summer months. Patients
are advised to rid the environment
of flowers and to rid the la-vn of
clover. It should be stressed that in-
sects are more likely to sting on
bright warm days, especially when
they are disturbed during the process
of gathering nectar. Avoidance of
perfumes, hair sprays, hair tonics,
sun lotions, and other attractants is
helpful. Bright colors and flowery
print fabrics should also be avoided.
The most suitable articles of cloth-
ing are those made from smooth
360
fabrics. Clothing should be light in
color — white, green, tan, and khaki.
Shoes are a must at all times! The
wearing of shoes is the most impor-
tant preventive measure to be taken.
Long trousers, gloves, and head cov-
erings will prevent many severe reac-
tions. Children should not be al-
lowed to eat such foods as water-
Table 6
Remember the 3 A's
Adrenalin
Antihistamine
Aminophylline
(Steroids, I.V. fluids, plasma expanders,
and oxygen may also be necessary.)
melon and popsicles out of doors
since the sweet smell of these food
attracts insects.
TREATMENT OF ACUTE
REACTIONS TO INSECT
STINGS (Table 6)
At the present time, the treat
ment of choice appears to be th
prompt administration of epim
phrine I.IOOO.' Epinephrine 1:100(
0.2-0.3 ml should be injected sut
cutaneously as soon as possible, an' fi
in extreme cases, intravenously. Thi
drug can be given at intervals (
ten to 30 minutes as indicated, unt
the vital signs are stabilized. Th
child should be watched closely an,t
his blood pressure should be takafc.
every few minutes, for early detci -
tion of shock. A tourniquet shou
be placed proximal to the site of tl
sting, whenever possible, and tl
epinephrine should be injecU
above the tourniquet. Antihist
mines and steroids can be givi
either by mouth or parenterally.
may also be necessary to administ
aminophylline if bronchoconstri
tion is a problem.
:
Table 7
Prevention of Insect Stings
Do's
Do wear shoes
Do wear smooth fabrics
Do wear light colors
Do wear long trousers,
gloves, and head coverings
Don'ts
Don't go barefooted
Don't wear rough fabrics
Don't wear gaily colored clothing
Don't use perfumes, hair sprays, hair tonics,
and sun lotions
Don't eat popsicles and watermelons outside
Tables
Managing Insect Sting Reactions
1. Immediate treatment is necessary for
acute reactions to insect stings.
2. Remember the three A's— Adrenalin, Anti-
histamine, and Aminophylline, if broncho-
constriction is not relieved.
3. Desensitization should be given to all
patients having a severe reaction, by a
person knowledgeable m this field.
4. An insect kit should be prescribed for a
patient who has had an acute reaction.
5. A list of preventive measures should be
given to the patient and or parents.
6. All children should wear shoes when they
are out of doors.
i
k
LONG-TERM MANAGEMENT
OF INSECT STING
REACTIONS
Insect sting kits are available
prescription for patients who ha
had severe reactions. This kit shou
be carried at all times; immedi*
treatment is essential for preventi
of death from severe reactions.
Patients with severe insect sti^
hypersensitivity should be deseij
tized to the offending insect or
sects. This treatment can be hazai
ous and should be done by a speci
ist in allergy.
Important aspects of preventi
and management of insect hypers(
sitivity are summarized in Tab
7 and 8.
References
Frazier CA: Insect Allcrcy: Allergic i
Toxic Reactions to Insecls and Other Art
pods St. Louis, Missouri: Warren H Or
Inc, 1959.
Frazier CA: Diagnosis and treatment of
■ sect bites. Clin Symp 20: 75-101, 1968.
Murray JA: Case of multiple bee sti
Cent Afr J Med 10: ;49-:51, 1954.
Frazier CA: Insect sting reactions in
dren. Ann Allergy 23: 37-46. 1965.
Vol.. 35, Nt
THE SPRING MEETING OF THE
EXECUTIVE COUNCIL
iror the second year since completion of the New
Fidquarters Building, the Executive Council con-
V ed in Raleigh on May 5, 1974 for the usual
ni'ting, preliminary to the Annual Convention in
Plehurst. The cool, rainy day helped the golf and
filing enthusiasts to better concentrate on the busi-
nh at hand.
J\mong the items considered were more than a
d(en resolutions from county Societies for reference
tc he House of Delegates and for action by that
i)i y after open consideration by Reference Com-
H'Ces. Major issues involved were Professional
itvice Review Organizations, new rules and
re'iirements by the Joint Committee on Accredita-
;i(^ affecting hospital staff procedures, and the need
'c-expanding activities on the legislative and public
•e'tions fronts. Members wishing to be heard on
a lor all of these topics should attend the Reference
Z imittee sessions at Pinehurst.
[ 'urchase of additional property adjoining the
i'dquarters Building parking lot was approved,
n action was deemed appropriate in view of pos-
& ■. future additions to the building.
"ledpac reported an increase in sustaining mem-
)e to 70, and presented a resolution asking all
ij. ;utive Council members to become sustaining
ai'ibers of Medpac. Further, the Medpac resolution
T 'OSes that the members of the House of Delegates
oi' Medpac and adopt a resolution to the AMA
Ide of Delegates, proposing that its members join
Ai^oac.
le Council received a proposal from Mr. Wil-
a Henderson, formerly Director of the Medical
'a" Commission, representing three North Caro-
n, Foundations — Duke, Reynolds, and Kate Bit-
njReynolds — to develop a plan of financial sub-
id^:o aid hospitals to resolve emergency room prob-
'Ti by the employment of full-time physicians. Pres-
oi , of 140 North Carolina general hospitals, 12
a" full-time emergency room coverage, 14 have
3^ age on nights and weekends, and an additional
5 n weekends only. The Council approved the
re jsition in principle pending further study and
;f t.
i . Josephine Newell, Chairman of the Annual
0 ention Commission, reported more than 1,500
■p' s to a questionnaire concerned with the Annual
Meeting. The larger number indicated preference for
Pinehurst as a meeting place, more than half chose
a May date rather than September, and a majority
expressed a willingness to meet a registration fee
for a quality program of Continuing Education.
J. S. R.
PROBLEM-ORIENTED RECORDS
In the past few years there has been much interest
in what is currently called the problem-oriented
record (POR) — some would call it a fad — and this
new method of record keeping has the backing of
some very bright and energetic medical leaders, in-
cluding some here in our state. The idea of identi-
fying the patient's problems as one goes through the
initial examination process, then dealing with them
in a positive way during the period of patient-physi-
cian interaction sounds good, especially when all of
us can recall fruitless searches through records to find
how a patient's major problems had been dealt with,
or had resolved naturally. Most of what one has read
about the POR thus far has been favorable, often
enthusiastic, although there have been some calls
for caution. In a recent article (N Engl J Med
290:829-833, 1974) Robert Fletcher cites some of
the pertinent literature and presents his own evalua-
tion of the traditional source-oriented record (SOR),
as opposed to the POR, in auditing medical records,
a task all of us are going to have to be concerned
with.
Fletcher took the histories of four patients with
complex illnesses and cast them into both the POR
and SOR formats. After suitable independent review
to see whether the records were fair examples of the
two forms, 36 house officers at two teaching hospi-
tals were asked to read them. The time it took to
read each record once and answer ten factual ques-
tions on its content was recorded, as were the
accuracy of the answers and the proportion of major
medical care errors recognized independently.
No significant differences were detected. Thus,
Fletcher feels that if the POR is adopted, it should
be for reasons other than facilitating medical audit.
In an accompanying editorial. Dr. Neelon from
Duke expresses some of his concerns about the study,
especially his feeling that the POR may be good
discipline, leading to a better record — something not
judged in Fletcher's study, since the PORs and
'> 1974, NCMJ
361
SORs he used were equal in content, though different
in form. Dr. Neelon's apparent view of the POR —
a more structured record — would certainly seem rea-
sonable, though perhaps harder to test than Fletcher's
measuromcnt^of the POR"s utility for audit proce-
dures. A new format like the POR, being promoted
by an energetic chief, would seem likely to produce
more information than the usual record, but would
it be better than the SOR's being systematically and
constantly reviewed by the same energetic chief?
Or could the same results be achieved by requiring
each house officer to write up an institution's ex-
perience with some clinical condition? At the end
of such efforts most people start to keep better
records, having seen how bad most records are, even
in "good" institutions. The answer, dear reader,
probably lies within ourselves, not within our record
formats — we remain our own chief problems.
Emergency
Medical
Services
A MOBILE SYSTEM OF ACUTE CARDIAC
CARE
Joseph Robert Anthony. M.D.. Chief of
Cardiology
St. Mary's Hospital, Waterbury, Connecticut
In spite of the advances of coronary care units
(CCUs), more than 300,U00 victims of heart at-
tacks continue to die annually before reaching a
hospital. This situation has led to an extension of
the ecu into the community in the form of mobile
units. One such mobile unit ( Heartmobile ) has been
operating in Waterbury, Connecticut, for more than
a year, receiving an average of two calls a day, 60
percent of them cardiac.
The Heartmobile is manned by a CCU nurse,
emergenev room nurse, and two paramedics, all with
special, intensive training in emergency medicine and
acute coronary care. Initially, there was also a resi-
dent physician. The Heartmobile is activated by call-
ing 573-1313; a trained dispatcher alerts the person-
nel by radio signal and dispatches the unit. More than
50 percent of the homes in the area can be reached
in five minutes. .After arrival of the unit, the pa-
tient's electrocardiogram is telemetered back to the
hospital, and the patient is given medication and
362
PRESCRIBING INFORM.-^TIO:
Antiminth (pyrantel pamoate) Oj
Suspension
Actions. .Antiminth (pyrantel pan
ate) has demonstrated anthelmin
activity against Enterobius vermi,
larts (pinworm) and Ascaris lumh
coides (roundworm). The anthelm
tic action is probably due to tl
neuromuscular blocking property i
the drug.
.Antiminth is partially absorb
after an oral dose. Plasma levels
unchanged drug are low. Peak lev?
(0.05-0. iS/ig/ ml.) are reached in
hours. Quantities greater than 5(
of administered drug are excreted
feces as the unchanged form, whert
only 7% or less of the dose is fou
in urine as the unchanged form
the drug and its metabolites.
Indications. For the treatment
ascariasis (roundworm infection) a
enterobiasis (pinworm infection)
Warnings. Usage in Pregnancy:
production studies have been p
lormed in animals and there was
evidence of propensity for harm
the fetus. The relevance to the
man is not known.
There is no experience in pi
nant women who have received t
drug.
Precautions. Minor transient ele
tions of SCOT have occurred ir
small percentage of patients. The
fore, this drug should be used w
caution in patients with pre-exisii
liver dysfunction.
Adverse Reactions. The most f
quentlv encountered adverse re
tions are related to the gastroini
tinal system.
Gastrointestinal and hepatic re
tions: anorexia, nausea, vomiti
gastralgia. abdominal cramps, d
rhea and tenesmus, transient ele
tion of SGOT
CNS reactions: headache, di
ness, drowsiness, and insomnia, S
reactions: rashes.
Dosage and .Administration. C
dren and Adults: .Antiminth 0
Suspension (50 mg. of p\rantel b.i
ml.) should be administered
single dose of 1 1 mg. of pvrantel b
per kg. of body weight (or 5 mg./l
maxinumi total dose 1 gram. 1
corresponds to a simplified dos
regimen of 1 cc. of .Antiminth per
lb. of body weight. (One teaspoor
- 5 cc.)
An timin til (pvrantel pamoa
Oral Suspension may be admi
tered without regard to ingestion
food or time of day; and purgiuj
not necessary prior to, cjuring,
after therapy. It may be taken v
milk or fruit juices. Because of \
ited data on repeated doses, no
ommendations can be made.
How Supplied. Antiminth is a\
able as a pleasant tasting camr
flavored suspension which cont;
the equivalent of 50 mg. pyrai
base per ml., supplied in 60 cc.
ties.
ROeRIG<®
A division ot Plizer Pharmaceuticals
New York. New York 10017
WORMS BLITZED
A single dose of Antuninth
( 1 cc. per 10 lbs. of body
weight, 1 tsp 750 lbs— max-
imum dose, 4 tsp=20 co)
offers highly effective control
of both pinworms and
roundworms.
Antimmth has been shown
to be extremely well tolerated
by children and adults alike
m cHnical studies* Pleasantly
caramel-flavored, it is
non-staining to teeth and oral
mucosa on ingestion...
doesn't stain stools, Imen or
clothing.
One prescnption can
economically treat the entire
family
ROGRIG <9
A division of Pfizer Pfiarmaceulicals
New York. New York 10017
latei
its,'
^iAworms,roiiAdwonns controlled
With a single, non-staining dose of
ANTIMINTH
(pyrantel pamoate)
ihii
'?«
chto
I'
■^^n file at Floerig.
.^qui\-alent to 50 nig. p\raj^td/ini
ORAL SUSPENSION
Please see prescribing information on facing page.
treatment by instruction from a physician at the
hospital until the patient's condition is stable. Cardio-
pulmonary resuscitation is started if necessary. The
patient is transported only after his cardiovascular
system has stabilized.
Further information, including survival statistics
and cost analysis, is given in "The Heartmobile —
A Mobile System of Emergency Cardiac Care,"
(1973) a publication prepared by the author and
available from him at St. Mary's Hospital, 56 Frank
lin Street, Waterbury, Connecticut 06702.
Abstracted by Lewis Becker, M.D.
From "Emergency Medicine Today," AM A Con,
mission on Emergency Medical Services, Volume •
No. 4, John M. Howard, M.D., Editor. Originc
article can be obtained from the American Medici
Association, 535 North Dearborn Street, Chicagi
Illinois 60610.
Correspondence
POISONS TH.\T KILLED
To the Editor :
In the April 1974 issue of the North Carolina
Medical Journal there is an article on page 227
entitled "Poisons that Killed: .An .Analysis of 300
Cases." I commend the authors on their paper. How-
ever, I would like to point out some facts and con-
clusions from the drug abuse perspective.
Both in the statistical table and in the discussion,
the authors referred to morphine deaths. No attempt
was made to suggest that there is a probability that
90 percent of these deaths were due to the injection
of heroin. The authors may have supposed that the
physicians of North Carolina are aware that heroin
is metabolized, and reported at autopsy as morphine.
I have no such faith in this awareness of our phy-
sicians and would like you to point out the evidence
that the vast majority of these young males are
heroin addicts.
I concur in the conclusion that one must see these
deaths as accidental. Although the heroin addict has
a substantial self-destructive element in his per-
sonality, the specific timing of the injection that leads
to death is not usually related to suicidal intent. The
authors might have discussed briefly the controversy
as to whether these deaths are, in truth, overdoses
or whether they represent a kind of sudden death
seen in heroin addicts that is postulated to have
an allergic cause similar to anaphylactic shock.
Inasmuch as the authors are interested in prevent-
ing "accidents," it might be pointed out that the best
prevention for heroin deaths would be a well-run
drug abuse program.
For the State To.xicology Laboratory to make
some attempt to distinguish between an accidental
overdose and a deliberate overdose, in the single drug
and combined drug listings, might be important fi
the physicians of the state. For example, the comt
nation of Mellaril and Doriden, presumably taken 1
an individual who is mentally ill, might result in aa
dental or suicidal death. Only "careful psychologic
autopsy" might reveal the difference.
Again, let me commend the authors on the exci
lent emphasis upon alcohol as the leading drug
abuse and the leading cause of death among dr
abusers. I do believe the emphasis on accideni
death is somewhat different because of the mann--
of reporting in other parts of the country.
R. W. Whitener, M.D.
Greensboro, N. C.
Dr. Fatteh replies:
Dr. Whitener is perfectly correct in saying thai
large majority of the deaths we reported as "nn
phine" deaths were caused by injections of "heroii
We feel, though, that almost every physician in t
state is aware of this fact. As to the statement tl
"the vast majority of these young males are hen
addicts," we would like to stress that deaths amc
novice drug abusers are not uncommon.
Every attempt is made, during the investigation
a fatality, to determine the precise manner of dea
and this includes, whenever necessary, a "psycholi
ical autopsy" also. As far as heroin deaths :
concerned, "accidental" manner of death is a ri
I have not come across a single case in which sulci ,,
use of heroin was substantiated. Death is not w-C
to overdose of heroin in a creat maiority of cas'f-: ■
^ (ii'
It is believed that many fatalities result from hypij"
sensitivity reactions. These facts indicate the
cidental" nature of death.
The State Toxicology Laboratory does attet
364
Vol. 35, NcllC:
lenever possible, to identify the drugs thought to
1 involved in a fatality. The conclusion regarding
1 : manner of death is drawn after complete consi-
( ration of investigative, autopsy, and toxicological
I'dings. No doubt, determination of precise quanti-
i of drugs, especially in the cases of combined use
ialcohol and barbiturates, does help in separating
'cides from accidents. The overall effect of a well-
'i drug abuse program on society will be good,
L it has to be a very involved, elaborate pro-
fm to make an impact as a preventive measure.
Fortunately, the drug scene is changing for the
t ter. In North Carolina, as in the nation, the num-
t s of deaths from heroin have been dropping. In
f rth Carolina, heroin, alone or in combination with
c er drugs, caused 17 deaths in 197], sixteen in
172, and five in 1973.
Abdullah Fatteh, M.D., PH.D., LL.B.
Associate Chief Medical Examiner
Chapel Hill, N. C.
INSECT BITES
To the Editor :
Again, this year I am compiling case reports of
allergic reactions to biting insects, i.e., mosquitoes,
fleas, gnats, kissing bugs, bedbugs, chiggers, black
flies, horseflies, sandflies, deerflies, and the like. I
am also interested in reactions to the Imported and
Southern Fire Ants.
I would like for physicians to supply me with
case reports of those patients who have had reac-
tions to such insect bites. Please include in your
reports the type of reaction; complications, if any;
the age, sex, and race of the patient; the site of the
bite(s); the season of the year; the immediate symp-
toms; the skin test results; descnsitization results, if
any; and any associated allergies. Anyone who is
interested may send this information to the following
address:
Claude A. Frazier, M.D.
4-C Doctors' Park
Asheville.N.C. 28801
Bulletin Board
I-
NEW MEMBERS
of the State Society
Ins, Leon Ashby, M.D. (OTO), 1700 S. Tarboro St.,
jlson 27893
!, Frederick Joseph, M.D. (PD), 720 Grove St., Salis-
L*p 28144
mr, Elizabeth Renwick (Student), Box 2734, Duke Med.
mh., Durham 27710
Frank Rudolph, M.D. (P), 1308 Highland Dr.,
kshington 27889
'W. J. Montgomery, M.D. (U), (Renewal), 2227 Wood-
sf{<e Ave., Burlington 27215
>p, Linda Alice (Student), 19 Town House Apts., Dur-
n 27705
Won, Lillian Ruth, M.D. (PD), Duke Med. Ctr.,
K 3936, Durham 27710
(hagen, Dan William (Student), 918 Exum St., Dur-
In 27701
allien, Wm. Frederick, 111, M.D. (IM), N. C. Mem.
jspital. Chapel Hill 27514
ley, Edward George (Student), 10 Lebanon Circle.
Irham 27705
Idres, Romulo Ernesto, M.D. (IM), N. C. Mem. Hosp..
jlipel Hill 27514
jngley, Gary Edward (Student), 4429-A Ryan St.,
frham 27704
i>son, Jonathan Robert Tolme, M.D., 1917 White Plains
.Chapel Hill 27514
\vvocato, Victor Alberto, M.D. (Intern-Resident), Box
1*5, Raleigh 27611
1 1974, NCMJ
r
Eldridge, Frederic Louis. M.D. (IM), N. C. Mem. Hosp.,
Chapel Hill 27514
Forciea, Mary Ann (Student). Box 2764, Duke, Durham
27710
Fox, Gary Norman (Student). Duke Hospital, Durham
27710
Fox, Raymond Morris. Jr., M.D. (OBG), 615 College St.,
Jacksonville 28540
Furman, Richard Warren, M.D. (WGS), State Farm Road,
Boone 28607
Gable, Walter DeLay, M.D. (PTH), Onslow Mem. Hosp.,
Jacksonville 28540
Glascock, Frank Blackwell, M.D. (R), 1172 Huntsmoor
Dr., Gastonia 28052
Grossman, Herman Lewis, M.D. (R). Duke. Box 3834.
Durham 27710
Hamilton, Buford Lindsay, Jr., M.D. (GP), 709 W. End
Ave., Statesville 28677
Hamilton, Gene Thomas, M.D. (ORS), 125 Lee St., Route
9, Greenville 27834
Harrell, Lonnie Clayton, HI, M.D. (Intern-Resident), 408
Colony Woods Dr.. Chapel Hill 27514
Huehes, Claude LcBernian, Jr., (Student), Box 2799, Duke,
Durham 27710
Jarrett, David Lincoln. M.D. (ORS), 9 All Souls Crescent,
Asheville 28803
Kingdon, Henry Shannon, M.D. (IM), N. C. Mem. Hosp..
Chapel Hill 27514
Khot, Prakash Nilkonth, M.D. (Intern-Resident), 2131 S.
17th St., Wilmington 28401
Laclergue, Edward Gregory, M.D. (GP). 213 Riverside
Dr., N. Wilkesboro 28659
Lesesne, Henrv Roby, M.D. (IM), N. C. Mem. Hosp..
Chapel Hill 27514
Leslie, John Bruce (Student). Box 2811. Duke, Durham
27710
365
Lloyd. Stephen Carroll (Student), 4111 Toroella St., Dur-
ham 27704
Lohavichan. Choomsanc, M.D. (IM), 2431 Vandevere Ave.,
Fayetteville 28304
Lutman, George Benton. M.D. (PTH), 3284-C Turtlepoint
Dr., Favetteville 28305
Marsicli. .Adolfo Hector, M.D. (ORS), Tau Valley Estates,
.•\pt. W-1. Rocky Mount 27801
Maltern. William Douglas, M.D. (IM). N. C. Mem. Hosp.,
Chapel Hill 27514
McGinnis. James Wm.. Jr.. (Student). Box 2799, Duke.
Durham 27710
McLaurin. Lambert Paschal. Jr.. M.D. (LM). N. C. Mem.
Hosp.. Chapel Hill 27514
Mmtz. Rudolph Ivev. Jr., M.D. (OBG). 3219 Carev Rd..
.Apt. 2-B. Kinston 28501
Naca. .Ahmed Hadv. M.D. (R). Duplin Gen. Hosp.. Ken-
ansville 28349
Nco. Corazon. M.D. (IM). Bo.x 538. Kenansville 28349
Noble. John, M.D. (IM), N. C. Mem. Hospital, Chapel
Hill 27514
Olsen. Kenneth Geo.. NLD. (AN), 400 Carman .Ave.. Jack-
sonville 28540
Omer. Syed. M.D. (N). 19 Staff Circle. Broughton Hosp.,
Morganton 28655
Pfister, Wm. Charles (Student). Box 2847, Duke. Durham
27710
Prendes. Jose Luis, M.D., 106 King Richard Ct., Jack-
sonville 28540
Proctor, Camilla .Allvn. M.D. (L\I). Rt. 6. Box 23. Chapel
Hill 27514
Rhodes. Herbert Paul, ,M.D. (R). Valdese Gen. Hosp..
Valdese 28690
Schatz. Richard .Alan (Student). 802 Vickers Ave., Durham
27701
Simrel. Kermit Oscar. Jr., (Student). 3040 Wedcedale Dr..
Durham 27702
Smith. Robert Lee. .\LD. (PTH). 236 Wrenn Ave.. Mt.
Airy 27830
Snow. Joseph Robert (Student), Box 2851. Duke, Durham
27710
Steiner. .Alton Louis. M.D. (IM). N. C. Mem. Hospital,
Chapel Hill 27514
Sullivan, Robert Joseph. Jr.. M.D. (IM), 306 Highland
Dr., Chapel Hill 27514
Taylor. Britton Edcar. NLD. (OBG). 1612 Doctors Circle
Dr.. Wilmincton 28401
Teta, Joseph Michael, M.D. (GP). Box 242, Roaring Gap
28668
Thakur. Veda Nand, M.D. (ORS). Nth and Chestnut Sts..
Lumberton 28358
Trofatter. Kenneth Frank. Jr.. (Student). Box 2865. Duke.
Durham 27710
Tucker, Landrum Sylvanius. Jr.. M.D. (Intern-Resident).
313 Woodhaven Road. Chapel Hill 27514
Walden. Burt Marcus Noland. M.D. (P), 718 S. Fifth
.Ave., Wilmincton 28401
Watts, Hugh Bcvd, M.D. (Renewal). (ORS), Granite
Quarry 28072
Wells, Samuel Alonzo. Jr.. M.D. (GS) Duke. Durham 27710
Wilkinson. Sarah Frances (Student). 301 Swift Ave.. .Apt.
19. Durham 27705
Willis. Henrv Stuart Kendall. Ill (Student). Box 2874.
Duke. Durham 27710
WHAT? WHEN? WHERE?
In Continuing Education
June 1974
("Place" and "sponsor" are listed only where these differ
from the place and group or institution listed under "for
information.")
In North Carolina
June 20-22
Mountain Top Assembly
Place; Waynesville Country Club. Waynesville
For Information: R. Stuart Roberson. M.D.. P. O. Box
307. Hazlewood 28738
Rondomyciti
(methacycline HCI)
CONTRAINDICATIONS: Hypersensitivity 10 any ol Ihe tetracyclines
WARNINGS Tetracycline usage during looth development (last half of pregnancy to ei(
years) may cause permanent tooth discoloration (yeHow-gray-brown), which is mt
common during long-lerm use Out has occurred after repeated short-term coursi
Enamel hypoplasia fias also been reported Tetracyclines should not be used in this)
group unless ottier drugs are not likely to be effective or are contraindicati
Usage m pregnancy. iSee above WARNINGS at)out use during tooth developma,
Animal siddies moicate that tetracyclines cross the placenta and can tie loxic to the
velopmg felus lotlen related to retardation of skeletal development) Embryotoxicityl
also been noted in animals treated early in pregnancy
Usage in newborns, infants, and children. (See above WARNINGS about use dur;
tooth development )
All tetracyclines form a stable calcium complex m any bone- forming tissue A decrei
m fibula growth rate observed m prematures given oral tetracycline 25 mg/kg even
hours was reversible when drug was discontinued
Tetracyclines are present m milk of lactatmg women taking lelracyctmes
To avoid excess systemic accumulation and liver toxicity in patients with impaired re
function, reduce usual total dosage and. if therapy 15 prolonged, consider serum level
terminations of drug The anti-anabolic action of tetracyclines may increase BUN. Wl
not a problem m normal renal function, in patients with significantly impaired funcft
higher tetracycline serum levels may lead to azotemia, hyperphosphatemia, and acifio^
Photosensitivity manifested by exaggerated sunburn reaction has occurred with trf
cydmes Patients apt to be exposed to direct sunlight or ultraviolet light should be sol
vised, and treatment should be discontinued at first evidence of skm erythema
PRECAUTIONS: If superinfection occurs due to overgrowth of nonsusceptible organisf
including fungi, discontinue antibiotic and start appropriate tfierapy
In venereal disease, when coexistent syphiits is suspected, perform darkfield exa
nation before therapy, and serologically test for syphilis monthly for at least four montl
Tetracyclines have been shown to depress plasma prothrombin activity, patients ci
ticoagulant therapy may require downward ad|ustmeni of their anticoagulant dosage.
In long-term therapy, pertorm periodic organ system evaluations (including bio
renal, hepatic)
Treat all Group A bela-hemolylic streptococcal infections tor at least 10 days.
Since bacteriostatic drugs may interfere with Ihe bactericidal action of penicillin, ai
giving tetracycline with penicillin
ADVERSE REACTIONS: Gastrointestinal (oral and parenteral forms) anorexia, naus
vomiting, diarrhea glossitis, dysphagia, enterocolitis, inflammatory lesions (with mo
lal overgrowthi m the anogenital region
Skin: naculopapular and erythematous rashes, exfoliative dermatitis (uncommon) P
tosensitivity is discussed above (See WARNINGS)
Renal toxicity nse m BUN. apparently dose related (See WARNINGS) ^
Hypersensitivity: urticaria, angioneurotic edema, anaphylaxis, anaphylactoid purpiV
pencarditis. exacerbation of systemic lupus erythematosus \ ■'
Bulging fontanels, reported in young mlants after full therapeutic dosage, have disi r
peared rapidly when drug was discontinued | r
Blood: hemolytic anemia, thrombocytopenia, neutropenia, eosmophilia / ,"
Over prolonged periods, tetracyclines have been reported to produce brown-black', ^■
croscopic discoloration of thyroid glands, no abnormalities of thyroid function stud ^5
known to occur
USUAL DOSAGE: Adutts- 600 mg daily, divided into two or four equally spaced ::■
More severe infections an initial dose of 300 mg followed by 150 mg every six hcji:
300 mg every 12 hours Gonorrhea In uncomplicated gonorrhea, when penicillin ^c
tramdicated. Rondomycm' (methacycline HCl) may be used for treating both mai>:^s
females in the following clmical dosage schedule 900 mg initially, followed by 3J0
q I d. foratotalofS 4grams
For treatment of syphilis, wfien penicillin is contramdicated. a total of 18 to 24 gram
Rondomycm' (methacycline HCI) m equally divided doses over a period of 10-15 t'A
should be given Close follow-up. including laboratory tests, is recommended. ■'
Eaton Agent pneumonia 900 mg daily for six days
Children -3 to 6 mg lb day divided into two to four equally spaced doses
Therapy should be continued for at least 24-48 hours after symptoms and feve' f
subsided
Concomitant therapy: Antacids containing aluminum, calcium or magnesium imc^u
sorption and are contramdicated Food and some dairy products also interfere Gu? t
one hour before or two hours after meals Pediatric oral dosage forms should ^o
given with milk formulas and should be given al least one hour pnor to feeding
In patients with renal impairment (see WARNINGS), total dosage should be decie;
by reducing recommended individual doses or by extending time intervals t)et»
doses
In streptococcal infections, a therapeutic dose should be given for at least 10 da. s
SUPPLIED: Rondomycm (methacycline HCI) 150 mg and 300 mg capsules, syr.3 >
taming 75 mg,'5 cc methacycline H(^l.
Before prescribing, consult package circular or latest PDR information.
Re. (
k??i WALLACE PHARMACEUTICALS
^^ CRANBUBY, NEW JERSEY 08512
366
Vol. 35, No
J July 8-13
1 1 Annual Duke Medical Post Graduate Course
t:e: Atlantis Lodge. Atlantic Beach, North Carolina
gram: designed primarily for the generalist. but with
jfficient variation to appeal to the interest of the in-
:rnist and the pediatrician. Conferences and lectures will
e given in the morning; afternoons and evenings will
e left free for recreational activities.
: $85, payable in advance. Course limited to 75 par-
cipants.
dit: A certificate of attendance will be given. Program
; acceptable for 30 accredited hours by A AFP.
Information: W. M. Nicholson. M.D.. P.
088, Duke University Medical Center. Durham
I
O. Box
27710
July 29-August 2
Annual Beach Workshop: Selected Topics in General
internal Medicine
(Hsors: Bowman Gray, Duke, and UNC Schools of
dedicine, in conjunction with the Medical University of
Houth Carolina
pe: St. Johns Inn, Myrtle Beach, South Carolina
^- $100
Information: Emery C. Miller, M.D., Associate Dean
pr Continuing Education. Bowman Gray School of
Jledicine. Winslon-Salem 27103
I
] September 6-7
liual Meeting of the North Carolina Chapter of the
(vmerican Academy of Pediatrics and The North Carolina
ediatric Society
:e: Pinehurst Hotel and Country Club
Information: Mrs. John McLain. Executive Secre-
nry, 3209 Rugby Road, Durham 27707
I
B September 18-19
f 1 Annual Angus M. McBryde Perinatal Symposium
p.: $50.0(1
F Information: George Brumley, M.D., Division of
erinatal Medicine. P. O. Box 2911, Duke University
ledical Center. Durham 27710
September 20-21
i 4 Walter L. Thomas Symposium on Gynecologic Malig-
' ancy and Surgery
Psjram: The two day symposium will be clinically oriented
ith the main emphasis on "Ovarian Cancer" and "Dif-
cult Office Gynecology." Invited guest speakers include
,T. J. Donald Woodruff. Baltimore, .Maryland: Dr.
erbert Buchsbaum. Iowa City. Iowa; and Dr. J. Tay-
ir Wharton. Houston, Texas.
C Jit: A.AFP credit applied for.
Fi Information: W. T, Creasman. M.D.. Director of Gyne-
: )logic Oncology. P. O. Box 2079. Duke University
ledical Center, Durham 27710
Gray School of
Cox. Forsyth County
Street. Winslon-Salem
October 4
F .yth County Heart Association
Pi-e: Babcock .Auditorium. Bowman
iedicine. Winston-Salem
F': $15.00
Fi Information: Mrs. Katherine
eart Association. 2046 Queen
'/1 03
October 20-22
A-ual Joint .Meeting of the North Carolina-South Caro-
^a. Societies of Ophthalmoloay and Otolaryngology
P e: .Asheville Hilton Inn. .Asheville. N. C.
S] isor: The North Carolina Society of Ophthalmology and
Otolaryngology
Fi Information: Banks Anderson, Jr., M.D., Secretary-
■easurer, P. O. Box 3802, Duke University Eve Center,
urham 27710
October 28-November 1
R iology Postgraduate Course
P e: Southampton Princess Hotel. Southampton, Bermuda
P ;ram Chairman: Richard G. Lester. ,M.D., Professor
id Chairman of Radiology, Duke University Medical
;nter. Guest speakers will include: Robert G. Eraser.
.D., Professor and Chairman of Radiology, McGill
University Medical School, Montreal, Canada; John A.
Evans, M.D., Professor and Chairman of Radiology,
Cornell University Medical College; William B. Sea-
man. M.D., Professor and Chairman of Radiology, Co-
lumbia University College of Physicians and Surgeons,
New York, N. Y.; Harold G. Jacobson, M.D., Professor
and Chairman of Radiology, Albert Einstein College of
Medicine (MHMC), Bronx, New York; and David H.
Baker, M.D., Director of Radiology. Babies Hospital,
Professor of Radiology, Columbia University College
of Physicians and Surgeons, New York. N. Y. Subject
matter will cover Pediatric and Adult Radiology of the
Chest, Genitourinary Tract, Gastrointestinal Tract and
Musculoskeletal System.
Fee: $200
Credit: Twenty-three hours ,AMA "Category One" accredi-
tation
For Information: Robert McLelland, M.D., Department of
Radiology, Box 3808, Duke University Medical Center,
Durham 27710
November 15-16
.Anesthesiology Fall Seminar
Place: Charlotte Memorial Hospital .Auditorium
Fee: $40.00
For Information: Dr. H. A. Ferrari. Chairman, Depart-
ment of Anesthesiology, Charlotte Memorial Hospital,
P. O. Box 2554. Charlotte 28201
In Contiguous States
June 17-19
PSRO For Hospital Management
Place: The Marriott, Atlanta, Georgia
Fee: ACHA affiliates— $225; nonaffiliates— $275
For Information: American College of Hospital Admin-
istrators. 840 North Lake Shore Drive. Chicago. Illi-
nois 60611
September 30 & October 1
Tennessee Valley Medical .Assembly annual meeting
For Information: Thomas L. Buttram. M.D.. Chairman.
Tennessee Valley Medical .Assembly, Whitehall Medical
Center, 960 E. Third Street, Chattanooga, Tennessee
37403
October 5-8
Southern Psychiatric .Association annual meeting
Place: The Homestead, Hot Springs, Virginia
For Information: Mrs. Annette BoutweM. P. O. Box 10387.
Raleigh 27605
Items submitted for listing should be sent to: WHAT?
WHEN' WHERE.', P. O. Box 8248. Durham. N. C.
27704. by the 10th of the month prior to the month in
which they are to appear.
News Notes from the —
BOWMAN GRAY SCHOOL
OF MEDICINE
WAKE FOREST UNIVERSITY
Dr. Manson Meads, Wake Forest University vice
president for medical affairs, has been named director
of the Medical Center — the Bowman Gray School
of Medicine and North Carolina Baptist Hospital.
The appointment was announced recently by
Francis E. Garvin of Wilkesboro, chairman of the
recently established joint administrative board of the
Medical Center.
Dr. Meads was nominated as the Medical Center's
first full-time director by the joint administrative
board. The nomination received the unanimous ap-
h I 1974. NCMJ
369
proval of the trustees of Wake Forest University and
the trustees of Baptist Hospital.
As director. Dr. Meads will serve as chief execu-
tive officer of the Medical Center and will be respon-
sible for its overall direction. He will be responsible
directly to the Medical Center board for the execu-
tion of duties delegated to the board by the two trus-
tee bodies.
The responsibilities include the formulation of
policies relating to the Medical Center, and planning
for its future needs and growth.
Dr. Meads will continue as vice president for medi-
cal affairs. Overall authority for the two institutions
will continue to be held by Dr. Richard Janewa\,
dean of the medical school, and John E. Lynch,
chief executi\e officer of the hospital.
The 73 members of the medical school's senior
class have been awarded internship appointments for
1974-1975.
They will serve their internships at 41 hospitals
in 25 states, the District of Columbia, and one foreign
countr\. Eighteen members of the class will remain
at Baptist Hospital for their training.
The seniors received the M.D. degree May 27
during commencement exercises on the Wake Forest
University campus. The commencement speaker was
Dr. Alvin M. Weinberg, director of the Office of En-
ergy Research and Development.
* * :;=
Three members of the medical school's faculty will
be promoted to the rank of professor, effective Julv
1.
They are: Dr. John P. Gusdon, Jr., obstetrics and
gynecology; Dr. Robert N. Headley, medicine; and
Dr. Milton Raben. radiology.
They are among 1 S Bowman Gray faculty mem-
bers for whom faculty appointments were announced
by Dr. Richard Janeway, dean.
Promoted to the rank of associate professor were;
Dr. .Alexander A. Birch, anesthesia; Dr. Thomas E.
Clark, community medicine (sociology); Dr.
Robert J. Cowaji, radiology; Dr. Louis S. Kucera.
microbiology; Dr. Dixon M. Moody, radiology (neu-
roradiology); Dr. G. Joseph Poole, radiology (neu-
roradiology ) ; Dr. John D. Tolniie, anesthesia; and
Dr. Nancy 0"\. Whitley, radiology.
Receiving promotions to assistant professor were;
Dr. Edward S. Season, surgery (plastic surgery);
Dr. James E. Crowe, radiology; Dr. John W. Den-
ham, community medicine; Dr. Kenneth E. Ekstrand.
radiology (radiologic ph_\sics); Thomas R. Gnau.
radiology ( radiopharmacy ) ; Dr. Richard E. Hall.
physiology; and Dr. Frederick Kremkau. medicine
( research ).
Dr. J. Edward Holl was promoted to assistant
professor in the medical school's Division of Allied
Health Protrrams.
J. Patrick Kelly, former executive news editor o
the \y'iiiston-Salei>i Journal and Twin City Sentinel
has been appointed director of development for t
Bowman Gray School of Medicine and North Can
lina Baptist Hospital.
The appointment was effective June 10.
Kelly's responsibilities include supporting thi
Medical Center's fund raising activities, particular!'
as they relate to the private sector. He also will b|
involved in long-range planning for the Medica
Center and will provide administrative support in th)
further de\'elopment of alumni affairs.
Kelly is a graduate of the University of Nort^fi,
Carolina at Chapel Hill and studied as a Niemai
Fellow at Harvard University.
i
Twelve students have been installed as new memi
bers of .Alpha Omega .Alpha, national medical honoij s
ary society .
Election to AOA is based on scholastic achiev
ment and character.
Senior students elected to AO.A include Joseph J
Dobner of Melrose Park, 111.; John S. Kelley a
Whiteville; Edward F. Haponik of Fall River, Mas;
William R. Lambeth of Greensboro; Richard MaH
of Wheaton. 111.; Joel B. .Miller of Statesville c
James D. Rogers of Big Rapids, Mich.; James S
Strohecker of Columbia, S. C; and Bruce D. Walle'
of New Castle. Del.
Elected from the junior class were Michael C .
Scruggs of Henrietta. James D. Sink of Lexingtonic:
and Edwin H. Shoaf of Charlotte.
* * +
The Department of Neurology has received a $10,
OUU grant to support research into myasthenia gra\i'
and related neuromuscular disorders.
The grant was made to the department's Welch
Kempton .Mvasthenia Gravis Research Fund by Misi
Mary E. Welch of Horse Shoe. N. C.
The grant will support the Welch-Kempton Myas
thenia Gra\ is Research Award, given each year to ;
medical student for a research project. The awar&m
carries a S 1 50 prize and a plaque.
The medical school has received a $53,199 gran
from the National Fund for Medical Education tc_
develop a new audiovisual self-instructional course
in radiographic anatomy.
Dr. Joseph E. Whitley, professor of radiology ai
Bowman Gray, will work with Dr. L Meschan. pro-
fessor and chairman of the Department of Radiolog)
at Bowman Gray, and Dr. Lucy Frank Squire, pro- ;.
fessor of radiology at the Downstate Medical Centei,|:.
in Brooklyn of the State University of New YorLj..
The research project is a cooperative effort be-
tween Bowman Gray and the Downstate Medica
Center. ,,
The grant is intended to provide more efficien^k
teaching methods to allow the future physician tc
370
Vol. 35. No. 6
ii what he must know to give the best possible
'fhile the new course will be developed primarily
reshman anatomy students, it may also be used
y dvanced medical students, interns, and residents
it would like to review the material.
' prototype of the program is planned to be ready
lifall for use in teaching freshman anatomy stu-
e: i here and in Brooklyn.
, * * *
'•. Robert A. Diseker, assistant professor of com-
u ty medicine, has been appointed to the board
f ' rectors of the North Carolina Health Council,
[{fvill serve as chairman of the council's Health
f;ation Committee.
* * *
r. Robert Dixon, assistant professor of radiology,
aiioeen elected president of the Southeastern Chap-
;r )f the American Association of Physicists in
4(' cine. He has also been appointed to the Scien-
li Tommittee of that organization.
J, * * *
I". Richard Janeway, dean of the medical school,
a!i')een appointed to the National Advisory Coun-
il.n Regional Medical Programs of the Health
leliurces Administration.
'■ie appointment was made by Casper Weinberger,
aitary of Health, Education, and Welfare. The
oicil advises and assists the Secretary in the pre-
aiJon of regulations for the policy matters con-
er;ng the regional medical programs.
, . Joseph E. Whitley, professor of radiology, has
eej elected to a Fellowship in the American College
f (adiology. He has been elected to the Board
f 1 rectors of the James Picker Foundation of White
la s, N. Y. The foundation was established with
ie\jrpose of fostering research in radiology.
I-
Ns/s Notes from the —
UNIVERSITY OF NORTH CAROLINA
DIVISION OF HEALTH AFFAIRS
■'e persons were honored in Chapel Hill in
Ta'h when the UNC School of Medicine gave them
s '|hest honor, the Distinguished Service Award.
hi are: Dr. Nathan A. Womack, first chairman
f '; Department of Surgery at the UNC School
f T'dicine; Mrs. Martha Love Ayers, a Greensboro
hi-ithropist; Dr. Sarah T. Morrow, director of the
iui )rd County Health Department, through which
,ie' arted the nationally recognized Comprehensive
hi -en and Youth Project; Dr. George Denman
lai' lond, internationally known pediatric malignant
ise e specialist and associate dean. University of
Southern California; and Dr. Corbett L. Ouinn, a
family practitioner in Magnolia.
Crohn's Disease which has no known cause and
which can mock any disorder affecting the abdominal
organs, including appendicitis, is being examined at
UNC-Chapel Hill.
UNC physicians headed by Dr. John T. Sessions,
chief. Division of Gastroenterology, will study the
effects on patients of the three most commonly pre-
scribed medications.
Officially, this three-year program is called the
National Crohn's Cooperative Study and is funded
by the National Institute of Arthritis, Metabolism and
Digestive Diseases.
Fred M. Eckel, director of pharmacy services for
North Carolina Memorial Hospital, and associate
professor in the UNC School of Pharmacy, has been
named 1973 Hospital Pharmacist of the Year by the
North Carolina Society of Hospital Pharmacists. The
award was presented by the Pfizer and Roerig Divi-
sion of Pfizer Laboratories in New York.
Dr. Larry J. Leoffler, assistant professor of medici-
nal chemistry at the UNC School of Pharmacy in
Chapel Hill, has received a $27,820 research grant
from Sandoz Pharmaceuticals of Hanover, New Jer-
sey.
The grant will support research in the development
of methods potentially useful for measuring very
small quantities of ergot alkaloids which are found in
biological fluids, such as plasma or urine. These com-
pounds are part of drugs used in the treatment of
ailments such as migraine headache and excessive
bleeding. ^ ^ ,,
The UNC Department of Nutrition in Chapel Hill
has been tapped to conduct a nationwide medical
evaluation of the $40 million federal food and nu-
trition program for women, infants, and children.
Dr. Joseph Edozien, chairman of the Department,
said the bulk of the $40 million from the U.S. De-
partment of Agriculture will go into food for preg-
nant women, nursing mothers, infants, and children.
The UNC nutritionist and his staff will conduct
medical evaluation studies in 15 states, from Califor-
nia to New York and from Minnesota to Texas.
North and South Carolina are included in the project.
Students at North Carolina Central University in
Durham will have an opportunity next year to major
in health administration in the school's Department
of Business Administration.
The new program will be made possible through
a cooperative arrangement with the UNC School of
Public Health's Department of Health Administration
in Chapel Hill.
John V. Turner of NCCU and Dr. Patricia Barry
of UNC are serving coordinators of the curriculum
JNM974, NCMJ
371
development committee. Turner is chairman of
NCCU's Department of Business Administration. Dr.
Barry is a professor of healtii administration at UNC.
Tfie first joint meeting of British and .American
physicians to be held in the United States was held
.April 8-9 at UNC-Chapcl Hill.
The three-day .Anglo-American conference on
Continuing Medical Education was sponsored by the
Royal Society of Medicine in London, the Royal
Society of Medicine Foundation in New York, and
the UNC School of Medicine.
The conference brought authorities from both sides
of the Atlantic to discuss how physicians can learn
new skills and information to improve patient care.
:;: !;: *
A dedication service for the Louis G. Welt Fel-
lowship in the Department of Medicine at the UNC
School of Medicine in Chapel Hill was held March
30 on the UNC campus.
Dr. Robert L. Ney. professor and chairman. De-
partment of Medicine, announced the establishment
of the fellowship in honor of the late Dr. Welt who
died earlier this year.
Dr. Welt joined the UNC faculty in 1952 and was
named chairman of the Department of Medicine in
1965. He served in that chair until 1972 when he
went to Yale University.
* ■:■ -■:■-
Robert Wilson of the Carolina Population Center
at UNC-Chapel Hill has edited a guide to problem
pregnancy and abortion counseling. The 120-page
resource book contains up-to-date information for
counselors on the general principles of problem preg-
nancy counseling. Chapters examine alternatives in
continuing a pregnancy, the abortion alternative in-
cluding medical and legal information, promoting re-
sponsible sexual behavior, responsibilities in contra-
ceptive counseling, and contraceptive and reproduc-
tive education.
This book came from the first North Carolina
Workshop on Problem Pregnancy Counseling, at-
tended by more than 500 counselors from nearly
all of North Carolina's 100 counties.
News Notes from the —
DUKE UNIVERSITY MEDICAL CENTER
Two School of Medicine faculty members have
been named to James B. Duke Professorships, the
highest academic honor the university bestows on
its distinguished teachers.
They are Dr. Robert L. Hill, professor and chair-
man of the Department of Biochemistry, and Dr.
372
NEW ! Patient Therapy Packs
Because many patients tend to
stop treatment prematurely, the
full course of bid. therapy is
now specially packaged to
encourage patients to complete
the full course of therapy.
CANDEPTIN Vaginal Ointment
Therapy Pack— two 75 gm. tubes
CANDEPTIN Vagelettes
Therapy Pack— 2S vaginal capsules
CANDEPTIN Vagina! Tablet
Therapy Pack— 28 vaginal tablets
Brief .Siinilliar>
Description: Candeptin (Candicidin) Vaginal
Ointment contains a dispersion of Candicidin
powder equivalent to 0.6 mg. per gm. or 0.06%
Candicidin activity in U.S.P petrolatum. 3 mg.
of Candicidin is contained in 5 gm. of oint-
ment or one appticatorful. Candeptin Vaginal
Tablets contain Candicidin powder equivalent
to 3 mg. (0.3%) Candicidin activity dispersed
in starch, lactose and magnesium slearate.
Candeptin Vagelettes Vaginal Capsules
contain 3 mg. of Candicidin activity dispersed
in 5 gm. U.S.P petrolatum.
Action: Candeptin Vaginal Ointment. Vaginal
Tablets, and Vagelettes Vaginal Capsules
possess anti-monilial activity.
Indications: Vaginitis due to Candida albicans
and other Candida species.
Contraindications: Contraindicated for pa-
tients known to be sensitive to any of its com-
ponents. During pregnancy manual Tablet or
Vagelettes Capsule insertion may be pre-
ferred since the use of the ointment applicator
or tablet inserter may be contraindicated.
Caution: During treatment it is recommended
thai the patient refrain from sexual inter-
course or the husband wear a condom to
avoid re-infection.
Adverse Reaction: Clinical reports of sensiti-
zation or temporary irritation with Candeptin
Vaginal Ointment. Vaginal Tablets or
Vagelettes Vaginal Capsules have been ex-
tremely rare.
Dosage: One vaginal appticatorful of
Candeptin Ointment or one Vaginal Tablet
or one Vagelettes Vaginal Capsule is in-
serted high in the vagina twice a day. in the
morning and at bedtime, for 14 days. Treat-
ment may be repeated if symptoms persist or
reappear.
Available Dosage Fonns: Candeptin Vaginal
Ointment is supplied in a Patient Therapy
Pack, containing two 75 gm. tubes with two
applicators for the full course of treatment.
Candeptin Vaginal Tablets are packaged in
boxes of 28, in foil with inserter - enough
for a full course of treatment. Candeptin
Vagelettes Vaginal Capsules are packaged in
a Patient Therapy Pack, containing
28 Candeptin Vagelettes Vaginal Capsules
(2 boxes of 14), for the full course of treat-
ment. Store under refrigeration to insure full
potency.
Federal law prohibits dispensing without pre-
scription.
References:
1, IVIelges, F J.: Obstet. Gynecol. .'-<:92l, Dec.
1964. 2. Cameron. P F: Practitioner 202:695,
May 1969. 3, Olsen, J. R.; Journal-Lancet 85:
287, July 1965. 4, Giorlando. S. W.; OB/GYN
Digest /.;:32, Sept. 1971. 5, Decker, A.: Case
Reports on file, Medical Department, Julius
Schmid. 6. Friedel. H. J.: Md. State Ivied. J.
75:36, Feb. 1966. 7, Roberts. C. L. and Sulli-
van, J.J : Calif. IWed. /OJ: 109, Aug, 1965. 8, Gior-
lando, S. W. Torres, J, F and Muscillo, G.: Am.
J, Obstet. Gynecol, 90:370, Oct. 1, 1964.
9, Abru7?i, W. A,: Western Med, 5 62, Feb.
1964
Innovators in candicidin therapy
rZlSCHMID
IM I LABORATORIES INC
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for complete therapeutic flexibility— even for adoles-
cent and gravid patients.
■ Symptomatic relief in many patients as early as
48-72 hours''^; usually cures in a single 14-day course
of therapy.
■ Exact dosage assured when used as directed.
■ High patient acceptability, easy to use in all forms;
helps keep patients on the full 14-day regimen —
important in controlling recurrences.
■ Clinically proved— CANDEPTIN Vaginal Ointment
and Vaginal Tablets have more than nine years of
clinical experience.
■ Sensitivity and temporary irritation with
CANDEPTIN (candicidin) Vaginal Ointment, Vaginal
Tablets, and VAGELETTES Vaginal Capsules have
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And a dosage form for all your patients
. VAGELETTES™
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Guy L. Odom, professor and chief of the Division
of Neurosurgery.
Hill is a specialist in protein and enzyme chemis-
try. A graduate of the University of Kansas, he came
to Duke in 1961 from the University of Utah. He
has headed the department since 1969.
Odom is a graduate of the Tulane University
Medical School and has been at Duke since 1943.
Odom has headed the neurosurgical division since
I960.
* * *
Dr. Andrew G. Wallace, a professor of medicine
and chief of the Division of Cardiology, has been
named to the newly estabHshed Walter Kempner
Professorship.
Kempner, a member of the Duke faculty for 38
years, is widely known as creator of Duke's "rice
diet" program.
Kempner was brought to Duke by Dr. Frederic
Hanes, who first met him while in Berlin \'isiting
Dr. Otto Warburg, the Nobel laureate in biochemis-
try. Kempner came from a distinguished background,
both of his parents having held professorships in
medical schools in Germany. Warburg regarded
Kempner as a man of extraordinary promise.
Eager to add a full-time medical investigator of
outstanding competence to the Department of Medi-
cine he then headed, Hanes offered Kempner an
appointment which he eventually accepted, becorti
the first salaried member of the Department
Medicine whose major responsibility was medical
search. He remained on the faculty at Duke \x,
his retirement in .August, 1972. He is now ser
in a consultant capacity to the medical center.
The professorship established in his name ha
twofold purpose — to honor Kempner by the appo
mcnt of an outstanding clinician-investigator to
endowed professorship, and to encourage additic
support for the continuation of Kempner's spe
interests, notably the program of research in care
vascular and nutritional diseases. In this way
Department of Medicine hopes to recognize in sr
part the contributions Kempner has made to
patients, to his field, and to Duke University Mi
cal Center.
Wallace graduated from the Duke Medical Scl
in 1959. He was appointed to the Duke facuU;
1964, and in 1967 he was named director of
Myocardial Infarction Research Unit. Wallace, \
also holds an appointment as assistant professoi
physiology, became chief of cardiology in 1970
was promoted to full professor the following y
* * *
Genie Kleinerman, a third-year medical stud
presented a paper on "Depression of Mono
Chemotaxis by Virus" at a meeting of the Fed-
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.
Accredited by the Joint Commission on Accreditation and
Certified for Medicare
James Asa Shield, M.D.
James Asa Shield, Jr., M.D.
Catherine T. Ray, M.D.
Weir M. Tucker. M.D.
George S. Fultz. Jr., M.D.
Graenum R. Schiff. M.D.
374
Vol. 35, N
I'jn of American Societies for Experimental Biology
I Atlantic City.
* * *
With what is believed to be one of the largest
fts donated by a hospital auxiliary at one time, the
uke Hospital Auxiliary has pledged $100,000 over
le next four years to the building fund of the new
(Duke Hospital North."
J The Duke expansion project is expected to cost
[iproximately $90 million. Dr. William G. Anlyan,
(;e president for health affairs, said the auxiliary's
;pdge will be applied to the more than $30 million
vjke needs as equity on which to borrow the remain-
g funds for construction.
iDr. W. Gerald Austen, professor of surgery at
arvard and chief of the surgical services at the
jHSsachusetts General Hospital, delivered the 12th
i|nual Deryl Hart Lecture in April.
His topic was "Surgical Treatment of .Acute Coro-
ry Artery Disease."
The lecture honors Dr. Deryl Hart, former chair-
in of surgery and president-emeritus of Duke Uni-
rsity.
(
(R FORCE RECRUITING DETACHMENT 307
Eight North Carolina medical students have been
'arded Armed Forces Health Professions Scholar-
,ps. including commissions as Air Force Reserve
.:ond lieutenants, through the work of the Air Force
kdical recruiting team in Raleigh.
Harold A. Nichols, UNC School of Medicine, was
; first medical student in the nation to be commis-
'ined under the program. Others are: from UNC
lool of Medicine — Gwendolyn M. Boyd, Herman
lady Morgan, Jr., Scott H. Norwood, and Uril C.
leene; from Bowman Gray School of Medicine —
Michael C. Scruggs and William S. Browner; from
Duke University School of Medicine — Jeffrey B.
Symmonds.
The scholarship includes tuition, books, equip-
ment, fees, and $400 monthly during the student's
pursuit of an M.D. degree. Upon graduation, the
student may enter active duty (a commitment of one
year for each scholarship year), or, if selected, he
may pursue post-graduate medical education at a
civilian institution.
For information regarding graduate medical edu-
cation programs ( residencies and fellowships ) avail-
able to active duty medical professionals on a com-
petitive basis. Captain Glenn T. Satterfield, MSC,
USAF, and Technical Sergeant James C. Dotson of
the Air Force medical recruiting team are available
to meet with those interested in the program at the
Federal Building, 310 New Bern Ave., Room 333,
Raleigh, N. C. 27611 (or telephone: 919-755-
4130).
ROCHE LABORATORIES HAS NEW
IDENTIFICATION SYSTEM
All the benefits which accompany fast and accu-
rate patient identification of prescription medicines
soon will be applicable to Roche products through
their new Tel-E-Mark'''^' program. Under this sys-
tem, product and company name and, where applic-
able, dosage strength will be imprinted on each tablet
and capsule.
The advantages of this innovation are many.
Prompt knowledge can be a life-saving factor in
such emergencies as accidental overdose, attempted
suicide, or patient allergies. It can prevent confusion
in cases of multiple prescriptions, alert patients in
case of a drug recall or public warning, and be help-
ful to the patient who changes physicians.
Month in
Washington
'ifriggered by the surprise introduction of a Ken-
ly-Mills proposal for national health insurance and
iiajor effort by the Nixon Administration to get its
1 bill through this year, the Congress has again
fted a hot and heavy debate on the complex issues
■blved.
[Appearing before the House Ways and Means
nmittee, Russell B. Roth, M.D., president of the
f^ierican Medical Association, warned that most of
,p 1974. NCMJ
the Congressional push for national health insurance
(NHI) is based on the false premise that there is a
health care crisis.
"The fact is," Dr. Roth told the Committee, "more
people are recei\'ing more and better medical care
from more and better trained physicians in more and
better equipped facilities than ever before in history.
These are not elements of crisis. The fact also is that
the public, as its opinion has been judged in various
375
polls, does not perceive medical service to be a major
problem area.
"No doubt the Committee recalls a recent Louis
Harris poll, commissioned by a Senate subcommit-
tee, which indicated that, whereas 64 percent of the
sample identified inflation as our nation's most seri-
ous problem, health care rated 15th, or next to last
on the list, with only tliree percent of the respondents
putting emphasis on this. Inasmuch as any of the
proposals for extensions of federal subsidies for
medical service are inevitably inflationary to some
degree, one wonders about the advisability of further
aggravating this most serious problem in order to
attack a problem of much lesser magnitude.
"Poll after poll confirms that people are generally
satisfied with the type of health care they personally
receive. This satisfaction relies on wide experience,
for some 2.5 million people a day see a physician.
A 1971 University of Chicago study, based on a na-
tionwide sample, found 84 percent of the people
satisfied and only ten percent dissatisfied. Just last
month, a survey commissioned by the Washington
Post uncovered a virtually identical pattern in this
area. According to Mr. Jay Mathews" story, six
every seven local residents are at least 'pretty satis
fied' with their medical care. Only one person in te
expressed any measure of discontent. It would be a
interesting exercise to see if you could find anothQ
issue or subject these days upon which American
would voice 85 or 90 percent agreement.
"Reflected in the results of the polls is a recoi
of at least ten years of substantial progress. Durin
this period, the number of American medical schoo
and the number of physicians available to the Amer
can public have been increasing. The number of phj
sicians will continue to increase at a pace which e:
ceeds the general population growth rate."
Speaking strongly in support of the AMA spot
sored Medicredit bill for NHI, Dr. Roth urged tl
Committee to follow the guiding principles deve
oped by the AMA in its proposed legislation.
"We are convinced," Dr. Roth said, "that finai
cial barriers to medical services are as real for midd
income persons as for the poor — that there is gre
virtue in attention to ability to pay deductible ar
coinsurance amounts — and that our graded tax-crec
Facility, program and environment
allows the individual to maintain
or regain respect and recover viith
dignity.
Medical examination upon admis-
sion.
Modern, motel-like accommodations
witli private batli and individual
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-Exem
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Group Therapy
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FOR AOMIHANCE CALL
JAMIE CARRAWAY
EXECUTIVE DIRECTOR
919-621-3381
Recognized by:
Blue Cross & Blue Shield • Life Assurance Co. of Carolina
• Pilot Life Ins Co • Aetna Life & Casualty
• John Hancock Mutual Life Ins. Co • Kemper Ins.
• Metropolitan Life Ins. Co. • United Benefit Life Ins, Co
• Security Lite & Trust Co
FELLOWSHIP HALL mc
P, 0. BOX 6928 • GREENSBORO, N. C. 27405
Member of:
• N. C. Hospital Associati ■•
• Ttie Alcoholic & Drug Proinl
Assn. of Nortti America
• American Hospital Assofi A
FOR MEDICAL INFORMATItCH
J. W. WELBORN, JR., )•
MEDICAL DIRECTOf
919-275-6328
Located off U.S. Hwy, No. 29 at Hicone Road Exit,
Wz miles north of downtown Greensboro, N. C.
Convenient to 1-85, 1-40, U.S. 421, U.S. ;
and ttie Greensboro Regional Airport,
FELLOWSHIP HALL WILL ARRANGE CONNECTION WITH COMMERCIAL TRANSPORTATION.
376
Vol. 35. Nol
jproach is a superior feature in adjusting subsidies
imeeds."
1 Lashing out at the Kennedy-Mills NHI proposal,
. Roth said, "It is one thing to mandate the pur-
Ijase of private insurance by employers. It is some-
ing quite different to institute increased payroll
xes, destroy the future of private insurance, and
« lift a well-regarded private function into a federal
lency.
("The financing envisioned in the Kennedy-Mills
^ ioposal gives us several problems:
H l|"It creates a massive four percent increase in the
■lii icial Security tax. Wage earners will not be de-
ded by the fact that three percent is to be paid by
uployers and one percent by employees. The public
sophisticated enough to know that there is no free
fie in this respect and that the source of the funds to
y for such federal programs is from their compen-
|tion.
t"'We would point out further that under Social
Rcurity taxes, he who earns $20,000 a year pays the
fne as the person who earns $90,000 or $100,000.
ijour view, it would be more equitable for those who
ike more to pay more. We would prefer the sort of
nsistent sliding scale approach that is embodied in
■3 Medicredit bill. Finally, we would seriously ques-
<n the proposition that, by eliminating the profit
ctor. Social Security handling of health insurance
lances will bring economies and efficiencies.
"The track record of government — our own and
tiers as well — provides scant historical evidence
It the government's capacity to manage surpasses
ivate management in terms of cither efficiency or
[onomy.
'("Administrative control derives in large part from
tancing mechanisms, and, since we advise strongly
ainst control of a new program by the Social Secu-
y Administration, we would avoid Social Security
lancing.
["There can be no justification for the establish-
!;nt of a vast and expensive new corps of clerks and
ireaucrats, dedicated to the task of complicating
jiat should be a relatively simple program for plac-
i? in the hands of the eligible beneficiary a policy
insurance or a contract for service tailored to his
feds."
* * *
The day before the AMA testimony before the
wys and Means Committee, Health, Education,
jd Welfare Secretary Caspar Weinberger told com-
uttee members that the Administration is dead seri-
s about pushing for enactment of an NHI program
\s year.
r^ Secretary Weinberger came down hard on the
-nnedy-Mills proposal that would move toward the
ieralization of the nation's health care.
' Discussing the "fundamental differences" between
'; so-called compromise plan sponsored by Kennedy
^d Mills, and the Administration's Comprehensive
iE 1974, NCMJ
//
Health Insurance Plan (CHIP), Weinberger de-
clared:
"I would be less than candid if I did not stress how
strongly we are committed to the basic principles of
the CHIP proposal."
The Secretary told the crowded hearing room that
"the national climate has never been more favorable
for the development of a sound concensus on a na-
tional program of health insurance. ... I am here to
urge — ^just as strongly as I possibly can, personally
and on behalf of the Administration — that this clear
chance at solid accomplishment not pass without the
nation's action.
"We firmly reject the views of those few who coun-
sel that no action be taken until some vague, future
time when, they believe, their own plan can be
enacted. Such a time will never arrive."
A major reason for prompt action, Weinberger
said, is the prospect that "the American people ap-
pear to be in for a very rough period indeed as far as
health care costs are concerned." Congress' failure to
approve continued wage-price controls on health
could lead to a $4-5 billion increase in health
care costs next fiscal year and $9 billion the following
year, he cautioned.
If this happens, all current cost estimates for
various NHI proposals "would be far too low." He
said "the nation desperately needs measures to avoid
such a pocketbook disaster."
In devising the CHIP plan, based on mandated
employer health insurance plans for employees.
Weinberger said the Administration believed "it is
imperative to improve, rather than demolish, the
present system."
Although the cabinet Secretary took swipes at all
the major NHI competitors to CHIP, he not surpris-
ingly reserved most of his fire for the Mills-Kennedy
compromise. This bill calls for a Social Security NHI
financed by a four percent tax and administered by
Social Security as a virtually independent agency.
Mills-Kennedy, according to Weinberger, "would
take a major step down the road toward complete
federal financing and control of all health care in the
United States. If that policy approach were to pre-
vail, I feel there would be no turning back."
The financing of health care is too important to
the people "to turn over to a federal bureaucracy,"
he asserted. Noting the complexities of the health
system and the relative lack of knowledge of its
workings, he said, "in these circumstances the dan-
gers of turning financial control of this vital industry
over to an enormous new federal bureaucracy are
considerable."
Quashing speculation that the Administration
might try to reach an accommodation on the Mills-
Kennedy approach, Weinberger hammered away at
it. making it plain that he regarded the Mills-Kennedy
plan as the big danger. He said it would stifle private
377
initiative "under piles of paperwork and federal regu-
lations."
"We believe that the federal role in health financ-
ing must be clearly limited, as it is in CHIP. National
health insurance should not be the nationalization of
the health system," he continued.
The Administration officer said Mills-Kennedy
would impose $40 billion of new federal taxes "on
top of a tax burden that many Americans already
believe is excessive." Furthermore, Weinberger said,
"payroll taxes are a much greater burden on the poor
than is general revenue financing."
He said the Kennedy-Mills plan would virtually
eliminate privately administered health insurance
and substitute a fully federally financed and adminis-
tered system. "Our present system should be im-
proved upon rather than dismantled in favor of a-
costly, inflexible federal system," he said.
"The budgetary impact on the federal government,"
Weinberger maintained, "is simply unacceptable."
* * *
The government's procedures to assure that Pro-
fessional Standards Review Organizations (PSROs)
represent physicians in their local areas have been
announced.
The PSRO law requires that the HEW department,
before entering into an agreement with an organi-
zation to be the PSRO for an area, must notify the
physicians of that area of the intent. The physicians
then have the opportunity to object to a specific or-
ganization's being named as the PSRO. The me
to be used in notifying the nation's physicians o
proposed PSROs, and the subsequent steps t
taken in assuring that the organizations are ac
able to the physicians, are detailed in the Ft
Re\;ister of .'Xpril 16.
"In keeping with the PSRO legislation, we
developed procedures to assure that the organizai
established as PSROs throughout the country
truly representative of the physicians in each o
PSRO areas," HEW Secretary Caspar Weinbc
said. "It is the local physicians who will plan, ope
and control the PSRO in each area, and, there:
the organization designated as the PSRO mus
their organization," he said.
When the Secretary has determined that a 1
physician organization is qualified to perform
PSRO functions required by law, he will notify
area's physicians and other health professional
announcements in the local press and mailed no
to physician and hospital organizations active in
area. The notice will also be published nationall
the Federal Register.
The notice will announce the Secretary's inter
enter into a financial agreement with a specific
ganization. describe the organization, and indi
that active, practicing physicians in the area havt
days in which to protest the proposed selectior
less than ten percent of the local area's physic
object to the proposed organization, the law prov
Westbrook
Psychiatric Hospital, Inc.
Richmond, Virginia
FOUNDED 1911
PSYCHIATRY
REX BLANKINSHIP, M.D.
Chairman, Advisory Group
JOHN R. SAUNDERS, M.D.
Medical Director
THOMAS F. COATES, JR., M.D.
Assistarf Medical Director
OWEN W. BRODIE, M.D.
Associate in Psychiatry
M. M. VITOLS, M.D.
Associate in Psychiatry
WESLEY E. McENTIRE, M.D.
Associate in Psychiatry
BOBBY W. NELSON, M.D.
Associate in Psychiatry
NEUROLOGY
GERALD W. ATKINSON, M.D.
Associate in Neurology
HUGH HOWELL, M.D.
Associate in Neurology
CHILD PSYCHIATRY
GILBERT SILVERMAN, M.D.
Associate in Child Psychiatry
ADMINISTRATION
H. R. WOODALL
Administrator
378
Vol. 35. N^-'i
(I
I'm sorry,
Doctor !
You're not
going to be
able to
continue
your
practice."
Have you ever stopped to consider the effect on
yourself and your family if this were ever to
happen to you? Even when you are covered
with insurance for the medical and hospital bills,
the expenses of day-to-day living can quickly
use up the money it has taken you years of
work to accumulate.
Now, a Disability Income Protection Plan,
especially designed for younger doctors, is avail-
able for members of the North Carolina Medical
Society.
This plan can help see to it that your family's
future will be protected if you should become
sick or hurt and unable to work. Depending
upon the plan you select and qualify for, bene-
fits are available from $600 to $1,200 a month.
These tax-free benefits are yours for use as you
see fit. In addition, benefits are payable whether
you are confined to the hospital or are at home
recovering.
If you are under 55 years of age, just fill out
the coupon below and mail it today. There is
no obligation to learn more about the benefits
of this plan to you.
Mutual
^moha
The people who paii . . .
Life Insurance Affiliate: United of Omaha
MUTUAl OF OMAHA INSURANCI COMPANY
HOME OFFICE OMAHA, NEBRASKA
Mutual of Omaha Insurance Company
Dodge at 33rd Street
Omaha, Nebraska 68131
/ am interested in learning more about the program of Disability Income Protection available to me.
Name
Address .
City
Slate .
ZIP
that the Secretary can designate and fund the PSRO
that he has chosen. However, if more than ten percent
do object, the Secretary will conduct polls of the phy-
sicians in the area. To each physician who practices
in the area, HEW will mail a ballot on which he can
indicate whether the organization provisionally se-
lected by the Secretary does or does not represent
him.
A 30-day period will be allowed for the ballots to
be returned. If more than 50 percent of the respon-
dents to the poll indicate that the organization does
not represent them, the Secretary will no longer con-
sider that organization for PSRO designation. If less
than half object, the Secretary, by law, can conclude
his agreement with the local PSRO.
The government has labeled as "factually inac-
curate and misleading" a kit on Professional Stan-
dards Review Organizations (PSROs) prepared by
the American Medical Association.
In a critique of the kit, the Health, Education and
Welfare Department said many of the PSRO review
functions actually are embodied in the Social Security
Act's Medicare and Medicaid provisions that were
approved long before PSRO.
The HEW paper contends that the purpose of
PSRO "was to give practicing physicians priority in
undertaking the review of care provided, rather than
have the review performed by those outside the medi-
cal profession."
Contents of the kit, entitled "PSRO— DELETE-
RIOUS EFFECTS," have been criticized by HEW
and Senator Wallace Bennett (R., Utah), chief Con-
gressional sponsor of the PSRO provision. The kii
was prepared and distributed by the AMA at the be-
hest of the AMA's House of Delegates to alert the
medical profession to the dangers of such a review
system.
Theodore Cooper, M.D., has been appointed
deputy to Assistant HEW Secretary for Health
Charles Edwards, M.D. Dr. Cooper is director o
the National Heart and Lung Institute. Henry Sim
mons, M.D., who has been serving as Dr. Edward'
right-hand-man, will continue to hold a deputy p'
sition, but will concentrate henceforth most of hi
efforts at directing the Professional Standards Review
Organization (PSRO) program. Dr. Cooper is re
garded as one of the government's most capabl
health officers. One of the first heart transplant rt
searchers, he is a renowned expert on the heart.
John Chase, M.D., a Veterans Administratio
career medical official for 22 years, has been a{
pointed Chief VA Medical Director. VA Adminii
trator, Donald Johnson, also announced the appoin
ment of Dr. Laurance Foye, Jr., M.D., as Depul
Chief Medical Director of the agency. Dr. Chase
succeeding Marc Musser, M.D., who resigned. Fo}
replaces Benjamin Wells, M.D., who retired la
January 23.
Book Reviews
Faith Healing: Finger of God or Scientific Curiosity?
Compiled by Claude A. Frazier, M.D. 192 pages. Price,
$5.95. New York and Nashville: Thomas Nelson. Inc.,
1973.
Claude A. Frazier was taught by his mother that
he was healed by divine intervention when he was
seriously ill as a child. He learned that prayer helped
bring healing to his own son. As an active layman of
the church Dr. Frazier was asked by ministers, "What
do you think of faith healing?" This book, says
Frazier, "is an attempt to answer this question"
(p. 9). Frazier shares twenty responses by other
physicians, rather than answering the question him-
self. He gives no criteria by which he selected the
essays, nor does he organize them in any topical or
developmental sequence.
Some of these essays preclude that faith heali
could not be experienced by a person who is n
of the Christian faith. A few of the chapters are
overly simple in their approach to faith healing tt
they become superficial. Omitting some chaptf
would have strengthened the quality of the book a
would have done away with extensive duplicatic
Some of the writers come across as Biblical interp:
ters rather than physicians, and in some cases t
Biblical scholarship is very limited.
The subject addressed in this book is timely t
does not give the reader the comprehensive histr-
cal foundation for faith healing that one finds ir3
book like Healing ami Christianity by Morton '.
Kelsey ( Harper and Row, 1 973 ; 398 pp., $8.95 ) .
The strength of Frazier's book is in the quality oa
380
Vol. 35, N(i6
ijsw good essays, which makes me pleased to have
piiis book in my library.
Many of these essays communicate the thesis that
i) healthy spirit is essential to a healthy mind and
bdy, and that faith has transformed the lives of many
^peless and dying people.
The last chapter, "From Epidauros to Lourdes: A
fistory of Healing by Faith," by David H. L. Robert-
in, gives an overview of faith healing as practiced in
n-Western cultures, in Judaism, in the Christian
iiurch, and modern day religions, including the dc-
;i!"relopment and use of relics. This chapter is useful
it -ackground for reading or viewing The Exorcist.
(Obertson declares that in all of the exercises of faith
-:aling, and in some cases, demonstrations, "no one
ill ever know how much of the cure depends on the
> intient's desire and expectation that he be healed.
; Jiut most physicians recognize that motivation is a
I iDwerful force aiding recovery. In spite of this, there
e surely few in the field of medicine who have not,
1 some rare occasions at least, witnessed a recovery
) unexpected, so contrary to the usual prognosis,
*itid so apparently complete, that the word 'miracle"
temed the only appropriate description of it" (p.
i88f.).
"" '■ "The Personal Meaning of Faith Healing" by
Mansell Pattison discusses the use of the MMPI
an instrument in studying persons who have ex-
Irienced faith healing. The author says that these
Wsons arc characterized by a high degree of denial
id repression of disturbing emotions, and an exag-
irated need for social acceptance. Dr. Pattison says
fhese subjects participate in faith healing as a
jeans of rectifying their perception of being in a sin-
[l state in their relationships to God . . . the faith
laling experience reinforces to the person the value,
jiportance and certainty of rightness of their reli-
ous style of life" (p. 113).
lAs a hospital chaplain, 1 found the essay "The
pights Hospitallers" by Bernard J. Ficarra an in-
^guing chapter, tracing the history of hospitals
trough religious Crusaders. I was especially inter-
ted in this subject, in light of the recent establish-
,ent of hospices in both Europe and the United
ates.
^Several chapters speak of the need for the physi-
jin to utilize his faith in treating patients. Health
,d healing is a medical-faith-personality dynamic of
.ith the patient and the physician.
jl"Death, Dying and Cancer — Implications for the
,- jiristian Physician," by Donald M. Hayes, is, in my
limation, the best written of the twenty essays,
iyes points out the limitations of the physician in
Jating the cancer patient. The physician is caught
H
,)j,|iE 1974. NCMJ
in the dilemma of the Hippocratic Oath, between "to
relieve suffering" and "to prolong and protect life."
Hayes has no evidence of ever having seen faith
healing occur, yet he says "I have seen remarkable
instances of improvement or disappearance of can-
cer. . . which are explainable on the basis of immu-
nology of the patient rather than some bizarre meta-
physical abridgment of natural law" (p. 145).
For the physician or chaplain who takes seriously
his role to bring about healing in the lives of people,
this book raises important questions which no profes-
sional person can afford to put aside lightly.
Earl A. Hackett, S.T.M.
Review of Physiological Chemistry. By Harold A.
Harper, Ph.D. ^45 pages. 14th edition. Los Altos.
California: Lange Medical Publications, 1973.
The title of this book renders it a small disservice,
since it implies that the reader should have some prior
knowledge of the subject in order to use the volume.
Such is not the case, as thousands of medical students
who use it as a primary textbook can attest. This
volume, first published in 1939, has at least three
characteristics which render it highly useful: it is con-
cise, and yet reasonably complete; it is more medi-
cally oriented than the standard textbooks of bio-
chemistry; and it is updated every two years.
The 14th edition has just been released and it
carries on the tradition of its predecessors. Once
again, the author has resisted the temptation to turn
this volume into a compendium, so that this edition
has increased in size by only 16 pages. Most of the
chapters have been retained virtually intact; the new
material largely emphasizes recent advances in medi-
cally related topics. A short, but much needed, sec-
tion on erythrocyte metabolism has been included,
and the section on solubilization of cholesterol in the
bile has been expanded to reflect recent interest in
this area. The pages devoted to disorders of amino
acid metabolism have been thoroughly revised and
updated. The description of these disorders is the
best I have encountered in a biochemistry textbook.
But perhaps the best chapter of the book is that
dealing with hormone activity. Chapter 20 is the best
single introduction to the biochemistry of hormones
currently available. This material has been updated
to include information on recent topics, such as the
mechanism of action of glucocorticoids and inter-
relationships between c-AMP and calcium ion.
If you already own the 13th edition of this book,
the changes are probably not sufficient to make it
outdated; if you do not, the 14th edition is well worth
the small investment.
Lawrence DeChatelet, Ph.D.
381
Shankar Nath Kapoor, M.D.
Dr. Shankar Nath Kapoor died at Watts Hospital
in Durham, North Carolina on December 23, 1973
at the age of 42 years. He was born on September 15.
1931 in Lucknow, India.
Dr. Kapoor received his M.D. degree from King
George's Medical College in 1953. From 1955 to
1957 he served a surgical residence at Nashville
General Hospital. From 1957 to 1961 he received
his residency training in orthopedics with the Duke
Medical Center affiliated training program. He en-
tered the private practice of orthopedic surgery in
Durham on July 1, 1961. He was on the staffs of
Watts Hospital, Lincoln Hospital, and the Veterans
Administration, and he served as an Assistant Clini-
cal Professor of Orthopedic Surgery at Duke Univer-
sity Medical Center.
He was a member of the American Medical Asso-
ciation. Durham-Orange County Medical Society.
Southern Medical Association, North Carolina Medi-
cal Society, Piedmont Orthopedic Society, and Fellow
of the American .Academy of Orthopedic Surgery.
Dr. Kapoor was held in the highest esteem by his
colleagues and patients. He was widely respected as
a teacher and practitioner of orthopedic surgery, and
his untimely parting will be felt by all who knew him.
Surviving are his wife, Mrs. Nancy Nelms Kapoor,
two sons, Kristopher of the home and Karl of Dur-
ham, and a daughter. Miss Pam Kapoor. He is also
survived by several brothers in India.
Durham-Orange Counties Medical Society
Dan Parker Boyette, Jr., M.D.
Whereas, we, his medical colleagues, are soreh
grieved by the unexpected death of our friend anc
fellow physician on March 1, 1974, and
Whereas, we are fully cognizant of his diligen'
and devoted service to the children of the Roanoke
Chowan area and beyond over a generation of time
and
Whereas, we recall with pride his preparation fn
medicine and his selected speciality, his service in th i
.Army of the United States, his contributions to thj
pediatric literature, his role of leadership in organize
medicine, and his accomplishments in promoting e
cellence in the field of pediatrics, and
Whereas, this outstanding gentleman gave freel
of his available time and energy to the betterment c
this community, as an inspiring leader and enlighl
ened citizen through his fond association with th
First Baptist Church, Kiwanis International, th
Ahoskie District School Committee, the Social Se
vices Board of Hertford County, and other organiz;
tions, and
Whereas, we respect and admire his example as
devoted husband, father, and son, and will truly mi:
him as a friend, be it therefore
Resolved, that the abo\e statements, revealing oi
fondness and respect for our departed friend, be ii
corporated into the permanent minutes of the Her
ford County Medical Society and of the Medic
Staff of the Roanoke-Chowan Hospital, and furthe
more, that copies be sent to his bereaved family ar
to the official Journal of the North Carolina Medic
Society.
Hertford County Medical Society
The basis of juleps is generally common water, or some simple distilled water, with one-third
or one-fourth its quantity of distilled spirituous water, and as much sugar or syrup as is suffi-
cient to render the mixture agreeable. This is sharpened with \egetable or mineral acids, or
impregnated with other medicines suitable to the intention. — William Buchan: Domestic Medi-
cine, or a Treatise on the Prevention and Cure of Diseases hv Rei;imen and Simple Medicines,
etc.. Richard Fohvell. 1799. p. 453.
382
Vol. 35, Nol
_HEAL111 ^amCES lJBP
fM. D.
IMP
cAROLir^A
e Official Journal of the NORTH CAROLINA MEDICAL SOCIETY
July 1974, Vol. 35, No. 7
tlORTH CAROLINA
Hi:
»'!*-
Medical Journal
i THIS ISSUE: The President's Address: Wtiere We Stand, George G. Gilbert, M.D,- Message of the President to the
juse of Delegates, George G. Gilbert, M.D.; Control of Diseases Preventable by Active Immunization in North Caro-
a— Past, Present, and Future, J. N. MacCormack, M.D., M.P.H., and Jacob Koomen, M.D., M.P.H.; Carpal Desmotomy:
Technical Note, Timir Banerjee, M.D., and John N. Meagher, M.D.
i
1
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'.
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Jan. 31-Feb. 1— Raleigh
1975 ANNUAL SESSIONS
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For more information about PAPS, please write or call us. We will be happy
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NORTH CAROLINI
MEDICAL JOURNA'
EDITORIAL BOARD
Robert W. Prichard, M.D.
Winston-Salem
EDITOR
John S. Rhodes, M.D.
Raleigh
ASSOCIATE EDITOR
Ms. Martha van Noppen
Winston-Salem
ACTING ASSISTANT EDITOR
Mr. William N. Milliard
Raleigh
BUSINESS MANAGER
W. McN. Nicholson, M.D.
Durham
CHAIRMAN
Louis deS. Shaffner. M.D.
Winston-Salem
Rose Pully, M.D.
Kinston
George Johnson. Jr.. M.D.
Chapel Hill
Charles W. Styron, M.D.
Raleigh
NORTH CAROLINA MEDICAL JOUR-
NAL, 300 S. Hawthorne Rd., Winston-Salem.
N. C. 27103, is owned and published by The
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Address manuscripts and communications re-
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paid at Raleigh, North Carolina 27611.
Published Monthly as the Official Organ
The North Caroli
Medical Socie
D n D July 1974, Vol. 35, No.
Original Articles
The President's Address: Where We Stand 4
George G. Gilbert, M.D.
Message of the President to the House of Delegates 4
George G. Gilbert, M.D.
Control of Diseases Preventable by Active Immunization
in North Carolina — Past. Present, and Future 4.
J. N. MacCormack, M.D.. M.P.H., and Jacob Koomen,
M.D.. M.P.H.
Carpal Desmotomy: .\ Technical Note 4
Timir Banerjee, M.D.. and John N. Meagher, M.D.
Editorials
Suggestions for Authors A
Transactions of the House of Delegates, North Carolina
Medical Society, May 19-21, 1974 4
Emergency Medical Sermces
"STATES'" Keeps an Eye on Highway Safety ^
Mr. Vincent R. Gallalee
Abstracted by George Johnson, Jr., M.D.
Correspondence
Alcoholism Research in North Carolina '
John A. Ewing, M.D.
CO.M.MITTEES & ORGANIZATIONS
Committee on Medicare
Committee on Public Relations
com.mittee and commission appointments 1974-1975..
Bulletin Board
New Members of the State Society
What? When':" Where':"
News Notes from the Duke University Medical Center.. ..
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
American Academy of Facial Plastic and Reconstructive
Surgery, Inc
Boy Scouts of .America
Month in Washington
Book Reviews
In Memoriam
Classified .Ads
Index to Advertisers.
56
Contents listed in Current Contents/Clinical Practice
I
1
■
The President's Address
Where We Stand
George G. Gilbert, M.D.
'WO years ago, T assumed the duties as your Presi-
dent-elect, with the utmost humility, and still feel
,same way. On the one hand, the experience has
n most rewarding and inspiring so that it will be a
imark the rest of my life. On the other hand, I
e much the same feelings as a previous president
he California Medical Society who wrote in the
'A News that he surely would not want to tackle
)r another year.
■or fear of omitting some of the names of the
ly people who have greatly contributed to this
iety, in my remarks to the House of Delegates
xpressed my thanks in general. Now, however,
ant to pay tribute to two of our members, both
whom have been invaluable to me with their
>, and once again this does not exclude the my-
ils of others who have made outstanding contri-
!:ons. I refer to Dr. John Glasson, my predeces-
whose wisdom and experience have taught me so
ih, and equally to Dr. Frank Reynolds, your
' President, who has been of inestimable help as
sident-elect.
.'rior to my assuming office, it was mentioned to
by Mr. William Milliard, our Executive Direc-
that each president had a central theme for his
linistration. For the life of me, I must say that
. extreme variety of the demands of the office
e left me without any such central theme. The
nary activity has been a matter of acting and
:ting to many rapidly changing situations, so that
Itches one's breath. Coping with the crises and the
adane duties, day in and day out, has left little
■Jad before the Second General Session, North Carolina Medical
fity, Pinehurst, Mav 21. 1974.
iprint requests to Dr. Gilbert, 1 Doctor's Park, Asheville, N. C.
I 1974, NCMJ
time for innovations, although I do hope that I have
been responsible for a few.
As my predecessors, I too have turned to past
presidential addresses for guidance and inspiration.
As Dr. Styron mentioned in his 1972 message to
the House of Delegates, there has been a common
thread weaving its way, with varying emphasis,
through all of the presidents" administrations,
throughout each year. However, for the most part,
the challenge has involved the experiences and prob-
lems that are with us year in and year out, along
with some new ones. In fact, my predecessors have
so well expressed the fundamentals we believe in,
that I have the temptation to say "me too" and
sit down, with just the recommendation that you read
what they have had to say.
I agree with them, however, that at least a list
of these common threads, with comments on some
and a look into the hectic future, seem to be a logical
approach to bring you up-to-date as to where we
stand with our State Medical Society.
COMMUNICATIONS
One of the major threads that have been men-
tioned and are forever a basic requirement for suc-
cess in any society, as well as in our lives individually,
is constantly improving communications. I was told
by Mr. Hilliard that he thought the President's News-
letter, initiated by Dr. Louis Shaffner, was the best
communications medium the State Society had with
its members, and that the Newsletter was probably
read by more members than any other avenue of
communication. My experience confirms this view,
and 1 want to take this opportunity for thanking
a great many of you for expressing your apprecia-
405
tion of these monthly newsletters. I certiiinly recom-
mend that my successors continue them.
HEADOL'ARTERS STAFF
Each of my predecessors has expressed praise for
our Headquarters staff. It has been a fiectic year for
them, with lots and lots of long hours, over and above
the call of duty, by all concerned. As you well
know, the increasing load of work in setting up and
cooperating with our new North Carolina Medical
Peer Review Foundation, Inc., took more and more
of Mr. Dan Mainer's time. The increased responsi-
bility led ultimately to his officially leaving the Medi-
cal Society Headquarters staff to become Executive
Director of the Peer Review Foundation. This, of
course, left a gap and placed additional burdens on
not only Mr. Hilliard, but LaRue King, Steve Mor-
risette, and Gene Sauls. Furthermore, with our
crises, both in politics and legislation, it was recom-
mended to the Executive Council that we have a
full-time staff person for legislative and MEDPAC
activities. Steve Morrisette has. of course, been the
logical person for this position and has done a yeo-
man's job. With this recent reshuffling of our Head-
quarters staff, this area will be his primary sphere
of interest. The rest of the staff have had their titles
modified and their salaries have been raised, but be-
lieve me. not nearly as much as they deserve. We
are getting a bargain with our wonderful staff.
Because the work of our staff members is essential
(and we are still short at least one staff person),
should it become necessary budgetary-wise. I would
not hesitate to recommend increasing our dues,
onerous as that is to everybody.
STATE AND NATIONAL LEGISLATION
in my inaugural address a year ago, 1 stated that
the primary crisis facing the State Medical So-
ciety, and medicine in general, was PSRO. and
I believe the experience of this past year has borne
me out. Our New.slciter and the AMA News substan-
tiate that there has been a tremedous turmoil in this
area of activity. My own summary as to the cause of
the increasing rebellion regarding this law is that
all of us who tried, in our various state and county
societies, to tool up for the PSRO effort, became
increasingly thwarted and discouraged by not having
our recommendations taken. This is probably an
over-simplification, but look at it from this point of
view. I believe that if, from the beginning, the PSRO
office in Washington had listened to their own Ad-
visory Council (and they did not on many occasions),
and secondly, if they had gone along with all the
various states" recommendations, as far as the geo-
graphic boundaries were concerned, rather than set-
ting up their own capricious guidelines, there could
be much more harmony on the PSRO front than
there is today. Most recently. Dr. Russell Roth.
President of the AMA. and our own Ed Bedding-
406
field gave testimony before a committee in Congrd
on this very subject, and they have reflected in great
detail our concerns on the national level.
From all indications. I believe that one of o
goals has been achieved to some degree, and that tl
average physician does know what PSRO is all aboi'
Despite the fact that we failed in our goal of havit
a single PSRO for the state, we went ahead, wi
colossal work being done particularly by Dr. Fraf
Sohmer and Mr. Dan Mainer. with the formation i
our North Carolina Peer Review Foundation. Evi
though most of us are convinced that this is a b:
law. there is still no question whatsoever that t'
physicians must be accountable to the taxpayers f
how they spend the taxpayers' money. Because v
all have agreed with this view, we persisted not or
in forming the Peer Review Foundation, but al
in getting the contract with the State Departme
of Human Resources for peer review of nursi
homes and mental hospitals in the state. As 1 me
tioned in my message to the House of Delegat
an application for the so-called Support Cent
Category for our Peer Review Foundation has be
submitted to be a basic aid in helping the eight are
set up their own PSROs.
MEDPAC AND LEGISLATION
All of these threads obviously are intertwined, t
1 must mention the critical matter of the PAC mo\
ments on the national, state and local levels. As
stated in one of my newsletters, it is crucial that '
let our representatives in all government categor
know how we feel about the myriad angles of hea
legislation. It is also crucial that we let our own rep
sentative know, if it be the case, that we are sl
porting him. Legislative activity has become
creasingly crucial and. along with other interest
groups, the "lobby" has developed somewhat na:
connotations. In basic politics there is no questi
that the various lobbies are absolutely essential
merely educating legislators faced with so many fae
of legislation that it is impossible for any one pers
to assimilate them. Lobbying could be better referi
to as a form of continuing education for legislators.
THE AUXILIARY
Another constant thread with us. which is close;
all of us personally and as an organization, is c
own medical auxiliary. I have let their leaders kn^
that, in traveling to AMA functions. I have fou
that our North Carolina Medical Auxiliary enj(
a very high national reputation; in fact, they probal
enjoy a better reputation than we do!
THE PRESIDENCY
A thread that takes a little time to sink in, as ^e
goes through the two years of President-elect A
President, is that your Society's office of e
Presidency enjoys more respect than you might gu..
Vol. 35, N 7
jie and time again, when there has been a ehance
; representation to people in Washington — for
itance, when it would seem that some other parties
bid have more infiuenee — all have seemed to
!(ee that the President of the State Medical Society
lild have more clout than almost any other in-
sisted party in the state. This, of course, is a tre-
lOdous tribute to the working of our organization,
,1 particularly to my predecessors. Speaking of
jpect, which 1 touched on in my inaugural address,
I past year has evidenced that the public's trust
their physician has stayed at the top of the list,
ereas their respect for politics and government
!. plummeted to a new low. In talking with your
islators, it would be worthwhile to remind them
!t we do, indeed, enjoy this respect of the public,
Jl that it would be wise for them to listen to our
|Ommendations.
CRISIS IN HEALTH CARE— FALLACY
For years, having lived with the outpourings of
jipaganda, usually from government and social
jnners, that there is a horrible crisis in health care,
jtress that this warning is very far from the truth.
■,, of course, must face our deficiencies, of which
are reminded at every turn. But, indeed, we should
t hesitate to stress the positive side of our medical
e system. One basic truth which comes home
larer and clearer is that the deficiencies quoted to
) in comparison with other countries, are in no
"y caused by our medical care system. It is the
'y reverse. Again, I recommend that everybody
'd the book. The Case for American Medicine.
' Harry Schwartz. Another truth which is borne
. repeatedly is that, in spite of the maldistribu-
1 of physicians, access to health care is far down
list in the major determinants of the health of an
a or a nation. Consider the major facets — poverty,
or education, poor housing, and poor transporta-
'i; and perhaps the largest factor of all is "life
e," the abuses that human beings are responsible
perpetrating on themselves. Having a physician
^' 'lilabic on every street corner would not correct
:se fundamental deficiencies. A recent illustration
the "crisis in health in this country" can be seen
President Nixon's open news conferences held in
; past several months. These question-and-answer
I'litlnods have been open and free for all, with con-
ritration on the real crises in this country. But with
it I that, "health" has not been mentioned by one
:1( 'orter, at any time.
tt /
i MEMBERSHIP
Dur membership has continued to climb at a
lilthy rate, and I believe physicians, as a whole,
'OSS the state and the country, are becoming con-
iced, as they should, that the only way they can
irt any influence on some of the horrors that face
MS to be active in their own medical societies.
ji foi also pleased that we are seeing an influx of
(Y 1974, NCMJ
young physicians, which is, of course, basic. Last
year I was set back on my heels when I overheard
someone say, "I'm tired of going to Pinehurst and
finding the State Society run by a bunch of old men."
I cannot leave "membership" as a category, without
mentioning another organization that you have
heard me recommend many times — that is, the North
Carolina Association of Professions. Some of our
dues go to this organization, and, as has become ap-
parent, if one merely pays the dues, he could prob-
ably justly ask, "What is it doing for me?" The or-
ganization has indeed done great things for all the
professions in the past, and will continue to in the
future, but the benefits are not fully realized until
we attend the meetings. It is a heartening and re-
freshing experience to meet with the other professions
and learn of their problems and successes which are
amazingly similar to ours. One Virginia member
characterized this organization as a "sleeping giant."
MEDICAL EDUCATION
One of the biggest changes for the future of medi-
cal education in this state has taken place during the
past year. This has involved the combined efforts of
our three medical schools, the Governor, the State
Legislature, and most important of all. the practicing
physicians. I speak of the growing establishment of
Area Health Education Centers — AHECs. Depend-
ing, perhaps, on where you live, you may regard the
continuing efforts to expand ECU Medical School
as a priority of equal importance, down the road.
In our Society, the innovation of making our
General Sessions primarily a place for continuing
medical ediication is a step forward.
I have left for the last on the list the one thread
that I hope will bear more fruit than any other in-
novation. The time has come for us to concentrate
on our "rotten apples." As mentioned in my message
to the House of Delegates, it becomes increasingly
obvious that there is only a fraction of physicians
in our Society and elsewhere who give ammunition
to our critics. We can identify them, but we have not
had the clout to do as much as we want with them,
and we hope that with our newly proposed legisla-
tion we can achieve this goal.
CONCLUSIONS— LOOKING TO THE FUTURE
Depressing thoughts
I have become tired, in the last two years, of hear-
ing various speakers say that the question is not
"whether" we should have national health insurance,
but "when." I suppose they are right, and the bills
before Congress are indeed a source of considerable
depression, should we go through most of them,
barring, of course, the Medi-Crcdit legislation spon-
sored by the AMA.
Hopeful thoughts
It did all of our hearts good when, on January
25 at a press conference, our AMA President, Rus-
407
sell Roth, announced that the minute Casper Wein-
berger implements his directive for preadmission cer-
tification of hospital admissions, "we are going to
take him to court." The encouraging thing is that
the powers that be in government did, indeed, very
actively back off on that item.
Certain thoughts
We can be sure that we are going to be faced
with "future shock," as indicated by Alvin Toffler,
the author of a book by that name. Here again,
we must learn to cope, at an accelerating pace, or we
are going to get left far behind.
Of crucial importance in the up-coming electic
is that the ne.xt Congress will probably be the boc
politic that will determine what type of nation
health insurance we may have imposed upon us.
Lastly, a final bit of advice. We should open
admit our real defects and try to correct them. Bi
we should not forget to stress the "gut" issues of ti
superior quality of our medical care system, with i
fundamentals. Preserving the sanctity of the inc
vidual is the reason for our better medical car
which many of us forget is the bedrock of our Co
stitution. It is our responsibility to continue in o
effort to help each patient and to fight for his righ
as an individual, as well as for our own.
In the exliihition of medicine, regard should not only be had to simplicity, hut likewise to
elegance. Patients seldom reap much benefit from things that are highly disagreeable to their
senses. To taste or smell like a drug is become a proverb; and to say truth, there is too much
ground for it. Indeed, no art can take away the disagreeable taste and flavour of some drugs,
without entirely destroying their efficacy; it is possible, however, to render many medicines less
disgustful, and others even agreeable; an object highly deserving the attention of all who admin-
ister medicine. — William Biichan: Domestic Medicine, or a Treatise on the Prevention and Cure
of Diseases hy Regimen and Simple Medicines, etc., Richard Folwell, 1799, p. 438.
408
Vol. 35, NoJ
Message of the President
To the House of Delegates
George G. GUbert, M.D.
r USTOM dictates that I give a summary of the ma-
jor events and activities involving our Society
i ng the past Society year. This report focuses on
\ state and on North Carolina Medical Society ac-
ie^, obviously intertwined with myriads of other
:es, and an incredible variety of activities locally
outside the state.
•s I have worked for and with you as your Presi-
;, I find that words cannot express my ever-
easing impression of what an outstanding or-
.zation we have. I have taken great pride in your
vities, particularly when compared with the ac-
ies of other state medical societies. Perhaps our
lest asset in this light is our universal ability to
municate in our dealings with many other people
1 organizations. When in medical circles outside
state, you can hold your head high, realizing
value of our communications as an asset, having
. built from bedrock over a period of many
s.
Bme of the other areas of our communications
Ivement (which other states do not enjoy with
; respective organizations and institutions) in-
5(1) the North Carolina Hospital Association,
(the insurance carriers and our two major com-
ies on claims adjudication — the Blue Shield
imittee and the Insurance Industry Committee,
Ithe three medical educational institutions in
state — the University at Chapel Hill, the Bow-
Gray School of Medicine, and Duke University,
state and local government, including the inter-
onships involving health facets directly and the
lant checker game with the State Legislature,
H before the House of Delegates, North Carolina Medical So-
»'inehurst, May 19, 1974.
w int requests to Dr. Gilbert. 1 Doctor's Park, AsheviUe, N. C.
j;H|'1974, NCMJ
'/
(5) the North Carolina State Pharmacy Association,
(6) the North Carolina Nurses' Association, (7)
the North Carolina branch of the American Cancer
Society, and (8) the North Carolina Chapter of the
American College of Surgeons. Needless to say,
they are too numerous to list. I have merely hit
the high spots.
The "Compilation of Annual Reports'" further il-
lustrates the multiple activities that go on within
the Society. Nearly all of these publications have
reported the major activities continued in their re-
spective areas.
In view of the impressive features regarding the
magnitude and scope of the responsibilities of our
Medical Society members, including those of the
officers and staff — your dedicated servants — it is my
privilege to summarize some of the major develop-
ments of this past year. Our progress must be viewed
within the context of the incredible variety of hard
work continually accomplished in the other areas to
which I have referred.
First, the most crucial Society activity this past
year has been in our dealings with the PSRO matter.
Those of you who have followed both the national
and our state publications know of the developments
in this area. As we predicted a year ago, although we
did everything in our power to have Washington
approve a statewide PSRO, as did many other states,
all our efforts were of no avail. Our representatives
were greeted politely, but we lost for rather slim rea-
sons, whereas our sister state of Georgia was granted
its single PSRO. During the year, our North Caro-
lina Medical Peer Review Foundation, Inc., became
increasingly active, and outside of PSRO developed
a contract with the State Department of Human
Resources to conduct peer review, as required under
Social Security, for our nursing homes and mental
409
hospitals. Under the changing rules of the ball game,
it has now become appropriate for our North Caro-
lina Peer Review Foundation to apph' to Washington
for a so-called support center grant to help the eight
designated PSRO areas to get off the ground with
their own applications for planning grants. I \iew our
situation as similar to that of the AMA in which a
colossal amount of work has been done by dedicated
people tooling up to cooperate with the government
in implementing this law. On the other hand, many
of us. as well as the .-WI.A, have realized that it is
indeed a bad law.
Perhaps the second most significant activity was
the House of Delegates" mandating continuing medi-
cal education as a necessity for membership in our
Society. This action led to national publicity and
dovetailed the development of .Area Health Education
Center programs, fostered primarily by the Univer-
sit\ of North Carolina, the State Government, and the
Regional Medical Prograin. Both these developments
are viewed as ha\ing great significance, and they
should be of far reaching benefit to our Society.
As a third activity, I mention the colossal labors
of our Legislative Committee, and all others con-
cerned (particularly while the Legislature was in ses-
sion), on the contro\ersial ECU question. There
were many other bills screened by our Legislative
Committee, and often prompt action was taken in
the pursuit of our goals.
.A fourth significant piece of legislation, regarding
drunk dri\ers, came from our mutual efforts, in be-
half of the Department of Motor X'ehicles.
Fifth, a novel development which came as a result
of the mutual meetings of our Pharmacy Committee
and the Pharmacists" Medical Committee was the
form designed for use by our pharmacists and
physicians in an atteinpt to improve the sersice be-
tween the physician and his office staff, and the
pharmacist.
Si.xth, we were asked to assist the Commissioner
of Mental Health in upgrading the salaries for the
physicians in that department, not only in the mental
health hospitals but in their clinics. We were asked
to encourage more cooperation and interplay between
these facilities and the county medical societies where
thev are located.
Seventh, a colossal amount of work has gone int
setting up the program to make our general sessiot
an opportunity for continuing medical education.
Finally, last year I set as one of my major goa,
the task of trying to improve our methods of deahr
with so-called "rotten apples." As we have attendf
our various claims adjudication committees and oi
professional insurance committees, we have realizi
that the possible incompetent or dishonest physicia
are readily identifiable and represent a very sm;
group. "V'et it has been a source of great frustratic
that we have not sunk our teeth into our Medic
Practice Act to improve the situation. With
recommendations of an ad hoc committee, and act
by the Executive Council, we are going forward w
an amendment to the Medical Practice .Act, wh
we hope will add to its present provisions, so tha
physician may be investigated or may have
license revoked for "medical incompetence."" W
this in mind, I ha\'e every hope that you will go f(
ward with Report O and the recommendations frc
the E.xecutive Council.
CONCLUSIONS
We must not forget that our number one prior
is to impro\e the health of our patients. That g<
is the beginning and the end of our \ ery being.
Throughout the year, I have tried in all my acti
ties to reflect your desires and mandates, some
which are still controversial. Another broad, bz
precept that has guided me — one which most of \
prove every day in your own practice — is that
highest quality of medical care must continue to
based on the mutual respect and trust developed
tween phssician and patient. It is especially imp
tant to keep this in mind, since every national he;
insurance scheme will tend to increase the diffici
for you to maintain that relationship.
In this brief summary, although I have mentio
no names, my deep gratitude goes out to the m
wonderful people who have helped me and
Society throughout the year. They know who t
are. Crises seem to crush in on us faster thanT
can assimilate them in these critical times, so I i|
all of you to be ever aware of how you can influel
the future practice of medicine in North Carol'
and possibly in the whole country.
Notwithstanding the extravagant encomiums which ha\e been bestowed on different (oint-
ments, liniments, and cerates), with regard to their efficacy in the cure of wounds, sores, etc..
it is beyond a doubt, that the most proper apph'cation to a green wound is dry lint. But though
ointments do not heal wounds and sores. \et they serve to defend them, deterging. destro\ing
proud flesh, and such-like. — William Biulian: Doiticslic Malicinc, or a Treatise on llif Prtvcii-
tion and Cure of Diseases hv Rei;inien and Sir)iple Meiiicines. etc.. Ricliard Folwell. 1799,
p. 457.
410
Vol. 35. ^1
Control of Diseases Preventable by Active
Immunization in North Carolina-
Past, Present, and Future
I:
I
J. N. MacCormack, M.D., M.P.H.*
and
Jacob Koomen, M.D., M.P.H.r
HE topic chosen for presenta-
Q tion to the Conjoint Session this
I r represents one aspect of one of
oldest pubhc health programs —
, attempt by communities to pro-
themselves from communicable
jase epidemics. Indeed, a num-
of early state, county and city
]Jth departments was organized
,;ifically to establish ongoing
;ncies responsible for quarantine
sanitation matters. As an exam-
in June 1911, Guilford County
pme the first North Carolina
nty to employ a full-time health
[ctor; his primary duty was to
jibat hookworm disease.'
i
SMALLPOX
Jthough a few immunizing
:its were available at the turn of
.century, control of communica-
jdisease outbreaks at that time re-
heavily upon quarantine mea-
s. Consider the following situa-
i described in an 1 894 report of
Secretary of the State Board of
ilth:
n our last issue we called atten-
to the rapid spread of smallpox
d before the Conjoint Session. North Caro-
vledical Society and the North Carolina
lission for Health Services, Pinehurst.
!2. 1974.
ead. Communicable Disease Control
fi. Division of Health Services.
irector. North Carolina Division of Health
es.
rint requests to Dr. Koomen. North Caro-
'ivision of Health Services. Department of
n Resources, P. O. Box 2091, Raleiah,
27602.
!i, ! 1974, NCMJ
over the United States and sounded
a note of warning. Since that time
the disease has made its appearance
in our own State — in Cherokee; but
thanks to the prompt and vigorous
action of the County Superintendent
of Health looking to the quarantin-
ing of the patient he did not abide
with us long. Rather than be quar-
antined he left the State, thereby
demonstrating in a very practical
and satisfactory manner the value to
the community of an organized
health department with an alert
health officer. ■'-
One must remember that, even as
late as the 1890s, smallpox vaccina-
tion continued to meet with much
resistance:
"Most persons not acquainted
with the temper of our people would
say at once make vaccination com-
pulsory. That sounds well, but it
would be vox et preterea nihil. In the
first place, in the opinion of the
writer, our Legislature could not be
induced to enact such a law; and if
it could the law would, unsupported
by public sentiment, be a dead letter.
As to what public sentiment on this
subject is the following will illus-
trate: At the conjoint session of the
State Board of Health with the State
Medical Society in Wilmington in
1892 one of our County Superin-
tendents reported that going to a
public school-house to vaccinate the
children, according to a previous ap-
pointment, he found the house shut
up and the entire school, teacher and
all, taken to the woods. "-'
With the realization that early
quarantine and isolation procedures
for smallpox often did more to dis-
courage seeking medical attention
and vaccination, the quarantine law
for this disease was repealed during
the first decade of this century, and
a statute requiring smallpox vaccina-
tion was enacted in 1911. As shown
in Table 1, however, one cannot
state that the enactment of this
statute had any immediate effect
upon smallpox morbidity and mor-
tality in the state. The last smallpox
Table 1
Reported Smallpox Cases and Deaths,
North Carolina, 1914-1930
Year
Cases*
Deaths
1914
—
26
1915
—
11
1916
—
13
1917
—
13
1918
983
3
1919
2,322
9
1920
2,961
28
1921
2,513
20
1922
1,409
8
1923
3,352
13
1924
3,845
29
1925
1,920
5
1926
1,594
14
1927
1,702
15
1928
2,419
17
1929
589
2
1930
556
6
Smallpox cases became reportable
in 1918.
411
death was recorded in 1943, and the
last case was reported in 1948. Since
that time, until 1973, smallpox vac-
cination of children continued as a
requirement of North Carolina law.
Our adult population remained
largely unvaccinated. In the early
1960s a group of physicians work-
ing in the Smallpox Eradication
Program of the National Communi-
cable Disease Center ( now the Cen-
ter for Disease Control, but still
■'CDC" ) began to study complica-
tions of vaccination with the vac-
cinia virus. In 1963, for example,
seven persons in the United States
died from postvaccinal encephalitis
or eczema vaccinatum, and an addi-
tional 426 cases of nonfatal com-
plications were identified. ■■ This and
subsequent studies, coupled with a
world-wide campaign by the World
Health Organization to eradicate
smallpox, finally led to the contro-
versial recommendation by the
United States Public Health Service
Advisory Committee on Immuniza-
tion Practices in 1971 that routine
smallpox vaccination of children be
discontinued in this country — a rec-
ommendation endorsed by the Com-
mittee on Infectious Diseases of the
American .'\cademy of Pediatrics.
The 1973 General Assembly, after
considerable debate, enacted a
change in the state immunization law
to permit the Commission for Health
Services to determine whether small-
pox vaccination of children should
be required. This statute was rati-
fied on May 22, 1973, and on the
following day the Commission for
Health Services decided to omit
smallpox from the list of required
Table 2
Deaths From Selected Communicable
Diseases,
20 North Carolina Municipalities,*
1906-1907
Table 3
Reported Cases and Deaths By Five-Year Periods for Diphtheria, Pertussis,
and Tetanus, North Carolina, 1920-1969
Deaths
Disease
1906 1907
Typhoid
140 140
Malaria
58 66
Pertussis
37 38
Diphtheria
12 16
Measles
8 25
Diphtheria
Pertussis
Tetanus*
Years
Cases
Deaths
Cases
Deaths
Cases
Death
1920-24
25.460
1.864
53,908
1,934
—
268
1925-29
17,832
1,554
52.827
1,543
—
171
1930-34
12.910
1,107
50.676
1,375
—
159
1935-39
10.933
842
43,652
1,005
—
147
1940-44
5,407
359
36,752
654
—
72
1945-49
3.872
229
15,538
288
—
74
1950-54
1,330
70
6,823
135
67
1955-59
256
15
3,044
67
56
35
1960-64
52
4
667
27
63
45
1965-69
7
not become a
1 297
reportable disease until 1952.
1
27
22
• Tetanus did
'Charlotte, Durham. Elizabeth City, Fayette-
ville. Greensboro, Henderson. Marion. Ox-
ford. RaleiRh, Rocky Mount. Salem, Salis-
bury. Southport. Tarboro. Wadesboro. Wash-
ington. Waynesville, Weldon, Wilmington,
and Wilson
412
immunizations in North Carolina.
Many physicians had already begun
refusing to vaccinate their patients
with vaccinia virus, citing as a medi-
cal contraindication the recommen-
dations of the Public Health Service
and .American Academy of Pediat-
rics that this not be done.
Today we find smallpox endemic
in only five countries, four of which
— Bangladesh, India, Nepal, and
Pakistan — are on the Indian sub-
continent. The fifth endemic coun-
try, Ethiopia, is on the verge of
eradicating the disease. India,
probably the last frontier of small-
pox, will be subjected to an intensi-
fied eradication program through the
remainder of 1974. so that the
worldwide eradication of this ancient
scourge might be achieved in the
near future. If this is achieved —
and indications are that it will be —
it will mark the first time man has
ever intentionally and successfully
eradicated a disease from the world.
Let us hope for success.
"DPT" AND POLIO
Now let us discuss some historical
aspects of other communicable
diseases preventable by active im-
munization. Smallpox was not the
only communicable disease problem
of the early 1900s. as shown in
Table 2. Interestingly, the reduction
in typhoid morbidity today can be
attributed almost entirely to im-
provement in sanitation rather than
to the utilization of typhoid vaccine.
Malaria control has also been based
on environmental manipulation.
Diphtheria, on the other hand, is
not a disease that yields to sanitary
practices alone, if at all. The fir
breakthrough in immunization w;
the production of diphtheria am
toxin in 1894 by Roux and Marti
Diphtheria toxoid was developed
the early 1920s. Pertussis vaccii
became available a few years lat
but was not effectively standar
ized until the late 1940s. Tetan
toxoid, the third component of ti
"DPT'" vaccine in common use t
day, was available in the late 192
but did not enjoy widescale use u
til the World War II years. The Ge
eral Assembly added these vaccin
to the list of immunizations requir
for North Carolina children in 192
1945, and 1957, respectively. Tal
3 shows the downward trend in mt
bidity and mortality for these thi
Table 4
Reported Poliomyelitis Cases and]
Deaths, North Carolina, 1948-1968
Year
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
Cases
Deaths
{includin}
late
effects)
2,516
143
229
16
756
24 '
314
11
538
24
926
35
732
22
463
12
315
8
233
3
74
3
313
23
85
9
19
6
15
6
7
2
9
1
0
2
0
4
1
2
1
0
Vol. 35, Nl
I. 1. Measles morbidity rates per 100,000 population, North Carolina, 1952-1973.
teases. As we shall see, some work
inains to be done in their control.
;|The dramatic story of polio-
j'elitis vaccine development need
It be reiterated here, for it un-
ded not so long ago. The accelera-
ia in the decline of morbidity and
&rtality from this disease after the
ensure of Salk's inactivated vac-
"e in 1955, continuing after
Bin's oral polio vaccine became
iilable in 1962, is quite impres-
i2 (Table 4). In 1959 the Legisla-
e made polio immunization man-
i;ory for children.
lln the early 1960s, the advent of
T ss immunization campaigns in the
f m of "'Polio Sundays" was an im-
f tant development in its own right.
Yinks to the support and participa-
te by county medical societies, al-
ifSt three million North Carolinians
r'cived oral poUo vaccine in, 1964.
f'- a technique for rapidly reaching
1 le groups of people with a new
V cine, the mass campaign is quite
e ;ctive. However, it cannot be used
9 nauseam in lieu of an effective,
;oing immunization program.
i:n though the National Founda-
'i has progressed to the field of
ih defects, we are reminded by
torts from other states that the
lie virus is not dead and that we
(inot afford to forget it.
\ MEASLES, MUMPS, AND
1 RUBELLA
jiVith the advent of the 1960s, de-
»pment of new vaccines concen-
trated on attenuated live viral
preparations to combat the common
childhood diseases of the day. Licen-
sure of measles (1963), mumps
(1967), and rubella (1969) vac-
cines paved the way for new mass
immunization programs. There was
a definite decline in measles mor-
bidity as a result of the introduction
of the vaccine (Figure 1), but a re-
surgence of the disease in 1970 and
1971 sparked a new interest in pub-
lic campaigns. Measles immuniza-
tion given before the age of two
years became an added requirement
of the state immunization law in
1971. Rubella was under good con-
trol in 1972 and 1973 In North
Carolina: 1974 will be a crucial year
in determining whether we can keep
it suppressed in the state. The dis-
ease continues to be out of control
in a number of other states.
Rubella vaccine has been one of
the most controversial developments
in the history of immunopro-
phylaxis. Suffice it to say that con-
centration on the immunization of
one to 12-year olds has not eradi-
cated the disease, as evidenced by
last spring's rubella outbreaks on
several college campuses in the state.
The Student Health Service at the
Chapel Hill campus of the Univer-
sity of North Carolina registered 710
patients with rubella between Jan-
uary 7 and May 6, 1973. A few
cases were seen in the local senior
high school, but younger Chapel
Hill-Carrboro area children escaped
[c 1974, NCMJ
this epidemic. No cases of maternal
rubella were recognized and no ru-
bella syndrome-affected infants have
been born in the community. How-
ever, the risk of exposure of nonim-
mune pregnant women does exist in
such situations, and the prevention
of rubella infection in pregnant
women — the goal of any rubella im-
munization program — should en-
compass individualized immuniza-
tion of childbearing-age women, in
addition to immunization of chil-
dren.
Mumps vaccine has rightfully
been assigned a lower priority than
either measles or rubella vaccine.
Although incorporated as a compo-
nent of "M-M-R" vaccine since
1971, its use has not been empha-
sized in public health programs in
this state. Perhaps its day is coming.
IMMUNIZATION STATUS OF
NORTH CAROLINA'S
CHILDREN
What can be said about the cur-
rent immunization status of North
Carolina's citizens'? Our efforts have
traditionally been concentrated on
immunizing children, and perhaps —
particularly in the realm of tetanus
and diphtheria prevention — more
attention should be directed toward
protecting our adults as well. This
is borne out by observing that the
average age of patients contracting
tetanus has been creeping upward
for several years.
A survey of the immunization
status of two-year-olds in 1972
showed some striking deficiencies.
Five percent of this group had re-
ceived no immunizations at all, 18
percent had not received three doses
of DPT, 35 percent had not received
three doses of oral polio vaccine,
33 percent had not been immunized
against measles, and 47 percent had
not received rubella vaccine. Only
38 percent had completed a mini-
mally-defined basic series of three
doses each of DPT and polio vac-
cine, and measles and rubella vac-
cines.^ The survey will be repeated
this summer to assess what changes
may have occurred.
A survey involving first-graders
413
Table 5
Percentage of First Grade Public
School Children Meeting Minimum
Immunization Requirements; Ten Most
Populous and Ten Least Populous
North Carolina Counties, September,
1973
Percent
Meeting
County
Requirements
10 Most-populous:
Mecklenburg
77.5
Guilford
82.9
Wake
77.0
Cumberland
87.2
Forsyth
74.3
Gaston
81.3
Buncombe
89.2
Durham
75.5
Onslow
84.5
Davidson
90.1
Average
81.0
10 Least-populous:
Alleghany
86.0
Perquimans
97.6
Swain
92.1
Dare
91.5
Currituck
92.2
Graham
78.4
Hyde
92.0
Camden
96.4
Clay
86.8
Tyrrell
84.0
Average
90.1
entering our publie schools was con-
ducted last tali. For the state as a
whole, S5.2 percent of these chil-
dren met the requirements of the
immunization law: three doses each
of DPT and oral polio vaccine, and
measles vaccine. Surprisingly, some
of the most populous counties had
the lowest percentages of first-grad-
ers meeting the minimum require-
ments (Table 5 ).''
The United States Public Health
Service has e\idenced concern in re-
cent years regarding declining im-
munization levels; it points to out-
breaks of polio, diphtheria, and
measles in a number of states as dire
portents of the future unless an in-
creased effort is made in improving
these sagging le\els. October 1973
was designated as "Immunization
Action Month" to kindle interest in
improving the status quo.'' '
As. during the late 1960s, when
federal support of measles vaccine
programs was supplanted by Con-
gressional interest in the new rubella
vaccine, the development of new
vaccines seldom awaits optimal
utilization of already licensed prod-
ucts; if not pursued at the expense
of existing programs, perhaps this is
as it should be. A vaccine to prevent
group C meningococcal infection has
recently been licensed for use in the
military and ""high risk groups." yet
to be defined by the Bureau of
Biologies of the Food and Drug Ad-
ministration. A field trial of an inac-
tivated type B Hemophilus influen-
zae vaccine is currently underway in
Charlotte. Other vaccines axe ab
in various stages of development.
SUMMARY
We know that diseases pr
ventable by active immunization a
not conquered overnight, that se
dom does vaccine alone eradicate
disease, and that there is conside
able overlap in the stages of vaccii
development, utilization, and obs
leseence. The primary role of t
publie health worker and prima
care physician is in the utilizatii
stage, for only through proper uti
zation of available vaccines c
diseases such as diphtheria, perti
sis, tetanus, polio, measles, and r
bella be controlled.
References
1. W-ishburn BE: A HiMorv of the North d
lina State Board of Health. 1877-1925.
lei^:h; North Carolina State Board of Hea
|y(if>. p 7«.
2. l.evMs RH; Vaccination. Bulletin of the Nc
Carolina Board of Health .S: 121-122. 1894.
.1. Neff JM. Lane JM. Pert JH. Moore
Millar JD. Henderson DA: Complications
smallpox vaccination. 1. National survey
the Linitcd States, 1963. N Engl J Med :
125-132. 1967.
4. North Carolina Immunization Level Sur
of Two-S'ear-Old Children. Immunization I
gr.im. Division of Epidemioloiiv. North C;
lina State Board of Health. Raleigh. NC. I'
5. September 1973 Survey Report: Immun
lion Status of First Grade Children (Pu
Schools). Immunization Program. Epide
olog> Section. Division of lleallh Servi
North Cariilina Department of Human
sources, Raleigh. NC 1973.
6. Kalz SL: Immunization action month. O
ber 1973. Pediatrics 52: 4S3-4,S4. 1973.
7. Witte JJ: Immunization action month — O
ber 1973. JAMA 226: 65-66. 1973. (Editor
Early in the morning the patient is to take in any liquid, tuo or three drachms, according to
his age and constitution, of the root of the male fern reduced into a fine powder. .About two
hours afterwards he is to take of calcomel and resin of scammony, each ten grains; gum gam-
boge, six grains. These ingredients must be finely powdered, and given in a little syrup, honey,
treacle, or any thing that is most agreeable to the patient. He is then to walk gently about, now
and then drinking a dish of weak green tea. till the worm is passed. If the powder of the fern
produces nausea, or sickness, it may be removed by sucking the juice of an orange or lemon.
This medicine, which had been long kept a secret abroad for the cure of the tape-worm, was
some lime ago purchased by the French King, and made public for the benefit of mankind. —
William Biuhari: Dunh^lic Malicinc. or a Treatise on tlie Prcniuion and Cure of Diseases by
Rixinien and Simple Medicines, etc.. Richard Foluell. 1799. p. 464.
-414
Vol. 35, N
Carpal Desmotomy: A Technical Note
Timir Banerjee, M.D., and
John N. Meagher, M.D.
PHE exact cause of carpal tunnel
' syndrome is not known. Several
|tors, e.g., osteoarthritis, collagen
Jease, my.\edema, and repeated
juma play an important role in the
:cipitation of this compression
Jidrome.' ■'' A case of carpal tun-
; syndrome associated with rubella
imunization has been reported re-
itly."
llOrdinarily, subjective symptoms
Dear weeks or months before de-
mstrable abnormalities are seen
I routine examination. Accentua-
a of the symptoms, as seen in
don or extension of the wrist, or
positive Tinel's sign at the wrist
y aid in making the diagnosis, but
^se symptoms or signs do not
i:ur consistently. The accompany-
I: pain is often diffuse and may be
■. in the forearm. As noted by
JCormack,'' the pain is usually
irse at night. Distressing numbness
quently occurs, and paresthesia of
1 hand, usually sparing the little
^er and the ring-finger, may be
:sent. According to their histories,
py patients say that they often
ike up in the middle of the night
I shake their hands in a "jerky
lion" to get relief from pain and
esthesia. In advanced cases or in
tiom the Division of Neurological Surgery.
fersity of North Carolina School of Medi-
I Chapel Hill, N. C. 27514 (Dr. Banerjee)
Uhe Ohio State University School of Medi-
! Columbus, Ohio (Dr. Meagher).
;:print requests to Dr. Banerjee.
1 1974. NCMJ
instances of severe pain, the patient
may be weak and unable to "pinch."
Electrodiagnostic studies help to
CARPAL TUNNEL SYNDROME
MOTOR
2mV
1
I millisec
i
SENSORY JlO/iV
I millisec
Fig. 1. EMG of carpal tunnel syndrome:
(a) motor nerve conduction delay (normal
up to 4.5 msec); (b) sensory nerve con-
duction delay (normal up to 3.5 msec).
ULNAR N.
I I ABD. P. BR.
■ \ LpL. p. BR.
■n /' — RECURRENT
MEDIAN N.
-FLEXOR RETINACULUM
Fig. 2. Semidiagrammatic picture of the
wrist showing the position of the recur-
rent branch of median nerve.
demonstrate the delay in median
nerve conduction at the wrist; they
are also reliable in following up the
patient's recovery. When a bipolar
supramaximal stimulus is adminis-
tered to the median nerve by an elec-
trode at the proximal flexor crease,
and the evoked response in the
thenar musculature is recorded by a
surface or a coaxial needle-elec-
trode, the delay should not exceed
4.5 msec (Figures 1-3).
There is considerable dispute
among orthopedic, plastic and neu-
rosurgeons regarding the technique
of carpal desmotomy. This paper is
■;..
■ft
Fig. 3. Skin incision.
415
Fifi. 4. Appearance of the carpal liga-
ment (flexor retinaculum) after the re-
tractor is placed.
Fig. 5. Placement of the Sachs dissec-
tor between the median nerve and the
lower end of carpal ligament and the ex-
tended fat identifying the distal border of
the ligament.
Fig. 6. Flattened relaxed nerve after
pressure is released.
a report on the value of this simple
technique, of which the striking re-
sults are negligible morbidity and the
immediate relief of pain, numbness,
or minimal weakness in the distribu-
tion of median nerve in the hand.
OPERATION
In order to reduce morbidity and
the inconvenience to the patient, we
prefer to operate on one hand at a
time if there is e\'idence of bilateral
disease.
The patient's hand and forearm
are cleaned with an antiseptic solu-
tion while he is awake. A pneumatic
tourniquet is placed around the arm.
Esmarch's rubber tourniquet is
used to compress the hand, starting
from the fingers and progressing
pro.ximally to the middle of the fore-
arm while the hand is elevated. The
general anesthesia used is a com-
bination of thiopental sodium (Pen-
tathal) and nitrous oxide. .An endo-
tracheal tube is unnecessary. The
pneumatic tourniquet is inflated and
the Esmarch tourniquet is removed.
The fingers are draped within the
operative field to allow movements
of the thumb to be observed when
the median nerve is stimulated, thus
confirming the preser\'ation of the
recurrent branch and elevation
threshold to stimulation for contrac-
tion.
A vertical incision 3 to 4 cm long
is made on the palm, slightly ulnar
to the midline, approximately 2 mm
from the distal crease at the wrist.
This incision is designed to spare
the recurrent branch of the median
nerve supplying the thenar muscles
(Figures 2 and 3). Hunt and Luckey^
discuss the value of sparing the pal-
mar cutaneous branch of the median
nerve although there is overlap by
the branches from the ulnar nerve
and radial nerve. After a mastoid
self-retaining retractor is placed, the
distal end of the transverse carpal
ligament (flexor retinaculum) can
be recognized (Figure 4). Usually
at this point, slightly whitish-yellow
fat extrudes spontaneously at the
lower border of the carpal ligament.
A Sachs dissector is placed between
the ligament and the nerve, and the
vertical incision is made in succes-
sion until the proximal edge of the
ligament is divided and the nerve is
free (Figure 3). Consequently, the
Sachs dissector rides freely above
the nerve. The nerve often appears
to be red and flattened; the fat nor-
mally present between the ligament
and the nerve is absent (Figure 6).
Metzenbaum scissors are used to
make the final cuts, until the sc
sors freely enter Parona's spa
Parona's retroflexor space in the d
tal forearm is limited by the flc?f
digitorum profundus and the flcr
pollicis longus in its synovial she i
which forms the anterior bound j;
the pronator quadratus and the
terosseous membrane form
posterior boundary. Proximally,
rona's retroflexor space is o
tinuous with the intermusci
spaces of the forearm; distally,
reaches the level of the wrist am
potentially connected with the ir
palmar space. It is usually necess
to make one or two cuts distally
well, until the scissors appear to
free in the palm. We routinely (I
form a biopsy of the ligament. "
After irrigation the wouniiis
closed in two layers; 4-0 silk is ud
for the subcutaneous tissue and 0
nylon is used for the skin. The la-
niquet is removed after a light ;^'
sure dressing is completed wit ; •
ace bandage. The entire procecl
takes approximately 15 minutes. ■
Our follow-up has shown e\l-
lent results; only one patient ofie
50 who were operated on by u:i|
the above technique required e-
exploration because of persistencDf
symptoms. Four patients ca-
416
Vol. 35, Nl
jned of tenderness at the site of
incision, and they expressed
imal discomfort wlnle working,
ri after six weeks. However, nerve
duction studies showed improve-
jit in only two patients. A trial
]men of Decadron, administered
J ry six hours for three days, ini-
" ived the symptoms of all but one
ent.
We believe that this simple surgi-
cal technique reduces the operating
time and is effective in alleviating
symptoms. The scar is hardly notice-
able after approximately six months.
References
1. Flunt WE. Luckcy WT: The carpal tunnel
syndrome: Diagnosis and treatment. J Neu-
rosurg 21: 178-ISl, 1964.
2. Marinacci AA: CInical application of nerve
conduclion velocity (motor and sensory) and
llie II reflex. Bull Los Angeles Neurol Soc 2«:
i -2 1 , 1963.
McCormack RM: Carpal tunnel syndrome
Surg Chn North Am 40: 517-520, I960.
Nissen Kl: tjiology of carpal tunnel com-
pression of the median nerve. J Bone Joint
.Surg .UH: 514-515. 1952.
Fhalen GS, Gardner WJ, LaLonde AA: Neii-
ropathy of the median nerve due to com-
pression beneath the transverse carpal liga-
ment. J Bone Joint Surg 32A: 109-112, 1950.
Hale MS. Ruderman JE: Carpal tunnel syn-
drome associated with Rubella immunization
Am J I'hys Med 52: 189-193, 1973.
H;,H-'?i!!l^i'''"' '^"'^n,''hft commonly applied to people of a certain temperament, marked by a
dark complexion black hair spare diet, etc. which the ancients supposed to arise from ihcatra
^u,frlr}'^i'']v^ b,le.--(^,7/,«„, Buchan: Donw.snc Mcdicuu: oraTrcau.sc or,Zprcv!r,Zn
and Lure of Diseases by Regimen ami Simple Medicines, etc.. Richard Folwell, 1799, p. 473.
I 1974. NCMJ
417
Editorials
SUGGESTIONS FOR AUTHORS
The North Carolina Mi dical 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
applications to the practice nf medicine in North Carolina
are developed, are one of the main objectives of this
JOL'RNAr.
.Articles reporting original uork b\ North C arolina phy-
^icians 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 sta-
tistical tests where indicated.
Historical articles, especially those dealing with local his-
tor\', are considered of real value and interest.
2. Manuscripts
.\n original and a carbon copy of the m.iniiscript should
be submitted, 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
conseculise numerals throughout the text and then nped,
double-spaced, on a separate page Lit the end of the manu-
script. Books and articles not indicated b\ numerals in the
paper should not be included.
References will be much more \aliiable to the re.ider if
they are given in a proper form and contain the full infor-
mation necessary to locate them easily. The North Caro-
MNA MrniCM. JoiRNAL follows the form used in the journals
of the American Medical Association and the li\dc.\ Mitlims,
giving the author's surname and initials, title of the article,
name of the periodical, volume, inclusive page numbers, and
the date of publication. It is believed that this style makes it
easier for the reader to judge whether the reference is likely
to prove useful to him. and enables him to locate it more
quickh .
4. Tables and Illustrations
Tables and legends for illustrations should be t\ped on
separate sheets of paper. The illustrations should he glossy
black-and-white prints or line drawings. It is necessary to ob-
tain 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, tt
outlined in the Style Book issued by the Scientific Publit
tions Division of the American Medical .Association, John
Talbot, M.D., director. All manuscripts are subject to el
torial revision for such matters as spelling, grammar, a
the like.
By following the above suggestions, writers will grea
expedite the publication of papers accepted by the Nor
C^ROI 1N\ Mfdical Joi rnal.
*' HlecK-U :ii this yen's .innii.il nieeunj^;
iny on ;i tt-mirc hi:isis.
418
Other t'fticers are continii-
TR.\NSACTIONS OF THE HOUSE OF
DELEGATES
NORTH CAROLINA MEDICAL SOCIETY
Pinehurst. May 19-21, 1974
The Hotise of Delegates of the North Carol
Medical Society met in Pinehurst during the ann
session of the Societv'. Reference committees of
House had excellent discussions and participati
For the first time, the House of Delegates this yi
had delegates from specialty societies; the numbe
such delegates will increase, of course, as new s'
tions continue to be created.
Elections
The House elected the following officers for
current year:
President: Frank R. Reynolds, M.D,, Wilmingtc
President-elect*: James E, Davis, M.D.. Durhar
First Vice-President* : Jack Hughes, M:
Durham
Second Vice-President*
M.D., Winston-Salem
Secretary: (1973-1976
M.D.,' Durham
Speaker- : Chalmers R. Carr, M.D.. Charlotte
Vice-Speaker*: Henry J, Carr, Jr., M.D., Clintc
Past President: George G. Gilbert. M.D.. Ashe\
Executive Director: William N. Hilliard, Raleig
Councilors and Vice Councilors
First District (1977):
Councilor*: Edward G. Bond, M.D., Edenton
Vice Councilor*: Joseph A. Gill, M.D., Eliza!
City
Second District ( 1976):
Councilor: J. Benjamin Warren, M.D.. New Be
Vice Councilor: Charles P. Nicholson, Jr., M
Morehead City
Vor. 35, N'
M. Frank Sohmer,
E. Harvey Estes,
ri d District (1976):
oiinciior: E. Thomas Marshburn, Jr., M.D.,
Wilmington
ice Councilor; Edward L. Boyette, M.D., Cliin-
quapin
•i til District (1977):
ouncilor*: Harry H. Weathers, M.D., Roanoke
Rapids
ice Councilor*: Robert H. Shackleford, M.D.,
'Mt. Olive
•i , District ( 1975):
nmcilor: Albert Stewart, Jr., M.D., Fayettcville
ice Councilor: August M. Oelrich, M.D., Sanford
1 District (1977):
Ouncilor*: J. Kempton Jones, M.D., Chapel Hill
;ice Councilor*: W. Beverly Tucker, M.D.,
'Henderson
e nth District (1975):
luncilor: Jesse Caldwell, Jr., M.D., Gastonia
icc Councilor: William T. Raby, M.D., Charlotte
;i. ih District (1976):
.Hincilor: Ernest B. Spangler, M.D., Greensboro
cc Councilor: James F. Reinhardt, M.D.,
Greensboro
li'i District (1976):
'nmcilor: Verne H. Blackweldcr, M.D., Lenoir
ce Councilor: Jack C. Evans, M.D., Lexington
'a District (1975):
,Duncilor: Kenneth E. Cosgrove, M.D., Hender-
sonville
ice Councilor: Otis Bentley Michael, M.D.,
(Asheville
Actions
(rhaps the most significant actions taken by the
lie this year were the following:
J In spite of five resolutions which collectively
id have (a) changed the position of the Society
pRO, (b) called for repeal of the "PSRO Act,"
jnandated noncollaboration with PSRO, and (d)
lived the North Carolina Medical Peer Review
dation. Inc., the House instead adopted a substi-
fesolution as follows:
kSOLVED, that, although the North Carolina
seal Society strongly supports the concept of Peer
KW, having improvement of the quality of
cal care as its goal, we are opposed to many as-
:iof PSRO legislation; and, be it further
SSOLVED, that in view of the fact that repeal
<!R0 is not likely at this time, we support the
;(. of the American Medical Association to have
»w amended.
|irhe House implemented a stand, taken last year,
):ontinuing medical education be a requirement
embership. At this session, the House adopted
fllowing requirements:
i) That a minimum of 150 hours of continuing
ition every three years be required of each mem-
•11974, NCMJ
ber of the state medical society, reportable on an an-
nual basis.
(B) That wide latitude be allowed in the manner
in wliich the required time is spent. Attendance at
scientific meetings, participation in clinical confer-
ences, and perusal of the scientific literature are
recognized as worthwhile forms of continuing educa-
tion, and credit will be given for time so spent.
(C) That each physician keep and submit such
records as will enable him to certify each year that
he has met the minimal requirements of 50 hours.
(D) That a form for certifying compliance with
the above requirement be included with the annual
notice of dues sent to each physician. This form
would then be returned along with the dues payment
beginning with the 1976 dues.
(E) That the committee on medical education be
requested to study and recommend methods of
awarding credits, processing and recording replies,
managing cases of hardship and noncompliance, and
report their findings to the House of Delegates next
year.
3. The North Carolina Medical Society requested
the present and future Governors to refrain from ap-
pointing chiropractors to the North Carolina Division
of Health Services. The Society also went on record
opposing any legislation which would give recogni-
tion or accreditation to any chiropractic school,
voiced its opposition to the granting of eligibility to
chiropractors or other cultists for Medicare and
Medicaid funds in the performance of their services,
and requested the Executive Council of the North
Carolina Medical Society to determine whether any
legally constituted educational institution in North
Carolina has accepted academic transfer credits from
any chiropractic school, and express our disapproval
of such practices if found.
4. By Constitution and By-Laws changes, a medi-
cal student in North Carolina is eligible for student
membership without necessarily being "an active
member of his local Student American Medical As-
sociation Chapter." He may become a delegate with-
out being a member of SAMA; interns and resi-
dents who are in training "in the United States" and
not only "in the State of North Carolina," and who
certify their intention, to the best of their knowledge
at that time, to practice medicine in North Carolina,
may now be admitted to membership in the Society
without becoming a member of a component county
medical society.
5. The House took a definite position on the ques-
tion of delineation of hospital privileges. The follow-
ing resolution was adopted:
^RESOLVED, that the North Carolina Medical
Society believes that hospital staff privileges should
be delineated in a manner which is specific enough
only to insure that the professional activities of each
physician are consonant with good medical care
practiced in his medical community; and be it further
RESOLVED, that the North Carolina Medical So-
419
ciety expresses to the Joint Commission on Accredi-
tation of Hospitals and to the House of Delegates
of the American Medical Association, in minute de-
tail, its opposition to delineation of hospital staff
privileges.
Society Matters
In other actions related to intrinsic Society matters,
the House:
1 . Endorsed an amendment to the .Medical Prac-
tice .Act to the effect that the Board of Medical
Examiners may revoke or restrict a license to prac-
tice medicine for lack of professional competence.
2. Established separate sections on ophthalmology
and on otolaryngology.
3. Instructed the North Carolina Medical Societ\
to increase its acti\itity in the area of public rela-
tions, legislative contact, and go\ernmental relations.
4. .Approved the annual budget estimates for 1974.
5. .Appro\ed the pa\ment of a per diem of S25.O0
per day to the President for each day spent outside
his home town on Society business, in addition to
his other expenses. .Also approved was reimburse-
ment to the President-elect and the immediate Past
President for their tr.ivel and li\ing expenses, when
involved in official Society functions.
6. Approved the purchase of property adjacent
to the Medical Society parking area on Blooduorth
Street in Raleigh.
7. .Approved a By-Laws change which dissolves
the Committee on .Memorial Services — these duties to
be assumed by the Committee on Medicine and
Religion.
8. Officially encouraged members, delegates, and
officers of the North Carolina Medical Societv to be-
come dues-paving members of MEDPAC, and. when
possible, to
MEDPAC.
Emergency
Medical
Services
"ST.ATES" KEEPS .\N EYE ON
HIGHWAY SAEETY
\ intent R. Callalee, Manager
Eield Ser> ice Department
National Safety Council
Chicago. Illinois
The ST.ATES Program is a joint effort b> 37
national organizations and their counterparts in each
of the 50 states, whose aim is to mobilize citizen
and organizational support for the adoption and im-
plementation of the national highwav safety stan-
420
become sustaining members
Health Issues
.irea of health care and its delivery.
In the
House:
1. Established guidelines for a medical diric
in a long-term care facility.
2. Made recommendations concerning the ideiit
cation and treatment of cases of tuberculosis.
3. Recommended that Hemophilus influci
meningitis be made a reportable disease.
4. Called attention of the membership to
authoritative, unbiased, and lucid study on the
livery of primary medical care for VVinston-Sal(
North Carolina
5. .Approved the position paper "Need for M
and Better Distributed Primary Care Physicians," ;
complimented Dr. J. Kempton Jones" committee;
Dr. John McCain's subcommittee for an excell
paper.
Matters Referred to the .\MA
The House referred, through the Society's dele
tion. the following matters to the .AM.A:
1. Feeling that there should be more balance
the .AM.A Council of Medical Education, betw
practicing physicians and AAMC members, the
ciety proposed that the Council on .Medical Edi
tion consist of ten active members, of which t
fewer than one. nor more than five, shall be m
bers of a medical school faculty.
2. ,A resolution urging that medical spec!
examining boards" articles of incorporation and
laws restrictions for membership that are conti
to the ""peer"" concept be removed
J AMt;.s E. Dams, M.D., Past Speake
dards. The title is an acronvni meaning, "Si
Through .Action To Enlist Support.""
This program is designed to operate in eac:
the .^0 states assisting state government to attain
compliance with the national highway safety s
dards. In each state there is a governor"s reprc
tativc, whom the governor appoints as his
between the federal government and those elerr
in the state, whether legislative or administra
vv hich are concerned with highway safety. In coof
tion with ST.ATES, the representative for
Governor of Illinois works closely with the pr
Vol. 35, >
I
IT. through a resource coordinator who is selected
ini, in conjunction with the assigned field repre-
itive from one of STATES' participating organi-
ms.
hus, there is a team — governor's representative
L). resource coordinator (RC), and field repre-
jtive (FR). This team seeks the full cooperation
11 elements of STATES' participating organiza-
i to obtain desired legislation and to achieve ad-
strative follow-through once the legislative
ority is in place. The team makes joint plans to
'ilize all elements in the state, to study the needs,
Driorities, and build support among key officials
citizen groups. Meetings, speeches, published
•les, and newsletters are designed to start the
md swell of the public voice.
Some members of the American Medical Associa-
tion have been actively participating in this program
at national, state, and local levels. More help, how-
ever, is needed to complete the job. Contact the
STATES team in your state to find out what the
needs are now. Everyone has a place in this program.
— Abstracted by George Johnson, Jr., M.D.
From "Emergency Medicine Today," AM A Com-
mission on Emergency Medical Services, Volume 3,
No. 5, John M. Howard, M.D., Editor. Original arti-
cle can he obtained from the American Medical
Association, 535 North Dearborn Street, Chicago,
Illinois 60610.
\
ALCOHOLISM RESEARCH IN
' NORTH CAROLINA
I
\he Editor :
h 1973 the North Carolina General Assembly
ted the North Carolina Alcoholism Research
k lority which is authorized to receive and disburse
fu is through a specially created Alcoholism Re-
>e ch Fund. As of July 1 of this year the Fund
fi receive $250,000 as a state appropriation which
*. voted by the 1974 legislature.
he Act creating the Alcoholism Research
\ lority states: "The Authority shall expend these
fu !s on research as to the causes and effects of
d hoi abuse and alcoholism and for the training of
d hoi research personnel. Expenditures for the
31 loses specified in this section shall be made as
^'opriations to non-profit corporations, organiza-
ti( ;, agencies, or institutions engaging in such re-
Jfe-;h or training."
'orth Carolina has supported alcoholism rehabili-
ta n services for a long time, but it is the first
it' to appoint a Research Authority with the power
m' istribute funds throughout the state which are
it-tly for research and research development. The
^ creating the Authority recognized that North
2 )lina has the potential talent pool of qualified
>c itists to perform necessary studies and that these
ptole need assistance to focus their efforts upon the
cause, prevention, and cure of alcoholism.
Procedures for receiving grant applications, for
having these reviewed by committees of scientific
consultants, and for arranging to distribute available
funds are being developed by the Alcoholism Re-
search Authority. The purpose of this letter is to pub-
licize the existence of the Authority and to establish
contact with interested scientists.
All that is necessary initially is a brief letter ad-
dressed to the undersigned which should contain the
following: names and qualifications of those making
inquiry; name of educational institution or scientific
body with which affiliated; a brief statement indicat-
ing what alcohol-related work is presently being un-
dertaken and what would be done with a grant from
the Alcoholism Research Authority; and, a rough
estimate as to the amount of money for which appli-
cation is contemplated. All such letters of inquiry will
receive a reply, and those proposals which seem most
promising will be studied in more detail by our send-
ing out official invitations to submit a grant ap-
plication.
John A. Ewing, M.D.
Executive Secretary
North Carolina Alcoholism Research Authority
623 East Franklin Street
Chapel Hill. North Carolina 27514
li 1974, NCMJ
421
Committees and
Organizations
COMMITTEE ON MEDICARE
Greensboro, April 6. 1974
The committee discussed the recommendation of
the Council on Re\ie\v and Development that the
Medicare Committee be dropped and its function be
added to the Insurance Industry Committee.
Although a formal recommendation was not made,
the concensus of the members present was the fol-
lowing: that the Committee on Medicare should con-
tinue as a separate committee and should not be
merged with the Insurance Industry Committee.
William T. Raby. M.D.. Chainiian
COM.MITTEE ON PUBLIC RELATIONS
Raleigh, April 10, 1974
The committee recommended that:
( 1 ) Dr. Elizabeth P. Kanofs pamphlet "How to
a Good Doctor's Good Patient" be distributed
the membership as an enclosure with the "Public I
lations Bulletin"; that an appropriately marked re
card be included for physicians" orders and cc
ments. and that; authorized orders for up to I
pamphlets per physician be pro\ided on a gn
basis, and a nominal charge be made for orders
more than 1 00. (2) A member of the Headquart
staff be assigned to devote most of his time to
North Carolina Medical Society's public relati(
programs.
John L. McCain, M.D., Chainnar.
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.
Accredited by the Joint Commission on Accreditation and
Certified for Medicare
James Asa Shield, M.D.
James Asa Shield, Jr., ]M.D.
Catherine T. Ray, M.D.
Weir M. Tucker, M.D.
George S. Fultz, Jr., M.D.
Graenum R. Schiff, M.D.
422
Vol. 35, No
Committee and
Commission Appointments
1974-1975
)
Note: The Committees listed lierein ha\e been authorized by President Frank R. Reynolds, M.D.. and/or as
required under the Consiiiiiiioii ami Bylaws.
Particular note should be taken of the authorization of the HOUSE OF DELEGATES of a Commission
form of organizational activity and that all Committees, excepting COMMITTEE ON NOMIXATIOMS
A\D MEDIATION COMMITTEE are segregated under the respective Commission in which the func-
tion of the Committee logically rests. This will tend to eliminate overlapping and duplication in activity
programs and result in coordination of the work of the Society in a manner to lessen the work of the
delegates in the Annual Meeting of the HOUSE OF DELEGATES.
The President, Secretary and Executive Director of the Society are ex officio members of all Commit-
tees and. along with the Commission Chairman, should receive notice of meetings, agenda and minutes
of committee meetings during the activity year.
iperior figures (e.g. 21) indicate tlie component County Society from whicli ttie member emanates, as in tlie Membership list of tlie ROSTER.)
I. ADMIMSTR.4TION COMMISSION
.\. Hewitt Rose, Jr.. M.D., Chairman
3801 Computer Dr., Raleigh 27609
J Finance, Committee on (I-l)
T. Tilghman Herring. M.D., Chainuan
1 Wilson Clinic. Wilson 27893
Coniitiitlci'
No. 22
Personnel & Headquarters Operation,
I Com. on (1-2) No. 41
A. Hewitt Rose. Jr., M.D., Cliainnan
3801 Computer Dr., Raleigh 27609
I Insurance, Com. on Professional (1-3) No. 45
John C. Burwell. Jr.. M.D., Cliainnan
1026 Professional Village, Greensboro 27401
I Retirement Savings Plan Committee (1-4) No. 50
I Jesse Caldwell. Jr., M.D., Cliairman
114 W. Third St.. Gastonia 28052
II. ADVISORY AND STUDY COMVIISSION
Roy S. Bigham, Jr., M.D., Chairman
1708 E. Fourth St., Charlotte 28204
Allied Health Professionals, Com. on (II-l) No. 1
' W. B. McCutcheon, Jr.. M.D., Cliairman
1830 Hillandale Rd., Durham 27705
Anesthesia Study, Com. on (II-2) No. 2
Albert .■\rthur Bechtoldt, Jr., M.D., Chairman
I UNC Sch. of Med.. Chapel Hill 27514
Auxiliary, Committee Advisory to (11-3) No. 6
I Gloria F. Graham, M.D., Chairman
1010 W. Nash St.. Wilson 27893
4. Cancer, Committee on (II-4)
Rose Pully, M.D., Chairman
1007'/2 N. College St., Kinston 28501
5. Constitution & Bylaws, Com. on (II-5)
Louis deS. Shuffner. M.D.. Cliairman
Bowman Gray. Winston-Salem 27103
6. Medical Education, Com. on (II-6)
■Albert L. Chasson, M.D.. Chairman
Rex Hospital. Raleigh 27603
7. Medical Students, Com. .\A\. to (II-7)
William P. J. Peete. M.D., Chairman
Duke Univ. Med. Ctr.. Durham 27710
8. Relative > alue Study, Com. on (II-8)
Arthur E. Davis. Jr., M.D.. Chaiinian
Rex Hospital, Raleigh 27603
9. Traffic Safety, Com. on (II-9)
Edgar T. Beddingfield. Jr.. .\1.D.. Chairman
Wilson Clinic. Wilson 27893
III. ANNUAL CONVENTION COM.MISSION
Josephine E. Newell, M.D., Chairman
P. O. Box 68. Bailey 27807
1. Arrangements, Committee on (III-l)
E. Harvey Estes, Jr., M.D., Chairman
Duke Univ. Med. Ctr.. Durham 27710
2. .Audio-Visual Programs, Com. on (III-2)
George Pat Henderson. Jr.. M.D., Chairman
1 15 Highland .^ve.. Southern Pines 28374
3. Awards, Committee on Scientific (III-3)
David S. Citron. M.D., Chairman
Box 2554, Charlotte Mem. Hosp.. Charlotte 28201
No. 9
No. 14
No. 31
No. 33
No. 49
No. 52
(.Y 1974, NCMJ
No. 3
No. 5
No. 7
423
4. Credentials, Com. on (of House of Delegates)
(III-4) No. 15
John A. Payne, II. M.D.. Chairman
Box l?7, Simbury 27974
5. Exhibits, Coniniiltee on (III-5) No. 20
Josephine F. Newell, MD., Chainiian
Box 68. Bailey :7X(17
6. Programs for Cieneral Sessions, Com. on (III-6) No. 46
T. Reginald H.irris. M.D.. Cliainiian
SdS N. DeK;;lb St.. Shelby 28150
l\ . PRO! KS.SION AL .SKRMCF, COMMISSION
Bernard A. W.insker. M.D., Chainiian
14(10 Randolph Rd., Charlotte 28207
1. Blue Shield, Committee on (IV-1) No. 8
Leon VV. Robertson, M.D.. Cliainiian
107 Med. .Arts Mall, Rocky Mount 27801
2. Crippled Children's Program,
Com. .VdMsorj to (l\-2) No. 16
Robert Underd.d. M.D.. Cliainiian
1900 S. Hawthorne Rd., Winston-Salem 27103
3. Hospital & Professional Relations and Liaison to
North Carolina Hospital .\ssociation (IN-3) No. 23
Joe M. Van Hoy, M.D.. Chainiian
353? Randolph Rd., Charlotte 2821 I
4. Industrial Commission,
Com. to Work with N.C. (IV-4) No. 24
Frnest B. Spangler. ,M.D., Chainiian
381 I Henderson Road, Greensboro 27410
5. Insurance Industry Committee (H-S) No. 25
Charles H. Diickett, M.D., Chairman
Midway Med. Clinic, Canton 28716
6. Phjsical & Notational Rehabilitation,
Com. on (I\-6) No. 43
Fdwin H. Martinat, M.D., Chainiian
3333 Silas Creek Parkway, Winston-Salem 27103
7. ad hoc Study Committee on Fees (IV-7) No. S3
T. Reginald Harris, M.D., Chairman
808 N. DeKalb St., Shelby 28150
\ . PI BLIC RELATIONS COMMISSION
John L. McCain, M.D., Cliainiian
Wilson Clinic, Wilson 27893
1. .Association of Professions, Com. on (V-1) No. 4
Thomas G. Thurston, M.D., Chairman
512 Mocksville Ave., Salisbury 28144
2. Community Medical Care, Com. on (\'-2) No. 12
J. Kempton Jones, M.D., Chairman
1001 S. Hamilton Rd., Chapel Hill 27514
3. Disaster and Emergency Medical Care,
Com. on (V-3) No. IS
George A. Watson, M.D., Chairman
4023 Bristol Rd., Durham 27707
4. Eye Care & Eye Bank, Com. on (V-4) No. 21
Ernest W. Larkin, Jr., \TD., Chairman
21 I N. .Market St., Washington 27889
Legislation, Com. on (V-5) No,
H. Da\id Bruton, M.D., Chairman
Town Center, Southern Pines 28387
.Medical-Legal Committee (V-6) No.
Julius Howell, M.D., Chairman
Bowman Gray, Winston Salem 27103
North Carolina Pharmaceutical .Association,
Com. Liaison to (\-7) No.
Charles W. Byrd, M.D., Chairman
Bo.x 708. Dunn 28334
Public Relations, Committee on (\-8) No.
John L. McCain, M.D., Chainiian
Wilson Clinic. Wilson 27893
VL PL BLIC SERVICE COMMISSION
Philip G. Nelson, NTD., Chairman
Medical Pavilion. Greenville 27834
Child Health and Infectious Diseases,
Com. on (M-1) No.
William L. London. NLD., Chairman
306 S. Gregson St.. Durham 27701
Chronic Illness, TB and Heart Disease,
Com. on (M-2) No.
Dirk Verhoetf, .M.D., Chairman
Huntersville Hosp., Hunters\ille 28078
Drug Abuse, Committee on (\ 1-3) No.
Wm. J. K. Rockwell. M.D., Chairman
Duke Univ. Med. Ctr., Durham 27710
Marriage Counseling & Family Life Education,
Com. on (\ 1-4) No.
John B. Reckless, M.D.. Chainiian
5504 Durham-Chapel Hill Blvd., Durham 27707
Maternal Health, Committee on (M-5) No.
W. Joseph May, M.D., Chairman
121 Prof. BIdg., Winston-Salem 27103
.Medical .Aspects of Sports, Com. on (\ 1-6) No.
Frank C. Wilson, Jr., .M.D., Chairman
N. C. Mem. Hosp., Chapel Hill 27514
Medicine and Religion, Com. on (\'I-7) No.
Jack W, Wilkerson, M.D.. Chainiian
Green\ille Clinic. Greenville 27834
Mental Health. Committee on (M-8) No.
Philip G. Nelson, M.D., Chairman
Medical Pavilion, Greenville 27834
Occupational & Environmental Health.
Com. on (M-9) No.
Harold R. Imbus, M.D., Chairman
P. O. Bo\ 21207, Greensboro 27420
VII. DEVELOPING GON ERNMENT HEALTH
PROGRAMS COMMISSION
John A. McLeod, Jr., M.D., Chairman
Memorial Mission Hosp., .Ashcville 28801
Comprehensive Health Service Planning,
Com. on (Mil) No.
Robert C. Moffatt, M.D., Chainiian
309 Doctors' BIdg., Asheville 28801
424
Vol. 35, No.
i Medicare, Committee on (VII-2)
William T. R;iby, M.D., Cliaiiiiuui
1012 Kings Drive, Ch;irlotte 28207
f Peer Review, Committee on (VII-3)
M. Frank Sohmer, Jr., M.D., Cliainiuiii
Prof. Bidg., Winston-Salem 27103
No. 34
No. 40
V
j Social Service Programs, Com. on
'i (including Medicaid) (VII-4) No. 51
I James S. Mitchener, M.D., Chainuan
[Box 1599, Laurinbiirg 28352
' Committees Not Assigned to A Commission
IDIATION, COMMITTEE ON No. 29
,dgar T. Beiltlingfield. Jr.. M.D., Cluiiniuiii
ik'ilson Clinic, Wilson 27893
■ieorge G. Gilbert, M.D., Secretuiy
(Doctors Park. Asheville 28801
MINATIONS, COMMITTEE ON No. 37
4 Elliott Dixon, M.D., Cliainiiun
fl5 E. 2nd St.. Ayden 28513
UNCIL ON REVIEW & DEVELOPMENl No. 17
bhn Glasson, M.D., Chiiiinuiii
|06 S. Gregson St.. Durham 27701
Committee on Allied Health Professionals (6) II-l
'W. B. McCutcheon. Jr., M.D.^'- Cluiinncm
1830 Hillandale Road, Durham 27705
J. Samuel Holbrook, M.D.^"
Davis Hospital, Slatesville 28677
^Frederick C. Hubbard, M.D.'-'T
Box 39, N. Wilkesboro 28659
lOIiver Ray Hunt, M.D.""'
1607 Doctors Circle, Wilmington 28401
IWayne B. Venters, M.D.'^^
200 Doctor Dr., Suite J, Jacksonville 28540
iDonald K. Wallace, M.D.'-'
945 Sandavis Rd.. Southern Pines 28387
Committee on Anesthesia Study (6) II-2
Albert Arthur Bechtoldt, Jr., M.D.-- Chairman
UNC School of Medicine, Chapel Hill 27514
Lewis J. Gaskins, M.D."-
Rex Hosp., Dept. of Anes., Raleigh 27603
iC. T. Harris. M.D.''"
401 Fesbrook Court, Charlotte 2821 I
John R. Hoskins, III, MD."
;02 Doctors BIdg., A.sheville 28801
Albert R. Howard, M.D.'
506 N. Gurney St., Burlington 27215
Bill Joe Swan, M.D.'-
776 Williamsburg Dr., Concord 28025
Committee on Arrangements (3) (6 Consultants) III-l
B. Harvey Estes, Jr., M.D.'- Chairman
Duke University Med. Ctr., Durham 27710
ifohn Glasson, M.D.''-
306 S. Gregson St., Durham 27701
rJ. David Bruton. M.D."-
Town Center, Southern Pines 28387
'onsultants:
''Chalmers R. Carr, M.D.''" (Speaker-House of
Delegates )
1822 Brunswick Ave.. Charlotte 28207
1974, NCMJ
David S. Citron, M.D.«" (Chrm.-Com. on Awards)
Box 2554, C harlotte 28201
T. Reginald Harris, M.D.-' (Chrm.-Com. on General
Sessions Programs)
808 N. DeKalb St., Shelby 28150
Michael Pishko, M.D.'''
Pinehurst Surgical Clinic, Pinehurst 28374
William H. Romm, M.D. 7"
Box 26, Moyock 27958
Mrs. A. J. Crutchficld (Auxiliary)
Quail Hollow Rd.. Rt. 2, CIcmmons 27102
4. Committee on Association of Professions (6) (6
Consultants) V-1
Thomas G. Thurston, M.D."*" Chairman
512 Mocksville Ave., Salisbury 28144
John C. Hamrick, M.D.-'
Box 668, Shelby 28150
Edward K. Ishcy, Jr., M.D."
3-C Doctors Park, Asheville 28801
John R. Kernodle. M.D.'
Kernodle Clinic, Burlington 27215
John S. Rhodes, M.D.»-
1300 St. Mary's St., Raleigh 27605
George G. Gilbert, M.D."
1 Doctors Park, Asheville 28801
Consultants:
H. Fleming Fuller, M.D.'-t
Kinston Clinic, Box 268, Kinston 28501
Thomas P. Nash, II, M.D.'"
I 142 N. Road St., Elizabeth City 27909
Edward Leon Roberson, M.D.-''
Tarboro Clinic, Tarboro 27886
Richard V. Surgnier, M.D."*
419 2nd St., NW, Hickory 28601
Walter T. Tice, M.D.^i
624 Quaker Lane, High Point 27262
John L. Hazelhurst, M.D."
108 Doctors BIdg.. Asheville 28801
. Committee on Audio-Visual Programs (7) III-2
George Pat Henderson, M.D."'' Chairman
115 Highland Rd., Southern Pines 28387
Paul McB. Abernethy, M.D.'
P. O. Box 2480. Burlington 27215
Thornton R. Cleek, M.D.'?"
379 S. Cox St., Asheboro 27203
Jack C. Evans, M.D.-"'
244 Fairview Dr., Lexington 27292
John C. Grier, Jr., M.D."'
Box 791, Pinehurst 28374
John L. Monroe, M.D."-'
Pinehurst Surgical Clinic. Pinehurst 28374
J. Benjamin Warren, M.D.-"'
Box 1465, New Bern 28560
Committee Advisory to Auxiliary (6) (1 Consultant)
1 1-3
Gloria F. Graham, MD."^ Cliairmau
1010 W. Nash St., Wilson 27893
Robert J. Andrews, M.D."''
5221 Wrighlsville Ave.. Wilmington 28401
Bruce B. Blackmon, M.D.'-'
P. O. Box 8, Buies Creek 27506
A. J. Crutchficld, M.D.-'^
93 Prof. BIdg., Winston-Salem 27103
425
//
Rose PuUy, M.D."''
U)07'.2 N. College St.. Kinston 28501
Philip E. Russell, M.D."
204 Doctors BIdg.. .■\she\ille 2S8U1
Consultant:
Mrs. William Corpening {.AMA-ERF .-\uxiiiary Chair-
man )
Box 200. Granite Falls 28630
Committee on Scientific Awards (9) (3-jr Terms)
III-3
David S. Citron. M.D.''" ( 1975). CImininm
Box 2554. Charlotte Mem. Hosp.. Charlotte 28201
John .A. Brabson. M.D.''" (1976)
225 Hawthorne Lane. Charlotte 28204
Frank M. Mauney. Jr.. M.D.' ' (1976 )
Suite 412. Doctors Park. .Asheville 28801
Emery C. Miller. M.D. ^i (1977)
Bowman Gray. Winston-Salem 27103
James Tidier. M.D. '■'■ (1977)
|9|9 S. 16th St.. Wilmington 28401
Ted D. Scurletis, M.D.-'- (1976)
1301 Hunting Ridge Rd.. Raleigh 27609
John k. Williford. MDJ- (1975)
Box 278. Lillington 27546
Thomas Wood. III. M.D. ^1 (1975)
624 Quaker Lane. Suite 116. High Point 27262
Robert Smith. M.D.-- (1977)
L'NC Sch. Med.. Chapel Hill 27514
i. Committee on Blue Shield (31 ) (10 Consultants) IV-1
LeonW. Robertson. M.D.' (FP) (IV) i^lS. Chairma:,
107 Med. .Arts Mall. Rocky Mount 27801
William B. McCutcheon. Jr., M.D.'- (S) (VT) 1975,
\'i< i-CJuiiniiiin
1830 Hillandale Rd.. Durham 27705
.Arthur F. DaMs. Jr.. M.D.-'^ (PTH) (VT) 1976
Rex Hospital. Raleigh 27603
Melvin F. Eyerman. M.D.iMPH) (VII) 1977
Box 636, Lincolnton 28092
William W. Farley, M.D.-'- ( Pd ) (VI) 1976
1300 St. Mary's St., Raleigh 27605
JoeThomasFox. Jr.. M.D.''" (P) (VII) 1977
1900 Randolph Rd.. Charlotte 28207
Robert M. Gay. M.D." ( PTH ) (Vlll) 1977
P. O. Box 13227, Moses Cone Hosp.. Greensboro
27405
Gloria F.Graham. M.D."- (D) (IV) 1977
1010 Nash St.. Wilson 27893
Lawrence B. Haynes, M.D."- (.AN) (VI) 1975
1205 Kershaw Dr.. Raleigh 27609
Charles L. Herring. M.D. ■■' (1) (ID 1976
310 Glenwood .Ave.. Kinston 28501
Victor G. Herring, III, M.D.:''' (PD) (IV) 1977
Tarboro Clinic, Tarboro 27866
Charles .A. Hoffman, Jr.. M.D.-'' (U) (V) 1975
513 Owen Drive. Fayetteville 28301
John T. Langley. M.D. -'^ (Or) (ID 1976
Kinston Clinic. Kinston 28501
H. Raymond Madry, Jr.. M.D."- (R) (VI) 1976
3821 Merton Dr.. Raleigh 27609
.AngusM.McBryde. Jr.. M.D.''" (ORS) (VII) 1977
1822 Brunswick ,Ave.. Charlotte 28207
JohnH. Monroe, M.D.-" (ObG) (VllD 1976
Suite 718, Forsyth Med. Park. Winston-Salem 27103
426
Frank C. Morrison, Jr., M.D. 'MGP) (X) 1976
Box 1 192. Canton 28716
Sarah .A. T. Morrow, M.D." (PH) (Vlll) 1976
Guilford C. Hlth. Dept.. Greensboro 27401
PhilipG. Nelson. M.D. "MP) (ID 1975
Medical Pavilion, Greenville 27834
Robert D. O'Conner, M.D."- (OTO) (IX) 1976
24 2nd -Ave., N.E., Hickory 28601
Philip Henderson Pearce. M.D.-- (ObG) (VI) 1975
1821 Green St.. Durham 27705
John O. Perrilt. M.D. '•'■• (R) (HD 1975
Box 3686. .Azalea Sta.. Wilmington 28401
William .Allan Phillips, M.D.'""' (Dl (III) 1976
3208 Oleander Dr.. Wilmington 28401
Irvin P. Plaisance. Jr., M.D." (U) (X) 1977
100 Victoria Rd.. .AsheviUe 28801
Luther C. Sappenfield. Jr., M.D.-'' (Oph) (V) 1975
1629 Owen Dr., Fayetteville 28304
Benjamin Vatz, M.D." (1) (Vlll) 1975
I (.101 N. Elm St.. Greensboro 27401
C.Carl Warren. Jr.. M.D.''" (AN) (VII) 1977
932 Granville Rd.. Charlotte 28207
R. Bertram Williams, Jr.. M.D.'"' (GS) (111) 1977
1414 Med. Ctr. Dr.. Wilmington 28401
(OTO)
(To be filled by E. C. 9/29/74)
(To be filled bv E. C. 9/29/74)
(To be filled by E. C. 9/29/74)
19
(Oph) 19
(NSl
(NS)
,C
Consultants:
Frank E. Altany. M.D.''" (PS)
2027 Randolph Rd.. Charlotte 28207
Hoke V. Bullard. M.D."- (IM)
Wilson Clinic. Wilson 27893
William M. Ginn. Jr.. M.D."-' (C)
3105 Essex Circle. Raleigh 27608
Hamilton W. McKay, Jr.. M.D.''" (A)
Box 4387. Charlotte 28204
Marshall G. Morris. Jr., M.D." (S)
1309 N. Elm St., Greensboro 27401
Francis Robicsek, M.D."" (S-Thoracic & CV)
1929 Randolph Rd., Charlotte 28207
Wayne Rundles, M.D.''- (Hematology)
Duke Univ. Med. Ctr.. Durham 27710
John T. Sessions, Jr., M.D.''- (GE )
UNC Sch. of Med.. Chapel Hill 275 14
Robert L. Timmons. M.D.'' (NS)
1709 W. Sixth St., Greenville 27834
John L. Wooten. M.D.'< (OR)
6 Medical Pavilion. Greenville 27834
9, Committee on Cancer (12) (I.esal-1 ea. Congressionj
District) 11-4
Rose Pully, M.D.''^ ( 1st) Cluiiinian
1007' 2 N. College St., Kinston 28501
Joshua E. B. Camblos. M.D." ( 1 llh)
108 Doctors BIdg.. Asheville 28801
Warren H. Cole, M.D."
8 W. Kensington Rd.. .Asheville 28804
Richard DeWitt Jackson. M.D.-'' (5th)
821 Rockford St.. Mt. Airy 27030
Vol. 35, N'
Charles Pell Lewis. Jr., M.D."" (6th)
P. O. Box .^29. Reitlsville 27320
James A. Maher. M.D.»'' (-3rd)
Wayne C. Hosp., Goldsboro 27.'i30
Richard W. Martin. M.D.^!• (9th)
435 E. Statesville Ave., Mooresville 28 II 5
F. M. Simmons Patterson, M.D.-'- (4th)
1911 Front St., 3-E, Durham 27705
Lewis S. Thorp, M.D.-*' (2nd)
100 Nash Med. Arts Mall. Rocky Moimt 27801
John Morris Wallace, M.D.'*^ (8th)
Stanly C. Hosp., Albemarle 28001
D. E. Ward, Jr.. M.D."'* (7th)
2604 N. Elm St., Lumberton 28358
Committee on Child Health & Infectious Diseases
(13) VI-1
William L. London, M.D.-'- Cliainnan
306 S. Gregson St., Durham 27701
Frederick A. Blount, M.D.-^
3001 Maplewood Ave., Winston-Salem 27103
Harrie R. Chamberlin, M.D."-
UNC Sch. of Med., Chapel Hill 27514
E. Stephen Edwards, M.D.''-
1300 St. Mary's St., Raleigh 27605
Thomas A. Henson, M.D.^'
1006 Prof. Village, Greensboro 27401
Victor G. Herring, 111. M.D."
Tarboro Clinic, Tarboro 27886
Archie T. Johnson, Jr., M.D.'-'-
3000 New Bern Ave., Raleigh 27610
Richard S. Kelly, M.D.-''
Box 3127, Fayetteville 28305
John F. Lynch, Jr., M.D.^i
624 Quaker Lane. High Point 27262
John W. Nance. M.D.^-
403 Fairview St., Clinton 28328
Oliver F. Roddey, Jr.. M.D.''"
1928 Randolph Rd.. Charlotte 28207
Ted D. Scurletis, M.D.'-'-
1301 Hunting Ridge Dr., Raleigh 27609
David T. Tayloe, M.D."
608 E. 12th St., Washington 27889
I Committee on Chronic Illness, Including TB &
) Heart Disease (13) VI-2
1 Dirk Verhoeff, M.D.''" Chainnan
Huntersville Hosp., Huntersville 28078
I J. Dewey Dorsett, M.D.'"'
21 1 Hawthorne Lane, Charlotte 28204
I O. David Garvin, M.D.-'-
Box 191, Old Frat Row. Chapel Hill 27514
I Isa C. Grant, M.D.^'-
Div. of Health Services, Box 2091, Raleigh 27602
I David M. Hurst. M.D.-''
1003 Pine Needle Lane, Thomasville 27360
^Thomas F. Kelley, M.D.^t
320 Yadkin St., Albemarle 28001
I Thomas D. Long, M.D."-'
Box 797, Roxboro 27573
^ Michael A. McCall, M.D."'»
442 Fleming Ave., Marion 28752
I Hubert G. Pierce, M.D."'^
1007 College St., Kinston 28501
VWilliam D. Poe, M.D."-
Croom Court, Chapel Hill 27514
( 1974, NCMJ
i
Wilbur James Steininger, M.D.^^
McCain Hospital. McCain 28361
Abram L. Van Horn, M.D.^'-
UNC, Dept. of Hosp. Adm.. Chapel Hil
George A. Watson, M.D.''-
4023 Bristol Rd., Durham 27707
27514
12. Committee on Community Medical Care (17) V-2
J. Kempton Jones, M.D.-'- Chairmcm
1001 S. Hamilton Rd., Chapel Hill 27514
Edward L. Boyettc, M.D.--
P. O. Box 65, Chinquapin 28521
F. Murray Carroll, M.D.-<
722 N. Brown St., Chadbourn 28431
W. T. Grimsley, M.D. J'
P. O. Box 8, Summerfield 27358
Donald M. Hayes, M.D.-"
Bowman Gray, Winston-Salem 27103
Roger A. James, M.D.'i
946 Tunnel Rd., Asheville 28803
Lyndon K. Jordan, M.D."''
P. O. Box 769, Smithfield 27577
Maurice A. Kamp, M.D.''"
1200 Blythe Blvd., Charlotte 28203
Julian F. Keith, Jr., M.D.'i-i
5029 Country Club Rd., Winston-Salem 27103
Flam S. Kurtz. M.D.''
Lansing 28643
C. Rex LaGrange, M.D.'-'
Box 157. Clarkton 28433
George M. Leiby, M.D.^-*
907 Honeysuckle Lane, Albemarle 28001
Ronald H. Levine, M.D.'-'-
2404 White Oak Rd.. Raleigh 27609
J. J. Pence, Jr.. M.D.»-
2305 Parham St., Wilmington 28401
Emery L. Rann, M.D.""
1001 Beatties Ford Rd., Charlotte 28216
Cecil D. Rhodes, M.D.'^
Carolina General Clinic, Wilson 27893
Robert Smith, M.D.''-
UNC Sch. of Med.. Chapel Hill 27514
13. Committee on Comprehensive Health Service Planning
(18) VII-1
Robert C. Moffatt. M.D." Chainnan
309 Doctors BIdg., Asheville 28801
Hugh A. Matthews. M.D.-i^ (Region A-State of
Franklin )
Western Carolina Univ., Cullowhee 28723
W. Wyan Washburn, M.D.-- (Region C)
P. O. Box 795, Boiling Springs 28017
John A. McLeod. Jr., M.D." (Region B-Central High-
lands)
Memorial Mission Hosp., Asheville 28801
James T. McRae. M.D.'''i (Region D-W,\MY)
Dept. of Surgery. Bowman-Gray, Winston-Salem
27103
John C. Reece, M.D.'- (Region E-Eastern Appalachia)
Grace Hosp., Morganton 28655
Henry H. Nicholson, Jr., M.D.''" (Region F)
1012 Kings Dr.. Charlotte 28207
O. Norris Smith. M.D." (Region G-Piedmont-Triad)
1019 Prof. Village. Greensboro 27401
Alfred G. Siege. M.D.''"' (Region H-South Central)
Moore Co. Health Dept., Carthage 28327
427
r
Lyndon K. Jordiin. M.D/'' ( Region J )
P. O. Box IM). SmithfleM 27577
J;mies P. Green, M.D.'" (Region K)
176 Beckford Dr., Henderson 27536
Bruce B. BUiekmon, MD.'' (Region M)
P. O. Box S, Buies Creek ;75()6
Willi;ini H. Ronim. M.D. (Region R)
Box 26, Moyock 27958
Hurry H. SLinimerlin, Sr., M.D,^' (Region N)
Box 506. Liiurinburg 28352
Lawrence M. Cutchin, M.D.-'' (Region L)
P. O. Box 40, Tarboro 27886
Zack J. Waters, Jr.. ,\LD. 25 (Region P)
Box 1089, New Bern 28560
Joseph C. Knox. M.D.''-' ( Region O)
21 N. 4th St.. Wilmington 28401
Lynwood E. Williams. MD.''' (Region Q)
400 Glenwood -Vse.. Kinslon 28501
14. Coiiiinittec on Constitution & Bylaws (5) II-5
Louis deS. Shaffner. M.D. ■' Chairman
Bowman Gray. Winston-Salem 27103
Chalmers R. Carr, M.D.'-"
1822 Brunswick .Ave.. Charlotte 28207
Henry J. Carr. Jr.. M.D.^-
603 Beamon St.. Clinton 28328
P. G. Fox. Jr.. M.D.''-
1110 Wake Forest Rd.. Raleigh 27604
John H. Hall. M.D."
I 100 Olive St., Greensboro 27401
15. Committee on Credentials (Of Delegates to House of
Delegates) (3) III-4
John .\. Payne. 11. M.D.-'' Chainiuiii
Box 157, Sunbury 27979
L. Harvey Robertson, Sr., M.D.""
Box 519, Salisbury 28144
Louis R. Wilkerson. M.D.-'-
100 S. Boylan .-\ve.. Raleigh 27603
16. .Advisory Committee to the Crippled Children's Program
(7) IV-2
Robert Underdal. ,\LD. '< Cluiinnan
612 Forsyth Med. Park, Winston-Salem 27103
John I. Brooks. Jr.. M.D.''
Tarboro Clinic, Tarboro 27886
Ralph W. Coonrad, M.D.'-
1828 Hillandale Rd.. Durham 27705
Charles G. Longenecker. M.D."
30 Victoria Rd.. Asheville 28801
William W. Morgan. M.D."
Doctors Office Bldg.. .Asheville 28801
James C. Parke. Jr.. M.D.''"
Charlotte Mem. Hosp.. Box 2554. Charlotte 28201
William R. Pitser. M.D.''
1420 Pla/a Dr.. Winsion-Salem 27106
17. Council on Review & Development (10) (4-F.x Officio
with > ote)
John Glasson. M.D.-'- Chainiian
306 S. Gregson St.. Durham 27701
Charles W. Styron. M.D.-'- i'icc-Chainiiaii
615 St. Mary's St.. Raleigh 27605
Louis deS. Shaffner. NLD. •''
Bowman Gray. Winston-Salem 27103
428
Edgar T. Beddingfield, Jr., M.D.''«
Wilson Clinic. Wilson 27893
David G. Welton. M.D.''"
3535 Randolph Road, Charlotte 28211
George W. Paschal. Jr., M.D.-'-
1110 Wake Forest Road. Raleigh 27604
John S. Rhodes. M.D.-'-
1300 St. Mary's St.. Raleigh 27605
John R. Kernodle. .M.D.i
Kernodle Clinic. Burlington 27215
Amos N. Johnson. M.D.-'''-
Box 158, Garland 28441
John C. Reece. M.D.'-
Grace Hospital. Morganton 28655
Ex Officio With Vote:
Frank R. Reynolds. M.D.'-' (President)
1613 Dock St.. Wilmington 28401
James E. Davis. M.D.-'-- ( President-Elect )
1200 Broad St., Durham 27705
George G. Gilbert. M.D." (Past President)
1 Doctors Park. Asheville 28801
E. Harvey Estes. Jr.. M.D.-'- (Secretary)
Duke Univ. Med. C tr.. Durham 27710
William N. Hilliard. (Executive Director) (Non-votinf
222 N. Person St.. Raleigh 276U
IS. Committee on Disaster & Emergency Medical Cai
(12) V-3
George .A. Watson. M.D. ■-' Cliairnnin
4023 Bristol Road. Durham 27707
Frank W. Clippinger. .\LD. •-'
Box 2919. Duke Med, Ctr., Durham 27710
Sara J. Dent. M.D.-'-
Box 3094. Duke Hosp.. Durham 27710
Paul Edward Hill. M.D.i'
P. O. Box 518. Hendersonville 28739
George Johnson. Jr., M.D. '-^
N. C. Mem. Hosp.. Chapel Hill 275 14
Jesse Meredith. M.D.-"
Bowman Gray. Winston-Saleni 27103
Robert E. Miller. M.D.''"
1822 Brunswick Ave.. Charlotte 28207
.4. T. Pagter. Jr., M.D.'-''
107 Wilderness Rd.. Tryon 28782
W. D. Rippy. M.D.'
1610 Vaughn Rd., Burlington 27215
David R. Williams, M.D.-"-'
Southgate Shopping Ctr.. Thomasville 27360
Joyce H. Reynolds. M.D.■'^
Rt. 2. Kernersville 27284
R. Tempest Lowry, M.D.'-'-
104 Perth Court. Gary 2751 1
19. Committee on Drug .Abuse (8) (5 Consultants) M-3
William J. K. Rockwell. M.D.-'- Chairman
Duke Univ. Med. Ctr.. Box 3812, Durham 27710
Benjamin E. Britt. M.D.'-'-
1209 Glen Eden Dr.. Raleigh 27609
R. Jackson Blackley. M.D.'-'-
Box 27327, Raleigh 2761 1
John .\. Ewing, M.D. '-
N. C. Mem. Hosp.. Chapel Hill 27514
William A. Robie. M.D.!'-
5437 Thayer Dr.. Raleigh 27612
Vol. 35. No.
Jonnie H. McLeod, M.D.«"
14)6 E. Morehead St., Charlotte 28204
Richard L. Spencer. M.D.-'i
704 Government Center. Winston-Salem 27101
Robert W. Whitener. M.D.n
1024 Prof. Village. Greensboro 27401
Committee on Exhibits (6) III-S
Josephine E. Newell, M.D.'"* Cluiininin
Box 68, Bailey 27807
Robert G. Brame, M.D.:'-
Dept. Oh-Gyn. Duke Hosp., Durham 27710
Gloria Graham, M.D.'"*
1010 W. Nash St.. Wilson 27893
Rose Pully, M.D.'^
1007'/2 N. College St., Kinston 28501
George G. Gilbert, M.D."
1 Doctors Park. Asheville 28801
Josephine T. Melchior, M.D.-"
1661 Owen Dr., Fayetteville 28304
Committee on Eye Care & Eye Bank (15) V-4
Ernest W. Larkin. Jr., M.D." CIniinnaii
21 1 N. Market St.. Washington 27889
Paul M. Abernethy. M.D.'
1610 Vaughn Rd.. Burlington 27215
Lloyd W. Bailey, M.D.-='
109 Foy Dr.. Rocky Mount 27801
Arthur C. Chandler, Jr., M.D. •-
Dept. Oph., Duke Hosp.. Durham 27710
Lee Andrew Clark, M.D.'-''*
Wilson Clinic, Wilson 27893
Daniel S. Currie, Jr.. M.D.-''
1 I 1 Bradford Ave., Fayetteville 28301
Alan Davidson. M.D.-"'
Box 250, New Bern 28560
Albin W. Johnson, M.D.'-'-
1300 St. Mary's St.. Raleigh 27605
Thomas C. Kerns. Jr.. M.D.-'-
mow. Main St.. Durham 2770 1
Marshall S. Redding. M.D.'"
708 W. Church St.. Elizabeth City 27909
Davids. Sloan, Jr.. M.D.''-
1915 Glen Meade Road. Wilmington 28401
J. David Stratton. M.D.'"'
1012 Kings Dr., Room 402. Charlotte 28207
Shahane R. Taylor, Jr., M.D.<i
348 N. Elm St., Greensboro 27401
Charles W. Tillett, Jr.. M.D.""
2200 F. 7th St.. Charlotte 28204
Wayne Woodard. M.D."
607 Flatiron BIdg.. Asheville 28801
Committee on Finance (3) (7 Consultants) (2 Vice-
Presidents) I-l
T. Tilghman Herring, M.D.'"* Cluiinuiin
Wilson Clinic. Wilson 27893
Jesse Caldwell. Jr., iM.D. ■''
1 14 W. Third Ave.. Gastonia 2X052
Marvin N. Lymberis. M.D.''"
1600 E. Third St., Charlotte 28204
Consultants:
I — A. Hewitt Rose. Jr.. M.D.'-'-
3801 Computer Dr.. Raleigh 27609
11 — Roy S. Bigham. Jr., M.D.«"
1708 E. Fourth St., Charlotte 28204
III— Josephine E. Newell, M.D.^''*
Box 68. Bailey 27807
IV— Bernard A. Wansker, M.D.''"
1900 Randolph Rd.. Suite 400, Charlotte 28207
V— John L. McCain. M.D.''"*
Wilson Clinic. Wilson 27893
VI— Philip G. Nelson, M.D.^^
9 Medical Pavilion, Greenville 27834
Vll— John A. McLeod. Jr., M.D.i'
Memorial Mission Hosp.. .Asheville 28801
Vice-Presidents:
Jack Hughes. M.D.'-
923 Broad St., Durham 27705
M. Frank Sohmer, Jr., M.D.-'^
Prof. Bldg.. Winston-Salem 27103
23. Committee on Hospital & Professional Relations &
Liaison to North Carolina Hospital Association
(10) IV-3
Joe M. Van Hoy, M.D.'-" (7th) Chairman
3535 Randolph Rd., Charlotte 2821 1
Charles P. Scheill, M.D.^ (9th) Vicc-Clniiniian
Blackwelder Clinic, Lenoir 28645
Lawrence McG. Cutchin, M.D.-'-' (4th)
P. O. Box 40, Tarboro 27886
Archie Y. Eagles, M.D.^'' (1st)
Medical Arts Center, Ahoskie 27910
Charles L. Herring. M.D.''^ (2nd)
310 Glenwood Ave.. Kinston 28501
Charles O. Van Gorder, M.D.-" ( 10th )
Valley River Clinic, Andrews 28901
Claude A. McNeil. Jr., M.D."*'' 18th)
180-B Parkwood Dr., Elkin 28621
J. Olin Perritt. Jr.. M.D.''"' (3rd)
P. O. Box 3686, Azalea Sta., Wilmington 28401
Kenneth A. Podger, M.D.-'- (6th I
1830 Hillandale Rd., Durham 27705
E. Wilson Staub, M.D.'i'' (5th)
Pinehurst Surgical Clinic. Pinehurst 28374
24. Committee to Work With North Carolina Industrial
Commission (15) IV -4
Ernest B. Spangler, M.D.^' Cliainiiaii
3811 Henderson Rd., Greensboro 27410
LeRoy Allen, M.D.^'-
P. O. Box 14027, Raleigh 27610
William T. Berkeley. Jr.. M.D.""
1330 Scott Ave., Charlotte 28204
Thomas E. Castelloe. M.D.»-
P. O. Box 10707, Raleigh 27605
George M. Cooper, M.D."-
201 Bryan Bldg., Raleigh 27605
Benjamin Goodman, M.D.'^
24 2nd Ave.. NE. Hickory 28601
Robert L. Means, M.D.-"
2240 Cloverdale Ave., Winston-Salem 27103
Carl J. Hiller, M.D.-"
P. O. Drawer 1694, New Bern 28560
Julius A. Howell, M.D.^'^
Bowman Gray, Winston-Salem 27103
Thomas C. Kerns. Jr., M.D.'^-
1 1 10 W. Main St.. Durham 27701
LY 1974. NCMJ
429
Jack Powell, M.D."
190 W. Doctors BMg., Ashes ille :!S8(11
Richard C. Proctor, M.D.''
Bovvnian Gray, Winston-Salem 27103
Robert E. Miller, M.D.''"
1S:2 Brunswick Ave., C harlotte 2S:07
Charles L. Nance, Jr., M.D.''"'
31.S N- 17th St., Wilmington 2S40I
Samuel A. Sue. Jr., M.D."
13 1 I N. Flm St.. Greensboro 27401
Insuriinct' liidiislrj C'oimnittei' (28) I^ -5
C harles H. Duckelt, M.D." (GP) Cluiiriiiaii
.\li(Jwa> .Medical C linic. Canton 28716
Marcus L. Aderholdt, M.D." ( Pd I l'iii-Chair,»o.
624 Quaker Lane. High Point 27262
Richard .\1. Adcrhold, M.D." (Pi
2IK Forsuh \lcd. I'.uk. Winston-Salem 2710-
Ro\ A, Agner. Jr., .M.D.'^" (I)
61 I Mocksville .Ave., Salisbury 2SI44
Frank F. Altany, M.D."" (Pi)
2027 Randolph Rd., C h.irlotte 2S207
James D. Anderson, .M.D.''" ( ObG )
1340 Romany Rd., Charlotte 28204
H, Haynes B.nid, NFD.''" (U)
1012 kings Dr., Charlotte 28207
G. Frick Bell. Jr.. M.D."" (Or)
Wilson Clinic. V\ ilson 27843
\lbert B. Brown. M.D.''"' (ObGynl
1415 Med. C tr. Dr., Wilmington 2840 1
Edward H. Camp, M.D." (S)
Midway Med. t tr.. Canton 28716
A. J. Crutchfield. M.D."
93 Prof. BIdg., Winston-Salem 27103
J. Elliott Di\on, M.D.'' ( FP )
215 E. Second St., Ayden 28513
Sidney R. Fortney, M.D.' ■' (1)
68 Lake Concord Rd., NE. Concord 28025
Bruce J. Franz. M.D." (Si
304 Doctors Bldg., AsheviUe 2S801
Norman H. Garrett, Jr., M.D." (Il
1038 Prof. Village. Greensboro 27401
Lewis J. Gaskin, M.D."- (AN I
Re\ Hosp,, Anes. Dept., Raleigh 27603
T. Reginald Harris, M.D.--' (1)
808 N. Dekalb St., Shelby 28150
Hubert B. Hay.\ood, Jr., M.D.'-'- (Oph)
201 Bryan Bldg.. R.ileigh 27605
Hector H. Henr\, II. M.D.' ■ (Ul
102 Lake C oncord Rd., NE, Concord 28025
R.ilph V. Kidd, Jr., NLD.''" (ll
1928 Randolph Rd., Charlotte 28207
Odell C. Kimbrell, Jr., M.D."-' (END I
232 Bryan Bldg., R.ileigh 27605
Da\id S. Johnston, M.D.''" (ORSi
1822 Brtinswick .\\e.. C harlotte 28207
Jesse H. Meredith, NLD." (Si
Bowman Gray, Winston-Salem 27103
Harold R. Silberman, .M.D.'- (ll
Duke Hosp.. Durham 27710
Hal NL Stuart. \LD.-'' (FP)
108C Parkway Dr.. Flkin 28621
Samuel A. Sue, Jr., M.D." ( Orl
1311 N. Flm St., Greensboro 27401
430
George T. Wolff, NLD.^' (FPI
1311 N. Elm St., Greensboro 27401
Richard E. Weiss, M.D." (NSl
200 N. Griffing Blvd., Asheville 28804
26. Coiiimiltee on Legislation (3 Plus President and
Secretary) (17 Consultants) \ -5
H. D.i\ id Bruton. NLD.''' C'luiiniuiii
Town Center. Southern Pines 28387
John H. Hall. NLD.^' \'icc-Chaiiman
I 100 Olive St.. Greensboro 27401
Edgar T. Beddingfield. Jr.. M.D.'"-
Wilson Clinic. Wilson 27893
Frank R. Reynolds, NLD.'"' (President)
1613 Dock St.. Wilmington 28401
F. Harvey Estes. Jr.. NLD.''- (Secretary)
Duke Univ. Med. Ctr.. Durham 27710
Consultants:
1 dw.ird G. Bond. MD.-'
(. howan Med. Ctr.. Fdenton 27432
Kenneth E. Cosgrove, M.D.''
510 7th Ase.. W.. Hendersonville 28739
J. Henry Cutchin. Jr.. NLD.'-
Sherrills Ford 28673
Mrs. Leduird DeCamp (Katie) (.Auxiliary)
34 1 I Seward Place. Charlotte 2821 1
John T. Dees. NLD.'-''
P. O. Box 815. Burgaw 28425
Edna Hoffman. NLD.-''
348 Valley Rd.. Favetteville 28305
W ilham F. Hollister. M.D.'' ■
Box 2000. Pinehurst 28374
Joseph W. Hooper. Jr.. NLD.''"'
1905 Glen Meade Rd.. Wilmington 28401
Archie T. Johnson. Jr.. M.D.'-'-
3000 New Bern Ave.. Raleigh 27610
C. Clement Lucas. NLD.-'
( how.m Med. Ctr., Edenton 27932
Charles P. Nicholson. Jr.. NLD."'
3108 Arendell St., NIorehead City 28557
L. Har\ey Robertson. Sr.. NLD.~-"
Box 519. Salisbury 28144
Delford L. Stickel. NLD. ■-'
Box 3052. Duke Hosp.. Durham 27710
J. David Stratton. NLD.''"
1012 Kings Dr.. Charlotte 28207
James F. Toole. M.D. "
Bowman Gray, Winston-Salem 27103
John L. .Abernethy. NLD.-'-
Duke Hosp.. Box 2701. Durham 27710
Mrs. Benj.imin Ferdon (Kathleen) (Auxiliary)
719 Richmond St.. Raleigh 27609
27. Committee on Marriage Counseling & Family Life
Education (II) VI-4
John B. Reckless. NLD.-'- Cluiinium
The John Reckless Clinic, 5504 Durham-Chapel Hi
Blvd.. Durham 27707
Karl Lee Barkley. NLD."
1305 Wendover .Ave.. Greensboro 27403
Marianne S. Breslin. NLD.-'-
Box 3167. Duke Univ.. Med. Ctr.. Durham 27710
James Edwin Clement. M.D.''
1705 W. 6th St.. Greenville 27834
Vol. 35. No. ,
ITakey Crist, M.D.*''
200 Memorial Dr., Jacksonville 28540
. Rachel D. Davis. M.D.'''
1 1 1 E. Gordon St., Kinston 28.'>01
.W. Davis Fort, M.D."'
; 1001 W. 5th St., Albemarle 28001
I Jerry Hiilka, M.D.^'-
UNC, Dept. of OhG, Chapel Hill 27514
! Eugene B. Linton, M.D.'"
751 Belhcsda Rd., Winston-Salem 27103
I Hans Lowenhach. M.D.''-
Diike Univ. Med. Clr., Durham 27710
i Luther M. Talbert, M.D.-'-
N. C. Mem. Hosp., Chapel Hill 27514
: Committee on Maternal Health (14) VI-5 (6 yr. Terms)
iW. Joseph May. M.D.-'* (8th) (1976) Cluiiniuin and
Sccrclury
300 S. Hawthorne Rd.. Winston-Salem 27103
■Stephen G. .\nderson, M.D.-' (1977)
Bowman Gray, Winston-Salem 27103
Glenn E. Best, M.D."-- (3rd) (1978)
' 104 Main St., Clinton 28328
; Clifford C. Byrum, M.D."- (6th) (1979)
\ 3803 Computer Dr., Raleigh 27609
I Jesse Caldwell, M.D.-"' (7th) (1979)
1 12 W. 3rd Ave., Gastonia 28052
Arthur C. Christakos, M.D.-' (Duke) ( 1978)
Duke Hosp., Box 3274, Durham 27710
.William E. Easterling. Jr., M.D.-- (UNO (1975)
UNC School of Med., Chapel Hill 27514
H. Fleming Fuller, M.D. •'■< (2nd) (1975)
Kinston Clinic, Box 268, Kinston 28501
Edgar C. Garher. Jr., M.D.-" (5th) (1977)
1641 Owen Dr., Fayetteville 28304
.William A. Hoggard, Jr., M.D."" ( 1st) (1977)
1142 N. Road St., Elizabeth City 27909
f Ann H. Huizenga, M.D.'-'- (1978)
Div. of Health Services, Raleigh 27602
. John A. Kirkland, M.D."'^ ( 4th ) (1 976 )
' Wilson Clinic, Wilson 27893
•Robert L. Rogers, M.D.'-i (9th) (1976)
328 Mulberry St., NW, Suite 2, Lenoir 28645
(Fletcher S. Sluder, M.D." (10th) (1975)
; 406 Flatiron Bldg., Asheville 28801
(Mediation Committee (5) VHI (Five Immediate Past
•Presidents)
'Edgar T. Beddingfield, Jr.. M.D.""* Chiunnan
Wilson Clinic, Wilson 27893
;George G. Gilbert, M.D.'i Secretary
1 Doctors Park, Asheville 28801
Louis deS. Shaffner, M.D.-^
Bowman Gray, Winston-Salem 27103
Charles W. Styron, M.D.^'-
615 St. Mary's St., Raleigh 27605
I John Glasson, M.D.-'-
1 306 S. Gregson St., Durham 27701
I Committee on Medical .Aspects of Sports (15)
(3 Consultants) VI-6
I Frank C. Wilson. Jr., NLD.-'- Chainiuin
N. C. Mem. Hosp., Chapel Hill 27514
I Frank H. Bassett, III, M.D.--
Duke Univ. Med. Ctr., Durham 27711)
\Hl '•Y 1974, NCMJ
31,
James F. Bowman, M.D."'
6 Medical Pavilion, Greenville 27834
Basil M. Boyd, Jr., M.D.""
1822 Brunswick Ave., Charlotte 28207
Frank W. C lippinger, Jr., M.D.--
Duke Med. Clr., Durham 27710
James R. Dineen, M.D.''"'
1616 Medical Center Dr., Wilmington 28401
Joseph L. DeWait, M.D.'-
Iris Lane, Chapel Hill 27514
William A. Herring, Jr., M.D."'"'
Watauga Med. Arts Bldg., Boone 28607
Carl J. Hiller, M.D.-"'
P. O. Drawer 1694, New Bern 28560
Roger A. James, M.D."
946 Tunnel Rd., Asheville 28805
A. Tyson Jennette, M.D."''*
Carolina General Clinic, Wilson 27893
Wayne S. Montgomery, M.D.'i
Doctors Dr., .-Xsheville 28801
Donald B. Reibel, M.D."-
P. O. Box 10707, Raleigh 27605
Timothy N. Taft, M.D.-'-
N. C. Mem. Hosp., Chapel Hill 27514
Richard N. Wrenn, M.D.""
1822 Brunswick Ave., Charlotte 28207
Consultants:
David A. Harris, Jr., .-Xthletic Director
Charlotte-Mecklenburg School System, Box 149
Charlotte 28201
Al Proctor, N. C. Dept. Public Instruction, Sports
Medicine Div., Education Bldg., Raleigh 27605
Raymond K. Rhodes, Director of Athletics State Dept.
of Public Instruction. Raleigh 27605
Committee on Medical Education (21) (4 Consultants)
(5-yr. Terms) II-6
Albert L. Chasson, M.D.»- ( 1976) Cluiirinan
Rex Hosp., Raleigh 27603
John D. Bridgers, Sr.. M.D.^' ( 1979)
624 Quaker Lane, High Point 27262
David S. Citron, M.D."" (1979)
Box 2554, Charlotte 28201
William J. Demaria, M.D.''- (1979)
1 126 Woodburn Rd., Durham 27705
Donal Leo Dunphy: M.D.-'- (1979)
UNC Dept. of Pediatrics, Chapel Hill 27514
Christopher C. Fordham, 111, M.D.-'- (1977)
Dean, UNC School of Med., Chapel Hill 27514
Richard Janeway, M.D.''-i (1977)
Dean, Bowman Gray Sch. of Med., Winston-Salem
27103
Lyndon K. Jordan, M.D.-"'' (1979)
P. O. Box 760, Smithfield 27577
George D. Kimberly, M.D."*" (1976)
717 Hospital Dr., Mocksville 27028
Francis B. Lee, VLD."" (1978)
404 S. Sutherland Ave., Box 457, Monroe 281 10
Paul A. Mabe, Jr., M.D. 7" (1978)
Box 330, Reidsville 27320
Lockert B. Mason, M.D."-"' ( 1978)
New Hanover Mem. Hosp., Wilmington 28401
Emery C. Miller, Jr., M.D.-" (1977)
Bowman Gray, Winston-Salem 27103
431
r^
m
Ralph S. Morgan, M.D.''" (1978)
Box 668, Sylva 28779
Carl N. Patterson, M.D. •- (1976)
mow. Main St., Durham 277(11
F. M. Simmons Patterson. M.D.'- ( 1975)
191 1 Front St,. 3-E, Durham 27705
Richard B, Patterson, M.D. -^ (1976)
Bowman Gray, Winston-Salem 27103
Oscar L. Sapp. Ill, M.D.'- ( !97(W
UNC School of Med., Chapel Hill 27514
Charles K. Vernon, .M.D.''-'' (1977)
7225 Wrightsville .-Xve.. Wilmington 28401
William H, Waugh, M.D.'^ (1979)
Box 2701-ECU. Greenville 27834
Emile F. Werk, Jr., .M.D '•'■ ( 1979)
2504 C.mterbury Rd., Wilmington 28401
Consultants:
Mr. David L. Kaney. Director, Medical TV-UNC
Medical Science leaching Labs., Chapel Hill
Mr Mich.iel E. Wa>d.i, .Audio-Visual Education
Duke L'nn. Med. Ctr., Durh.im 27710
Mr. George Lynch. Audio-Visual Dept,
Bowman Gray, Winston-Salem 27103
Ron W. Davis, Fd.D.
Bo\ X248, Durham 27704
32. Medicul-l.tgal Committee (9) \-b
Julius .A, Howell. .M.D.'^ Chainiuni
Bowman Gray. Winston-Salem 27103
Thornton R. Cleek. M.D.'*^
379 S. Cox St., Ashehoro 27203
George R. Clutts, M.D.ti
344 N. Elm St., Greensboro 2740!
Ralph W. Coonrad. .M.D. ■-
1828 Hillandale Rd.. Durham 27705
Thomas B. Dameron, Jr., M.D.'-'-
P, O, Box 10707, Raleigh
James B. Greenvvood, Jr., M.D.''"
4101 C entral Ave., Charlotte 28205
June U. Gunter. M.D.''-
Watts Hosp.. Durham 27705
L. L. Schurter. M.D.''-
505 Northwood Ct.. Garner 27529
Henry D. Severn. M.D."
283 Biltniore Ave.. Ashcville 28801
33. Committee .Advisory to Medical Students (6) 11-7
William P. J. Peete, .M.D.-'- CIniiiman
Duke Univ. Med. C tr., Durham 27710
James A. Bryan, 11, M.D.--
N. C. .Mem. Hosp., Chapel Hill 27514
Oscar L. Sapp. M.D. •-
UNC Sch. of Med.. Chapel Hill 27514
Mr. Fred Sanfilippo (Dukei
Box 2831. Duke .Med. Ctr.. Durham 27710
Mr. Van J. Stitt. Jr. (UNC)
607 Northampton Plaza. Chapel Hill 27514
Mr. Edward Warren ( BG )
1 105 W. End Blvd.. Winston-Salem 27103
34. Committee on Medicare (10) MI-2
William 1. R.ib\. M.D.''" Clniiniiaii
1012 Kings Dr.. ( harlotte 28207
Charles H. Reid. Jr.. M.D.'''
2240 Cloverdale .-Xve.. Winston-Salem 27103
:75 14
Thomas E. Castelloe. M.D.'-'-'
P. O. Box 10707, Raleigh 27605
.-^mos N. Johnson. M.D.^-
Bo\ 158, Garland 2841 1
J, P. McCracken, M.D. •-
609 Vickers .'\ve., Durham 27701
Walter Spaeth, M.D.'"
I 16 S, Road St.. Elizabeth City 27909
H. Frank Starr. Jr., M.D.^i
P. O. Box 20727, Pilot Lite. Greensboro 27404
Robert Lee West. M.D.'"
2013 Pinecrest Dr.. Green\ille 27834
Douglas Smith. M.D.''"
200 Greenwick Rd.. Charlotte 2821 I
Marvin L. Slate. M.D.^l
204 Bhd,. High Point 27262
35. Conmiittee on Medicine & Religion (9)
(6 Consultants) Vl-7
Jack W. Wilkerson. NLD."' Chainnan
Green% ille Clinic. Greenville 27834
John R. Bender. M.D..-'^ I'icc-Chainuan
1401 S. Hawthorne Rd.. Winston-Salem 27103
Bruce B. Blackmon. .M.D." ■
Box 8. Buies Creek 27506
George M. Cooper, Jr.. M.D."-
201 Bryan BIdg., Raleigh 27605
Donald .M. Hayes, M.D.'"
Bowman Gray. Winston-Salem 27103
Richard M. Maybin. M.D.--'
Route 2, Lawndale 28090
.'Mexander S. Moffett. M.D.-
Box 1028, Taylorsville 28681
William E. Rabil. M.D.'"
218 Prof. BIdg.. Winston-Salem 27103
W. Wyan Washburn. M.D.-"
P. O. Box 795. Boiling Springs 28017
Consultants:
Re\. Orion N. Hutchinson. Jr.
1 130 Westridge Rd.. Greensboro 27410
Rev. T. Max Linnens
Box 161. Boiling Springs 28017
Rev. Fred W. Reid, Jr.
N. C. Mem. Hosp.. Chapel Hill 27514
Re\ , Samuel Wiley
Box 6637. College Sta.. Durham 27708
Rev. Richard R. Young
Rt. 2. Roxboro 27573
Father Thomas J. O'Donnel
Box 859. C linton 28328
36. Committee on Mental Health (28) VI-8
Philip G. Nelson. NLD.'" Cliainiuin
Medical Pavilion, Greenville 27834
William E. Bakewell, Jr., M,D. ■-
N. C, Mem. Hosp., Ch.ipel Hill 27514
Wilmer C. Belts, M.D.'-'-
3125 Glenwood Prof. Village, Raleigh 27608
R. Jackson Blackley, M,D.-'-
Bo\ 2fi327, Raleigh 2761 1
Robert S. Cline, M,D.-'-"
555^ Carthage St., Sanford 27330
Thomas E, Curtis, M.D. "-'
N. C. Mem. Hosp., Chapel Hill 27514
432
Vol, 35.
Paul G. Donner, M.D,""
2201 Randolph Rd., Charlotte 28207
John A. Ewing, M.D.-'-
N. C. Mem. Hosp.. Chapel Hill 27514
William W. Fowlkes, Jr., M.D.»-
Box 27327. Raleigh 27611
Robert W. Gibson, Jr., M.D.i-
14 Staff Circle, Morganton 28655
Alanson Hinman, M.D.-'^
Bowman Gray, Winston-Salem 27103
Hervy Basil Kornegay, Jr., M.D.'"i
238 Smith Chapel Rd., Mt. Olive 28365
Charles E. Llewellyn, M.D.-'-
Duke Univ. Med. Ctr., Durham 27710
Hans Lowenbach, M.D.-'-
Duke Univ. Med., Ctr., Durham 27710
'Vernon P. Mangum, M.D.'"'
O'Berry Center, Goldsboro 27530
IJames G. McAllister, 111, M.D.i><
24 2nd. Ave., NE, Hickory 28601
(Donald E. Macdonald, M.D."»
100 Billingsley Rd., Charlotte 2821 1
[Harry H. McLean, III, M.D."
1 ECU Infirmary, Greenville 27834
JMary Margaret McLeod, M.D.-"'-*
! Drawer 1047, Sanford 27334
Ijames W. Osberg, M.D.''-
Box 230-A, Rt. 6, Raleigh 27604
■William M. Petrie, M.D."-
Duke Univ. Med. Ctr., Durham 27710
John B. Reckless. M.D.'-
5504 Durham-Chapel Hill Blvd., Durham 27707
'.Leon W. Robertson, M.D.-'''
107 Nash Med. Arts Mall, Rocky Mount 27801
iRay G. Silverthorne, M.D.f
408 East 12th St., Washington 27889
'Nicholas E. Stratas, M.D.'-'-
I Box 26327, Raleigh 27611
ISilas O. Thorne, Jr., M.D.-''
Med. Arts Bldg., Morehead City 28557
Charles R. Vernon, M.D.«"'
7225 Wrightsville Ave., Wilmington 28401
'A. H. Zealy, Jr., M.D.'"'
206 Herman St., Goldsboro 27530
Committee on Nominations (10) X
:J. Elliott Dixon, M.D.^ (2nd) Chairman
215 E. 2nd Ave., Ayden 28513
John A. Payne, 111, M.D.''!' (1st)
Box 157. Sunbury 27979
Thomas Craven, Jr., M.D.*""' (3rd)
315 N. 17th St., Wilmington 28401
.Lawrence McG. Cutchin, M.D.-''' (4th)
P. O. Box 40, Tarboro 27886
Charles T. Johnson, Jr., M.D.";* (5th)
222 S. Main St., Red Springs 28377
Oscar L. Sapp, 111, M.D.-'- (6th)
UNC School of Medicine, Chapel Hill 27514
James B. Greenwood, Jr., M.D."" (7th)
4101 Central Ave., Charlotte 28205
'Roy S. Clemmons, M.D.^i (8th)
803 Simpson St., Greensboro 27401
James H. Segars, M.D.^ (9th)
Med. Arts Bldg., Lenoir 28645
iBenjamin Raymond dinger, M.D." (10th)
131 McDowell St., Asheville 28801
r 1974, NCMJ
38. Advisor to North Carolina Association of
Medical Assistants (1)
Emmett S. Lupton, M.D."
1 100 Olive St., Greensboro 27401
39. Committee on Occupational & Environmental Health
(15) (2 Consultants) VI-9
Harold R. Imbus, M.D." Cliainiian
P. O. Box 21207, Greensboro 27401
Harold Dear Belk, M.D. "
3300 Lexington Rd., SE, Winston-Salem 27102
John L. Brockmann, M.D.^i
624 Quaker Lane, High Point 27262
M. C. Battigelli, M.D.-'-
UNC Sch. Med., Chapel Hill 27514
Emil C. Beyer, M.D."'
Lands End Rd., Spooners Creek, Morehead City
28557
Thomas Craven, Jr., M.D."-"'
315 N. 17th St., Wilmington 28401
James N. Dawson, M.D.-^
Box 68. Reigelwood 28456
Clyde J. Dellinger, M.D.'-
Box 8, Drexel 28619
Charles P. Ford, Jr., M.D.-"'^
E. 1. DuPont DeNemours & Co., Box 800, Kinston
28501
Austin P. Fortney, M.D.^'
Box 329, Jamestown 27282
Charles G. Gunn, M.D.-«
Hanes Corp., Box 5416, Winston-Salem 27104
Sarah A. T. Morrow, M.D.-"
Guilford Co. Hlth. Dept., Greensboro 27401
Joseph B. Henninger, M.D.^-'
652 Davie Ave., Statesville 28677
Austin T. Hyde, Jr., M.D.si
Norris-Biggs Clinic, Rutherfordton 28139
Charles F. Martin, M.D."
1201 Maple St., Greensboro 27405
Consultants:
Mr. John Lumsden
State Board of Health, Box 2091, Raleigh 27602
David A. Eraser, Sc.D.
UNC Sch. of Public Health, Chapel Hill 27514
40. Committee on Peer Review (21) Vn-3
M. Frank Sohmer, Jr., M.D.-'^ Cliairman
Prof. Bldg., Winston-Salem 27103
David S. Johnston, M.D."" (OR)
1822 Brunswick Ave., Charlotte 28207
Curtis R. Lashley, M.D.^i
Box 20727, Pilot Life, Greensboro 27401
James S. Mitchener, M-D.^-' (S)
Box 1599, Laurinburg 28352
Ernest B. Spangler, M.D."
3811 Henderson Rd., Greensboro 27410
Floyd Alan Fried, M.D.-'-
Dept. Surgery, UNC. Chapel Hill 27514
Bernard A. Wansker, M.D.""
Suite 400, Metroview Bldg. 1900 Randolph Rd.,
Charlotte 28207
James G. Jones, M.D.'i^ (FP)
510 College St., Jacksonville 28540
Lawrence M. Cutchin, M.D.-'''' (IM)
Box 40, Tarboro 27886
433
, 2
K. Randolph Wilkerson, Jr.. M.D.''" (O&O)
101 ; Kings Dr., Charlotte 28207
William W. Farley, M.D.'-'- ( PD )
13(10 St. Mary's St., Raleigh 27605
Robert G. Brame, M.D.-'- (OB-G)
Duke Hospital. Durham 27710
John J. Wright, M.D.-- ( PH&E )
Box 1267, Chapel Hill 27514
Robert W. Gibson, Jr., .M.D.'- (N&P)
14 Staff Circle, Morganton 28655
Stuart Wynn Gibbs, M.D.-'' (R)
Box 1495. Gastonia 28052
Walter R. Benson, M.D.-- ( PTH )
Dept. Pth., UNC. Chapel Hill 27514
Merel H. Harmel. M.D.-- (AN )
Duke Univ. Med. Ctr., Durham 27710
Royal G. Jennings, M.D.-" (D)
624 Quaker Lane, High Point 27262
Vernon H. Voungblood, M.D.i-* |U)
1421 Highway 20 North, Concord 28025
Robert Voungblood, M.D.'-'^ (GS)
1201 Brookside Dr., Wilson 27893
Dineen, James R.. M.D.''-'' (ORS)
1616 .Medical Center Dr., Wilmington 28401
41. C'ommittet on Personnel & Headquarters Operations
(5) 1-3
A. Hewitt Rose, Jr., M.D.-'- Cluiiniian
3801 Computer Drive, Raleigh 27609
Charles W. Styron, M.D.!'-
615 St. Mary's St.. Raleigh 27605
W. Lester Brooks, Jr., M.D.''"
851 E. Third St.. Charlotte 28204
John S. Rhodes. M.D.'-'-
1300 St. Mary's St., Raleigh 27605
Louis deS. Shaffner, M.D.-'
Bowman Gray. Winston-Salem 27103
Ex Officio:
Frank R. Reynolds, M.D."-"' (President)
1613 Dock St., Wilmington 28401
E. Harvey Estes, Jr., M.D.'- (Secretary)
Duke Univ. Med. C tr., Durham 27710
George G. Gilbert, M.D." (Past President)
1 Doctors Park, Asheville 28801
42. Committee Liaison to North Carolina Pharmaceutical
Association (6) (2 Consultants) \-l
Charles W. Byrd. M.D.'- Chairman
Box 708. Dunn 28334
Charles E. Cummings, M.D."
281 McDowell St., Asheville 28801
John T. Dees. M.D."-''
Box 815. Burgaw 28425
Richard A. Fewell. M.D.'
1610 Vaughn Rd.. Burlington 27215
T. Reginald Harris, M.D.--
808 N. Dekalb St.. Shelby 28150
John A. Payne. III. M.D.-^
Box 157, Sunbury 27979
Consultants:
Mr. W. J. Smith. Exec. Secy.
N. C. Pharmaceutical Assn.. Chapel Hill 27514
Mr. Clarence B. Ridout
Dept. of Social Services. Raleigh 27602
434
43. Committee on Phjsical & Vocational Kehabilitat i
(9) IV-6
Edwin H. Martinat, M.D.-' Cliairnian
3333 Silas Creek Parkway, Winston-Salem 27103
Stanley S. Atkins, M.D."
283 Biltmore Ave., .-ksheville 28801
Scott B. Berkeley. Jr.. M.D.'-"'
2400 Wayne Mem. Dr., Suite E, Goldsboro 27530
L. Lloyd Davis, M.D.-' -
Beechwood. Box 1 163. Tryon 28982
A. Tyson Jennette, M.D.'""
Carolina General Clinic. Wilson 27893
Charles E. Llewellyn. Jr.. M.D.-*-
Duke Univ. Med. Ctr., Durham 27710
Edwin T. Preston. M.D. '-
517 North St.. Chapel Hill 27514
Chauncey L. Royster. M.D."-
515 St. Mary's Street, Raleigh 27605
H. William Tracy, Jr., M.D.
1822 Brunswick Ave., Charlotte 28207
44. Medical Society Consultant on Podiatry (1)
Donald B. Reibel, M.D."-
P. O. Box 10707, Raleigh 27605
45. Committee on Professional Insurance (19) 1-3
John C. Burwell. Jr.. M.D.^' Cliainnan
1026 Prof. Village. Greensboro 27401
William B. Blythe. M.D.--
UNC Sch. of Med.. Chapel Hill 27514
H. Robert Brashear. Jr., M.D.--
N. C. Mem. Hosp.. Chapel Hill 27514
Michel Bourgeois-Gavardin. M.D. '-
Watts Hosp.. Box 247, Durham 27705
Thomas B. Dameron, Jr.. M.D."-
P. O. Box 10707, Raleigh 27605
John W. Foust, M.D.""
3535 Randolph Rd., Charlotte 2821 1
Lewis J. Gaskin, M.D."-
1300 St, Mary's St., Raleigh 27605
Julius .\. Green. Jr.. M.D."-
3821 Merton Dr.. Raleigh 27609
Charles M. Hasseli. Jr.. M.D.^'
1200 N. Elm St.. Greensboro 27405
Ira M. Hardy. 11. M.D.'^
1709 W. 6th St.. Greenville 27834
William W. Hedrick. M.D."-
331 I North Blvd.. Raleigh 27604
David Herman Jones. M.D.'-'-'
1300 St. Mary's St.. Raleigh 27605
Willis E. Mease. M.D."'
Box 97, Richlands 28574
W. B. McCutcheon, Jr., M.D.^'-
1830 Hillandale Rd.. Durham 27705
Charles E. Morris. M.D.-'-
UNC. Chapel Hill 27514
Kenneth A. Podger, M.D.'-
1830 Hillandale Rd.. Durham 27705
Ronald A. Pruitt. M.D.i
Kernodle Clinic. Burlington 27215
Samuel H. Walker. M.D."
528 Biltmore Ave.. Asheville 28801
W. Howard Wilson. M.D.'-'-
230 Bryan Bldg., Raleigh 27605
Vol. 35. No,
i Committee on Programs for General Sessions (7) III-6
T. Reginald Harris. M.D.--' Chiiiniuin
808 N. Dekalb St., Shelby 28150
' Kenneth E. Cosgrovc, M.D.'"'
510 7th Ave.. W., Hendersonville 28739
i Lawrence McG. Cutchin, M.D.'-'
' Box 40, Tarboro 27886
; John Glasson, M.D.'-
306 S. Gregson St., Durham 27701
I Emery C. Miller, M.D. '^
I Bowman Gray Sch. of Med., Winston-Salem 2710?
I Oscar L. Sapp, III. M.D.'-
UNC Sch. of Med.. Chapel Hill 27514
Delford L. Slickel. M.D.--
Box 305, Duke Hosp.. Durham 27710
I Committee on Public Relations (4) (8 Consultants) V-8
) John L. McCain, M.D.''"* ( 19771 Chainuun (4th)
i Wilson Clinic, Wilson 27893
1 Elizabeth Kanof, M.D.»- (6th) (1977)
1300 St. Mary's St., Raleigh 27605
I Philip Naumoff, M.D."" (7th) (1976)
1012 Kings Dr., Charlotte 28207
I David R. Williams, M.D.--' (9th) (1975)
' Southgate Shopping Ctr., Thomasville 27360
1 Consultants:
William H. Burch, M.D.^- ( 10th)
Lake Lure 28746
I Ernesto E. de la Torre, M.D.-^ (8th)
256 Forsyth Med. Park, Winston-Salem 27103
I E. Thomas Marshbiirn. Jr., M.D.''"' (3rd)
1515 Doctors Circle. Wilmington 28401
! Josephine T. Melchior. M.D.-'' (5th)
1661 Owen Dr., Fayetteville 28304
: C. O. Plyler, Jr., M.D.-" (9th)
1025 Randolph Rd., Thomasville 27360
^ Marshall S. Redding, M.D.'" ( 1st )
708 W. Church St., Elizabeth City 27909
: Cecil D. Rhodes. Jr., M.D.''" (4th)
Carolina General Clinic, Wilson 27893
Lynwood E. Williams, M.D.''' (2nd)
I 400 Glenwood ,\ve., Kinston 28501
I
', Committee on Radiation (I)
I Thomas Clarkson Worth, M.D.''-
Rex Hospital, Raleigh 27603
! Committee on Relative Value Study (16) II-8
'Arthur E. Davis, Jr., M.D.-'- (PTH) Chaiinian
Rex Hosp., Raleigh 27603
William T. Berkeley, Jr., M.D."" (P)
1330 Scott Ave., Charlotte 28204
Henry Jackson Fowler. M.D.-'^ (GP)
Box 38, Walnut Cove 27502
Duwayne G. Gadd, M.D.'i-' (U)
Pinehurst Surg. Clin., Pinehurst 28374
John R. Hoskins, III, M.D." (AN)
202 Doctors Bldg., Asheville 28801
David H. Jones, M.D.''- (OPH)
1300 St. Mary's St., Raleigh 27605
O. Hunter Jones, M.D.'"' (OB-G)
1012 Kings Dr., Charlotte 28207
Riley M. Jordan, M.D." (GP)
Box 276, Raeford 28376
Curtis R. Lashley, M.D." (Admin)
Box 20727. Pilot Life. Greensboro 27401
William L. London. M.D.-'- ( Pd )
306 S. Gregson St., Durham 27701
Hoke S. Nash, Jr., M.D."" (Otol )
1600 E. Third St., Charlotte 28204
Ernest B. Spangler, M.D.^i (R)
Drawer X3, Greensboro 27402
Walter T. Tice, M.D." (I)
624 Quaker Lane. High Point 27262
Bernard A. Wansker, M.D."" (D)
Suite 400. Melroview Bldg.
1900 Randolph Rd., Charlotte 28207
Roston M. Williamson. M.D.-- (OB-G)
306 S. Gregson St., Durham 27701
Isaac C. Wright, M.D.»- (I)
1 19 N. Boylan Ave.. Raleigh 27603
50. Retirement Savings Plan Committee (6) 1-4
Jesse Caldwell, Jr., M.D.-'' ( 1975) Chairman
I 14 W. Third St., Gastonia 28052
Vernon L. Andrews, M.D.''- (1976)
Box 8. Mount Gilead 27306
William F. Hollister, M.D."- (1975)
Box 2000, Pinehurst 28374
George W. James. M.D.-' (1977)
205 S. Hawthorne Rd., Winston-Salem 27103
(to be filled by E. C. 1975 (9/29/74)
A. Hewitt Rose, Jr., M.D."- ( 1977)
3801 Computer Dr., Raleigh 27609
Robert W. Williams, M.D."'' (1976)
3208 Oleander Dr.. Wilmington 28401
51. Committee on Social Services Programs
(Including Medicaid) (18) VII-4
James S. Mitchener. M.D."*- Cliainuaii
Box 1599, Laurinburg 28352
Edgar T. Beddingfield. Jr., M.D.'"<
Wikson Clinic. Wilson 27893
Bruce B. Blackmon, M.D.^-
P. O. Box 8. Buies Creek 27506
J. Elliott Dixon, M.D."^
215 E. Second St., Ayden 28513
E. Stephen Edwards, M.D.'-'-
1300 St. Mary's St.. Raleigh 27605
Albin W. Johnson. M.D."-
1300 St. Mary's St., Raleigh 27605
Ralph V. Kidd, M.D.""
1928 Randolph Rd., Charlotte 28207
Thomas W. Kitchin, Jr., M.D."^
510 College St., Jacksonville 28540
William T. MacLauchlin, M.D.'S
Box 774, Conover 28613
Tom N. Massey, M.D.''"
217 Travis Ave., Charlotte 28204
Campbell White MacMillan, M.D.--
N. C. Mem. Hosp., Chapel Hill 27514
Otis B. Michael, M.D."
208 Doctors Bldg., Asheville 28801
Leslie M. Morris, M.D.'"'
Box 1495, Gastonia 28052
Charles P. Nicholson. M.D.'"
3108 Arendell St., Morehead City 28557
s >
■{ 1974, NCMJ
435
George W. Piischul. Jr., M.D.'-'-
1110 Wake Forest Rd.. Raleigh :76(I4
Emery L. Rann. M.D.''"
1001 Beatties Ford Rd., Charlotte 28204
Donald B. Reibel. M.D.'-'-
P. O. Box 10707, Raleigh 27605
Russell L. Smith, M.D,''
1 14 E. 3rd St., Win.ston-Salem 27101
52. Committee on Traffic Safety (12) (3 Consultants) II-"*
E. T. Beddingfield, Jr., M.D.'''^ Cluiinnan
Wilson Clinic, Wilson 27893
Vernon L. Andrews. M.D.''-
Box 8. Mt. Gilead 27306
.•\llan B. Coggcshall, .M.D.^i
P, O. Box 10186, Greensboro 27404
Daniel S. Ciirrie, M.D.-'"
Ill Bradford Ave., FayetteviUe 28301
William J. DeMaria, M.D. ■-
I 126 Woodbiirn Rd.. Durham 27705
Harold D. Green. M.D.-'»
Bowman Gray, Winston-Salem 27103
Jesse H. Meredith, M.D.'i
Bowman Gray. Winston-Salem 27103
John W. Morris, M.D."'
2410 Evans St., Morehead City 285.57
James F. Newsome, M.D. '-
N. C. Mem. Hosp., Chapel Hill 27514
Fred G. Patterson, M.D.^'-
1001 S. Hamilton Rd , Chapel Hill 27514
53.
Jack M. Rogers. M.D.-^
Bowman Gray, Winston-Salem 27103
Albert Stewart. Jr.. M.D.-''
I 14 Broadfoot Ave., FayetteviUe 28305
Consultants:
Col. Charles Speed (Ret.)
Box D-25801, Raleigh
Mr. Douglas Wooten
Dept. Transportation & Highway Safety
Raleigh 27610
Dr. Verne Roberts
State Services Dept.. National Driving Ctr..
255 Engineering Annex. Duke Univ., Durham 27705
ad hoc Study Committee on Fees (6) IV-7
T. Reginald Harris, M.D.--' Chairman
808 N. Dekalb St., Shelby 28150
J. Benjamin Warren. M.D.-"'
Box 1465, New Bern 28560
Bernard A. Wansker. M.D.«"
1900 Randolph Rd., Suite 400. Charlotte 28207
William L. London. M.D. •-'
306 S. Gregson St.. Durham 27701
.Mbert Stewart. Jr., M.D.-'b
114 Broadfoot Ave., FayetteviUe 28305
Ira M. Hardy, II, M.D.7^
1709 W. Sixth St., Greenville 27834
1
t
436
Vol. 35, Nd ■)<,
w
Bulletin Board
NEW MEMBERS
of the State Society
nin, Ms. Patricia Anne (Student), 421 Cliateau Apts.,
topel Hill 27514
cnza, Romeo Briones, MD (GS), 106 Stewart St., South-
ort 28461
'tti, Muhammad Arshad, MD (IM), 3111 Maplewood
,ve., Winston-Salem 27103
lie, James Alexander, MD (TS), Ivy & W. 3rd St.,
■iler City 27344
,y, James Kearney, MD (DR), 1416 Brookgreen Ave.,
itatesville 28677
yn, Anna Bauhofer, MD (AN), 117 Pinetree Rd., Salis-
ury 28144
ndelj Clifford Craig, MD (Intern-Resident), 608
Churchill Dr., Chapel Hill 27514
nan, Wm. Henry, Jr., MD (ORS), 194 Summer Hill
l.d., Fayetteville 28303
is, Wm. Walter, III, MD (GP), Rt. 1, Box 92-14,
wansboro 28584
ler, Leonard M., MD (IM), Connestee Falls, Rt. 1,
trevard 28712
hian, George Gene, MD (FP), Coach Road, Reidsville
vry, Roswell Tempest, MD (GS), 104 Perth Court,
:ary 27511
ins, James Francis, MD (GS), Chestnut Dr., Box 446,
;Iowing Rock 28605
;ri, Anthony John, MD (PTH), Morehead Mem. Hosp.,
iden 27288
itus, Simon, MD (Former Member), Box 37, Cherry
iospital, Goldsboro 27530
uwalla, Sorab Pestonji, MD (GS), 512 Raymond St..
llocksville 27028
inteson, Rodney Allen, MD (ORS), 1226 W. Kenan
,t., Wilson 27893
rrison, Robert Lord, MD (AN). 327 Robert E. Lee Dr.,
Wilmington 28401
;h, Carl Wm., MD (R), P. O. Box 368, Eden 27288
mess, John Lavon, MD (OBG), Fletcher Medical Cen-
:r, Fletcher
row, Barry Seymour, MD (P), Rt, 3, Box 97, Zebulon
7397
mn, Rayford Edwin, MD (GPl, 117 W. Pennsylvania
ive., Bessemer City
lldon, Frank Chadwick, MD (GS), 310 N. Smithwick
t., Williamston 27892
ilman, Louis Cromwell, MD (GP), 2860 Holyoke Place,
i/inston-Salem 27103
iimpson, John Albert, Jr., MD (D). 1900 Randolph Rd.,
i:harlotte 28207
Wey, Robert Riley, MD (GP), 907 Country Club Dr.,
:eidsville
Dd, Everet Hardenbergh, MD (OPH), 205 Park View
)r., Brevard 28715
ling, Charles Gibson, MD (IND), Fieldcrest Mills, Eden
7288
^§'.Y 1974, NCMJ
WHAT? WHEN? WHERE?
In Continuing Education
July 1974
("Place" and "sponsor" are listed only where these differ
from the place and group or institution listed under "for
information.")
In North Carolina
July 29-August 2
Second Annual Beach Workshop: Selected Topics in General
Internal Medicine
Spon.sors: Bowman Gray, Duke and UNC Schools of
Medicine, in conjunction with the Medical University of
South Carolina
Place: St. Johns Inn, Myrtle Beach, South Carolina
Fee: $100
For Information: Emery C. Miller, M.D., Associate Dean
for Continuing Education, Bowman Gray School of
Medicine, Winston-Salem 27103
September 6-7
.Annual Meeting of the North Carolina Chapter of the
American Academy of Pediatrics and The North Carolina
Pediatric Society
Place: Pinehurst Hotel and Country Club
For Information: Mrs. John McLain, Executive Secretary,
3209 Rugby Road, Durham 27707
September 6-7
Symposium on .Arthritis
Place: Babcock Auditorium
Fee: $30.00
For Information: Emery C. Miller, M.D., Associate Dean
for Continuing Education, Bowman Gray School of
Medicine, Winston-Salem 27103
September 13
Pathology and Treatment of Conditions Affecting the Knee
Joint
This is a one day course designed for rehabilitation nurses,
insurance carriers and members of the Industrial Accident
Commission of N. C.
Sponsor: Division of Orthopaedic Surgery, Department of
Surgery
For Information: Frank H. Bassett, III, M.D., Box 2919,
Duke University Medical Center, Durham 27710
September 18-19
19th Annual Angus M. McBryde Perinatal Symposium
Fee: $50.00
For Information: George Brumley, M.D., Division of Peri-
natal Medicine, P. O. Box 2911, Duke University Medical
Center, Durham 27710
September 19-21
Topics in Internal Medicine, the Fourth Annual Seminar
in Medicine
Place: Babcock Auditorium
Fee: $75.00
For Information: Emery C. Miller, M.D., Associate Dean
437
Cancer Center (CR-IIl), which is scheduled to be
completed by 1977.
A native of Philadelphia. Abramson received his
B.S. degree from Ursinus College in Collegeville, Pa.,
and M.D. degree from Temple University Medical
School in Philadelphia.
He served a rotating internship at Mount Zion
Hospital in San Francisco, and received special train-
ing in psychiatry at Boston University Medical Center
and in therapeutic radiology at Duke from 1967-
1970.
Following training, Abramson was in private prac-
tice in therapeutic radiology for one year at Alta
Bates Hospital in Berkeley, Calif.
He returned to Duke in 1971, as assistant pro-
fessor of radiology.
* * *
The National Multiple Sclerosis Society has
awarded a two-year postdoctoral fellowship grant of
$18,350 to Dr. Ronald Charles Waldbillig.
Waldbillig will work under the supervision of Dr.
J. David Robertson, professor and chairman of the
Department of Anatomy.
News Notes from the —
BOWMAN GRAY SCHOOL
OF MEDICINE
WAKE FOREST UNIVERSITY
The Bowman Gray School of Medicine has re-
ceived an $805,000 grant from the National Heart
and Lung Institute for research into lung diseases
and the lung's defenses against those diseases.
The project, which is supported for a five-year
period, will involve faculty members from several
departments and graduate students in the Department
of Microbiology. Some medical students will also
be involved.
Dr. Ouentin N. Myrvik, professor and chairman of
the Department of Microbiology, is director of the re-
search effort. Dr. Joseph E. Johnson, professor and
chairman of the Department of Medicine, is the co-
director.
^. :i; ;{:
The Rev. Frank R. Campbell of Statesville has
been elected chairman of the Joint Medical Center
Administrative Board of the medical school and
hospital.
He succeeds Francis E. Garvin of Wilkesboro, the
first chairman of the administrative board.
The board, established in February, has eight trust-
ees from Wake Forest University, eight trustees from
the hospital and a member of the professional staff.
It was delegated the responsibility for overall super-
vision of the medical center.
440
b1
i
Rondomycir
(methacycline HCI)
CONTRAINDICATIONS: Hypersensitivity to any ot the tetracyclines
WARNINGS: Tetracycline usage tJunng tooiti development tiast trail ol pregnancy to ( ..
years) may cause permanent tootti discoloration (yellow-gray-Orown). which is r "-"
common during long-term use but has occurred alter repeated short-term cour
Enamel hypoplasia has also been reported Tetracyclines shouU nol be usei) in Ihi:
group unless other drugs ate not likely lo be ellective or are contrainilicj jj
Usage in pregnancy. (See above WARNINGS about use during tooth developm/
Animal studies indicate thai tetracyclines cross the placenta and can be toxic to tht
veloping tetus iotten related to retardation ot skeletal development] Embryotoxicity
also been noted m animals treated early in pregnancy :
Usage in newborns, inlanls. and chililien. (See above WARNINGS about use d^
tooth development )
All tetracyclines form a stable calcium complex m any bone-tormmg tissue A deer
in tibula growth rate observed in prematures given oral tetracycline 25 mg/kg eve
hours was reversible when drug was discontinued
Tetracyclines are present in milk of lactatmg women taking tetracyclines
To avoid excess systemic accumulation and liver toxicity in patients with impaired
lunction, reduce usual total dosage and , it therapy is prolonged consider serum leve
terminations ot drug The anti-anabolic action ot tetracyclines may increase BUN 1/
not a problem in normal renal (unction, m patients with significantly impaired fund
higher tetracycline serum levels may lead lo azotemia, hyperphosphatemia, and acidt
Photosensitivity manifested by exaggerated sunburn reaction has occurred with tj
cyclines Patients apt to be exposed to direct sunlight or ultraviolet light should be sc
vised, and treatment should be discontinued at first evidence ol skin erythema
PRECAUTIONS: If superinfection occurs due to overgrowth ot nonsusceptible otgarti!
including fungi discontinue antibiotic and start appropriate therapy ;
In venereal disease, when coexistent syphilis is suspected perform darklield ex
nation before therapy, and serologically test lor syphilis monthly lor at least four mot(
Tetracyclines have been shown to depress plasma prothrombin activity, patients 0(
ticoagulant therapy may require downward adiustment ot their anticoagulant dosage.
In long-term therapy, perform periodic organ system evaluations (including bli
renal, hepatic)
Treat all Group A beta-hemolytic streptococcal inlechons for at least 10 days
Since bacteriostatic drugs may interfere with the bactericidal action of penicillin
giving tetracycline with penicillin
ADVERSE REACTIONS: Gastrointestinal (oral and parenteral forms) anorexia, nau,
vomiting, diarrhea glossitis, dysphagia, enterocolitis, inflammatory lesions (with ii<
lal overgrowth) in the anogenital region
Skin: maculopapular and erythematous rashes, exfofiative dermatitis (uncommon)
tosensitivity is discussed above (See WARNINGS)
Renal toxicity rise m BUN. apparently dose related iSce WARNINGS)
Hypersensitivity: urticaria, angioneurotic edema anaphylaxis, anaphylactoid pun
pericarditis exacerbation ol systemic lupus erythematosus
Bulging fontanels, reported m young infants after full therapeutic dosage, have di
peared rapidly when drug was discontinued
Blood: hemolytic anemia, thrombocytopenia, neutropenia, eosmophilia
Over prolonged periods, tetracyclines have been reported to produce brown-blacl
croscopic discoloration ol thyroid glands, no abnormalities of thyroid function studie
known to occur
USUAL DOSAGE: Adults - 600 mg daily, divided into two or tour equally spaced oc
t^ore severe mleciions an initial dose of 300 mg followed by 150 mg every six hoit-
300 mg every 12 hours Gonorrhea In uncomplicated gonorrhea, when penicillin is'
traindicated, Rondomycin' (methacycline HCI) may be used for treating both males
females in the following clinical dosage schedule 900 mg initially, followed by 301
q I d for a total of 5 4 grams
For treatment of syphilis, when penicillin is contraindicated, a total ol 18 to 24 grar
■Rondomycin' (methacycline HCI) m equally divided doses over a period ol 10-t5
should be given Close follow-up including laboratory tests is recommended
Eaton Agent pneumonia 900 mg daily tor six days
Children - 3 to 6 mg/lb/day divided into two to lour equally spaced doses
Therapy should be continued for at least 24-48 hours after symptoms and fever
subsided
Concomitant therapy: Antacids containing aluminum, calcium or magnesium impai
sorption and are contraindicated Food and some dairy products also interfere Give
one hour before or two hours after meals Pediatric oral dosage forms should ni
given with milk formulas and should be givenjt least one hour prior to feeding
In patients with renal impairment (see WARNINGS), total dosage should be decri
by reducing recommended individual doses or by extending time intervals bet
In streptococcal infections, a therapeutic dose should be given lor at least fO days,
SUPPLIED: Rondomycin (methacycline HCI) 150 mg and 300 mg capsules, synjp
taming 75 mg/5 cc methacycline HCI
Before prescribing, consult package circular or latest PDR information.
aWl WALLACE PHARMACEUTICALS
' ' CRANBUBY, NEW JERSEY 08512
Rev.
*».
Vol. 35, Noj
"he medical school's graduating students dedicated
r yearbook. The Gray Matter, to Dr. John H.
iionds, Jr., professor of medicine, and Dr.
)ert L. Gibson, assistant professor of anesthesia.
)rs. Edmonds and Gibson were recipients last
r of citations for excellence in clinical teaching.
[)r. William H. Boyce, professor and chairman of
: Section of Urology, has been presented the
aest research award of the American Urological
ociation (AUA).
^ le received the sixth annual Hugh Hampton
,'mg Award at the association's meeting in St.
,iis.
The award, which carries a $2,000 prize, is given
loutstanding contributions to the study of urinary
t infections. This year it also recognized the
'rail excellence of the total program of research
*i training in urology at the medical center.
i)r. Boyce is a six-time winner of research awards
n the AUA.
* * *
|)r. Jesse H. Meredith, professor of surgery, has
■n installed as president of the North Carolina
ipter, American College of Surgeons.
i)r. Meredith is the third faculty member from
B vman Gray to head the chapter. Past presidents
ir,ude Dr. Felda Hightower, professor of surgery,
a- Dr. William H. Sprunt, Jr., clinical professor
e jritus of surgery.
* * *
Or. Robert C. McKone, associate professor of
p,iatrics, received the highest award given to a
n nber of faculty during the student-faculty awards
0 ;mony in May.
)r. McKone was presented the second annual
^ ard for Teaching Excellence. He was also one of
fl.'r recipients of citations presented by the senior
ttLS for excellence in clinical teaching.
'■|)r. N. Sheldon Skinner, professor and chairman of
fl'' Department of Physiology, was presented the
C den Apple Award for teaching excellence in the
b ic medical sciences.
leceiving citations in clinical teaching were, in
a ition to Dr. McKone, the following: Dr. Fran-
c M. James, associate professor of anesthesia; Dr.
E'ls Allen, clinical assistant professor of medicine;
a , Dr. Walter M. Roufail, clinical instructor in
n licine.
.louse officer teaching awards went to Dr.
F"sey E. Miller, resident in otolaryngology, and
1 Sara H. Sinai, resident in pediatrics.
* * *
)r. Paul C. Bucy, an internationally prominent
D rosurgeon, has been appointed to the medical
S' ool faculty as clinical professor of neurology and
n rosurgery.
M it is a professor emeritus and former director of
neurosurgery at Northwestern University Medical
School. He now lives in Tryon, N. C.
Dr. Bucy is best known for his work on the
pathology of brain tumors, the anatomy and physi-
ology of the central motor system, the treatment of
abnormal movements and the development of cen-
ters for spinal cord injury.
He is president of the American Neurological As-
sociation and a past president of the World Federa-
tion of Neurosurgical Societies, the Second Interna-
tional Congress of Neurological Surgery, the Society
of Neurological Surgeons and the American Associa-
tion of Neurological Surgeons.
* * *
Dr. Jimmy L. Simon, professor and chairman of
the Department of Pediatrics, has received special
recognition for teaching excellence from the 1974
graduating class of the University of Texas Medical
Branch at Galveston.
Dr. Simon was deputy chairman of pediatrics at
Galveston before joining the Bowman Gray faculty.
He was presented the James W. Powers Award,
which is the highest honor the students at the Uni-
versity of Texas Medical Branch can bestow upon a
faculty member.
This is the second time Dr. Simon has won the
Powers Award.
* * *
Dr. James A. Harrill, professor and chairman of
the Section on Otolaryngology, has been elected
president-elect of the American Laryngological,
Rhinological and Otologioal Society.
Dr. Harrill will be installed as president during the
society's annual meeting next April in Atlanta.
He has been a fellow of the society since 1950
and has served as both secretary and vice president
of the society's southern region. He also served on the
governing council several times.
H< ^ *
Dr. Paul M. James, Jr., associate professor of
surgery, has been elected to a four-year term on the
Executive Board of Directors of the American
Trauma Society.
News Notes from the—
UNIVERSITY OF NORTH CAROLINA
DIVISION OF HEALTH AFFAIRS
Dr. George D. Allen, assistant professor of speech
and hearing sciences at UNC at Chapel Hill, has been
awarded a $41,000 grant from the National Science
Foundation to support his research into the develop-
ment of timing control in human speech.
He hopes to shed light on underlying neural con-
trol processes. His research will examine the range
llf 1974, NCMJ
445
of timing abilities in normal adult speakers as well
as the development of this ability in children. In doing
so, he hopes to help children with speech problems.
» *
The potential of new programs intended to prevent
mental retardation among vulnerable infants and
young children was evaluated at a national conference
which began here in May.
The President's Committee on Mental Retardation
(PCMR) called together approximately 300 re-
searchers, public officials, parents of retarded chil-
dren, and professionals in the field for the four-day
meeting on the UNC campus at Chapel Hill.
The programs examined were based on the theory
that many children who would otherwise become
mentally retarded can be helped to develop normally
if they are identified early in life.
Dr. Ralph H. Boatman, director of the UNC Of-
fice of Allied Health Sciences in Chapel Hill, has
been named director of the University's Office of
Continuing Education in Health Sciences.
Dr. Boatman moved into the position vacated in
May by Francis C. Lindaman who moved to New
York City to join the City Health Department's
health education program.
The office of continuing education which Dr.
Boatman heads performs a planning and coordinat-
ing service for the Division of Health Sciences and its
five schools. It also is responsible for certain devel-
opment and manpower information services for these
schools and for special conference planning and
coordination.
Dr. Royce Montgomery, associate professor of
anatomy at the UNC School of Medicine in Chapel
Hill, was awarded the Richard F. Hunt Memorial
Award for excellence in undergraduate teaching at
the annual Spurgeon Dental Society awards banquet.
The award is presented annually by the Loblolly
Dental Study Club of Eastern North Carolina in
memory of the late Dr. Richard F. Hunt of Rocky
Mount. Dr. Hunt graduated from the UNC School
of Dentistry and was an outstanding civic and pro-
fessional leader.
The award recipient is determined by a joint
faculty and student committee of the UNC School
of Dentistry at Chapel Hill. Montgomery teaches
gross anatomy and is an honorary member of the den-
tal fraternity Psi Omega.
* * *
Dr. Jim Hart, Raleigh, North Carolina orthodon-
tist, has been elected president of the Alumni .Asso-
ciation of the UNC School of Dentistry in Chapel
Hill. Serving with Dr. Hart are Dr. Eugene Howden,
vice president, and Dr. David Simpson, secretary-
treasurer. Both are on the faculty of the UNC School
of Dentistry.
Researchers at the UNC School of Medicine in
Chapel Hill, probing for elusive facts in the bleedir
disorder, von Willebrand's disease, have come u
with a new complication.
Dr. Kay M. Sarji and R. D. Stratton presents
their findings at a Federation of American Societi(
for Experimental Biology meeting, April 1 1, in Atldi
tic City. New Jersey. Both Sarji and Stratton are
the medical school's Department of Pathology.
Until recently, there was no way of measuring tl
von Willebrand factor, an essential clotting element
the blood. Using a newly-developed test, the r
searchers found that plasma from one patient v.]
von Willebrand's disease prohibited platelet cluni
ing in normal blood, while plasma from other \(
Willebrand patients did not.
Since two separate clotting factors are missing
von Willebrand's disease, the refractory conditio
which was not previously recognized in the disea
could be caused by an inhibitor to either the an(
hemophilic factor or to the von Willebrand facto
The patient with this newly-recognized complicatic
had an inhibitor only to the von Willebrand facte
The researchers believe the new inhibitor is an anl
bodv.
Dr. Kenneth M. Brinkhous, Alumni Distinguishc
Professor at the UNC School of Medicine and
internationally recognized researcher, was honori
by the Department of Pathology at a symposia
in April which focused on Dr. Brinkhous's speci
interests, hemostasis and thrombosis.
Dr. Brinkhous. who made the first of his eig
major medical discoveries while still a medic
student, has concentrated on the clinical treatment
hemophilia and other blood disorders relating to clt,
ting mechanisms.
More recently he has been concerned with paticn
who have the opposite problem — a clotting mech
nism which endangers the patient's life.
* * *
Dr. Daniel Test Young, professor of medicine
the UNC School of Medicine in Chapel Hill, h
won the Thomas Jefferson Award for 1974.
The cash prize is made each year to the memb
of the University community whose life and activiti
show the qualities of integrity and character th
marked the life of Thomas Jefferson and which 1
would have recognized as essential to the politic;
religious, and intellectual advancement of society.
Dr. Young, a graduate of Guilford College ui
Harvard Medical School, came to UNC in 1955. I
has directed the Cardiac Catheterization Laborato
at N. C. Memorial Hospital and served as preside
of the N. C. Heart .Association.
Dr. Betsy J. Stover, associate professor of pharm
cology at the UNC School of Medicine in Chap
Hill, has been appointed to the Fellowship Re\i£
Panel of the National Science Foundation. She w
446
Vol. 35, No.
jve on the Biomedical Sciences Panel, one of 12
aels that review fellowship applications.
jA $25,000 trust fund to help support the UNC
iiool of Medicine's research and teaching programs
fperipherai vascular disease has been established
ii Mr. and Mrs. Calvin Kovens of Chapel Hill.
The gift to the Department of Surgery is an ex-
j 'ssion of appreciation for the medical care ren-
tred their son, Scott, in the fall of 1973.
* * *
>Dr. Paul L. Munson, Sarah Graham Kenan Pro-
iisor of Pharmacology and Endocrinology, has been
{ cted president of the Association for Medical
; lool Pharmacology (AMSP).
'Or. Charles F. Gregory, professor and chairman
(• orthopaedic surgery at the University of Texas
J'jthwestern Medical School, is the 1974 R. Beverly
J'ney Visiting Professor at the UNC School of
I'^dicine.
'A senior medical student at the UNC School of
1 ;dicine in Chapel Hill has had his third book pub-
1 led by Warner Paperback Library. He also has
s-rted a publishing company and published his first
\bk.
.Karl Edward Wagner has added Bloodstone to his
(i.ier science-fiction novels and short stories.
^■Wagner, who received his M.D. degree on May 12,
f ns to specialize in psychiatry.
. * * *
-\ member of the UNC School of Pharmacy
. f ulty. Dr. Claude Piantadosi, is collaborating in
cacer research with Dr. Fred Snyder, a senior sci-
e ist at the Oak Ridge, Tennessee Institute of Nu-
car Studies and other scientists to try to learn how
:: l»!ds are formed in cancer cells and in normal cells.
This year the project is financed by two grants
f m the National Institutes of Health, totalling some
'5,000. Other parts of the lipid study are supported
1 funds from the Atomic Energy Commission,
t American Cancer Society, and the National Can-
Cj Institute. ^. ,^ ^.
'Barbara Lowe Bumgarner of Greensboro was pre-
s ted the Senior Recognition Award by the Divi-
s a of Physical Therapy. The award is presented by
t professional staff and faculty to the student in the
t ' one-third of the class with the total best perfor-
r nee.
The first Mindel C. Sheps Award in Mathematical
. Tmography was presented at the annual meeting of
t Population Association of America in New York
( y in April.
■Established as a memorial to the late Dr.
I; .idel C. Sheps of the UNC School of Public Health
j;iulty, the award was given to Dr. Ansley J. Coale,
,- I ifessor of economics at Princeton University.
Dr. Cecil G. Sheps, vice chancellor of health sci-
ences at the University of North Carolina at Chapel
Hill, presented the $1,000 award to Dr. Coale. Dr.
Sheps was the husband of the late Dr. Mindel Sheps.
The award was established by the Mindel C. Sheps
Memorial Fund and is sponsored by the Population
Association of America and the UNC School of
Public Health in Chapel Hill.
* * *
Dr. C. Arden Miller, professor of maternal and
child health at the UNC School of Public Health
and president-elect of the American Public Health
Association, has been elected to the board of trustees
of Appalachian Regional Hospitals (ARH), a non-
profit health care system serving ten communities
in Kentucky, Virginia, and West Virginia.
AMERICAN ACADEMY OF FACIAL
PLASTIC AND RECONSTRUCTIVE
SURGERY, INC.
Carl N. Patterson, M.D., Durham, N. C, was
chosen president-elect (1975) of the American
Academy of Facial Plastic and Reconstructive Sur-
gery. Inc., at their April 1974 meeting in Palm Beach,
Florida.
Dr. Patterson is currently on the staff of McPher-
son Hospital in Durham. He is Assistant Clinical
Professor in Surgery (otolaryngology) at Duke Uni-
versity Medical Center, and Clinical Consultant in
Surgery (otolaryngology) at North Carolina
Memorial Hospital. He is on the attending staff at
Watts Hospital and Lincoln Hospital, Durham, and
Consultant in Otolaryngology at Murdock and John
Umstead Hospitals, Butner, and at Dorothea Dix
Hospital, Raleigh.
After graduating from the University of Maryland
Medical School in 1944, Dr. Patterson interned at
Mercy Hospital in Baltimore and completed his resi-
dency in otolaryngology at Mercy Hospital in 1946.
Dr. Patterson is currently a member of the Board
of Directors of the American Academy of Facial
Plastic and Reconstructive Surgery, Inc. He is Chair-
man of the Board of Directors of the Training Center
for Hearing Impaired Children in Durham.
BOY SCOUTS OF AMERICA
The medical Exploring program of the Boy Scouts
of America ( BSA ) is having a definite impact in
North Carolina. Operating under a three-year grant
from the AMA, the BSA"s Exploring Division is
expanding its special interest program in medicine
and the allied health careers.
Robert G. Maxfield, National Director of medical
Exploring, was in North Carolina recently assisting
local Scouting officials in Raleigh, Durham, Fayette-
ville. Chapel Hill, and Greensboro.
Presently, 620 young adults are actively involved
hv 1974, NCMJ
447
in the 36 medical and liealtli career Explorer posts
in North Carolina. Career interest surveys conducted
by local Exploring divisions indicate a sufficient in-
terest in health careers to greatly expand the pro-
gram. The interest in entering a health career is very
high among North Carolina youth. Exploring off.
these young adults an opportunity to experience .
in-depth exposure to the realities of a health car- (
and thus better prepare them for the necessary tra i
ing and education.
Month in
Washington
With the exception of a possible last-minute
catastrophic bill to the liking of both the Senate and
the House, the prospects for a national health in-
surance (NHI) bill this year appear to be fading.
Preoccupied with the possible impeachment and
other matters, the pace of House and Senate hear-
ings on NHI has definitely slowed, despite a strong
desire of Republicans and Democrats to take a widely
popular health measure with them to the polls this
November.
Its late April testimony on NHI before the House
Ways and Means Committee behind it, the Ameri-
can Medical Association again advanced its Medi-
credit proposal for NHI before the Senate Finance
Committee at the end of May.
Senate Finance Committee chairman Russell Long
(D-La.) and other committee members heard AM A
president Russell Roth, M.D., president-elect Mal-
colm Todd, M.D., and Ernest Livingstone, M.D.,
chairman of the AMA Legislative Council, support
the Medicredit measure.
"As the nation's largest association of actively
practicing physicians, the ones who will be called
upon to provide the professional services which are
contemplated under any program which may be
authorized by Congress, we feel that our viewpoints
are extraordinarily important, "' Dr. Roth told the
committee.
"If we are to meet the principal needs, not only
of the aged and the poor, but of the vast middle-in-
come group, it would seem we must endeavor to
provide basic coverage for medical service and, if
possible, add to this protection against ruinous cata-
strophic major medical expense. (Senators Long
and Abraham Ribicoff, D-Conn., are sponsors of a
catastrophic-only type NHI proposal ) .
"We appreciate the economies of pro\iding only
catastrophic coverage, but feel that it will meet too
few of the needs and will prove very difficult to ad-
minister. We appreciate the appeal of first dollar
coverage but recognize the inordinate expense in-
volved.
"The catastrophic coverage should be adjusted to
ability to pay, since it is obvious that an amour
which could be easy for the well-to-do family to pa
could be disastrous for the much larger group c
middle and low-income individuals. If the insuranc
is to protect, it must be operative at the level c
need.
"If I provide $10 worth of service for my patiei
and he pays me directly, I have earned $10 and h
has spent $10. If, instead, money is to be collecte
from the patient as a tax to be transmitted to Was!
ington, processed, transferred to another agenc;
processed, passed to an intermediary, processed, pai
out as a benefit, and then reviewed for appropriat(
ness. I will need to leave it to others to estimal
how much more must be collected from the patiei
to yield the $10 necessary to cover the service ret
dered. Each complicating step in the process contril
utes to a shrinkage in service purchased by tl:
medical dollar.
"We believe that the public will look with disma
on a financing mechanism which increases the Socii
Security tax by four percent, as with the Kenned;
Vlills proposal.
"We have enthusiasm for the financing mechanisi
in the .Medicredit bill which uses tax credits to min
mize the number of dollars making a round trip t
Washington as tax to return as a shrunken benefi
and which places the obligation to contribute the
share on those who have the ability to pay all c
part of their premium cost. It uses an existing goven
mental collection agency, minimizes new demands fc
an increase in bureaucracy, and reduces administn
tive costs.
"Finally, there is the matter of administering th
program. There is precious little evidence that an
particular economy or efficiency results from goverr"
ment health programs, but a growing body that th
opposite may be true.
"In the case of National Health Insurance, we fei
assured that if any part of the funding derives froi
Social Security taxes there would be a compulsio
for Social Security control of the program.
"We are confident that the administration of if
448
Vol. 35, Nc
" I'm sorry,
Doctor !
You're not
going to be
able to
continue
your
practice."
Have you ever stopped to consider the effect on
yourself and your family if this were ever to
happen to you? Even when you are covered
with insurance for the medical and hospital bills,
the expenses of day-to-day li\ing can quickly
use up the money it has taken you years of
work to accumulate.
Now, a Disability Income Protection Plan,
especially designed for younger doctors, is avail-
able for members of the North Carolina Medical
Society.
This plan can help see to it that your family's
future will be protected if you should become
sick or hurt and unable to work. Depending
upon the plan you select and qualify for, bene-
fits are available from $600 to $1,200 a month.
These tax-free benefits are yours for use as you
see fit. In addition, benefits are payable whether
you are confined to the hospital or are at home
recovering.
If you are under 55 years of age, just fill out
the coupon below and mail it today. There is
no obligation to learn more about the benefits
of this plan to you.
Mutual^
^mahaVL/
The people who pai/ . . .
Life Insurance Affiliate: United of Omaha
MUTLi4L Of OMAHA I^SUIIA^C^ COMPANY
HOME OFFICt OMAHA. NEBRASKA
Mutual of Omaha Insurance Company
Dodge at 33rd Street
Omaha, Nebraska 68131
/ am interested in learning more about the program of Disability Income Protection available to me.
Name .
Addre^b .
City
Slate
ZIP
r
program will best be accomplished by existing en-
tities in the field. Federal involvement, while in-
escapable when dealing with federal tax dollars,
should be kept minimal.
"We again believe that our Medicredit program
fulfills these objectives in respect to administration
more aptly than does any other proposal to date.
We believe the public, in opinion poll after poll, has
reiterated its high degree of confidence in the medical
profession and its low esteem for bureaucratic ad-
ministration. We believe that there is validity in other
current public opinion polls which indicate that the
chief national concern is over inflation." Dr. Roth
concluded.
After Dr. Roth had read the statement. Chairman
Long said he agreed with the many things the AMA
official had talked about, particularly the concern
regarding wastage of funds that are channeled
through Washington.
Long asked about the merits of a tax credit as
opposed to a payroll tax. Dr. Roth said the tax credit
is the most equitable in that it relies on the federal
income tax which provides an accurate gauge of
family income. The money retained by the individual
for health insurance does not "have to make the
round trip to Washington."
First witness before the Senate Finance Committee
hearing was Health, Education and Welfare Secretary
Casper Weinberger who urged that an NHI bill
"should be the highest priority item in the closin j
months of this Congress." He expressed hope the
the areas of disagreement between competing NH,
proposals would not be found insurmountable. |
The Secretary, however, criticized all of the corti
peting proposals, with special attention to the Mills
Kennedy and the Health Security bill of organize,
labor. "Both vest too much power with the feders
government," Weinberger said.
.At the sometimes stormy meeting. Sen. Vane
Hartke ( D-Ind. ) and Sen. Clifford Hanse
{ R-Wyo. ) chided the Secretary for criticizing th
AM.A plan, pointing out that Medicredit had powei
ful backing.
Sen. Hansen said that when negotiating time ai
rives, strong consideration should be given to th
Medicredit bill which has 182 sponsors, including fiv
members of the Finance Committee and 1 1 membei
of the House Ways and Means Committee.
Hansen said that the Council of Economic Ad-
visors and the Brookings Institute have recommends
that the tax credit method of financing employed b
Medicredit should be used in broad federal program;
Weinberger said he preferred tax credits to a Soci;,
Security payroll tax, but thought general revenue fi
nancing was best. Hansen said controls could imped
productivity and cause personnel to leave the healf
system. j
Sen. Hartke said Medicredit has more sponsor;!
than all other NHI bills combined. Weinberge [
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I
450
Vol, ^5. No,
■jani
Hn
poi
lie
jei
mi
.So
m
imp
m
ijmised to keep that in mind while conferring with
/Hgress. "You are going to have to deal with 182
'us somewhere along the line," Hartke said. "Not
t 'President' Kennedy or 'President' Mills."
jiHartke said that despite Weinberger's criticism of
idicredit the fact is that all NHI bills deal basically
'ch financing, including the Administration's plan
'Lich doesn't provide anything concrete about
anging the system.
Sen. Abraham Ribicoff (D-Conn.) said the .Ad-
nistration was being deceptive about the true costs
its program. He contended that Weinberger is
ling the American people they will have a $55
ilion "free lunch."
"You are dealing with the most complex social
,d economic program in the history of our nation,"
jbicoff said. "If all sides can't agree to work out a
mpromise there will be no program."
Sen. Long added that Americans must be given all
! the facts about exactly what an NHI bill would
[St them, pointing out that he couldn't ". . . sec a
•e lunch in any of them."
Meanwhile, on the House side, the Ways and
i£ans Committee completed the second month of
e-day-a-week hearings on NHI.
It appears that almost every health-related or-
nization in the country wishes to be heard. For
ample, one day's hearing saw the following organi-
tions testify before the powerful House Committee:
ue Cross Association, National Medical Associa-
m, American Osteopathic Society, National Council
Health Services, American Podiatry Association,
tional Council of Community Health Centers,
Ijterans of Foreign Wars, and Americans for Demo-
iatic Action.
Some sparks flew when Andrew Biemiller, direc-
r of the AFL-CIO's Department of Legislation,
peared in place of AFL-CIO president George
eany. Biemiller, in effect, took an all-or-nothing
proach, insisting that, unless a bill similar to the
iginal Kennedy-Griffiths measure is approved, it
buld be better to wait until next year.
'Of major interest to most Capitol Hill watchers
' the fact that House Ways and Means Committee
Vairman Wilbur Mills (D-Ark.), co-sponsor of the
ennedy-Mills proposal, attended only the first
aring.
",
3 Labor's stand drew criticism from committee mem-
rs, some of whom stressed a theme that there is
"ong pressure for Congress to act this year, es-
cially on a catastrophic bill.
I Biemiller said, "If Mills-Kennedy is this commit-
: e's idea of a compromise, then I must say, in all
'J ndor, we will oppose it." Labor's strongest criti-
im came on the Long-Ribicoff bill. "It is not
; itional health insurance, and does not pretend to be.
would be, therefore, a catastrophe if the Congress
J '. acted catastrophic insurance," said Biemiller.
Rep. Omar Burleson (D-Texas) told Biemiller,
"You are not really willing to compromise at all."
He said labor expects a Congress of a "different
nature" next year so that it can get all it wants.
Biemiller replied that the elections of 1964 caused
many people in Congress to change their minds about
Medicare, and resulted in its passage in 1965.
Congressional backers of the Medicredit national
health insurance plan rallied on the floor of the
House of Representatives in early May to praise the
NHI approach developed by the AMA.
A score of speakers rose to urge congressmen and
senators to join them in backing Medicredit, which
has more sponsors (182) than all other NHI pro-
posals combined.
"One reason the legislation has such support in
the Congress is that it is based on some solid princi-
ples which are both realistic and workable," declared
Rep. Omar Burleson ( D-Texas ) .
Rep. Richard Fulton (D-Tenn.), principal co-
sponsor and, like Burleson, a member of the key
House Ways and Means committee, told the House
that "Medicredit's benefits are comprehensive; its
ability to meet our present needs seem unarguable;
its price tag, in terms of new tax dollars, seems to
be within the nation's means; and, the method it pro-
poses for financing the plan appears to me to rest
fairly on the taxpayer without overburdening our
Social Security system."
Rep. Joel Broyhill (R-Va.), chief GOP sponsor
and a high-ranking member of the Ways and Means
panel, said 182 members of Congress "have seen
through the fog of rhetoric and printed word swirling
about national health insurance. They have chosen
Medicredit. I invite more of you to come aboard
in support of a sensible piece of legislation."
Broyhill said Medicredit enjoys two prime virtues
— free choice of health care setting and physician,
and "the American philosophy of voluntarism."
Rep. Tim Lee Carter, M.D., a Kentucky Repub-
lican said no other NHI proposal offers as liberal
a psychiatric benefit as Medicredit.
The American Psychiatric Association had pointed
out that Medicredit stands alone in this regard. "All
other NHI proposals contain some discrimination
that separates treatment of the mentally ill from that
of the physically ill," noted Dr. Carter.
"Medicredit is a workable approach. The medical
profession and the public want a plan that keeps the
federal government's role at a minimum. From the
standpoint of benefits, efficiency, financing, and ac-
ceptability, I am convinced that the Medicredit ap-
proach is by far the best we have before us," Carter
said.
Rep. Jerry Pettis (R-Calif. ), a member of Ways
and Means said his colleagues should consider foreign
national health systems, and he cited the following
cases: (a) In Sweden the per capita health care costs
increased by 614 percent from 1950 to 1966, com-
pared to 174 percent in the United States. Since 1960
LY 1974. NCMJ
451
medical costs in Sweden have increased almost 900
percent, (b) In West Germany there is a serious
maldistribution of medical personnel, (c) Norway re-
ports a shortage of practitioners, (d) Hospital rates
in Canada are higher and length of stay longer than
in the U.S.
Pettis said we had better be very careful about
tinkering with our present system. ""Certainly there is
clear warning in these facts to all of us that wc should
not abandon the strengths of the American system
for the type of health delivery system which has been
developed in some other country," he added.
Rep. Peter Kyros (D-Maine), said Medicredit
■'goes right to the heart of the catastrophic problem.
No matter how large or small a family's income,
its medical expenses would never exceed ten percent
of that income," said Kyros. ""This would be a tre-
mendous reassurance to every family. At the same
time, it offers a fair method — a sliding scale — for
sharing the country's major health costs."
Rep. Robert Michel (R-III.), said Medicredit
■"meets the true test of any workable national health
insurance plan — it provides access to high quality
medical care to all .Americans on the basis of sharing
the cost in an equitable fashion. The poor would pay
nothing. In a fair wa_\'. the better-off would pay on
a sliding scale that reflected their income. Most im-
portantly, this legislation would insure that no
American would have to go bankrupt because of a
catastrophic illness."
The Professional Standards Review Organization
( PSRO ) program is off to '"an incredibly bad start"
and is encountering increasing physician resistance,
the .American Medical .Association has told Congress.
AMA President Russell Roth, M.D,, testifying be-
fore the Senate Finance subcommittee on health,
said that 1 3 state medical societies have formally
declared for repeal of the PSRO law and that 29
societies support a policy of amendment or repeal,
or both (as of May 7, 1974).
"We cannot be precise in numbers, but it seems
evident that, as understanding of the PSRO law
spreads, the resistance to it grows," said Dr. Roth.
The health subcommittee, chaired by Sen. Eugene
Talmadgc (D-Ga.), slated two days of hearings on
the spreading controversy over the PSRO law. '
Dr. Roth said ""The best efforts of the legislator
involved, the staff of the Senate Finance Committee
the staff of the PSRO administrative office in HEW
and physicians from AMA, from assorted state medi
cal societies and specialty medical organizations, hav
not succeeded in creating in the profession the climat
of acceptance and cooperation essential to success
The fault does not lie with the sincerity or intensit
of the effort to cooperate — it lies with the basic in
eptitudes of the statute."
The AVIA President said it has been seriously pro
posed that, because of the bad start on PSRO, i
may be best to fall back, regroup, and start again
The official AMA position, he noted, is that repea
may need to be considered if amendatory patchworl
is unacceptable.
Robert Hunter, M.D., chairman of the AM/
special advisory committee on PSRO and a membe
of the .AM.A board of trustees, described to the sena
tors the .AMA's extensive ""constructive efforts" t(
cooperate with congress and the government to mak^
PSRO work.
Edgar T. Beddingfield, Jr., M.D.. vice chairmai
of the .AMA's council on legislation, said "Th
PSRO law has created a great deal of confusion am
misunderstanding."
""Sections on norms of health care services are pa
tently contradictory, and we anticipate that the ne
result will be that the norms of care will be viewec
as rigid federal minimum requirements. Patients aiK
the profession alike are legitimately concerned wit)
the prospect of cookbook medicine," Dr. Bedding,
field said. He recommended that the ""norms" shouk
be guides for care and should be clearly understooc
as initial points of evaluation and review. ""Further
more," Dr. Beddingfield said, ""such guides must no
be substituted for the medical judgment of individua
physicians in the delivery of health care services."
During the two days of hearings, some 20 medica
associations, state societies, and speciality group;
testified their general misgivings with respect to thi
workability of the statute. Throughout the hearings
Sen. Wallace Bennett (R-Utah), against, at time^
shouting and hostile witnesses, stoutly defendet
PSRO. ""I won't live long enough to see repeal O;
PSRO," he remarked.
452
Vol. }?, No.
5,!
Book Reviews
lii;
li
Current Pediatric Diagnosis and Treatment. By
C. H. Kenipo, M.D., H. K. Silver, M.D., and
Donough O'Brien, M.D. 3rd Edition. 1,020 pages.
Price, $12.00. Los Altos, California: Lanee Medi-
,cal Publishers, 1973.
fTiis book represents a compromise between the
iiprehensiveness of a standard pediatric textbook
;i the briefness of a handbook. By and large, this
{: is completed quite admirably. Especially
liable are the current references in the book, with
liiy subjects being indexed through 1973. The pub-
' Ij tion is quite up to date — a distinct advantage over
's(iie of the traditional textbooks which have a rather
k I gap between the time the books were written
ai' the time they were printed. The tables on drug
tfl'apy, antibiotic therapy, and the interpretation of
bi;hemical values are especially useful.
"he only major disadvantage of the book is the
0! inherent in all such attempts, i.e., it lacks infor-
iriion on the pathophysiology that is essential to the
sidents" understanding. On the other hand, for the
pie, the book is certainly a bargain for the shelf
. o'l family physician, pediatric resident, or practi-
-ti^er.
II Jimmy L. Simon, M.D.
SThe Cardiac Arrhytlimias. By Brendan Phibhs,
, M.D. 205 pages. Price, $7.50. 2nd edition. Saint
Louis: C. V. Mosby Co., 1973.
irhis book is intended not for the cardiologist,
I for the beginning student, nurse, or physician
) is interested in being able to recognize most
iiac arrhythmias.
the Cardiac Arrhythmias is divided into four
ks. Part I is a brief review of basic anatomy and
p-siology. Part II delves into the simple arrhythmias
a :o mechanisms of origin, recognition, and treat-
niit. Part III goes into more complex arrhythmias
iiiuding Digitalis-induced arrhythmias, A-V disso-
c ion, sick sinus syndrome, and arrhythmias seen
in the coronary care unit. Part IV has to do with
drugs, dosages, and indications for use. It also in-
cludes a discussion of pacemakers, defibrillators, and
cardioversion.
In the preface the author states that most scien-
tific writing is needlessly obscure and can be de-
scribed in simple, clear English. He also states that
most writers do not take the trouble to do this. I was
subsequently disappointed to find that the author did
not heed his own advice in many instances, and on
occasion he is quite verbose. Aside from this de-
ficiency and a few poor reproductions of EKG's,
this very nice little book is recommended.
John Edmonds, M.D.
Dentistry and the Allergic Patient. Claude A.
Frazier (ed). 429 paces, with illustrations and
tables. Price, $18.75. Springfield: Charles C.
Thomas, 1973.
This well-documented book contains altogether
3 1 pages of references at the end of the chapters, ten
pages of author index, and 52 pages of subject index.
The 22 contributors have varied and interesting back-
grounds.
Most dentists will agree with the statement that
"it behooves every dentist to become well versed in
allergy"; however, many members of the profession
might be surprised to find x-rays of the maxillary
teeth placed upside down.
This book can be helpful to every member of the
health team — the physician, the dentist, the occupa-
tional therapist, the physical therapist, and all
other providers of health care. When one is aware
of the allergic reactions, he can help the patient by
sharing pertinent information with other members of
the health care team.
Some problems discussed as being peculiar to
members of the dental profession are in reality prob-
lems which are common to all members of society.
D.^viD L. Beavers, D.D.S.
|(f 1974, NCMJ
453
In Mptttortam
Clyde R. Hedrick. M.D.
Clyde R. Hedrick, M.D.. at the age of 73. died
sliortly after admission to Caldwell Memorial Hospi-
tal, Lenoir, North Carolina on December 18, 1973.
Dr. Hedrick was born in High Point, North Carolina
on May 31, 1900, and in his early childhood he
moved to Lenoir with his parents, the late hey Tilton
and Cora R. (Hedrick).
Dr. Hedrick was a graduate of Lenoir High School
and graduated from the University of North Carolina
in Chapel Hill. He received his M.D. degree in 1925
from Georgetown L'niversity Medical Center in
Washington, D. C. He interned at Stuart Circle Hos-
pital in Richmond, Virginia.
He returned to Lenoir and established his medical
practice in 1926 and was in continuous practice since
that time. Through the years Dr. Hedrick made an
indelible contribution to the civic, religious, and
medical aspects of community life in Caldwell
County. Dr. Hedrick served Caldwell County Medical
Society and the State Medical Society in many capaci-
ties including participation on the State Board of
Medical Examiners. In addition to numerous posi-
tions held in the medical field, he was named to the
American Men of Medicine Personalities of the
South. Dr. Hedrick was one of the initial organizers
of Caldwell Memorial Hospital and was the first
Chief of Staff.
I
A week prior to his death, he was named Cal
well County Man of the Year as recipient of tl
L..A. Dysart Award presented by the Lenoir-Caldwi
County Chamber of Commerce.
Dr. Hedrick was a past president of the Lenc'
Kiwanis Club, a member of the North Carolina Hi
torical Society, had been a post commander of t
American Legion, and was a member of the Pythi;
Lodge and Moose Lodge. Some of the early civ
activities he initiated included the organizing of ti
first Lenoir High School football team in 1927 ar
serving as the team physician since that time.
Dr. Hedrick was a member of the Zion Unitlfc
Church of Christ and was a member of the boa
of managers of Nazareth Children's Home. '
He was married to the former Stella .Mae Lamkj
of Selma, Alabama in June, 1929. Surviving ai
his widow, three daughters, one brother, and ni'i
grandchildren. He was preceded in death by tvl
brothers including Dr. Paul E. Hedrick, a Lencj
dentist, and a sister. Burial was in the Blue Ridj
Memorial Park.
Dr. Hedrick contributed greatly to the civic, rejl
gious, and medical affairs of Lenoir and Caldwiil
County. He will be missed by his community and tii,
Caldwell County Medical Society. :,
Caldwell County Medical Society
When any substance Ls detained in the gullet, there are two ways of removing it. either by ex-
tracting it, or pushing it down. The safest and most certain way is to extract Tt; but this is not
always the easiest; it may be more eligible sometimes to thrust it down, especially when the ob-
structing body is of such a nature, that there is no danger from its reception into the stomach.
The substances, which may be pushed down without danger, are all common nourishing ones,
as bread, flesh, fruits, and the like. All indigestible bodies, as cork, wood, bones, pieces of~ metal,
and such-like, ought, if possible, to be extracted, especially if those bodies be sharp pointed, as'
pins, needles, fish-bones, bits of glass, etc. — William Biuhan: Domestic Medicine, or a Treatise
on the Prevention and Cure of Diseases h\ Regimen and Simple \tedicincs. etc.. Richard Fol-
well. 17 W, p. 4117.
454
Vol. 35, N >.
\
t
JORTH CAROLINA
Medical Journal
THIS ISSUE: The President's Address: Shoals Ahead, Frank R. Reynolds, M.D.; Certain Ethical Aspects of Biomedical
esearch: Evolution of Concepts of Ethical Standards, James F. Toole, M.D., LL.B.; Reimplantation of Extremities by
^crovascular Suture, James G. Boyes, Jr., M.D.
Simple, accurate test for glycosuria
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Bolh often
Predominant
• psychoneurotic
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Associated
• depressive
symptoms
Before prescribing, please consult com-
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Indications: Tension and anxiety states;
somatic complaints wliich are concomi-
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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 frequeni
and/ or severity of grand mal seizures m;
require increased dosage of standard an'
convulsant medication; abrupt withdraw,
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) hav'
occurred following abrupt discontinuanc
(convulsions, tremor, abdominal and mu
cle cramps, vomiting and sweating). Kee
addiction-prone individuals under carefu
' I'm sorry,
Doctor !
You're not
going to be
able to
continue
your
practice."
Have you ever stopped to consider the effect on
yourself and your family if this were ever to
happen to you? Even when you are covered
with insurance for the medical and hospital bills,
the expenses of day-to-day living can quickly
use up the money it has taken you years of
work to accumulate.
Now, a Disability Income Protection Plan,
especially designed for younger doctors, is avail-
able for members of the North Carolina Medical
Society.
This plan can help see to it that your family's
future will be protected if you should become
sick or hurt and unable to work. Depending
upon the plan you select and qualify for, bene-
fits are available from $600 to $1,200 a month.
These tax-free benefits are yours for use as you
see fit. In addition, benefits are payable whether
you are confined to the hospital or are at home
recovering.
If you are under 55 years of age, just fill out
the coupon below and mail it today. There is
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Name
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City
State .
ZIP
EDITORIAL BOARD
Robert W. Prichard. M.D.
Winston-Salem
EDITOR
John S, Rhodes, M.D.
Raleigh
ASSOCIATE EDITOR
Ms. Martha van Noppen
Winston-Salem
ACTING ASSISTANT EDITOR
Mr. William N. Milliard
Raleigh
BUSINESS MANAGER
W. McN. Nicholson, M.D.
Durham
CHAIRNT\N
Louis deS. Shaffner. M.D.
Winston-Salem
Rose Pully. M.D.
Kinston
George Johnson. Jr.. .\LD.
Chapel Hill
Charles W. Styron, M.D.
Raleigh
NORTH CAROLINA MEDICAL JOUR-
NAL, 300 S. Hawthorne Rd., Winston-Salem,
N. C. 27103. is owned and published by The
North Carolina Medical Society under the di-
rection of its Editorial Board. C^opynght (c;
the North Carolina Medical Society 1174.
Address manuscripts and communications re-
t^ardinfz editorial matter to this W'lnston-
Salem address. Questions relating to sub-
scription rates, advertising, etc, should be
addressed to the Business Manager. Box
27167, Raleigh. N. C. 27611. All adver-
lisements are accepted subject to the ap-
proval of a screening committee of the State
Medical Journal Advertising Bureau. 711
South Blvd.. Oak Park. Illinois 60302 and or
b> a Committee of the Editorial Board
of the North Carolina Medical Journal
in respect to strictly local advertising. In-
structions to authors appear in the January
and Julv issues. Annual Subscription. S?-00.
Single copies. SI. 00. Publication office:
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Raleigh. N. C. 27611. St-cnrHl-clj-ii postage
I'lmt tit Raleii^h. Sorth Curnhnti 27611.
NORTH CAROLIN/
MEDICAL JOURNAl
Published Monthly as the Official Organ c
The North Carolin
Medical Societ
August 1974, Vol. 35, No.
Original Articles
The President's .\ddress: Shoals Ahead 46
Frank R. Reynolds. M.D.
Certain Ethical .\spects of Biomedical Research:
Evolution of Concepts of Ethical Standards 47
James F. Toole, M.D.. LL.B.
Reimplantation of Extremities by Microvascular Suture 47.
James G. Boyes. Jr.. M.D.
Editorial
Medical Evaluation for Driver Licensing 48
Emergency Medical Services
Organizing and Establishing a Rural Emergency
Medical System 48
Bond L. Bible, Ph.D.
Abstracted by George Johnson. Jr., M.D.
iv
Oi
Committees & Organizations
Committee on Medical Education.
4f b:
Bulletin Board
New Members of the State Society 45
What? When? Where' 4' ■
News Notes from the University of North Carolina
Division of Health Affairs 4f
News Notes from the Duke University Medical Center 4S ^
News Notes from the Bowman Gray School of Medicine of
Wake Forest University - 5(f^
.American College of Obstetricians and Gynecologists 51 .'
North Carolina Heart .Association Sit
News Note 5( ■*
Month in Washington 5(
!:
Book Reviews 5(
In Memoriam 5(
Classified .Ads ^1
Inde.x to .Advertisers
Contents listed in Current Contents Clinical Practice
The President's Address
Shoals Ahead
Frank R. Reynolds, M.D.
i
t
igives me a great sense of humility and pride to
ave been chosen to serve as your President for
u :oming year. One should never forget, however,
^''honors never fail to bring responsibility, and we
ai'ot accept one without having placed on us the
tl •. At a time such as this, one has an acute
;e ig of personal inadequacy in confronting the
u erous. complex issues that lie ahead, since they
it inly have no simple, immediate solution. Public
It est in quality medical care has never been
r{ er, and perhaps never less understood by the ma-
tt ' of the people to whom it is being administered.
p alphabet game has reached a new high with
;t.s like PSRO, CHP, RMP, HEW, SSA, NHl,
I , CPT, Q.\P, CHIP, and an occasionally mut-
;| SOB at every medical meeting. Obviously, one
a quickly learn the new language if he is to un-
dr and the game.
aave spent the past year taking numerous trips
read the state and nation, attempting to prepare
)r he coming year as your President. One cannot
el being impressed by the quality of the meetings
3( sored by the AMA, as well as the efficiency
f ; staff and the tremendous knowledge and ability
f officers.
: ice I am from the coastal area, permit me to
sc jme nautical terminology to describe our voyage
)r le coming year. I will try to point out "shoals"
la lie ahead, and I will enlarge upon what I feel
■il le of greatest interest to us individually and col-
■c ely.
R before the Second General Session. North Carolina Medical
)C . Pinehursl. North Carolina. May 22. 1974.
R int requests to Dr. Reynolds. 161.^ Dock Street. Wilminjiton.
or Tarolina 28401.
Ui ;t 1974. NCMJ
FIRST SHOAL: ACCESS TO
APPROPRIATE MEDICAL CARE
There is no doubt in anyone's mind that we in
the United States have the best system of medical
care in the world — the private practice, fee-for-
service system. However, I am sure that all of you
can remember times when people needing our ser-
vices had difficulty gaining access into our system,
usually because they had a lack of knowledge con-
cerning the system. If a patient is moving from one
city to another and has the foresight to obtain a letter
of referral to another physician, then he usually has
no difficulty in obtaining the needed continuing
medical services. The referring physician can see that
the family receives the type of medical care that is
needed, or it might be said that the patient is re-
ferred "into the system." However, if a family moves
into a new community without physician contacts and
suddenly seeks to obtain the services of a physician,
it can be very time-consuming, or even impossible.
Dollars are not the primary deterrent to access to
appropriate health care. Ignorance of the system is
the deterrent. In large cities, and in most large coun-
ties, there is a hospital emergency room where care
can be received; however, the availability of emer-
gency care does not gain the patient access into the
system unless the physician on call agrees to furnish
continuing care for the family. Each medical society
needs to make available information that will allow
newly relocated families to gain access to a primary
care physician.
I also predict much wider use of the hospital emer-
gency room for nonemergency care and increased
use of continuous physician coverage in our emer-
gency rooms. As far as the public is concerned.
469
('
they use the emergency room for after-hours illnesses
or injury because that is the only place they know
to go. Whether or not we feel that the service is
being abused, this practice continues to grow in
North Carolina. There were more than 1.5 million
visits to emergency rooms in our state last year. One
must admit that this is an expensive type of care,
but the cost does not seem to cool the demand.
Another trend in medical practice is toward the re-
gionalization of maternal and infant care as a prac-
tical, and reasonably obtainable, method for the re-
duction of perinatal mortality and morbidity. North
Carolina ranks approximately fortieth in perinatal
mortality. Therefore, the governor's task force for
maternal and infant care, chaired by Dr. George
Brumley, has recommended the regionalization ap-
proach.'
SECOND SHO.\L: PHYSICIAN SHORTAGE
Our Society has long recognized the physician
shortage in North Carolina. In May 1971. the House
of Delegates passed the Lincoln County Medical
Society's resolution asking the North Carolina Medi-
cal Society to undertake a study to determine the
number of additional medical students needed. The
resolution called for another study to determine the
most economical and efficient way to educate these
students.
President Styron requested the North Carolina
Joint Conference Committee on Medical Care to
undertake these studies. To implement this monu-
mental request, a subcommittee of the Joint Con-
ference Committee was established, with Dr. John
Glasson as Chairman. After extensive in-depth
studies for a period of more than a year, the final
report was presented to the House of Delegates in
May 1973, and their recommendations were passed.
Their recommendation to utilize the present four-
year medical schools and increase both the number
of medical students and the percentage of North
Carolinians was most timely. I predict that the in-
creasing emphasis on training primar\' care physi-
cians and the increasing number of North Carolinians
staying home to practice will alleviate, within the next
few years, the acute physician shortage; however,
the distribution of these physicians continues to be
another problem. Since the State Legislature, in its
wisdom, has elected to increase the number of medi-
cal students at East Carolina, I can assure them that
they will be welcomed into the system with open
arms.
The shortage of primary care physicians and their
maldistribution has been studied in-depth by Dr.
Kemp Jones and his Committee on Community
Medical Care.- I recommend strongly that everyone
read their report, "Need for More and Better Dis-
tributed Primary Care Physicians in North Carolina."
in the .April 1974 issue of the North C.arolina
Medical Journal. I feel certain that many of their
recommendations will be followed in the coming
years and that we will see continued improvement ii
the distribution of primary care physicians in otij
state.
EDDIES: CONTIMNUING MEDICAL
EDUCATION
The 1973 House of Delegates adopted a resolutio
making continued education a requirement for men
bership in the North Carolina Medical Society. Th
will drastically change the pattern of living for soi]
of our members, but I feel that the majority are
ing a good job in keeping themselves up-to-dat
It has been said that medical information doubli
every eight to ten years, so you can see the task \»
have ahead of us. Many physicians think that tl
definition of continuing education is a "deductib
trip to San Francisco" — but this idea will have i
change. The Committee on Continuing Education hi
recommended that a minimum of fifty hours of coi
tinuing medical education each year be required i
each member of the State Society, and that wide lal
tude be allowed in the manner in which the requirf
time is spent. Attendance at scientific meetings, pari
cipation in clinical conferences, and perusal of tl
scientific literature are worthwhile forms of coi i
tinuing education, and credit will be given for times
spent. Each physician will be asked to keep and sul
mit records which will enable him to certify eve
third year that he has met the minimum requiremei
of 150 hours. A form for certifying compliano
will be included with the annual notice of dues se:
to each member.
Continuing education has to be aimed at the in
dividual physician, for his individual deficiency at;
needs. If it is to be acceptable, good continuing edij
cation must ensure better patient care. Ten statei
including Alabama, have already instigated this r^
quirement. Most of the uneasiness among physiciail
that arises when this subject is discussed comes fro
fear of reexamination or relicensure, which certain
is not contemplated. In those states that require co j
tinued education, the quality of the programs ai
the attendance at the state meetings has improvej
Maybe our meetings could use just such a "shot
the arm." As we all know, medical education is
hfetime job, and physicians should be gi\en fi
credit for all the "keeping up" they have done
the past, as well as for the high quality of care th
is presentK being rendered in our state.
PSRO: TROLIBLFI) \V,\TERS
.As all of our members must know, with the co
tiniious pounding of President George Gilbert, Pu
lie Law 92-603 was signed into law by Preside
Nixon on October 30, 1972. This law requires ar
view of every hospital and nursing home patient wl
comes under the Medicaid or Medicare program, ai
to accomplish this, professional standard review 0
ganizations (PSRO) must be established in eve
state. This re\iew is to have three parameters —
47(1
Vol. .^-V No-
Dr. Frank R. Reynolds
iS it medically necessary? (2) was it given at the
propriate level of care? and, (3) was it of such
ality as to meet professionally organized standards?
North Carolina there are eight designated areas,
eight separate organizations must be formed. The
[73 House of Delegates, by adopting the report of
: Executive Council which established the North
rolina Peer Review Foundation, Inc., went on
; ord as approving professional standard review in
ir state. The state PSRO organization is actively
licating our membership concerning the law. It is
lO conducting an ongoing review of the Medicaid
lients in skilled nursing homes and in psychiatric
i TBC hospitals within the state, under a contract
\ h the Slate Department of Human Resources. It
[ ; also applied to become a medical resource center
help other PSROs become functional in North
rolina. I feel that our membership will cooperate
^h this program, since it is the law of the land;
we do not cooperate, lay personnel will be con-
L'ting the so-called peer review. If this is a bad
j', as our colleagues predict, then it will fail on
own merits and not because there was no coopera-
ji by the medical profession. One bright hope is
t if effective organized utilization review is being
d le (as is presently being carried out in most of the
h pitals in the state), then their results can be ac-
c ted by the PSRO organization. If you do not have
e ,'ctive peer review in your hospitals, it would be in
y nr best interest to see that it is set up.
One difficulty seems to be that the government is
it -rested primarily in cost curtailment, whereas we
ii the medical profession are interested in quality
a';ssment. As you know, this subject is creating
n,ch controversy in the AMA.
HIGHWAY SAFETY: CALMER SEAS
highway safety in North Carolina has always been
iparamount importance to our Society. Our old
inmittee Advisory to the Department of Motor
nicies had been changed to the Committee on
ffie Safety; it has worked closely with the State
¥. hvvay Department and the Legislature in promot-
ir laws for improved highway safety. Passage by the
I 4 Legislature of Senate Bill 89, making a blood
aJihol level of 0.10 percent, or above, prima facie
c' lence of driving under the influence, is a great
si ' toward improving highway safely. This bill was
ai vely supported by our Committee, which also
SI Dorted mandatory seat belt legislation. Wc all
k w that the drinking driver (not those who break
th speed limit) is the greatest menace on our high-
w s today, causing more than fifty percent of all
h: iway accidents. This law should go a long way in
gi ing the drinking driver off the road.
NATIONAL HEALTH INSURANCE:
! TURBULENT SEAS
Ve should watch closely, in the coming year, any
le .lation promoting national health insurance. This
seems to be a popular subject at present — since this
is a year of congressional elections, everyone is jump-
ing to get aboard the bandwagon. President Nixon
has already announced his comprehensive health in-
surance program, financed by mandated employer
health insurance plans for the employees. Repre-
sentative Wilbur Mills has joined forces with Senator
Ted Kennedy promoting the Kennedy-Mills Health
Insurance bill, financed by a massive four percent
increase in the Social Security tax and administered
by Social Security as a virtually independent agency.
1 do not need to tell you that politics makes strange
bedfellows. This would take a major step down the
road toward complete federal financing and control
of all health care in the United States. All of these
bills plan to build upon or utilize the previously dis-
cussed PSRO concept.
As of now, the AMA-sponsored Medicredit bill
seems to be the least objectionable one. We should
join in support of this legislation. It appears to be
certain that some form of catastrophic insurance
will pass; if we are fortunate, since this is a mother-
hood type bill (wedded motherhood, that is). Con-
gress will stop at this. However, the climate seems
right for some type of national health insurance
bill. Also, needless to say, this will be quite a busy
year on the political front in Washington. It would
behoove our membership to keep current on this sub-
ject and to support MEDPAC 100 percent.
VIEW FROIVI THE CAPTAINS DECK
Many other concerns will arise but suffice it to say
that I have brought up enough subjects for you to
mull over in the coming months; I feel certain that
you will have some timely suggestions for OLir fall
Committee Conclave.
I do not want to leave you with the idea that
all is dark on the horizon and that there are only
turbulent waters, because this is certainly not so.
My good friend, the late Dr. J. Buren Sidbury of
Wilmington, the last pediatrician to be president of
our Society, spoke in his 1940 presidential address
of the swift approach of socialized medicine. As you
can lell from my previous remarks, we are still on
the same subject ihirly-four years later!^'
We in medicine today have more going for us than
any other profession. You have heard our AMA
President, Dr. Russell Roth, slate repeatedly that
"more people are receiving more and better medical
care from more and better trained physicians in more
and better equipped facilities than ever before in his-
tory."^
I feel that our prestige continues at the top of the
professions. The AM.A, through its aggressive leader-
ship in fighting the administralion and the Cost of
Living Council, is held in higher esteem by its mem-
bers than ever before. Our Slate Society, through its
eonlinued. sound progressive leadership — its dedi-
cated executive director and staff — continues to hold
a position of en\'ious esteem among the leaders of
A jsT 1974. NCMJ
47.^
our state. As Society officers, commissioners and
committee members, more physicians are working
harder for organized medicine in North CaroHna than
ever before. My plea to you is to continue the good
work, because this is yuiir Society. 1 pledge to you
that in the coming year 1 will do everything in my
power to continue to maintain our Society as one
in which you can be justifiably proud.
I conclude my message by quoting a paragraph
from the late Daddy Ross's 1968 address: "This is
a time when the productivity and the complexity of
our Societv is so enormous that it defies accurate
analysis. The only possible course is to hold on ti
that which is good, of proven fundamental soundncs
and to try to build in the light of sane study of th
past and sane flexibility of the future."''
References
1 Report ol the Task Force on Maternal Intanl Care ol ih
Go\ernor"s CouHLil on Comprehensive Health Planning. Apr
1973.
2- Need tor more and better distributed primary care physiciar
in North Carolina. Committee on tiommunit^ .Medical Can
NC Med J 35;2.'4-:37, 1974.
,3. SitJburv JB; The doctor and socialized medicine. NC Med J I
1-K. 1940
4. A \tA ,Vc« 1. .April 29, 1974.
5. Ross RA: President's farewell addn-ss. NC Med J 29; 233-231
196K.
Tcmpc'i anient: A peculiar habit of body, of \\hlch there are generally reckoned four, viz. the
sanguine, the bilious, the melancholic, and the phlegmatic. — William Biicliiiii: Doiucslic Medi-
cine. Ill a Tic-iilisf nil rlic Pievciilion and Cure of Diseases hv Re;^iiiiien and Simple Meilieines.
etc.. Richard Folnell. I79Q p. 475.
474
Vol. 3.*;, No. , s.r
Certain Ethical Aspects of Biomedical Research:
Evolution of Concepts of Ethical Standards
James F. Toole, M.D., LL.B.*
'"•HERAPEUTICS, 5,000 years
of discovery by trial and error
d 200 years of increasing use of
; scientific method, is in my
linion humanity's most important
complishment.'-' Despite this suc-
:;s, the public has maintained
ambivalent attitude toward medi-
e. In particular, investigators, the
■y group who have made these ad-
ices, are associated with a Jekyll
j Hyde image which hardly en-
iders trust.
Why has this happened? Perhaps
;ause patients and their families,
their search for cures of diseases,
xed supersitition, tradition, magic,
■r, and religious belief with their
Wication. Only in the past 50
iirs have generous portions of sci-
:ific medicine been added to the
\ture. Disease, once accepted as
will of God. has been shown to
the result of identifiable natural
Kcsses and thus, in many cases,
able. This understanding has
nc about because innovators and
5erimentalists have educated prac-
oners and they, in turn, have edu-
ed society. But understanding has
noved the mystery, the art has be-
onusT 1974. NCMJ
rom the DepartiriL-m of Neurology, the
/man Gray School of Medicine of Wake
est University. Winston-Salem, North Caro-
2710.V
The \\aller C. Teagle Professor of Neu-
gy. Chairman of the Department of Neu-
'gy.
ead before the Association of American
lical Colleges, Council of Academic Societies
liram. November 5, iy73
come a craft, the awe has been lost,
and the public is making ever in-
creasing demands upon its physi-
cians. Consequently, the physician,
traditionally one of the most re-
spected leaders of society, has lost
much of his status.
What does this preamble ha\e to
do with the ethics of human experi-
mentation? Just this: as long as di-
sease processes are not understood,
and as long as there is mystery and
fear, physicians can do as they wish,
and the distinction between treat-
ment and experimentation need not
be made. Furthermore, if no treat-
ment is effective, depending upon
the severity of the illness, anything
may be worth a try. I am certain that
this risk-taking was once accepted by
the public; nevertheless, from time
immemorial, the insestigator has
faced an enormous risk when he has
tried a new technique. For example,
the first codification of principles of
medical practice was that of Ham-
murabi, a statement of rules and
regulations governing medical prac-
tice in Babylon. This 4,000-year-old
precursor of NIH guidelines was
probably necessitated by the \iola-
tion of ethical standards. Whether
these stone-etched engravings on a
temple pillar were a federal response
to public pressure will never be
known, but one can be certain that
the practitioners of the time were
rendered far more conservative
when the penalty for infringement
became amputation of the hand.
This federal regulation can be
contrasted to the self-regulation of
the Hellenic tradition, wherein each
physician vowed to the gods, "I
will follow that system of regimen
which according to my ability and
judgment I consider for the benefit
of my patients and abstain from
whatever is deleterious and mischie-
vous." For 23 centuries this oath has
been the ethical creed of the medical
profession, embodying ideals of ser-
vice to the patient and emphasizing
the healing power of nature.
Nevertheless, Hippocrates per-
formed research as an incidental
part of treatment, certainly without
informed consent, and surely not to
the benefit of his patient when, in
the course of treating a head wound,
he repeatedly scratched the cerebral
corte.x with his fingernail, causing
contralateral focal motor seizures.
For humanity and science he dem-
onstrated the cross-relationship be-
tween hemisphere and body, and he
showed that convulsive movements
originate from the central nervous
system. For Hippocrates' patient, the
inducement of seizures was, no
doubt, a meddlesome maneuver
which would be frowned upon by an
intramural research committee of to-
day. Yet, countless observations
475
r
such as this, unrecorded and passed
from teacher to pupil, have pro-
duced the lore of medicine. This trial
and error accumulation of knowl-
edge constitutes the core of rational
medical knowledge which we use to-
day.
In addition to the fortuitous accu-
mulation of medical knowledge, we
have been handed down results of
experimentation; an outstanding ex-
ample is the work of Edward Jen-
ner.^ In the eighteenth century,
2,000 people in London died an-
nually of smallpox. Because Jen-
ner rigorously adhered to the ex-
perimental method, he pro\ed that
he could prevent smallpox. His pub-
lished results spread the news and
his discovery saved millions of lives.
Even though the benefits far ex-
ceeded the risks, a committee on
human experimentation today would
question Jenner's prudence in ex-
perimenting with diseases in chil-
dren, one of whom was his own;
1 doubt that any man living in the
eighteenth century would have done
so. Are we creating a climate in
which future Jenners cannot de-
\elop''
In contrast to Jenner"s approach.
Beaumont'' never planned to do re-
search. Yet this surgeon, stationed
at an outlying army post, converted
a patient's tragedy into an un-
equaled experimental opportunity
He assumed risk by de\'iating from
the norms set by the arms . .Although
he was not an academician and his
work was not performed in a uni-
versity setting, his observations
opened a new vista in human phy-
siolog\. In the course of his studies
on Alexis St. Martin, Beaumont for-
mulated the first American code of
ethics, although personal, for human
experimentation. Although he was
a member of the regular army (gen-
erallv a conservative group) Beau-
mont proposed: (1) that areas of
medicine in which human experi-
mentation is necessary and in which
the information cannot otherwise be
obtained must be recognized, and
( 2 ) that the subject's \oluntary con-
sent is necessary. With regard to the
second criterion, Beaumont bound
St. Martin with a contractual ar-
rangement and had him recruited
into the United States Army for one
year to:
serve, abide and continue with the said
WiUiam Beaumont, wherever he shall go
or travel or reside in any part of the
world his covenant servant and diligently
and faithfully, etc that he, the said
Alexis, will at all times during said term
when thereto directed or required by said
William, submit to assist and promote
by all means in his power such philoso-
phical or medical experiments as the said
William shall direct or cause to be made
on or in the stomach of him, the said
Alexis, either through and by means of
the aperture or opening thereto in the side
of him, the said .Alexis, or otherwise,
and will obey, suffer and comply with
all reasonable and proper orders of or
experiments of the said William in rela-
tion thereto ;ind in relation to the ex-
hibiting and showing of his said stomach
and the powers and properties thereto
and of the appurtenances and the powers,
properties and situation and state of the
contents thereof. The agreement was that
he should be paid his board and lodging
and SI 50 for the year.
By today's standards such a contract
would probably be illegal, and in
any case, unethical.
Walter Reed, working with the
sanction of the Surgeon General of
the United States .Army, found the
cause and the means for the preven-
tion of yellow fever by giving to
military volunteers injections of
blood from patients who had this
disease. Today his methods would
not be tolerated by a human experi-
mentation committee, because he
took risks with the lives of healthy
volunteers. Yet, he received the
commendation of the President and
Congress for his success.''
I mention these several milestones
in successful human experimenta-
tion, not to participate in historical
revisionism a la Soviet, but to de-
\elop an historical perspective for
the changing concepts of the ethics
of human experimentation and to set
the stage for the subject of the fol-
lowing discussion — a need for
heightened public awareness of the
necessity for human experimentation
and for a societal acceptance that
some risk to individuals is neces-
sarily concomitant.
In a discussion of the ethics of
htmian investigation, it is popular to
raise the specter of the German phy-
sicians who, under the Nazi regime,
performed experiments on unwilling
subjects.' However, the conduct of
past and present biomedical investi-
gations in Germany and in this coun-
try are not comparable in any wa\.
The German physicians' expen-
ments were, in essence, unethical be-
cause unwilling subjects were ex-
posed to high-risk investigations
which, in some instances, were uni-
formly fatal. State-employed physi-
cians worked at the direction of the
German government. Their experi-
ments were designed to accumulate
information relevant to the German
effort. They reported many of the;
results of experiments at German •-
medical meetings where no ethicaji si-
objections from the profession were i'
raised. As defendants at Nurem-i:!
berg'' they used the following argu-, ;a
ments ; ' E
1. They worked under orders of s
the state. -r.
2. They worked as a part of a to-.aii
tal war effort wherein the benefit to: !e
society outweighed the harm to con- ai:
denined individuals. L
3. Their work was approved byli;
the community of German physi-i;
cians and was therefore the ethical'
norm.
4. Clinical investigators around';
the world had used captive popula-
tions as unwilling or unknowing sub-
jects for research and had published
their results without censure. ( In the:
United States the work of Gold-
berger'-' of the United States Publicu::.
Health Service on pellagra, alteringii:.
diets in prisons and orphanages, was
placed in this category. )
Each of these arguments was con-
sidered and rejected by the Nurem-
berg tribunal, the upshot being that
medicine has a worldwide ethic not '
limited by national boundaries. This,
proposal was codified at Helsinki.
Finland, by the World Medical .As-
sociation, and it has been endorsed
by most members of the Commtinit)
of Nations. All United States invesii-
gators work within the bounds ol
this code and those of the .American ■
Medical .Association,'" and more
recently in U.S.P.H.S. guidelines."
Why. with all of these safeguards, ]■
has society chosen to cast its eyen-
upon clinical research'.' The reasons
involve sexeral factors: (1 ) the tax-
pavers' support of our clinical re-
search. (2) the interest in civilit;
rights, from which has developed the
patients' bill of rights, (3) the prin-
476
■Vol. .15, No.
tple of a right to health, (4) our
lilure at times to maintain the most
tacting standards for the conduct
if human experimentation, and (5)
jjr own lack of awareness that there
■ a problem. For example, of 100,-
sDO articles indexed in medical jour-
nals in 1950, none addressed them-
j^lves to the ethics of human experi-
[(lentation, and in 1969 there were
Bily 32 articles, of which most dealt
lith organ transplantation or brain
^;ath. Yet at the same time, ethi-
:sts, sociologists, jurists, theolo-
ijans and philosophers were becom-
g interested in the field, and with
creasing influence they were begin-
:ng to publish thier views. '-'^ Over
ie years their voices have become
jminant; with the exceptions of
watz" and Beecher,'" the medical
ipmmunity has, by and large, re-
Oi jiained mute.
Let me illustrate. Today, nearly
II clinical research is carried out in
Be teaching hospital environment.
Mciety perceives that, in this envi-
inment, too much emphasis has
ijen placed on science rather than
Si excellence and the delivery of
i'Te. Furthermore, in the "publish
perish" ambiance, the clinician
pay be under pressure to experi-
Ijent and therefore may have con-
( cting goals. Although medical
3 ihools can be proud of their record
«: scientific leadership, their lack of
adership in the development of
ontrols for safeguarding human
(fbjects, and for assuring that
ijerapy is not subverted for research
inrposes, has led to our present pre-
Jlcament.
(•'A remarkable aspect of the cur-
I'lnt interest in ethical guidelines is
«at clinical investigators generally
not accept that regulation is
Seded. The pressure from the pub-
to define ethical guidelines for
man experimentation is expressed
trough the media''"'" and more
Icently by the Congress."*
)'iThis trend was first identified, but
5orly expressed, by medical practi-
Oiners who muttered about re-
•archers' admitting patients to uni-
ksity hospitals, not for the treat-
fint of the patient's disease, but for
ook at his "interesting problem."
rtients were minimally aware that
they were being used for experimen-
tal purposes; many such patients had
a naive trust that physicians would
serve them in the best way they knew
how, and others who were charity
patients had no alternative to sub-
mitting to experimental procedures.
Owing to the rise of the civil rights
movement, the advent of Medicare,
and particularly the increasing so-
phistication of patients regarding
good medical practice, society is de-
manding involvement in the deci-
sions regarding human experimenta-
tion. Some members of society as-
sert that biomedical research is too
important a responsibility to be
given to only the physicians, just as
war is too important a responsibility
to be given to only the military.
Society's demand for involvement
in these decisions is embodied in the
Congressional hearings which have
been held since 1971, and in the bills
now pending. One of the bills, HR
10403 (and parts of 7724), pro-
poses to create a commission of lay-
men and clinical investigators to de-
vise guidelines for human experi-
mentation. These guidelines, of
course, would become legislated
ethics if the bill were enacted. This
bill represents a departure from the
norm, positively suggesting an in-
creasing sense of societal responsi-
bility and, at its worst, bureaucratic
restriction of new ideas. It capital-
izes, as we in clinical research should
have been doing, upon the wide-
spread public interest in the selection
of donors for cardiac transplanta-
tions; the studies on syphilis which
were conducted on Alabama
Negroes; the submission of the men-
tally retarded and prisoners, by
their custodians, to experimentation;
and. the possible effects of psycho-
surgery on society.
An unexpected aspect of this in-
terest is that the Congress had in-
corporated into its bill directives that
may prohibit the performance of
certain brain operations. Thus, for
the first time, we would have regula-
tions which prohibit a specific cate-
gory of research and treatment, in-
serting the political element into
what has heretofore been a medical
responsibility.
Of course, surgical psychiatry has
been practiced since the 1940s, and
the Nobel Prize was awarded in
1949 to Egas Moniz,''' a neurolo-
gist, for his research in the use of
frontal lobotomy for psychotic
states.-" Behavioral control by
medication is a daily occurrence
practiced by every physician who
dispenses psychotropic agents. Cur-
rent interest in the matter relates
primarily to the control of socio-
pathic and psychotic behavior, and
the public is questioning the justifi-
cation for these procedures. An un-
expressed aspect of this doubt is a
direct outgrowth of the Soviet's use
of insane asylums for the incarcera-
tion of political dissidents. This is
the fear — that psychosurgical tech-
niques could be manipulated for po-
litical ends; that is, if one does not
agree with our political philosophy,
the state could employ its physicians
to alter one's brain in such a way
that there would be no alternative.
The Congressional demand for
regulation of research is based upon
conflict between two competing in-
terests: the improvement of medical
care and prevention of disease, and
the protection of the rights of the in-
dividual. We investigators know that
both aims are essential to medical
progress. The public must be shown
that they are not necessarily mu-
tually exclusive, although they may
well prove to be so if legislation is
passed without the benefit of
thoughtful input from the medical
and scientific community. I would
advise you to make yourselves fami-
liar with the pending bills and to
consider carefully their long-term ef-
fects on biomedical research; act
through your specialty societies and
the Association of American Medi-
cal Colleges and the American
Medical Association to ensure that
appropriate safeguards for the pub-
lic, which will not jeopardize our
proud record of scientific achieve-
ment, are enacted into law.
References
1. CnLincil fnr International Organizations of
Medical Sciences with the assistance of
WHO and UNESCO: Medical research;
priorities and responsibilities. Proceedings
of a Round Table Conference. Geneva. Oc-
tober 1969, Geneva: World Health Organi-
zation, 1970.
2. Gregg A: The Furtherance of Medical Re-
search, New Haven: Yale University Press.
1941.
3. Lyght CE (ed): Reflections on research
and the future of medicine; a symp>osium
GUST 1974, NCMJ
477
and other addresses. New York: McGraw-
Hill 1967.
4. Jenner E: An Inquiry into the Causes and
Effects of the Vanolae Vacinnae. a Disease
Discovered in Some of the Western Coun-
ties of England. Particularly Gloucestershire,
and Known by the Name of the Cow Pox.
(facsimile of the original edition, London:
Sampson Low. 1798.) London: Dawsons of
Pall Mall. 1966.
5. Beaumont W: Experiments and Observations
on the Gastric Juice and the Physiology of
Digestion, (facsimile of the original edition
of 1S33, together wiih a biographical essay,
A Pioneer American Phvsiologist. bv Sir
Wiliiam Osier.) New York: Dover. 1959
6. Yellow Fever. Document S22. 61st Congress.
January 27. 1911, United Slates Government
Pnntm^; Office.
7. Katz J: Experimentation with Human Be-
ings; the Authority of the Investigator.
Subject. Professions, and State in the Human
Experimenlaijon Process. New York: Russell
Sage Foundation, 1972.
8. Nuremberg Military Tribunals. Trials of
War Criminals. Vol. II. United States Gov-
ernment Printing Office. 19?0.
9. Goldberger J. Tanner WF: A Study of the
Treatment and Prevention of Pellagra. Pub-
lic Health Reports. Vol. 39. No. 3. pp 87-99.
United States Government Printine Office,
1924.
10 Beecher HK: Research and the Individual;
Human Studies. Boston: Little Brown &. Co.
1970.
11 Department of Health. Education and Wel-
fare: Grants Administration Manual, Part
1. Ch 40, HEW TN 71.6. April 15, 1971-
United States Government Prtniinfi Office.
12, Barber B Lally JJ. Makarushka JL, Sullivan
D: Research on Human Subjects; Problems
of Social Control in Medical Experimenta-
tion. New York: Russell Sage Foundation,
1973.
13, Ladimer I. Newman RW (eds): Clinical In-
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Moral Aspects; An Anthology and Bib-
liography. Boston : Law-Medicine Research
Institute. Boston University, 1963
14, American Academy of Arts and Sciences:
Ethical Aspects of Experimentation with Hu-
man Subjects. Daedalus. Proceedings of the
American Academv of Arts and Sciences,
Vol. 98. No, 2. American Academy of Arts
and Sciences, spring, 1969.
15. Pappworth MH: Human Guinea Pigs; Ex-
perimentation on Man. London: Routledge
and Kegan Paul. 1967.
16. Thompson T; The vear they changed hearts,
Liie. 71:56-70, 1971. (excerpt from Hearts.
McCall Books. 1971).
17. Tuskegee Syphilis Study Ad Hoc Advisory
Panel: Final Report. United Stales Govern-
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18. United States Senate. Committee on Labor
and Pubbc Welfare: Quality of health care-
human experimentation. 1973, part 2. hear-
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93rd Coneress. United States Government
Printing Office. 1973.
19. Sourkes TL: Nobel Prize Winners in Medi-
cine and Physiology. 1901-1965. (Revision
of earlier work by Stevenson LG ) . pp 270-
277. London: Abclard-Schuman. 1967.
20. Lailinen LV, Livingston KE (eds): Surgi-
cal Approaches in Psychiatry; Proceedings
of the 3rd International Congress of Psy-
chosurgery, Cambridge. England, August,
1972. Lancaster, England: Medical and
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Polypus: A diseased excrescence, or a substance formed of coagulable lymph, frequently found
in the large blood-vessels. — Williani Buchan: Domestic Medicine, or a Treaiise on the Preven-
tion and Cure of Diseases hv Reui"ien and Simple Medicines, etc., Richard Folwell, 1799,
p. 475.
478
Vol. 35. No. S
1
i
i
,
Reimplantation of Extremities
by Microvascular Suture
James G. Boyes, Jr., M.D.
pURRENTLY, our medically so-
phisticated populace desires
.urgical replacement of injured or
vorn organs and limbs. Medical
echnology has responded with some
lucccss to the public demand. Tem-
jorarily, there is a growing interest
n peripheral microvascular suture
IS reflected by published medical
vents. The pinnacle of microvas-
iular anastomoses has occurred with
ome frequent successful restoration
)f upper extremity severances.
HISTORICAL PERSPECTIVE
Whereas American Civil War sur-
';eons proved to be masters at am-
iiutation for gangrenous limb parts,
hilitary and civilian surgeons since
he Korean War have emphasized
econstructive techniques. Their
ontributions were inspired by in-
(ovative surgeons using animal e.\-
'icrimentation at the turn of the cen-
ury.
In 1903 Hoepfner' first at-
bmpted reimplantation of com-
pletely severed limbs in dogs. Car-
fell and Guthrie,- in 1906, reported
lie reimplantation of a canine leg
imputated at mid-thigh; the dog sur-
vived vascular anastomosis but
uccumbed to sepsis. Carrel,' in
H Reprint requests to Dr. Boves. Suite ."^10.
!I2S Randolpli Road, Charlotte. Norlli Caro-
.(la 28207.
.UGUST 1974, NCMJ
1908, reporting upon his "Results of
Transplantation of Blood Vessels,
Organs, and Limbs," described the
transplant performed in April 1907
of a "fresh cadaver dog thigh to a
white bitch with resuture of femoral
vessels and limb parts completed in
three hours and ten minutes." This
animal succumbed to an abscess on
the tenth day but with an other-
wise viable extremity. The following
year Carrel,^ using more careful
aseptic techniques, completed "his
first e.xperimental grafting" of a
male fox terrier below knee limb to
a female fox terrier. Halsted,"' in
1924, reported that "thirty-five
years ago (in 1887) in the labora-
tory of Dr. Welch, Dr. Halsted suc-
cessfully transplanted the hind leg
of a dog from one side to the other,
leaving however, the main artery in-
tact a few days, until union between
the muscles and other divided tissues
had taken place." Halsted related
also that on June 6, 1921, a canine
hind leg was transplanted success-
fully despite the presence of a ves-
sel surgically occluded seven months
previously by Dr. Bidgood ;ind
Reichert.
From Alexis Carrel's studies
were formulated the principles for
anastomosis — namely, hemostasis
with non-crushing clamps; adequate
preparation of \'essel ends; the
placement of triangular stay sutures;
and the closure of the triangulated
vessel with running everted sutures.
From 1953 to the present the
surge of interest and development
has compounded. The principles of
vascular surgery were explored ex-
tensively during the Korean War."
Techniques of small arterial anasto-
mosis, use of vein grafts, and control
of postoperative thrombus forma-
tion were refined. ''■'•' Perhaps the
greatest impetus to successful small
vessel suture was contributed by
Jacobson and Suarez'" " with the
development of the Zeiss operating
microscope and his design of surgi-
cal instruments in 1959.
Malt and McKahnn.'-' of Boston,
reported in the JAMA the first suc-
cessful reimplantation of a human
upper extremity severed at the mid-
arm in 1962. Although the humeral
shaft was shortened to achieve reim-
plantation, some residual neurologi-
cal defect remained. Following this
event was a series of reports of suc-
cessful reimplantations using com-
parable techniques. In 1971, Engber
and Hardin' ' recorded 32 cases of
upper limb reimplantations, with
eight failures occurring from tissue
anoxia.
Kleinert, Kasdan and Romero."
in 1963, reported four devascular-
izcd upper extremities, from the up-
479
per forearm to the proximal hand,
that were successfully restored with
skeletal fixation, gentle handling,
atraumatic clamps, and atraumatic
6-0 nylon suture. Douglas and Fos-
ter'"' reported successful reimplan-
tation of human terminal digit grafts
and demonstrated, in 1963. reconsti-
tution of non-sutured vessels in 27
Rhesus monkeys by careful coapta-
tion of skin only at the proximal
phalangeal level. Difficulties of re-
implantation of vessels gave birth to
appliances such as conformers,
cuffs, stapling instruments, adher-
ents, and more refined suture ma-
terial. "■ '■ In 1963. Lapchinsky of
Russia devised a machine that was
superior to suture for vessel anasto-
mosis of 2.3 mm diameter.
[n 1965. Buncke and Schultz.'"-
using the Zeiss operating micro-
scope, fine nylon suture, and
clothespin clamps, attempted ten
monkey digital amputations and re-
implantations before achieving their
first survival. In spite of early fail-
ure, each attempt improved tech-
nique, suture, instrumentation and
after-care. Later, their mastery al-
lowed them to reimplant the rabbit's
ear.'" Finally, an immediate Nico-
ladoni-" procedure (hallux to hand)
was successfully performed in a
monkey using microminiature anas-
tomotic technique.-'
While the Chinese were re-
porting successful extremity re-
implants,-'--' Herbsnian.-'' in the
United States, reported in 1966 a
three-_\ear folku\-iip of a transcai-
pal reimplantation. Smith-' reaf-
firmed the practicality of the micro-
scope for neural as well as vascular
suture. Cobbett.-" while a registrar
at Queen Victoria Hospital, Eng-
land, culled a \ast bibliography of
\ascular literature to 1967, and in
addition, gained sufficient experi-
ence to perform a "free digital trans-
fer"'-'' from a human toe to a thumb
(1968).-'' Concurrently, the Japa-
nese team of Komatsu. Shigo, Tanai.
and Susuniu'" successfully reim-
planied a completely sectioned
thumb.
Lendvev •' in .Australia, in 1968.
reported a successful thumb anipu-
tation-reimplantation. The following
year he repeated his success with a
480
completely severed fifth finger using
8-0 monofilament nylon upon a 1-
mm heparinized vessel. ■'-'
Kutz, Hay and Kleinert,'" in
1969, reported on an accumulated
102 patients with 119 arterial in-
juries. Their results, evaluated by
pulse, claudication, Allen's test, and
arteriography in some patients indi-
cated an arterial patency rate of 52
percent, with slightly higher results
in a forearm vessel. The Chinese-''
results as reviewed by Horn-"- in the
same year indicate that after 20
failures, there were 24 successful
digital reattachments in 34 attempts.
In 1970, O'Brien, '^ using a Zeiss
Triploscope and fine suture tech-
nique, achieved an arterial patency
rate of 81 percent and a venous
patency rate of 90 percent in fifty-
eight 1-mm femoral vessels in rab-
bits. Baxter,'''' a fellow investiga-
tor, then reviewed the cause of sur-
gical failure histopathologically and
found arterial endothelialization to
occur between eight and 12 days.
Most recently, O'Brien and 'Miller''''
reported and portrayed dramatic
success in eight patients with trau-
matic complete amputations in one
or more digits. In 1972, the Japa-
nese group of Tamai ■' reported four
successful digital reimplantations
since 1965 using variations of what
now appears to be a "standard tech-
nique."
CURRENT PERSPECTIVE
Inspired by recent events, surgical
teams in large centers throughout
the United States are prepared to at-
tempt restoration of dismembered
upper extremities. Suture manufac-
turers are able to produce sutures
of 1.0 mils diameter with equally
fine needles. Military air e\acuatioii
teams are now available for rapid
transport. Optical manufacturers are
offering 4.5.\ focal telescoping mag-
nification in e\e glasses.
Currently, a cleanly severed or
crush injur\' of moderate severity to
a hand part has a reasonable (bet-
ter than 50 percent ) chance of re-
implantation under the following
conditions:
1 . Transport of the patient and
specimen within 12 hours — lique-
faction necrosis of muscle occurs
when devitalized beyond 12 hours.
2. An experienced operating team
with binocular diploscope prepared
for a four to eight-hour sta\.
3. .Adequate surgical instru-
ments.
4. Fine nylon suture 9-0 or 1 0-0
size.
5. Heparin (1:10,000 units) for
both local and systemic purposes.
6. Peripheral dilatation by
brachial plexus block together with
general anesthesia.
7. Adequate preparation of the
amputated stump. Transport should
be at 4 C. the stump double-wrapped
dry in plastic bags to prevent direct
contact of the specimen with ice
chips.
.At reimplantation, the proximal
stump is debridcd and the bon>
skeleton shortened and fixed with
intramedullary pins. The separated
part, immersed in cold saline or
Ringer's solution, is flushed with
heparin. The arterial ends for anas-
tomosis, being adequately clamped,
are freshened after the adventia has
been stripped back. The vessels are
distended with heparin, and mag-
nesium sulphate solution is applied
locally. Interrupted fine monofila-
ment nylon suture is placed cir-
cumferentially about the vessel. Sa-
ran Wrap'^'. temporarily wrapped
about the juncture site after clamp
remosal. is reported to facilitate
sealing leaks.''" The veins are su-
tured comparably. Papaverine or
chlorpromazine 0.25 mg ml has
been applied to overcome spasm.
Once vascular continuity has been
established, a single digital nerve
and the extensor tendon is sutured.
S\stemic antibiotic, 6 percent dex-
tran 40 ( Rheomacrodex"? ), and sys-
temic heparin (25,000 units per
liter of saline) have been used rou-
tine!}, postoperatively. Finally, a
two-stage flexor tendon grafting us-
ing silicone reds completes the resto-
ration.
CONCLUSION
Although the composite graft of
an amputated terminal phalanx sur-
\ives with simple skin closure alone
restorations at more proximal skele-
tal levels demand more precise tech-
nique and equipment.
Currently, of some 219 vascular
Vol. .V;, No. 8
nastomoses of separated hand
larts, 105 reimplants have survived.
ifter a decade of international mi-
rosurgieal trials and triumphs, the
-;construction of vessels as small as
0 mm by microsuture has become
(reality.
References
(■
3
I!
Hoeplner E: Ufbcr Geliissniihl. Gcffass-
Iransplantationen iind Replantation von
amputirten Extremilaiten. Lanpenbecks
Arch Chir 70; 417-471, 1901.
Carrel A. Guthrie CC : Complete amputation
of the thigh, with replantation. Am J Med
Sci l.'l: :97-.101, 1906
Carrel A: Results of the transplantation
of blood vessels, organs and limbs. J.AMA
51: 1662-1667, 1908. (Abstract).
Carrel A: Further studies on transplantation
of vessels and or^ians. Proc Am Phil Soc
47: 677-698, 1908.
Halsted \VS, Rtichert FL. Reid MR: Re-
implantation ot ent.re limbs without suture
of vessels. Surgical Papers of William
Stewart Halsted. Baltimore: Johns Hopliins
Press. Vol 2, pp 485-491, 1924.
Jahnke EJ, Seelev SF: Acute vascular in-
juries in the Korean War: An analysis of
77 consecutive cases. Ann Surg ns: 1 S8-
177, 19.5.1.
Engler HS, Christopher PE, Williams HG,
Spears RS. Moretz WH: Prevention of
thrombus formation in small-arterv anasto-
moses. Arch Surg T.i: 766-771, 1959'
Urschel HC Jr. Roth EJ : Small arterial
anastomoses. Ann Surg 15.1: 599-610, 1961.
Venner B: Vein graft for arterial injury.
Aust NZ J Surg 25: 229-2.10. 1956.
Jacobson JH II, Suarez EL: Microsurgery
in anastomosis of small vessels. Surg Forum
11 : 243-245. 1960.
Jacobson JH II: Microsurgical technic in
repair of the traumatized extremity. Clin
Orlhop 29: 112-145, 196,1.
12. Malt RA. McKhann CF: Replantation of
severed arms. JAMA 189: 716-722, 1964.
1.1. Engber WD. Hardin CA: Replantation of
extremities. Surg Gynecol Obstet 1.12: 901-
916, 1971.
14. Kleinert HE, Kasdan ML, Romero JL:
Small blood-vessei anastomosis for salvage
of severely injured upper extremity. J Bone
Joint Surg45A: 788-796. 196.1.
15. Douglas B. Foster JH: Union of severed
arterial trunks and canalization without su-
ture or prosthesis. Ann Surg 157: 944-959,
196-1.
16. Shaw RS: Treatment of extremity suffering
near or total severance with special con-
sideration of the vascular problem. Clin
Orthop 29: 56-71, 196.1.
17. Snyder CC, Knowlcs RP: Autoplantation of
extremities. Clin Orthop 29: 113-122, 1963.
18. Buncke HJ, Schul? WP: Experimental digi-
tal amput;ition and reimplantation. Plast Re-
constr Surg 36: 62-71), 1965.
19. Buncke HJ, Schul/ WP: Total car reimplan-
tation in the rabbit utilizing microminiature
vascular anastomoses. Br J Plast Surg 19:
15-22, 1966.
20. Nicoladoni C: Daumenplastik und or-
ganischer Erasatz der Fingerspitze (Anti-
cheiroplaslik und Daktvloplastik). Langen-
becks Arch Chir 61: 606-614, 1900.
21. Buncke HJ. Buncke CM. Schuiz WP: Im-
mediate Nicoladoni procedure in the Rhesus
Monkey, or hallux-to-hand transplantation,
utilizing microminiature vascular anasto-
moses. Br J Plast Surg 19: 332-337. 1966.
22. Horn JS: The reattachment of severed ex-
tremities, in Apley AG (ed): Recent Ad-
vances in Orthopedics. London, JA Chur-
chill. Ltd, 1969, pp 49-78.
23. Ch'En CW, Chien UC, Pao YS: Salvage of
the forearm following complete traumatic
amputation: Report of a case. Chinas Med
82: 632, 1963.
24. Hwa W: Chinese surgeons break another
world medical barrier. Acta Med Philipp 3:
221. 1967.
25. Sixth People's Hospital, Shanghai: Reat-
tachment ol traumatic amputations. A sum-
ming up of experience. Department of Sur-
gery, Sixth People's Hospital, Shanghai.
Chinas Med 5: 392-402. 1967.
26. Herbsman H, Lafer DJ, Shaftan GW: Suc-
cessful replantation of an amputated hand:
Case Report, Ann Surg 163: 137-143. 1966.
27. Smith JW: Microsurgery: Review of the
literature and discussion of microtechniques.
Plast Reconstr Surg 37: 227-245, 1966.
28. Cobbett JR: Microvascular surgery. Surg
Clin North Am 47: 521-542, 1967.
29. Cobbett JR: Free digital transfer: Report
of a case of transfer of a great toe to
replace an amputated thumb. J Bone Joint
Surg 51 B: 677-679. 1969.
30. Komatsu S, Tamai S: Successful replanta-
tion of a completely cut-off thumb: Case
report. Plast Reconstr Surg 42: 347-377,
1968.
11. Lendvav PG : Anastomosis of digital vessels.
Med J Aust 2: 723-724, 1968.
32. Lendvay PG, Owen ER: Microvascular re-
pair of completely severed digit: Fate of
digital vessels after six months. Med J
Aust 2: 818-820. 1970.
33. Kutz JE, Hay EL. Kleinert HE: The fate of
small vessel repair. J Bone Joint Surg 51 A:
792. 1969,
34. O'Brien BM. Henderson PN. Bennett RC.
Crock GW: Microvascular surgical tech-
nique. Med J Aust 1: 722-725, 1970.
35. Baxter TJ. O'Brien BM. Henderson PK.
Bennett RC: The histopathology of small
vessels following microvascular repair. Br J
Surg 59: 617-622, 1972.
36. O'Brien BM. Miller GDH: Digital reattach-
ment and revascularization. J Bone Joint
Surg 55A: 714-724, 1973.
37. Tamai S, Sasauchi N, Hori Y. Tatsumi
Y, Okuda H: Microvascular surgery in or-
thopaedics and traumatology. J Bone Joint
Surg 54B: 637-647, 1972.
38. McLean DH, Buncke HJ Jr: Use of the
Saran Wrap cuft in microsurgical arterial
repairs. Plast Reconstr Surg 51: 624-627,
1973.
,eti 1
irt 3
i! i
? '
Hectic Fever: A slow consuming fever, generally attending a bad habit of body, or some
incurable and deep-rooted disease, — Williain Biichun: Donicslic Medicine or a Treatise on tlie
Prevention and Cure of Diseases hx Rei;it>ien and Simple ,\tedieines, etc.. Riehard Folwell.
1799, p. 474.
jfi i
\i
jloi
ske
ii
IJUST 1974. NCMJ
481
MEDICAL EVALUATION FOR
DRIVER LICENSING
Whereas the automobile is a product of a tech-
nological triumph and cause of a revolution in mo-
bility, it has at the same time proved to be a health
hazard of critical proportions. During the past five
years, North Carolina has had an annual average of
126,396 motor vehicle accidents, resulting in an aver-
age of 1,853 fatalities, 63.219 injuries, and millions
of dollars in property damage, loss of wages, and
costs arising from deaths and injuries. Experts in
the field of driver medical e\'aluation believe that
drivers" impairment resulting from chronic medical
problems, other than alcoholism, is a contributing
factor in 13 to 25 percent of automobile crashes.
Alcohol is the largest single factor leading to fa-
talities in automobile crashes.
Although the great majority of people having
acute or chronic illnesses drive safely, driving is con-
traindicated, either temporarily or permanently, for
some of these people who have such conditions as
uncontrolled epilepsy and diabetes, severe vision
problems, certain vascular diseases, neurological dis-
orders, orthopedic diseases and some forms of men-
tal illness. The single medical condition of greatest
importance in highway safety, however, is the abuse
of alcohol. During the four-year period (from 1970-
1973), the Office of the Chief Medical E.xaminer
analyzed the bloods of 2,944 operators and pedes-
trians killed on North Carolina highways and found
that more than 48 percent were under the influence
of intoxicating liquor, and another eight percent had
been drinking.
In an attempt to aid in the prevention of highway
deaths and injuries, the Medical Society, working
with the North Carolina Department of Motor Ve-
hicles, established in 1964 a program to medically
evaluate drivers. In brief, the program operates as
follows: Drivers suspected of having a pertinent
medical condition are referred for evaluation by
driver license examiners, law enforcement officers,
court officials or physicians. The driver is asked to
have the physician of his choice complete a medical
report form which is sent by the physician to the
Department of Motor Vehicles. The report is
screened at the Division of Health Services by a phy-
sician and, if necessary, additional medical informa-
tion is obtained. The case may then be reviewed bv
a panel of three practicing physicians (there are 36
physicians recruited by the Medical Society Com-
mittee Advisory to the Department of Motor Vehicles
serving on these panels). The panel reviewing a case
recommends approval of the person's driving privi
lege; approval with certain restrictions, such as a 45
mph speed limit, or daylight driving only; or dis-
appro\al. Panel members review each case inde-
pendently, and the recommendation to the Depart-
ment of Motor Vehicles is based on the summation
of the three recommendations. The AMA pamphlet
Physician's Guide for Determining Driver Limitation
and the U.S. Public Health Service pamphlet Driver
Guidelines for Medical Advisory Boards are used by
the panelists as general guides in furnishing their
opinions.
A person whose driving privilege has been dis-
approved by the panel can appeal his or her case
to a medical review board. Three sections of the
board, each consisting of a minimum of two physi-
cians appointed by the President of the Commission
for Health Services, and a representative appointed
b\ the Commissioner of Motor Vehicles, meet
monthly in Raleigh to hear these appeals, and the
person whose license has been denied appears before
the board. The board has authority to restore, re-
strict or continue the denial of driving privileges,
and its decisions are binding on the Commissioner
of Motor Vehicles. Actions of the board, however,
are subject to judicial review. n
What is the Dri\'er Medical Evaluation Program '
accomplishing? Its goal is to reduce accidents b|
either remo\'ing from the highways those drivers
who are medically unfit to drive or by restricting to
reduced speeds, daylight driving only, and similar
limitations, drivers who have lesser degrees of medi- T
cal impairment. During 1973, the program evaluated ■
9,784 drivers and driver license applicants. In a size-
able number of the cases evaluated it was obvious -
that the person's medical condition would interferer
with driving; but a large percentage of cases are
not so obvious. .Approximately ten percent of tht
people reviewed in 1973 were disapproved for medi-
cal reasons, and an additional 25 percent were given
restricted driving privileges. One must always keep ^
in mind that removal or even restrictions of a per-
son's driving privilege may seriously interfere wit!
his or her livelihood. This factor must be balancec
against the danger inherent in the decision to permii
a medically unqualified driver to continue driving
Such decisions are very often not easy to make
Taking away the drinking driver's license is also ar
e
48:
Vol. 35, No.
i i
Newark is a vertigo festival.
Antivert/25
(25 mg. meclizine HCl) Tablets
for ver t^o*
Antivert"® (mecli2,ine HCl) has been found
ruseful in the management of vertigo associ*
Sated with diseases affecting the vestibular sys'
tern. It is available as Antivert/25 (25 mg.
>mecli2,ine HCl) and Antivert (12.5 mg.
'^meclizine HCl) scored tablets for convenience
^nd flexibility of dosage. Antivert ^25 (25 mg.
amecli2,ine HCl) Chewable Tablets are avail-
^able for the management of nausea, vomiting,
and di2,2,iness associated with motion sickness.
f^BRIEF SUMMARY OF PRESCRIBING INFORMATION
M
r '
♦INDICATIONS. Based on a review of this drug by
the National Academy of Sciences-National Research
Council and/or other information, FDA has classified
the indications as follows :
Effective. Management of nausea and vomiting and
diz:;iness associated with motion sickness.
Possibly Effective: Management of vertigo associ-
ated with diseases affecting the vestibular system.
Final classification of the less than effective indica-
tions requires further investigation.
CONTRAINDICATIONS. Administration of Antivert
during pregnancy or to women who may become pregnant
is contraindicated in view of the teratogenic effect of the
drug in rats.
The administration of meclizine to pregnant rats during
the 12-15 day of gestation has produced cleft palate in the
offspring. 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 mdividu.ds who have
sliown a previous hypersensitivity to it.
WARNINGS. Since drowsiness may, on occasion, occur
with use of this drug, patients should he warned of this pos-
sibility and cautioned against driving a car or operating
dangerous machinery.
Usage in Children: Clinical studies establishing safety and
effectiveness in children have not been done ; therefore, usage
is not recommended in the pediatric age group.
Lhage ni Pregnancy: See "Contraindications."
ADVERSE REACTIONS. Drowsiness, dry mouth and,
on rare occasions, blurred vision h.ivc been reported.
More detailed
professional information
■1 1, ^ A division ol Pfizer Pharmaceuticals
avaifahie on request. New York. New York iooi7
ROGRIG <9
p
inadequate solution since alcoholics, probably more
than any other group of people with medical prob-
lems, often continue drinking and driving whether or
not they ha\e a driver's license. A combined law
enforcement and treatment program might be the an-
swer to the problem of these potentially dangerous
dri\ers and their potential victims.
As of January 1. 1974, there were more than 3,-
300.000 licensed drivers in North Carolina. Of these,
the following had one or more convictions for driving
while into.xicated: 136,280 — one conviction; 36.850
— two convictions; 14.300 — three convictions; 4.840
— four con\ictions; 1.700 — five con\ictions; and 960
had more than five convictions.
During the four-year period (from 1970-1973).
28,744 medical reports were reviewed for drivers
licensing purposes and of these. 8.767 were for
alcohol-related instances of abuse or illness. More
than 30 percent of the drivers being medically evalu-
ated, therefore, are reviewed as a result of alcohol
abuse.
The physician should consider it his professional
responsibilits to ad\ise and counsel his patient whom
he feels would be unsafe, or a hazard to himself or
others, as a dri\er of a \ehicle. He should be alert
to warn his patient of any physical condition
(diabetes. epileps_\. C\'.A. heart disease and other
medical problems ) which would restrict or affect
the patient's driving abilitv It would be advisable
that the physician give positive instructions on when
to drive and when not to drive, driving and rest
periods, speeds, and whether to avoid rush hours or
nighttime driving. When the physician is presented
with a medical report for driver medical evaluation,
he should include ;ill the necessarv information, re-
Emergency
Medical
Services
gardless of how minor it might seem. It is important
to the panel that they review all facts in order tc
make an adequate appraisal of the driver.
Information provided on the medical reports is
treated in a confidential manner and is not released
to the driver license applicant or to any other un-
authorized person. The examining physician is al-
ways in the best position to determine a person's
fitness to operate a motor vehicle safely. The examin-
ing physician's recommendation, therefore, is ex-
tremely valuable. Accurate and essential medical in-
formation acts as a safeguard against licensing po-
tentialh dangerous drivers, on one hand, and need-
lesslv removing the opportunity of the citizen to
drive, on the other. When a physician considers that
it would be hazardous for a patient to continue driv-
ing, he may report the patient's name and address
to the Medical Advisor, Driver Medical Evaluation.
Division of Health Services, Post Office Box 2091.
Raleigh 27602. .'Action will then be initiated by the
Medical .Advisor to have the patient evaluated for
driver licensing purposes.
Identifying the impaired driver and compensating
for his physical and mental conditions continue to
be problems of major proportions. The ultimate so-
lution will unquestionably reduce traffic fatalities.
This program is steadily progressing, and the medical
profession is exerting a profound influence in the re-
ductions of injuries and highway deaths.
Fred G. Patterson, M,D.
Medical Advisor
Driver Medical Evaluation Program
Division of Health Services
North Carolina Division of Human Resources
ORGAMZINC AM) ESTABLISHING A RURAL
EMERGENCE MEDICAL SYSTEM
Bond L. Bible. Ph.D.
Secretary
.\MA Council on Rural Health
Emergency Medical Service Councils, if organized,
could initiate planning, education and funding ac-
tivities for large service areas in rural regions. This
was recently suggested by Dr. John VN'iggenstein. a
member of the .AMA's Committee on Community
Emergency Services, There should be some attempt
to collect data regarding emergency medical trans-
portation, communication and facilities for the rural
area. Following this, an Emergency Medical Service
Council could be formed consisting of providers of
health services, public agencies involved in health
care, community leaders, and perhaps the news
media.
Funding for activities could be obtained from local
municipal or private funds, the Comprehensive
Health Planning .Agency or federally appropriated
funds. The funds should be used to support work in
personnel and training, transportation, health care
facilities, comnumication and public relations.
Dr. Julian \. Waller of the University of Vermont.
at a recent national conference on rural health, sug-
gested that these councils should not be merely
Vol, 35, No, S
miniaturized versions of cities and suburbs. He sug-
gested that the following be considered:
Two-way radio between ambulances and hospital.
Nurses or Physician's Assistants properly trained
and in the emergency room 24 hours a day.
Careful plans to cover emergency activity while
the physician is enroute to the hospital.
A physician trained in emergency medicine on call
and available within 15 minutes.
Proper signs on highways and in the community
to the treatment facility and emergency care center.
Dr. Waller also suggested that the Emergency
Medical Service councils could work closely with the
administrative and medical staff of their local hospital
to coordinate relations and procedures with police
and ambulance services on their role in community
safety and health education.
:1
1 * * *
_ For further information on EMS Councils and pro-
grams, write for "Developing Emergency Medical
Services — Guidelines for Community Councils,"
Commission on Emergency Medical Service, Ameri-
can Medical Association. 535 North Dearborn Street.
Chicago. Illinois 60610.
— Abstracted by George Johnson. Jr., M.D.
From "Emergency Medicine Today" AM A Com-
mission on Emergency Medical Services, Volume 3.
\No. 6. John M. Howard, M.D., Editor, Original ar-
ticle can be obtained from the American Medical As-
sociation, 535 North Dearborn Street, Chicago, Illi-
nois 60610.
Committees and
Organizations
COMMITTEE ON MEDICAL EDUCATION
I Research Triangle Park. Feb. 21,1974
j The following recommendation was adopted:
! Whereas, the Committee on Medical Education of
[the North Carolina Medical Society is convinced of
rthe potential which Area Health Education Centers
•..(AHECs) have for increasing continuing educational
liopportunities for physicians, nurses, and allied health
Npersonnel in North Carolina, and
I Whereas, the Area Health Education Centers pro-
„igram will increase the number of physicians and im-
\
J August 1974, NCMJ
YOU CAN SEE STANMAR HOMES in Alabama,
Arkansas, Colorado, Conn., Delaware, Florida,
Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky,
Louisiana, Maine, Maryland, Massachusetts, Mich-
igan, Minnesota, Missouri, Nebraska, Nevada, New
Hampshire, New Jersey, New York, N. Carolina,
Ohio, Pennsylvania, Rhode Island, S. Carolina,
Tennessee, Texas, Vermont, Virginia, West Vir-
ginia, Wisconsin, Canada, Puerto Rico and The
Virgin Islands.
thecustom
home
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Every Stanmar home is
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If yoitare plaiming to build a priiuary
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4sy
prove the quality of medical care in North Carolina,
and
Whereas, the Committee feels that AHECs provide
the most economically feasible program for improve-
ment of health care needs in North Carolina, there-
fore
Be it Resolved, that the Committee on Medic;
Education of the North Carolina Medical Societ
reaffirms its support of the continued development o
Area Health Education Centers throughout the Stat
of North Carolina.
Richard H. Ames, M.D.. Chairman
NEW MEMBERS
of the State Society
.Mien, James Lathan, M.D. (OBG), 1821 Green St., Durham
27705
Averill, John Bradley, M.D., Meadow Park Dr., Drawer I,
Tryon 28782
Bevis, Charles Alan, M.D. (ORS). 2709 Ellerbe St., Win-
ston-Salem 27103
Bomhatepe. Vamik. M.D. (GP). 204 N. Herman St., Golds-
boro 27530
Clark, Richard Lee, M.D. (DR), 602 Emory Dr., Chapel
Hill 27514
Ciinnincham, Jerome James, M.D. (R), Bowman Gray,
Winston-Salem 27103
Dillon, Robert Gwyn, M.D. (IM), 912 Carolyn St., States-
ville 28677
Dunphy, Donal Leo. M.D. (PD), 517 Red Bud Road,
Chapel Hill 27514
Eaton, Hubert .-Arthur, Jr., M.D. (IM), 411 N. 7th St.,
Wilmington 28401
Gib.son, Noah Francis, IV, M.D. (Intern-Resident). 920
Knollwood St., Winston-Salem 27103
Grant, Paul Joseph, M.D. (Intern-Resident), Bo.\ 121, N. C.
Baptist Hospital, Winston-Salem 27103
Grisham, Joe Wheeler. M.D. (PTH). 1703 Curtis Road,
Chapel Hill 27514
Hammer, Donald Edwin, M.D. (GS), 2206 Cumberland
Ave., Charlotte 28203
McLelland, Robert. M.D. (R), Bo.x 3808. Duke Med. Ctr.,
Durham 27710
Nichols, George Louis, M.D. (P), 1431 Laurel Lane. Gas-
tonia 28052
Redick, Llovd Franklin, ,\1,D. (AN), Box 3094. Duke Med.
Ctr.. Durham 27710
Keid, Richard Alton, M.D. (PUD), 1404 Seminole Dr.,
Greensboro 27401
Wallace, Raymond Dewey, Jr.. M.D. (FP), 127 Main St..
Box 36, Hudson 28638
Waller, Fed James. M.D. (ORS), Uni\ersitv Villace, Boone
2K607
Wyman, John Sheldon. M.D,. 1810 Country Club Rd.. Hen-
dersonville 28739
WHAT? WHEN? WHERE?
In Continuing Education
August 1974
("Place" and "sponsor" are listed only where these difft
from the place and group or institution listed under "ft
information.")
In North Carolina
September 6-7
Symposium on Arthritis
Place: Babcock .Auditorium
Fee: $30.00
For Information: Emery C. Miller. M.D.. Associate Dei
for Continuing Education. Bowman Gray Schoo
Medicine, Winston-Salem 27103
September 6-7
.Annual Meeting of the North Carolina Chapter of tt
.American .Academy of Pediatrics and the North Carolii
Pediatric Society
Place: Pinehurst Hotel and Country Club, Pinehurst
For Information: Mrs. John McLain, Executive Secretar
3209 Rugby Road, Durham 27707
September 13
Pathology and Treatment of Conditions Affecting the Kn(
Joint. This is a one day course designed for rehabilit
tion nurses, insurance carriers and members of the I
dustrial .Accident Commission of N. C.
Sponsor: Division of Orthopaedic Surgery. Department
Suruery
For Information: Frank H. Bassett, 111. M.D., Box 291
Duke University Medical Center, Durham 27710
September 18-19
19th .Annual .Angus M. McBrvde Perinatal Svmposiuni
Fee: S50.00
For Information: George Brumlev. M.D.. Division of Pe ■
natal Medicine. P. O. Box 2911. Duke University Mes-
cal Center. Durham 27710
September 19-21
Topics in Intern.il Medicine, the Fourth .Annual Semin"
in Medicine
Place: Babcock .Auditorium
Fee: S75.00
For Information: Enierv C. Miller, M.D., .Associate Del
490
Vol. 35, No <
The case (£the motorcycle rider
wiio was quick^ cast in a new role.
James McWillis of Winslon-Salem Fourth in a scries of actual case hislorics from the files of Blue Cross and Blue Shield of Norlh Carolina.
The man with the plaster arm is James McWillis
of Winston-Salem — an ardent cyclist who had an
accident trying to avoid an accident. It happened
at Myrtle Beach. While swerving to miss a car,
his motorcycle overturned, he broke his arm and
sprained both ankles.
James was rushed to a hospital. They x-rayed
his arm, put the cast on, and taped his ankles-
all in the Outpatient Department- After he got
back home, his doctor sent him to the hospital for
more X rays to see if his arm was healing properly.
And they were also made as a hospital outpatient.
The accident was unfortunate. But James was
lucky in one way. He's a member of a Blue Cross and
Blue Shield group plan paid for by his employer.
It covers outpatient treatments like X rays and
casts. So at least he wasn't hobbled with hospital
bills. He's back at work now, at the Reynolds
Division of the Forsyth County Hospital
Authority, Inc.
Outpatient benefits are just one example of the
broad coverage provided by Blue Cross and Blue
Shield of North Carohna. In addition to basic
inpatient care, these extra benefits include visiting
nurse service, skilled nursing facihty care, and the
services of home health agencies. And all are
available on a group or non-group basis. Blue Cross
and Blue Shield of North Carolina— a good
influence on everybody's health.
Outpatient benefits.
Another strong case for
Blue Cross and Blue Shield security.
w
Blue Cross
Blue Shield
..(rjor1hC.itulirL3
■ mmi
You've made a sirong case
coveraee- Please send me
for Blue CroiyS and Bin
mformaiion on how lo
e Shield
joiD.
r,rw
]] Association of Blue Shield Plar
A6C (check one}. D Under 65 D '65 or over
n •Full-lime sludcni under 26
•Special programs available.
If you're noi already a subscriber, mail coupon to
Blue Cro.« and Blue Shield of Norlh Carohna.
I Etiiollmeni Depi.. Box 2291. Durham, N C. 2770:
This advertisemeni appeared in North Carolina nen'spapers.
(GUST 1974. NCMJ
y
L
491
for Continuing Education. Bowman Gray School of
Medicine, Winston-Salem 27103
September 20-21
1974 Walter L. Thomas Symposium on Gynecologic Malig-
nancy and Surgery
Program: The two day symposium will be clinically oriented
with the main emphasis on "Ovarian Cancer" and "Diffi-
cult Office Gynecology." ln\ited guest speakers include
Herbert Buchsbaum. Iowa City. Iowa, and Dr. J. Ta>lor
Wharton. Houston. Te.xas.
Credit: ,^.AFP credit applied for.
For Information: W. T. Creasman. M.D.. Director of Gy-
necologic Oncology. P. O. Box 2079, Duke University
.Medical Center, Durham 27710
September 25-28
North Carolina Medical Society Annual Committee Con-
cla\e
Place: ,Mid-Pines Club. Southern Pines
Regular meetings will be scheduled for the chairmen and
members of almost all regular committees of the Medical
Society. Committee members should plan to be present
if at all possible.
For Information: Mr. William N. Hilliard. Executive Direc-
tor, North Carolina Medical Societv, P. O. Box 27167,
Raleigh 27611
September 27-29
Invitational Assembly for .Advanced Urology-Urinary Cal-
culi and Related Diseases
Place: Pinehurst Hotel and Country Club. Pinehurst
Fee: $100
For Information: James F. Glen, M.D.. Box 3707. Duke
University Medical Center. Durham 27710
October 2-3
Fourteenth .Annual Charlotte Postgraduate Seminar
Place: Charlotte Memorial Hospital .Auditorium
Sponsor: Mecklenburg County Chapter .American .Academy
Family Physicians
Program: Topics will include acute leukemia and solid
tumors in children, acute myocardial infarction, difficult
EKGs, oral contraception in the female, perimenopausal
problems, respiratory emergencies, infectious diseases and
difficult lung diseases. Spouses of participants are invited
to attend Dr. Gordon Deckert's Wednesday afternoon ses-
sion. Transactional .Analysis, Concepts, and Sex.
For Information: Mrs. Farrior Harloe, 1336 Brockton Lane.
Charlotte 2821 I
October 4
Forsvth County Heart .Association
Place: Babcock .Atiditoriuni. Bowman Gray School of Medi-
cine. Winston-Salem
Fee: SI5.00
For Information: Mrs. Katherine Cox. Forsyth County Hean
.Association, 2046 Queen Street, Winston-Salem 27103
October 20-22
.Annual Joint Meeting of the North Carolina-South Carolina
Societies of Ophthalmology and Otolaryngology
Place: Asheville Hilton Inn, Asheville
Sponsor: The North Carolina Societv of Ophthalmologv'
and Otolaryngology
For Information: Banks Anderson, Jr.. M.D.. Secretary-
Treasurer. P, O. Box 3802. Duke Uni\ersit\ Eve Center.
Durham 27710
October 28-Novtmber 1
Radiology Postgraduate Course
Place: Southampton Princess Hotel. Southampton. Bermuda
Program Chairman: Richard G, Lester. M.D.. Professor and
Chairman of Radiology. Duke University .Medical Center.
Guest speakers will include: Robert G, Eraser. M.D..
Professor and Chairman of Radiology, McGill University
Medical School, Montreal, Canada: John .A. Evans. M.D.'.
Professor and Chairman of Radiology. Cornell University
Medical College: William B. Seaman. M.D.. Professor
and Chairman of Radiology. Columbia University College
of Physicians and Surgeons, New York. N. Y.; Harold G.
Jacobson, M.D., Professor and Chairman of Radiology.
.Albert Einstein College of Medicine (MHMC). Broi
New "Vork; and David H. Baker, M.D., Director
Radiology, Babies Hospital, Professor of Radiology, C
lumbia University College of Phssicians and Surgeo
New York, N. S'. Subject matter will cover Pediat
and Adult Radiology of the Chest. Genito-Urinary Tra
Gastrointestinal Tract and Musculo-Skeletal System.
Fee: S200
Credit: Twenty-three hours AM.A "Category One" accre
tation
For Information: Robert McLelland, M.D., Department
Radiology. Box 3808, Duke University Medical Cent
Durham 27710.
November 4-6
.Amputations and Prosthetics
Place: Holiday Inn West. Durham
Sponsor: .American .Academy of Orthopaedic Surgeo
Chicago. Illinois
Fee: SIS'O
For Information: Frank W. Clippinger, M.D.. Box 29
Duke University Medical Center, Durham 27710
November 15-16
.Anesthesiology Fall Seminar
Place: Charlotte Memorial Hospital Auditorium
Fee: $40.00
For Information: Dr. H. .A. Ferrari, Chairman, Depi
nient of .Anesthesioloev. Charlotte Memorial Hospi
P. O. Box 2554. CharloVte 28201
December 6-7
What's New in New born Care'.'
Place: Babcock .Auditorium
Fee: $45.00
For Information: Emery C. Miller. NLD., .Associate Di
for Continuing Education, Bowman Gray School of Mi
cine, Winston-Salem 27103
New Dircctorj Available
The second edition (OP-414) of the Directory of S'-
AssC'.siiicn! Proi:raiiis tor Pliy.'.iciuiLS is now available ir
$1.00 from the Order Department, American Medical i-
sociation, 535 N. Dearborn. Chicago. Illinois 60610. e
new edition lists six new self-assessment programs in: I-
lergy. Cardiology, Chest Diseases, Colorectal & .Anorciil
Surgery. Emergency Medicine, and Neurological Surgt/.
A total of 21 programs is sponsored by specialty socieis,
a county medical society and one university. Each progi 1,
listed b\ topic and sponsor, is described with regard to: l-
tended participant, sites and time of testing, dates of Isl
test and most recent revision, objectives and content, fornt.
time required, method of scoring, aids to learning provi 1.
fees charged and where to write for further informatio
Cancer Information by Phone
.A toll free phone call to The Southern Medical .Associ, m
Cancer Education Service ( 1-800-23 I -69701. makes cane. >
formation available b> phone to phvsicians in North C .3-
lina and other states in the Southern Medical .Associ:: M)
area. Tapes must be requested by number. For a c *■
indexed list of over 260 tapes call the above number. iJ
vourself by name, address, city and state, and requi
copy of the index.
In Contiguous States
.\ugust 19-22
Recent Advances in Allertiv: daih semin.us. iS:()() a.n to
10:00 a.m.
Place: The Homestead. Hot Springs. Virginia
For Information: Claude .A. Fra/ier. \1 D . 4-C Do
Park. .Asheville. North Carolina 28801
September 9-1 1
.A Symposium on Cardiovascular Nursing
Place: University of Tennessee. 323 McLemore Street. N^h-
ville, Tennessee
Sponsors: The .American College of Cardiologv, The Caiio-
492
Vol. 35, N
ji/ascular Education Program,
miessee at Nashville
'i: $100
ind the University of Ten-
ftic
ii|j,;dit: Accredited by the State Board of Education in
[,i'Vlaryland
)grani: Designed for the experienced cardiovascular nurse.
4ighlights electrocardiography with particular reference
;[j^, 0 electrophysiology and interpretation of both rhythm
ind contour.
.gl jr Information: Miss Mary Anne Mclnerny, Director,
[j.pepartment of Continuing Education Programs, .American
College of Cardiology, 9650 Rockville Pike, Bethesda,
Maryland 20014.
' September 16-21
rth Annual Family Practice Refresher Course
,ice: Mills Hyatt House Hotel
;: $140.00 payable in advance on or before September
). Enrollment limited to 75 persons,
ijidit: Forty hours AAFP credit approved.
i registration fee includes the Social Hour and Banquet
on Wednesday evening. Wives are cordially invited.
r Information: Vince Moseley, M.D., Director. Division
>f Continuing Education. Medical University of South
Carolina, 80 Barre Street, Charleston, S. C. 29401
September 30 & October I
;.Tinessee Valley Medical Assembly annual meeting
■ Information: Thomas L. Buttram. M.D.. Chairman.
Tennessee Valley Medical Assembly, Whitehall Medical
>nter, 960 E. Third Street. Chattanooga. Tennessee
,17403
I October 5-8
ithern Psychiatric Association annual meeting
(Ce: The Homestead, Hot Springs, Virginia
|- Information: Mrs. Annette Boutwell. P. O. Box 10387,
(aleigh 27605
Ins submitted for listing should be sent to: WHAT?
iVHEN' WHERE?, P. O. Box 8248. Durham. N. C.
I .7704. by the lOth of the month prior to the month in
ivhich they are to appear.
iews Notes from the —
UNIVERSITY OF NORTH CAROLINA
DIVISION OF HEALTH AFFAIRS
for 1
pr. Raymond P. White, Jr.. of Virginia Common-
,alth University was appointed dean of the School
.Dentistry and professor of oral surgery at UNC-
!apel Hill, effective July 1. Dr. White succeeds
( i James W. Bawden, who will return to teaching
» ■! research.
;fhe Rev. Philip Washburn was commencement
eoit ilaker for 124 graduating students in the School
(Dentistry on May 12. During the special gradua-
I 1 program, 59 doctor of dental surgery candidates
4 e hooded, and 60 bachelor of science degrees
i I certificates in dental hygiene and five bachelor
•[rscience degrees in dental auxiliary teacher educa-
I 1 were awarded.
..,^s1ary C. George was appointed director of the
j.ital Auxiliary Teacher Education (DATE) Pro-
I tn in the Department of Dental Ecology at the
! ool of Dentistry, effective July 1 . Mrs. George
i/ceeds Alberta Beat Dolan who directed the pro-
! in since its beginning in 1 968.
^ Charles G. Shea has been appointed assistant pro-
^y>
<UST 1974, NCMJ
fessor in the Department of Oral Surgery. He holds
the B.S. and D.M.D. degrees from the University of
Pittsburgh.
Eugene F. Howden has been promoted to asso-
ciate professor in the Department of Pedodontics.
* + :|c
The UNC School of Medicine is one of nine medi-
cal centers in the United States chosen to study the
membrane oxygenator and the effects of its prolonged
use. The purpose of the $330,000 study is to identify
the best patient population for extended use of the
machine — from 10-14 days. Dr. Herbert Proctor,
chief investigator and head of the trauma section in
the Department of Surgery, and Drs. Noel McDevitt
and Peter Starek will study the results.
A $436,310 HEW grant to assist the family prac-
tice residency program has been awarded to the
Department of Family Medicine at the UNC School
of Medicine. Dr. Robert Smith, chairman of the De-
partment, said the federal grant is their first.
A $142,414 grant from the National Heart and
Lung Institute to study pulmonary circulation in pa-
tients undergoing open heart surgery has been
awarded to a team of surgeons at the UNC School
of Medicine. Dr. Benson R. Wilcox, chief of the di-
vision of thoracic and cardiovascular surgery, will
be assisted in the project by Drs. Norman A. Coul-
ter, Jr., Carol Lucas, Gordon F. Murray and David
Downie.
The National Cancer Institute has awarded UNC-
Chapel Hill $137,202 to continue studies of specific
genes believed to predispose human beings to leu-
kemia and certain cancers. A group of researchers,
under the direction of Dr. Michael Swift, hope to
show how specific genes increase the probability of
malignancies in their carriers. Dr. Swift is chief of
the Division of Medical Genetics in the UNC Depart-
ment of Medicine and a research scientist in the Child
Development Institute's Biological Sciences Research
Center.
Under a five-year $235,699 research grant from
the National Heart and Lung Institute, Dr. Henry S.
Kingdon and his research associate. Dr. Gilbert
White, will study the chemical changes that take place
in the blood when it clots. Dr. Kingdon is professor
of medicine and biochemistry at the UNC School of
Medicine and professor of oral biology in the depart-
ment of periodontics at the UNC School of Dentistry.
A team of scientists at the UNC School of Medi-
cine is trying to discover whether the body's natural
immune response to disease can be manipulated to
light cancer. The research program — a collaborative
effort between the departments of surgery and bac-
teriology and immunology — is funded by a $914,-
979 grant from the National Cancer Institute. The
research will be under the general direction of Dr.
Geoffrey Haughton, bacteriology and immunology.
Dr. Edward B. Glassman of the UNC School of
Medicine is the first elected president of the newly
493
formed North Carolina Chapter of the Society of
Neurosciences.
New appointments to assistant professor include:
David W. Ange, Department of Radiology; Wil-
liam J. Arendshorst, Department of Physiology; Ed-
ward E. Ragoff, Department of Radiology; and
Rick I. Suberman, Department of Radiolog\'.
Promotions (professors) include: Arthur L. Finn,
medicine; Mario C. Battigeili, medicine and School
of Public Health; Robert A. Briggaman, derma-
tology; Floyd A. Fried, surgery; Joseph H. Perlmutt,
physiology; and, Mary C. Singleton, physical therapy.
Promotions (associate professors) include: Da-
vid R. Brown, anesthesiology; Timothy K. Gray,
William Grossman and Don W. Powell, medicine;
Faustino C, Guinto, Jr., radiology; and Edwin T.
Preston, surgery.
Dr. James A. Bryan, II, professor of Medicine and
Family Medicine at the UNC School of Medicine,
for the third time, was named "Professor of the Year"
by the 1974 senior class.
Dr. Frederic G. Dalldorf, professor of pathology,
was named recipient of the 1974 Central Carolina
Bank Excellence in Teaching Award at the UNC
School of Medicine's Student-Faculty Day program
.April 27.
Other awards included the following: the second-
year class gave the Medical Basic Science Teaching
Award to Dr. James N. Weakley, assistant professor
of physiology; Dr. Gordon Leigh Phillips, a resident
in medicine, was voted recipient of the Henry C.
Fordham Award by the fourth-year medical students;
Dr. James Nello Martin, Jr., 1973 graduate of the
UNC School of Medicine, was given the Outstanding
Intern Award by the third-year students; and, Rich-
ard Ni.xon Duffy, III. received the William deB. Mac-
Nider Award, established by the second-year class of
1950.
Dr. James A. Bryan, II, professor of Medicine and
family medicine, made his graduation address on
three men who shaped the UNC School of Medicine
— Drs. William MacNider, Richard Whitehead, and
Isaac Manning. It was a new perspective for the 96
graduating students.
* * *
The following students and a faculty member of
the UNC School of Nursing were honored May 12
at the School's special commencement: Celeste Ann
Roberson of Fayetteville received the George Livas
.Award; Deborah Jane Carpenter of Gastonia.
Alumni Award; Carol Lynn Zimmerman of Upper
Montclair. N. J., Sigma Theta Tau Award; and, Betty
Ann Taylor of Orlando, Fla., Sigma Theta Tau Writ-
ing Award. Instructor Bobbie Sue Frye was presented
the Nursing Faculty Award.
State Senator Ralph H. Scott of Alamance County
addressed the UNC School of Nursing graduating
class on May 12. There were 110 bachelor of sci-
ence degrees and 1 8 master's degrees awarded.
Promotions in the School of Nursing include: Vir-
Rondomycin
(methacydine HCI)
CONTRAINDICATIONS: Hypersensilivity to any ol Ihe lelracyclines
WARNINGS Telracycline usage dunng tooth development (last nail ol pregnancy to eig
years) may cause permanent tootn discoloration (yellow-gray-brown), which is mo
common during long-term use Out has occurred alter repeated short-term course
Enamel hypoplasia has also been reported Tetracyclines stiould not be used in litis a\
group unless other drugs are not likely lo be elleclive or are conlraindicale
Usage in pregnancy iSee above WARNINGS about use during tooth developmen
Animal studies indicate Ihal tetracyclines cross the placenta and can be toxic to Ihe c
veloping lelus lotten related lo retardation ol skeletal development) Embryotoxicity It
also been noted in animals treated early in pregnancy
Usage in newborns, infants, and children. iSee above WARNINGS about use dun
looln development )
All lelracyclines loim a slable calcium complex m any bone-lorming tissue A decreg
in fibula growth rate obser^reO in prematures given oral tetracycline 25 mg/kg every
hours was reversible when drug was discontinued
Tetracyclines are present m milk ol ladating women taking tetracyclines
To avoid excess systemic accumulation and liver toxicity in patients with impaired rei
lunclion reduce usual total dosage and. it therapy is prolonged, consider serum level (
terminations ol drug The anti-anaboiic action ol tetracyclines may increase BUN WH
nol a problem in normal renal lunclion m patients with signihcanily impaired lunche
higher telracycline serum levels may lead to azotemia hyperphosphatemia, and acidos
Pholosensitivity maniiesled by exaggerated sunburn reaction has occurred with let
cyclines Patients apt to be exposed to direct sunlighi or ulliaviolel light should be so i
vised, and Irealment should be discontinued at lirsi evidence ol skin erythema
PRECAUTIONS II superinlection occurs due lo overgrowth ol nonsusceplible organisn
including lungi discontinue aniibiotic and start appropriate therapy
m venereal disease, when coexistent syphilis is suspected pertorm darklield exai
nation belote therapy, and serologically test lor syphilis monthly lor at least lout montt
Tetracyclines have been shown to depress plasma prothrombin activity, patients on r
ticoagulani therapy may require downward adiuslmeni ol Iheir anticoagulant dosage
In long-term therapy pertorm periodic organ system evaluations (including bici
renal hepalicl
Treal all Group A bela-hemolytic streptococcal inlections lor at least 10 days
Since Oacleriosiatic drugs may mlerfere with the bactericidal action ol penicillin, av
giving letracycline with penicillin
ADVERSE REACTIONS; Gastrointestinal (oral and parenleral lorms) anorexia, naub
vomiting, diarrhea, glossitis, dysphagia, enterocolitis, mllammatory lesions (with mo
lal overgrowth) in the anogenilal region
Skin: maculopapular and erythematous rashes, exioliative dermatitis (uncommon) t-
tosensitivity IS discussed above (See WARNINGS)
Renal loiicily: nse m BUN apparently dose related (See WARNINGS)
Hypersensitivity; urticaria, angioneurotic edema, anaphylaxis, anaphylactoid purp;.
pericarditis exacerbation ol systemic lupus erythematosus
Bulging lonlanels. reported m young inlanis alter lull therapeutic dosage have di .
peared rapidly when drug was discontinued
Blood- hemolytic anemia, thrombocytopenia, neutropenia eosmophilia
Over prolonged periods tetracyclines have been reported to produce brown-black
croscopic discoloration of Ihyroir) glands, no abnormalities ol thyroid lunclion studie-,
known to occur
USUAL DOSAGE- Adults- 600 mg daily, divided into two or lour equally spaced do.
tviore severe mleclions an initial dose ol 300 mg loilowed by 150 mg every six hour;'
300 mg even/ 12 hours Gonorrhea In uncomplicated gonorrhea, when penicillin is c^
iraindicated Rondomycin- (melhacycline HCI) may be used lor treating both males -I
lemales m Ihe lollowmg clinical dosage schedule 900 mg initially loilowed by 300 I
q I d lor a total 015 4 grams
For Ireatmeni ol syphilis when penicillin is contraindicaled. a total ol 18 to 24 gram i
Rondomycin (melhacycline HCI) in equally divided doses over a period ol 10-15 .
should be given Close lollow-up. including laboralory tests, is recommended
Eaton Agent pneumonia 900 mg daily lor six days
Children - 3 to 6 mg;ib,-day divided inio two to lour equally spaced doses
Therapy should be coniinued lor at least 24-48 hours alter symptoms and lever n
Concomilani therapy: Antacids containing aluminum, calcium or magnesium impar-
sorption and are contraindicaled Food and some dairy products also intertere (3ivc )
one hour belore or two hours alter meals Pediatric oral dosage lorms should n .
given wiih milk tormulas and should be given al least one hour prior to leeding
In patients with renal impairmeni isee WARNINGS) total dosage should be decrs 1
by reducing recnmmended individual doses or by extending time intervals bet.'i
doses
In streptococcal inlections a Iherapeulic dose should be given lor al least 10 days
SUPPLIED: Rondomycin (methacydine HCI) 150 mg and 300 mg capsules, syrup i •
tainmg 75 mg/5 cc methacydine HCI
Belore prescribing, consult package circular or latest PDR inlormalion.
Rev 1 3
WALLACE LABORATORIES
CRANBURY. NEW JERSEY08512
494
Vol. 35.
ginia F. Cover, professor, and Joyce A. Scniradek
and Sylvia K. Hart, associate professor.
+ * *
Dr. Charles C. Pulliani has been chosen one of
eight scholars at UNC-Chapel Hill to receive a Spen-
f cer Foundation grant to study "The Pharmacist's Im-
pact as a Health Educator for the Hypersensitive
Patient." The eight UNC scholars will share a
t $90,000 grant.
( W. Whitaker Moose of Mt. Pleasant delivered the
annual School of Pharmacy commencement address.
This year bachelor of science degrees were awarded
to 85 men and 43 women.
More than 200 persons attended a testimonial
dinner May 13 honoring Dr. George P. Hager, Jr.,
l'*>who is resigning as dean of the UNC School of
1 1 Pharmacy to return to teaching.
k
North Carolina physicians who invest a large part
J of their professional time in nursing homes met May
!29 in Chapel Hill to take stock of their unique role.
*y These physicians may become known as "medical
jdirectors" in the nursing homes to which they give
iconcentrated attention as a result of a new federal
M regulation.
On an invitation from the United Methodist
Church, Dr. James E. Allen has written a book. The
'.Early Years of Marriage, for use in church-related
"idiscussion groups. Dr. Allen, an ordained minister,
HJs a lecturer in the Department of Religion and an
associate professor in the Department of Health Ad-
*iministralion. He also serves as a senior research as-
sociate for the Carolina Population Center.
Dr. Philip C. Singer, associate professor in the
"••''lUNC Department of Environmental Sciences and En-
gineering, has been named the first recipient of the
'tNewton Underwood Award for Teaching Excellence.
John W. Hatch has been appointed associate pro-
ifessor, Department of Health Education. He is cur-
jrently a research associate for the UNC Health Ser-
ijvices Research Center.
Promotions include the following: Associate pro-
^ifessor — Linda W. Little, environmental sciences
"and engineering; Ronald W. Helms, Richard H.
Ijjj '{S'hachtman and Michael J. Symons, biostatistics; As-
sistant professor — Beatrice B. Mongeau, public
health nursing.
Arthur C. Stern, professor in the Department of
^Environmental Sciences and Engineering at the UNC
'School of Public Health has been elected first vice
i president of the Air Pollution Control Association.
Drs. Michel Ibrahim and Dennis Gillings of the
;khool of Public Health have been presented Found-
;rs Awards by the North Carolina Heart Association
lOr their contribution and participation in the Asso-
ciation's programs.
1 * * '
Some of the South's most colorful spokesmen for
ihe poor and hungry joined church, civic, educational
und government officials at UNC-Chapel Hill re-
,,i'\UGusT 1974. NCMJ
V
m
cently to work out detailed plans to feed the poor,
the aged, and the hungry in eight southern states.
* * *
Dr. Craig T. Ramey, psychologist, and Dr. Al-
bert M. Collier, pediatrician, of the Child Develop-
ment Center have been awarded a Spencer Founda-
tion grant to study "The Effects of Febrile Illnesses
on Learning in Preschool and Elementary School
Children." Drs. Ramey and Collier will share a $90,-
000 grant with six other UNC-Chapel Hill Spencer
Foundation Scholars.
* * *
Family planning directors from throughout North
Carolina met in Chapel Hill June 12-14 for an
evaluation workshop sponsored by the State Services
Office of the Carolina Population Center of UNC-
Chapel Hill.
* + *
The North Carolina Health Manpower Develop-
ment Program at UNC-Chapel Hill has received a
$15,000 grant from the Z. Smith Reynolds Founda-
tion, Inc., of Winston-Salem to support a clinical
work-study summer health program this summer for
75 minority and disadvantaged students enrolled at
the following schools; Pembroke State University,
North Carolina Central University, Elizabeth City
State University, Durham College, and UNC-Chapel
Hill.
News Notes from the—
DUKE UNIVERSITY MEDICAL CENTER
Edwin C. Whitehead of Tarrytown, N. Y., has
announced that he will establish a multi-million-
dollar "purpose-oriented" biomedical research insti-
tute on the campus of and in association with the
medical center.
Whitehead is chairman of the board of directors
of Technicon Corporation of Tarrytown and owns
the bulk of the stock of Technicon.
The research center will be known as the White-
head Institute for Medical Research. It will be af-
filiated and associated with Duke Hospital and the
School of Medicine, providing for a joint effort be-
tween the institute, the hospital, the medical school,
and members of the staffs of each organization.
Initially. Whitehead will commit sufficient funds
to provide an operating budget of approximately
$1 million for the institute's operations, and in the
future capital funds consisting of Technicon stock
will be made available for endowment of the institute.
Technicon was started as a one-room operation
in 1939 by Whitehead and his father. Today the cor-
poration has five major divisions, eight distribution
centers in the United States and Canada, and has
offices in 20 other countries.
Technicon manufactures scientific instruments
449
used primarily for automated chemical analysis of
blood, blood serum, air and water (for pollution con-
tent ) and various chemicals, pharmaceuticals, foods,
and other products for quality control and production
monitoring.
Whitehead emphasized that the institute will be
"purpose-oriented" in its research efforts, explaining
that ■'the major goals will be long in range and each
will encompass the definitive solution of a major
problem area in medicine."
The selection of Duke as the site for the institute
came after an exhaustive search of more than a year
by Whitehead and his associates for a university
setting where his institute's work would tie in with
existing biomedical research programs.
Whitehead said that he and his advisors, headed
by Dr. James A. Shannon, special assistant to the
president of Rockefeller University and former direc-
tor of the National Institutes of Health, had visited
and considered more than 10 leading universities
in the country before selecting Duke.
The institute will be self-governing through a board
of directors which will have a mutally interlocking
relationship with the University Board of Trustees.
Overall guidance will be in the hands of a chief
executive officer to be known as the director of the
institute. The director is expected to be selected
within the next few months.
Research programs of the institute's work will
be determined on the advice of a scientific advisory
group made up of some of the world's most dis-
tinguished scientists.
Duke has received as a gift a private collection of
rare books considered to be one of the finest private:
collections in the history of science and medicine.
The collection contains hundreds of first editions,
and a number of the books date from just after the
dawn of printing in the 15th century.
The donors are Samuel I. and Cecile M. Barchas
of Sonoita, Ariz. They declined to disclose the exact
appraised value of the collection, but it is in the mil-
lions of dollars.
Barchas was a prominent trial lawyer in Los An-
geles in Beverly Hills before his retirement to Ari-
zona in 1956.
"We investigated all of the leading institutions in
the country that we thought had the scholarly pur-
poses and capabilities of receiving a unique collection
of this kind," Barchas said. "After six years, we de-
termined that, because of its excellence, Duke was
the ideal place for these books."
Under the terms of an agreement signed by the
Barchases and President Terry Sanford, Duke will
supplement the Barchas Collection by acquisitions
totaling $100,000 annually for at least ten years.
The books, which total approximately 3,25(1
volumes, will be known as the Samuel I. and Ce-
cile M. Barchas Collection. They will be housed in
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.
Accredited by the Joint Commission on Accreditation and
Certified for Medicare
James A.sa Shield, M.D.
James Asa Shield. Jr., M.D.
Catherine T. Ray. M.D.
Weir M. Tucker. M.D.
George S. Fultz, Jr., M.D.
Graenum R. Schiff, M.D.
MK)
Vol. 35, No.
is-|ae Barchas Center for the History of Science, lo-
ated in the medical library section of the Seeley G.
ludd Building, the library and communications cen-
;r which will be completed in the fall of 1975.
The Barchas Collection will be located adjacent to
"''he Josiah C. Trent Collection, one of the country's
iiajor collections of books on the history of medicine.
Duke also has agreed to begin a program of pub-
shing scholarly books and monographs in the his-
|')ry of science and medicine growing out of research
'i the Barchas Center, and to translate into English
,, 'nd publish classics in the field.
Ill--
] The Barchas Center will have a director appointed
!'-om the Duke faculty and an editor-in-chief of the
^^ Dllection. A six-member committee, on which the
archases will serve, will manage and guide the col-
,;ction, including future acquisitions.
lur-
D
Iw
Dr. Roy T. Parker is the new president-elect of
:ie American College of Obstetricians and Gynecolo-
gists (ACOG) and will be president during the or-
janization's silver anniversary year, 1975-1976.
I Parker's predecessor as chairman of the Depart-
ionijient of Obstetrics and Gynecology, Dr. F. Bayard
larter, is a past president of ACOG, as was the late
2S(br. Robert A. Ross. Another past president is the
,i;tired department chairman at Bowman Gray, Dr.
jjjj^rank R. Lock.
"This makes our district (District IV) the only
istrict in the ACOG, and North Carolina the only
late, that will have produced four national presi-
ents," Parker said. The ACOG has 16,000 mem-
[ers in the United States and Canada.
I
I Russell James Kilpatrick, a rising junior in the
chool of Medicine, from Asheboro, N. C, has been
elected as the 1974 winner of the Wilburt C. Davi-
i)n Travel Scholarship, an award presented annually
iJ an outstanding medical student.
I The award, amounting to $500, will be used by
)ilpatrick to help offset the cost of two months in
phannesburg. South Africa, at the University of Wit-
tatersrand where he plans to study advanced general
hd thoracic surgery. The student said he also intends
1 visit medical missionaries in Zaire, formerly the
fcpublic of the Congo.
' Kilpatrick is a 1972 graduate of the University of
lorth Carolina at Chapel Hill and has a bachelor
.- arts degree in economics. While at UNC, he was
IMorehead scholar.
. Dr. James J. Morris, Jr., associate professor of
(edicine and director of the Myocardial Infarction
research Unit, was installed as president of the North
i, arolina Heart Association during the 25th annual
i eeting of the organization in Winston-Salem.
.JGusT 1974, NCMJ
News Notes from the —
BOWMAN GRAY SCHOOL
OF MEDICINE
WAKE FOREST UNIVERSITY
Dr. I. Meschan, professor and chairman of the
Department of Radiology at Bowman Gray, and Dr.
James F. Martin, professor of radiology, are co-au-
thors of a new book on the diagnosis of head and
neck disorders. Collaborating with them on the book
was Dr. Lee F. Rogers, associate professor of ra-
diology at the University of Texas Medical School
in Houston.
The Heatl ami Neck Disorders Syllabus is included
in a series of 14 books being published by the Ameri-
can College of Radiology as part of its program on
professional self-evaluation and continuing education,
:i: * *
Dr. John R. Ausband, professor of otolaryngology,
has authored a new book called Ear, Nose and Throat
Disorders. The book is presented as a guide for the
practicing physician caring for patients with problems
of the ear, nose and throat. It also includes sections
on neck masses, the salivary glands and the facial
nerve.
* * *
Dr. Richard C. Proctor, professor and chairman of
the Department of Psychiatry, has written an article
entitled ■'Winners Walk .'Mone" which appears in the
7974 PGA Book of Golf. The article deals with the
psychological differences between winners and losers.
^ :■;: :;:
Dr. Jimmy L. Simon, professor and chairman of
the Department of Pediatrics, has received special
recognition for teaching excellence from the 1974
graduating class of the University of Texas Medical
Branch at Galveston. Dr. Simon was deputy chair-
man of pediatrics at Galveston prior to his appoint-
ment to the Bowman Gray faculty in March.
He was presented the James W. Powers Award,
which is the highest honor the students at the Uni-
versity of Texas Medical Branch can bestow upon a
faculty member. This is the second time Dr. Simon
has won the Powers Award.
;;: i: *
Dr. Robert N. Headley, associate professor of
medicine, was elected as a North Carolina Heart
Association member on the American Heart Asso-
ciation Board of Directors at the May 30 N.C.H.A.
meeting in Winston-Salem. He also was awarded the
Silver Distinguished Service Medallion for outstand-
ing leadership.
* :!: *
George Lynch, professor and director of the De-
partment of AudioN'isual Resources, has been reap-
501
pointed as consultant to the Committee on Medical
Education of the North Carolina Medical Society.
* ■;: ■■':■
Dr. Joseph E. Whitley, professor of radiology, re-
cently became the first member of the Association
of University Radiologists to be elected to member-
ship on the American College of Radiology Council.
* + *
Dr. Hal T. Wilson, associate professor in the Di-
vision of .Allied Health, has been elected secretary
of the Exeeuti\e Committee of the Piedmont Medical
Foundation.
,■:: :;! *
Dr. Paul C. Bucy, an internationally prominent
neurosurgeon, has been appointed clinical professor
of neurologv and neurosurgery.
He is professor emeritus and former director of
neurosurgery at Northwestern University Medical
School. He now lives in Tryon.
* * *
Dr. James C. Leist has been appointed an assis-
tant to the vice president for medical affairs. His
primary responsibilities will be in the development
of an Area Health Education Center (AHEC) pro-
gram to serve a I6-county area in northwest North
Carolina.
He also will hold a faculty appointment as instruc-
tor in community medicine.
For the past two years he has been director of
health manpower planning for the Forsyth Health
Planning Council in Winston-Salem.
amp:rican college of obstetriclws
and cynecolocists
Dr. Ro\ T. Paiker of Durham. North Carolina,
was named president-elect of the .American College
of Obstetricians and G\'necologists (ACOG) at the
College's recent annual meeting in Las \'egas.
Dr. Parker, who is chairman of the Department of
Obstetrics and Gynecology at Duke University Medi-
cal Center, will head the 15,875 member obstetrics
gynecology specialty organization in 1975-1976.
A I'-Ul graduate of the University of North Caro-
lina, he received his M.D. degree from the Medical
College of Virginia in 1944. He was appointed as-
sistant professor in the Department of Obstetrics
and G\necology at Duke in 1955, professor in 1963.
chairman in 1964, and was named F. Bayard Carter
Professor of Obstetrics and G\necology in 1970.
NORTH CAROIIN A HEART ASSOCLXTION
The North Carolina Heart .Association has set a
deadline of October 1, 1974. for receiving applica-
tions for research grants-in-aid up to S2,500. except
in unusual circumstances when it will consider appli-
cations for larger amounts from investigators within
the state working in the cardiovascular field. Grants-
in-aid are awarded b\ the Heart .Association and its
chapters to scientists to serve as pilot projects am
as a method of encouraging postdoctoral scientist'
toward a research career. Preference in funding wi
be given to junior investigators.
Applications for the grants may be forwarded ti
William E. Lassiter, M.D., Chairman, Research Re
view Subeonmiittee, North Carolina Heart Associa
tion, P. O. Box 2408, Chapel Hill, North Carolin
27514.
The grants-in-aid are one phase of the Heart As
sociation's research program which is supported b
public contributions to the annual Heart Fund cam
paign.
The North Carolina program is separate from thr
of the American Heart Association, which annuall
makes numerous research grants to scientists withi
the state. Those interested in inquiring about the n.i
tional program should write to the American Hea;
Association, 44 East 23rd Street, New York, Ne\
York 10010.
POLYCYTHEMIA VERA STUDY CROUP—
MYELOPROLIFERATIVE DISORDERS: A
NEW INTERNATIONAL STUDY
The Polycythemia Vera Study Group (PV'SG
was organized seven years ago to better define th
natural history of the disease, the optimal therapj
and the influence of the various therapeutic modal
ities on the course of the disease, particularly i
development of myeloid metaplasia, myelofibrosi
and acute leukemia. Four-hundred and ten patient
with poKcythemia vera have already been entere
into this randomized prospective study, and thes
cases are being followed.
The PVSG has recently instituted a major ne\
protocol to study other myeloproliferative syndrome;
exclusive of granulocytic leukemias. Previously ur
treated patients diagnosed as having agnogenic mj
cloid metaplasia, myelofibrosis or sclerosis, primar
ihrombocvtosis. or unclassifiable myeloproliferativ
\ariants will be enrolled for study. The twofold pui
pose of including other myeloproliferative disordei
in the stud\ is to learn as much as possible aboi
the pathophysiology of these disorders and to pei
form randomized therapeutic trials to determine th
most effective therapy.
Each patient will receive extensive diagnostic tesi
ing aimed at quantitating blood and bone marrc
function and structure, relevant chemistries, cyto
genetics, levels of growth stimulators such as erytl
ropoietin and colony stimulating activity, and fei
rokinetics. To determine common patterns of disea-
progression and to identify prognostic factors, kc
iibser\ations will be repeated at regular interval
Such comprehensive testing requires the combine
efforts of many hematology centers. The therapeuii
trials are designed to answer the following questions
( 1 ) how frequently do androgens improve anemia'
(2) is there a difference between the remission rai
of low dose androgens and high dose androgens, an
502
Vol. .V"!. No
1' are oral androgens as useful as parenteral andro-
i gens?; (3 ) how does splenectomy compare to chemo-
therapy in treatment of patients having severe hemo-
lytic manifestations and painfully enlarged spleens?;
(4) what are the relative merits of P'- in compari-
son to chemotherapy ( 1-phenylalanina mustard) in
treatment of primary thromboeytosis?; (5 ) how often
do patients with MPS have coexisting iron or folate
deficiency, and do they benefit from replacement?
There are 43 cooperating institutions in the United
States, France, Sweden and Israel. We welcome in-
A:i
4
quiries regarding entry and follow-up of potential
study patients. Patients undergoing investigative stud-
ies may be admitted to the Clinical Research Unit
at the participating institutions. Further information
can be provided by PVSG or by the individual in-
vestigators at the following addresses: John Laszlo,
M.D., Box 3096, Duke University Medical Center,
Durham, North Carolina 27710, (919-684-2512);
Charles L. Spurr, M.D., Division of Hematology,
Bowman Gray School of Medicine, Winston-Salcm,
North Carolina 27 1 03 ( 9 1 9-727-4354 ) .
Month in
Washington
:rsli ;i
The humdrum hearings on national health insur-
lance (NHI) before the House Ways and Means
J Committee got something of a lift when the long-
it absent chairman, Wilbur D. Mills (D-Ark.), unex-
opectedly showed up one Friday in mid-June and an-
Snounced that whatever bill his committee approves
[undoubtedly would not look like any single bill pres-
!i ently under consideration.
This pronouncement from the august chairman
ite li immediately gave rise to the belief that closed door
It stalks may be going on among committee members
in an effort to hack out a compromise bill that
could secure congressional enactment this year.
But the startling lack of interest in the House
1 ifWays and Means Committee hearings — only two or
ilthree members attending each hearing and chairman
tMills showing up for only the second time in months
and the indefinite postponement of Senate Finance
pi ^Committee hearings would seem to say the Congress
orit iis not "busting its britches"" to pass an NHI bill
alit if this year.
Mills said his own plan (Mills-Kennedy) "doesn't
ii£|)ido everything 1 would like it to do."" He added,
however, that he believes the method of reimburs-
icK aing physicians under Mills-Kennedy is better than
latB i^Medicare's method. Mills believes it would elimi-
C)1 linate the apparent discrimination between the city
en' SIphysician and the rural physician.
]ili} His primary concern is that medical services for
Jjsti B'the poor be at least as good as that received by
[S, liithose people in other income groups. Referring to
lert tithe compromise with Kennedy, he said, "We were
mbJD Hrying to lay before the public a program wc thought
ap£( lihad a chance to pass."" He said he wanted to avoid
islioi la bill that "would provide nothing more than catas-
10 litrophic coverage,"" which would cover only five per-
oit Icent of the need. Mills said that the compromise
nU'i'is subject to further compromise. "Catastrophic is
\ '\ucusT 1974. NCMJ
I
//
the roof, and we need the floor and walls along with
the roof,"" he said.
Mills stated that his intent with the Mills-Kennedy
compromise NHI bill was not to exceed the cost of
the Administration"s "CHIP"" plan and to come up
with a different method of financing. He said the
bill was introduced to present an alternative to the
.'Administration plan for discussion and comment.
The following selected sample bits of testimony
are from the many medical-health care oriented or-
ganizations who have trooped to Washington to have
their say about NHI:
(1) The American Public Health Association
urged more consumer policy input than provided in
any of the major NHI bills before the committee
and more preventive services benefits. APHA Presi-
dent C. Arden Miller, M.D., said the major measures,
for the most part, provide insufficient benefits and
controls.
(2) The American Association of Medical Clinics
supported maintenance of the free enterprise system
of health care, and said that funding should be
from mandated employer plans and general tax funds
for the poor and medically indigent.
(3) The Colorado Health and Environment Coun-
cil witness discussed the Colorado Community-Co-
operative-Decentralized plan which emphasizes pre-
ventive medicine and home health care. The impor-
tance of the physician"s office as a basic health care
facility was stressed.
(4) The National Association of Social Workers
favored the Kennedy-Griffiths Health Security Act
provisions.
(5) The American Academy of Family Physicians
told the House Ways and Means Committee that
any NHI bill must provide that family physicians re-
ceive the same fee as other specialists when provid-
ing the same service. Family physicians should not be
.M13
treated as "second class members of the health care
delivery team." said James Price, M.D., Academy
president.
He told the committee that wealthier people should
pay a greater portion of the cost for catastrophic
coverage as provided in the American Medical As-
sociation's Medicredit plan.
"We are skeptical as to just how all-encompassing
a program can be effectively administered by the
federal government and would strongly urge that,
insofar as possible, continued reliance be placed on
the expertise which has been developed by the private
insurance industry," he said.
Dr. Price opposed a provision of the Mills-Ken-
nedy bill (Medicare for all) regarding payment for
services by specialists, saying that the determination
of which physicians should not be providing specific
services should be left to their peers rather than to
the Social Security .Administration.
(6) Another witness, Donald Schiff, M.D., of the
American Academy of Pediatrics, said, "We must
build upon the strengths of our present medical care
system, taking special pains to retain the currently
productive programs such as Crippled Children's,
Maternal and Child Health, and Children and
Youth."
Dr. Schiff said that preventive health services
should encompass the entire pediatric age scale to
21 years. Deductibles and coinsurance should not be
used for preventive health care for children or preg-
nant women, he asserted. Comprehensive child health
care should be a spelled-out benefit, and increased
funding of psychological services is necessary, ac-
cording to the physician. He urged the creation of a
cabinet post. Secretary of Health.
( 7 ) Ned Parish, president of the National Associa-
tion of Blue Shield Plans, said that the concept of a
totally ta.x-supported and government-administered
national health program is "a solution for a problem
which no longer exists."
"We have built in America a private system which
extends to the vast majority of the population and
serves most of them quite well." he said.
Declaring that the public does not support radical
restructuring of the health system or its financing,
Parish said federal action is clearly necessary that
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 individual
temperature control.
FELLOWSHIP HALL
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TREATMENT AND LEARNING CENTER FOR ALCOHOL RELATED PROBLEMS
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FOUR WEEK MULTI-DISCIPLINE THERAPY PROGRAM
indtvrdual counseling
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FOR ADMIHANCE CALL
JAMIE CARRAWAY
EXECUTIVE DIRECTOR
919-621-3381
Recognized by:
Blue Cross & Blue Shield • Life Assurance Co. of Carolina
• Pilot Life Ins Co • Aetna Life & Casualty
• John Hancock Mutual Life Ins. Co • Kemper Ins
• Metropolitan Life Ins. Co. • United Benefit Life Ins Co
• Security Lite & Trust Co
FELLOWSHIP HALL mc
p. 0. BOX 6928 • GREENSBORO, N. C. 27405
Member of:
• N C. Hospital Association
The Alcoholic & Drug Problems
Assn of North America
> American Hospital Association
FOR MEDICAL INFORMATION CALL
J, W, WELBORN. JR., M.D.
MEDICAL DIRECTOR
919-275-6328
Located off U.S. Hwy. No. 29 at Hicone Road Exit
6V'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.
.'i04
Vol . 35. No.
i would strengthen private coverage and, at the same
; time, eliminate problems that "can never be resolved
; without the active participation of government."
! He called for: federal financing of coverage for the
( poor and medically indigent; catastrophic coverage
not federally-financed, tied to a program of basic
■ benefits; regulation of carriers, with respect to cov-
( ered benefits and solvency; minimum standards for
d t coverage; and, free choice and maximum participa-
tion by the private sector.
(8 ) In other testimony, the U.S. Chamber of Com-
merce urged approval of its own mandated-coverage
NHI plan as "realistic, reasonable and affordable."
il The Mills-Kennedy plan would lead to "federal domi-
\ nation of the health program" and impose excessive
r new payroll taxes, the Chamber said. The Admin-
istration's CHIP plan would significantly increase
It costs to small and medium-sized businesses, and the
fAMA's Mcdicredit plan is nOt comprehensive
enough, according to the Chamber.
(9) Pharmaceutical Manufacturers Association
,! President C. Joseph Stetlcr said the Mills-Kennedy
If bill provision for a restrictive national formulary for
out-patient drugs would distort prescribing de-
cisions. The PMA is most concerned with the pro-
posed price controls on drugs, Stetler testified. TTiis
would force a diversion of sales from research-
1 based firms to the nonresearching sector, he said.
(10) The National Protestant-Catholic Hospital
'Association said the Mills-Kennedy bill does not ade-
quately ensure that hospitals will be reimbursed for
their costs and could force nonprofit hospitals "into
a hand-to-mouth existence." Voluntary donations
would cease, the Association warned.
(11) The Consumer Federation of .America fa-
ifored the labor-backed Health Security bill, and ar-
gued that sole reliance on payroll tax, as in Mills-
; Kennedy, is regressive. The Federation indicated it
1 would prefer a program financed solely out of gen-
eral revenues.
(12) The National Cancer Foundation contended
(that all bills fall short of providing adequate catas-
trophic coverage.
(13) The National Association for Mental Health
iheld that legislation should emphasize outpatient ser-
ivices and stimulate Comprehensive Community Men-
;tal Health Centers.
(14) The National Kidney Foundation said, "We
.have major trepidation about the ability of existing
'administrative machinery to manage an NHI pro-
gram of far greater dimensions and scope than the
end stage renal disease program."
P. O'B. Montgomery, M.D.. of Dallas, has been
^nominated by the President to the Board of Regents
lof the new Uniformed Services University of the
ilHealth Sciences.
Dr. Montgomery, a professor of pathology at the
■University of Texas Southwestern Medical School,
i,was named to serve the remainder of the four-year
No, .August 1974. NCMJ
«.o.
term of Anthony R. Curreri, M.D., recently ap-
pointed president of the new school. The nomination
goes to the Senate for approval.
Other members of the board of the new school in-
clude Malcohn Todd. M.D.. president of the AMA;
Charles E. Odegaard. M.D., president of the Uni-
versity of Washington; Joseph D. Matarazzo, M.D.,
chairman of medical psychology. University of Ore-
gon Medical School; Durward G. Hall, M.D., a re-
cently retired Congressman from Missouri; Alfred A.
Marquez, M.D., of San Francisco, and Lt. Gen.
Leonard D. Heaton, MC, USA (Ret.).
* * *
Working on a sweeping tax reform bill, the House
Ways and Means Committee tentatively has decided
to change the tax laws affecting medical deductions
and business expenses that would affect consumers
and physicians.
Apparently with an eye on the possibility of a na-
tional health insurance program being enacted, the
Committee voted to remove the present deduction for
one-half the amount an individual pays for his health
insurance premium (up to $150), and to increase the
present three percent of income floor applicable to
medical expenses to five percent. The one percent of
income test for drug costs would be abandoned, with
the drug expenses coming under the five percent
medical expenses category. Only prescription drugs
would be covered.
In addition, the Committee decided to do away
generally with the sick pay exclusion under which a
tax break is provided employees who are paid while
sick beyond a certain length of time.
In the business field, the Committee closed the
door on business expenses resulting from attending
conventions overseas (excluding Puerto Rico, Ha-
waii, and American possessions) unless there is an
overriding reason for holding the meeting abroad. All
cruise ship business expenses would not be accepta-
ble, if the Committee's decision should be enacted
by Congress.
* * *
Florida's experience is that the average start-up
time for a full service Health Maintenance Organi-
zation (HMO) is three to five years, Tampa phy-
sician-legislator Richard S. Hodes, M.D., has told the
House Ways and Means Committee.
Testifying at the Committee's national health in-
surance hearings. Dr. Hodes headed a delegation of
the National Legislative Conference, an organization
of state legislators.
Dr. Hodes outlined Florida's recent activities in
health services, noting that unless federal support is
continued for such programs as Hill-Burton, Com-
prehensi\e Health Planning and Regional Medical
Programs, a state's health program might be further
snarled by adding national health insurance.
Dr. Hodes is chairman of the Florida House of
Representatives Committee on Health and Rehabili-
505
tative Services, and heads the Human Resources
Task Force of the National Legislative Conference's
Intergovernmental Relations Committee.
Florida has had an HMO licensing act for more
than two years, he noted, but thus far, only five are
licensed.
Careful heensing to ensure both the quality care
and financial soundness has protected the patient,
"but the experience has taught us a hard lesson,"
he said.
"This lesson is that the average start-up time for
a full service HMO is from three to five years, and
that the popular conception of HMOs as a panacea
for our ills is unfounded. In fact, HMOs have a some-
what limited utility since the institution is totally
dependent on resources within the community," said
Dr. Hodes.
Rural HMOs will require more time and planning
before they can become one of the remedies for
rural health needs, he added.
Book Reviews
Treatmtnt of Cardiac Emergencies. Bv Emanuel Gold-
berger. M.D, .Vv'^ pages. Price, S14.u6. St. Louis. Mis-
souri: C. V. Mosby Company. 1974.
This 346-page manual on the diagnosis and treat-
ment of cardiac emergencies represents a distillation
of the larger, more comprehensive textbooks of car-
diology. Dr. Goldberger has developed within this
monograph an orderly breakdown of the major emer-
gencies with pertinent topics which are well indexed
and referenced. The book is appropriately divided
into subtopics so that a synopsis can be achieved with
relative ease and dispatch.
This reviewer finds the content scientifically ac-
curate and current. The sections on temporary and
permanent pacing arc particularly informative and
well written. The electrocardiographic figures are
abundant and accurate.
Dr. Myron Wheat's chapter on aneurysms reiter-
ates a position which he has espoused on numerous
occasions in the medical literature.
In summary, this reviewer would judge the manual
to be basic, yet adequate for the needs of the gen-
eralist and internist. It is scientifically accurate, well
organized, and presented in an orderly format. This
handbook should find good use in the offices of gen-
eralists, internists, and in the emergency departments.
ICU's. and CCU's of general hospitals. As the
Merck Manual, this manual might also become well
utilized by house officers in training.
RoBiiRT N. HtADLr'i. M.D.
A Surgeon's Odvssev. Bv Loval Davis. M.D 'i'Sf\ paces
Price. SS.y.s. New \or\.\ Doubledav & Co.. 1973.
Loyal Davis stands as one of the strong influences
in .American medicine of the past 20 years. A
man of brilliiincc. energv and integrity, he is out-
spoken sometimes lo his own detriment, but is rarely
compromising in matters he considers of high prin-
ciple.
In his A Surgeon's Oily.s.sey. he has written an au-
tobiography, liberally interspersed with his own
thoughts and opinions. In several instances, as in his
struggle on behalf of the American College of Sur-
geons to stop fee-splitting among surgeons, he has
offered an explanation for his strong opinions.
As a neurosurgeon and chairman of a department,
of surgery at Northwestern University, Davis was in a
position to influence the direction to be taken by
medical educators and to influence the lives of many
students who, by good fortune, worked and learned
under him.
He was in the top echelon of almost all surgical
organizations in this country, including the U.S.
.Arm\ Medical Corps in World War II, the .American
College of Surgeons and the .American Surgical As-
sociation. His longstanding position of prominence
permitted him to comment frankly concerning his
acquaintance with the surgical leaders of the past
two decades. These observations are sometimes more
critical than one usually sees in print, but they come
from a conscience motivated to correct all wrongs
if possible and to "tell it like it is."
His three heroic figures were: his father, a skilled
engineer with the Biuiington Railroad; Allen Kana-
\el. one of the nation's most skilled surgeons; and
Harvey Cushing, under whom Lo\ii\ Davis spent a
year of his training.
To most surgeons and neurosurgeons (the group
who will profit most b\ reading this hook), his
intimate glances and fr^uik comments regarding
Kanavel and Cushing will be of greatest interest.
Chapter six of the book is almost exclusively a de-
scription of Loyal Davis' experience with Dr. Cushing
and is the strongest portion of the book. It is the most
well-written and well-organized section, since it deal>
with one period of time; it does not suffer the fat:
5i)h
Vol. .35. No. s
f much of the rest which skips from one subject to
nother, from one person to another, and, in fact,
Imost without notice, from one time to another.
There are observations about Dr. Gushing which
re not recorded elsewhere, and some of the recorded
npasscs arising between two strong men. Gushing
nd Davis, are worthy of reflection. There is one
nique reference to a small joke Dr. Gushing told on
imself. In this instance Dr. Gushing told the follow-
ng story to his assembled staff:
"You all know Gus, my chauffeur. I came out of
ne house this morning to find the lawn strewn with
javes, the front porch filthy dirty, the car needed
/ashing, and Gus was standing there holding the
cor of the automobile open, trying his best to ap-
ear like a footman. The whole scene irritated me.
told him he should be ashamed of the way he had
jeglected to keep the place and the car clean and
xderly." He paused and grinned broadly. Then, "Gus
istcned with a patient look on his face. As he closed
.le door, he peered in at me and said, 'You forgot
5 wipe the egg off your chin. Dr. Gushing." '"
Loyal Davis" recording of the development of
jforthweslcrn University and its affiliated hospitals,
is observations of the beginning of the American
)'ollege of Surgeons and Surgery. Gynecology, ami
'Obstetrics, of which he has been editor, and his poig-
ant opinions of how one should conduct himself
in a surgical practice are strong points in this in-
teresting book.
I recommend the book to many types of read-
ers, but particularly to those trained and in training
in surgery and neurosurgery.
Eben ALi;xANni r, Jr., M.D.
Parents Guide to AllcrK> in Children. Bv Cliiudc A.
Fnizier. M.D. .V^8 pages. I'nce, $7.95. Garden Cily,
N. Y.: Doiihleday & C onipany. Inc., 1973.
In his preface. Dr. Frazier states that his inten-
tion was to make the complex problems of allergy
comprehensible to the nonmedical reader. This he has
accomplished in a reassuring way. Since allergy is
"in" these days, it is important that all who are al-
lergic understand the causes, the symptoms, the treat-
ment, and the prognosis of their disease. From the
beginning of the book, with Dr. Frazier"s explanation
of allergy as overprotcction by the body, to the last
statement of encouragement, there are 322 pages of
good advice that destroys myths, undermines
quackery and reveals the "mysteries"" of allergy.
All symptoms, from the most minor sniffle to the
worst wheezing, are explained. I do not mean that
Dr. Frazier has oversimplified; I mean that he has
{ ^
■Ji I
ii i
1* il
TENNESSEE VALLEY
MEDICAL ASSEMBLY
THE READ
HOUSE
CHATTANOOGA
TENNESSEE
Sept. 3D S
act.1.197'4
SEPT. 30, 1974
.PROGRAM
^^P^- MONDAY
REGISTRATION
Read House
William H Maslers M D
Virginia E Johnson. Si Loui;
Mo, "SEX AND SEXUALITY'
COFFEE BREAK
EKhlbil Vis-lalion
Louis C Lund:
Motors Corp , Warren, Mich
■THE STATUS OF AUTO
SAFETY (GM ESV e'hibiil
Joseph D Godlrey, M D .
BuHalo, N Y , ■WHATS N
IN SPORTS MEDICINE
LUNCHEON
SPEAKER
Joseph 0 Godlrey, M 0
Team Physician. Buffalo E
"CONTACT-
2 00prT,
400pm SYMPOSIUM
-SEXUAL DYSFUNCTION"
WrlHam H Maslers M D
Virginia E Johnson
Reproduchve Biplogy Res
Foundalion
St Louis Mo
ISymposiurT
phys'CiBn
opan
lo phys
s and A
OCT. 1, 1974
PROGRAM
Oct.
1
TUESDAY
REGISTRATION
Wm E Thornlon. M D .
NASA, Houston, Te« ,
WHAT'S NEW— SKYWAFID '
C A Harv
SuDf
. M D ,
p Mr-i;
Res Lab .
Groton Conn , PACKAGED
ENVIRONMENTS— MAN S
PROGRESS IN SUB-AOUATIC
SURVIVAL
COFFEE BREAK
Peter C Gazes, MO,
Charleston, SC , "WHAT-S
NEW IN MEDICAL OFFICE
EMERGENCES '•
E C Wong, Masier
Acupunclurist Denver, Colo
■ ACUPUNCTURE AS AN ADJUI
Arlhur Taub M D , Ph D
New Haven. Conn ,
ACUPUNCTURE— AN
HISTORICAL ANALYSIS
AND PHYSIOLOGICAL
CRITIQUE
LUNCHEON
Conlinenlal Room
SPEAKER
W .
. M D, Chi
AMPAC Board. Dayton, Ohi
■POLITICAL ACTION— AN
EFFECTIVE LONG-RANGE
PLAN
2 00prT.
4 00 pm
SYMPOSIUM
NEW MEDICAL HORIZONS IN
SPACE AND UNDER THE SEA'
C A Haivey. M D
JuDmafine Medical Rt
ratorv Groton Conne
'UCusT 1974, NCMJ
507
done as he intended — he has made allergy under-
standable.
The only statement of Dr. Frazier's with which I
can disagree is that insect desensitization injections
should be postponed for four or five days after a child
has been stung. Any immunity that hyposensitization
therapy has given the child is essentially gone after
that sting or bite, and therefore he needs his immunit\
started again immediately. Also, the continuation of
desensitization can relieve his s\'mptoms. We have
completely relie\'ed all symptoms of insect stings
within a few hours by using the titration method.
These remarks, however, represent only a personal
disagreement, and a minor one.
Here, finally, is a publication that you. the allergist.
or pediatrician can recommend to distraught parer
of moderately to severely allergic children. By rea
ing it. parents will find answers to all those questio
that they have asked when their physicians have oft'
been too busy to answer fulh. (Whether it should
recommended to parents of a child with mild allergi
depends on the emotional maturity of the paren
— they should be able to distinguish between the
child's mild allergic problems and the very serioi
problems covered in the book.) Even the medic
student or physician wishing to brush up on th
symptomatology and management of allergies shoul
find this book enlightening.
Waltf.r a. Ward, M.D.
in MftttDrtam
Nathan Carl Wolfe, Sr., M.D.
The New Hano\er-Bruns\>.ick-Pender Medical So-
ciety expresses with deep regret the passing of
Nathan Carl Wolfe. Sr.. M.D.. of Burgaw. North
Carolina.
Dr. Wolfe's dedication to his profession, loyalty
to his fellow physicians, and interest in people,
which enhance his contribution in the life of residents
of Pender County and the entire area, are a great
tribute and challenge for all to emulate.
By his knowledge and his deeds, he won the re-
spect and admiration of all with whom he came into
contact, and these memories will li\e on with all of
those who knew him and lo\ed him.
Dr. Wolfe's quiet strength, sincerits and contribu-
tions to his profession combined in him a friend, a
dedicated famih man and distinguished physician.
The Tri-County Medical Societ). on behalf of
medical personnel, gratefully records its appreciation
to Dr. Wolfe and adopts the following resolution:
Bi u Ri;soL\ED. that the New Hanover-Bruns
wick-Pender County Medical Society extend the
tribute in honor of Dr. Nathan Carl Wolfe. Sr., an
that his services, his medical code of ethics, and fee
ings for his fellow man are personal attributes th;
distinguished him above most and endeared him
all. making it truh an honor in knowing him.
served in the capacities of all medical staff position
Pender Memorial Hospital, the Pender Count
Health physician, and practicing physician, as a moi
treasured friend whom it was a special privilege fc
;ill to know.
Br n t-L RTHER Resolved, that a copy of this res(
Union which shared the passing of a truly great pe:
son. whose deeds and memories li\c on with u
be furnished to the State Medical Journal, the new;
papers and members of Dr. Wolfe's family.
New Hano\ er-Bruns\mck-Pendlr County
Medical Society
-MJ8
Vol. .^."i. No
pais
M. O.
HEALTH SCIENCES LIBRARY
-ABOtiW
n'
lOUNA
(he Official Journal of the NORTH CAROLINA MEDICAL SOCIETY
D D
September 1974, Vol. 35, No. 9
:\IORTH CAROLINA
Medical Journal
THIS ISSUE: Emergency Medical Services in North Carolina: I. A Proposal for the Organization of a Statewide
Emergency Services System in North Carolina, Frank Cordle, M.P.H., Ph.D.; Drug Deaths in North Carolina: A Brief
Survey of Deaths Attributed to Drugs in North Carolina, 1973, Arthur J. McBay, Ph.D., and Page Hudson, M.D.; To Com-
mit or Not to Commit, A Continuing Dilemma: Some Guidelines, David Raft, M.D., David S. Werman, M.D., and Roger F.
Spencer, M.D.
lie*'
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BECOTIN®-T
Vitamin B Complex with Vitamin C, Therapeutic
DISTA PRODUCTS COMPANY
Division of Eli Lilly and Company
Indianapolis, Indiana 46206
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1975 LEADERSHIP CONFERENCE
^fi'i. Jan. 31-Feb. 1— Raleigh
1975 ANNUAL SESSIONS
May 1-4— Pinehurst
1975 COMMITTEE CONCLAVE
September 24-27— Southern Pines
iu»i
r^
.^^ ^
-^ M
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).
Contralndicated: 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 frequerjl
and/ or severity of grand mal seizures rr^
require increased dosage of standard ar -i
convulsant medication; abrupt withdraw
may be associated with temporary in-
crease in frequency and/ or severity of
seizures. Advise against simultaneous ir
gestion of alcohol and other CNS depres
sants. Withdrawal symptoms (similarto
those with barbiturates and alcohol) hj\
occurred following abrupt discontinuati'
(convulsions, tremor, abdominal and m-
cle cramps, vomiting and sweating). Ke^
addiction-prone individuals under caret
UsTareyton smokers
would rather fight than switch!
Warning; The Surgeon General Has Determined
That Cigarette Smoking Is Dangerous to Your Health.
King Size; 21 mg. "tar". 1,4 mg nicotine;
I mm: 2) mg. "lar'. 1,5 mg, nicotine, av. pet cigatEiie, FTC Report Match 74,
NORTH CAROLIN,a
MEDICAL JOURNAl
EDITORIAL BOARD
Robert W. Prichard. M.D.
Winston-Salem
EDITOR
John S. Rhodes. M.D.
Raleigh
ASSOCIATF. EDITOR
Ms. Martha van Noppen
Winston-Salem
ACTING ASSISTANT EDITOR
Mr. William N. Milliard
Raleigh
BUSINESS MANAGER
*W. McN. Nicholson, M.D.
Durham
CHAIRMAN
Louis deS. Shaffner. M.D.
Winston-Salem
Rose Pully, M.D. ;>
Kinston
George Johnson, Jr.. M.D.
Chapel Hill
Charles W. Styron. M.D.
Raleigh
♦ ( Deceased)
NORTH CAROLINA MEDICAL JOUR-
NAL, 100 S, Hawlhorne Rd., Winston-Salem,
N. C. 27103, is owned and published by The
Nonh Carolina Medical .Society under the di-
rection of its Editorial Board. Copyright ©
The North Carolina Medical Society 1974.
Address manuscripts and communications re-
garding editorial matter to this Winston-
Salem address. Questions relating to sub-
scription rates, advertising, etc., should be
addressed to the Business Manager, Box
27167, Raleigh, N. C. 27611. All adver-
lisemenis are accepted subject to the ap-
proval of a screening committee of the State
Medical Journal Advertising Bureau, 711
South Blvd., Oak Park, Illinois 60?02 and or
bv a Committee of the Editorial Board
of the North Carolina Medical Journal
in respect to strictly local advertising. In-
structions to authors appear in the January
and July issues. Annual Subscription, $5.00.
Single 'copies. SI. 00. Publication office:
Edviards & Broughton Co., P. O. Box 27286.
Raleigh. N. C. 27611. Second-class postage
iwiil ol Raleieli. \nrlh Ciirolimi 27611.
w
Published Monthly as the Official Organ o
The North Carolin;
Medical Societ
September 1974, Vol. 35, No.
Original .Articles
Emergency Medical Services in North Carolina:
I. .\ Proposal for the Organization of a Statewide
Emergency Services System in North Carolina 53
Frank Cordle. M.P.H.. Ph.D.
Drug Deaths in North Carolina: .\ Brief Survey of
Deaths .\ttributed to Drugs in North Carolina, 1973 54
-Arthur J. McBay. Ph.D., and Page Hudson, M.D.
To Commit or Not to Commit, A Continuing Dilemma:
Some Guidelines 54
David Raft, M.D., David S. Werman, M.D.. and
Roger F. Spencer. M.D.
Editorials
A New Editor 55
The Neglected Disease of Modern Society 55
Bulletin Board
New Members of the State Society 55
What'? When'^ Where':'.... 55
Auxiliary to the North Carolina Medical Society 55'
News Notes from the Bowman Gra\ School of Medicine
of Wake Forest University .- - 56
News Notes from the University of North Carolina
Division of Health Affairs 5^
News Notes from the Duke University Medical Center.. 57
News Notes 57
Month in Washington 57
BtioK Ri;\iE\vs 57
Ln Memoriam 57
Classieied Ads 57
Index to .Advertisers
5e
Contents listed in Current Contents Clinical Practice
i
I
Emergency Medical Services in North Carolina:
I. A Proposal for the Organization of a
Statewide Emergency Services System
in North Carolina
Frank Cordle, M.P.H., Ph.D.
jlURING the past few years
Emergency Medical Services
>MS) have received considerable
clonal attention. There is evidence
it a high percentage of emergen-
^, if treated promptly and proper-
f could result in a substantial sav-
;; in loss of life, disability, cost of
Idical care, long term use of medi-
( facilities and loss of income dur-
j; periods of impairment.
jThe magnitude of the problem of
'ddents and emergencies can be
in in data from the National
;:'ety Council. In 1969 there were
!,I00,000 disabling injuries from
(I types of accidents' with wage
fses, medical expenses and ad-
iiistrative costs, resulting from
t-uma, totaling approximately $13,-
(» 3,000,000. The estimated cost of
Ij pandemic of accidents is $20 bil-
1 1 annually.-- '
The National Safety Council esti-
I tes that 105,000 civilian acciden-
t deaths occur annually and ap-
1 >ximately 47,000 are caused by
V licle injuries.^ The one-millionth
t ffic fatality occurred in 195 I, and
i. the present rate continues, the
,-om the Office of the Chief Medical Ex-
;ler. Division of Health Services. Depart-
t of Human Resources, P. O. Box 2488,
>pel Hill, N. C. 27514.
urrenl address: Epidemiolopy Unit (HFK
, Office of Science. Bureau of Foods. FDA.
C Street, S.W.. Washint^ton. D. C 20204
ITEMBER 1974. NCMJ
two-millionth victim will die by
1976.'' Accidents are currently the
third most common cause of death
in the United States; the rate is
slightly less than that of deaths from
cardiovascular disease and cancer."
Trauma is our leading cause of death
in people under 40 years of age.
More than fifteen million significant
injuries of children under 14 years
of age are occurring; of these in-
juries, more than 16,000 are fatal.''
The National Health Survey esti-
mates that more than two million
victims of accidental injury were
hospitalized in 1965; they occupied
65,000 hospital beds for 22 million
bed-days and they received the ser-
vices of 88.000 hospital personnel. '
From the total number of disabling
injuries, approximately 400,000 of
these result in some degree of per-
manent impairment.
One of the major problems today
in the provision of emergency care,
in both the lay and professional
areas of responsibility for such care,
is the broad gap between knowledge
and its application. In the military,
excellence of initial aid, efficiency of
transportation, adequate care during
transportation, and energetic treat-
ment of casualties are the major fac-
tors in the progressive decrease in
death rates of battle casualties.
Most, if not all, of these skills used
successfully by the military in the
treatment of emergencies must be
developed in the civilian population
if an EMS is to operate in the way
it can and should.
COMMUNICATIONS
A successful EMS involves many
activities, including detection of the
accident or emergency, notification
of a proper EMS agency, dispatch
of the proper equipment and per-
sonnel to the scene, adequate treat-
ment at the scene and en route to
the proper EMS facility, and proper
emergency care and follow-up at the
EMS facility.
A successful EMS involves many
people, including the victim or vic-
tims, the people who detect the acci-
dent or emergency and notify an
agency, operators and attendants of
emergency vehicles, police and fire
department personnel, physicians,
nurses and other hospital personnel.
Obviously, it is a complex system.
The first post-incidental act after
the detection of a medical emer-
gency always involves communica-
tions in some form. Emergency
medical incidents are detected by
people whose ability to respond to
such incidents depends upon their
ability to recognize medical emer-
gencies and on their knowledge
about EMS. One of the weakest
535
links in the chain of an EMS com-
munications system may be the tim-
ing and handling of the notification
to the appropriate EMS facihty. "
Within a community or region,
whether the emergency vehicle ser-
vice is a private enterprise or a gov-
ernmentally operated system, each
ambulance system has traditionally
developed its own operating proce-
dures and definition of purpose,
without much concern for other
similar agencies. In many instances
these systems are so parochial in
their viewpoint that they may not
work together. They fear loss of au-
thority, prestige and funding. These
private companies and governmental
agencies have developed a myriad
of communication systems for their
own benefit. Few of them have made
a real effort to provide the average
citizen with full and quick access to
their services.
In the event of an emergencs in a
rural community, or on a rural high-
way, often it is necessary that a per-
son notify the local sheriffs depart-
ment or the highway patrol, who
then must contact the closest emer-
gency service agency or unit. .All of
these activities take time, for they
require retransmission of the notifi-
cation message to the emergency ser-
vice unit. Distortion and inaccuracy
are common.
An ideal arrangement would be
an EMS communication center that
would receive all notification mes-
sages within its region of operation;
dispatch the appropriate equipment
and personnel to the scene; provide
consultation for management and
care of tiiC sictim to the emergency
vehicle personnel en route to the
EMS facility; and equally important,
educate the public in the use of such
an EMS communication system. In
addition, it would be necessary to
provide adequate information to
people traveling through the area
who are unfamiliar with the s\stcm.
Ideally, the coordinating system
for communications should be lo-
cated in a major EMS facilitN
(which will be defined later) in the
region with sub-s\ stems at other
levels of the EMS system in order
to form an emergenc\ comniLuiica-
tions network that is appropruilc to
536
the needs and capabilities of the re-
gion. In general, the network should
include interhospital links; direct
hospital to emergency vehicle ties;
and the central or coordinating cen-
ter which has radio communications
with all regional hospitals, emer-
gency vehicle services and other
public services. The capability for
telemetry of physiological data be-
tween mobile units and designated
EMS facilties. e.g.. those having
coronary care units, should also be
provided.
Competent personnel are essential
to any effective communication sys-
tem. EMS hospitals must ensure that
the personnel who operate the
equipment are adequately trained,
not only to operate the communica-
tions equipment, but. in the case of
emergency medical services vehicle
attendants, they must achieve a level
of expertise that enables them to ef-
fecti\ely use their vehicle communi-
cations and other equipment to de-
li\er lifesaving care.
EMERGENCY VIEDKAL
SERVICE VEHICLE
PERSONNEL
The increase in public and legis-
lative demands for vast improve-
ments in the EVIS system should re-
sult in a critical esaluation of the
role and training of those people
who. in most accident cases, are re-
sponsible for the initial care gi\en
at the scene, as well a\ the care ren-
dered en route lii an EMS facility.^
namel\. the individuals who man the
EMS vehicles. In I4fi7. standards
were published b\ the United States
Department of Transportation con-
cerning the requirements for such
personnel. Under Standard II. the
first eight minim. il requirements
were addressed to the need for the
establishment of training, licensing
and related requirements for ambii-
lace and rescue workers. In 14h,S.
the National .Academy of Sciences
and the National Research Council
analszed the regulations then current
regarding ambulance ser\ices and
training throughout ihe nation. '
One concliisiiui reached h\ the
academ_\ was that the courses of
instruction lacked uniformity. The
acadenn foLind thai 70 different
r3
ft
ill
programs, ranging in length froii ji,
three hours to three and one-haj ^;
days, used 20 different textbooks
A second conclusion was th;
there was no generally accepte
standard of proficiency. Only l! -
states required training of emergenc
vehicle personnel, and only eight (j
these specified course content. Def, -
ciencies noted by the academy ir,
eluded a lack of coverage in the -fo, v
lowing areas: (1) operation ( j
medical equipment such as resuscit£
tors and cardiac message equipmen ^,
(2) obstetrics; (3) communico j;
tions; (4) extraction of victims frot
vehicles; (5) handling of multipk
trauma situations; and (6) tec!
niques for holding a patient in
stable condition.
As a result of these finding
the Department of Transportatioi
through a consulting firm, develope
a basic course for Emergency Med
cal Technician I. The course was dt
signed to be completed in 60 to 8
hours and would consist of two t|
three lessons given by various ir
structors. .After reviewing a large s(
lection of training manuals, the cot
suiting group selected a textbook dt
veloped by the American Academ
of Orthopedic Surgeons, Einergem,
Cure and Transportation of the Sic
and Injured. The training unit cot
sists of 25 lesson units and an addi
tional unit for clinical experience t
be pro\ided in a hospital.
Pilot programs conducted in sev
eral states ha\e clearly demonstra
ed the \alue of training be_\ond tf
basic level." Such programs provic
career opportunities for the erne
genc\ medical technicians who ha\
a high level of ability, intent an
motivation. The EMS-II course n
quires an understanding of why ce
tain drLigs and treatment are pri^
scribed. It requires appro\imate|
4X0 hours of classroom lectures an
practice and an additional 500 hoii
of clinical practice and observation
As in the case with other educ;.
tional programs in which hospita,
participate, coLirse credits at con
niLinitv colleges should be sought tc
those people who successfully con
plete emergencv medical technicia
courses. Main of these programs i
cdmnuinitv colleges use hospit.
Vol.. .i.s. Nc,
rji
l;
M
M
'Issrooms as an extension of the
vlege campus.
Financial support for the sophis-
iited emergency vehicles and the
!hly trained technicians who man
im is beyond the financial means
any private enterprise system cur-
tly operating ambulance services,
'me means must be found to inte-
!.te the EMS vehicles and techni-
cs into a regional EMS, with fi-
acial support coming from com-
linity, region, state or federal
|ids, and additional support from
" Vment by patients who are trans-
■j' 'bted by the system. Without the
"bhistication of the EMS vehicles
1 technicians described, it is dif-
T'ilt to determine how improve-
jjl nt in mortality rates and mor-
liity from accidents can occur at
i next level of EMS care.
1
CATEGORIZATION OF
EMERGENCY MEDICAL
FACILITIES
'For decades the emergency facili-
; of most hospitals have consisted
I only "accident rooms," poorly
iiipped, inadequately manned, and
linarily used for a limited num-
'■■ of seriously ill people or for
•irity victims of disease or injury.'-'
|;iety now looks to the hospital
ergency department as a com-
inity center for outpatient care.
IPlanning groups should be con-
med by the fact that approximate-
J80 percent of the people utilizing
'ergency departments are people
Ihout emergencies. The great per-
;itage of emergency department
'its results from the diminishing
mber of physicians in the primary
e area. Hospital emergency de-
ftments have never sought the role
iproviding primary care, but they
Ve inherited it by default.
'Despite the consumers" dissatis-
'ition with what they consider to
V the indignity of impersonal care
r' dered by an institution, individual
I mbers of society, in their fear,
■' ithy, financial in^ability, or ignor-
; e, seek health care by the epi-
e, and in doing so they look to
emergency department as the
'y source available.
')Dver a period of years, hospitals
I'e become the point of entry into
,
the health care delivery system for
about one-third of the United States'
population.'' For example, of the 40
million emergency room visits dur-
ing 1966, more than two-thirds can-
not be classified as emergencies.
Those people who are responsible
for designing an EMS system for a
state or region must face two facts.
It is a fact that the system providing
EMS in most communities needs
equipment, staffing and refinement
if trauma, "the neglected disease of
modern society," is to be controlled.
The number of physicians who me
experienced in the treatment of mul-
tiple injuries is limited. The need
for special training in immediate
care in the overall direction of emer-
gency departments of a calibre com-
mensurate with that attained by only
a few individuals (those in active
military field units who care for
combat casualties) is obvious. Medi-
cal undergraduate schools and resi-
dency training programs are gen-
erally inadequate in traumatology
and mass casualty care.
It is a second fact that until suffi-
cient and separate hospital ambu-
latory clinics are set up to provide
primary medical care, or until suffi-
cient numbers of physicians become
available to deliver such care, and
to do so during hours other than
from nine a.m. to five p.m. on week-
days, emergency medical depart-
ments are going to be faced with this
dual and wasteful use of resources.
The current dictum that an EMS
vehicle should deliver a patient to
the nearest emergency unit is no
longer acceptable. It is essential that
the patient be transported to the
EMS facility which is best prepared
to handle his particular problem. In
the absence of a descriptive categori-
zation of the level of care that might
reasonably be expected at a facility,
neither the patient nor the EMS ve-
hicle personnel can judge which fa-
cility is adequate to the immediate
need.
Basic to the concept of categoriza-
tion is the recognition that all hospi-
tals in a community or region need
not have equal EMS capability. Al-
though all should provide life-sup-
port services, it would be unrealistic
'ITEMBFR 1974. NCMJ
to expect all emergency departments
to be manned 24 hours each day by
board certified surgeons.
However, it is usually taken for
granted by the general public that
every emergency room can render
full care for injuries of all magni-
tudes. That the public be thoroughly
informed of the extent of care that
can be administered at EMS facili-
ties at various levels of competence
is an obligation to the severely in-
jured patient as well as to the lone
physician, to the small staff of re-
mote hospitals, and to institutions
with minimal emergency department
facilities. A categorization of EMS
facilities would serve to indicate the
level of care that a patient can rea-
sonably expect (Figure 1 ).
Hospital EMS departments should
be surveyed in the various re-
gions designated to determine the
numbers and types of EMS facilities
necessary to provide optimal emer-
gency treatment for the population
of each region. Provisions must be
made for expected changes in the
population for the next few dec-
ades. When the required number and
types of treatment facilities have
been determined, it may be neces-
sary to lessen the requirements of
some institutions, increase them in
others, and even redistribute re-
sources to support space, equipment,
and personnel in the major EMS
facilities. Until patients. EMS ve-
hicle personnel, and hospital staffs
are in accord as to what the patient
might reasonably expect and what
the staff of an EMS facility can real-
istically be expected to administer,
and until effective transportation
and adequate communications are
provided to deliver accident victims
to proper facilities, our present
levels of knowledge cannot be ap-
plied to achieve optimal care, and
little reduction in mortality or last-
ing disability can be expected.
In North Carolina the Medical
Care Commission" has proposed
the following levels of categorization
for EMS facilities. In an opinion
from the Attorney General of North
Carolina (See Appendix A) the
Medical Care Conmiission does
have authority to categorize hospi-
537
Category
Comprehensive
Emergency
Center
II
General
Emergency
Center
III
Intermediate
Emergency
Center
IV
Limited
Emergency
Center
V
First Aid
Emergency
Center
Scope of
Capabilities
Inmed-
iate
Care
Yes
Yes
Types
of
Emer-
gencies
2*
3*
5*
Full
Time
Direc-
tor
MD
Emergency Services
Department Staffing
Yes
Yes
Admin
Person-
al Data
Collec-
tion
Other
MD's
lir*
1**
2*^
3iv*
3*Tir
Yes
Yes
Hospital
Staffing
l^r*
2i\-*
3^^-*
3**
m u
c c
o (0
O X
o c
^ QJ
On
Call
On
Call
On
Call
On
Call
On
Call
In
ER
In
Hosp
In
Hoap
Support Services
In
Hosp
In
Hosp
In
Hosp
In
Hosp
on
Call
In
Hosp
or
on
Call
In
Hosp
In
Hosp
In
Hosp
In
Hosp
In
Hosp
In
Hosp
In
Hosp
Ready
and
Staffed
Ready
and
Staffed
Readily
Avail-
able^
Readily
Avail
able
Ready
and
Staffed
Ready
and
Staffed
Readily
Avial-
able
Readily
Avail-
able^
B
2 s; S :ii!
Ready
and
Staffe
Ready
and
Staff*
Ready
and
Staffe [
ii
Figure 1. Suggested Guidelines for Categorization of Hospital Emergency Services
* See Scope of Care
** 1 = More than two years of residency training and on duty in ER.
** 2 = More than one year of residency training and on duty in ER.
** 3 = Twenty-four hour staffing by qualified personnel on premesis or on call.
(10,11).
S
tals as it proposes under current sta-
tutes in the State of North Carolina.
The proposed categories of EMS fa-
cihties in North CaroHna are out-
Hned as follows:
Type I — Comprehensive emergency
center
Facilities: Fully equipped to ren-
der complex and comprehensive
emergency care on the premises, as
well as any required definitive
care. Diagnostic facilities constantly
available for even the most special-
ized procedures. Blood bank avail-
able. Ready accessibility to special
purpose operating room.
Staffing: Twenty-four hour staff-
ing by highly qualified medical and
hospital support personnel. Reads
accessibility to a full range of
specialists on a 24-hour basis.
Scope of care: Routinely capable
of providing the most advanced sur-
gical and medical procedin'es in-
cluding heart lung surgery, kidney
dialysis and major plastic surgery.
(Such procedures are generally pro-
vided onh at medical school affili-
ated hospitals. )
Type II — (General emergency center
Facilities: Equipped to render
complex emergencv care on the
538
premises. Diagnostic facilities con-
stantly available for most specialized
procedures. Blood bank available.
Ready accessibility to special pur-
pose operating rooms. Adequate fa-
cilities and equipment available to
provide services listed in this section
under "Scope of care.""
Staffing: Twenty-four hour staff-
ing by highly qualified medical and
hospital support personnel. Ready
accessibility to a broad, but not full,
range of specialists on a 24-hour ba-
sis.
Scope of care: Routinely capable
of providing advanced surgical and
medical procedures. Services avail-
able include: anesthesiology, gen-
eral surgery, internal medicine,
neurosurgery, obstetrics/gynecology,
ophthalmology, orthopedics, pedia-
trics, psychiatry, radiology, thoracic
surgery and urology. One or more
highly specialized services, in addi-
tion to the services listed, may be of-
fered.
Type III — Intermediate emergency
center
Facilities: Equipped for most life-
threatening emergencies, but not
necessarily providing highly special-
ized resuscitative and surgical pro-
cedures. In addition to routine dh
nostic laboratory and x-ray faciliti
blood bank is constantly available.
Staffing: Twenty-four hour sta
ing by qualified personnel on pre
ises or on call but lacking a bro
range of specialist services and met
cal support personnel. Physici;
coverage sufficient to provide re
tine medical and surgical services
the absence of physicians assign
to provide primary coverage.
Scope of care: Equipped to re
der general medical care and to p
form procedures usually includ
under general surgery. Lacking
some specialized diagnostic, medii
and surgical procedures. May of
one or more specialized servic
such as internal medicine, orthof
dies, thoracic surgery or uroloj
Total needs for stabilization or c;
of the critically ill or injured nr
exceed the capabilities of faciliti
medical staff and personnel.
Type IV — Limited service em^
gency unit
Facilities: Same as for Type IN
Intermediate emergency center.
Staffing: Normally provides I-
hour staffing by qualified personi
on premises or on call, but lacki
Vol. }5. No
r
broad range of specialist services
-d medical support personnel. Dif-
-s from staffing of Type III fa-
ities in that professional coverage
not available at times when regu-
^•ly assigned physicians are unable
be in attendance.
Scope of care: Equipped to ren-
r general medical care and to per-
rm procedures usually included
& Jder general surgery. Lacking in
me specialized diagnostic, medical
d surgical procedures. Total needs
^r stabilization or care of the criti-
llly ill or injured may exceed the
pabilities of facilities and person-
|(pe V — First aid emergency unit
Facilities: Emergency units
;uipped for only first aid and lim-
d diagnostic procedures.
iStaffing: May be limited to part-
'iie professional nursing coverage
d part-time physician coverage.
.Scope of care: May be limited to
inimum procedures such as emcr-
1 iacy resuscitation and treatment of
'inor conditions. Capable of per-
j-ming procedures such as hemo-
'.sis, shock therapy, maintenance
i airway and cardiopulmonary re-
scitation. Able to provide profes-
31 iiinal assistance so as to expedite
\i 3msfer of patients to more appro-
late facilities elsewhere if indi-
ted. (All hospitals should be re-
m jired to furnish this type of service
a minimum. )
THE EMS EMERGENCY
) ROOM/TRAUMA CENTER
^Sophisticated communication and
jitj Jnsportation equipment is criti-
ly needed for emergency services,
it is of little use if the pcrson-
; manning the EMS facility are
,t competent or trained to render
); kind of care required.
The intensive care and continued
i'se surveillance which are neces-
;y to the life-maintenance of a cri-
ially ill patient are beyond the
ipe of the average practicing sur-
i)n or physician.' The average
.;l! luctitioner cannot devote the nec-
tary time and involvement re-
red for the long-term intensive
nagement of these patients. Only
|;en around-the-clock observation
ti
let.
Ida
llat
s \
is available by hospital-based physi-
cians, or by senior surgical and
medical residents in training, can a
high quality of medical care be con-
tinually available." Such high
quality personnel in these facilities
are often eager to manage the diffi-
cult problems that are truly beyond
the scope of one physician.
At the present, there are many
competent medical personnel in the
community who perform in an ex-
emplary manner, especially in the
acute resuscitation phase. These
physicians, unfortunately, have no
back-up and they are held responsi-
ble for complex problems that are
beyond the ability of one physician.
The patients in such a situation
(who sometimes may require ma-
jor surgery), after adequate resusci-
tation, must be transported to facili-
ties having more adequate equip-
ment and staffing.
As a solution to this problem,
many states, including North Caro-
lina, are organizing, on a statewide
basis, regional EMS systems with
specialized trauma centers to be lo-
cated at the appropriate level of the
categorized EMS facilities. The
trauma unit proposal, suggesting
that such units be located at appro-
priate levels of the EMS system,
should provide an excellent plan for
the in-hospital care of the critically
injured. The plan of early physical
segregation of patients into a special-
ized area, staffed and equipped to
completely resuscitate and evaluate
the patient having serious multiple
injuries, can be adapted to hospitals
of ranging size and potential. Under
the plan proposed for North Caro-
lina, trauma centers probably would
be located in Types 1, II, and 111
EMS facilities, with Types IV and
V delivering the emergency services
as described previously. The patient
flow throLigh the proposed EMS sys-
tem is presented in Figure 2.
A solution to this complex prob-
lem will require the cooperation of
many interest groups and the effici-
ent use of many resources. Of the ut-
most importance, in instituting an
EMS system on a statewide basis, is
convincing individual physicians,
hospitals, emergency vehicle opera-
[ITEMBER 1974, NCMJ
r
tors and, perhaps most important,
the general public, that such a sys-
tem can save many lives and reduce
the long-term or permanent dis-
ability resulting from trauma.
A satisfactory outcome, after se-
vere traumatic injury, is dependent
upon two basic factors: the availa-
bility of initial medical care, and the
adequacy of those early therapeutic
measures. According to Frey et
al,'-' their study showed that 18 per-
cent of 150 accidental deaths might
have been avoided with better emer-
gency medical care. Delays in prop-
er resuscitation and evaluation in
life-endangering injuries are the cru-
cial indices to survival. Injudicious
or inadequate emergency medical
management can cause unnecessary
fatalities and temporary or perman-
ent disabilities.
RESEARCH AND
EVALUATION
The complexities involved in the
various aspects of severe injuries,
in conjunction with the deficiencies
in our health care delivery system,
have thus far precluded comprehen-
sive quantitative analysis. Emer-
gency case records are often inade-
quate. Sufficient thought has not
been given to extracting informa-
tion concerning the nature of the ac-
cident; the clinical condition of the
patient at the scene of the accident,
during transportation, and at the
time of entry to the emergency de-
partment; the resuscitative measures
used; the responses of the patient;
the medical laboratory records and
x-ray records; and to the ultimate
outcome, whether or not it is tem-
porary or permanent disability or
death.
This information is vital on sev-
eral scores. It is essential in re-creat-
ing the circumstances of the acci-
dent and in relating the mechanisms
of trauma to outcome. It is neces-
sary for clinical analysis, for im-
provement of therapy, and for the
assessment of the entire EMS sys-
tem.
The exact cause of death i many
an injured person can be learned
only from complete autop y exami-
nations. Especially in tl" event ol
multiple injuries, prior , of treat-
539
ACCIDENT
Motor Vehicle
Fire
Firearm
Drugs
Poison
Other
EMS VEHICLE
SERVICE
Type of EMS
Vehicle
Level of
Personnel
Training
/What kind \
jf Vehicle \
, and Personnel/
\to Scene? /
Initial
Contact With
EMS System
K Survived \ L
Injured J ~}
Condition of
Patient
Treatment at
Scene and En-
route
Selection of
EMS Center
Communication
with Center
CME Report
Crash Report
Pathology Repor
Death Certi-
ficate
Re -admit
at Later
Date
I
Examined and Released
Examined, Treated
and Released
3
Examined and Admitted \
to Hospital J
1
Admitted
Intensive
Care
L'nit
Admitted
Trauma
Unit
Routine
Hospital
Admission
{ Discharged J
Figure 2. A Patient Flow and Information System Model for EMS Systems in North Carolina.
ment may have been directed toward
obvious or overt injtiries. But covert
injuries such as laceration of major
blood vessels, retroperitoneal hem-
orrhage or fat embolism may have
been the primary cause of death.
The findings in large numbers of
autopsies must be critically analyzed
in order to point the way to neces-
sary changes in treatment. One such
study of 950 consecutive autopsies
of accident victims revealed an un-
expected finding; in 3cS percent of
those who died in the hospital, or af-
ter returning home, following frac-
ture of the hip, the primary cause
of death was pulmonary embolism.
Yet. pulmonary embolism was the
recorded cause of death in only two
percent of a large number of patients
who had not been autopsied, but
whose c.ises were similar.' '
Ol the utmost importance in un-
dertaking the design and implemen-
tation of an Emergency Medical Ser-
\ices system is the inclusion, from
the start, of methods for evaluation
and monitoring of the system. With
the introduction of modern com-
puter technology . it is no\\ possible
to thoroughly iinestigate the epide-
miological and clinical aspects of
this major health problem. As infor-
mation is collected for the epidemio-
logic information system — kind of
accident, treatment at the scene and
en route to the EMS facility, extent
of anatomic damage, operative treat-
ment employed, and specific compli-
cations — the program will not only
be formulating solutions but also ini-
tiating feedback based on fact rather
than on intuition. I'he information
system will be instrumental in
analyzing morbidity and mortality
rates for graded injuries in paired
patients, or in comparable groups
of patients managed by the various
regions, different kinds of emer-
gency vehicle services, and different
or similar levels of EMS facilities.
Other areas of assessing an EMS
system should be concerned with
quantifying some of the variations in
convalescence, disability and reha-
bilitation. In order to carr\ out this
kind of L|uantiiati\e assessment, ac-
ceptable scales of measurement in
these areas must be developed. The
development of such scales is no
easv iiKitter. l-dr example, at a meet-
ing of a local t'omniitlee vin 1 rauma
of the American College of Surgi
ons. approximately 50 distinguishe,
surgeons were presented with a thet
retical problem as to when a your
man should resume heavy labor fo,
lowing specific injury. ■■ Their est
mates of the duration of disabili
ranged from two months to one yea
with little concentration of the est
mates between.
There is currently scant scientif
basis on which to predict or measui
convalescence or the duration of di
ability. The information coUecte
and studied by epidemiologic metl
ods from various EMS systems ar
facilities should begin to shed soni
light on these problem areas.
SIIVIIVIARY
Ihe implementation of a broa(
based EMS system as described
this paper is a very real probler
Ihe development of any major
organization scheme and the coi
comitant distribution of medical r
sources will unfortunately meet wi
resistance to change. The medic
societv, the hospitals, and most ir
pcrtant, the physicians in the fie
must be convinced of the value
Vol. is. No.
iqh a system as has been described
■ this paper. Hopefully, support
ay be obtained when the organiza-
ons and people involved are aware
' the necessity for the development
I' such a system. The medical staffs
: hospitals in various regions must
; assured that they will be given
e necessary modern equipment es-
l^ntial to carrying out their tasks.
ti However, the most important as-
;;ct of convincing the public and
e hospital personnel that an effec-
v/e EMS system is feasible is a
)ntinuing surveillance and evalua-
on information system which can
oduce hard data rather than mere
(ipressions for decision-making,
t the same time, the information
stem should be designed in such a
ay that the continuous surveillance
ill allow modification and changes
I take place in the various regional
istems to improve their overall per-
irmance. Without a responsible
aluation and surveillance informa-
)n system, a statewide EMS system
ems to be an inappropriate use of
s taxpayers' money, as well as the
.;e of scarce medical resources cur-
;ntly available.
'iXhis paper is intended as a forum
] present problems encountered in
'her states and to stimulate some
jinking about such an EMS system
Ithe community level. After all, the
|(ccess of any system of this sort is
'jing to require much cooperation
>' concerned individuals at the local
t/el, and unless they are reasonably
{til informed, I seriously doubt that
Ich cooperation will be forthcom-
Ic
Appendix A
9BJFXT:
^Hospitals; Emergency Services; Classi-
ification of Services; Required Services.
JQLESTED BY:
'Mr. William F. Henderson
F.xeculive Secretary
jrhe Norlh Carolina Medical Care
Tommission
OPINION BY:
Robert Morgan, .AUorncy General
Harry W. McGalliard. Deputy Attor-
ney General
QIKSTION:
Does the North Carolina Medical Care
Commission have authority to classify
hospital emergency services in accord-
ance with types or classifications or
emergency service available, and to re-
quire hospitals to maintain the stand-
ards of emergency care service of the
type or classification which such hos-
pit;d selects for itself?
CONCLUSION:
Yes, the North Carolina Medical Care
Commission does have authority to
classify hospital emergency services in
accordance with types or classifications
of emergency service available, and to
require hospitals to maintain the stand-
ards of emergency care service of the
type or classification which such hos-
pital selects for itself.
1 he North Carolina Medical Care
Commission is considering classification
and defining hospital emergency services
according to the types and quality of
service which may be available, perhaps
in five types such as:
Type I — Comprehensive Emergency
Center
Type II — General Emergency Center
Type III — Intermediate Emergency
Department
Type IV — Limited Service Emergency
Unit
Type V — First Aid Emergency Unit
Each type would be fully described
with respect to the facilities, staffing,
.md scope of care required with respect
to each type of service. Once the classi-
fications were adopted, each hospital
would be expected to designate the type
of emergency services it pioposed to
render. Ihe furnishing of the type of
emergency service so selected would be
tied in with the licensing of the hospital
under the Hospital 1 icensing Act. and
lhere;ifter each hospital would be re-
quired to furnish and maintain the stand-
ards of the type of emergency service
which it elected to render.
The question is whether the North
( arolina Medical Care Commission has
authority to do this under the provisions
of the Hospital Licensing Act. G.S. 131-
I 26.2 provides as follows:
S .31-126.2. Purpose — The purpose
of this article is to provide for Ihe
development, establishment and en-
forcement of basic standards:
{ 1 ) For the care and treatment of
individuals in hospitals and
(21 For the construction, main-
tenance and operation of such hos-
pitals, which, in the light of existing
knowledge, will ensure safe and ade-
quate treatment of such individtials
in hospitals, provided, that nothing
in this article shall be construed as
repealing any of the provisions of
the General Statutes of North Caro-
lina.
G.S. 131-126.3 provides in part ;is
follows:
After July 1st, 1947, no person or
governmental unit, acting severally
or jointly with any other person or
governmental unit shall establish,
conduct or maintain a hospital in
this Stale without a license.
The above statutory provisions con-
stitute an adequate grant of authority
from the General Assembly for the North
Carolina Medical Care Commission to
carry out such a program with respect
to hospital emergency services as is de-
scribed above.
1, Accidental Facts. 1969. National Safety
Council. Chicago, Ulinois.
2. 196S Annual Report. National Institutes ol
Health. U.S. Government Printing Office.
.1. Accidental Death and Dibability; The Neg-
lected Disease of Modern Society. Division
of Medical Sciences. National Academy ol
Sciences. Washington, DC. 1969.
4, Report conference on trauma. J i rauma H:
11.1-120. I96S.
.V Keelon RE. O'Connell J: The Basic Pro-
tection for the Traffic Victim: A Blue-
print for Reforming Automobile Insurance.
Boston: Little. Brown and Co. 1966.
6. Report of a Conference on Trauma. Na-
lioULd Institute General Medical Sciences.
Belliesda. Md. Feb 1965.
7. Reid HV: Communications improve care.
Hospitals. JAHA 47: 99-l(B. 197.1.
5. Smith LR: From ambulance driver to EMT.
Hospitals. JAHA 47: inj-IOS. 197.1.
9. Harvey JC: Categorization of emergency
capabilities. Hospitals. JAHA 47: 69-72.
197.1.
ID. Suggested guidelines for categorization of
hospital emergency services. From: Cate-
goriz.ition of Hospital Emergency Capa-
bilities. Chicago: The American Medical As-
sociation. 1971.
II. Hospital Emergency Services in N*>rlh Caro-
lina — A Study of Existing Patterns and
Policies: A Recommended Approach to At-
tainable Improvements. From: The North
Carolina Medical Care Commission. Ra-
leigh, 1970.
12 Flashner BA. Boyd DR: The critically in-
jured patient: A plan for the organization
of a statewide system of trauma facilities.
Ill Med J 119: 256-265, 1971.
II, Frey CF. Hueike DF. Gikas PW; Resus-
citation and survival in motor vehicle acci-
dents. J Trauma 9: 292-,1IO. 1969.
14. Fitts WT. Lchr HB. Bilner Rl . Spelman
JW: An analysis of 95(1 fat.il injuries.
Surgery 56: 661-66K. 1964.
ICll
el! ^1
iid
Oil
lel
)
Critical days: The fourth, fifth, seventh, ninth, eleventh, thirteenth, fourteenth, seventeenth,
and twenty-first, are, by some authors, denominated critical days, because febrile complaints
have been observed to take a decisive change at these periods. — H'illidiii Biulian: Dmiusiic
Medicine, or a Trcalisc on llic I'nvcniion and Cure of D/.uii.ic.v h\ Rci;inicn tiiul Simple Medi-
cines, etc.. Richard F, dwell. I7W. p. 474.
iriEMBLR 1974. NCMJ
541
Drug Deaths in North Carolina:
A Brief Survey of Deaths Attributed to Drugs
in North Carolina, 1973
Arthur J. McBay, Ph.D.* and Page Hudson, M.D.v
'T' HERE is rapidly growing in-
terest and concern about drug
and other chemical hazards, if ques-
tions of this office from professional
groups and individuals are any mea-
sure. The queries are probably well
directed, since death is a finite mea-
sure of hazard and the Medical Ex-
aminer System is responsible for the
determination of the cause and man-
ner of death for any person who
dies in circumstances indicating pos-
sible accident, suicide, homicide or
absence of medical care. Included
are all deaths directly, and most
deaths indirectly, caused by drugs.
It is important to try to distinguish
between "drug deaths" and "drug-
related deaths." We define the for-
mer as the effect of a drug in an in-
appropriate quantity being the
proximate cause of death. Examples
include ingestion of 20 propoxy-
phene capsules and fatal aspiration
pneumonia as a result of ingestion
of a handful of secobarbital capsules
' Chief Toxicolojiist, Dep.trtmcnl of Human
Resources. Di%ision of Health Services. Office
of the Chief Medical Examiner. P.O. Bo.\ 248S.
Chapel Hill. N. C 27514. and Professor of
Pathology. School ol Medicine and Professor
of Pharmacy, School of Pharmacy, Universit\
of North Carolina. Chapel Hill. N.C.
t Chief Medical Examiner. Department of
Human Resources. Division ol Health Services.
Office of the Chief Medical Examiner.
Box 24S8, Chapel Hill. N,C, 27514. and
fessor of Pathologv. School of Medicine,
versity of North Carolina. Chapel Hill. N C
Reprint requests to Dt- McBav.
542
PO.
Pro-
L ni-
— even after the barbiturate has dis-
appeared from the system. Drug-
related deaths include occurrences
such as one heroin pusher's shooting
another who is crowding in on his
"territory" and the pedestrian with
a blood alcohol of 300 mg/dl stag-
gering across the road and being
struck by an automobile.
The data presented in this brief
survey represent close approxima-
tions of reports from the Toxicology
Laboratory of the Office of the Chief
Medical Examiner (Table 1) and
preliminary reports from the Vital
Statistics Section of the Division of
Health Services.'
.■\lcohol is the principal agent in
drug deaths and in drug-related
deaths in North Carolina and in the
rest of the nation. Approximately
one-half, or 175, of North Carolina's
deaths from poisons in 1973 re-
sulted from acute ingestion of large
quantities of alcohol (500-1,000 ml
of 50 percent ethanol ) within a short
period of time. The number of alco-
hol-related deaths is much greater
and includes the disease states
brought on by alcohol — liver dis-
ease, pancreatitis, central nervous
svstem damage, and others. Also in-
cluded are the majority of auto crash
deaths, fatal shootings and stab-
bin2s, drownings, deaths in fires, and
deaths from suicidal or accident;
overdosing with other drugs whil
the person is under the influence c
alcohol. We conservatively estimal
that there are at least 3,000 alcoho
related deaths in North Caroliti
each year. The total number c
deaths in North Carolina for 197
was approximately 47,000. Onl
four deaths were attributed t
isopropvl (rubbing) alcohol, an
four to methanol (wood alcohol'
No deaths were attributed to lea
from alcohol or from any othe
source. Dr. Chafetz, Director of th
National Institute of Alcohol Abus
and Alcoholism has commented, "E
whatever standard we weigh tt
drug situation, number of user
abusers, availability, dollar valui
death, disease, destruction, shattere
lives — alcohol is number one."-
Barbiturates killed 35 people f
1973 and continue to be directly ri
sponsible for the largest number (
medicinal drug deaths in Norl
Carolina and in the rest of tl
United States. Nearly all of thes
deaths have resulted from patient
purposefully taking an overdose i
secobarbital, pentobarbital or am<
barbital which they obtained legal
by prescription. Of the rapid-actir
barbiturates, a fatal dose for i
adult is approximately one gra
Vol. 35. No.
froent
iilO
19
29
t!
W9
!59
l!69
Table 1
Toxicological Findings in Medical
Examiner Cases— 1973*
BLOOD VOLATILES
Ethanol
(mg/dl)
ital Negative
■0-90
0-190
10-290
0-390
0-490
0-
ital Positive
Number
of
Cases
3,301
452
727
620
273
87
29
Other Volatiles
pe
Dpropanol
iraldehyde
bthanol
■ Ivents
jothane
'nbalming fluid
tal
,tal Volatiles
Number
of
Cases
4
3
3
5
1
115
5,620
S79
89
fta^i
F
CARBON MONOXIDE
Number
of
Cases
266
30
11
9
12
14
15
37
40
3
437
BARBITURATES
_^ipid-acting:
liftmobarbital
Pentobarbital
Secobarbital
lAmobarbital
Wntobarbital
Pentobarbital
Number
of
Cases
Secobarbital
Butabarbital
Secobarbital
^barbital + Amitriptyline
Secobarbital
Secobarbital
-f Propoxyphene
Ethchlorvynol
"Subtotal
■enobarbital
renobarbital
[botal
24
10
-f Propoxyptiene 1
11
tal
[
he
OTHER SIGNIFICANT FINDINGS
Number
of
Cases
IHPOxyphene
^ichlorvynol
icy I ate
Hiitriptyline
iroin
Jiprobamafe
Wttiimide
iinide
lenic
'roridazine
21
6
6
4
4
3
3
2
2
2
•I'TEMBER 1974, NCMJ
('
Quinidine
Methadone-related
Amptietamine
Imtpramine
Ptiosphorus
Methaqualone
Pentazocine
MDA
Morptiine
Total 64
TOTAL MEDICAL EXAMINER CASES 5,628
* Ttiese totals represent the number of
cases in which a sufficient amount of a drug
or chemical was found to be the primary
cause of death in the cases submitted to the
Toxicology Laboratory. The exceptions to this
may be: less than 30 mg dl of ethanol, less
than 30 percent of saturation of carbon
monoxide and embalming fluid. Alcohol,
when present with other drugs, is recorded
as the other drug with no mention of alcohol.
(10-100 mg doses); approximately
four grams of phenobarbital is a
fatal dose. Analysis of individual
case records suggests that possibly
the prescription of fewer capsules
and the less toxic phenobarbi-
tal, diazepam, or chlordiazepoxide
would reduce the hazard. The Drug
Enforcement Administration has
called the rapid-acting barbiturates
more dangerous than heroin. These
drugs have been rescheduled from
schedule III to II in the Controlled
Substances Law.-^
Accidental and suicidal deaths
from overdoses of propoxyphene
have increased greatly in North
Carolina and in many other com-
munities in the past two years. Most
of these deaths have been caused by
propoxyphene hydrochloride (Dar-
von®), not the newer Darvon-N's'
or the still newer generic forms of
propoxyphene hydrochloride. It is
unfortunate that the efficacy of this
drug as an analgesic has been so
seriously questioned and is so toxic.
Ingestion of approximately 1,300
mg (20-65 mg doses) may cause the
death of an otherwise healthy adult.
The dangers of this drug were not
fully appreciated until recently be-
cause of difficulties in detecting and
quantitating it in blood and tissues,
Superior methods are now available
for analysis. Twenty-one deaths in
1973 were attributed to propoxy-
phene in North Carolina.
Although alcohol and barbiturates
have been, and apparently continue
to be, the major problem drugs in
North Carolina and in most of the
country, heroin and other illicit
drugs are receiving the attention of
the government in drug abuse pre-
vention. Heroin, however, is rela-
tively new to North Carolina, as to
most communities. The first known
heroin death was identified in this
state in 1969. Seventeen heroin
deaths were identified in 1971 and
20 were identified in 1972. In keep-
ing with the diminished number re-
ported from many parts of the coun-
try, only four heroin deaths were re-
corded in North Carolina in 1973;
one of those who died had recently
come from New York and another
was a Vietnam veteran.
The mechanism of heroin deaths
is unknown. In most cases the victim
dies rapidly after the injection of a
solution prepared from a combina-
tion of two to five percent heroin
and diluents. Although the victim in
each case has used heroin before
and should be tolerant, he dies
within a matter of minutes. A small
amount of morphine is detected in
the blood and no other cause of
death is found. The major medical
problems with heroin deaths are
those caused by nonsterile injections
of a drug of unknown strength and
quality. We have not identified any
deaths caused by the major medical
complications of chronic heroin
abuse, such as bacterial endocarditis
or viral hepatitis. During 1973
methadone contributed to, but was
not the single proximate cause, of
two deaths. MDA (methylendioxy-
amphetamine) accounted for one
death, as did a suicidally inflicted
morphine injection.
Salicylates accounted for six
deaths during 1973. Most of these
were not accidental overdoses in in-
fants, as might be expected, but
rather, they were intentional over-
doses by middle-aged women. Eth-
chlorvynol (Placidyl's") caused solely
and in combination with other drugs
the deaths of six people; amitripty-
line, four; meprobamate, three; pa-
raldehyde, three; and Doriden'a', two.
Drugs known to account for only
one death included pentazocine
(Talwins"), methaqualone, and
imipramine.
Fewer than ten percent of the
drug deaths in 1973 could be related
to illegall) obtained drugs. More
than 90 percent of the drugs in-
543
volved in drug deaths are either eon-
trolled drugs or over-the-eounler
preparations.
Cyanide accounted for two deaths
in this state in 1973, and arsenic
caused two. Carbon monoxide
deaths are not included in this sur-
vey of drugs and poisons.
A small but significant group that
deserves special mention is the six
deaths caused from "sniffing" sol-
vents and propellants. characteristi-
cally done among teen-agers for
"kicks" or "highs." These deaths in-
clude those who intentionally in-
haled the Freon propellant from
aerosol cans and one who sniffed tri-
chlorethylene from plastic cement.
There is a tendency for the public
to hold teen-agers responsible for the
prevalence of drugs and to believe
that drugs are the cause of violent
teenage deaths. Our 1972 review of
teenage deaths (ages 15-19 years)
revealed that of the total 705 deaths.
1 I were caused by drugs, including
two by alcohol and three by barbi-
turates. Most of the teen-age deaths
were caused by motor vehicle crash-
es (312), firearms (84), and
drownings (55). The majority of
these deaths occurred while the teen-
age victim was under the influence of
alcohol. No one has been able to
validly attribute a death in North
Carolina to the direct to.xic effects of
LSD (lysergic acid diethylamide) or
to marihuana; in deaths alleged to
have been indirectly attributable to
these drugs, significant quantities of
alcohol have been found on toxico-
logical examination. In the world of
scientific literature, fewer than three
or four deaths have been reported
to be directly caused by the toxic
effects of LSD; there is one dubious
case attributable to marihuana. Most
toxicologists and forensic patholo-
gists are skeptical of reports of
deaths caused by these two drugs.
Nine children, ages one to four
years, were killed by drugs and poi-
sons in 1972. Two deaths were
caused by each of the following:
salicylates (aspirin), pesticides and
petroleum products. One death was
caused by each of the following:
cleaner, cardiac depressant and
other poison.
A review of the death statistics
in North Carolina for 1972. the lat-
est available, reveals that 5,269
deaths of the approximate total
of 47, 1 75 are attributed to poison-
ings, accidents and violence. Motor
vehicle traffic accidents killed 1,943
people. 1,143 died of firearm injur-
ies. 365 died of falls, 242 were killed
in fires and 194 drowned. Our ex-
perience indicates that alcohol was
influential in at least half of these
3,885 deaths. Alcohol intake and
alcohol-related diseases accounted
for 1,423 deaths. More than 3,000
deaths were related to alcohol, and
approximately 100 deaths could be
attributed to other drugs.
The medical profession must as-
sume the major role in solving the
drug problems. Its members must
not contribute adversely to the prob-
lems by personally abusing drugs.
Great care should be exercised in
prescribing psychoacti\e substances.
Barbiturates should be prescribed in
small amounts, avoiding, when po^-
sible, the rapid-acting barbiturates
or substituting other drugs for them.
The need to prescribe propoxyphene
should be carefully evaluated in vie\\
of its toxicity. The treatment of al-
cohol abuse and alcoholism shoulc
be strongly advocated by the physi-
cian. Finally, the medical professior
must be a source of the correct druj
information.
CONCLUSIONS
The great majority of drug deaths
other than those resulting from the
use of alcohol, are deaths of adult:
who ingest overdoses of legally ob
tained drugs. A very small minorit;
of young people die as a result o
the abuse of illeeal drugs and sol
vents.
Nine children were fatally poi
soned bv drugs or chemicals ir
1972.
The majority of teen-age death
are accidental; they are caused b'
motor vehicle accidents, the use o*
firearms and drowning; most o
these deaths are alcohol-related. Ap
proximately one percent of teen-ag
deaths is caused by the abuse of il
legal drugs.
Marihuana-related deaths havi
not been found.
References
1- Ofl.iikd Mortalit> Suiislic-., North Carolin
Rcsidcnls 1*^72- bcp.irtmctit of Human Ri
sources. Public Health Statistics. Raleigl
N C
2. Alcoholism described as society's problen
('..V. SfiJiuiif. JiJiv 1?. 197.V Pace 22.
.1. Federal Register .IK: .11310. Nov. l.t, 1973
.•\ir may be many ways rendereij noxious, or even destructive to animals. 'T liis may either hap-
pen from its vivifying principle being destroyed, or from subtle exhalations with which it is im-
pregnated. Thus air that has passed through burning fuel is neither capable of supporting fire
nor the life of animals. Hence the danger of sleeping in close chambers, with charcoal fires.
Some indeed, suppose the danger here proceeds from the sulphureous oil contained in
the charcoal, which is set at liberty and diffused all over the chamber: while others imagine it
is owing to the air of the room being charged with phlogiston. — Williniu Biuluiii:
Dninc.s!ic Mctlitiiw. or a Treali.se on the Prevention nm! Cure of Diseases /n fieyinun
pie Meiiieincs. etc.. RiclianI Fohfell. 1799. p. 413.
! (inti .Sini-
544
Vol. 35, No.
::
To Commit or Not to Commit,
A Continuing Dilemma:
Some Guidelines
B
David Raft, M.D.
David S. Werman, M.D., and
Roger F. Spencer, M.D.
■COMMITMENT of patients,
against their will, to mental hos-
als, remains a confusing and con-
iversial issue. Increasingly, pos-
(le violations of the constitutional
ihts of the individual are scruti-
ied, and the courts are challenging
ppital commitments that, in the
J5t, were effected without diffi-
jlty. Physicians are more and more
titious about being the agency of
meone's forcible hospitalization,
«d the courts arc asserting that
mmitment to a hospital is a medi-
^ problem.
ilndividuals such as Thomas
asz,'"-' basing their claims on the
nciples of civil rights and indivi-
■al freedom, contend that no one
')uld ever be forcibly hospitalized,
iin if he intends to kill himself,
1 that persons dangerous to them-
,<ves or to others should be dealt
ih under the laws they are violat-
:. Szasz"" considers any form of
intal hospitalization to be impris-
ment. For others, commitment has
flitionally functioned as a multi-
irpose remedy. It has been used
,: only to prevent breaches of the
ice and harm to persons and
iperty, but also to provide for the
utment and rehabilitation of the
,ntally ill, to relieve a family of
"om the Department of Ps>LhKi[r\. the
/ersity of North Carolina School ol MeJi-
I, Chapel Hill. North Carolina 27.M4
:print requests to Dr. Raft.
the responsibility for the care of a
disabled member, and to provide a
refuge for the destitute, the aged, the
mentally deficient, the maladjusted
and the maladapted who are not
welcome by society. There are, of
course, positions between those two
extremes, such as that taken by Mc-
Garry and Greenblatt'' at the Mas-
sachusetts Mental Health Center.
The physician is faced with the
practical problem of caring for the
patient as well as being sensitive to
the demands of the family and com-
munity. When these two points of
view conflict, he finds himself in a
painful dilemma. Physicians share
the reluctance of many Americans
to hospitalize a patient against his
will, but they are aware that others
favor still more flexible criteria for
involuntary hospitalization, since
commitment of a dangerous person
not only may be necessary for the
patient and the community, but ma\
prevent the former's condition from
deteriorating.'' This latter view be-
comes even more persuasive when
the patient clearly lacks the capacity
to make responsible decisions.
The North Carolina State laws
enacted by the General Assembly in
May 1973'' describe new procedures
for both voluntary and involuntary
admission to inpatient facilities for
the treatment of persons with mental
illness, alcoholism or drug de-
pendency, in this paper we do not
,ITEMBFR 1974, NCMJ
U
intend to extensively review these
new laws, but rather we propose to
examine the specific modalities and
some of the clinical circumstances
under which involuntary commit-
ment procedures may be carried out.
We hope to establish some guide-
lines for the physician to deal with
commitment problems in a humane
and rational manner, especially
when he docs not have the benefit
of prompt legal advice or psychiatric
consultation.
COMMITMENT LAWS
Two types of involuntary hospi-
talization are now available in North
Carolina: ( 1 ) emergency hospitali-
zation, and (2) judicial hospitaliza-
tion. The emergency procedure is
initiated by a law enforcement offi-
cer who regards the patient as "vio-
lent and of imminent danger to him-
self or others."" The officer is re-
quired to bring such an individual
before a magistrate who determines
whether the patient is to be hospi-
talized. At the mental health facility,
this patient must be examined by a
physician who is to notify the magis-
trate of his findings within 24 hours.
Under judicial hospitalization, a
person is taken to a physician ( one
who is licensed to practice medicine
in North Carolina) by a law en-
forcement officer. If the physician
finds that the person, after his ex-
amination (on the basis of specific.
identifiably overt acts), is "violent
and of imminent danger to himself
or to others," or "gravely disabled,"
the individual is to be taken to an
appropriate mental treatment fa-
cility. Within 24 hours of his exami-
nation, the physician must submit to
the magistrate a written statement of
his findings. "Gravely disabled"
means that, because of mental ill-
ness or inebriety, the patient is un-
able to "provide for basic personal
needs for food, clothing or shelter."
In addition to the procedures for
involuntary hospitalization men-
tioned above, the new laws have
changed the modalities for voluntary
admission to mental health facilities.
It is no longer necessary for a per-
son to have a written statement from
a physician recommending that he
be admitted. The person may now
present himself for admission for
mental illness, alcoholism or drug
dependency. At the facility itself he
is to be examined within 24 hours
of his admission by a staff person
who will determine whether he is in
need of further hospitalization. Be-
cause the new laws have changed the
modalities for voluntary and invol-
untary hospitalization, the physi-
cian's main task is to determine
whether the patient whom he has
examined warrants involuntary hos-
pitalization.
The new law emphasizes that
ph\sicians. in determining the need
for involuntary hospitalization, take
into account overt acts. Implicit too.
in this procedure, is the observation
of relatively sudden changes in the
person's behavior. Thus, a patient
who. for years, has made suicidal
gestures would not be regarded as
being "of imminent danger to him-
self" unless something specifically
different in his behavior has been
observed.
C.\SE REPORTS AND
COMMENTS
The following vignette appropri-
ately satisfies the law as described
in the preceding paragraph.
Case 1
A 39-year-old Negro man with
one previous hospitalization for
schizophrenia was functioning ade-
.•i46
quately as a science teacher. After
the assassination of Martin Luther
King, he developed the belief that his
"brain was wired to an electrical de-
vice that might explode any min-
ute," destroying himself and his
family. He said that he was going
to shoot himself to prevent this
catastrophe. He refused voluntary
hospitalization because "this might
endanger other patients." One week
after forced hospitalization and
treatment, he was no longer suici-
dal. He was discharged in six weeks,
and six months later he was able to
work in the school as a clerk.
In the following case, commit-
ment was clearly indicated; how-
ever, when the patient changed her
mind and agreed to remain in the
general hospital, the necessity of
transferring her to a mental health
facility became questionable.
Case 2
A black, alcoholic woman on wel-
fare, separated from her husband,
had several admissions to the hospi-
tal. She wished to leave before her
dangerously high blood pressure was
controlled. She had a history of leav-
ing the hospital against medical ad-
vice, and, although her thinking was
not impaired, her current behavior
was seen as "psychopathic"; she was
to be sent to a state hospital on an
emergency certifciate. She offered to
remain in the general hospital, but
commitment was carried out not-
withstanding.
In the past, emergency commit-
ments were frequently abused, and
were carried out for a variety of rea-
sons. The new law, emphasizing ex-
amination of the patient within 24
hours of admission to a mental
health facility, should militate
against these abuses.
A patient may not pose an im-
mediate danger to himself or to oth-
ers, as a suicidal or homicidal risk;
however, because of defective or de-
ranged thinking, he may be in danger
of being "gravely disabled" as in the
following case.
Case 3
.•\ 68-year-old man was noted by
his neighbors to have become aloof
and to be actint; slraneeK. They
called a physician to examine the
patient after he refused to make an
office visit. The physician found that
the patient was malnourished, con-
fused and totally unreasonable in re-
gard to his own condition. There
was evidence of moderately ad-;
vanced arteriosclerosis and possible ■
congestive heart failure. When hos-
pitalization or further examination
was suggested, the patient became i
angry and for several days he barri
caded himself with a shotgun, refus4iK
ing any form of communication otiir.
help. Commitment was indicated, ,o
since, without prompt medical care, k:
this man's life was endangered. ;r.
In the following brief case his-jt :
tories we shall present what oc-;t
curred at the time the patient was^i:
seen by a physician and evaluate thd.;
procedure undertaken.
Case 4
A middle-aged, poor, black mar
was being followed-up in a clinic foi
headache, weight loss, insomnia anc
general lassitude. Part of his condi-
tion dated back to the time his wife
died and he was left to care for fiv(
difficult children. He was hospital
ized in a general hospital where an
arteriogram was read as negative an^
his symptoms were attributed to de
pression. Out-patient treatment wa;
of little benefit and he refused psyj
chiatric hospitalization, pleading th(
need to care for the children. Th(
clinical staff did not move towan
commitment. His condition wor
sened and he died in unclear circum
stances. Suicide was not proved bu
his death wishes were indisputably
In retrospect, more active inter
vention was necessary. The patien
was seen as hopeless, and sympath
for his devotion to his children pre,
vented the physicians from takin,
the proper position — insistence o'
hospitalization, even if the patien
refused.
Cases
.An elderly white man, who ha
always been impulsive, periodical!
became violent. As mild dementi
set in. his control became poor an
his wife could no longer tolerate h:
assaults. After he threw her to th
floor, inflicting multiple fracture:
Vol. 35, No.
was hospitalized on a general
ijsdical ward for some minor medi-
jl problems. He was committed at
urging of his children. At this
Bint, he agreed to place his wife
a nursing home. At the mental
alth facility, it was the opinion of
(J staff that he could safely live
Mrt from his wife since his impul-
sye behavior was directed at only
hr.
rin this case, involuntary hospitali-
21 ion served to protect the wife
fiim her husband's assaults, but it
yo led him to provide for her
• {^icement in a nursing home. How-
( ?r, it was obvious that the staff
ill considerable sympathy for his
Me. Consideration of social and
I'lily situations can obscure a
iUation by arousing feelings which
] y result in the neglect of the pa-
t It's well being or in an inap-
] ipriate disposition.
''when family units are treated as
i whole, the relationship between
I physician and his patient may
home confused. In such instances,
c'essment of the whole situation
i' y be difficult.
( se 6
'\ middle-aged, black, alcoholic
N^man with liver disease (quiescent
i' the time) was brought to the
c'lic several times by her sister, re-
.■ic',;sting that she "be committed."
'': sister was hardworking and
r ralistic. Her family life was dis-
r ited by the patient's frequently
s'king refuge in her house after
■ rits of excessive drinking. The pa-
• t'!t had exhibited such a pattern of
c Idish and provocative behavior
f several years. The sister pleaded,
" le needs to go in — she had been
t^je, you know."
Ifhe staff was supportive of the
■ler and condemning of the pa-
lit. When a psychiatric consultant
Uenged both the previous hospi-
zation and the need for it now.
It' staff and the sister grew angry
ji him. Clearly, the patient was a
iisance and everyone wanted her
;it away." However, there was no
tceable change in her behavior
she did not exhibit overt be-
jjj iior that would, according to the
new law, indicate the need for invol-
untary hospitalization.
It is important that physicians not
allow the genuine or fantasied dis-
tress of a family to lead them to
hospitalize a patient. At times, a
family member may take advantage
of a physician's own irritation with
a provocative, uncooperative indivi-
dual. But patients of this sort often
have been behaving in this manner
for many years, with no physical
violence to themselves or to those
around them. Involuntary hospitali-
zation in these cases will lead only
to a patient's prompt discharge from
the mental health facility. Some ef-
fort to deal with the family as a
group might prove to be more re-
warding.
The physician should avoid tak-
ing over the responsibility that the
patient's family should rightfully
bear. When the physician does as-
sume this responsibility, it only
evokes the patient's hostility. Conse-
quently, the patient feels punished,
and the physician is placed in the
position of being an agent of the
family. Effectiveness in serving the
family is ultimately reduced since
they may feel guilty for having ma-
nipulated the physician into a role
they know is their responsibility.
Supporting the family in order to al-
low them to make a reasonable de-
cision should be differentiated from
taking things out of their hands.
Case?
Several members of a family re-
ported that a son had been threat-
ening violence off and on and that he
would periodically drink excessively.
In the past he had harmed a sister
and had served a prison term for dis-
orderly conduct. Involuntary hospi-
talization was carried out although
he was then only mildly intoxicated.
In this case, commitment is open
to question; if contested, the burden
of proof is on the physician who de-
clared this patient "suddenly" homi-
cidal.
Cases
A middle-aged white man moved
toward a window and talked about
jumping out. He was known to have
lEMHhR 1974, NCMJ
papilledema from an operable brain
tumor. He was involuntarily hospi-
talized. When he arrived at the state
hospital he was disoriented, but
quiet, and expressed no intent to
harm himself or anyone else. Later,
he developed some difficulty in mov-
ing one side of his body and was
transferred to another hospital.
In retrospect, it appears that this
patient should not have been hospi-
talized involuntarily. Admission to a
general hospital would have been
more appropriate.
Although the appearance of the
patient, on his own behalf, before a
court of law is recommended by
legal authorities mindful of the pro-
tection of individual constitutional
rights, such a procedure may, at
times, prove detrimental to the men-
tal health of the patient. A GAP
(Group for the Advancement of Psy-
chiatry) report' recognizes the trau-
matic effects of a "personal notice"
served on the mentally ill.
Case 9
A middle-aged male worker, with
a documented history of manic-de-
pressive episodes, was placed in the
hospital following bizarre behavior
indicative of poor judgment. Al-
though the patient was at first forci-
bly detained, his physician was able
to establish a good relationship with
him. The patient wished to stay
longer to stabilize his treatment on
Lithium; however, during a court
procedure where he was released, he
became angry and decided to leave
the hospital. Later he inflicted in-
jury on himself, necessitating a sur-
gical hospitalization.
This case is cited to induce phy-
sicians to seek appropriate changes
in the law that would not only guar-
antee the patient's civil rights, but
would protect his well being.
The preceding clinical vignettes
were chosen to illustrate some of the
typical problems that confront the
physician who is called upon to ex-
amine a patient who might under-
go involuntary hospitalization. The
critical issue appears to be that the
examining physician must try to
maintain his role as a physician and
avoid being put in the position of
547
either a "friend of tiic family"" or a
law-enforcement agent.
If he bases his statement on the
presence of the patient's recent overt
behavior, indicating that the patient
is indeed dangerous to himself or
others, or is "gravely disabled."" then
the physician will not only be fol-
lowing the law in its letter and spirit,
but will be usefull\ serving as the
patient"s physician by proceeding to
an in\'oluntary hospitalization.
SUMMARY
In\oluntary hospitalization, when
exercised judiciously, is an effective
and humane method of dealing with
people who have certain forms of
mental illness. It has, however, been
increasingly questioned as denying
patients the due process of law. The
new North Carolina laws relating to
commitment clarify the role of the
physician and define the limits of his
duties and responsibilities. In this
paper we have described these laws
and presented several clinical vi-
gnettes that illustrate how in-
voluntary hospitalization should and
should not operate.
Acknowledgment
This work was partly supported
bv NIMH Grant No. MHO 8048-1 1 .
References
1. Szasz. TS: The Mylh of Mental Illness
New York: Hoeber Medical Division. Hari .
and Row. pp 208-:i;. 1461
2- Szasz. TS: The Manufacture of Madne^sj
New \oTk: Dell Publishini^ Co. pp 54-5f>,
64-6''. 1M7I.
?. Szasz. TS: Law, Liberty and Psychiatry: ,\i
inquiry into the Social Uses of Men's
Health Practices. New ^'ork : The MacMil
Ian Co. p 229, 1963.
4. Szasz. TS: Voluntary mental hospitalizatiorj
an unacknowledged practice of medical frauf
N Ehfi J Med 2S7:277-27S. 1972. \
?. .McGarry AL. and Greenblatt. M: ConJ.
tional voluntary mental-hospital admissit/
N Engl J Med 287:279-21<0. 1972.
6. Slate of North Carolina Sessions La\*
197.1. House Bill Number 1081. Chapter 726]
7. Group for the .Advancement of Psychiat)
Commitment Procedures. Second Repc
Number 4. April. 1948.
f
When the patient ii in danger of being jmmedKileK suffocated, and all hope of freeing the pas-
sage IS vanished, so that death seems at hand, if respiration be not restored, the
operation of bronchotomy, or opening of the wind-pipe, must be directly performed. As this op-
eration is neither difficult to an e.vpert surgeon, nor \ery painful to the patient, and is often the
onh method which can be taken to preserve lite in these emergencies, we men-
tion it, but it should only be attempted by persons skilled in surger\. — \\ iUiain Bucluiii: Do-
mestic Medicine, or a Treatise on the Prevention and Cure of Discuses by Reftinicn and Simple
Medicines, etc.. Richard Folnell. 1799, p. 410.
[1
548
Vol. -Vs. Ni
Is le a Source of Information?
tYes, with certain reservations.
.! average sales representative
' a great fund of information
ut the drug products lie is re-
- nsiblefor. He is usually able to
wer most questions fully and
uiiilligently. He can also supply
tints of articles that contain a
atdeal of information. Here,
'\ I exercise some caution. 1 usu-
;accept most of the statements
: opinions that I find in the
i>ers and studies which come
nthe largerteachingfacilities.
es without saying that a physi-
1 should also rely on other
■ces for his information on
0 rmacology.
r mingof Sales Representatives
Ideally, a candidate for the
pi ition as a sales representative
ot pharmaceutical company
st Lild be a graduate pharmacist
W!ihasa questioning mind. I don't
ti" k this is possible in every case,
ai so it becomes the responsibility
II
Ci acity they are indeed useful;
p, :icularly in the fact that they
d .eminate broadly based educa-
ti al material and serve not just
a; pushers" of theirdrugs.
TI Other Side of the Coin
Obviously, the pharmaceuti-
:a ;ompanies are not producing all
th material as a laborof love —
tlrare in the business of selling
31 Jucts for profit. In this regard
th ambitious and improperly moti-
/cld sales representative can
3> t a negative influence on the
ot :ticing physician, both by pre-
36 inga one-sided picture of his
or luct, and by encouragingthe
Dt :titioner to depend too heavily
V rugs for his total therapy. In
tl" e ways, the salesman has often
i\ 3rted objective reality and
U! ermined his potential role as an
3c ;ator.
n Industry Responsibility
Since the detail man must be
ar iformation resource as well as
a jresentativeof his particular
3l' maceutical company, he
'JiJM be carefully selected and
of the pharmaceutical company to
train these individuals comprehen-
sively. It is of very great importance
that the detail man's knowledge of
the product he represents be con-
stantly reviewed as well as up-
dated. This phase of the sales rep-
resentative's education should be a
major responsibility of the medical
department of the pharmaceutical
company.
I am certain that most of these
companies take special care to give
their detail men a great deal of in-
formation about the products they
produce — information about indi-
cations, contraindications, side
effects and precautions. Yet, al-
though most of the detail men are
well informed, some, unfortunately,
are not. It might be helpful if sales
representatives were reassessed
every few years to determine
whether or not they are able to ful-
fill their important function. Inci-
dentally, 1 feel the saTne way about
periodic assessments of everyone
thoroughlytrained. That training,
perforce, must be an ongoing one.
There must be a continuing battle
within and with the pharmaceutical
industry for high quality not only in
the selection and training of its
sales representatives, but also in
the development of all of its promo-
tional and educational material.
The industry must be ready to
accept constructive as well as cor-
rective criticism from experts in
the field and consumer spokesmen,
and be willing to accept independ-
ent peer review. The better edu-
cated and prepared the salesman
is, the more medically accurate his
materials, the better off the phar-
maceutical industry, health pro-
fessionals and the public— /.e., the
patients — will be.
Physician Responsibility
The practicing physician is in
constant need of up-dated informa-
tion on therapeutics, including
drugs. He should and does make
use of drug information and an-
swers to specific questions sup-
plied by the pharmaceutical repre-
sentative. However, that informa-
in the health care field, whether
they be general practitioners, sur-
geons or salesmen.
Value of Sampling
I personally am in favor of
limited sampling. I do not use
sampling in order to perform clini-
cal testing of a drug. I feel that drug
testing should rightly be left to the
pharmacology researcher and to
the large teaching institutions
where such testing can be done in
a controlled environment.
I do not use samples as a
"starter dose" for my patients. 1 do,
however, find samples of drugs to
be of value in that they permit meto
see what the particular medication
looks like. I get to see the various
forms of the particular medication
atfirst hand, and if it is in a liquid
form I take the time to taste it. In
that way 1 am able to give my pa-
tients more complete information
about the particular medications
that 1 prescribe forthem.
tion must not be his main source of
continuingeducation. The practi-
tioner must keep up with what is
current by making use of scientific
journals, refresher courses, and
information received at scientific
meetings.
The practicing physician not
only has the right, but has the re-
sponsibility to demand thatthe
pharmaceutical company and its
representatives supply a high level
of valid and useful information. I
feel certain that if such a high level
is demanded by the physician as
well as the public, this demand will
be met by an alert and concerned
pharmaceutical industry.
From my experience, my
impression is that sectors of the
pharmaceutical industry are indeed
ethical. I challenge the industry as
a whole to live up to that word in its
finest sense.
Pharmaceutical
Manufacturers Association
1155 Fifteenth Street, N.W.
Washington, D.C. 20005
P'M-A
Editorials
A NEW EDITOR
For the first time in my 1 1 years as editor of
this Journal, I am abandoning editorial anonymity
to write a more personal note to all of you con-
cerning the Journal's past and future, and especially
its new editor.
Dr. Wingate Johnson founded the Joi.rnal in
1941, and he called me about some Journal busi-
ness a few minutes before his death in September
1963. He was a great editor, from a family of notable
literary talent. He was supported by his editorial
boards and the Society in a wholehearted way.
The Journal's history had not been entirely without
criticism, but that too is a good sign and is better
than going unnoticed. During the interregnum, when
the Society was deciding what to do about the Jour-
nal and the editorship. I too was pondering the
matter, should I be asked to succeed Dr. Johnson
from my post as acting editor. As everyone else, and
maybe more than most, since I ha\e the pathologist's
task of keeping up with medicine generally, I had
to question whether a state journal was worth sup-
porting. You can guess that 1 thought it was. and
my reasons are reflected in the statement of the
Journal's objectives which appear in every January
and Juh' issue's "Instructions to Authors." We have
our own people and problems here in North Carolina,
and the Journal does its part in printing informa-
tion about them. It is a chronicle of North Carolina
medical affairs that has no substitute presently. Dur-
ing my tenure, this view of the Journal's identity
has been shared by the fine editorial boards it has
had. and by an investigati\e committee of the House
of Delegates.
The editorial board of this Jolirnal has always
been one of its strengths, and I have especially ap-
preciated it. Dr. Nicholson brought experience, wis-
dom and continuits to it. Dr. John Rhodes' eloquent
pen and profound knowledge of the Society's ac-
tivities bring the Journal a dimension lacking in
the editor. Other members of the Board have helped
with paper reviewing and in setting Journal policy
on sticky matters. The headquarters staff manages
the business affairs of the Journal with skill and
speed.
Now a new editor \sill take the Journal with
the October issue. Dr. John H. Felts, professor of
medicine at the Bowman Gray School of Medicine,
was elected unanimousK b\ the editorial board after
554
my wish to resign was brought to their attention. N
resignation is prompted by the pressure of oth
duties, and in no small way by the feeling that
was time for a new view for the Journal. A varie
of people was canvassed by the Board in a sean
for candidates, and Dr. Felts was selected after d
process. Since Jack has been in the state for 25 yea:
and a member of the Society since he finished h
specialty training in 1955. many of you know hi
already. Some think of him as a nephrologist. b
many know him also as a deeply thoughtful ma
with wide interests, including nonmedical literatur
Some may recall his entertaining "Medical Spectato
columns during Dr. Johnson's editorship. For me, I
has been a constant, friendly critic of the Journa
and not a\erse to letting me know when he thoug
my aim was off. Having thus kept in touch wi
the Jolirnal over the years, he is especially suit(
to his task, and I think we are lucky that he co:
sented to take on this addition to his heavy load
the medical school. As for me, 1 look forward
assuming his role as friendly critic and recommer
the same role to all of you.
Robert W. Prichard, M.D
THE NEGLECTED DISEASE OE MODERN
SOCIETY
"The Neglected Disease of Modern Society" is tl
"catchy" title of a booklet published under tl
auspices of the National .Academy of Science-N
tional Research Council in 1966.' North Carolina
one of the states that have not neglected this disea
over the past ten years. One of the most active sta
trauma committees of the American College of Su
geons in the United States became interested in th
problem in the earh 1960s and developed trainii
programs for ambulance attendants throughout tl
state. Riding on the crest of this wave of enthusiasi
training programs were established in the communi
colleges of North Carolina — again, the first state
the nation to make such an effort. In 1967, we we
one of the first states to establish a minimal traini:
and \ehiele law for transporting the injured. Tl
Committee on Emergency Medical Services of tl
North Carolina Medical Society has had a lot of i
fluence on these activities, with support when it w
most needed. North Carolina now has a State Eme
gency Medical Services organization under the D
Vol . .^5. No.
tment of Human Resources. Recruitment of a
f -time staff witli tfie best personnel available from
t oughout the nation is now in its final stages.
The people and the Legislature of the state of North
rolina have been aware of the problem in delivery
jmcrgency medical services and have given it their
ral and financial support in an appropriate fash-
. With recent federal support and guidelines,
Dugh a bill on emergency medical services and the
oroval of the military air evacuation system for the
)lic (helicopter), we should expect even more dra-
tic improvements.
.n this issue of the Journal, Dr. Frank Cordle
|Sents a succinct overview of the emergency mcdi-
services in North Carolina. He appropriately
II
5
{
concludes his presentation with a challenge to those
directing the state emergency medical services for
evaluation of their accomplishments. With the con-
tinued support of the physicians and the public of a
statewide emergency medical service system in North
Carolina, we have no doubt that the evaluation
will be positive. If you are not familiar with the
emergency medical service system in North Carolina
and arc not actively participating in. or supportive
of, the emergency medical service system in your
commimity, we urge you to become involved.
Georgi: Johnson, Jr., M.D.
References
1. Accidenltil death and disabiUly: The neglected disease nf modern
society. National Academv of Sciences-National Research Council.
Washington, D. C, 1966.
I
J
ll
1
<
NEW MEMBERS
of the State Society
i/jilman, James U.. M.D. (N), 210 W. Wendover .^ve.,
ireen.shoro 27401
E :ht. Don Clark, M.D. (Intern-Resident), 3026 Truitt
)r.. Burlington 2721?
.ig, John Hamilton, M.D. (.\N). Mercy Hosp. Dept.
if Anes, Charlotte 28204
lard, Dulon Devon. M.D. (P). P. O. Box 411. Smith-
ileld 27577
"lie, Gordon Joseph, M.D. (R), 901 Goodwood Rd..
i/inston-Salem 2710.3
ppuUa, Elliott John, M.D. (Intern-Resident), 1304 Wat-
bn Ave., Winston-Salem 27103
)ertson, Merritt Ezekiel. M.D. (GPl. Rt. 2. Box 967.
S/endell 27591
ppley, Ben Gordon, M.D. (PD) (Renewal). 1800 W.
«h St., Greenville 27834
ke, Walter Franklin, M.D. (GS). Rt. 1. Box 50-CC,
ilaldese, N. C.
aurst, Georae Monroe. M.D.. Catawba Mem. Hosp..
Jickory 286(fl
Wthan, Gordon Earl, .\1.D. (PDl. (Renewal). 1908
iorest Hill, Greenville 27834
Mbaecher, David .Mbert. M.D. (GS). 86 Victoria Rd.,
Jshevjlle 28801
,irEMBFR 1974. NCMJ
f
In Continuing Education
Note; ( I ) Programs sponsored by the Bowman Gray, Duke
or UNC School of Medicine are approved for "Category 1"
.AM.A Physicians Recognition .Award credit, and for .A.XFP
"Prescribed" continuing education credit. (2) "Place" and
"sponsor" are listed only where these differ from the place
and group or institution listed under "For information. '
In North Carolina
September 17-19
Rehabilitation of the Patient with Myocardial Infarction —
Interdisciplinary .•Approach
Place: Velvet Cloak Inn. Raleigh
Sponsors: UNC School of Nursing, the Physical Therapy
Division of the UNC Medical School's Department of
Medical .Mlied Health Professions, and the North Caro-
lina Heart .Association
Fee: Tuition $75: registration $25; open to physicians,
registered nurses, dietitians, physical and occupational
therapists and social workers. Financial assistance avail-
able to qualified applicants.
Program: Designed for those involved or to be involved
in an organized cardiac rehabilitation program, hence
team application is strongly encouraged. Each health team
member will learn now to integrate and use pertinent
theoretical concepts of rehabilitation in the process of
assessment, intervention, and evaluation of patient man-
agement.
For Information: Launce Ferris. .Assistant Professor. UNC
School of Nursing. Chapel Hill 27514
September 18-19
IVth Annual Sngus M. McBrxJe Pcrinat.il SympoMiini
Fee: i5().()()
For Information: George Brumley. M.D., Division of
Perinat:il Medicine, P. O, Bin 2911. Duke I'niversity
Medical C'enler, Durham 27710
September 19-21
Topics m Internal Medicine, the Fourth Annual Seminar
in Medicine
Place; Babcock Auditorium
Fee: $75.(10
For Information: Emery C. Miller, M.D.. .Associate Dean
for Continuing Education. Bowman Gray School of
Medicine, Winston-Salem 2710.^
September 20-21
1474 Walter L. Thomas Symposiimi on Gynecologic Malig-
nancy and Surgery
Program: The two day symposium will be clinically oriented
with the main emphasis on "Ovarian Cancer" and
■'Difficult Office Gynecology."
Invited guest speakers include Herbert Buchsbaum. Iowa
City. Iowa, and Dr. J. r:iylor Wharton. Houston. Texas.
Credit: A.AFP credit applied for.
For Information: W. T. Creasman. M.D.. Director of Gyne-
cologic Oncology. P. O. Bo,\ 2079. Duke University
Medical C enler.^burham 27710
September 21
Ophthalniologv Clinical Gr.ind Rounds
Place: Hornaday Conference Room. Eye Center Building
For Information: Maurice landers. III. M.D.. Box 3802,
Duke University Medical Center, Durham 27710
September 25-2«
North C.irolina Medical Society ,\nntial Committee Con-
clave
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. Committee members should plan to he present
if at all possible.
For Information: Mr. William N. Hilliard. Execuinc Di-
rector. North Carolina Medic, il Societv. P, O. Box 27 167.
Raleigh 27hl I
September 27-29
Invitational XssombK tor .\dv.inced L'rology — Urinary Cal-
culi and Related Diseases
Place: Pinehurst Hotel. Pinehurst
Fee: 'ilOO
For Information: Times E. Glen. M.D.. Box .^707. Duke
Uni\crsii\ Meilic:il Center. Durham 27710
October 2
Fifth Disincl Medical Society Meeting
Place: C otinti \ t lub of North C arolina. Pinehurst
For Information: E. Wilson Sl.uib. M.D.. Pinehurst Surgi-
cal Clinic. Pinehurst 2S.'(74
October 2-3
Fourteenth ,\nnual Charlotte Postgraduate Seminar
Place: C harlotle Memorial Hospital .Xuditorium
Sponsor: Mecklenburg Coiinly Chapter .\nierican .Ac.idenn
Family Physicians
Program: topics will include acute leukemia and solid tu-
mois in chiklren. :icute myocardial infarction, difficult
EKCis. or:il contraception in the female, perimenopausal
problems, respiratory emergencies, infectious diseases and
difficult lung dise:ises. Spouses of participants are invited
to attend Dr. Gordon Deckerl's Wednesday afternoon
session. " Irans.iclional ,\nalysis. ( oncepts. and Sex."
For Information: \I, I awrence kouri. Jr.. M D.. 202S
Woodland Dri\e. C harlotte 2X20.'^
October 2-3
Use of Psychotropic Metlicines. The Broughton Hospii:il
Psychiatric Symposium
For Information: Dr. Robert W. Gibson. Jr.. Director of
Clinical Services. Broughton Hospital. Morganton 2i<fi.5.s
556
PRESCRIBING INFORMATION
Antiminth (pyrantel pamoate) Oral
Suspension
Actions. Antiminth (pyrantel pamo-
ate) has demonstrated anthelmintic
activity against Enterobius vermicu-
laris (pinvvorm) and Ascaris lumbri-
coides (roundworm). The amheliiiin- >
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
(0.05-0.13/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 77o 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 (pinworni infection).
Warnings. Usage in Pregnancy: Re-
production studies have been per-
foriricd 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 SCOT
CNS reactions: headache, dizzi-
ness, drowsiness, and insomnia. Skin
reactions: rashes.
Dosage and Administration. C/i!7-
drcn 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 grain. 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 Pfizer Pharmaceuticals
New York, New York 1001 7
WORMS BUTZED
A single dose of Antimmth
( 1 cc, per 10 Ibs^ of body
weight, 1 tsp./50 lbs.— max-
imum dose, 4 tsp=20 cc.)
offers highly effective control
of both pinworms and
roundworms.
Antiminth has been shown
to be extremely well tolerated
by children and adults alike
m chnical studies* Pleasantly
caramel-flavored, it is
non-staining to teeth and oral
mucosa on ingestion...
doesn't stain stools, Imen or
clothing.
One prescnption can
economically ti:'eat the entire
family
ROGRIG <9
A division of Ptizer Pharmaceuticals
.'Jwii'""'^' New York. New York 1001 7
IPiAwormSii^iindworms controlled
I with a single, non-staining dose of
ANTIMINTH
(pyrantel pamoate)
jlPata on file at Roerig.
equivalent to 50 nig- pxraiitel/inl.
ORAL SUSPENSION
Please see prescribing iniormation on facing page.
October 4
25th Annuiil Winslon-Saleni Heart Symposium
Place: Babcock Auditorium. Bowman Gray School of Medi-
cine. Winston-Salem
Fee: $15.00
For Information: Mrs. Katherine Co.x. Forsyth County
Heart .Association, 2046 Queen Street, Winston-Salem
27103
October 8-10
Cardiac .Arrhythmia Course
Place: Orthopedic Clinic Conference Room
Fee: S75
Credit: 21 hours .A.AFP credit applied for.
For Information: Galen Wagner, M.D.. Box 3327, Duke
University Medical Center, Durham 27710
October 18-19
Sixth .Annual Orofacial .Anomalies S\mposium
Enrollment limited to 250 registrants
For Information: Raymond Massengill. Jr., Ed. D., Box
3523. Duke LIni\ersil\ Medical Center. Durham 27710
October 20-22
.Annual Joint Meeting of the North Carolina-South Carolina
Societies of Ophthalmology and Otolaryngology
Place: Great Smokies Hilton Inn, .Ashesille, N. C.
Sponsor: The North Carolina Society of Ophthalmology
and Otolaryngology
For Information: Banks .Anderson, Jr. M.D., Secretary-
Treasurer, P, O. Box 3H02. Duke L'niversit\ F\e Center.
Durham 27710
October 21-22
Institute on Disaster Preparedne-.s
Place: Gro\e Park Inn. .Ashe\ille
Sponsors: North Carolina Hospital Association and the
.American Hospital .Association
Fee: S65.(I0
For Information: Mr. Courtl.md Newman. .American Hos-
pital .Association. S40 North L.ike Shore Dri\e. Chicago,
Illinois fiOhl 1
October 28-No\ ember 1
Current Concepts in General Radiology
Place: Southampton Princess Hotel, Southampton, Bermuda
Program Chairman: Richard G. Lester. M.D.. Professor and
Chairman of Radiology, Duke University Medical Cen-
ter. Guest speakers will include: Robert G. Eraser. M.D.,
Profc-sor and Chairman of Radiology. McGill Univer-
sity Medical School. .Montreal. Canada: John .A. Evans,
M[D., Professor and Chairman of Radiology, Cornell
University Medical College; William B. Seaman. M.D.,
Professor and Chairman of Radiology, Columbia Uni-
\ersit> College of Physicians and Surgeons, New ^'ork,
N. Y.. Harold G. Jacobson. M.D.. Professor and Chair-
man of R,idioloi;v. Albert Einstein Colleee of Medicine
(MHMC). Bronx; New ^ork; and David H. Baker. M.D.
Director of Radiology. Babies Hospital. Professor of
Radiologv. Columbia University College of Physicians
and Stirgeons. New >ork. N. \ . Subject matter will
cover Pedi.ilric :ind Adtilt Radiology of the Chest.
Genitourinary Tract. Gastrointestinal Tract and Mus-
culoskeletal Svstem.
Fee: S200
Credit: Twentv -three hours AM.A "Category One"" accredi-
tation
For Information: Robert McLelland, M.D.. Department of
Radiologv, Box 3S0X. Duke U^iver^itv Medical (enter.
Durh.inr27710,
November 4-6
.Amputations and Prosthetics
Place: Holiday Inn West, Durham
Sponsor: .American .Academy of CJrthopaedic Surgeons.
Chicaco. Illinois
Fee: SI 50
For Information: Frank W. Clippinger. M.D.. Box 2919.
Duke Lmiversity Medical Center, Durham 27710
November 7-9
Academy of Famih Phvsicians
Annual
North Carolina
Meeting
Place: Sheraton C rabiree Motor Inn, Raleigh
For Information: North Carolina Academy' of Family Phv-
sicians, 1002 Wake Forest Road, Raleigh'27fi()3
558
ts
November 15-16
.Anesthesiology Fall Seminar
Place: Charlotte Memorial Hospital .Auditorium
lee: ^40
For Information: Dr. H. ,A. Ferrari, Chairman, Deparl
ment of .Anesthesioloey. Charlotte Memorial Hospita
P. O. Box 2554, Charloue 28201
December 6-7
What's New in Newborn Care?
Place: Babcock .Auditorium
Fee: S45
Credit: 9 hours .A.AFP credit
For Information: Emery C. Miller, .M.D., .Associate Dea
for Continuing Education. Bowman Gray School c
.Medicine, Winston-Salem 27103
December 1 1-12
Hospital Emergency Room Services and .Ambulatory Car
Place: Winston-Salem Hvatt House and Convention Cer
ter. Winston-Salem
Sponsors: North Carolina Hospital .Association and tH
North Carolina .Medical Society
Program: Designed for hospital administrators, trustees an
physicians
For Information: Mrs. Diane Turner. North Carolina Ho!
pital Association, P. O. Box 10937, Raleigh 27605
■lanuary 24-25
Suruical Infections
Fee": $75
Credit: 12 hours
For Information: Emerv C. Miller. M.D., .Associate Dea
for Continuing Education. Bowman Gray School
Medicine. Winston-Salem 27103
Continuing Education for Nurses
October 21-23: Problem-Oriented Medical Record Syster :;'
October 23-25: The Nursing Audit
November 4-6: The Nurse: Planning Classes for E.xpectai
Parents
November 6: .A Practical .Approach to Drug Interactioil
November 18-22: Planning Patient Care
For Information: Judith E. Wray, Administrative Secrf
tary, Continuinc Education Program, UNC School c
Nursing, Chapef Hill 27514
Cancer Information by Phone
A loll free phone call to The Southern Medical .Associatio
Cancer Education Service (1-800-231-6970). makes cat
cer information available by phone to phvsicians
North Carolina and other states in the Southern Med' ;-
cal .Association area. Tapes must be requested by nun
ber. For a cross indexed list of over 260 tapes, call th
.ibove number, identify yourself by name, address, cil
and state, and request a copy of the index.
Nev» Directory .Available
The second edition lOP-414) of the Dincloiy of Sil,
.■1\st'\Mm'nl Pn}i;ruins for Plnwiciaii.s is now available fc
Sl.OO from the Order Department, .American Medic;
.Association, 535 N. Dearborn, Chicago, Illinois 60611
The new edition lists six new self-assessment prograrr
in: .Allergy, Cardiology. Chest Diseases, Colorectal an
Anorectal Surgery, Emergency Medicine, and Neurolog
cal Surgery, A total of 21 programs is sponsored b
spccialtv societies, a county medical society and one un
versity. Each program, listed bv topic and sponsor,
described with regard to: intended participant, sites an
time of testing, dates of first test and most recent revisio
objectives and content, format, time required, method c
scoring, aids to learning provided, fees charged and whei
to write for ftirlher information.
In Contiguous States
September 16-21
Fifth Annual Family Practice Refresher C ourse
Place: .Mills Hvatt House Hotel
Fee: SI 40 payable in advance on or before September 9tl
Enrollment limited to 75 registrants
Credit: Forty hours A.AFP credit approved .
The registration fee includes the Social Hour and Banqiii
Vol. 35. No
on Wednesday evening, lo which wives are cordially
invited.
r Information: Vince Moseley. M.D., Director, Division
of Continuing Education, Medical University of South
-Carolina. 80 Barre Street, Charleston, South Carolina
'"#129401
SeptciiibcT 19
mposium on the Management of Diabetes Mellittis
onsors: Division of Endocrinology and Metabolism, and
the Departments of FamiK Pr.ictice and Continuing Edu-
cation
edit: Accredited by AMA; 5-U prescribed hours AAFP
» teredit applied lor
,1 iT Information: Dr. H. St. George Tucker, Professor
and Chairman. Division of Endocrinology and Metabo-
lism. Medical College of Virginia. Box 111, MCV Sta-
tion, Richmond, Virginia 23298
September 30 & October 1
innessee Valley Medical Assembly annual meeting
ir Information: Thomas L. Buttram, M.D.. Chairman,
Tennessee Valley Medical Assembly. Whitehall Medical
Center. 960 E. Third Street. Chattanooga. Tennessee
37403
October 5-8
uthern Psychiatric Association annual meeting
ice: The Homestead. Hot Springs. Virginia
r Information: Mrs. Annette Boulwelf. P. O. Box 10387,
[Raleigh 27605
December 5-8
jire Curriculum: Clinico-Pathologic Correlations in Car-
'diovascular Disease
ice: Williamsburg Conference Center, Williamsburg. Vir-
ginia
r Information: Miss Mary Anne Mclnerny, Director,
Pepartment of Continuing Education Programs, Ameri-
can College of Cardiology, 9650 Rockville Pike, Bethesda,
jMaryland 20014
December 6-8
[turologic Problems of Infancy and Childhood
ace: Cascades Meeting Center, Williamsburg, Virginia
jonsors: University of Virginia School of Medicine: Medi-
cal College of Virginia of Virginia Commonwealth Uni-
iversity; Eastern Virginia Medical School
e: $85
ledit: 13% prescribed hours AAFP credit applied for
jirollment limited to 80 registrants
jK litems submitted for listing should be sent to: WHAT?
iHEN? WHERE'.', P. O. Bo\ 8248. Durham, N. C.
I J704, by the 10th of the month prior to the month in
J fich they are to appear.
il
I
AUXILIARY TO THE NORTH CAROLINA
MEDICAL SOCIETY
AUXILIARY MEMBERSHIP
'COMMUNICATION. COOPERATION, EDU-
i|^TION, was the theme emphasized by Mrs. Philip
jsissell at her installation as the 1974-1975 president
J the Auxiliary to the North Carolina Medical So-
ty. "Lofty phrases," you say, "but who are we to
Immunicate to. cooperate with, and what education
iaeeded?"
IThrough the generosity and coopcratioit of your
orth Carolina Medical Society and the editors of
'lur North Carolina MEbiCAL Journal, we hope
coDiDiiiiu'cate with you, the physicians who receive
(tS journal — and hope that all of you take the
>tembf:r 1974. NCMJ
/
Journal home to your wives. We hope to educate
by telling you and your wife about needs in your
state and your community, and what the North Caro-
lina Auxiliary can do and is doing to meet these
needs.
But before the Auxiliary can be effective, we must
have the hands and hearts of physicians" wives
throughout North Carolina. Therefore, niei>]hcrship
has to be the first priority.
The Medical Society membership totals over 4.-
300; the Auxiliary, 2,800 — a gap of 1,500! Even
"allowing" for widowers and bachelors, the North
Carolina Auxihary is not reaching many of the phy-
sicians" wives whom we need.
More than 98 percent of our members belong to
an organized county auxiliary. Some physicians'
wives have not joined hands with us, even in those
counties which have an available organized auxiliary.
We hope that the county auxiliary presidents and
membership chairmen will stimulate their interest
and encourage membership.
But what about the physicians" wives in counties
where there is no auxiliary? Frequently these women
have been the first called upon to handle everything
health-related in the county — Red Cross blood re-
cruitment, P.T.A. programs, immunization, pre-
school screening, and drug and venereal disease edu-
cation. We in the organized auxiliary have the ma-
terial and manpower to help. Much of this informa-
tion is already being sent to our membcrs-at-large
through our national magazine, M.D.'s Wife, our
state newspaper. "Tarheel Tandem,"' and many other
mailings.
Perhaps you or your wife says, "I am not inter-
ested" in auxiliary work. But, can you say, "I am
not interested" in AMA education and research,
when last year it brought to our three four-year
inedical schools 25 percent more than we North
Carolinians donated through pro-rated, unrestricted
funds? No one can say, "I am not interested"" in
legislation, when so much has happened because of
indifference, apathy and "don"t bother me"" attitudes.
No one can say. "I am not interested'" in health
education and promoting health careers, when we so
desperately need nurses, technicians, and others in
the field. We in the Auxiliary are interested. We are
working actively and effectively to try to fill some of
these needs.
The Auxiliary needs the help and support of every
physician"s wife in North Carolina. Dues are $4.00
for the state auxiliary and $4.00 for the national
Auxiliary — making a total of $8.00. From counties
with an organized auxiliary, prospective members
may send dues to the county auxiliary treasurer.
Physicians" wives from counties without an organized
auxiliary may become members-at-large by sending
dues to: Mrs. Edward P. Benbow, Treasurer, 3809
Friendly Avenue, Creensboro, North Carolina
27410.'
JOIN US! Together we can do more!
559
Next month we will emphasize some of our pro-
grams and projects. Communicate with us. and if you
find our ""Auxiliary Page" worthwhile, let us know.
News Notes from the —
BOWMAN GRAY SCHOOL
OF MEDICINE
WAKE FOREST UNIVERSITY
The medical school has received a $39,900 grant
from the North Carolina Regional Medical Program
as part of a statewide program to provide improved
care to arthritis patients. The major emphasis of the
program at Bowman Gray will be providing that care
outside of the Bowman Gray-Baptist Hospital medi-
cal center.
Bowman Gray will run one-day-a-wcek clinics for
arthritis patients at the Family Health Center of
Reynolds Memorial Hospital, at the East Bend Com-
munity Health Center in Yadkin County and at the
Farmington Community Health Center in Davie
County.
A registered nurse has been trained by the medical
school to provide follow-up care and to do some of
the laboratory work patients will need at the arthritis
clinics.
Dr. Robert .A. lurner, assistant professor of medi-
cine at Bowman Gray, will direct the school's arthritis
program in the clinics. He and other physicians, both
on the medical school faculty and in private prac-
tice, will perform initial examinations on arthritis
patients. Although the specially-trained nurse will
do the follow-up. she will have the physicians to call
upon for back-up.
■■:■■ * *
Dr. Melvin Levitt, associate professor of phvsi-
ology. has received a five-year. $128,388 grant from
the National Institute of Neurological Diseases and
Stroke to conduct research on pain.
His work is an outgrowth of observations on re-
search animals which had a pain pathway severed.
His observations contradict the classical concept of
nerve pathways, the classical concept being that pain
impulses travel a relatively straightforward line from
the site where pain originates 'o the brain.
Even when the research animals had a pain path-
way cut, they continued to exhibit what Dr. Levitt
calls ""disturbing sensations." He does not know
whether the animals are feeling pain in the area of
the body served by the cut pathway, but thev are
feeling something uncomfortable in that area. Ac-
cording to the classical concept, they should not be
feeling anything in the area.
-.' -:■ *
.1- Ben Haste has been appointed director of the
Medical Center Computer Center. He succeeds Dr.
Rondomycin
(methacycline HCI)
CONTRAINDICATIONS. Hypersensitivity to any of the tetracyclines
WARNINGS Tetracycline usage during tooih development (last half o( pfegnancy to eight
years) may cause permanent lootti discoloration (yeltow-gray-brown). which is more
common during long-term use but has occurred after repealed short-term courses.
Enamel hypoplasia has also been reported Tetracyclines should not be used in this age
group unless other drugs are not likely to be elfective or are contraindicated.
Usage in pregnancy. (See above WARNINGS about use during tooth development.)
Animal studies indicate that lelracycimes cross the placenta and can be toxic to the de-
veloping fetus (Often related !o retardation of skeletal development) Embryoloxicity has
also been noted m animals treated early m pregnancy
Usage m newborns, intants, and children. (See above WARNINGS about use during
looth development )
All tetracyclines form a stable calcium complex in any bone-formmg tissue A decrease
m fibula growth rate observed in prematures given oral tetracycline 25 mg/kg every 6
hours was reversible when drug was discontinued
Tetracyclines are present m milk o' lactatmg women taking tetracyclines
To avoid excess systemic accumulation and liver toxicity m patients with impaired renal
function reduce usual lotal dosage and ii therapy is prolonged consider serum level de-
terminations of drug The anii-anabohc action of tetracyclines may increase BUN While
not a problem m normal renal function, m patients wiih significantly impaired function,
higher tetracycline serum levels may lead to azotemia, hyperphosphatemia, and acidosis.
Photosensitivity manifested by exaggerated sunburn reaction has occurred with tetra-
cyclines Patients apt to be exposed lo direct sunlight or ultraviolet light should be so ad-
vised, and treatment should be discontinued at first evidence of skm erythema
PRECAUTIONS: il superinfection occurs due to overgrowth of nonsusceptible organisms,
including lungi discontinue antibiotic and start appropriate therapy
In venereal disease, when coexistent syphilis is suspected, perlorm darkfield exami-
nation before therapy, and serologically test for syphilis monthly tor at least four months.
Tetracyclines have been shown to depress plasma prothrombin activity, patients on an-
ticoagulant therapy may require downward adjustment of their anticoagulant dosage
In long-term therapy, perform periodic organ system evaluations (including btood,
renal, hepatic}
Treat all Group A beta-hemolylic streptococcal infections for at least 10 days
Since bacteriostatic drugs may interfere with the bactericidal action ol penicillin, avoid
giving tetracycline with penicillin
ADVERSE REACTIONS: Gastrointestinal (oral and parenteral forms) anorexia, nausea,
vomiting, diarrhea, glossitis, dysphagia, enterocolitis, inflammatory lesions (with monil-
lal Overgrowth) m the anogenilal region
Skin: maculopapular and erythematous rashes, exfoliative dermatitis (uncommon) Pho-
tosensitivity IS discussed above (See WARNINGS)
Renal toxicity: rise m BUN. apparently dose related (See WARNINGS)
Hypersensitivity; urticaria, angioneurotic edema, anaphylaxis, anaphylactoid purpura,
pericarditis, exacerbation of systemic lupus erythematosus
Bulging fontanels, reported m young infants after full therapeutic dosage have disap-
peared rapidly when drug was discontinued
Blood: hemolytic anemia thrombocytopenia, neutropenia, eosmophiha
Over prolonged periods, tetracyclines have been reported lo produce brown-black mi-
croscopic discoloration of thyroid glands, no abnormalities of thyroid function studies are
known to occur
USUAL DOSAGE: Adults- 500 mg daily, divided into two or four equally spaced doses
IVIore severe infections an initial dose of 300 mg lol'owed by 150 mg every six hours or
300 mg every 12 hours Gonorrhea In uncomplicated gonorrhea, when penicillin is con-
traindicated, Rondomycin' (methacycline HCl) may be used for treating both males and
females in the following clinical dosage schedule 900 mg initially, loHowed by 300 mg
q I d for a totaf of 5 4 grams
For ireatment of syphilis, when penicillin is contraindicated. a total of 18 lo 24 grams ol
Rondomycin (mettiacydme HCt) m equally divided doses over a period of 10-15 days
should be given Close follow-up. including laboratory tests, is recommended
Eaton Agenl pneumonia 900 mg daily tor six days
Children- 3 to 6 mg/lb,'day divided inlotwo to four equally spaced doses
Therapy should be continued for at least 24-48 hours after symptoms and fever have
subsided
Concomitant therapy Antacids containing aluminum, calcium or magnesium impair ab-
sorption and are contraindicated Food and some dairy products also mtertere Give drug
one hour before or two hours after meals Pediatric oral dosage forms should not be
given with milk formulas and should be given al least one hour prior to feeding
In patients with renal impairment (see WARNINGS) total dosage should be decreased
by reducing recommended individual doses or by extending time intervals between
doses
In streptococcal infections, a therapeutic dose should be given for at least 10 days.
SUPPLIED; Rondomycin' (methacycline HCl) 150 mg and 300 mg capsules, syrup con-
taining 75 mg/5 cc methacycline HCl
Before prescribing, consutt package circular or latest FOR information.
Rev 6/73
WALLACE LABORATORIES
CRANBURY, NEWJERSEY08512
V.ir. 3.";. No.
. Leonard Rhyne, who resigned the position to de-
)te full time to his position as associate professor
community medicine ( biostatistics), which in-
udes increasing responsibilities in statistical analy-
[ Haste comes to Bowman Gray-Baptist Hospital
Kmi Lynchburg, Va., where he was manager of
igineering and financial marketing systems with the
eneral Electric Company's Communications Sys-
ims Business Division.
j The computer center, which has a 28-man staff,
I equipped with a Honeywell 6040 computer. Its
i)plication is primarily for business and scientific
'•Qgrams.
JDr. James C. Leist has been appointed an as-
i>tant to the vice president for medical affairs, with
jfimary responsibility for the development of an
rea Health Education Center (AHEC) program
I serve a 16-county area of northwest North Caro-
,ia.
jl Dr. Leist also will hold a faculty appointment as
Istructor in community medicine.
(For the past two years he has been director of
,talth manpower planning for the Forsyth Health
lanning Council in Winston-Salem.
* « *
I Dr. David L. Kelly, Jr.. associate professor of
";urosurgery. was elected vice president of the North
Carolina Neurosurgical Society at the group's organi-
zational meeting in Pinehurst.
Dr. William S. Pearson, associate professor of
psychiatry, has been elected a fellow of the American
Psychiatric Association.
Dr. Harold D. Green, professor of physiology,
has been appointed to the Committee on Traffic
Safety of the North Carolina Medical Society.
News Notes from the —
UNIVERSITY OF NORTH CAROLINA
DIVISION OF HEALTH AFFAIRS
New appointments in the UNC School of Medi-
cine include:
Betsy J. Stover, associate professor. Department of
Pharmacology, has been for the past four years an
associate professor, part-time, at the University at
Chapel Hill and consultant in the Department of
Anatomy. University of Utah. She holds the A.B.
from the University of Utah and Ph.D. from the Uni-
versity of California.
Joanna S. Dalldorf, assistant professor. Depart-
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.
Accredited by the Joint Commission on Accreditation and
Certified for Medicare
James Asa Shield, M.D.
James Asa Shield. Jr., M.D.
Catherine T. Ray, M.D.
Weir M. Tucker, M.D.
George S. Fultz. Jr., M.D.
Graenum R. Schiff, M.D.
rPTEMBER 1974. NCMJ
565
ment of Pediatrics, has been affiliated with the Pedi-
atric Supcr\isory Clinic. District Health Department
in Hillsborough since 1968. and the Biological
Sciences Research Center at the University at Chapel
Hill since 197U. She received her A.B. and MD.
from Cornell University.
Nancy M. Johnson, assistant professor of psy-
chology. Department of Psychiatry, holds the B..A.
from Occidental College and the M..A. and Ph.D.
from the University at Chapel Hill. She has been a
clinical scientist at the University's Biological
Sciences Research Center since 1970. lecturer in the
School of Education since 1973. and assistant pro-
fessor, part-time, in the Department of Psychiatry
since 1967.
Gerald W. Blake, assistant professor. Department
of Medicine, received his B.S. and M.D. from UNC
at Chapel Hill. He currenth is completing a fellow-
ship in infectious diseases and clinical instructorship
at the School of Medicine.
John H. Br_\an. assistant professor. Department of
Pediatrics, received his undergraduate and medical
training at UNC. For the past year he has been a
fellow and part-time instructor at the School of Medi-
cine.
Robert G. Dillard. assistant professor. Department
of Pediatrics, is completing a two-sear tour of dut\
as a pediatrician at Army Hospital. Ft. Riley. Kan.
A graduate of the University of the South, he re-
ceived his medical training at ^'ale Uni\ersit> School
of Medicine and the University of Tennessee.
William F. Finn, assistant professor. Department
of Medicine, has been a fellow in nephrology at the
UNC School of Medicine for the past two _\ears. He
holds the B.S. degree from Le .Moyne College and
the M.D. degree from S.U.N.Y. College of Medicine.
Syracuse.
Neil .-X. Hoffman, assistant professor. Department
of Pathology, is a member of the Medical Corps of
the U.S. .Army and a pathologist, part-time, for the
.Alabama State Department of To.xicology and Crimi-
nal Investigation. He holds the B.S.. M.S.. and
M.D. from the Uni\ersity of Wisconsin.
David Metz, assistant professor of hospital ad-
ministration, comes to Chapel Hill from Beth Israel
Medical Center where he was assistant director. He
also has been a lecttirer at Columbia L'ni\ersit\
School of Public Health and Administrative .Medi-
cine. A graduate of Queens College of the City Uni-
versity of New York, he received the M.P..A. from
New York Universitv.
Felix .A. Sarubbi. Jr.. assistant professor. Depart-
ment of Medicine, has been a research and teaching
fellow in the UNC Departments of Medicine and
Bacteriologv since 1472. He received his B.S. from
Manhattan College and his M.D. from New >'ork
University School of Medicine.
Peter D. Utsinger. assistant professor. Department
of Medicine, currentiv is completing a clinical fel-
lowship in rheumatologv at the Universitv of Cali-
.^66
fornia at San Diego. He holds the .A.B. from Lef;-
College de L'Assomption and M.D. from Gcorge-i
town School of Medicine.
* * *
Promotions to assistant professor in the UNCj
School of Medicine include: William H. Bowers.i •,;
Department of Surgery; Edward W. Davidian and;
Edward A. Norfleet. Department of Anethesi-
ology; .Alexander B. Filimonov and H. .Allen Mat-
thews, Jr.. Department of Radiology; Harvey J.
Hamrick, Departments of Pediatrics and Family
.VIedicine; Elaine Hilberman. Department of Psychia
trv ; and David J. Leander. Department of Pharma
cology.
Louis E. Underwood, assistant professor of pedia
tries at the UNC School of Medicine, has been se
lected the Jefferson-Pilot Fellow in Academic Medi
cine for 1974-1975.
The award, established three years ago by the
Jefferson-Pilot Corporation, provides the recipient
with 52. 000 per year for four year
The fellowship program is designed to attract and
hold yoimg facultv to the UNC School of Medicine
b_v enabling them to "explore new ideas, new ways of
teaching sttidents. treating patients or investigating
biological problems." Selection of each fellow is
made by a committee of medical facultv at UNC
Dr. Underwood, a member of the division of pedi-.
atric endocrinology, is interested in the hormonal fac-
tors controlling growth. Now he is turning his atten-
tion to the siudv of factors infkiencing fetal growth.
.An understanding of these factors. Dr. Underwood
believes, will enable phvsicians to deal more et-
fectivelv with disorders resulting from abnormal fetal
growth. The research findings also have potentially
important miplications in the treatment of nutri-
tionallv deprived infants, infants of diabetic mothers
and premature infants. |
Dr. Timothy N. Taft. senior resident in orthopae-
dic surgery at North Carolina Memorial Hospital, isi
the 1974 recipient of the Nathan .A. Womack Surgi-
cal Socictv Scholarship.
The societv gives the award [o the senior surgica
resident considered to "best epitomize the qualities]
of Nathan .A. Womack — general excellence in
teaching, clinical investigation and patient care." Dr.;
Womack was the first chairman of the Department
of Surgery when the four-year UNC School of Medi
cine opened.
Dr. Taft will join the School of .Medicine teach
ing staff as an instructor, specializing in sports medi
cine.
=;: * *
O'Dell W. Henson. Jr.. has been appointed profes-
sor in the Departments of .Anatomy and Surgerv. He
is currentiv an associate professor in the Department
of .Anatomv at ^ale University. He received his
Vol. .v;. No. 9
Jlergraduatc and master's training at the Univcrsitv
'Kansas and his Ph.D. at Yale.
I|
Two appointments have been made in the Division
ICommunitv Heahh Serviee of the UNC School oi
felic Health at Chapel Hill.
■Sherman Brooks, former Fayetteville State Univer-
■ associate professor of health, has been named
(irdinator of Technical .Assistance. Coordinator of
■lid Relations is Elizabeth Tisdale. former health
Unner in Charlotte. N. C.
i * :ir S:
Other new appointments in the UNC School of
blic Health include:
Mildred E. Francis, assistant professor, Depart-
tat of Biostatistics, holds the B.S. degree from
\C. Teachers College and Sc.M. and Sc.D. from
hns Hopkins University. She has been a statistical
Ijsultant for the World Health Organization in New
«lhi, India, and for the Food and Drug Directorate,
awa, Ontario, Canada.
:?eter B. Imrey, assistant professor. Department of
Statistics, has been a visiting assistant professor
Ithe University here since 1972. A graduate of
lumbia Univcrsitv, he received his Ph.D. from
ViC.
Alfred W. Rademaker has been appointed as-
s- ant professor. Department of Biostatistics. con-
t'^ent upon completion of his Ph.D. degree from
I insylvania State University. He holds the B.Sc.
;1 M.Sc. degrees from the University of Manitoba.
I has been a research assistant on the "Choice of
[(del for Reliability Studies" prepared for .Aero-
s'lce Research Laboratories.
rhirayath M. Suchindran. assistant professor. De-
[ tment of Biostatistics. has been a visiting assistant
I'lfessor at the University for the past year. A na-
t ? of India, he holds the B.Sc. and M.Sc. degrees
f m the Univcrsitv of Kerala, India, and the
1 S.P.H. and Ph.D. degrees from UNC.
* ::; :!:
Pranab K. Sen. professor. Department of Biostatis-
:;, will spend a year beginning Aug. 15. 1974. at
;va State University Department of Statistics. Dur-
■; his leave of absence he also will write a major
irtion of a research monograph.
■Dr. Dorothy M. Talbot has been named professor
:1 head of the School of Public Health's Depart-
int of Public Health Nursing at UNC— Chapel Hill.
'Formerly director of the Public Health Nursing
|';tion. School of Public Health and Tropical Medi-
ae at Tulane University. Dr. Talbot holds the
i.N. degree from Texas Woman's Universit\ at
inton; a diploma from Jefferson Medical College
iiool of Nursing. Philadelphia. Pa.; the M.A. de-
e from Teachers College. Columbia Universitx.
^Y.: and the M.P.H. and Ph.D. degrees from Tu-
^.e Uni\ersity.
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1'
1/
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Dr. Stephen M. Zeck, graduate dental student at
UNC at Chapel Hill, has been awarded a $7,500
clinical fellowship in pedodontics by the United Cere-
bral Palsy Research and Educational Foundation.
Inc. He will use the one-year award which began
Sept. 1 to study the dental problems associated with
cerebral palsied children.
* * :::
New appointments in the UNC School of Dentistry
include:
Richard J. Cray, assistant professor, Department
of Periodontics, is completing a year's clinical study
at the Indiana University School of Dentistrs where
he received his M.S.D. A graduate of Michigan
State University, he holds the D.M.D. from the
New Jersey College of Medicine and Dentistry.
Duane A. Dreyer, assistant professor of oral
biology. Department of Oral Surgery and Depart-
ment of Physiology, School of Medicine, comes to
Chapel Hill from Duke University Medical Center
where he is a research associate in the Division of
Neurosurgery. He holds the B.S. degree from the
University of Cincinnati School of Pharmac\ and the
Ph.D. from the University of Pittsburgh School of
Medicine.
Richard D. Jordan, assistant professor. Depart-
ment of Operative Dentistry, received his B.S. from
North Carolina State University and his D.D.S. from
the University at Chapel Hill. For the past two years
he has been assistant dental officer and division of-
ficer of the Naval Dental Corp.s at Cecil Field. Jack-
sonville. Fla.
Robert P. Kusy, assistant professor of oial bi-
ology. Department of Orthodontics, has been a re-
search associate in the UNC School of Dentistrv for
the past two years. .A graduate of Worcester Pol\-
technic Institute, he holds the M.S. and Ph. [3. from
Drc.xel University.
Charles E. Lew. assistant professor. Department
of Periodontics, received his B..\. and D.M.D. from
the University of Pennsylvania and a certificate from
the Boston University School of Graduate Dcntistrv.
David E. Kelly, assistant professor. Department of
Oral Surgery, has been a teaching assistant in (iral
surgery at New York University College of Dcntistrv
where he received his D.D.S. degree. He holds the
B..A. from Bcloit College.
Promotions in the School of Denlistrv include:
To professor: Gerald M. Cathey. Department of
Endodontics: Eleanor A. Forbes. Department of
Dental Ecology: and Jacob S. Hanker. Department
of Oral Sin-gerv .
To assistant professor: Robert B. McCabe. De-
partment of Denial Ecology,
On leaves of absence in the School of Dcntistrv
a re :
James \\\ Bawdcn. professor. Depaitmeiit of Pe-
dodontics. is on Kenan leave loi' a vear to conduci
5M
research with Dr. Lars Hammarstrom, participate ii
teaching of pedodontics and observe the Swedisj
dental system. He also will consult on curriculum rq
vision at the University of Lund, Malmo, Sweden.
John M. Gregg, associate professor, Department c
Oral Surgery, will work with the University of Wash
ington School of Medicine Pain Control Clinic an
study research projects while on leave from Aug. 1
1974 to Jan. 31. 197.5. ^
;i
Dr. Seymour M. Blaug of the University of low
was appointed dean of the School of Pharmacy an
professor of pharmacy at UNC-Chapel Hill effectiv
August 15.
Dr. Blaug succeeds Dr. George P. Hager. who wii
return to teaching and research after eight years i
the administrative role.
Dr. Blaug joined the University of Iowa facult
in 1955 and has been a Professor of Pharmceutic
there since 1962. A native of New York City. Di
Blaug earned the B.S. and M.S. Degrees from Cc
lumbia University College of Pharmacy and th
Ph.D. degree from the University of Iowa.
* * *
Congressman L. H. Fountain announced that th
School of Pharmacy at UNC at Chapel Hill has re
ceived a $386. 22S federal grant for the 1974-197
school year.
The grants represent a slight increase over th
previous capitation grants.
The grant is based on the number of enrolled sti
dents and is in support of the school's activities-
curriculum improvements, training of pharmacy sti
dents for new roles and levels of service and clinic;
pharmacv and drug education programs.
Hie University of North Carolina at Chapel Hil
has received $315,000 in grants to support alliel
health programs in the Medical and Dental Schoolf
Dr. Ralph H. Boatman said the grants would
used to strengthen and expand allied health prograiri
in physical therapv and radiologic technology anj
to provide trainee support in physical therapy anj
the dental auxiliarv teacher education program.
Boatman is director of the Office of .Allied Heali
Sciences at UNC.
Physical therapy in the Medical School gets $I87J
50ti. .Another $98,600 goes to radiologic tecl]
nology, also in the Vledical School. Dental auxiliai''
in the Dental School, receives $29,000.
Pat Lawrence of the UNC School of Nursing ii
Chapel Hill has been elected to the Board of Dire
tois of the American Diabetes Association.
Miss Lawrence, assistant professor in the Contini'
ing Education Program, has been a member of il
Board of Directors of the N. C. Diabetes Associi
tion and educational director of the Diabetes Projt
of the N. C. Regional Medical l^-ogram.
Vol. 3.'5. No.
■(Promotions to new assistant professors in the
'lool of Nursing include: Jane M. Hayward,
jne M. Parfitt and Sandra L. Venegiini.
The AIN panel also recommended the passage of
a national nutrition education act.
iThe U. S. Senate was urged June 20 to create an
•j/isory conmiission on nutrition because of the
¥ld food crisis.
Or. Howard A. Schneider, reading a report pre-
-ed by the American Institute of Nutrition ( AIN ),
1 the Senate's Select Committee on Nutrition and
(iman Needs "a new governmental apparatus nuist
Iset in place to provide for the emerging role of
United States as the foremost world food ex-
ter."
^Schneider, director of the Universtiy of North
rolina Institute of Nutrition, is cochairman of the
N's panel on "Nutrition and the Consumer" and
i,iirman of the subpanel "Popular Nutrition Edu-
l^on," which prepared the report.
(
]
North Carolina has some 300,000 persons whose
drinking has caused problems for them, their fami-
lies, their friends, employees or the police. Dr.
John A. Ewing told members of the N. C. Associa-
tion of ABC Boards' meeting in Mvrtle Beach, S. C,
July l-"^.
Calling for the support of the N. C. Alcoholism
Research .Authiirity, Dr. Ewing urged that North
Carolinians invest their dollars in alcohol research
in addition to spending millions on rehabilitation.
Dr. Ewing is director of the University of North
Carolina Center for Alcohol Studies in Chapel Hill.
Nobody knows what alcoholism costs in North
Carolina, he said. State treatment programs alone
run well over $10 million.
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Vemhi r 1974, NCMJ
I
^W
News Notes from the—
DUKE UNIVERSITY MEDICAL CENTER
Dr. Ewald W. Bussc. chairman of the Department
of Psychiatry at Duke University, became Duke's
Director of Medical and Allied Health Education on
Sept. I.
He succeeds Dr. Thomas D. Kinney, who has
been director since 1969 and who is retiring from
administrative responsibilities to return to teaching
and research.
Kinney also is chairman of the Department of
Pathology, a post he has held since coming to Duke
in I960. He will continue to administer that depart-
ment until a successor arrives within the ne.\t few
months.
Unlike most medical schools, Duke does not have
a dean of the School of Medicine. Instead, the Direc-
tor of Medical and Allied Health Education is the
chief educational officer of the medical center. He
functions as a medical dean and also is responsible
for graduate and continuing medical education, as
well as education in the multiple fields of allied health
training under way at Duke. The School of Nursing
is administered separately by a dean.
in structuring medical and allied health education
in that manner, the Duke administration felt it pro-
vided a more completed overall coordination of edu-
cational functions at the medical center.
In addition to the director, there are associate di-
rectors reporting to him who are responsible for un-
dergraduate medical education, admissions, allied
health, continuing education and gradL:ate medical
education.
■■ The imi\ersit\ and its medical center are deeply
grateful for Dr. Kinney's strong and effective leader-
ship in medical and allied health education during
the past five years," said Dr. William G. Anlyan,
vice president for health affairs.
""Under his stewardship, the evolutionary major
changes in the medical curriculum at Duke have
been firml\ established and improved substantially.
Dr. Kuiney has also established a formal Division of
.Allied Health with high quality programs. We are
certain that Dr. Busse will continue the traditiim
of excellence in medical and allied health education
as well as to provide his own intellectual leadership
to the future directions of deveUipment." Anlyan
said.
KinncN, who is recognized as one of the countrv's
leading medical educators, is the only person to
have held the medical-allied health directorship at
Duke.
He is chairman of the Liaison Committee on Medi-
cal Education of the .Association of .American Medi-
cal Colleges (.A.AVIC) and the .American Medical
51i)
lir..
liii
Association (AMA), and he also was president P'
the AAMC's Council of Academic Societies.
In 1972-1973 Kinney was president of the Fedei
tion of American Societies for Experimental Biolo^''''
and he has served as chairman or president of
number of other professional organizations includi
the Association of Pathology Chairmen.
Kinney currently is editor of the American Joitr^^
of Pathology.
A native of Pennsylvania and a graduate of t Ioh
University of Pennsylvania with an A.B. in 19: >)
Kinney received his M.D. at Duke in 1936. Folio i"*
ing internship and residency, he held teaching -jf
pointments at the Tufts College of Medicine and
Yale, Boston and Harvard universities from 193
1947.
In 1947 he began a 13-year association with w(
is now Case Western Reserve University in Cle
land, leaving there in 1960 to chair the Depa|e
ment of Pathology at Duke.
Since 1967 Kinney has been R. J. Reynolds ?\\
fessor of Medical Education.
The new director, Busse, who will retain his A
pointment as J. P. Gibbons Professor of Psychiatjn
has received national recognition for his work
psychiatry and gerontology. He was president of ij^:
.American Psychiatric Association ( APA ) in 19'
1972.
He holds a Certificate of Commendation from
.APA and a Citation of Merit from the Gerontola
cal Society, of which he also was president.
It was Busse who established Duke's Center
the Study of Aging and Human Development
1957, four years after coming to Duke to chair
Department of Psychiatry. He headed the center i
til 1970.
Busse has held numerous research awards, c(
sultant appointments to federal agencies and
served as a member or officer of more than 30 p
fessional organizations and as editorial advis
board member of eight professional publications.
Busse is a native of Missouri where he recei'
an .A.B. degree in 1938 at Westminster College
Fulton. The college awarded him an honorary d
torate in I960. He received his M.D. degree at Wa
ington Universitv in St. Louis in 1942.
Following postgraduate training and military ;
vice, Busse joined the faculty of the University
Colorado School of Medicine where he advan
from instructor to full professor between 1946 ;
1953, the vear he accepted the psychiatry chairm
ship at Duke.
* ::- =:<
Dr. H. Keith H. Brodie of Stanford Universit;
the chairman of the Department of Psychiatry.
Brodie, who is an assistant professor of psychi
at Stanford, will succeed Dr. Ewald W. Busse v
is assuming the position of Director of Medical :
Vor. .v;. N(
,llied Health Education. Brodie's Duke rank will
e full professor.
ejlj In addition to his teaching duties at Stanford,
jTodie has been program director of the medical
^;hoors General Clinical Research Center.
Brodie earned an A.B. degree in chemistry at
rinceton in 1961 and was awarded an M.D. degree
inilit Columbia in 1965.
He served an internship at Ochsner Foundation
Jospital in New Orleans, followed by a residency in
(iychiatry at Columbia-Presbyterian Medical Center
(I New York. He was a clinical associate in the
ection on Psychiatry, Laboratory of Clinical
aife;ience, of the National Institute of Mental Health
or two years prior to joining the Stanford faculty
( 1970.
' Brodie is a member of the editorial board of
'Psychiatry Digest" and he is associate editor of
'"Pflie American Journal of Fsychialry.
He is a member of numerous professional organi-
'itions and currently is chairman of the program
ommittee of the American Psychiatric Association.
fC also has served as a consultant to the federal
wernment on narcotics and drug abuse, and in
))72 he was a visiting lecturer at Duke for a sym-
osium on drugs and the aging patient.
Among administrative and departmental responsi-
lities at Stanford, Brodie has been special assistant
the chairman of psychiatry for administration, a
member of the department's administrative and
budget committees, premedical advisor and chairman
of the Medical School Faculty Senate.
Is. (3
inii
3111 i
idvii
lis.
recti II
lies 1,
in'
iiW:
jrs
:rsil!
dvai
lain 1
,'ersil I
sycli
)iS£
MEDICAL DIRFXT MAIL DECLINES
According to the Pharmaceutical Manufacturers
Association (PMA), the typical busy physician re-
ceives an average of four pieces of medical mail
per day. "This represents a 38 percent decline since
1959," C. Joseph Stetler, PMA president, said, "and
negates any claim that such mail is proliferating.
Actually, through the use of the computer and other
techniques, medical mail today is much more sele-c-
tive and efficient; the circulation of an average mail-
ing dropped to less than 20,000 in 1973 compared to
an average of 55.000 in 1959."
Sharply increasing costs for paper, printing, copy-
writing, design, royalties, and handling charges have
also contributed to a decline in the volume of direct
mail.
Medical direct mail serves a number of valuable
goals including speed in transmitting information
about drug therapy, providing more detailed informa-
tion than may be possible in other ways, and en-
hancement of the dialogue between physician and
manufacturer.
"This is particularly important to the 36 percent
of the total physician population which practices in
&li
'■ -m*
Westbrook
Psychiatric Hospital, Inc.
Richmond, Virginia
FOUNDED 1911
PSYCHIATRY NEUROLOGY
REX BLANKINSHIP, M.D. GERALD W. ATKINSON, M.D.
Chairman, Advisory Group Associate in Neurology
JOHN R. SAUNDERS, M.D. HUGH HOWELL, M.D.
Medical Director Associate in Neurology
THOMAS F. COATES, JR., M.D.
Assistant Medical Director CHILD PSYCHIATRY
OWEN W. BRODIE, M.D. GILBERT SILVERMAN, M.D.
Associate in Psychiatry Associate in Child Psychiatry
M. M. VITOLS, M.D.
Associate in Psychiatry ADMINISTRATION
WESLEY E. McENTIRE, M.D. H. R. WOODALL
Associate in Psychiatry Administrator
BOBBY W. NELSON, M.D.
Associate in Psychiatry
,d "l
l"PTEMHhR 1974. NCMJ
//
571
rural areas where detail men are seen irregularly,
if at all," Stetler said.
A NEW BOOKLET FOR THE NEW
OSTOMATE
A brochure prepared to aid the new ostomate re-
turn to a full and normal life is being made avail-
able without charge, as a professional service b>
E. R. Squibb & Sons. Inc., to surgeons, family phy-
sicians, nurses and enterostomal therapists.
The booklet, "An Ostomy is for Living." is de-
signed to reassure the new ostomate that there are
only a few limitations to the return to a routine
life-style.
It answers many of the commonly asked ques
tions of the new ostomate concerning showering and
bathing, clothing, diet, exercise and sports, and trav
eling. The booklet discusses problems that might be
encountered with adhesives and appliances, and
ways to handle or avoid them.
Copies of the brochure may be obtained by writ-
ing Hospital Division, E. R. Squibb & Sons, Inc. J
P. O. Box 4000, Princeton, N. J. 08540.
Month in
Washington
Chances of passage this year of any national health
insurance (NHI) proposal seem to be dwindling
away. The indefinite postponement of Senate Fi-
nance Committee hearings on NHI and termination
of the House Ways and Means Committee's once-a-
week hearings seem to indicate that Congress feels
it has more pressing matters to deal with, or is baffled
as to how to proceed with mandating health insur-
ance for all.
Some veteran Capitol Hill observers belie\e the
most important factor in congressional dawdling on
the NHI issue is genuine bafflement — which has
led to sharp controversy — on how such a program
should be financed.
Most of the NHI proposals \ary only slightK in
the scope of benefits, and there is no sharp dis-
agreement that the program should be comprehensive
in nature. All but one or two of the proposals agree
that the administration of the program should be de-
rived from a combination of the federal and private
sectors, using the existing private health insurance
industry, controlled by federal guidelines and regu-
lations.
The problem is how the program should be fi-
nanced. Should the program be financed by a Social
Security payroll tax, by mandated employer-em-
ployee financing, or by a tax credit system, such as
proposed by the American Medical Association in
its Medicredit plan'.'
It is in the area of financing that conservatives find
the dangers of NHI. When a program is financed
directly through federal revenues, it is an open invi-
tation for government to use those dollars as a lever
to manipulate ihc entire pnigram — "an inappropri-
.W2
ate intervention of the federal government intc
private affairs and responsibilities."
Each of the proposed methods for financing ar
NHI program has powerful allies in both the Con-
gress and in the private sector. It would seem tha;
this Mexican standoff is a major reason for thi;
Congress' delay. Short of an imlikely compromist
brought on bv a complete about-face by one of tht
major contending forces, it appears that the 93rt
Congress will not legislate a national health insur
ance program.
.Another reason for congressional foot-dragging oi
NHI is that time is running out for the 93rd Con
gress and its "must" work is still piled high. Fo
example, still to surface from the powerful Housi
VVavs and Means Committee is its promised tax re
form measure, the long ago announced top priorit;
of the Commiltee.
The House's interstate and Foreign Commerc
sLibconimittee on health has crushed, by an eight t(
one vote, a public utility-like plan that would con
trol physician fees and hospital charges — a provisioi
regarded by many as the most threatening healtl
measure on Capitol Hill.
The vote appeared to assure the doom of the pub
lie utility concept both in the full House Commerc
Commiltee and the House. There remains the possi
hililv of Senate approval, however.
"I he controversial provision is part of a compre
heiisive lUid cimiplicated rewriting of the Compre
hensive Health Planning and Regional Medical Pre
giams of the federal government. The proposed stric
rate controls exercised by the states are backed b
Vol. .^.s. No.
i|n. Edward Kennedy (D-Mass.) and Rep. William
py (D-Kans.), the latter a physician who cast the
lie vote for the provision in the House subcom-
ijttee.
[Opponents of the plan were subcommittee Chair-
/jin Paul Rogers (D-Fla.) and Democratic Reps.
*jvid Satterficld (Va.), Peter Kyros (Maine),
Richardson Preyer (N.C.); and GOP Reps. An-
er Nelson (Minn.), Tim Lee Carter (Ky.), James
iiifustings (N.Y.), and H. John Heinz, 111 (Pa.).
•;Dsent, but favoring the majority position, were
;ps. William Hudnut (Ind.) and James Symington
/lo.).
IThe vote was on a motion to strike from the bill
pguage that would have authorized federal funding
r State Health Commission programs of regulating
arges in the medical field with ultimate authority in
; HEW Department.
Health providers have opposed the plan. Declaring
at the legislation has "far reaching implications for
; future delivery of health care services," Richard
ilmer, M.D., Chairman of the American Medical
isociation's Board of Trustees, told the subcom-
:ttee earlier this year that under the disputed plan
.le health sector in effect would be deemed to be
e vast, monolithic public utility."
'iDr. Palmer said, "We must caution against the
position of a massive bureaucratic control of the
^alth care system . . . the economic forces inherent
in this proposal could defeat the intention of this
Committee to foster the development of improve-
ments in our health care delivery system."
The subcommittee adopted a requirement that the
local planning agencies monitor individual institu-
tional rates within the state and publicly comment
on such rates.
Also included in the subcommittee draft are pro-
visions to require states to have certificate of need
legislation, or similar legislation relating to the con-
struction of new facilities.
States would be required within three years to
review and comment on the need for all facilities
and services provided within the state.
* * *
A slashing attack against the nation's reliance upon
foreign medical graduates (FMGs) has been
launched in Washington by the Association of Ameri-
can Medical Colleges (AAMC).
The present situation "undermines the process of
quality medical education in this country and ulti-
mately poses a threat to the quality of care delivered
to the people," according to a report by an AAMC
task force on FMGs headed by Kenneth Crispell.
M.D., vice president for health affairs at the Univer-
sity of Virginia.
Endorsed by the AAMC executive council, the
blunt assault on the immigration of FMGs called for
MECKLENBURG COUNTY
MEDICAL SOCIETY
AND INTRAV
Announce the 1975 Travel Adventures
To Africa for 2 weeks February 21 -March 7
To Dublin, Amsterdam, & London 2 weeks in June
To the Balkans 2 weeks in October
WATCH FOR BROCHURES
GIVING THE DETAILS
.'PTEMBKR 1974, NCMJ
573
siciuns. Said the AMA: ■"Licensure per se cannot
assure high quality of medical care or effectiveness
of the practice of physicians. Relicensure has the
same limitations. Under present circumstances, the
process of relicensure could severely disrupt the care'
of patients in many instances because physicians
would have to prepare for examinations and be away
from patient care while taking them." '
Book Reviews
Arthriti.s. Complete, I'p-to-Datc Facts for Pa-
tients and Their l-'aniilies. B\ .Sheldon P.iiil Bhui.
.\1.D.. iind Dodi .Schultz. Price. $4.95. Garden C]t\.
New ^ork: Doubleday & Compan\. Inc.. 1974.
This book has some interesting factual informa-
tion. The latter chapters on diet, home care and se.x
should provide useful information for arthritics and
their families.
However, most chapters seem too medically de-
tailed for the "average patient" and can therefore
easily lead to the patient's confusion. For example,
the discussion concerning phalangeal osteoarthritis
( page 68 ) emphasizes the absence of a history of re-
peated stress or trauma, but the discussion concern-
ing the etiology of osteoarthritis (page 69) empha-
sizes these factors in the pathogenesis of this disease.
Repeated statements are made condemning self-
diagnosis, but the middle chapters detailing the vari-
ous types of rheumatic diseases are written in such a
way as to perhaps encourage this practice in the un-
wary reader. The discussions on treatment seem to
emphasize too strongly the side effects, and too weak-
ly the anticipated therapeutic successes of present-
day therapeutic regimens for arthritis.
The book should be useful reading for interested
health professionals and previously well informed
arthritis patients and their families.
Bar[!.\ra H. Muse, Medical Assisianl
RoBt^RT A. Turner. M.D.
The I Itiniate .Stranger. B\ C ,irl H. Delacalo.
Kd.D. llh pages. Price. Sh.y?. Garden City. New
>'ork: Doiihleday ci Company. Inc.. 1974.
This is a book that will, in all likelihood, appeal
to those who accept the concepts and the diagnostic
and therapeutic approaches of the Institutes for the
.Achievement of Human Potential (I.AHP). It will
not appeal to those who do not agree with the lAHP
approach. The writing is not scientific, although the
scientific bibliograph) is relatively extensive. There
is much first person emphasis and bias and a ten-
dency toward o\erl\ enthusiastic statements.
It is to be admitted that the therapy of the main
l\pcs of children who arc categorized as autistic has
li
il
t
1-
been relatively unproductive. The number of casesi
the author cites in this volume is insufficient to allow
any judgment, pro or con his approach, which is only t
one of several "new" approaches being tried with
autistic children.
The book will undoubtedly raise the hopes of
many parents. It would have been more appropriate,
perhaps, to have treated a reasonable number of
children and published a scientific paper comparing
results to other series, before writing a book for par-
ents and nonprofessionals, extolling the virtues of an,
as yet, inadequately tested therapeutic approach,
.Al.^nson Hinman. M.D.
Handbook of Mitrobiolo(;j. \ ol. I. Organismic
Microbiology. .Allen 1. Laskin and Hubert A.
Lechevalier (eds). 940 paces. Price, $36.00. Cleve-
l.ind. Ohio: C R( Press. 19'73.
This book is the first in a series of four volumes.
.Subsequent \olumes will be entitled Microbial Com-
position {\ol. II). Microbial Products (Vol. Ill)
and Microbial Metabolism, Genetics and Immunity
(Vol. IV). As the title suggests, this publication is a
handbook of microbiolog\, rather than a textbook,
and is primarily intended for reference purposes. The
authors have been brief and utilized charts anc
tables whenever possible, as the editors instructed.
Volume 1 is divided into seven sections entitled
Bacteria. Fungi, Algae, Protozoa, Viruses, Method-
ology, and General Reference Data. The first sec-
tion on Bacteria (260 pages) is devoted primarily to
brief descriptions of Chlaniydiu. Rickettsia, and the
ten orders of Bacteria. The chapters vary fron
broad descriptions and generalities to the inclusion
of micrographs and drawings illustrating various or
ganelles and appendages. Approximately 35 pages
deal with bacteria of clinical significance. The chap
ter describing the family Enterobacteriaceae is lack-
ing in many respects and tends to confuse, rather
than to simplify, the subject matter.
The next 179 pages describe the four familiar, al
though older, classes of fungi: Phyeomycetes, Asco-
mycetes, Basidiomycetes, Deuteromyces. Taxonomi(
keys and some physiological characteristics are pri
.W6
Vol. 3.\ No. 'i
.arily presented. A short cliapter on lichens (six
ages) concludes this section.
The 34 pages comprising the section on algae are
■imarily a listing of pertinent references with a brief
iragraph describing each phylum.
The section on protozoa is even shorter (27 pages)
■ an those previously mentioned and is predomi-
antiy ta.xonomic.
The section on viruses ( 142 pages) is subdivided
,to plant, invertebrate and vertebrate viruses, and
jcteriophages. The chapters on plant and inverte-
■ate viruses perhaps are among the few that are pre-
nted in the manner of a handbook — a listing of
urious viral entities and a few well chosen gcneral-
es concerning each group. The chapter on verte-
■ate viruses is somewhat longer but tends to lose
:e reader in the vast complexity of taxonomic and
tochemical tables. The major chapter in this section
'eals with bacteriophages. There are 77 pages of
Ibles, charts and figures describing, in a rather neat
tiid concise form, virtually every known characteris-
of various phages.
)' The last two sections. Methodology and General
Reference Data (258 pages) include information
most microbiologists would expect to find in a hand-
book of this type, i.e., sterilization techniques, mi-
croscopy, staining methodology, safety rules and
postal regulations, international associations of mi-
crobiology, literature guides, procedures for preserv-
ing microorganisms, colleges and universities offering
degrees in microbiology, and the like.
It is difficult to determine to what practical end
anyone would seek out this book. Microbiology does
not readily lend itself to the strict regimentation seen
in this type of publication. Most areas considered
in this handbook, except Methodology, General Ref-
erence data, and some aspects of Virology, are not
the subjects that one would refer to in a handbook,
especially since specific texts are available.
As with most handbooks, this one was intended to
be used as a quick reference. However, a four
volume set could hardly be considered a handbook,
and the price of this handbook most likely will rele-
gate it to the shelves of university libraries.
Benedict L. Wasilauskas, Ph.D.
[
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PTEMBhK 1974. NCMJ
577
Jn lH?mortam
M. J. Hornovvski, M.D.
Dr. M. J. (Jerry) Hornowski died on January 8.
1974. at the age of 53. after a long illness. He
had practiced psychiatry in .Asheville since 1951.
A native of Brookhn. New York, he attended the
University of Virginia where he received both his
.■\.B. and M.D. degrees. He was a member of the
University of Virginia basketball and baseball teams
from 1937 to 194(1. He interned at King County
Hospital, served two years in the U.S. Navy Medical
Corps and had his specialty training at the Menninger
Clinic.
Dr. Hornowski was a staff member of Memorial
Mission Hospital. St. Joseph's Hospital and a mem-
ber of the Buncombe County Medical Society. North
Carolina State Medical Society. American .Medical
.Association. American Psychiatric .Association.
Southern Psychiatric .As.sociation and North Carolina
Psychiatric Society. He was a past president of the
.Academv of Rehgion and Mental Health and former
president of the .Viental Health Center of W.N.C.
Perceptive and articulate, Jerry was frequently in
demand as a speaker to professional and lay groups.
He maintained a vital interest in man and his com-
munity. His empathy and skill made him an excep-
tionally effective practitioner. He was accorded great
respect, and will be painfully missed by all who knew
him.
He is sur\i\ed b\ his widow. Mrs. Grace Young
Hornowski. his mother, three children and three
sisters.
BUNCOMBF COL'NTV MEDICAL SOCIETY
Leonard Palumbo, M.D.
Dr. Leonard Palumbo died at North Carolina
Memorial Hospital in Chapel Hill. April 21. 1974.
after a short illness. He was born May 18, 1921.
in New York City.
Dr. Palumbo received his underaraduate education
at Duke University. He earned his M.D. degree from
Duke University School of Medicine in 1944 undi-
an accelerated training program. From 1944 to 195
he served a residency in obstetrics and gynecologv
at Duke Medical Center. j
From 1950 to 1952 Dr. Palumbo was an associ
ate in obstetrics and gynecology at Duke Medical
Center. In November 1952 he joined the obstetrics
and gynecology faculty at the University of North
Carolina School of Medicine as assistant professor.
From 1956 to 1964 he was associate professor. He
was appointed professor of obstetrics and gyne-
cology in 1964.
He was a member of many professional organi-
zations and scholastic honorary societies includ'
ing Phi Beta Kappa. Alpha Omega .Alpha. Sigma Xi,
Diplomate .American Board of Obstetrics and Gyne-
cologv. .American Medical .Association. North Caro-
lina State Medical Society. .American College of Ob-
stetrics and Gynecology. North Carolina Obstetrical
Society, and the Southern Medical Association. Hf
was a founding member and past-president of the
Southeastern Society of Obstetrics and Gynecology
and past president of the South Atlantic Society ol
Obstetrics and Gynecology. He was a member oi
the Robert .A. Ross and Bayard Carter Obstetric
and Gynecology Societies.
Dr. Palumbo was the author of numerous papers
in his field. His special interest was cancer of the
female reproductive system.
He was one of the original members of the Ob
stetrics and Gynecologv Department. North Caro
liiia Memorial Hospital. He was a dedicated phy-
sician who was loved by his patients and highly re-
spected b\ his colleagues and students alike.
He is survived by his parents. Mr. and Mrs
Leonard Palumbo. and one brother. Edward .Arthui
Palumbo.
McPHERSdN Hospital Stale
57K
Vol. 35, No.
^ORTH CAROLINA
i
Medical Journal
^ THIS ISSUE: Pseudocholinesterase Abnormalities as a Cause of Postanesthetic Apnea, Francis M. James, M.D.;
amily Practice: One Answer, Lyndon K. Jordan, M.D.; Survey of Health Education in the North Carolina Public Schools,
lartha Y. Martinat.
.®
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Additional information
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1975 LEADERSHIP CONFERENCE
, Jan. 31-Feb. 1-Raleigh
1975 ANNUAL SESSIONS
May 1-4 — Pinehurst
1975 COMMITTEE CONCLAVE
September 24-27— Southern Pines
^
Both ofteo
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 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 frequenc
and/ or severity of grand mal seizures ma
require increased dosage of standard ant
convulsant medication; abrupt withdraws
may be associated with temporary in-
crease in frequency and/ or severity of
seizures. Advise against simultaneous Iri'
gestion of alcohol and other CNS depres-
sants. Withdrawal symptoms (similar to
those with barbiturates and alcohol) hav£
occurred following abrupt discontinuanci
(convulsions, tremor, abdominal and mu:
cle cramps, vomiting and sweating). Kee]
addiction-prone individuals under carefu
Why is WANS*
Children the
pediatric antiemetic
so often prescribed
n North Carolina?"
"Because
WANS" Supprettes^
are formulated
to rapidly and
effectively deliver
medication'.'
I
ii
WANS" Supprettes™,
rapidly deliver effective
levels of medication rectally
release medication through
hydrophilic action— no oils or
fatty acids to interfere with
drug utilization or to cause local
irritation
no refrigeration or lubrication
other than water required
grooved for accurate half dosage
and no phenothiazines. . .
no local anesthetics
DESCRIPTION: WANS' Children Supprettes™ con-
tain pyrilamine maleate 25 mg and sodium pento-
barbital y? gr (30 mg) (Warning: may be tiabit
forming) in rectal suppository form. CONTRA-
INDICATIONS: Infants under 6 monttis. Acute
ntermittent porphyria, known hypersensitiv-
ity to barbiturates or antihistamines, known
previousbarbiturateaddiction, severe hepa-
tic impairment. CNS injury and presence of
uncontrolled pain, WARNINGS: Barbitu-
rates may be habit forming. Pre-existing
psychologic disturbances may be aggra-
vated. Acquired sensitivity may result in
allergic reactions. Safety in pregnancy
has not been established. PRECAU-
TIONS- Use very cautiously with other
sedative, hypnoticornarcoticagents. Use
with caution in patients with acute hepatic
disease, fever, hyperthyroidism, diabetes
mellitus. severe anemia, and congestive heart
failure. May impair alertness and coordina-
tion with increased accident nsk./(Dl/£R5£ RMC-
r/OWS Drowsiness, fatigue, vertigo, incoordination,
tremor, muscle weakness, ataxia, hypotension, res-
piratory despression, delmuni and coma. Dryness
of nose, mouth, and throat, pupillary dilatation or
blurred vision, urinary retention, abdominal pain,
nausea, vomiting, diarrhea, and hypersensitivity
reactions. Overdose or paradoxic reaction may
cause excitation, insomnia, palpitation, tachycar-
dia, convulsions and death. DOSAGE: Child 2-12
years: one WANSChildrenSupprette rectally every
6-8 hours. Infant 6 months-2 years: J'; dosage.
WANS
CHILDREN
antinauseant/antiemetic pyrilamine maleate 25 mg .
sodium pentobarbital 'i gr (30 mg)
WEBCON
w
WEBCON PHARMACEUTICALS
Fort Worth, Texas 76101
Division of Alcon Laboratories, Inc,
John H. Felts. M.D.
Winston-Salem
EDITOR
John S. Rhodes. M.D.
Raleigh
ASSOCIATE EDITOR
Ms. Martha van Noppen
Winston-Salem
ACTING ASSISTANT EDITOR
Mr. William N. Hilliard
Raleigh
BUSINESS MANAGER
EDITORIAL BOARD
* W. McN. Nicholson, M.D.
Durham
CHAIRMAN
Robert W. Prichard, M.D.
Winston-Salem
John S. Rhodes, M.D.
Raleigh
Louis deS. Shaffner, M.D.
Winston-Salem
Rose Pully, M.D.
Kinston
George Johnson, Jr., M.D.
Chapel Hill
Charles W. Styron, M.D.
Raleigh
* ( Deceased)
NORTH CAROLINA MEDICAL JOUR-
NAL, 300 S. Hawthorne Rd., Winston-Salem,
N. C. 27103, is owned and published by The
North Carolina Medical Society under the di-
rection of its Editorial Board. Copyright ©
The North Carolina Medical Society 1974.
Address manuscripts and communications re-
garding editorial matter to this Winston-
Salem address. Questions relating to sub-
scription rates, advertising, etc., should be
addressed to the Business Manager. Box
27167, Raleigh, N. C. 27611. All adver-
tisements are accepted subject to the ap-
proval of a screening committee of the State
Medical Journal Advertising Bureau, 711
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. In-
structions to authors appear in the January
and July issues. Annual Subscription, $5.00.
Single copies. $1.00. Publication office;
Edwards & Broughton Co., P. O. Box 27286,
Raleigh, N. C. 27611. Second-class postage
paid at Raleigh, North Carolina 27611.
NORTH CAROLINA
MEDICAL JOURNAL
Puhlished Monthly as the Official Organ of
The North Carolina
Medical Society
October 1974, Vol. 35, No. 10
Original Articles
Pseudocholinesterase .Abnormalities as a Cause of
Postanesthetic Apnea 607
Francis M. James, M.D.
Family Practice: One .Answer 612
Lyndon K. Jordan, M.D.
Survey of Health Education in the North Carolina
Public Schools 614
Martha Y. Martinat
Editorials
An Otince of Prevention?
Will Sickness Become Illegal?.
Emergency Medical Services
Trauma Can be Conquered
Curtis P. Artz, M.D.
Abstracted by Herbert J. Proctor, M.D.
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 of
Wake Forest University
News Notes from the University of North Carolina
Division of Health Affairs
Three North Carolina Foundations Focus Attention on
Access to Care: Financial Support to Encourage
Full-time Emergency Room Physicians
JO
619*'"
n:
62CJjj3
a
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62Gjfne
isi;
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li:
62 r
621
62 $1
629
63
63::
il;:
Sv
63'
Month in Washington 63i
Book Reviews
In Memoriam ^'^'tej
Classified Ads 64
Index to Advertisers.
64;?*^
Contents listed in Current Contents/Clinical Practice
"12
lit I
Pseudocholinesterase Abnormalities as a
Cause of Postanesthetic Apnea
Francis M. James, M.D.
fCCINYLCHOLINE, a potent,
depolarizing muscle relaxant, is
in given before, or during, an op-
^on. Normally, the body provides
I enzyme, pseudocholinesterase,
;h rapidly metabolizes succinyl-
6|iine. However, for at least 16
"s it has been known that abnor-
forms of pseudocholinesterase
t in some patients, that these
lis are unable to destroy succinyl-
f ine in vivo, and that these ab-
"nalities are genetically linked
' appear in families. Decreased
£ [iiunts of pseudocholinesterase ex-
jin some patients, and these small
junts take an abnormally long
; to break down succinylcholine.
ise cases of abnormal succinyl-
ine metabolism with the rele-
; family genetic patterns that
; been seen in western North
iDlina hospitals within the past
,\years arc presented.
fi
CASE REPORTS
si
. single, white, 17-year-old pri-
Travida was admitted to the hos-
, at eight weeks' gestation, for
^ apeutic abortion for psychiatric
ons. She had had infectious
a'-
m the Department of Anesthesia, The Bow-
Gray School of Medicine of Walte Forest
rsity, Winston-Salem, North Carolina
hepatitis two years earlier. No prob-
lems had arisen when she was anes-
thetized for a tonsillectomy as a
child. She had no history of drug
idiosyncrasy, and she was taking no
medications. The patient weighed
135 pounds and was 69 inches tall.
Diazepam, 10 mg, and atropine,
0,4 mg, were administered one hour
before the operation began. Anes-
thesia was induced and supplement-
ed with an intravenous injection of
thiopental, total dose of 500 mg, and
maintained with nitrous oxide, 5
L/min, and oxygen, 2/L min, via a
face mask. Immediately before and
during cervical dilation, 0.1 percent
succinylcholine was administered via
an intravenous drip, a total of 50
mg being given over a five minute
period. Muscle fasciculations oc-
curred and all spontaneous respira-
tion ceased. Positive pressure ven-
tilation by mask was started, and a
paracervical block with 30 ml of
one percent lidocaine was used to
facilitate cervical dilation. The pro-
cedure was completed in less than
ten minutes.
Anesthesia was discontinued af-
ter a total of 15 minutes, but the pa-
tient remained apneic. Her pupils
were dilated equally and reacted
briskly to light. Soon thereafter a
nerve stimulator (Burroughs-Well-
come "Block-aid" Monitor) was ap-
i)BER 1974, NCMJ
plied near the ulnar nerve at the el-
bow and wrist, but no muscle acti-
vity could be seen. A tentative diag-
nosis of atypical pseudocholinester-
ase was made.
Intermittent positive pressure ven-
tilation was maintained with oxygen
via a mask. The patient's blood pres-
sure remained stable at 130/80
mmHg and her pulse ranged from
90 to 120 beats per minute. One
hour and 15 minutes after the suc-
cinylcholine drip was discontinued,
she began to make gross movements,
primarily with her legs. Five minutes
later, the patient began jerky dia-
phragmatic breathing. Nerve stimu-
lation with the Block-aid Monitor
produced a weak muscle twitch,
fade during tetanic stimulation and
post-tetanic facilitation. She im-
proved gradually, and three hours
after the succinylcholine administra-
tion she no longer needed ventilatory
assistance. One hour later the patient
was quite strong and could lift her
head off the bed. No residual myo-
neural block was demonstrated with
the Block-aid Monitor.
Case 2
This gravida 5, para 4, 33-year-
old white woman was admitted,
when 17 weeks pregnant, for a hys-
terotomy and tubal ligation for tox-
emia of pregnancy. Her blood pres-
607
sure on admission was 136/84
mmHg. and her pulse rate was 104
beats per minute. She weighed 125
pounds. The patient had had hyper-
tension during her first pregnancy,
and again during this fifth pregnancy
(180-190/100-110 mmHg). After
two previous pregnancies she had
problems with postpartum hemor-
rhage. Renal problems of an un-
known type occurred during her sec-
ond pregnancy. When her appendix
had been removed 10 years previ-
ously she had no difficulty when giv-
en a general anesthetic. The patient
had no history of drug sensitivity.
She was taking diazepam as needed
for nervousness, and hydrochlorothi-
azide to decrease her blood pres-
sure. Her serum potassium level was
3.3 mEq/L; results of other preop-
erative laboratory studies were nor-
mal.
Meperidine. 75 mg, and atropine,
0.6 mg, were given intramuscularly
one hour before the operation. An
intravenous infusion of potassium
chloride in dextrose and water had
been started three hours earlier.
Anesthesia was initiated with thio-
pental, 250 mg, and maintained with
nitrous oxide-oxygen and methoxy-
flurane, Succinylcholine, 20 mg, was
given to facilitate tracheal intuba-
tion. The patient stopped all spon-
taneous breathing for the next hour
and 15 minutes. She then was sus-
tained on assisted ventilation.
The operation was completed 25
minutes later and anesthesia was
stopped. At that time she was awake
and moving, her respirations ap-
peared to be adequate, and the endo-
tracheal tube was removed. Soon
afterward, she became cyanotic and
less mentally alert. Her blood pres-
sure rose to 260/120 mmHg, and
her heart rate increased to 1 1 8 beats
per minute. Approximately two and
one-half hours after the initial induc-
tion of anesthesia, the endotracheal
tube was reinserted and connected
to a Bird ventilator. Within an hour
her blood pressure decreased to
130/80 mmHg, and she was alert.
Four hours after succinylcholine was
given, the endotracheal tube was re-
moved a second time, but respira-
tions failed quickly and she again
became somnolent. The endotra-
cheal tube was reinserted and respi-
ration was again assisted with a ven-
tilator. .Approximately five hours
after the succinylcholine was admin-
istered the patient was able to raise
her head from the bed, had a strong
grip, and could breathe without as-
sistance. The endotracheal tube was
again removed. The remainder of
her hospital stay was uneventful.
Case 3
A 24-year-old white man was ad-
mitted to the hospital for repair of
an indirect, inguinal hernia on the
left side. His health was generally
good, he had had no previous op-
erations, and he was taking no medi-
cations. Results of laboratory tests
were normal. The patient weighed
182 pounds and was sixty-eight and
three-fourths inches tall.
He was given meperidine as pre-
medication. .Anesthesia was induced
with 250 mg of thiopental and main-
tained with nitrous oxide-oxygen
and halothane. The patient was giv-
en 20 mg of succinylcholine, intra-
venously administered, to aid
tracheal intubation. Very little anes-
thetic agent was needed to keep him
relaxed and asleep. At the end of the
operation, he failed to breathe spon-
taneously, and controlled ventilation
with oxygen via the endotracheal
tube was continued. Caffeine-sodi-
um benzoate was given, but it did not
arouse the patient; two 5 mg doses
of nalorphine did not produce sig-
nificant respiratory improvement.
Three hours and 20 minutes after
the operation was completed, the pa-
tient was alert, could lift his head
voluntarily, and had a good hand
grip. The endotracheal tube was re-
moved and he breathed well.
DISCUSSION
There are many reasons that pa-
tients fail to breathe after being giv-
en a general anesthetic. Premedica-
tion, narcotics included in premedi-
cation or used to augment light anes-
thesia, persistent effects of general
anesthetic agents, hypocarbia secon-
dary to hyperventilation, hypcrcar-
bia in excess of arterial levels of 100
Torr, residual effects of muscle re-
laxants, brain damage from hypoxia
or direct trauma, hypothermia, and
respiratory obstruction must be con
sidered. »■
In the foregoing three cases, mei ■^':'
surement of arterial blood gasd^-'
would have been useful in providiii '^■
acid-base status and levels of ox; '
gen and carbon dioxide. The na ""I
cotic meperidine was given as pr '
medication to the patients in cas ^^
2 and 3, but the narcotic antagoni **'
nalorphine, given in adequate doss ''
failed to improve the patient's ri
piration in case 3. Hypothermia
not occur in the patients in cases
and 2; temperature was not mo:
tore-d in the patient in case 3. In
three patients, the general anesthe
agents were discontinued sevei '"''
hours before adequate respiratic '''''
returned. Light levels of anesthes •*
were maintained during the open'''
tions, and in each case the duratio '' '
of respiratory depression was out ( '*''
proportion to the amount of anq "^
thesia administered. In case 2, tli '^■'
patient was alert at the end of tiji*'
operation but became somnolent 1 1™
her respiration failed. The periods ( pli
hypertension, tachycardia and son '»
nolence in this patient most like! k::
represented periods of hypercarbi! Ji'
whereas the cyanosis of the head ari i'^.
neck resulted from hypoxia. Fol fe
tunately. the hypoxia was corrects a:
promptly by controlled ventilatic s:
each time it occurred. There was n :
reason to suspect hypoxic brai ; ;
damage in any of the three patien^ fen
Considering all factors, we belief li
that residual effects of the muse K
relaxant, succinylcholine, were i| ''A]
sponsible for inadequate respiratia K
in these three patients. ?■'
The prolonged effect of a muse *
relaxant may be caused by overdcs' «™
inadequate reversal, acid-base iri '"
balance, interaction with certain ai ^^^
tibiotics (e.g.. streptomycin, neorn" "i
cin and kanamycin), electrolyte in -'■
balance, and in the case of succiny '-■
choline, abnormal or insufficiel ^
amounts of pscudocholinesteras "
The largest dose of succinylcholii *'-s
given to these three patients was ? *
mg. given in case 1 . Very smf ■'
amounts (20 mg) were given to tl ■■-
other two patients. None of the p J'
tients was taking antibiotics. On /;
in case 2 might an electrolyte id k
Vol. 35, No. Ss
[rince have been suspected. That
p ent had been given potassium
ci;)ride intravenously for three
h rs before the operation. She had
a,sarly postoperative serum potas-
si a level of 4.3 mEq/L. Again,
n isurement of blood gases would
he been helpful in determining
aiji-base status, but the measure-
nit was not made in any of these
.c;,is.
is j^he level of pseudocholinesterase
Ta iihe blood may be reduced by se-
Ci! ;:; liver damage, disease or mal-
mi fition (since the liver produces
1.1 |ddocholinesterase), and the late
esil ^es of pregnancy. The patient in
sfl f. 1 had no known residual effects
jin |he hepatitis occurring two years
;sll piously. The prolongation of a
pi ^mg dose of succinylcholine in a
ijr:( jent with hepatic failure is unim-
ioi ||isive, rarely being longer than 20
i[j [futes.' For these reasons we felt
]\ liver damage was not a factor
viiihe reduced level of pseudocho-
Ai'ljisterase in these patients. None of
nA patients was taking drugs that
idakknown to alter the level of pseu-
ijholinesterase in the blood.-' ^
rciJj||\"x and Orkin's^ study of healthy
eii ;:;etric patients showed that pseu-
i, jholinesterase is reduced by 28
mi ::ent during late pregnancy, 16
nil; pent during labor, 25 percent one
n i postpartum, and 32 percent
; I le days postpartum, although
jjlj |litatively the enzyme remains
[it )nal. The patients in cases 1 and
jj ihre pregnant, but neither was past
,j[( early portion of the midtrimester,
.j[ fpregnancy-induced prolongation
[ipnea should not have been a
,!0r.
__:'ormally, in vivo. 40 to 60 mg
iij luccinylcholine is destroyed by
.idocholinesterase within two to
minutes; a period of succinyl-
ine-induced apnea that lasts for
e than ten minutes, therefore, is
ormal. For this reason, abnor-
j or decreased amounts of pseu-
[iiolinesterase in these three pa-
,s was suspected. Abnormal
pUnts of pseudocholinesterase
! subsequently confirmed by lab-
lory tests.
,- (|(t least four genes exist for the
luction of pseudocholinesterase:
101
nei
0
,uiii; I"
esl3
,lcl
■ou
i\{i
N(
Table 1
*lnformation on Pseudocholinesterase Genes'
Average
Fluoride
Number
60
20
0
30
45
50
60
35
20
20
t Not yet observed
N = normal pseudocholinesterase gene
D = dibucaine resistant variant
F = fluoride resistant variant
S = silent gene
* Reproduced with permission from Pantuck EJ: Genetic aspect of neuromuscular blockade,
in Mark LC, Pappers EM (eds): Advances in Anesthesiology: Muscle Relaxants. New York:
Harper and Row, 1967, p 63.
Genotype
Incidence
N-N
96%
D-D
1:2.500
S-S
1:100,000
F-F
Rare
N-D
1:25
N-F
7
N-S
1:200
D-F
7
D-S
1:800
F-St
7
Average
Response to
Dibucaine
Succinylcholine
Number
Normal
80
Prolonged + +
20
Prolonged + + +
0
Prolonged +
70
Prolonged
60
Prolonged
75
Prolonged
80
Prolonged +
45
Prolonged +-f
20
Prolonged
70
normal, dibucaine resistant (atypi-
cal), fluoride resistant and silent.
These genes can combine to produce
ten different genotypes, six of which
cause greatly increased sensitivity to
succinylcholine (Table 1)."' Kalow''
has estimated that one of these six
genotypes occurs in every 1,500
patients. The two types of pseudo-
cholinesterase first identified were
termed normal (N) and atypical (D).''
The only difference between them is
one of degree — both can hydrolyze
succinylcholine in vitro, but only the
normal succeeds clinically in in-
stances of low concentration of suc-
cinylcholine. When succinylcholine
is given to a patient, the concentra-
tion in the blood is lowered rapidly
by dilution in the blood stream. The
relaxant's concentration thus falls
below the effective level for hydroly-
zation by atypical pseudocholines-
terase.
Atypical pseudocholinesterase is
termed dibucaine-resistant, because
dibucaine is used to determine its
existence. Benzoylcholine is a spe-
cific substrate of pseudocholines-
terase that is not hydrolyzed by true
cholinesterase. A lO-"' molar con-
centration of dibucaine hydrochlo-
ride under standard conditions inhi-
bits benzoylcholine hydrolysis by
atypical pseudocholinesterase by 20
percent or less. This same concen-
tration of dibucaine hydrochloride
inhibits hydrolysis of benzoylcholine
by normal pseudocholinesterase by
70 percent or more.*' The dibucaine
.BER 1974, NCMJ
number on Table 1 is the percent
of inhibition of benzoylcholine hy-
drolysis caused by dibucaine. In pa-
tients who are homozygous for
atypical pseudocholinesterase, 100
mg of succinylcholine will produce
approximately one hour of apnea.*
Even after respiratory effort returns,
it is often inadequate, and respira-
tion must be assisted for an addi-
tional two to three hours.
In 1961, Harris and Whittaker''
noted that sodium fluoride could be
used in place of dibucaine, and that
it revealed a flouride-resistant (F)
variant of pseudocholinesterase. The
following year, Liddell and col-
leagues'" found a fourth gene, the
silent gene ( S ) , while using the dibu-
caine test. Patients with the silent
gene have no pseudocholinesterase
activity and, therefore, have a very
prolonged response to succinylcho-
line.
Figures 1 and 2 show family
genotypes for all three cases. Cases
I and 3 represent DD genotypes,
and case 2 represents a heterozygous
DF genotype. These are two of the
genotypes which prolong the effects
of succinylcholine. Even though the
genotype was abnormal, the four
hours' prolongation of the effect of
succinylcholine was remarkable in
cases 2 and 3, when one considers
the small amount of succinylcholine
given (20 mg).
The diagnosis of abnormal pseu-
docholinesterase is made in the lab-
oratory. In addition to the dibucaine
609
and fluoride testing, there is mea-
surement of the cholinesterase rate
which determines in units the
amount of normal pseudocholines-
terase present. The normal range is
80 to 120 units.
Suspecte-d abnormal pseudocho-
linesterase activity can be confirmed
during anesthesia with a peripheral
nerve stimulator, as demonstrated in
case 1. The nerve stimulator depo-
larizes a peripheral nerve, causing
myoneural transmission and muscle
contraction. Although the pattern of
response to the nerve stimulator
helps one assess myoneural trans-
mission, it does not allow one to dis-
tinguish between abnormal forms of
pseudocholine^terase and low levels
of normal pseudocholinesterase.
When a patient fails to breathe
adequately at the end of anesthesia,
'cSM
FAMILY MEMBER ChE RATE*
DIBUCAINE NO
GENOTYPE
1 Maternal Grandmother
24
10
DD
2 Father
89
56
ND
3 Mother
36
60
ND
4 Potient
3!
II
DD
5 Sis1er#l
26
9
DD
6 Sister#2
9
12
DD
7 Sisterff3
30
14
DD
8 Brother
50
64
ND
Normal
80-120
70+
NN
=rn Case One
Patient
38
24
DD
2 Father
76
65
ND
3 Uncle »l
7!
67
ND
4 Uncle»2
107
73
ND
5 Aunt
81
68
ND
6 Mother
72
66
ND
7 Aunt
129
81
NN
8 Maternal Grondmothe
61
66
ND
Family Pseudocholinesterose Potterr Cose Three
*;jmoles of Benzoylcholine hydrolyzed per
ml plasma per hour
(J = Normal Pseudocholmesterase ^^- Dibucome Resistont Gene
Fig. 1. Family genotypes for cases 1 and 3.
PSEUDOCHOLINESTERASE PATTERN OF FAMILY OF CASE 2
CASE TWO
FAMILY MEMBER ChE RATE DIBUCAINE NO FLUORIDE NO GENOTYPE
I Patient
2 Mother
3 Pother
4 Brother » I
5 Brother t»2
6 Brother »3
7 Sister* I
8 Sister #2
9 Sister « 3
10 Sister #4
I I Doughter
12 Son#l
13 Son«2
14 Son» 3
15 Nephew # I
16 Nephew«2
17 Niece#l
76
162
?
124
65
I I I
78
7
82
112
106
129
107
123
44
63
■>
76
39
71
52
65
69
70
74
75
61
72
65
71
80
31
39
?
49
34
44
39
50
50
55
52
54
53
48
52
63
DF
NO
7FF
NF
DF
NF
DF
NO
NF
NF
NF
NF
ND
NF
ND
NF
NN
r^=Normol Pseudocholinesterose ^P= Dibucoine Resistont Gene ^P= Fluonde Resistant Gene
Fig. 2. Family genotypes for case 2.
1= Silent Gene
ventilation must be supported to en-iJ
sure adequate oxygenation and car^
bon dioxide removal. One hundret
percent oxygen can be used initially
If residual effects of succinylcholim
are the cause of inadequate breath ;
ing, the patient will recover unevent v
fully in several hours, since meta ;
bolic pathways other than pseudo
cholinesterase hydrolysis, primaril'
alkaline hydrolysis, will ultimate!
destroy succinylcholine. Until it i
clear, however, that the patient i,
breathing well and will continue til
breathe well, he must be watcho
by anesthesia personnel.
The strength of the patient's gri
and his ability to raise and hold hi
head off the bed are helpful guide
to the degree of clinical recover}
Muscle groups have varying sensit:
vity to relaxants. The diaphragm i
the least sensitive; the trunk, extn
mities, neck and ocular muscles fo
low in increasing order of sensitivit;
Therefore, if a patient can eleval
his head and has a strong hand gri]
his diaphragm and trunk muscli
probably have recovered, enablir
adequate support ventilation. I
Taking a careful preoperati^
anesthetic and family history helj
to prevent problems in surgery th
arise from abnormal pseudocholii
esterase activity. For example, tl
maternal grandmother of the patie
in case 1 had had severe respirato
depression following a should
manipulation under general anesth
sia a few years before the patieni
operation. Unfortunately, the patie
did not know of this incident wh(
we were taking her history; we d
not hesitate to give her succinylch
line. When a patient's diagno!
of abnormal pseudocholinesterase
made, that patient's blood relativ
should be tested for abnormal e
zyme activity. Any patient with a
normal or lowered normal pseud
cholinesterase should carry medic
identification to warn anesthe:
personnel of potential respiratc
problems when succinylcholine
used.
.<\cknow Icdgment
I wish to thank Dr. Alex S. Moffctt'
Taylorsville, North Carolina, for [■
mission to present tuo of his patientsi
cases 2 and 3. and Dr. J. Cripsin Srri
610
Vol. 35, No. if-:
.he Department of Pharmacology, Uni-
jsity of Rochester School of Medicine
1 Dentistry, for determining the geno-
f:s, dibucaine numbers and cholines-
jise rates for these three cases.
L
References
iBowen RA: Anaesthesia in operations for
jthe relief of portal hypertension. Anaesthesia
15:3-10, 1960.
(Pantuck EJ: Ecothiophate iodide eye drops
and prolonged response to suxamethonium:
A case report. Br J Anaesth 38: 406-407
1966.
3. Zsigmond EK, Robins G: The effect of a
series of anti-cancer drugs on plasma
chohnesterase activity. Can Anaesth Soc J
19: 75-82, 1972.
4. Marx GF, Orkin LR: Physiology of Ob-
stetric Anesthesia. .Springfield. Ill: Charles C
Thomas, 1969.
5. Pantuck ES. cited by Wylie WD. Churchill-
Davidson HC (eds): A Practice of Anaes-
thesia, ed 3. Chicago: Year Book Medical
Publishers, Inc. 1972. p 865.
6. Kalow W: Pharmacogenetics and anesthesia
Anesthesiology 25: 377-387. 1964.
Kalow W. Davies RO: The activity of vari-
ous esterase inhibitors towards atypical hu-
man scrum chohnesterase. Biochem Pharma-
col 1: 183-192. 1958.
Foldes FF: Muscle Relaxants: Clinical Anes-
thesia. Vol 2. Philadelphia: FA Davis Co.
1966.
Harris H. Whitaker M: Differential inhibi-
tion of human serum cholinesterase with
fluoride: recognition of two new phenotype.s
Nature 191: 496-498. 1961. (Letter to the
Editor.)
Liddell J. Lehmann H. Silk E: A 'Silent"
pseudocholincsterase gene. Nature 193: 561-
562, 1962.
There are many malingerers among hysterical subjects; but it is no less true that in certain
fhPr nr° ■""' ''f'' ""'"k°" ?"'' ""'"°" ^'^ ^^duced to the nnninuan. TT^ey main a n
their nutrition on two or three figs per diem, and excrete less than half an ounce of u ine
jind scarcely any feces at all. The observations of Empereur demonstrated also tha "hese
hysterical patients did not excrete one-fifth part of the normal amount of carbonic acid The
conclusion may be drawn from these facts that there exists a group of women in whom the
Tb r«.l/"f/9;V''6 27''''''"'''''''' ""■" '"' '' '"^°'' loren,.-lea,h a,u1 S.MeTSeX
C OBER 1974. NCMJ
611
Family Practice: One Answer
Lyndon K. Jordan, M.D."^
I
' I ' HE developing health care de-
■*■ livery crisis that is occurring in
the United States has been discussed
within the profession for many
years. It has reached such propor-
tions that it is being discussed by the
Executive and Legislative branches
of our government and by millions
of Americans who "can't get a phy-
sician." This shortage is both ap-
parent to the lay public and real in
the profession. Although the total
number of practicing physicians in
this country is, indeed, inadequate
for our needs, there is a dispropor-
tionate spread within the specialties.
For instance, surgeons are generally
in great supply and, according to Dr.
Walter C. Bornemeier,' past presi-
dent of the American Medical Asso-
ciation, we continue to produce
more than we need.
However, this trend does not re-
flect what is happening within the
entire profession. In December
1973, there were 356,534 physicians
in the United States. Of this number,
292,210 were involved in direct pa-
tient care. Forty-si.x percent of this
number who are directly involved
in patient care are in primary medi-
Read. in part, before the Section on Family
Practice. Nortti Carolina Medical Societv. Pine-
hurst, N. C May lP-:3, 197.1.
• Director. Familv Practice Program. Box 15^,
Watts Hospital. Durham. N. C. :770.'i.
cal care — general practice, internal
medicine, obstetrics, gynecology and
pediatrics. General practice, with
18.7 percent,- is the largest segment
of this population.
Of the 292.210 physicians in-
volved in patient care, only 201,302
are office based and look after the
daily medical needs of more than
200 million Americans who aver-
age seeing their physicians appro.xi-
mately four and one-half times per
year. Those who feel the brunt of
this burden are physicians in rural
areas. More than one-fourth of
America's population lise in non-
metropolitan areas which have only
16.5 percent of all nonfederal physi-
cians. In addition, many patients
who live in metropolitan areas travel
long distances to seek medical care
in small towns, either because to do
so is more desirable or because of
easier access.
FAMILV PRACTICE
The specialty of family practice
has been given new emphasis within
the medical profession and from the
United States Government in the
form of various grants for residency
training programs. In March 1974,
there were 191 family practice resi-
dency training programs in the
United States. Of this number. 100
were based at community hospitals,
49 were university medical center
I
based and 28 were university affili-
ated.
According to Dr. Robert Gra
ham. Director of Education, Ameri
can .Academy of Family Physi
cians (oral communication, Marcl!
1974), at the beginning of the \9lf^.
academic year there were 1,771' "
family practice residents in training
Of this number, 756 were first-yeai":
residents who filled 84 percent of th(!
first-year appointments available "
Six-hundred fifty-three second-yea
residents filled 72 percent of the \a
cancies. The 354 third-year resident
filled 39 percent of the vacancies
Eight fourth-year residents were ii
training. The disproportionate va;' '
cancies in the third and second,i '
It--
year programs can be accounted fo' '-
in that all family practice residencie
bciian during the past three or fou' -
years. The specialty was first recogl!;'
nized in 1969, and specialty boan
certification was first offered ii
1970. If.
The number of prospective famirr"
practice residents among third aniv'
fourth-year medical students is moslr'
encouraging; it is estimated that ap
proximately 25 or 30 percent will b
seeking appointments in such p^c _
grams upon graduation during th'P'^^
next five years.
This new popularity in primar
care is interesting from sever;
points of view. First, this specialt
has seldom been advanced by exis
612
Vol. 35. No.
ii department faculties of the tradi-
ti lal specialties. The fascination of
tl specialty is poorly understood by
p fessional academicians who usu-
a ' are oriented quite definitely in
d .'ctions other than direct patient
c e. This is a fault of the system
r: ler than of individuals. Embraced
fi decades by medical teachers is
tl philosophy that honor comes to
h 1 who develops an unusual depth
0 expertise in some specific sub-
s cialty. This philosophy has al-
V /s been advanced with some jus-
ti :ation, and it becomes the moti-
V ing force leading to the well
kown one-upmanship within the
n Idical teaching profession.
The second paradox is evident
w en one observes that family phy-
sjans are rarely on the faculties at
tl typical university medical
Shools. There is no traditional
ndel in this setting with whom the
airing medical student can iden-
ti . Perhaps this problem is related
t( he previously mentioned philoso-
p"' regarding subspecialties, and to
si;ae rather distorted connotations
ojthe words "depth of training."
See family physicians may not
he the "depth of training" or ex-
p, tise in a specific secondary or
tiiary medical specialty field, they
Si lorn receive faculty teaching ap-
pntments. Credence is seldom
gjm to the fact that the family phy-
|-,an is usually a better pediatrician
[a the internist, a better gynecolo-
than the pediatrician and, in
a better internist than the car-
d'logist! It is not debatable, how-
e.r, that pediatrics can best be
ti'^t by the pediatrician, gynccol-
oj by the gynecologist, and cardiol-
6'\ by the cardiologist. Who but the
fi lily physician is to integrate these
s! Is into a practical functioning
u ; for the thousands of smaller
t(, ns not large enough to support a
b';ery of secondary or tertiary spe-
c ists? There is no one to speak for
tlj large area of need. Therefore.
itj surprising that the specialty has
fl irishcd among our medical stu-
d ts in the absence of a traditional
n Jel with whom they can identify
a^ pattern themselves.
. 'hird, today's medical students
a: more interested in patient care
than most members of the preceding
generation were at the same point in
training. Most students ask this
question: We have clinics to take
care of virtually every organ and or-
gan system, and we have tertiary
specialists who consult with the con-
sultants, but who is going to take
care of sick people? Apparently, it
is this same question that is being
asked by the lay public, the profes-
sion itself and, indeed, the Congress;
all are demanding more practicing
physicians for the tax dollar spent
in medical education, and medical
students themselves are concerned
about the availability of primary
care. As noted by the Family Prac-
tice Club, Duke University School
of Medicine (oral communication,
1973), in many medical universities
where no such faculty interest has
traditionally existed, the medical stu-
dents have formed family practice
societies, set up primary care clinics
in the surrounding communities,
amassed sufficient financial re-
sources to invite guest speakers, and
have begun to exert some pressure
in an organized way upon the medi-
cal school faculty to develop family
medicine as a residency program and
as an undergraduate track.
Traditional medical school faculty
have met this entire movement with
some degree of predictable reserva-
tion. This people-oriented pursuit is
poorly understood by the academi-
cians, who have restricted their view,
sheltered their exposure to responsi-
bility and retreated into one small
authoritative subspecialty as a pro-
fessional home, complacently leav-
ing to someone else the responsibil-
ity of producing the broadly trained
product needed and requested by the
American people. A specialty of
breadth runs counter to all that they
have taught and have been taught.
The negativity is also expressed by
medical conservatives when any new
specialty area is advanced. Mainly,
anxiety and distrust are expressed
for fear that some new peer group
will invade still further those areas
considered sacrosanct by any given
specialty.
Ironically, medical students have
become more vocal, and they are
much more interested in policy
decisions concerning curriculum,
health care systems and national
health programs. It is unusual that
their voice is heard and that it has
been given the weight of authority
that, for decades, has been reserved
for the most senior attending faculty.
It is a very powerful voice! Medical
students have asked for family medi-
cine, and it is largely for this reason
that it is being developed.
Many contributing forces have
been leading to the establishment of
family medicine as a specialty and
residency pursuit. In the long run,
family medicine will remain a viable
specialty pursuit, because there are
many within our ranks (and junior
ranks) who feel that it is the most
rewarding and satisfying of all spe-
cialties. The American Academy of
Family Physicians will continue its
evangelistic crusades, firmly con-
vinced that theirs is the most noble
calling of them all. It is even more
likely that there will be a very defi-
nite impact upon the traditional cur-
riculum of American medical
schools. There will be a move
toward relevance of training — some-
thing that has been lacking in our
system for a long time. There will
be a return to the apprenticeship in
certain areas of teaching, for only
here can one be taught the subtle-
ties of the profession and the various
nuances of rapport and communica-
tion between the master physician
and his patient. These sometimes
subtle or intangible aspects can be
taught only by someone who is an
everyday professional providing
medical care for people.
If family medicine can produce
more primary care providers, the en-
tire effort will be worthwhile; it will
be one answer to our nation's grow-
ing health care problem. Moreover,
if it can effect a second look at how
we are training physicians, and if it
can help bring about some long
overdue changes, it will have per-
formed a service to the profession
that will last much longer than the
specialty itself.
References
1. Barnemeier WC: A revolution in medical
care. JAMA 21.1: 448-451. 1970.
2, Profile of Medical Practice. Steve G.
Vahovich (ed). American Medic.il Associa-
tion, l")?!. p 1.
\C OBHR 1974, NCMJ
613
Survey of Health Education in the
North Carolina Public Schools
Martha Y. Martinat*
TN May 1973, the House of Dele-
■*■ gates of the North Carohna Medi-
cal Society approved a resolution
calling for greater concern on the
part of local boards of education,
county medical societies and prac-
ticing physicians for the promotion
of courses on the venereal diseases
in junior and senior high schools.'
Cooperating with their societies,
county auxiliaries found that ve-
nereal disease education seemed to
vary from school to school within
each local system. The Executive
Committee of the .Auxiliary to the
North Carolina Medical Society and
its president. Mrs. J. Elliott Dixon,
felt that a sur\ey of several aspects
of school health education through-
out the state should be taken. They,
therefore, prepared a questionnaire
to ascertain how many students re-
ceived instruction in certain health
areas, the use of educational televi-
sion in health education, training of
teachers and use of community
health resources. The training of
teachers and use of community
health resources were included in the
" Chairman. Health EdUL-ation, Auxiliary lo
the North Carolina Medical Society.
Reprint requests lo 120 Sherwood Forest
Drive. Winston-Salem. North Carolina 27104.
survey because educators at a 1973
health education workshop in
Florida had expressed such a necd.-
RESULTS
Ninety-two of North Carolina's
I. SO school systems replied to the
survey, representing 855.204 stu-
dents, of whom 283.242 were in
grades K-4; 341,402 in grades 5-9;
and 178,649 in grades 10-12. Three
systems did not complete questions
for grades 5-9 and two did not com-
plete the section for grades 10-12.
All figures, except enrollment, are
estimates.
Answers to the question. "What
percentage of your enrollment (in
K-4, 5-9, 10-12) receives instruc-
tion in the following topics through
regular school curriculum?" are
given in Tables 1-9.
.Answers to the question. "Are
programs on any of the above pro-
vided by other organizations (health
department, police, etc.)?" were an-
swered as follows;
K-4; Sixty-four systems utilized
community resources to supplement
regular curriculum. The role of the
county health department in cover-
age of all topics, but especially den-
tal health, was reported by 36 sys- ^^
terns. One system qualified its aa;.^
swers by saying that the health d&.'„
partment furnished all health edu'";
cation included in its curriculum'"
Law enforcement officials presentee'^'
safety programs in 35 systems; firC',
departments in 26. Other organiza "
tions presenting programs includec',"
the mental health departments. Den ';
tal Society and its auxiliary. Fores '
Service (fire and pollution). Junio
League (drugs). Medical Socict;
and its auxiliarv (drues. health ex/;
hibits and fairs ).
it
5-9; Fittv-eieht systems used pro,,,
grams presented by community or-:.,
ganizations. Law enforcement, 5;,j.
(drugs and safety); health depart^j;,.
ments (venereal disease, sanitation,..:
personal health, drugs and alcohol..
family planning and sex educatioHitf;
and immunization ) ; others includetip,
fire departments, mental health a^nv
sociations. family life centers, Refp
Cross (first aid), alcohol associaifc
tions. School Food Service and 4-fi6;'
(nutrition). Forest Service (fire am'::
pollution), rescue squad, drug corner;,
mittees and centers. Medical Societitr;
and auxiliary (venereal disease
famih' planning, eye safety, nutr
614
Vol. .^5, No. It
In and drugs), wildlife associations
unter safety) and Dental Society.
10-12; Forty-two systems used
I )grams from the health depart-
1 nts (venereal disease, drugs and
1 nily planning) and law enforce-
I nt (driver education is taught at
1 s level ) . Other organizations pre-
siiting programs included family
1 : centers, mental health depart-
I nts, fire departments, drug and
i ohol centers and committees, res-
< : squad (water and boat safety),
1 wanis Club (drugs). School Food
; -vice (nutrition), Medical Society
i i auxiliary (venereal disease,
imily planning, drugs and nutri-
lin).
'Answers to the questions, "What
ircentage of your teachers has tak-
ij accredited health education
I arses?" and "What percentage of
] ur teachers has attended health
( ication workshops?"' were that
] ilth education is required for
t cher certification in the elemen-
1 y and intermediate grade levels.
< >ntent for the course is established
!'■ state guidelines. Ninety-two per-
( lit of the systems replying to the
( estionnaire reported that 1-25
l/cent of teachers in the upper
jades was estimated to have taken
: :ourse in health education; fifty-
I ee p>ercent estimated that 1-25
j.rcent of their teachers had attend-
0 health education workshops and
( nferences.
In an attempt to assess the use of
(,acational television, the question,
'Vhat percentage of your students is
' wing the 'Inside/Out Series'?"^
' s included under questions for
jides K-4. North Carolina was one
( 128 states presenting this new ser-
i this year — thirty 15-minute
(^;or programs. Situations are pre-
f'tited which require decisions on
f: part of the eight to ten-year-old
i Jience. Wallace Ann Wesley, Di-
lator, Department of Health Edu-
> ion, AMA, was one of the plan-
i''s and designers of the series,
'- ich was created under the super-
'Uon of the National Instructional
'Revision Center. The series will be
Deated for two additional years on
J irth Carolina's educational tele-
; ion stations.
1 In its first year, the "Inside/Out
Series" is being viewed by 1-25 per-
cent of the eligible children in 5 1 of
the 92 systems replying to the K-4
questions. Seventeen other systems
have reported that 26-50 percent see
the series. Six have reported 51-75
percent; 76-100 percent was re-
ported by Moore (all 3-5 grades),
Mecklenberg (all third and fourth
grades), Salisbury City (all 4-6
grades) and Columbus County.
Fourteen systems left the question
unanswered or commented on "poor
reception."
Grade
Level
No.
5-9 SYSTEMS
PUPILS
10-12 SYSTEMS
PUPILS
CONCLUSIONS
Inconsistency and fragmentation
describe health education in North
Carolina schools. This description
coincides with the results of a na-
tionwide sampling of schools taken
during a health education study in
Washington, D. C. during 1961-
1971.'
Although many systems use com-
munity resources, almost 30 per-
cent do not. The Division of Health
and Physical Education of the State
Department of Instruction has urged
Table 1
Nutrition
Grade
Level
No.
0%
1-25%
26-50%
51-75%
76-100%
K-4
SYSTEMS
1
2
6
6
77
PUPILS
589
4.375
17,506
11,622
249,150
5-9
SYSTEMS
2
7
13
67
PUPILS
7,233
18,493
36.833
278,843
10-12
SYSTEMS
31
35
11
13
PUPILS
75,755
67,556
Table 2
12,446
22,892
Mental Health (Coping w
ith Stress)
Grade
Level
No.
0%
1-25%
26-50%
51-75%
76-100%
Unanswered
K-4
SYSTEMS
1
22
21
20
21
7
PUPILS
7,369
66,112
88,140
59,178
60,168
2,275
5-9
SYSTEMS
13
13
24
39
PUPILS
41,963
43,535
65,778
190,126
10-12
SYSTEMS
1
31
32
14
8
4
PUPILS
2,700
62,966
75,238
18,309
15,463
3,973
Table 3
Communicable Disease (Including VD)
0% 1-25% 26-50% 51-75%
76-100% Unanswered
1
2,700
3
12,881
17
26,345
12
31,540
29
86,341
20
57,408
21
32,677
49
202.205
17
28,197
5
37,368
5
2,389
Table 4
Exercise and Physical Fitness
Grade
Level
No.
0%
1-25%
26-50%
51-75%
76-100%
K-4
SYSTEMS
PUPILS
1
2,600
13
21,124
78
260,518
5-9
SYSTEMS
PUPILS
1
4,200
1
1,153
8
22,832
79
313,217
10-12
SYSTEMS
PUPILS
18
27,647
33
59,671
Table 5
16
24,095
23
67,236
Grade
Level
No.
0%
1-25%
Safety*
26-50%
51-75%
76-100%
Unanswered
K-4
SYSTEMS
PUPILS
8
13,173
18
35,068
64
233,433
2
1,468
5-9
SYSTEMS
PUPILS
1
4,200
3
8,293
13
35,052
72
293,857
10-12
SYSTEMS
PUPILS
11
13,230
18
36,133
61
129,286
* In a breakdown under "Safety" for the topics of Fire, Water, Highway, and Poison, coverage
of Fire and Highway was reported "good." There was little instruction in water safety except
on the coast. Poison safety instruction was considered "poor."
TOBER 1974, NCMJ
615
Table 6
Cleanliness ■ Personal and Environmental (Pollution)
Grade
Level
No.
0%
1-25%
26-50%
51-75<>o
76-100%
K-4
SYSTEMS
PUPILS
1
938
5
15,985
13
19,936
73
236,383
5-9
SYSTEMS
PUPILS
1
1,153
5
22,247
14
33.397
69
284,605
10-12
SYSTEMS
PUPILS
2
4,293
Drug an
5
15,985
Table?
d Alcohol Ab
9
19,956
jse
74
138.415
Grade
Level
No.
0%
1-25%
26-50%
51-75%
76-100%
Unanswered
K-4
SYSTEMS
PUPILS
4
7,556
28
70,282
19
59,410
22
55.507
15
70,407
4
20.808
5-9
SYSTEMS
PUPILS
7
25,163
22
63.159
60
253.080
10-12
SYSTEMS
PUPILS
1
2.700
12
17,653
De
15
38,684
Table 8
ntal Health
27
41,319
30
72,844
5
5,449
Level
No.
0%
1-25%
26-50%
51-75%
76-100%
K-4
SYSTEMS
PUPILS
1
2,600
4
12.274
13
24,966
74
243,502
5-9
SYSTEMS
PUPILS
4
10,691
8
63,644
24
68.542
53
198,525
10-12
SYSTEMS
PUPILS
6
25,185
32
61.664
22
41,644
Table 9
16
30,276
14
19,880
Grade
Level
Family Planning
No.
0%
1-25%
26-50%
51-75%
76-100%
Unanswered
5-9
SYSTEMS
PUPILS
8
64,566
31
108,532
30
72,992
13
53,658
4
31,592
6
10,062
10-12
SYSTEMS
PUPILS
36
70.299
26
44,414
13
21,108
11
38,359
4
4,469
each system to appoint a health co-
ordinator. As of September, 1973,
four systems — Alamance, Green-
ville City-Pitt, Jackson and Warren
— have had health coordinators
funded by the North Carolina Drug
.\uthority to develop curriculum
and inservice teacher training, coor-
dinate community resources, give
demonstrations to other school units.
and form a community health counT)
cil. Three of these four systems re- -
plied to the survey.
The role of educational television ■
shows great promise and should be
made available to all schools.
Standards in health education for
the schools should be established.
The expertise of the Medical Society
should be utilized in this endeavor. •
Standardized curriculum, such as
the conceptual system of health edu-"'
cation already developed by the 3M,
Visual Products Division,"' should"
be evaluated.
References
<:.
Transactions of the House of Delegates, Nortbir-i
Carolina Medical Societv. NC Med J 34: 527 "'"
529. 1973. (Edilorial).
Stuart F: "First Annual Statewide Confer
ence on Health Education: An Evaluation'
St- Petersburt:. Florida. 1973.
NIT. "Inside Out." Teachers Guide. Box A
Bloomington. Indiana. 1973.
Sliepevich EM: School Health Education: A
Summary Report. Washington. DC, 1964.
Health Educition: A Conceptual Approach
to CurncLiUmi L^esijzn. 3M Education Press
St Paul. Minn. 1967.
That is a qtiestion [At what moment does life cease?] which looks very easy to answer.
There is not one of us. Gentlemen, who has not been present, at least once, at this final scene
of every human e.xistence, who has not seen a dying man draw his last breath. The stoppage of
respiration, or to use the customary expression, the last breath, is, as a matter of fact, con-
sidered by the public as the unequi\ocal sign of the disappearance of life. This is a gra\e
error. Gentlemen, for many persons who no longer breathe have been recalled to life by means
of care and skill. The moment of death cannot therefore be assumed to be identical with
cessation of respiration. — Death ami Sudden Death. P. Broiiaiitel. 1S97, p. 18.
ja
i^
[((
616
Vol. 35, No. IC
Editorials
i
AN OUNCE OF PREVENTION?
|lEIsewhere in this issue (page 614) a notable ef-
rt of the Auxiliary of the North Carolina Medical
jx;iety is addressed to the scope of health informa-
on in our state's school systems. The figures given
imittedly reflect partial (61 percent) response to a
^estionnaire, and a comparison of a complete school
iStem with others in the state could not be made.
Jawever, the conclusion that "inconsistency and
gmentation describe health education in North
rolina schools" appears inescapable. Wherein lies
e solution?
yAs a medical society, we have long espoused the
yctum that "an ounce of prevention is worth a
mnd of cure." On the balance scale of health care,
inetheless, we have directed our interests, efforts
.d resources toward quantum increases in pounds
?• cure. One might question whether the proverbial
)unce" is not more nearly a "dram." Indeed, do we
:lily give a dram for prevention? Our stated goals
jd our observed behaviors are not congruent. We
J.ve paid lip service to the axiom that the most ef-
f;,;tive mode of prevention of many disorders is
iVough adequate education of the individual at risk
r the disorder. The Auxiliary has clearly shown
I that we have not translated our intent into action,
uch less into actuality!
I In this vein, we certainly must question whether
i health information topics considered in the school
jTvey are truly applicable to primary prevention of
■l^nificant health problems. The relevance of each
lid all these topics to disease prevention (more
liisitively: to health enhancement) may be firmly
ftablished in either of two ways:
Ml. In utilization of risk-factor analysis, specific age
Dups may be identified as being "at risk" for speci-
problems, and intervention measures may be de-
;eated. In good medical practice, intervention is be-
^jn prior to development of risk. Interestingly, the
ist productive intervention points for most common
Id serious adult problems lie in childhood. The con-
quences of lack of knowledge or appropriate be-
vior in any one of the health information topics
nsidered in the Auxiliary's survey could be de-
loped at length. As a skeletal example, we recog-
:e that establishment of regular exercise patterns,
propriate dietary intake, abstinence from tobacco
d other toxins, and constructive responses to stress
I likely more effective in avoidance of coronary
ery disease than is the attempt to institute similar
measures once the problem is manifest. Grades K-12
appear more fertile ground for behavior modification
than do coronary care units.
2. In more immediate terms, the existence of seri-
ous problems within the school age population it-
self lends credence to the necessity for health educa-
tion. The prevalence of overall drug usage probably
is increasing, and the age group involved is progres-
sively younger. Venereal disease, pregnancy, abor-
tion and the stresses inherent in each demonstrably
are on the upswing. Suicide remains the third most
common cause of adolescent mortality. Accidents,
the second most common cause, appear to be less
related to health education; we cannot, however, es-
cape the intertwining of these existing problems with
conscious or subconscious motivation toward acci-
dents. Thus, in large measure, significant portions of
the above-mentioned problems are preventable
through effective education in advance of conditions
directly facing the school age group.
If we accept the problem as being the failure to in-
stitute salient principles or primary intervention (in
this case, health education), the solution appears to
be simple. There are, at the same time, two additional
factors — one philosophic, and one pragmatic — to be
considered. The approaches suggested by the Auxi-
liary in its report touch on both.
Philosophically, we as physicians must determine
our responsibility and accountability for health
education in the school systems. Our present attitude
may be glimpsed in the delegation of this study to our
.\uxiliary. At any rate, its members have done their
job well, and. in the doing, have presented a challenge
to us to act on their findings. It remains for us to
interact responsibly with the Board of Education and
with the Board of Health at the state level to de-
velop and institute a long-overdue health curriculum
to include; ( 1 ) medically-sound factual material, (2)
adequate preparation and continuing education for
teachers, (3) pertinent topic introduction at appro-
priate grade levels, (4) utilization of community and
state resources and innovative teaching methods, and
(5) meaningful continuity and emphasis on health
education from kindergarten through senior high
school.
At the pragmatic level, it must be continually borne
in mind that health information is not synonymous
with health education. "Information" is a process of
teaching. "Education" is a demonstrated change in
behavior as a result of incorporating and then acting
TOBER 1974, NCMJ
619
October 28-November 1
Current Concepts in General Radiology
Place: Southampton Princess Hotel, Southampton. Bermuda
Program Chairman: Richard G. Lester. M.D.. Professor and
Chairman of Radiology, Duke University Medical Center.
Guest speakers uill include: Robert G. Fraser. M.D..
Professor and Chairman of Radiology. McGill University
Medical School. Montreal. Canada; John A. Evans. M.D..
Professor and Chairman of Radiology. Cornell University
Medical College; William B. Seaman, M.D., Professor
and Chairman of Radiology, Columbia University College
of Physicians and Surgeons. New York. N. Y.; Harold G.
Jacobson, M.D., Professor and Chairman of Radiology.
Albert Einstein College of Medicine (MHMC). Bronx,
New ^"ork; and David H. Baker. M.D.. Director of
Radiology. Babies Hospital. Professor of Radiology. Co-
lumbia University College of Physicians and Surgeons,
New ^'ork, N. Y. Subject matter will cover Pediatric
and .Adult Radiology of the Chest. Genitourinary Tract,
Gastrointestinal Tract and Musculoskeletal svstem.
Fee: $200
Credit: Twenty-three hours AMA "Category One" accredi-
tation
For Information: Robert McLelland, M.D., Department of
Radiology, Box 380S, Duke University Medical Center,
Durham" 277 10
November 4-6
Amputations and Priisthetics
Place: Holiday Inn West. Durham
Sponsor: American Academy of Orthopaedic Surgeons.
Chicago. Illinois
Fee: $150
For Information: Frank W. Clippinger. M.D., Box 2919.
Duke University Medical Center, Durham 27710
November 7-9
North Carolina Academy of Family Ph>sicians Annual
Meeting
Place: Sheraton Crabtree Motor Inn. Raleigh
For Information: A. M. .Alderman. Jr., M.D.. 233 Brvan
Building. Raleigh 27605
November 13
Burn Symposium
Place: Babcock .Auditorium. Time: 12:30-5:30 p.m.
Fee: $10
Credit: 5 hours
For Information: Emery C. Miller. M.D.. .Associae Dean
for Continuing Education. Bowman Gray School of Medi-
cine. Winston-Salem 27103
November 15-16
Anesthesiology Fall Seminar
Place: Charlotte Memorial Hospital Auditorium
Fee: S40
For Information: Dr. H. .A. Ferrari. Chairman. Department
of .Anesthesiology. Charlotte Memorial Hospital. P. O.
Box 2554. Charlotte 28201
December 3-4 & 5-6
The Nursing Audit
Place: Dec. 3-4. Humanities Lecture. UNC-Asheville; Dec.
5-6. Southwest Technical Institute. Sylva
Sponsor: Health Education Commission of Western North
Carolina
Fee: $7
For Information: Mrs. Marian S. Martin. P. O. Box 7607,
Asheville 28807
December 5
American College of Physicians — North Carolina Society of
Internal Medicine, Annual Meeting
Place: Holiday Inn Four Seasons, Greensboro
For Information: John T. Sessions. Jr.. M.D., Department
of Medicine. UNC School of Medicine. Chapel Hill
27514 or John L. McCain. M.D.. Wilson Clinic Wilson
27893
December 5-6
2nd North Carolina Postgraduate Course on Pulmonary
Disease
Place: Velvet Cloak Inn, Raleigh. N. C.
Fee: $25 — Enrollment is limited. .Applications will be ac-
cepted in order received.
RondomyGin
(methacycline HCI)
CONTRAINDICATIONS: Hypersensilivity to any of Ihe tetracyclines
WARNINGS: Tetracycline usage dunng tootfi development (last naif ot pregnancy to eigh
years) rnay cause permanent tootfi discoloratton (yellow-gray-brown), which is more
common during long-ierm use t)ut has occurred after repealed shod-lerm courses
Ename! hypoplasia has also been reported Tetracyclines should not be used in this agf
group unless other drugs are not likely to be effective or are contraindicated
Usage in pregnancy. iSee above WARNINGS about use during looth development
Animal stud/es indicate that tetracyclines cross the placenta and can be loxic to the dei
veioping fetus (often related to retardalion ot skeletal development) Embryotoxicity ha'
also been noted m animals treated early m pregnancy
Usage tn newborns, infants, and children. (See above WARNINGS about use dunnt
tooth development )
All tetracyclines form a stable calcium complex in any bone-formmg tissue A decreasi
in fibula growth rate observed m prematures given oral tetracycline 25 mg/kg every
hours was reversible when drug was discontinued
Tetracyclines are present m milk o) lactating women taking tetracyclines
To avoid excess systemic accumulation and liver toxicity m patients with impaired rena
function, reduce usual total dosage and, i( therapy is prolonged, consider serum level de
terminations of drug The anli-anabohc action of tetracyclines may increase BUN Whili
not a problem m norma! renal function, m patients with significantly impaired function
higher tetracycline serum levels may lead to azotemia, hyperphosphatemia, and acidosis:
Photosensitivity manitesled by exaggerated sunburn reaclion has occurred with tetra,
cyclmes Patients apt to be exposed to direct sunlight or ultraviolet light should be so ao,
vised, and treatment should be discontinued at first evidence of skm erythema
PRECAUTIONS' If superinfection occurs due to overgrowth of nonsuscepfible organismsi
including fungi discontinue antibiotic and start appropriate therapy
In venereal disease, when coexistent syphiiis is suspected, perform darkfield exam
nation before therapy, and serologically test tor syphihs monthly for at least four months
Tetracyclines Uave been shown to depress plasma prothrombin activity, patients on an
ticoagulant therapy may require downward adjustment of their anticoagulant dosage
In long-term therapy, perform periodic organ system evaluations (including blood
renal, hepatic)
Treat all Group A beta-hemolytic streptococcal infections for at least 10 days
Since bacteriostatic drugs may interfere with the bactericidal action ot penicillin, avoi
giving tetracycline with penicillin
ADVERSE REACTIONS: Gaslroinlestinal (oral and parenteral forms) anorexia, nausea
vomiting diarrhea, glossitis, dysphagia, enterocolitis, inflammatory lesions (with mon
lal overgrowth) m the anogeniial region
Skin' nacuiopapuiar and erythematous rashes, exfoliative dermatitis (uncommon) Phd
tcse-r . ■, :.:scussed above (See WARNINGS)
Renal loxicity -^emBUN apparently dose related (See WARNINGS)
Hypersensitivity urticaria, angioneurotic edema, anaphylaxis, anaphylactoid purpura
pericarditis, exacerbation of systemic lupus erythematosus
Bulging fontanels, reponed m young infants after full therapeutic dosage, have disao
peared rapidly when drug was discontinued
Blood: hemolytic anemia, thrombocytopenia, neutropenia, eosmophiha
Over prolonged periods, tetracyclines have been reported to produce brown-black m
croscopic discoloration of ihyroid glands, no abnormalities ot thyroid function studies ar|
known lo occur
USUAL DOSAGE: Adulls- 600 mg daily, divided into two orlour equally spaced dose;
lUore severe infections an initial dose of 300 mg followed by 150 mg every six hours c
300 mg every 12 hours Gonorrhea In uncomplicated gonorrhea, when penicillin is cor
tramdicated, Rondomycm' (methacycline HCI) may be used for treating both males an
females in the following clinical dosage schedule 900 mg initially, followed by 300
q I d (or a total of 5 4 grams
For treatment of syphilis, when penicillin ts contraindicated, a total of 18 to 24 grams t
Rondomycm (methacycline HCi) m equally divided doses over a period of 10-15 dai;
should be given Close tollow-up, including laboratory tests, is recommended
Eaton Agent pneumonia 900 mg daily for six days
Children - 3 to 6 mg/lb/day divided into two lo tour equally spaced doses
Therapy should be continued for at least 24-48 hours after symptoms and fever hav
subsided
Concomitant therapy: Antacids containing aluminum, calcium or magnesium impair at
sorption and are contraindicated Food and some dairy products also interfere Give drJ
one hour before or two hours after meals Pediatric oral dosage forms should not 1
given with milk formulas and should be given at least one hour prior to feeding
Inpatients With renal impairment isee WARNINGS), lotal dosage should be decreasi
by reducing recommended individual doses or by extending time intervals betwes^
doses
In streptococcal infections, a therapeutic dose should be given for at least 10 days.
SUPPLIED: Rondomycm (methacycline HCI) 150 mg and 300 mg capsules, syrup c
taming 75 mg/5 cc methacycline HCI
Before prescribing, consult package circular or latest PDR information
Rev 6
iHi WALLACE LABORATORIES
\^ CRANBURY, NEWJERSEY08512
622
Vol. 35, NclO
Sponsors: North Carolina Thoracic Society, North Carolina
Lung Association and North Carolina Academy of Family
Physicians
Credit: This program is acceptable for 10 elective hours
by the American Academy of Family Physicians.
For information: C. Scott Venahlc, Executive Director.
North Carolina Lung Association, P. O. Box 127. Raleigh
27602 (919-832-8326)
I December 6-7
What's New in Newborn Care?
Place: Babcock Auditoriimi
Fee: $45
Credit: 9 hours AAFP credit
For Information: Emery C. Miller, M.D., Associate Dean
for Continuing Education, Bowman Gray School of Medi-
Wtt cine, Winston-Salem 27 103
I'm
December 1 1-12
awHospital Emergency Room Services and Ambulatory Care
Place: Winston-Salem Hyatt House and Convention Center.
;.,., Winston-Salem
"'Sponsors: North Carolina Hospital Association and the
!ifti North Carolina Medical Society
Program: Designed for hospital administrators, trustees and
:"l physicians.
For Information: Mrs. Diane Turner, North Carolina Hos-
pital Association, P.O. Box 10937, Raleigh 27605
.m
January 24-25
i.i.Surgical Infections
Fee: $75
"redit: 12 hours
For Information: Emery C. Miller, M.D,, Associate Dean
for Continuing Education, Bowman Gray School of
' Medicine, Winston-Salem 27103
I .laniiary 31 -February 1
'>Iorth Carolina Medical Society 1975 Conference for Medi-
^*:K cal Leadership
'lace: State Society Headquarters Building, Raleigh
Li'rogram: Designed especially for Society Officers and other
: members who carry leadership responsibility. Open to all
\f interested Society members,
f-or Information: Mr. William N. Hilliard,
rector. North Carolina Medical Society P.
"'} Raleigh 27611
February 14-15
vledical Ethics Symposium
/lace: Babcock Auditorium
"ee: $30
"redit: 15 hours
or Information: Emery C. Miller, M.D.. Associate Dean
I for Continuing Education. Bouman Gray School of Medi-
ti cine, Winston-Salem 27103
Executive Di-
O. Box 27167,
February 19
■^'•Jliyingate Johnson Memorial Lecture
dace: Babcock Auditorium. Time: 11:00 a.m.
j'^or Information: Emery C. Miller, M.D., Associate Dean
^''^tfor Continuing Education, Bowman Gray School of Medi-
i cine, Winston-Salem 27103
,?t|i March 17-21
(Utorial Postgraduate Course: Radiology of the Gastrointes-
t tinal Tract
= ace: Governors Inn, Research Triangle Park (between
Durham and Raleigh, near the airport.)
ogram: Designed for radiologists. biU open to other physi-
cians in training or practice. Emphasis on personalized,
tutorial type teaching, with ample opportunity for dis-
■ cussion. Two 80-minute tutorial sessions each morning,
and one in the afternoon: 12 registrants will join one
faculty member in a separate quiet room with view-
■ boxes for organized film reading-discussions and case
presentations. Each registrant will have a total of 14
different tutorial sessions. One hour "Panel" presentation-
idiscussion each afternoon. Guest faculty include: Drs.
Charles A. Bream, Harley C. Carlson, Joseph T. Fer-
irucci, Jr., Roscoe E. Miller, Jerry C. Phillips, Ber-
inard S. Wolf, and. from Kings College Hospital. Lon-
.don, England, Dr. John Laws, Chairman, Department of
iRadiology.
liTOBKR 1974. NCMJ
Fee: $300; enrollment limited.
Credit: 28 hours AM A "Category One" accreditation
For Information: Robert McLelland, M.D.. Department
of Radiology. Box 3808. Duke University Medical Center,
Durham 27710
Continuin}> Kducatiun via .Satellite
The following programs will be received live from the
AlS-6 commimications satellite, by the Veterans' Hospi-
tals at Fayelteville, Oteen and Salisbury on the dates
indicated. Sessions are open to all physicians and other
interested health professionals.
October 16—1 p.m. "CPR "; 2 p.m. "POMR"
October 23 — 1 p.m. & 2 p.m. "Acute Respiratory Failure"
October 30 — 1 p.m. "Coronary Care Unit"
November 1 — I p.m. &. 2 p.m. "Cardiac Rehabilitation"
November 13 — 1 p.m. "Hypertension"
November 20 — 1 p.m. "Radiology Conference"
November 27 — 1 p.m. "Patient Histology Tissue Confer-
ence"
Additional sessions are scheduled for the following months.
For Information: Fayetteville — Mr. Kenneth Gath; Oteen
— Stewart Scott, M.D. or Mary Ellen Luiz, R.N.; Salisbury
— Mr. Dante Spagnolo
stem
Continuing Education for Nurses
October 21-23 — Problem-Oriented Medical Record Systi
October 23-25 — The Nursing Audit
November 4-6 — The Nurse: Planning Classes for Expectant
Parents
November 6 — A Practical Approach to Drug Interactions
November 18-22 — Planning Patient Care
For Information: Judith E. Wray. Administrative Secretary.
Continuing Education Procram, UNC School of Nursing
Chapel Hill 27514
Cancer Information by Phone
A toll free phone call to the Southern Medical Association
Cancer Education Service. (1-800-231-6970). makes can-
cer information available by phone to physicians in North
Carolina and other states in the Southern Medical Asso-
ciation area. Tapes must be requested by number. For a
cross indexed list of over 260 tapes, call the above num-
ber, identify yourself by name, address, city and state,
and request a copy of the index.
New Directory Available
The second edition (OP-414) of the Direclory of Self-
As.scssmcnt Progruins for Pliy.siciuns is now available for
$1.00 from the Order Department, American Medical As-
sociation, 535 N. Dearborn, Chicago. Illinois 60610. The
new edition lists six new self-assessment programs in:
Allergy. Cardiology. Chest Diseases. Colorectal & Ano-
rectal Surgery. Emergency Medicine, and Neurological
Surgery. A total of 2 1 programs is sponsored by spe-
cialty .societies, a county medical society and one univer-
sity. Each program, listed by topic and sponsor, is
described with regard to: intended participant, sites and
time of testing, dates of first test & most recent revision,
objectives and content, format, time required, method of
scoring, aids to learning provided, fees charged and where
to w rite for further information.
In Contiguous States
December 5-8
Core Curriculum: Clinico-Pathologic Correlations in Car-
diovascular Disease
Place: Williamsburg Conference Center, Williamsburg.
■Virginia
For Information: Miss Mary Anne Mclnerny, Director,
Department of Continuing Education Programs, American
Colleize of Cardioloav, 9650 Rockville Pike, Bethesda.
Maryland 20014
December 6-8
Neurologic Problems of Infancy and Childhood
Place: Cascades Meeting Center. Williamsburg. 'Virginia
Sponsors: University of Virginia School of Medicine: Medi-
627
Computer Credit, Incorporated is a specially
designed computer collection letter service
for the medical profession, currently serving
ten North Carolma hospitals and more than
500 physicians and dentists in the Carolinas
and Virginia. CCI offers an effective, easy-to-
use service that can markedly improve your
delinquent account collections. This service
requires no more than a minute of your time
per account. There are no expensive fees or
retainers with CCI, just one small fee for each
account. CCI is not a traditional collection
agency; we do not handle your money. Before
you sacrifice up to 50% of a receivable or
write it off, consider Computer Credit.
Call or Write:
J. Gilmour Lake, President
CDI^PLITER CREDJT,
JlilCQRPafiflTED
Suite 607, First Center BIdg.
P. 0. Box 5238
Winston-Salem, N. C. 27103
Telephone (919) 723-9401
cal College of Virginia of Virginia Commonuealth L'|
versity; Eastern Virginia Medical School.
Fee: $85
Credit: 13-'4 prescribed hours AAFP credit applied for.
Enrollment limited to 80 registrants
For Information: Dr. Ronald B. David. Medical College
Virginia, Box 211, MCV Station. Richmond, Virci
23298
Items submitted for listing should be sent to: WH.A''
WHEN' WHERE\ P.O. Box 8248. Durham. N. .
27704, by the 10th of the month prior to the month j
which they are to appear. i
AUXILIARY TO THE NORTH CAROLINA
MEDICAL SOCIETY
LEGISLATION
Perhaps today, as at no time in history, have t
-American people been so aware of the government
process in this country. It goes without saying that t
sensationalism of "Watergate" and the you-ar
there coverage of television have made the politic
process as much a part of the household as the dai
weather report.
The .Auxiliary to the North Carolina Medical S
ciety. working with national headquarters, is eag
that its members be informed far beyond what
read in the newspapers and seen on television. Tl
heahh services in this country are dependent upi
good legislation, and good legislation comes fro
intelligent voting — first on the part of the electoral
and then by those who have been elected. The my
that the AMA, its feet supposedly mired in tl
muddy backwash of ]8th century thought, is tl
enemy of the people, can only be countermands
by a thorough knowledge of what is going on. TH
is what the legislative arm of the Au.xiliary attemp
to do through the various means at its disposal.
The legislative chain of command within tl
Woman's Au.xiliary to the AMA includes the natiori
chairman of legislation, the regional chairman, wt
in turn keeps in touch with the state chairman, wl
currentl) in North Carolina is Mrs. Charles Hot
man of Fayetteville. She keeps in touch with tl
county chairmen throughout the state. The role of tl
county chairman is to inform her membership
pertinent legislation. When such legislation is of
emergency nature — when telegrams and letters
congressmen and senators are in order — the coun
chairman makes use of a telephone committee whi(
notifies all the membership, requesting that tel
grams and letters be sent to their appropriate repr
sentatives. An example this past year was the o;
position to the SI. 5 billion Senate Health Mai
tenance Organization (HMO) bill. Nationwide a
tion by Au.xiliary members contributed to a compr
mise costing only $375 million. Action of this so
isn"t mandatory or partisan; it's what is in the bq
interest of medicine and the taxpayer.
Among the many means of distributing legislati'
information to the members of the Au.xiliary a
628
Vol. 3.*;. No.
will.
)ii-a[if'
olitifi'
^Ipthe "Legsline" newsletters which deal with current
I health legislation. They go directly to presidents and
presidents-elect of state medical societies as well as to
state legislative chairmen. In North Carolina, the
''Tarheel Tandem," the quarterly Auxiliary news-
letter, reports on what is pertinent from a long
•irange view. Many members of the Auxiliary are
pembers of MEDPAC-AMPAC, the state and na-
tional medical political action committees, respec-
;tively, and much is learned through them. So, know
[your candidates!
Political action committees are currently held as
■suspect by some, but AMPAC and the state sub-
sidiaries have done wonders in informing the medi-
bal communities. AMPAC is interested in electing
honest candidates to the state legislature and to
^Congress. It is interested in the qualified "friends of
;medicine," but much more than that, it is interested
n candidates who will look at both sides of the ques-
ion — not just those who will vote "right."
Concerning our contribution, the monies are di-
vided equally between MEDPAC and AMPAC, but
jften the AMPAC share is returned to the state if a
.jljfcequest for additional support of a candidate in the
^fjitate needs it and AMPAC decided that it is a worth-
,l,jl'j'Vhile investment. The candidates ask for help from
jlJj^EDPAC, and then the MEDPAC committee de-
. j.yides whom to support. The MEDPAC board is non-
j [j,jjjnartisan, equally divided between Democrats and
,,^,jj,,jlepublicans. There are three Auxiliary members on
j^he board.
jfl In a time when the news media are full of ab-
is{|!ireviated jargon, the Auxiliary is interested in an in-
naipDrmed membership. How will I know an HMO
J jjlVhen I see one? Health Maintenance Organizations
iljijiike many shapes. They are a legal entity which
ifliil TOvides a specified range of medical care services
lin ij||0 a voluntarily enrolled population. What is AHEC?
,jli(tlj(ikrea Health Education Centers will train residents
ij ,;[^iway from the university medical centers on the
mi'i^ieory that physicians tend to stay where they train,
ilf-yius spreading the physicians around. What's going
il) happen to PSRO? The AMA House of Delegates
I joted not to ask for repeal of the Professional Stan-
,T« ards Review Organization law, but for modification.
ihe Congress is receptive to the idea in hopes of
;..s_^ laking NHI more palatable.
coii li* With National Health Insurance (NHI), are we
ijjli leading toward socialized medicine? Not if President
ijl 1 jord has anything to do with it. There are numer-
SJS proposals to be voted upon, and doubtless the
llie( )lid result will be a compromise. What sort of com-
, jli s'omise depends upon the leanings of Congressional
fembers at the time the bill is passed. The AMA's
(jup {icdicredit plan will be all inclusive medical care,
girded out through voluntary private health insur-
Gtce, regardless of ability to pay. The Administra-
»n's Comprehensive Health Insurance Plan is three-
Jld: (1) for the employed (2) for the unemployed
Id low income groups, and (3 ) a new kind of Medi-
I'TOBER 1974, NCMJ
//
e Dlf :
in
care. Not unlike Medicredit, it has those who are
able sharing the cost of insurance. The Health Se-
curity Act, sponsored by Senator Edward Kennedy,
would be a compulsory insurance plan and would be
financed by special social security payroll, self-em-
ployment taxes and federal general revenue. The
latter would be closest to socialized medicine.
Thus, the Auxiliary membership is informed, and
from this information it draws reasonable conclusions
based on knowledge, not intuition. Women — phy-
sicians' wives — do have a place in government if
they want it. Interesting to note, the newly appointed
national Chairman of the Republican Committee is a
woman — a physician's wife — Mary Louise Smith,
from Iowa.
News Notes from the—
DUKE UNIVERSITY MEDICAL CENTER
Have medical scientists overlooked subtle and per-
haps common errors in the body's mechanism for
regulating the production and breakdown of fat?
Do these inherited defects underlie the tendency
within certain families toward obesity and early heart
and artery disease, the nation's major killers?
Has fat metabolism in fat storage cells been un-
derestimated and inadequately studied in relation to
high blood pressure, heart attacks and strokes?
With the aid of a $22,000 grant from the Na-
tional Foundation-March of Dimes, Dr. Robert M.
Bell, an assistant professor of biochemistry at
Duke, will be seeking the answers to these and
other related questions in experiments he will con-
duct here during the next year.
Using isolated fat cells from well-fed and fasting
rats. Bell will attempt to verify opposite regulatory
effects of two hormones, insulin and noradrenaline,
on the activity of fatty acid activating enzyme
(FAAE). Among other hormones he will examine
in trying to pin down the exact mechanisms by
which any or all of them alter fat cell FAAE activity
are glucagon, growth hormone, ACTH and prosta-
glandins.
* * *
Thirteen new physicians' associates have decided
to begin their careers in North Carolina.
The thirteen are among 43 recent graduates of
the medical center's Physician's Associate Program
— the largest graduating class in the program's nine-
year history. They bring to 193 the total number
of Duke gradLiatc physician's associates (PAs), and
to 53 the total number of graduates employed in
North Carolina.
Frederick S. Lipman has accepted a position with
the Garner Professional Center in Garner, about ten
miles south of Raleigh.
Russell E. Mitchell will be employed by the
629
Norris-Biggs Clinic of Rutherford Hospital in Ruth-
erfordton, about 50 miles southeast of Asheviile.
William G. Vaasen will be assisting physicians at
Drexel Medical Associates, a family practice group
in the town of Drexel with a population of 1,431 —
some 15 miles west of Hickory.
Bound for the community of Lawndale is Paul E.
Stout, who will be working with Dr. Richard M.
Maybin. Lawndale. ten miles north of Shelby, has a
population of 544.
Seven of the graduates will remain in Durham.
William F. Smith is working with a local cardiol-
ogist. Dr. D. Edmond Miller.
The Durham Veterans" Administration Hospital
has signed on Stephen J. Cox. Mrs. Madeleine Fralc\',
Preston J. Keeler, Carol J. Phillips, Delmar L. Shel-
ton and James M. Schmidt will be assisting phy-
sicians at Duke.
Moving to Asheviile, Robert L. Jackson will be
working with family practitioner. Dr. Claude E. Stcen.
William H. Morris, who also is a registered phar-
macist, has taken a position with Revco Pharmac\'
in Fayetteville.
:■( * *
Eight new assistant professors have been named to
the faculty of the Medical Center.
Six of the appointments came in the Departmen
of Radiology and one each came in the Department
of Medicine and Health Administration.
Named in radiology were Drs. Roger W. Byhardi
Peter J. Dempsey, Americo A. Gonzalvo, Robert A
Older. Michael Oliphant and Moody D. Wharair
Jr. Appointed in Health Administration and Medi
cine were Thomas J. Delaney and Dr. John J. Gal
higher, respectively.
^ -,' ^
Dr. Drew Edwards and Dr. Lea O'Ouinn hav
been named administrative director and medical d:
rector, respectively, of the Developmental Evaluatio
Clinic.
They succeed Dr. Ann Alexander who resigned t'
accept a post in San Antonio, Tex.
Edwards, a clinical psychologist, received hi
Ph.D. from Florida State University in 1972. Sine
September of that year, he has been a staff membc
of the clinic, serving for the last year as assistar
director.
Dr. O'Quinn was awarded an M.D. from Duk
in 1965 and completed an internship in pediatric
at Duke in 1966. Before beginning a residency i
pediatrics at Duke in 1970, she worked in healt
department clinics located in Denver, Colo.
Facility, program and environment
allows the individual to maintain
or regain respect and recover with
dignity.
Medical examination upon admis-
sion.
Modern, motel-lihe 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 Atmosphere • Psychiatric Hospital
FOUR WEEK MULTI-DISCIPLINE THERAPY PROGRAM
Individual coiiPseling
Group Therapy
Nature Trail
Indoor Outdoor Recreation
FOR ADMIHANCE CALL
JAMIE CARRAWAY
EXECUTIVE DIRECTOR
919-621-3381
Recognized by:
Blue Cross & Blue Sfiield • Life Assurance Co. of Carolina
• Pilot Life Ins. Co. • Aetna Life & Casualty
• John Hancock Mutual Life Ins, Co • Kemper Ins,
• Metropolitan Life Ins. Co. • United Benefit Life Ins Co
■ Security Life & Trust Co.
FELLOWSHIP HALL mc
p. 0. BOX 6928 • GREENSBORO, N. C. 27405
Member of:
• N, C. Hospital Association
• The Alcoholic & Drug Problems
Assn of f^orth America
• American Hospital Association
FOR MEDICAL INFORMATION Cl
J. W WELBORN, JR.. M.D.
MEDICAL DIRECTOR
919-275.6328
Convenient to i-85, 1-40. U.S. 421, U.S. 220,
and the Greensboro Regional Airport.
FELLOWSHIP HALL WILL ARRANGE CONNECTION WITH COMMERCIAL TRANSPORTATION.
Located oft U.S. Hwy. No. 29 at Hicone Road Exit
6V'2 miles north of downtown Greensboro. N. C.
630
Vol. .V\ No.
News Notes from the —
BOWMAN GRAY SCHOOL
OF MEDICINE
WAKE FOREST UNIVERSITY
News Notes from the —
UNIVERSITY OF NORTH CAROLINA
DIVISION OF HEALTH AFFAIRS
..
Dr. Charles E. McCall, associate professor of
,;iedicine, is the recipient of a Research Career Dc-
elopment Award from the National Institute of Al-
,;rgy and Infectious Diseases.
Dr. McCall is engaged in research on the ability
f white blood cells to fight bacteria and the means
,sed to kill the bacteria.
^ He plans to spend a year under the grant study-
ing in England with Dr. Peter Lachmann, an im-
jiunologist at the Postgraduate Medical School at
iammersmith, London.
! Dr. McCall is the third member of the Bowman
jTay faculty currently holding a career development
,"ant. ...
Eighty-nine first-year students have enrolled for
I'le medical school's 1974-1975 academic year.
The new class, selected from 3,915 applicants, in-
ludes students from 1 8 states and one foreign coun-
.y. Forty-six North Carolinians are in the class.
1 The class has the largest female contingent (20) in
e school's history. Seven members of the class are
(ack Americans.
'Total enrollment, also the largest in the school's
story, is 349 medical students and 73 graduate
Pdents. ^ ^,, ^
Dr. Thomas B. Clarkson, professor and chairman
) the Department of Comparative Medicine, has
len appointed to a one-year term on the Animal
:sources Advisory Committee of the National In-
.tutes of Health's Division of Research Resources.
[Dr. Clarkson previously served a four-year term
the committee. He also serves on the advisory
lard of the University of Washington Primate Cen-
)Dr. Courtland H. Davis, Jr., professor of neuro-
^■gery, recently was elected chairman of a subcom-
:ttee of the Continuing Education Committee of the
nerican Medical Association.
* ^ 4:
IDr. Earl Watts, associate professor of medicine,
i been chosen as a recipient of a $5,000 scholar-
p grant from the Sloan Foundation to develop self-
Iching aids in cardiology.
* * *
^Eighty-six physicians recently joined the house
Iff of North Carolina Baptist Hospital and the Bow-
in Gray School of Medicine. The house staff now
Ms 203, the largest number of residents and in-
sis ever to participate in the medical center's train-
[ programs.
» JOBER 1974, NCMJ
I
The country's most extensive collection of infor-
mation on family planning programs, abortion clinics
and population is housed in the Carolina Population
Center at UNC at Chapel Hill. A part of the Techni-
cal Information Service (TIS) Program Office, the
Population Center's library contains more than 4,000
books, 500 serial publications and 10,000 pamph-
lets, periodicals and research reports in the field of
population studies. The material is readily available
to community planners, researchers and students
throughout the state.
* * *
The responsibilities of the sex counselor is the
subject of a new booklet which defines human
sexuality and explores the interplay between society's
values and personal values, between the counselor
and the client.
"Introduction to Sexual Counseling" is written by
Robert Wilson of the Carolina Population Center
at UNC in Chapel Hill and is supported by the
N. C. Department of Human Resources and the
Statewide Family Planning Program.
In the UNC School of Dentistry, the following
new faculty have been appointed:
Caswell A. Evans, Jr., has been appointed assis-
tant professor, Department of Dental Ecology. He
has been director of research and evaluation and
chief of dental services for HEALTHCO., Inc. in
Soul City for the past year. A graduate of Franklin
and Marshall College, he holds the D.D.S. from
Columbia University and M.P.H. from the University
of Michigan.
John R. Hansel has been named an assistant pro-
fessor. Department of Removable Prosthodontics. He
completed his masters degree at Georgetown Uni-
versity this year. He received his undergraduate
education at St. Joseph's College and his dental train-
ing at the University of Pennsylvania.
James Edwin Noonan, Jr., has been appointed as-
sistant professor, Department of Fixed Prosthodon-
tics. For the past two years he has been an associate
to Dr. Ray Hailey of the Cody Dental Group in Den-
ver, Colo. A graduate of the University of Colorado,
he holds the D.D.S. degree from Case Western Re-
serve University.
Ronald P. Strauss, former chief investigator in a
dental health education research project at the Uni-
versity of Pennsylvania, has been appointed assistant
professor in the Department of Dental Ecology. He
holds the B.A. from Queens College, D.M.D. from
the University of Pennsylvania School of Dental
Medicine, and the M.A. from the University of Pcnn-
631
sylvania Graduate School of Arts and Sciences where
he has work for a Ph.D. in progress.
Outdated, detrimental or generally unconventional
forms of biological and psychological treatment have
been administered to children of military personnel
at a federally-funded Florida psychiatric center. Dr.
Morris Lipton of UNC-Chapel Hill testified July 23
before a Senate investigating committee.
Dr. Lipton, professor of psychiatry at the UNC
School of Medicine and director of the Biological Sci-
ences Research Center of the UNC Child Develop-
ment Institute, said that electrical prods were used at
Green Valley School, as well as "remote control elec-
trified dog collars used in the training of dogs."
This apparently was part of the Orlando, Fla. school's
"behavior modification" program.
According to Dr. Lipton, the children had been fed
from a kitchen too filthy to pass the Florida State
Board of Health inspection, and they had been physi-
cally tortured — both through the choice of medical
treatment and disciplinary measures.
Dr. Lipton was subpoenaed to testify before the
Senate Permanent Subcommittee on Investigations
after reviewing patient records, affidavits by nurses,
one patient contract and reports written by the
school's director, Georce Von Hilsheimer.
STAFF PHYSICIAN
Large, Modern Industrial Complex
This position, with the world's leading de-
signer and manufacturer of ships, affords the
industrially-oriented M.D. an outstanding pro-
fessional opportunity.
You will be a key member of our well-
equipped medical center . . . boasting exten-
sive lab facilities in clinical medicine and
environmental life sciences ... as well as a
large, professional staff. Your involvement will
include performing clinical examinations of
employees, treating industrial injuries and
occupational diseases. U.S. citizenship re-
quired. In addition to an attractive compen-
sation package we offer the benefit of a
regular schedule and the scenic beauty of
Newport News, Virginia — well known for its
exceptional historical, educational, recrea-
tional and cultural facilities.
If interested in this outstanding opportunity,
send curriculum vitae to Geral 0. Vaughn,
Professional Recruiter-Salaried Employment,
Newport News Shipbuilding, Newport News,
Virginia 23507 ... or call (804) 247-4878.
Newport News Shipbuilding
A Tenneco Company Newport News. Virginia
^^•^^ An Equal Opportunity Employer
Dr. Margaret Moore, director of the UNC Medic.
School's Division of Physical Therapy for 22 yean
is stepping down as director to return to teachinj
Under Dr. Moore's direction, the Division has
tained a national reputation of excellence in clinici
and educational areas. In addition to her duties
director. Dr. Moore was assistant dean for .Mile
Health Professions Programs in the School of Med
cine from 1970 to 1973.
* * *
Dr. Clayton E. Wheeler, Jr., chairman of the D(
partment of Dermatology at UNC School of Med
cine. Chapel Hill, has been elected president of th
Society for Investigative Dermatology.
The society, organized in 1937, has as its objei
tives, to "conduct, promote, encourage and assist ii
vestigation and research in medicine and surgery, ari
more particularly in dermatology and syphilogy an
allied subjects."
Dr. Wheeler is author or coauthor of more tha
80 scientific articles or chapters in books. His majc
research interest has been herpes simplex (fev(
blister virus) infections and the relationship of th
virus to host cells.
He is secretary-treasurer of the Association (
Professors of Dermatology, member and director (
the American Board of Dermatology and a membi
of the Council of the National Program for Derm;
tology.
Dr. Wheeler received his M.D. from the Universii
of Wisconsin in 1941. He joined UNC as profess^
and chief of the Division of Dermatology in 196,
and in 1972 was appointed chairman of the Depar
ment of Dermatology.
* * ::■:
At 41, Francoise Hall is discovering a new identii
— line that, she says, "seems to fit better with tl
kind of person I am." The lithe, energetic mothi
of three has just completed her first year as a residei
in psychiatry at the North Carolina Memorial Hosp
tal in Chapel Hill.
Until last July she was an assistant professor
public health at Johns Hopkins University. She spei
much of her time writing articles on populatic
growth and editing a special edition of a medic^
journal on international population problems.
* * :'fi
Dr. Philip R. Loe has been promoted to assistai
professt>r in the Department of Physiology,
'-^ * *
New faculty in the School of Medicine include tl
following:
Charles W. Carter. Jr., assistant professor, Depar
ments of Anatomy and Biochemistry and Nutritio
is completing a year's postdoctoral fellowship at tl
MRC Laboratory for Molecular Biology at Can
bridge University, England. A graduate of Yale Un
versity, he received his M.S. and Ph.D. at the Uri
versity of California at San Diego.
Henry T. Frierson, Jr.. assistant professor. Depai
ment of Family Medicine, completed his D.Ed, th
:
632
Vol. 35, No.
/ear at Michigan State University. He received his
B.S. and M.Ed, from Wayne State University.
Stephen H. Gehlbach, assistant professor, Depart-
Tient of Pediatrics, is completing his M.P.H. at the
Jnivcrsity here this year. He holds the A.B. degree
.rem Harvard and the M.D. from Case Western Rc-
;erve School of Medicine.
John C. Hisley, assistant professor. Department of
Obstetrics and Gynecology, is chief of the High
^isk Pregnancy Service and Ultrasonography at the
Jniversity of Maryland Hospital. A graduate of
Washington and Lee University, he received his M.D.
llegree from the University of Maryland.
Eng-Shang Huang, assistant professor. Depart-
ments of Medicine and Bacteriology and Immuno-
pgy, has been a visiting assistant professor here for
ihe past year. A native of Taiwan, he holds the B.S.
ind M.S. degrees from National Taiwan University
rnd the Ph.D. from UNC-Chapel Hill.
i Robert D. Stone, assistant professor. Department
if Family Medicine, contingent upon completion of
«is Ph.D. from Michigan State University received
tfis B.A. degree from Dennison University and his
i.A. from Michigan State University.
New faculty in the UNC School of Nursing are:
Eleanor M. Brosning, assistant professor, received
W B.S.N, from the Medical College of Virginia
od M. S. from Boston University.
I Cynthia Freund, assistant professor, received her
i.S.N. from the University here and her B.S.N, from
ilarquette University.
^ Carol J. Gleit, assistant professor, completed her
d.D. from North Carolina State University this year.
Ihe holds nursing degrees from the University of Wis-
pnsin, Boston University and the University of Pitts-
^ Vicky R. Hutter, assistant professor. School of
jursing, has been on the faculty of St. Petersburg
linior College for the past four years. She holds the
LS.N. from the University of Alabama and the M.S.
om the University of Colorado,
t Clara L. Milko, assistant professor, comes to
ihapel Hill from the University of Texas School of
ursing. A graduate of St. Peters School of Nursing,
e received her B.S. from the University of San
rancisco and her M.S. and P.N. P. from the Univer-
f.y of Colorado.
,^New faculty in the UNC School of Public Health
fclude :
(Donald L. Fo.x, assistant professor in the Depart-
bnt of Environmental Sciences and Engineering,
IS been a lecturer at UNC this year. He also was
|;onsultant with the Research Triangle Institute and
(; Environmental Protection Agency. He holds the
IS. from Wichita State University and the Ph.D.
ram Arizona State University.
Carol R. Hogue, assistant professor in the Depart-
i»nt of Biostatistics, has served as a teaching assis-
ji^i^roBER 1974, NCMJ
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■I
tant and research associate at the University here. She
graduated from William Jewell College and received
her M.P.H. and Ph.D. from UNC-Chapel Hill.
Mark D. Sobsey. assistant professor in the Depart-
ment of Environmental Sciences and Engineering, is
an assistant professor in the Department of Virology
and Epidemiology at Baylor College of Medicine.
His B.S. and M.S. are from the University of Pitts-
burgh and his Ph.D. from the University of California
at Berkeley.
;;: * *
The Department of Health .Administration, in
UNC's School of Public Health in Chapel Hill an-
nounced the award of a $300,000 Ford Foundation
grant for continuation of its PopCase Project through
1977. The grant funds will be administered through
the Carolina Population Center.
Established in 1971 with a $250,000 Ford grant,
the PopCase Project was the first organized attempt
to develop training materials and management train-
ing programs in population /family planning program
administration on a worldwide basis.
Director of the project is Dr. Sagar C. Jain, head
of the Department of Health Administration and an
associate director of the Carolina Population Center.
Project codirectors are Dr. Curtis P. McLaughlin and
Dr. James E. Allen.
* * *
Appointed to new assistant deanships in the School
of Public Health are William T. Small, Jr., and Ernest
Schoenfeld.
Small, former director of student and minority af-
fairs, has been named assistant dean for student af-
fairs. Ernest Schoenfeld is the new assistant dean for
management and operations. He will continue as ad-
ministrative director of the Occupational Health
Studies Group.
* * *
Dr. Jerry Solon has received an $18,389 si.\-month
contract to do background work on nursing homes
for the Health Resources Administration of the U.S.
Department of HEW. Solon, visiting professor of
health administration in the UNC School of Public
Health, said that the background material will help
the National Center for Health Statistics to analyze
better its national survey data and guide its future
surveys of nursing homes.
The class is made up of 83 men and 27 women
Three of the entering medical students are America!
Indians. 2 I are black and 86 are white.
Richard M. Schcffler, assistant professor of econo-
mics at UNC-Chapel Hill was awarded $149,850
from the Bureau of Health Resources Development
in the Department of HEW to conduct nationwide
surveys to estimate the optimal demand and supply
of physician extenders.
Most of the 110 persons accepted for admission
to the UNC Medical School this year are North Caro-
linians, according to Dr. William Straughn, director
of the admissions committee. Only ten are from out
of state.
THREE N. C. FOUNDATIONS FOCUS
ATTENTION ON ACCESS TO CARE:
FINANCIAL SUPPORT TO ENCOURAGE
FULL-TIME EMERGENCY ROOM
PHYSICIANS
Uneven distribution of health personnel and risin;
demands for health services are posing significan
changes in patterns of delivery of health care, wit:
resultant problems of access to health care by certaii
segments of the population.
Since November 1973, the trustees of the Duk
Endowment, the Kate B. Reynolds Health Car
Trust, and the Z. Smith Reynolds Foundation, in
desire to contribute to the solution of these problems
have been cooperating in sponsoring and funding
study to determine how they might use some of thei
resources to assist in meeting some of North Caro
lina's most pressing health needs.
Upon his retirement, Mr. William F. Henderson
formerly Executive Secretary of the North Carolin
Medical Care Commission, was retained by the thre
foundations to conduct the study. A panel of indi
viduals active in various facets of the health car
system in North Carolina was assembled for a three
day conference to view the health care system an
provide an opportunity for each participant to pre
sent his assessment from the viewpoint of his dis
cipline.
This was supplemented by Mr. Henderson in in
terviews with representatives of disciplines not rep
resented at the initial conference and with conversa
tions vviih people at the grass roots level about thei
health delivery problems. The most recurrent them
of these investigations was the inaccessibility c
medical services, particularly those that are requirei
at night and on weekends and by people who ar
without the knowledge or the means to find the car
they need when they need it. The problems are pai
ticularly crucial in rural and underprivileged areas
The foundation Trustees have expressed a willing
ness to undertake a series of projects that hopeful!
will develop practical ways in which communitie
throughout the state can begin to make primary gen
eral illness health services more easily available t
those who are having to do without them. An addi
tional recurrent theme was that the community hos
pital and its organized medical staff are a natura
and logical focal point in the provision of healt
services and have the potential for playing a wide
role in the solution to problems of access to healt
care.
The North Carolina Hospital Education and Re
search Foundation proposed to utilize its establishe
organization to assure continuity and cohesive
ness of the effort. It will assist project applicant
634
Vol. }5. No.
^
[;and sponsors in the development of the projects. The
three foundations have made grants to accomplish
:his purpose, as well as for implementation of projects
Jeemed in accordance with the philosophy, purpose
ind resources of each foundation.
The proposal was to establish a program to main-
ain a continuing liaison with providers of health
;ervices in North Carolina, with the objective of ( 1 )
nonitoring health needs, (2) identifying problems of
iccess to health care, especially in rural and under-
)rivileged areas, (3) developing practical approaches
■■or responding to perceived health needs, and (4)
identifying suitable sponsors to test proposed solu-
ions.
The three foundations, with the encouragement of
he North Carolina Hospital Association and the
Worth Carolina Medical Society, wish to determine
Whether or not start-up assistance to a selected num-
er of hospitals in supporting full-time physician cov-
-■rage of emergency rooms is an effective way of get-
'ing at the access problem. It has been estimated
hat it might involve grants of up to $600,000 initial-
V to test the feasibility of this approach. Both the
late B. Reynolds Health Care Trust and the Z. Smith
leynolds Foundation have made commitments to-
Vard this goal. The Duke Endowment is expected
> provide financial assistance to individual hospi-
ds as the program evolves and depending upon the
interest shown by hospitals and their organized medi-
cal staffs.
Hospitals which will test this approach will be se-
lected in accordance with the procedure outlined
below:
1. Recipient hospitals must be owned and/or op-
erated by governmental subdivisions (state-owned fa-
cilities excluded ) or community controlled, not for
profit corporations.
2. Application grants must be jointly approved
by each hospital's board of trustees and medical
staff and submitted on forms to be provided.
3. Grants will apply only to full-time physician
services and will usually be committed for more
than one year.
4. Recipient hospitals would be expected to agree:
(a) that during the initial visit to the emergency
room, patients will not be denied attention even
though their complaints may not be classified as
urgent by emergency personnel; and, (b) to institute
follow-through procedures whereby patients seen by
the emergency physician will be aided in obtaining
the additional care they may need.
5. Hospitals applying for grants will be selected in
the following general manner: (a) if applications ex-
ceed available funds, only one hospital serving basi-
cally the same geographical area will be approved;
(b) consideration will be guided by the extent of the
i
1
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.
Accredited by the Joint Commission on Accreditation and
Certified for Medicare
\
James Asa Shield, M.D.
James Asa Shield, Jr., M.D.
Catherine T. Ray, M.D.
Weir M. Tucker, M.D.
George S. Fultz, Jr., M.D.
Graenum R. Schiff, M.D.
.«roBER 1974, NCMJ
635
applicant's community orientation and support, the
comprehensiveness of its commitment to community
health care, its prospective role in the state's emer-
gency medical services plan and the availability of
other emergency and ambulatory care program in
the service area; and (c) hospitals with no full-time
emergency physicians will be given first priority;
then hospitals with existing contractual arrangements
for part-time physician services proposing the use of
the grant to convert to full-time services; and other:
in descending order.
For information regarding projects that may be de',
veloped under this cooperative endeavor, contact
Mr. William F. Henderson, Director, The Progran
on Access to Health Care, P. O. Box 12471 (50
Oberlin Road, Suite 237), Raleigh, N. C. 27605
(telephone: 919-832-5251).
Month in
Washington
Congress's on-again-off-again attempt to write a
national health insurance (NHI ) law is very much off
again — so far off that most observers believe there
is no chance whatsoever for the 93rd Congress to
go down in history as the author of mandated health
insurance for all.
The method of financing NHI was again the stum-
bling block, cutting the House Ways and Means
Committee down the middle in a 12 to 12 vote (a
tie vote defeats an amendment ) and thus scuttled a
patchwork proposal by Chairman Mills that seemed
to many likely to win Committee passage.
The dramatic tie vote came about the morning of
Tuesday, August 20, after the Committee had been
called to order by Chairman Mills with the admon-
ishment, "We need to work awfully hard."
Staff began to explain the draft compromise, point
by point, in routine fashion to the Committee when
Rep. Joel T. Broyhill, (R-Va.) said he believed
that the Committee should be given the opportunity
to vote on alternate methods of financing NHI (as
opposed to the Social Security payroll tax), such as
the tax credit idea in the AMA Medicredit plan.
Mills stalled Broyhill off until the financing section
of the compromise regarding mandated employer
coverage was completed. The Chairman was about
to go on, when Broyhill again reminded Mills that
he wanted a vote on his amendment. The AM.^ tax
credit approach would be voluntary and consistent
with the free enterprise SNStem, according to Broy-
hill.
The first roll call vote of the Committee defeated
the Broyhill proposal 11 to 10. One member. Rep.
Bill Archer ( R-Tcxas), changed his vote from "pres-
ent" to "aye," and the motion was tied. Rep. Charles
Chamberlain (R-Mich.), walked in and the proposal
was ahead 12-1 1. However, Rep. Herman Schneebeli
(R-Pa.), showed up to cast a "no" vote and the tii
12-12 tally defeated the Broyhill proposal.
Though not apparent at the time, this was the be
ginning of the end. Rep. Omar Burleson (D-Texas)
lost 13-12. on his bid to substitute the financing pro
posed by the health insurance industry's NHI plan
The crusher came at the afternoon session when th'
Committee approved 1 1 to 7 a motion to mak
voluntary, rather than mandatory, the compromis
provision for the poor and the self-employed. Thi
was a drastic setback for Mills who angrily adjournct
the hearings until the next day.
The following morning shortly after the Committe(
had convened, Chairman Mills threw up his hands
saying, "I've never tried harder on anything in m;
life. But we don't have it. I'm not going to go be
fore the House with an NHI bill approved by am
13-12 vote." He said that the staff should try t(
figure out a different approach, but indicated tha
he believed chances of reaching a future agreemen
on NHI were dim.
The forced abandonment of his compromise plai
was a bitter defeat for Mills and for the Administra
tion, which had been working closely with the Chair
man to steer a measure through the Committee
President Ford had urged Congress to give NHI top
priority this year.
The up and down fortunes of NHI, which ap'
peared to have a bright chance of passage followin/
Ford's plea and Mills determined push for a compro
mise, have now slumped to the point that only sonK
drastic intervention by President Ford could save th(
measure for this year.
Votes for the Medicredit financing plan came fron
Democratic Representatives Phil Landrum (Ga.)
Richard Fulton (Tenn.). Omar Burleson (Texas)
Sam Gibbons (Fla.), and Joe Waggonner (La.). Oi
636
Vol. 35. No. U
vhe GOP side, the pro-Medieredit votes were Repre-
ientatives Broyhill (Va.), Jerry Pettis (Cal.), John
.Duncan (Tenn. ), Donald Brotzman (Colo.), Donald
riancy (Ohio), Bill Archer (Texas), and Charles
■^Chamberlain (Mich.).
* * *
f
Self-employed physicians are about to receive
tome cheery news from Washington.
The House and Senate have passed and sent to
ihe White House a liberalization of the Keogh law
)roviding tax deferrals on retirement savings of self-
imployed people.
This means that physicians in this category can
mmediately start setting aside more money subject
lO tax deductions in qualified retirement programs.
The bill's Keogh plan arrangement is retroactive to
luly 1, 1974.
There is no threat of a Presidential veto to cast
iny shadow on the legislation's becoming law.
The bill substantially boosts the savings subject to
ax deductions. The present Keogh plan allows the
telf-employed to set aside, tax free, up to ten per-
|:ent of their annual income with a $2,500 a year
iiaximum. The new law will allow 15 percent of
arned income not to exceed $7,500 a year,
i House and Senate conferees, after months of work,
pally agreed on all provisions of a sweeping pen-
sion reform bill that contains the Keogh provision.
jfhe measure had earlier swept through both House
' ind Senate with only minor opposition to the Keogh
i-rovisions.
Organized labor had fought the liberalization as a
)ophole for wealthier people, but many of labor's
( aunchcst backers, including Rep. Martha Griffiths
D-Mich.), disputed labor's stand and supported the
irovision.
,' The liberalization capped a long fight by the
].merican Medical Association for tax treatment of
jie self-employed physicians that would give them
iie same tax incentives for retirement savings as are
3w present in most corporate pension plans.
1 The bill also contains a relatively minor restric-
ipn on corporation pension plans that would affect
)-called professional corporations that have been
jiiining favor with many physicians in recent years
i-'cause of the more attractive retirement tax treat-
ient. Tax deferrals will not be allowed on savings
fiat would exceed a pension that brings in more
jian 75 percent of highest earnings over a three-
•ar period with a maximum potential retirement in-
-ime of $75,000 the limit. A "grandfather clause"
j.empts current plans that exceed this standard.
The new Keogh provisions and a new Keogh-type
an for the non-self-employed, not covered by com-
; my pensions, is expected to cost the government
'proximately $500 million a year in lost revenues.
) In urging approval of the plan, Rep. Al Ullman
i)-Ore. ), second-ranking Democrat on the House
;i ays and Means Committee, told the House, "What
I ; have to do is to bring into balance as much
,TOBER 1974, NCMJ
as we can the tax treatment for the self-employed
as compared to the corporate community."
■■'f ■■[■■ *
Less than half of the nation's physicians are now
accepting assignment for all of their Medicare pa-
tients, according to the latest government figures.
Deputy Assistant HEW Secretary Stuart Altman re-
vealed the decline in testimony before the House
Ways and Means Committee on national health in-
surance. HEW Secretary Caspar Weinberger later
told the Committee that an NHI program should
carry inducements for physicians to accept the as-
signment route, but opposed making it mandatory.
* * *
Retired military physicians may now accept posi-
tions as active physicians with the Defense Depart-
ment without any loss of their retired pay. Defense
hopes the exception to previous Civil Service Com-
mission standards will induce retired military phy-
sicians to go to work for the Pentagon as civilian
employees to help ease the shortage caused by the
end of the military "doctor draft."
* * *
The Senate Labor and Education Committee has
approved a revolutionary medical education bill that
would require all medical graduates to serve in
shortage areas and compel relicensing of all physi-
cians.
The measure, written by the Health Subcommittee
headed by Sen. Edward Kennedy (D-Mass. ), carries
almost $1 billion in federal aid for medical and other
health schools for the next five years.
In addition to the controversial mandatory ser-
vice and relicensing provisions, the bill gives the fed-
eral government power to allocate and limit post-
graduate training positions for physicians. Designed
to curb reliance on foreign medical graduates and to
increase the numbers of primary care physicians, the
disputed provision also requires the Secretary of
Health, Education and Welfare to limit the number of
postgraduate physician training positions to no more
than ten percent above the number of domestic medi-
cal and osteopathic school graduates that year. The
HEW Secretary would assign the total number of
certified positions established to the various cate-
gories of specialty and subspecialty practice of medi-
cine.
The Association of American Medical Colleges
and the AMA were sharply critical of these pro-
visions. The legislation now before the House Health
Subcommittee is not expected to contain them. Even-
tual fate may hinge on the outcome of a House-
Senate conference.
+ * *
The government issued final regulations defining
the conditions under which Medicare will help pay
for services provided by independent physical thera-
pists and limited services by chiropractors.
Under the regulations, carrying out the Medicare
amendments law of last year, covered chiropractic
637
|i
services are limited to manual manipulation of the
spine to correct "subluxations" which can be dem-
onstrated by x-ray. Also, chiropractors must meet
strict educational and professional requirements be-
fore their services can be reimbursed under the pro-
gram.
The cost of x-ray will not be covered. HEW said
the x-ray must demonstrate "at least ... a mal-
positioning of a vertebra" identifiable by any ex-
perienced x-ray reader.
The American Medical Association has opposed
legislation that would eliminate the authority of the
Food and Drug Administration to control the kinds
and amounts of ingredients in dietary supplements
and other foods for dietary uses.
Appearing before the Senate Health Subcommit-
tee, AMA officials noted that excessive use of vita-
mins can be harmful and is scientifically unwar-
ranted. Combinations of vitamins should contain only
those vitamins shown to be essential in human nu-
trition.
The witnesses were C. E. Butterworth. Jr., M.D.,
Chairman of the AMA's Council on Foods and Nu-
trition, and Vice Chairman Theodore \'an Itallie.
M.D. "There is no valid evidence to demonstrate
that larger amounts of nutrients are beneficial under
ordinary psychological conditions," said Dr. Butter-
worth.
Recent FDA regulations limiting the inclusions of
certain vitamins or minerals, or both, in dietary sup-
plements have aroused the wrath of food-vitamin
faddists and prompted introduction of legislation t
overturn the FDA"s actions.
Restriction of FDA's powers in this field, the
AMA officials told the Subcommittee, "would per-'
mit an unchecked proliferation of health deception
and economic fraud."
President Ford met with .'\merican Medical As
sociation officials at the White House at the end ol
.'August. They discussed prospects for national healtl:
insurance in the current session of Congress and ar
AM.A delegation's recent visit to China.
Those who attended the White House meeting
included AMA President Malcolm Todd, M.D
Richard C. Palmer, M.D., Chairman of the Boarc
of Trustees; Russell Roth, M.D., Immediate Pasi
President; Max H. Parrott, M.D., President Elect
James Sammons, M.D., Executive Vice Presideni
Designate, and Joe Miller, Assistant Executive Vic^
President.
=H ^ ^
Correction: "Month In Washington" incorrectly
reported (September) that the public utility type pro-
vision, defeated by an 8-! vote by the House Health
Subcommittee, covered both institutions' and physi
cians' fees. The Administration's Comprehensive
Health Planning bill, which specifically called foi
regulation of fees of individual practitioners, was
never seriously considered by the Subcommittee, ac^
cording to a protest from Rep. William Roy. M.D.
(D-Ka'n.).
Book Reviews
Current Medical Diagnosis and Treatment. Mar-
cus A. Krupp. M.D., and Milton J. Chatlon, M.D.
(eds). 1.0 IS pages. Los Altos, California iLange
Medical Puhliuations, 1974.
This is the thirteenth annual edition of this medi-
cal reference. The format has remained unchanged.
All fields of internal medicine are concisely covered.
Disorders are approached according to organ system,
with special chapters on infectious disease, poisons,
and malignant and immunologic disorders. The
topics are discussed systematically according to the
essentials of diagnosis, clinical findings, differential
diagnosis, prevention and treatment. .Although il-
lustrations are few. there are numerous, clinically
useful tables.
Finally, the index, perhaps the "heart" of any ref-
erence, is complete, listing symptoms, diseases and
drugs.
Besides the standard and expected material, nu-
merous topics, frequently omitted from more erudite -■
publications, are included. The appendix includes i
recommendations for foreign travel and a prac-
tical guide to interpreting laboratory tests. The chap-
ter on dermatology contains lists of numerous lo- :;
tions. powders and ointments and their appropriate) :
indications. In addition, disorders such as halitosis, -:
discolored teeth and calluses are covered.
What is lacking in Current Medical Diagnosis and
Treatment is that w hich is lacking in any publication fi
which attempts to be concise and complete. Discus-
sions are brief and must be considered as only intro-
ductions or refreshers. For instance, the recently re-
638
Vol. 35, No. 10
.eased drug diazoxide receives only two short sen-
ences. This shortcoming is partially compensated
^or by bibliographies which, in most sections, have
,ieen updated in this edition.
. There are several other significant changes from
he 1973 edition. The chapter on psychiatric dis-
orders has been completely rewritten by a new
ontributor. The chapters on respiratory diseases,
ardiac diseases, and gastrointestinal tract and malig-
nant disorders now include discussions of immuno-
bgically mediated pulmonary diseases, the usefulness
sf echocardiography, the trifascicular cardiac con-
uction system, a more detailed classification and
description of liver disorders, and the use of BCG
U an immunostimulant. Additionally, the appendix,
tor the first time, contains a brief section on the
voblem-oriented record. Other chapters are un-
hanged or contain only minor revisions.
In their preface, the editors state that their inten-
Son is for this book "to serve the practicing phy-
cian as a useful desk reference . . . (and) not
(tended to be used as a textbook of medicine."
'ith this caveat in mind, this reviewer recommends
lis volume to any prospective reader, or referrer,
(Oking for an updated, comprehensive and concise
view of medical diagnoses and treatment at a mod-
it price.
R. DURWOOD ,\LMKUIST, M.D.
Immediate Care for the Acutely III and Injured.
Hugh E. Stephenson, Jr.. M.D. (ed.). 266 pages.
Price, $7.50. St. Louis, Missouri: C. V. Mosby
Company. 1974.
iWith his continued interest in the care of the
lutely ill and the injured patient, and with his teach-
l experience in this area. Dr. Stephenson has
lited this book in a" very orderly fashion. The au-
lOrs of the various subjects and chapters have pro-
ded fundamental rationale for the immediate diag-
isis and management of these patients. The subject
fitter is arranged in a systematic manner, and cross
;'erences to other chapters are provided. The index
■ jlthe end of the book is easily utilized.
'Because of the growing interest in emergency
v'dicine, by hospitals and emergency trained per-
: inel, and because the number of these facilities is
:)idly increasing, more acutely ill or injured people
:■ being seen for the first time in the emergency
i)m. Dr. Stephenson's book is well timed. This
j.lblication should be in every emergency medical
.. ipartment and in the libraries of all people who are
i.icerned with this type of practice — physicians,
1 dical students, residents, and physician's assistants
ni emergency medical technicians who handle these
|i ients. This book can be quickly and easily read.
,[t is a matter of interest that Immediate Care for
'• Acutely III ami Injured has no illustrations and
1- ' tables, especially noticeable in the chapter of
instruction on cardiopulmonary resuscitation. How-
ever, such material for the specific cardiopulmonary
resuscitation can be readily sought in other manuals.
Frederick W. Glass, M.D.
.Selective Inhibitor!) of Viral Functions. W. A.
Carter (ed.). 377 pages. Price: $.39.95. Cleveland,
Ohio: CRC Press, The Chemical Rubber Com-
pany, 1973.
This book, one of the Monotopics Series published
by the Chemical Rubber Company, includes 16 in-
teresting and challenging articles written by 22 au-
thoritative scientists who have made significant con-
tributions in basic or applied research on antiviral
agents. The articles cover new and relevant informa-
tion on viral pathogenesis and antiviral drugs beyond
the scope of any recent reviews; they are completed
with an updated and comprehensive reference list.
The first article in the series is devoted to current
concepts of viral pathogenesis at the molecular level,
and is followed by two articles which cover specific
approaches to viral chemo-prophylaxis and the cur-
rent status of viral vaccines. The five articles on in-
terferon give special emphasis to our understanding
of the basic structural features of interferon, molecu-
lar requirements for interferon induction by vi-
ruses, nonviral agents or synthetic polynucleotides
and the mode of action of interferon.
The last eight articles in the book present an in-
depth coverage of current facts and speculations on
known antiviral drugs, including amantadine (Sym-
metrel^), thiosemicarbazones (Marboran). arabin-
osyl nucleosides (ara-C). halogenated pyrimidines
(iododeoxyuridine). guanidine and hydroxybenzyl-
benzimidazole (HBB), the anamycins (rifampin de-
rivatives and streptovaricin) and the new synthetic
analogs of viral genomes. Each of these comprehen-
sive articles includes the antiviral spectrum of the
drug, its mechanism of action, results of antiviral
activity against infections in experimental animals
and in man, the efficacy and toxicity data, and the
drug's current promise as a clinically useful antiviral
or anticancer agent. Emphasis is placed on correlat-
ing experimental data on the biochemical basis for
antiviral or anticancer activity with clinical evalua-
tion of the drug in determining whether the molecu-
lar action of the drug has potential as a therapeutic
agent.
In summary, this book should be enlightening and
rewarding to the molecular biologist, animal virolo-
gist, oncologist and chemotherapist. Although it has
limited value to the physician faced with practical
problems related to viral diseases, the book does
present a full review of the researchers' efforts toward
gaining a better understanding of the problems and
of the current progress in finding useful drugs for
treating human viral diseases.
Louis S. Kucera, Ph.D.
( OBER 1974, NCMJ
639
I'
In JHptttoriam
L. Nelson Bell. M.D.
Dr. L. Nelson Bell died on August 2. 1973.
at
the age of 79.
From 1941 to 1956 he was in surgical practice
in .Asheville, and for many years he was a medical
missionary in China.
Following his retirement in 1936. Dr. Bell devoted
full activity to the Presbyterian Church. He was an
internationally known churchman, immediate past
moderator of the Presbyterian Church, and former
associate editor of the Presbyterian Journal.
A native of Virginia, he received his M.D. Degree
from the Medical College of Virginia in 1916. He
soon, thereafter, went to China where he was a mem-
ber of the staff of Tsingkiangu General Hospital of
360 beds. He became chief surgeon in 1925, and
superintendent in 1928. He continued in this capacity
until 1941.
Dr. Bell had a distinguished career in medicine
and was an important force in his church, serving
in many outstanding positions. He was a fellow of
the .American College of Surgeons.
A man of remarkable capacity for achievement.
Dr. Bell received man\ honors in his medical prac-
tice. He was a capable and devoted physician and
will be sorely missed.
Surviving are his widow, the former Virginia Left-
wich, four children, fifteen grandchildren and six
great-grandchildren.
Buncombe County Medical Society
Cecil L. Crump, M.D.
Dr. Cecil L. Crump died on March 13, 1974, at
the age of 68, after a long illness.
He had been in Eye, Ear, Nose, and Throat
(EENT) practice in Asheville before serving as an
officer in the United States Navy Medical Corps for
four years. He was in private practice in ophthal-
mology in Asheville from 1946 until a few years be-
fore his death.
A native of Te.xas, Dr. Crump attended public
schools in Fort Worth. He received his A.B. Degree
from Texas Christian University and his M.D. De-
gree from Baylor. He did his postgraduate studies
in ophthalmology at Wilmers Institute in Baltimore
He was a staff member of Memorial Mission Hos-
pital, Aston Park Hospital, and a consultant at Oteer
N'eterans Administration Hospital. He was a membei
of the Buncombe County Medical Society, the North
Carolina State Medical Society, the .American Medi-I
cal Association and various EENT groups. He wasj
also a member of the Christian Church.
A devoted physician. Dr. Crump will be missec
by all who knew him. He is survived by his widow
Agnes L. Sparks Crump.
Bi'Nco.MBE County Medical Society
640
Vol. 35. No. H
Il
!'
^lORTH CAROLINA
Medical Journal
THIS ISSUE: Fiberoptic Bronchoscopy: An Improved Approach to the Diagnosis of Endobronchial Disease, Frederick
L Taylor, M.D., Felix A. Evangelist, M.D., and Jasper Phillips, M.D.; Psychopharmacological Treatment of Disorders of
Tsnescence, William E. Fann, M.D., E. Jeanine Carver, and Bruce W. Richman; The Preoperative Localization of Hyper-
inctioning Parathyroid Tissue Utilizing Parathyroid Hormone Radioimmunoassay of Plasma from Selectively Catheterized
^iiyroid Veins, Samuel A. Wells, Jr., M.D., Irwin S. Johnsrude, M.D., George J. Ellis, M.D., John P. Biiezikian, M.D., Charles
Ihnson, M.D., William P. J. Peete, M.D., and Harry T. McPherson, M.D.
1 ^ 3i
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1975 COMMITTEE CONCLAVE
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Predominant
• psychoneurotic
anxiety
Associated
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symptoms
Before prescribing, please consult com-
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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 (net-for sole
therapy).
Contraindlcated: 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 frequenc
and/of severity of grand mal seizures me
require increased dosage of standard ant
convulsant medication; abrupt withdraw;
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 (similarto
those with barbiturates and alcohol) hav(
occurred following abrupt discontinuanc
(convulsions, tremor, abdominal and mu
cle cramps, vomiting and sweating). Kee
addiction-prone individuals under carefu
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Entrapped gas...
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partner of
GI spasm
Painful GI spasm in the presence of entrapped
gas causes even more pain and more discomfort. Yet,
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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; glaucoma, prostatic hypertrophy, pyloric
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skin rash, constipation or drowsiness. Dosage: one or two tablets
preferably before meals and at bedtime.
Reed & Carnrick/Kenilworth, N.J. 07033 ||n
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
belladorma 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
John H. Felts, M.D.
Winston-Salem
EDITOR
John S. Rhodes. M.D.
Raleigh
.ASSOCIATE EDITOR
Ms. Martha van Noppen
Winston-Salem
ACTING ASSISTANT EDITOR
Mr. William N. Milliard
Raleigh
BUSINESS MANAGER
EDITORIAL BO.\RD
* W. McN. Nicholson. M.D.
Durham
CHAIRMAN
Robert W Prichard, M.D.
Winston-Salem
John S. Rhodes. M.D.
Raleigh
Louis deS. Shaffner. .M.D.
Winston-Salem
Rose Fully, M.D.
Kinston
George Johnson. Jr.. M.D.
Chapel Hill
Charles W. Styron. M.D.
Raleigh
* ( Deceased )
NORTH CAROLINA MEDICAL JOUR-
NAL, 300 S. Hawthorne Rd., Winslon-Salem,
N. C. 271U3. is owned and published by The
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Address manuscripts and communications re-
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NORTH CAROLIN
MEDICAL JOURNA
Published Monthly as the Official Organ
The Notlh Caroli
Medical Socie
November 1974, Vol. 35, No.
Original .Articles
Fiberoptic Bronchoscop\: \n Improved .\pproach to the
Diagnosis of Endobronchial Disease 6
Frederick H. Ta\lor. .M.D.. Feli.x ,A. Evangelist. M.D..
and Jasper Phillips. M.D.
Psychopharmacological Treatment of Disorders of
Senescence 6
William E. Fann. M.D.. E. Jeanine Carver, and
Bruce V\'. Richman
The Preoperative Localization of Hyperfunctioning
Parathvroid Tissue L tiiizing Parathyroid Hormone
Radioimmunoassay of Plasma from Selectively
Catheterized Thyroid \ eins 6
Samuel .A. Wells. Jr.. .M.D.. Irwin S. Johnsrude. M.D..
George J, Ellis. M.D.. John P. Bilezikian. M.D..
Charles Johnson. M.D.. William P. J. Peete. M.D.. and
HarrvT. McPherson. M.D.
i.
Editorials
The Fall 1974 E.xecutive Council Meeting 6!-fc
William .McNeal Nicholson. M.D .". 6:-!;
Emerge.ncv Medical Sermces
Proposed Training Program for EMT .Advanced Training.... 64'b:
Rocco Morando
b
Bllletin Board
New Members of the State Society. 6Hlr
What':* When'.' Where'? 69
.Auxiliary to the North Carolina Medical Society 69
News Notes from the University of North Carolina
Division of Health .Affairs
News Notes from the Duke University Medical Center...
News Notes from the Bowman Gray School of .Medicine
of Wake Forest University
69
69
70
.Mo.sFH IN Washington... 70.
Book Remews 70'
In Memorum 71
Classieied .Ads 71
Inde.x to .Advertisers 71
Contents listed in Current Cuiuenis Clinical Practice
i.
k
li
6!
Fiberoptic Bronchoscopy: An Improved Approach
To the Diagnosis of Endobronchial Disease
Frederick H. Taylor, M.D.. Felix A. Evangelist. M.D.. and Jasper Phillips, M.D.
JHE groundwork for the develop-
ment of bronchoscopy may have
1 estabhshed by Green^ in 1847.
hat year he described, before the
licai and Surgical Society of New
k, a 19-year experience with
lication of the larynx by cathe-
cation. He had become adept in
eterizations of the trachea and
ichi, but the Society condemned
claims as "an anatomical ini-
ibility and unwarrantable inno-
3n in practical medicine"- and
lested him to withdraw from
ibcrship in the Society. The im-
nance of his observation, how-
, was soon recognized. "Green's
Dvery, 0"Dwyer"s observations
^ 'e in connection with his dis-
ry of the intubation tube and
i invention of the incandescent
rric light laid the foundation to
;t examination of the larynx and
leo-bronchial trec."-
illian-' performed the first bron-
copy in 1895. Illumination was
leadlamp, and secretions were
wed by sponging and sucking
a small pump designed by Kil-
Two years later Killian re-
id a foreign body, a piece of
Tint requests to Dr. Tavlor, 1900 Ran-
Road. Charlotte, N. C. 28207.
bone, from the right main stem bron-
chus with a bronchoscope.
In 1902 Einhorn^ described an
auxiliary tube in the wall of an
esophagoscope as a light carrier.
This instrument was the beginning
of the distally lighted bronchoscope.
In 1904, Ingalls^ reported the
removal of two foreign bodies
through a Killian tube. Jackson,"' in
1905, published his first report of
the removal of foreign bodies
through the bronchoscope. He de-
scribed a bronchoscope with an
obturator which he passed blindly
using his left index finger as a guide,
but he stated that Killian passed
bronchoscopes without obturators
using direct vision. Jackson also de-
scribed the necessity for four assis-
tants— one to watch respirations,
one to watch the pulse, a primary
assistant, and an unsterile assistant
to turn on and off the electrical
equipment.
The early endoscopists were con-
cerned primarily with foreign body
removal and cauterization of endo-
bronchial lesions.- ■■ '"'' The de-
velopment of thoracic surgery gave
increasing importance to the diag-
nostic value of bronchoscopy. In-
deed, thoracic training programs can
no longer be considered complete
f
MBER 1974. NCMJ
'/
unless the resident staff is taught to
master bronchoscopy.
The combination of a straight
tube with distal lighting, together
with the later addition of angled tele-
scopes, remained the basic principles
of the bronchoscope for the next
60 years.
Various biopsy forceps were de-
vised to collect bites of tissue which
could be seen on direct vision. Bron-
chial washings and brushings'*''-^
made possible the collection of se-
cretions from more distal areas for
cytology, bacteriology and the study
of particulate matter. These methods
limited access to more peripheral
areas.
The development of the flexible,
fiberoptic bronchoscope by the
Japanese in 1967 literally revolu-
tionized bronchoscopy.'^- '■' Im-
provement in visibility was made
possible by the high intensity light
and clarification of image by the
lens system. The fiberoptic principle
permitted accurate visibility around
corners into upper lobe segments
ana all peripheral subsegments (Fig-
ure 1 ). The 5 mm diameter of the
new scope permitted passage far into
peripheral segmental and subseg-
mental bronchi. A small channel
within the scope allowed secretion
667
Fig. I. Flexibilit) of the fibtroptic bronchoscope which has been inserted through
a rigid bronchoscope, enabling easy access to the upper lobes.
collections from peripheral segments
with suction. Small brushes on long,
thin wires could be passed, under
direct vision, far into the periphery
to obtain brush biopsies for cytolog-
ic and bacteriologic smears.
TECHNIQUE
In this series all bronchoscopic
examinations utilizing the flexible
fiberoptic equipment have been done
under local topical anesthesia using
one percent Pontocaine"'. Patients
were premcdicated with intramuscu-
lar injections of meridine hydrochlo-
ride (Demerol" ) and sodium pento-
barbitol (Nembutal"). With the pa-
tient in the supine reverse Trcnde-
lenberg position and neck recum-
bent extended, a No. 8-40 standard
Jackson bronchoscope was passed,
in the usual fashion, into the upper
trachea. The rigid scope was used as
a conduit for the passage of the flexi-
ble fiberoptic bronchoscope, thus
permitting the rapid removal and
reinsertion of the flexible scope
for lens cleaning or irrigation with
saline. It also made possible the
training of residents in passage of
rigid bronchoscopes. The flexible
scope was passed peripherally to vis-
ualize the distal trachea, carina, and
rieht and left bronchial trees (Fig-
ures 2A-F). The excellent visibili
and maneuverability of the flexih
scope made possible the Iocalizati(
of segments which were bleediii
producing pus, or containing mini
tumors or other lesions (Figur
3A-D). After visualization had be
completed, selective washings we
collected from the desired segmer
and appropriate brushings wc
taken for cell and bracterial stu
(Figures 4A-B). If gross tumor w
seen in a centrally located bronchi
the flexible scope was removed, t
rigid scope advanced to the lesid
and a bite biopsy taken with the fcl
ceps. After both the rigid and fie
ibie scopes were removed, the
tient sat up to cough out the po:
bronchoscopy sputum — often a d'u
nostic specimen.
ALTERNATE TECHNIQUES
Very rarely a rigid metal bro
choscope cannot be passed becaii
the patient has severe cervical art
ritis, temperomandibular joint m<
function, or the like. In such cas
the flexible bronchoscope can
used. With the patient in the sittii
or supine position and propeil
anesthetized topically, the flexi
scope can be passed through a n
tril down the trachea and out in
the bronchial tree for inspection ai
collections of secretions and brus
ings. A few drops of phenylephri
hydrochloride (Neo-Synephrine<
in the nostril may be necessary
produce an adequate nasal lume
A nasopharyngeal tube is recoi
mended by Wanner"'- '' as a co
duit for the fiberoptic bronchoscoj
The transnasal technique has st
eral disadvantages. It can be coi
plicated by laryngospasm, partic
larly if no hollow conduit is used
pass the scope. This technique d
not allow for free and easy wi
drawal and reinsertion of the fl
ble scope for cleansing between
lective brushings and washings fx<
different areas. Residents do
learn the techniques for rigid br
choscopy. Small nostrils can ca
damage to the flexible bronchosco
The passage of an endotrach^
tube makes a good conduit for tl
flexible scope, but large bite biopsj
cannot be taken, as when the ng
66X
Vol . .'15, No.
Fig. 3A
FiB. 3B
Fig. 2. Fiberoptic views of peripheral
bronchi: A. Left upper lobe and seg-
mental bronchi. B. Anterior segment and
subsegments of the left upper lobe. C.
Left lower lobe and basilar segments.
D. Right upper lobe and its three seg-
mental bronchi. E. Right middle lobe and
two segmental bronchi. F. Right lower
lobe and basilar bronchi.
FiB. .1C
Fig. 3. Visualization of peripheral bron-
chogenic carcinoma through the flexible
bronchoscope. A. Tumor in anterior seg-
ment left upper lobe. B. L'lcerating cancer
in subsegments of left upper lobe. C.
SmatI polypoid carcinoma in anterior
segment of left upper lobe. D. Carcinoma
producing stenosis of right upper lobe
bronchus.
Fig. 3D
'i'EMBtR 1974, NCMJ
/
669
He. 4\
bronchoscope is used. However,
newer flexible scopes do allow for
tiny bite biopsies.
Patients with tracheostomy tubes
in place are easily examined with the
fiberoptic bronchoscope (Figure 5).
A few drops of local anesthetic in-
stilled through the tracheostomy tube
permits passage of the broncho-
scope. The flexible scope will go
through No. ."^ or larger tracheos-
tomy tubes, and it is useful for
evaluating the tracheal mucosa of
patients with long-term tracheos-
tonn tubes.'"
LIMHATIONS
The flexible fiberoptic broncho-
scope is not yet useful for the re-
moval of foreign bodies, nor can it
be used in small children. Thick se-
cretions and blood are difficult to as-
pirate rapidly through the small suc-
tion channel. Sterilization of this in-
strument is a problem; cleansing
with Betadine is most often used,
but gas sterilization is necessary at
times and takes several hours. The
flexible bronchoscopes are expen-
sive and it is not practical to own
several instruments.
.Some writers have advocated the
use of the flexible bronchoscope at
the patient's bedside for diagnoses
and for removal of thick secretions
and correction of atelectasis."' '' '■'
Fig. 4B
Fig. 4. A. Chest x-ray showing biops;
brush passed through flexible broncho
scope into a small carcinoma in peripher'
of left upper lobe. B. Bronchoscopic viev
of brush.
We do not advocate this approach
routinely since complications, al'
though rare, arise which necessi
tate emergency measures — thu
is. in such instances as laryn
gospasm (especially when the tlexi
ble scope is passed through thi
nose), reactions to local anesthetic:
and severe endobronchial bleeding
Postoperative patients with thick se
cretions should rarely require bron
choscopy if they are managed wel
with early ambulation, assistec,
coughing and tracheal suction. If se
cretions are too thick to be managec
in this way. then the rigid broncho
scope with large bore suction cannu
lae are preferred. It would seem tha
the flexible bronchoscope is too fine
and expensive an instrument to us(
routinely for maintaining good bron
chial cleansing when more simpli
means are available. As we men
tioned previously, the small calibri
of the suction channel in the flexibli
scope does not allow effective re
moval of thick secretions.
S:
EXPERIENCE
The present report is based oi
727 bronchoscopic examination
done over the past two and one-hal
years in three hospitals. One hun
dred eighty-nine (26 percent) o ..
these patients had either or both his
tologically and cytologically provei
primarv bronchogenic carcinoma
The remaining patients had a variet;
of diagnoses including bronchitis
unresolved pneumonia, adenoma
670
\oi . .■?5, No.
»t 'J
;l
etastatic cancer, lymphoma, sar-
)id, tuberculosis and "hemoptysis
: undetermined etiology."
Of the 189 cases of primary lung
'incer, the lesion was seen through
rigid bronchoscope in 58 cases
g. 5. Fiberoptic bronchoscope passed through a tracheotomy tube.
1i0.7 percent. ) The flexible fiber-
')tic bronchoscope permitted visu-
ization of this tumor in an addi-
)nal 62 cases (33 percent); tu-
^or visibility more than doubled
!}3.7 percent) with the flexible
lOpe. The combination of brush
opsies, bite biopsies, bronchial
^hings and postbronchoscopic
utum examinations yielded a diag-
'-isis of cancer in 88, 61, and 52
rcent of patients with primary
fonchogenic carcinoma in three
spitals. These figures increased to
76, and 63 percent when the
'l|hly questionable specimens were
'ided to the positive specimens.
'Absolute negative studies were
and in 5, 24. and 37 percent in
«se three hospitals. There were no
ise positive reports in this series.
IJII
i
DISCUSSION
'■^The improvement in tumor visi-
Jity and diagnosis with the flexible
bronchoscope has made possible
early surgery for more patients with
cancer and has determined inopera-
bility in others. In three patients who
had hemoptysis and cancer cells in
their sputum but negative chest
roentgenograms and negative gross
bronchoscopic findings, tumors were
properly localized by selective five-
lobe brush biopsies and washings.
These patients had negative findings
at the operating table, but the proper
lobe was resected in each case.
Three patients v.ith apparently oper-
able unilateral cancer as determiried
by roentgenogram studies were de-
clared inoperable. Using the flexible
scope in each of these cases, an un-
suspected second primary cancer
was found in the contralateral lung.
In a few cases a primary bron-
chogenic carcinoma was detected by
brush biopsies under direct vision,
but the cytologist was unable to
make a diagnosis of cancer from the
smears. Despite those occasional un-
explainable cases, the ability to ob-
tain brush biopsies from a tumor
under direct vision has usually pro-
duced a positive diagnosis. Flexible
fiberoptic bronchoscopy has been a
very gratifying addition to our diag-
nostic approach to endobronchial
disease. It is hoped that instruments
will be developed for use in small
children in the near future. The
flexible fiberoptic bronchoscope has
not yet abolished the need for the
older rigid bronchoscope.
1. Donaldson F; The larynfzolojiy ot Trousseau
and Horace Green: an historical review.
Trans Am Laryncol Assoc 12: 10-lK. 1890.
2. Clerf LH: Historical notes on foreijzn bodies
in the air passages. Ann Med Hist 8: 547-
552. 1936.
."t. Killian G: Direct endoscopy of the upper
air passages and oesophagus: its diagnostic
and therapeutic value in the search for and
removal of foreign bodies. J Larvngol Otol
18: 461-468. 1902.
4. Meade RH: A History of Thoracic Surgery.
Springfield. Illinois: Charles C Thomas. 1961.
pp 779-780.
5. Jackson C: Foreign bodies in the trachea,
bronchi and oesophagus. The aid of oesoph-
agoscopy. bronchoscopy and magnetism in
their extraction. Laryngoscope 15: 247-281.
1905.
6. Clerf LH: Historical aspects of foreign
bodies in the air and food passages. Trans
Stud Coll Physicians Phila 20: 9-16. 1952.
7. Weist JR: Foreign bodies in the air-passages:
a study of 1000 cases to determine the pro-
priety of bronchotomv in such accidents.
Trans AM Surg Assoc 1: 117-1.16. 1883.
8. Fennessy JJ : A technique for the selective
catheterization of segmental bronchi using ar-
terial catheters. Am J Roentgenol Radium
Ther NucI Med 96: 936-943. 1966.
9. Fennessy JJ : Bronchial brushing in the di-
agnosis of peripheral lung lesions: A pre-
liminary report. Am J Roentgenol Radium
Ther Nucl Med 98: 474-481. 1966.
10. Fennessy JJ : Transbronchial biopsy of pe-
ripheral lung lesions. Radiology 88: 878-882,
1967.
11. Fennessy JJ: Bronchial brushing and trans-
bronchial forceps biopsy in the diagnosis ol
pulmonary lesions. Dis Chest 53: 377-389.
1968.
12. Fry WA. Manalo-Estrella P. Dorsey JM:
The technical details of bronchial brushing.
J Thorac Cardiovasc Surg 60: 636-6411, 1970.
13. \Mllson JK, Eskridge M; Bronchial brush
biopsy with a controllable brush. Am J
Roentgenol 109: 471-477. 1970.
14. Ikeda S. Yanai N. Ishikawa S: Flexible
hronchofiberscope. Keio J Med 17: 1-18.
1968.
15. Ikeda S: Flexible bronchofiberscope. Ann
Otol Rhinol Laryngol 79: 916-923. 1970.
16. Wanner A. Amikam B. Sackner MA: A
technique for bedside bronchofiberoscopy.
Chest 61: 287-288. 1972.
17. Wanner A, Zighelboim A, Sackner MA:
Nasopharyngeal airway; A facilitated access
to the trachea. Ann Intern Med 75: 593-595.
1971.
IS. .^mikam B. Landa J, West J et al: Broncho-
fiberscopic observations of the tracheo-
bronchial tree during intubation. Am Rev
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19. Faber LP. Monson DO, Amato JJ, Jensik
RJ: Flexible fiberoptic bronchoscopy. Ann
Thorac Surg 16: 16.1-171, 1973.
JVEMBLR 1974, NCMJ
f
Psychopharmacological Treatment of
Disorders of Senescence
William E. Fann, M.D..* Jeanine C. Wheless, I and Bruce VV. Richman.:
;
pSYCHOPHARMACOLOGI-
CAL treatment of disorders of
senescence has traditionally focused
on impairment of brain tissue func-
tion. Even when the elderly have
predominantly depressive or para-
noid symptoms, these symptoms are
frequently assumed to be merely
prodromal to the emergence of an
underlying cerebral disease, and the
possibility of psychoses, other than
those related to senility or arterio-
sclerosis, is excluded. HowcNcr,
chronic brain syndrome is not al-
ways the predominating mental ill-
ness of the elderly: functional psy-
choses, confusion and neuroses are
also common. Often. impro\ement
after the use of psychopharmacologi-
cal agents is due to the effects
of the medications upon the latter
categories of illnesses, occurring
separately or concurrently with
chronic brain syndrome, rather than
• Associate Professor. nfp.irimenl ol Ps>-
i;hiatr>. and Scientific .Associate. Center for the
Stud> of ,At:iny and Human [development. Duke
University Medical Center. Durfiam. North
Carolina.
t Research assistant. Department of Psvchia-
Iry. Clinical Research r'nit. Veterans .Adminis-
tration Hospital. Durham. North Carolina.
I Research assistant. Department of Psvchiatr>.
Clinical Research Unit. Veterans Administration
Hospital. Durham. North Carolina. New address:
Department of Psvchiatry. Veterans Administra-
lion Hospital, Houston. Texas.
Reprint requests to \\ . E. Fann. M.D.. De-
partment of Ps>chiatry, Ba>lor College of Medi-
cine. l^llK) Moursiind ,A\enue. Houston. Texas
771)25.
to any actual alteration of brain
function.'' ■
Emotional decompensation might
accompany the progressive loss of
intellectual function in the senium.
Hence, the senile are a group of peo-
ple who are at special risk for the
development of other psychiatric
disorders. Frequently, however, co-
existent anxiety, depression or psy-
chosis goes undiagnosed and un-
treated. Psychotropic agents used in
the treatment of mental disorders
accompanying chronic brain syn-
drome, either coincidentally or sec-
ondarily, are substantially those
prescribed for younger patients.
However, these drugs must be ad-
ministered on a modified basis to
asied, intellectuallv debilitated peo-
pie.
Pharmacological intervention in
the senile dementing process has not
succeeded in reversing the syn-
drome, but some tentative efforts
have mitigated symptomatic inten-
sity. Stimulant compounds, vasodila-
tors, hormones, vitamins, anticoagu-
lants, nootropic agents, and "re-
juvenating"" drugs have received
clinical trials, with varying degrees
of success, in reducing some indi-
vidual components of chronic brain
syndrome. Some of the benefits and
detriments of these druc classes will
be reviewed as applied to psychiatric
syndromes in the elderly.
CHRONIC BRAIN SYNDROME
Chronic brain syndrome is char-
acterized by a history of gradual in-
tellectual and personality disorgani-
zation for a period of several months
to several years; disturbances in in-
tellectual functions involving com-
prehension, memory and orienta
tion; disturbances of affect — emo
tional instability, irritability, anxiety,
apathy, and delusions or hallucina-
tions.^ Senile psychosis and arterio-
sclerotic psychosis are the two forms'
of organic brain syndrome.
Senile psychosis is indicated "by
a history of gradual and progressive
failure in general efficiency in ever)-
day life dominated by changes in
the intellect, memory, and person-
ality in the absence of specific etio-
logical factors. . . .""' Although the
cause of the condition is not known,
metabolic, endocrine and vascular
factors have been implicated, and
there may be genetic determinants."'
Onset usually occurs in the seventh I
to ninth decades and is more com- 1
mon in women than men. .Although ■
senile psychosis is similar to normal [
aging in many respects, senile dc-; ,
mentia brings about a more pro-»;
found and rapid deterioration and
672
Vol . .v'^. Nil. : 1
gher mortality. The pathological
I langcs in senile psychosis are dif-
se, resulting in a complete disor-
inization and degradation of be-
ivior."' '■
Arteriosclerotic psychosis is de-
entia associated with focal indica-
)ns of cerebrovascular disease. It
velops more rapidly than senile
ychosis, fluctuates in severity, and
usually accompanied by emotional
continence or epileptiform sei-
res, or both. Insight is usually in-
ct.' A general effect of arterio-
lerotic psychosis is the destruction
the more complex and subtle fea-
xes of personality, although judg-
i^nts based on experience and more
dent personality traits remain rela-
ely intact."
Many investigators claim that
'ebral blood flow diminishes with
ing. This proposition is apparently
e in cases of cerebral arterio-
erosis, and perhaps in senile de-
tntia, since a diminished oxygen
asumption is associated with de-
tased metabolic demands. By im-
kving cerebral blood flow, hy-
fcemic degeneration and death of
parens might be prevented, and the
fictional capacity of still unaffect-
(j neurons could be increased. The
I, of vasodilators has been the most
(,nmon therapeutic approach for
i proving cerebral blood flow."
\sodilators include nitrites, nico-
t c acid or its congener, and pa-
f erine. To date, no convincing
Ciience that these agents improve
-bjOd flow or mental functioning has
t n published. Additionally, some
d^-ger exists in the use of vasodila-
ti, compounds, in that induction of
a,, eneralized cerebrovascular dila-
ti , might redistribute blood flow to
tl,^: detriment of more compromised
3; as."'
',)ther agents used for increasing
o--bral blood flow, and thus for im-
, p> ving mental functioning in the
aiil, are anticoagulants. Walsh''
(-69) studied the use of bishy-
d cycoumarin in patients having
ch)nic brain syndrome. These pa-
tijts showed major improvements,
sui as regaining lost bladder and
W el control. Ratner et al' ( 1972)
cc ducted a study of warfarin pre-
sci led for patients afflicted with
■. N =:.MBKR 1974, NCMJ
senile dementing processes. The
anticoagulant group of subjects un-
derwent less mental deterioration
than the control group, although
there was no significant difference.
Both studies stressed the importance
of selecting patients who have early
symptoms of organic brain syn-
drome.
A recently proposed method of
increasing blood flow in patients
having senile dementia is hyperoxy-
genation in which hyperbaric oxy-
gen is used.' Jacobs et al'" (1969)
concluded that memory and concep-
tual ineffectiveness in senile patients
were improved by intermittent hy-
peroxygenation.
However, Dastur et al'' have
shown that the cerebral blood flow
of a 70-year-old patient is no differ-
ent from that of a 20-year-old pa-
tient when arteriosclerosis is not
present. Even in persons having sig-
nificantly reduced cerebral flow,
powers of memory for distant events,
abstract reasoning, arithmetical and
intellectual skills, and appropriate-
ness of emotional response remain
largely intact. Cerebral tissue con-
tinues to metabolize actively regard-
less of reduced cerebral flow. Utili-
zation of oxygen (CMRO- ) was not
significantly reduced in subjects hav-
ing arteriosclerosis; only in institu-
tionalized senile psychotic patients
was the CMROj finally significantly
reduced. The findings of Dastur et
al" suggest that, with age, the pri-
mary change in the central nervous
system is a diminution of cerebral
circulation, after which there is a re-
duction of metabolic function ac-
companied by a decline in menta-
tion.
Although they might have a bene-
ficial effect in the chronically mal-
nourished elderly, routinely admin-
istered hormones and vitamins for
the treatment of senility in an ade-
quately nourished person have not
been demonstrably efficacious. Hor-
mone replacement therapy, indi-
cated in hypothyroidism or Addi-
son's disease, might result in the
return of the patient's general sys-
temic status to normal and there-
by contribute to an overall improve-
ment in his state of health. However.
specific hormones for reducing the
psychiatric symptoms of senility
have not proven effective. There is
little indication that megavita-
min therapy, which has been ineffec-
tive in the treatment of psychoses
in other age groups, would relieve
the symptoms of senility.'- How-
ever, a recent study of megavitamin
therapy by Altman et al'-' (1973)
produced significant results. Twelve
patients having chronic brain syn-
drome resulting from arteriosclerosis
demonstrated a dramatic and unex-
pected decrease in Excitement Scale
scores after treatment with the multi-
vitamin "Allbee with C"; they im-
proved sufficiently to be sent home.
The authors did not know why the
method was successful, but they pos-
tulated that the combination of vita-
mins might have had a potentiating
or additive effect.
Stimulant compounds (Table 1)
include amphetamine and its con-
geners, such as methylphenidate.
These agents sometimes are effica-
cious in the apathetic, hypoactive
senile patient, but they cannot be
recommended for long-term therapy
because of their pressor effects on
the fragile and partially decompen-
sated cardiovascular systems of the
elderly. Because they have a high
potential for causing dependency,
stimulants should be administered to
the elderly in low doses (5 to 10 mg
amphetamine per day) for a very
brief period (one to seven days).
The therapeutic value of the stimu-
lants appears to be quite limited, and
they certainly cannot rejuvenate
function of brain tissue lost through
the attrition of age.
Nootropic agents are a recently
established class. '^ These com-
pounds supposedly increase neu-
ronal cellular repair and intraneu-
ronal protein synthesis, thereby acti-
vating, protecting and restoring the
working of the impaired nerve cells
while improving the function of
healthy neurons. Their supposed
preferential activity is situated at the
cortical levels. Most reports of suc-
cessful clinical trials of these com-
pounds have been published in
Europe.
The most widely publicized and
tested "rejuvenating"" drug has been
Gerovital H;,, a specially formulated
673
i'
Nonproprietary Name
dextroamphetamine sulfate
methamphetamine hydrochloride
methylphenidate hydrochloride
pipradrol
Table 1
Stimulants
U.S. Trade Name
Dexedrine
Desoxyn. Methedrine
Ritalin
Meratran
Total Daily Dosage (mg)
Outpatient Hospital
(Range)
(Range)
15-30
30-60
2.5-5
15-30
10-30
30-60
2-4
4-10
prepuration of procaine hycJrochlo-
ride. According to reports of Anna
Asian of Rumania, who originated
the drug. H,; has "anabolic" and
general ""eutrophic" effects, revi-
talizes tissue, leads to a more acti\e
life for geriatric patients and restores
physical and intellectual ability.^''
Studies have shown H,; to be an ef-
fective monoamine oxidase inhibitor
which seems to have selective af-
finity for certain multiple forms of
MAO. Since depression in the aged
and the process of aging itself are
correlated with high MAO ac-
tivity,"' the beneficial results of the
preparation might be a result of its
inhibition of MAO. Other clinical
studies with H;; have demonstrated
a beneficial effect on skin tone and
turgor, stabilization of blood pres-
sure in hypertension, alleviation of
depression and psychotic symptoms,
and improvement in symptoms of
senility.'-' Using the precise clinical
regimen dictated by Dr. Asian.
Friedman'" (1964) prescribed
Gerovital H;; to twelve patients suf-
fering from chronic brain syndrome.
Four of these patients showed good
improvement, primarily in relief of
senile confusion; the remaining eight
patients showed mild to minimal im-
provement. With discontinuance of
therapy, the improved group re-
lapsed to pretreatment condition.
Reinstitution of therapy again yield-
ed impro\ement.
AFFECTIVE DISORDERS
Depression in the elderly is often
precipitated b\ disruptive personal
events such as physical illness, be-
reavement or retirement.'' '"" How-
ever, many elderly people have had
depressive episodes throughout life,
and the symptoms of senescence are
added to those of depression. As de-
pression increases, symptoms of sad-
ness and dejection, slowing of intel-
lectual processes, and psychomotor
retardation become more apparent.
Frequently, the patient complains of
loss of appetite, insomnia and in-
creased fatigability. ■■ If depression
is severe enough to cause memory
disturbance, it may be difficult to
differentiate between the depression
and a chronic organic state; or when
the condition leads to self-neglect
and disturbed behavior, or marked
retardation, it might be difficult to
differentiate between depression and
dementia.'" Not infrequently, mod-
erate to severe depression with mini-
mal organic brain disease may be
misdiagnosed as chronic brain syn-
drome associated with cerebral ar-
teriosclerosis or senile brain dis-
ease.' Generally, however, func-
tional depression appears abruptly,
whereas depression secondary to
brain damage tends to appear gradu-
ally, with mild, early symptoms, and
to fluctuate, usually disappearing as
the effects of brain disease become
more pronounced and dementia su-
persenes.''
Classical psychiatry taught that
affective disturbances were early
manifestations of impending senile
or arteriosclerotic psychosis.' Al-
though disorientation, memory kis
and impairment of intellectual furc
tion and judgment are considere
primary characteristics of organi
brain syndrome, the possibility c
other psychoses or neuroses shoul
not be excluded,'-' and treatmer
should be expeditiously instated.
Psychopharmacological treatmei
of patients having psychiatric illnes;
es is most often effective in the are
of the major depressions.-' Drii
therapy is essentially that used wit
younger patients, except that startin
doses should be lower and the p;
tient should be carefully monitore
for the occurrence of side effects.'
The drugs most commonly employe
in the treatment of depressia
are the tricyclic antidepressani
and monoamine oxidase inhibitor
(Table 2). The tricyclics includ
sedative and nonsedative agents,
former types being indicated for ag
tated. restless elderly people; the la
ter are used for retarded depressio
in which hypoactivity and hypomer
tation secondary to the affective dif
order are target problems. Thes
medications are most efficacious ii
mild to moderate depression, art
the long time lag (two to foi;
weeks ) in the onset of therapeuti
action of tricyclics can be a contn
indication when depression is ud
usually pronounced. Atropine-lik j
and antiadrenergic actions of trie;
clic antidepressants can produC
unpleasant and dangerous side ef
feets in the elderly.-'
A recent study by Libow- ( 1973
confirn-ied a pre\ious report b
Table 2
Antidepressant Drugs
(Mood Active Agents; Mocd Elevators)
;■
Total Daily Dosage (mg X'
Nonproprietary Name
Tricyclic Derivatives:
amitnptyline hydrochloride
desipramine hydrochloride
imipramine hydrochloride
nortriptyline hydrochloride
protriptyline hydrochloride
Hydrazide MAO Inhibitors;
isocarboxazid
nialamide
phenelzine sulfate
Non-Hydrazide MAO Inhibitors:
tranylcypromine sulfate
U.S. Trade Name
Elavil
Norpramin.
Tofranil
Aventyl
Vivactil
Marplan
N iamid
Nardil
Pertofrane
Outpatient
Hospita
(Range)
(Range;
50-150
74-225
75-150
75-200
50-150
75-225
20-100
40-100
10-40
15-60
10-30
10-50 :
25-75
100-450
15-30
15-75
674
Vol. .^.'^. No.
ijtreese et al-- regarding enhancement
fi antidepressant action by adding
riiodothyronine (T;;) to a daily tricy-
clic dose. The mechanism of action
lay be in an increase in the level
if biogenic amines in the central
scrvous system. A decrease in thy-
jid hormone leads to an increase
j|i MAO in the brain. This is postu-
jited to be related to depression
jnce a decrease in MAO is antide-
pressant. Thus, the administration of
jiyroid may inhibit MAO and lead
j) an increase of biogenic amines in
,3e central nervous system. -
1 Monoamine oxidase inhibitors are
aed less frequently because they po-
[(intiate pressor amines and are in-
ierently toxic.--' These agents also
iptentiate the action of numerous
nrelated drugs (anesthetics, bar-
biturates, adrenal corticosteroids,
mglion-blocking agents, morphine,
sropine, and 4-amino-quinoline
iDmpounds); diuretics potentiate
e antidepressive and hypotensive
sfects of MAO inhibitors.-' How-
fer, Nies et al"' have shown an age-
flated increase in brain monoamine
iddase enzyme levels, indicating
S)ssibly the efficacious application
I MAO inhibitors in cases of geria-
(ic depression.
if Stimulant compounds (Table 1 )
live also been tried as antidepres-
Ints. However, their beneficial ef-
icts upon the patient's mood offset
i(pidly, they have potent pressor
fects, and there is a high risk of
patient's developing drug toler-
jce or dependency. The effective-
iss of the stimulants in the elderly
iquestionable, and although stimu-
Qts may be of adjunctive value
1th other agents, they are not rec-
imended for use as antidepres-
tits. When depression imposed
>on senility has reached psychotic
pportions, electroconvulsive ther-
ily might be indicated.-^
Delirium, or acute confusional
""te, usually occurs during the
jurse of chronic brain syndrome."
ji)wever. acute and potentially re-
^'sible mental change occurs fre-
iently among the elderly and is
|en misdiagnosed or overlooked. '-'
■■is often difficult to differentiate
E':se transient confusional states
im those associated with senile or
^VFMBER 1974, NCMJ
r
arteriosclerotic psychosis." Acute
confusional states are nearly always
associated with physical illness or
drug intoxication; antiparkinson
agents, tricyclics, digitalis and
phenobarbitone are especially liable
to cause delirium. The patient usu-
ally has a history of sudden onset of
mental impairment and recent medi-
cal or surgical illness or change in
drug therapy. Complaints of in-
creased restlessness, toward the end
of the day or at night, and visual
perceptual disturbances are com-
mon.'^
PSYCHOSIS
Late paraphrenia is a form of
schizophrenia, occurring late in life,
in which the patient exhibits a sys-
tem of well-organized paranoid delu-
sions, accompanied by an intact per-
sonality.' Factors which tend to
contribute to the development of
paranoid reactions at any age (social
isolation, solitary living, general in-
security, and sensory defects, par-
ticularly visual and hearing loss)
tend to be more frequent in old
age.-" However, senile degeneration
or cerebral arteriosclerosis, when
it occurs in a person with a
pronounced "schizoid" disposition,
might result in late paraphrenia."
Unless the paranoid reaction is a
component of depression, antipsy-
chotic medications are preferable.
Antipsychotic agents (Table 3)
include the phenothiazines, thioxan-
thenes, butyrophenones, rauwolfia
alkaloids, and the lithium ion.
The most commonly used are the
phenothiazines. Phenothiazines are
prescribed for the agitated, delu-
sional, hallucinating senile patient
and they are often effective in re-
ducing the symptomatic intensity of
a core psychotic process. Com-
mon dose ranges of chlorpromazine
(Thorazine-), the principal pheno-
thiazine, are 200 to 800 mg per day.
In a recent study, thiothixene, a
thioxanthene, produced notable im-
provement in psychiatrists' and
nurses' rating scales and global as-
sessment of 26 patients having senile
or arteriosclerotic psychosis. Side ef-
fects did not interfere with treat-
ment.--'' However, the patient who
is over 65 years of age has a greatly
reduced ability to metabolize, and
hence to tolerate the antipsychotic
medications. The physician should
initiate therapy at lower doses than
he would ordinarily prescribe for
a younger patient, and he should
be particularly alert to the inci-
dence of side effects, especially
those associated with the atropine-
Table 3
Antipsychotic Agents
(Neuroleptics; Major Tranquilizers)
Nonproprietary Name
Phenothiazines — classified by
side chain:
Aliphatic:
U.S. Trade Name
Total Daily Dosage (mg)
Outpatient Hospital
(Range) (Range)
chlorpromazine
triflupromazine hydrochloride
Thorazine
Vesprin
Piperidine:
thioridazine
Mellaril
mesoridazine
Serentil
Piperazine:
acetophenazine maleate
Tindal
carphenazine
Proketazine
prochlorperazine
Compazine
thiopropazate dihydrochlonde
Dartal
perphenazine
Trilafon
trifluoperazine
Stelazine
fluphenazine hydrochloride
Prolixin, Permitil
butaperazine maleate
Repoise
piperacetazine
Quide
Butyrophenones:
haloperidol
Haldol
Thioxanthene Derivatives:
chlorprothixene
Taractan
thiothixene
Navane
50-400
50-150
200-1,600
75-200
50-400
200-800
25-200
50-400
40-60
60-80
25-100
50-400
15-60
30-150
10-30
30-150
8-24
12-64
4-10
6-30
1-3
2-20
10-30
10-100
10-40
20-160
30-60
6-15
4-15
75-600
10-60
675
like and antiadrencrgic properties of
these agents. Possible side effects in-
clude dry mouth, urinary retention,
constipation, nasal congestion, ag-
gravation of glaucoma, drowsiness,
lethargy, hypotension and extrapyr-
amidal symptoms.' Because geria-
tric patients have a special sus-
ceptibility to phenothiazine-induced
states of confusion and delirium,
these states can be mistaken by the
physician for an increase in the in-
tensity of psychiatric symptoms; as a
result, the physician might increase
the dosage of the offending agent.
ANXIETY RE.ACTIONS
Intellectual and emotional mal-
functioning of senescence contrib-
utes to emotional problems. The el-
derly must adapt to new and essen-
tially unfavorable life circumstances
at a time when their ability to adapt
is greatly diminished. .Additionally,
old age can bring out latent neurotic
conditions, or it might aggravate ex-
isting neuroses.'' Anxiety is common
in the elderly.
Antianxiety agents (Table 4) can
be sedatives, muscle relaxants or
anticonvulsants. The group includes
a broad range of chemically hetero-
geneous compounds which have
similar clinical effects. Ethanol,
barbiturates, meprobamate, the ben-
zodiazepines such as chlordiazepox-
ide, diazepam, oxazepam, and even
paraldehyde and hydroxazine, are all
classed as anxiolytics. These clinic-
ally effective compounds are indi-
cated for allaying anxiety and reduc-
ing its unpleasant somatic com-
ponents. Chlordiazepoxide ( Lib-
rium's^), because it is comparatively
safe, is generally recommended for
treatment of anxiety in the elderly,
although idiosyncratic adverse re-
sponses are possible. The elderly can
develop dependency upon antianxi-
ety agents, and side effects such as
glaucoma are associated with some
of the compounds. Withdrawal
symptoms, after treatment with pro-
longed heavy dosages of these
agents, can be mistaken for the on-
set of psychosis in elderly patient;
such a misconception can be particu-
larly damaging.
Rauwolfia alkaloids appear to be
of some value in treating s\niptoms
of anxiety, agitation and inappro-
676
Table 4
Antianxiety Drugs
(Minor Tranquilizers)
Total Daily Dosage (mg)
Nonproprietary Name
U.S. Trade Name
(divided into 2-4 doses)
Glycerol Derivatives:
meprobamate
Equanil, Miltown
800-3,200
phenaglycodol
Ultran. Acalo
600-1.200
tybamate
Solacen. Tybatran
750-3,000
Benzodiazepine Derivatives;
chlordiazepoxide hydroctiloride
Librium
15-300
diazepam
Va 1 1 u m
5-60
oxazepam
Serax
30-120
Diphenylmethane Derivatives:
hydroxyzine hydrochloride
Atarax, Vistaril
75-400
Barbiturates:
phenobarbital
30-300
priate aggressiveness in the elderly;
these antianxiety agents are particu-
larly useful when a lowering of blood
pressure or pulse rate is desirable.
However, when taken orally, there is
a delay in onset of action; occasion-
ally an initial period of excitement
precedes improvement; the convul-
sive threshold is lowered; there is a
possibility of gastrointestinal bleed-
ing; and the increased gastrointesti-
nal activity may be detrimental to
patients with peptic ulcer and ulcera-
tive colitis. ■■
SUMMARY
A predisposition toward the diag-
nosis of senility in psychiatrically
compromised geriatric patients may
prejudice accurate assessment and
treatment within this population.
Geriatrics may present with the en-
tire range of psychopathological
symptoms, in either the absence or
presence of actual senile symp-
tomatology. Vasodilators have been
used in the pharmacological treat-
ment of the senile disease processes,
but no positive results have been
published to date. The anticoagu-
lants, bishydroxycoumarin and war-
farin, are reported to have been suc-
cessful in mitigating some senile
symptoms when patients were diag-
nosed soon after onset of the patho-
logical condition. Memory and con-
ceptualization in the senile were re-
ported to be improved by intermit-
tently using hyperbaric oxygenation.
Hormones and vitamins are not gen-
erally efficacious in the treatment of
senility, although one investigator
has obtained positive results in some
parameters with megavitamin thera
py.' • Stimulant compounds have
not effectively mitigated senile
symptomatology. Nootropic agents,
a recently established class, and re-
juvenators, such as Gerovital H
which bears resemblances to the
MAO inhibitors, are currently un
dergoing trial, with some prelimi
nary reports registering positive re
suits in alleviating senile confusion.
Thiothixene, a major tranquilizer of
the thioxanthene class, is reported to
have brought about notable im-
provement in patients with senile or
arteriosclerotic psychosis.
Affective disorders occurring in
the elderly can accompany senes
cence and might be mistaken for a
nonexistent senile state. Depressions
in the aged are most commonly
treated with tricyclic antidepressants,
monoamine oxidase inhibitors, and,
when psychosis is apparent, with
electroconvulsive therapy. Delirium
and paraphrenia frequently accom-
pany chronic brain syndromes.
Delirium is usually secondary to
illness, or it is drug induced and
should be treated accordingly. In
cases of paraphrenia, antipsychotic
medication is of benefit unless con-
traindicated. Since geriatric patients
are particularly susceptible to the
possible side effects of these drugs,
the antipsychotic medication should
be administered only when profes-
sional observation or consultation
can be arranged. Anxiety concomi-
tant to senility can be treated with,
the usual battery of anxiolytics,!
of which chlordiazepoxide (Lib-
VoL. .vs. No. II
im®) is generally the safest effcc-
e agent. Dependency upon anti-
xiety agents by the elderly is pos-
)le and should be guarded against.
^^Psychotropic agents can be use-
in treating the senile patient, but
ministration of these compounds
•1st be modified to accommodate
; reduced abilities of the elderly
imetabolize and withstand the side
I'ects.
Acknowledgment
iupported in part by V. A. Grant 2600.
References
^Alexander DA: "Senile demcniia": A chanji-
Ting perspective. Br J Psychiatry 121 : 207-214.
'1972.
^Libow LS: Pseudo-senility: Acute and re-
.(Versible organic brain syndromes. J Am
•tGeriatr Soc 21: 112-120. 197.1.
|!Lifshitz K.. Kline N: Psychopharmacology ot
■the aged, in Freeman JT (ed): Clinical Prin-
TlfCipIes and Drugs in the Aging. American
Geriatrics and Gerontology Series. .Spring-
field. Illinois; Charles C Thomas. 1963, pp
421-457.
l.owenthal MF: Lives in Distress: The Paths
1
of the Elderlv to the Psychiatric Ward. New
York: Basic Books Inc. 1964.
5. Busstr EW: Brain syndromes associated with
disturbances in metabolism, j^rowth, and nu-
trition, in Frcedman AM, Kaplan HI (eds):
Comprehensive Textbook of Psvchiatr\. Balti-
more: Williams and Wilkms, 1967. pp 726-
740.
6. Bromley DB: The Psychology of Human
Apeinj:. Baltimore: Penguin Books Inc. 1966.
pp 67*7S. 127-14S, passim.
7. Kalner J, Kosenbtrp G. Krai VA. Enpels-
mann F: Anticoagulant therapy for senile
dementia. J Am Genatr Soc 20: 556-5^9.
1972.
S. Nickcrson M : Vasodilator drugs, in Good-
man I,. Gilman A (eds): The Pharmacologi-
cal Basis of Therapeutics. New >'ork: Mac-
millan, 1970, pp 736-75.V
9. Walsh AC, cited in Alexander'.
10. Jacobs et al, cited in Alexander'.
11. Dastur et al. cited in Libow-.
12. Whanger AD: Vitamins and vigor at 65 plus.
Postgrad Med 53: 167-172, 1973.
13. Altman H. Mehta D. Evenson R. Sletten I:
Behavioral effects of drug therapy on psy-
chogenatric inpatients. II. Multivitamin sup-
plement. J Am Geriatr Soc 21 : 249-252. 1973.
14. Abuzzahab FS Sr. Merwin GE. Sherman
MC: A controlled investigation of piracetam
versus placebo on the memorv of geriatric
patients. Pharmacologist 15: 237. 1973. (Ab-
stract).
15. MacFarlane MD: Possible rationale for
procaine { Gerovital Ha ) therapy in geriat-
rics: Inhibition of monoamine oxidase. J Am
Geriatr Soc 21: 414-418, 1973.
16. Nies A. Robinson D. Davis JM, Ravaris L:
Changes in monoamine oxidase with aging.
in Eisdorfer C, Fann WE (eds) : Psycho-
pharmacology and Aginp. New York ;
Plenum Press, 1973. pp 41-53.
17. Friedman OL: An investigation of Gerovital
Ha (procaine hydrochloride) in treatment of
organic brain syndrome. Excerpta Medica 7:
(No, 572) 159. 1964.
lf<. 'I'oung JPR : Acute psychiatric disturbances
in the elderlv and their treatment. Br J Clin
Pract 26: 513-516. 1972.
19. Wang HS: Organic brain syndromes, in
Bussc E, Pfeiffer E (eds): Behavior and
Adaptation in Late Life. Boston: Little.
Brown and Co.. 1969. pp 263-2K7.
20. Busse EW, Pfeiffer E: Functional psychiatric
disorders in old age, in Bussc EW. Pfeiffer E
(eds ) : Behavior and Adaptation in Late
Life, Boston: Little. Brown and Co, 1969.
pp 1S3-235.
21. Davis JM. Fann WE. EI-Yousef MK, Janow-
sky DS: Clinical problems in treating the
aged with psychotropic drugs, in Eisdorfer C .
Fann WE (eds) : Psychopharmacolog> and
Aging. Advances in Behavioral Biology Se-
ries. Vol 6. New "^'ork: Plenum Press, 1973.
pp 111-125.
22. Breese GRT. Traylor D, Prange AJ : The
effect of triiodothyronine on the disposition
and actions of imipraminc. Psvchopharma-
cologia 25: 101-111, 1972.
23. Prange AJ Jr : Use of antidepressant drugs
in the elderly patient, in Eisdorfer C, Fann
WE (eds). Psychopharmacology and Aging.
Advances in Behavioral Biology Series,
Vol 6. New York: Plenum Press. 1973.
24. W ilson WP. Major LF: Elect roshock and
the aged patient, in Eisdorfer C, Fann WE
(eds) . Psychopharmacology and Aging. Ad-
vances in Behavioral Biology Scries, Vol 6.
New York: Plenum Press, 1973. pp 239-244.
25. Birkett DP. Hirschfield W. Simpson GM:
Thiothixene in the treatment of diseases of
the senium. Curr Ther Res 14: 775-779, 1972.
1
It has been thought possible to find a more e.\act criterion in the pulsation of the heart. The
cor idt'unum moriens has been regarded as the rule since the time of Galen; physiologists have
agreed upon it. In their laboratories stoppage of the heart is looked on as the end of life: as
soon as the heart of an animal that is being experimented upon ceases to beat, physiologists
admit that the animal is dead.
Can we accept this criterion in forensic medicine? I do not think so. In certain medico-legal
cases, the value of the sign may be disputed; the judge may ask you to say at what precise
moment death took place, and that for several reasons. — Death and Sudden Death. F. Brouardel.
1897. p. 18.
iSMBfR 1^74. NCMJ
677
The Preoperative Localization of Hyperfunction-
ing Parathyroid Tissue Utilizing Parathyroid
Hormone Radioimmunoassay of Plasma From
Selectively Catheterized Thyroid Veins
Samuel A. Wells, Jr., M.D., Irwin S. Johnsrude, M.D.,
George J. Ellis, M.D., John P. Bilezikian. M.D.*,
Charles Johnson, M.D., VVilliam P.J. Peete, M.D.,
and Harry T. McPherson, M.D.
/^VER the past several months
^-^ we have studied ten hyperpara-
thyroid patients preoperativeiy. at-
tempting to locahze their lesions by
measuring parathyroid hormone
(PTH) in plasma from selectively
catheterized thyroid veins. In two
patients, selective superior and in-
ferior thyroid arteriography was also
performed.
This described technique is spe-
cific in that it gives an objective
measurement of parathyroid hyper-
secretion. By contrast, the previous-
ly reported localization methods
such as "'selenomethionine scan-
ning,' thermography,'- arteriogra-
phy,'' venography^ and cine-esophag-
ography' are nonspecific in that both
parathyroid and thyroid lesions give
positive results. Furthermore, these
latter methods usually detect only
the large parathyroid neoplasms
which would have been relaiively
easy to identify at surgery without
localization aids.
MATERIALS AND METHODS
Patient population: Nine patients
with primary hyperparathyroidism
From the l^epjrlnients ol Surjicr>, McdiLinc.
;ind Rjdn^ln^:s. Duke L'Tlivcrsiu Medit.il Center.
Durh.im. North Curolin.i 27710,
' Present .iddress: i:)epartment ot Medicine,
CoIlej:e of Phssieuins .ind Surgeons, (."olumbi.i
University. New 'I'ork. New '^ ork
Reprint requests to l^r. Wells. I>ep.trtnient of
Suryer.v. Duke University MeUic.il C enter, Dur-
hain. North Carohna 2771(1,
and one patient with tertiary hyper-
parathyroidism were admitted to the
inpatient service of the Department
of Medicine or Surgery at the Duke
University Medical Center or the
Durham Veterans Administration
Hospital. There were five men and
five women ranging in age from 39
to 67 years. Six of the ten patients
had undergone prior surgical ex-
ploration for hyperparathyroidism,
and the lesion(s) had been either
missed or incompletely resected. The
diagnosis of primary hyperparathy-
roidism was established in each pa-
tient by clinical, biochemical, and
in some cases, radiological criteria.
The patients are listed in Table 1.
Venous catheterization procedure
All ten patients underwent selec-
tive venous catheterization as de-
scribed previously.'' " Under local
anesthesia the Muller guided cathe-
ter (U.S. Catheter and Instrument
Corporation ) was introduced percu-
taneously into a femoral vein. A 100
cm flexible guide wire attached to an
external handle which allowed de-
flection and rotation of the catheter
tip was guided with the aid of image-
itensified fluoroscopy. The anatomy
of the thyroid venous bed was out-
lined by serial films during retro-
grade injection of contrast material
L'C
into a thyroid vein. Heparinlzq
blood samples were obtained froi
the thvroid veins, the large nee
veins and from the hepatic, ran;
and iliac veins. The position of tl
catheter tip was recorded on a spfl
roentgenogram for each sample tal"
en (Figure 1). The blood samph
were chilled, and the plasma w;
separated and frozen at —20 '
until PTH radioimmunoassay \ .
performed. The sampling procedui
usually took from one and one-ha
to two hours, and the patients w^^i
ambulatory within three hours theri
after.
Arteriography
Two patients underwent bilaten
selective thyroid arteriography. Ur|
der local anesthesia, the catheter wi
introduced percutaneously into f
femoral artery. Contrast materii
was injected into the inferior an
superior thyroid arteries. Resul
were evaluated by direct roentgenc
grams after bony and soft tissi
shadows were neutralized by sul
traction. A lesion was interprctc
to be significant if it appeared as v.
area of persistent staining with >i
significant uptake on thyroid sen
The two patients remained supir^
for six to eight hours after comphlii
67X
Vol . 3.";, No.
J-
ttient
Sex Age
1
M 57
2
F 59
M 65
M 58
! 5
F 58
\6
F 39
\7
F 67
\a
M 49
i9
M 47
no
F 59
I3L — Mean background level of parathyroid hormone
;i.T. — Right inferior thyroid
I.T. = Common inferior thyroid
i.T.= Left inferior thyroid
l,\fl.T. = Right middle thyroid
,>.T. = Right superior thyroid
JJ.^Right internal jugular
Table 1
Ca
(mg dl)
PO4
(mg dl)
MBL*
(ng/ml)
Veins with
Elevated PTH
Location of
Lesion
Histology
Lesion
12.9
2.4
1.3
R.I.T.
Right inferior
Adenoma
11.0
3.4
1.5
C.I.T.
L.I.T.
Left superior
Adenoma
11.7
1.7
2.0
R.M.T.
R.I.T.
Right inferior
Adenoma
11.7
3.4
3.0
R.I.T.
R.S.T.
Right inferior
Adenoma
11.5
2.9
2.0
R.I.T.
Right inferior
Adenoma
11.1
3.5
0.4
None
Not explored
—
13.0
2.5
3.6
R.M.T.
L.I.T.
Right paratracheal
area
Adenoma
11.3
2.6
1.0
None
Mediastinum
Adenoma
11.0
2.7
0.4
L.I.T.
Not explored
—
11.0
3.0
0.6
C.I.T.
R.I.J.
Right superior
Adenoma
ii of the procedure,
lions occurreci.
No compli-
I rathyroid hormone radioimmuno-
i ay
"Parathyroid hormone was deter-
r led by radioimmunoassay as
p viously reported."^ '-''I-bovine
parathyroid hormone was prepared,
and either pure bovine or a partially
purified preparation from human
glands was used as standard. The
normal range for fasting adults is 0.3
to 0.8 ng/ml (human standard).
Samples were processed at one or
more dilutions in quadruplicate.
I lA. The catheter is placed in the
superior thyroid vein. The contrast
irial outlines the right side of the
')id venous plexus. (RIJ=:Right in-
ijijil jugular vein, RST:=Right superior
,iid vein, RIT^Right inferior thyroid
CIT=Coninion inferior thvroid
Fig. IB. The catheter is placed in the left
inferior thyroid vein and contrast ma-
terial outlines the left side of the thyroid
venous plexus. (CIT=:Coninion inferior
thyroid vein, LIT=Left inferior thyroid
vein, RIT:=Right inferior thyroid vein).
The mean background level of
PTH (MBL) represents the average
concentration in plasma samples
taken from three separate peripheral
veins below the diaphragm. The con-
centration of hormone greater than
twice the mean background level in
a particular vein was considered ab-
normal and indicative of parathy-
roid hyperactivity.
Surgery
Definitive surgery was performed
by members of the Department of
Surgery at Duke University Medical
Center and the Durham Veterans
Administration Hospital. Patients
were explored through a cervical in-
cision; in one patient, mediastinal
exploration was necessary.
RESULTS
Radioimmunoassay of PTH in
venous samples
In seven of the ten hyperparathy-
roid patients the mean background
level of PTH was above the normal
range. In seven patients unilateral
elevations of parathyroid hormone
were detected and bilateral eleva-
tions were detectd in one patient. In
two patients levels of PTH in the
small thyroid veins and large neck
veins did not differ appreciably from
the mean background level.
Arteriography
Two patients in this series (3 and
? ) had selective thyroid arteriogra-
N MBiR 1974, NCMJ
f.79
ii
phy performed prior to venous
catheterization. In both of these pa-
tients a parathyroid stain was dem-
onstrated arteriographicaliy. Great
caution must be exercised in per-
forming arteriography in this ana-
tomical region. Extravascular dissec-
tion of the contrast media, arterial
occlusion and inadvertent vertebral
artery injection, although infrequent,
can lead to severe neurological se-
quelae.
Surgical findings
Eight of the ten patients under-
went surgical exploration, and in
each a single parathyroid neoplasm
was found. Both sides of the neck
were explored in each patient, and
in six (75 percent) the side of the
neck harboring the parathyroid le-
sion had been correctly predicted
preoperatively (Table I ). In all
three patients who had not been pre-
viously explored (1, 2, and 5) the
parathyroid lesion was correctly lo-
calized by elevated PTH levels. In
patient 5 a parathyroid lesion was
also identified by arteriography. A
representative venogram with PTH
data from one of these patients (2)
is shown in Figure 2.
Five of the ten patients (3, 4, 7,
8, and 10) had been previously ex-
plored for hyperparathyroidism, and
in three the lesions were correctly
localized preoperatively by our stud-
ies. In one of these patients (3)
arteriography was performed prior
to venous catheterization. The ar-
teriogram which demonstrated an
adenoma and the venous catheteri-
zation data which confirmed locali-
zation are shown in Figure 3. In pa-
tient 8 no elevated level of PTH was
detected in the selectively sampled
thyroid veins or the large neck veins.
At reexploration the absence of a
cervical lesion was confirmed; dur-
ing mediastinal exploration a para-
thyroid adenoma was found embed-
ded within the thymus gland. In pa-
tient 7 bilateral elevations of PTH
were present, but only a unilateral
parathyroid neoplasm was found in
the right paratrachcal area at sur-
gery.
Postoperatively, all patients un-
dergoing surgery experienced a de-
crease in the serum calcium concen-
Fig. 2.\. N'enogram of patient 2 deni-
onstratinf; tli>roid \enoiis plexus.
s.w.
MBL = I 6ng / ml
L Superior Adenomo
Fig. 2B. PTH data from patient 2. (LIT=
Left inferior thyroid vein, CIT^Com-
mon inferior thjroid vein. RIT^Right
inferior thyroid vein. Ll^I.eft innomi-
nate vein. LI J^ Left internal jugular
vein. LMT^Left middle thyroid vein.
R.AJ^ Right anterior jugular vein).
u:;
Eli
tration, and none has develop^
recurrent hypercalcemia.
Of the two patients not yet el
plored, one (6) had no detectab|
elevation of PTH in the neck vein
Previously this patient had a thr|
and one-half gland parathyroide
tomy for renal osteodystrophy, ar
she has subsequently maintained I
mild hypercalcemia. She probabj
has a persistent autonomous hype
functioning glandular remnant. Tl]
other unexplored patient (9) hi
hypercalcemia and an elevated lev!
of PTH in the left inferior thyroj
vein.
DISCUSSION
Doppman and Hammond'-' fi
predicted that PTH measurement
plasma from selectively cathetcrize
thyroid veins might be helpfu
localizing parathyroid neoplasm ii
They demonstrated by arteric
graphic studies that, after inje(
tion of a single inferior thyroid ai "
tery, the venous drainage was ips
lateral by way of the inferior thyroj
vein in 17 of 20 cases. The classi
studies of Halsted and Evans'" ha
shown that the inferior parathyroi '^'^
glands nearly always received the:
blood supply from the inferior thj ^"i
roid artery and the superior par^ ^1
thyroid glands either directly froi
this artery or from its ascenc
ing anastomotic ramus. Doppmar
therefore, concluded that the inferic "^^t
thyroid vein should drain the efflv-
ent of the ipsilateral inferior an
superior parathyroid glands. Thi
postulation has subsequently pro\e
to be correct. Bilczikian and assc'
ciates." in a recent review of th
cumulative experience with this tecb
nique, at four centers, have showpJ
that parathyroid neoplasms can hcW'
be localized if PTH levels are ddfe
termined in plasma from each in -
ferior thyroid vein. Even with su -..
perior parathyroid lesions wherllllie
multiple veins are sampled, the highlii.-
est level of parathyroid horomoiUlfai
is nearly always detected in the \plR.\
silateral inferior thyroid vein. On'"
should thus speak of lateraliziiiE
rather than localizing, parathyroii
neoplasms since, with a unilatera
elevation in plasma PTH. one canno|i!::-
distinguish whether the inferior. thijlE
superior, or. indeed, both parath#^j
680
Vol. 3.^. No. iP*
g, 3A. Right inferior thyroid arterio-
am (late phase) in patient 3. The cathe-
is in the right inferior thyroid artery.
right inferior parathyroid adenoma
iree short arrows) is demonstrated be-
rv the right thyroid lobe. The upper long
irow denotes the course of the right
ddle thyroid vein; the lower long ar-
tv overlies the right inferior thyroid
in.
■fid glands are hypcrfunctional.
jIn the catheterization data from
jitient 2 (Figure 2), the level of
TH in the right inferior thyroid
fin is the same as the MBL, where-
the level in the left inferior thy-
ifid vein is much higher. This infor-
(ition strongly suggests the pres-
|ce of a left-sided parathyroid
enoma. In Bilezikian's study," it
.s found that of 49 patients having
jlilateral elevations in PTH, 47 (95
jTcent) had parathyroid adenomas.
DHversely, of 20 patients having
lateral elevations in PTH, 17 (85
^(Tcent) had bilateral parathyroid
ooplasms.
HS
iFigure 2 shows that the level of
I'M in the left inferior thyroid vein
jimuch higher than the PTH level
the large neck veins. Contrary
f earlier reports,'- '■' PTH mea-
•ement in the large neck veins is
ely as helpful as PTH measure-
nt in the small thyroid
jins'^' '•"'; presumably this is be-
■ise of the great dilution that oc-
ks between the thyroid venous bed
1 the large neck veins. This is not
(■say that large neck veins should
be sampled, for occasionally
MBL= I 8 ng /ml
R Inf Adenoma
Fig. 3B. Depicts PTH levels in selectively
catheterized thyroid veins of patient 3.
(RMT=Right "middle thyroid vein, RIT
^ Right inferior thyroid vein, LIT^Left
inferior thyroid vein, LI=Left innomi-
nate vein, RIJ^Right internal jugular
vein, SVC^Superior vena cava).
they give unique information, as
demonstrated in patient 10 (Table
1 ). She was the only patient in our
series in whom the PTH level in a
large vein (right internal jugular)
was higher than that in any thyroid
vein, and this sample was critical for
lateralizing her lesion.
This technique affords a great de-
gree of accuracy in lateralizing para-
thyroid lesions preoperatively in
those patients who have not been
previously explored, being success-
ful in 45 of 54 patients (86 percent)
in Bilezikian's series" and in all
three of the patients in our present
study. It is this group of people,
however, in whom this localization
technique is least indicated. One
would expect an experienced para-
thyroid surgeon to find the lesion (s)
at the initial exploration.
In the hyperparathyroid patient
who has been unsuccessfully ex-
plored previously, the reoperation is
technically more difficult, primarily
because scarring encumbers the sur-
geon's effort to preserve the recur-
rent laryngeal nerve and the normal
parathyroid glands. In this group of
patients, however, one encounters
the greatest difficulty in catheterizing
the small thyroid veins, since they
are commonly ligated during prior
surgery. Indeed, in our five reopera-
tive patients selective venous cathe-
terization data were of localizing
value in only three. In a previous
study of 15 patients undergoing re-
exploration for hyperparathyroid-
ism. Wells and associates"' found
that it was especially helpful to per-
form selective superior and inferior
thyroid arteriography prior to per-
forming venous catheterization for
PTH determination. Not only were
capillary stains, demonstrative of
parathyroid lesions, occasionally
seen, but more importantly venous
drainage patterns were located, fa-
cilitating subsequent selective cathe-
terization and PTH determination.
Of 1 1 patients undergoing arteri-
ography, seven (66 percent) had
parathyroid lesions which demon-
strated vascular stains. Of 15 pa-
tients undergoing selective venous
catheterization and subsequent para-
thyroid hormone determination, 12
(80 percent) had their lesions lo-
calized. Of 1 1 patients undergoing
both selective thyroid arteriography
and venous catheterization, ten (90
percent) had their lesions localized.
It is our current policy not to use
selective venous catheterization in
patients with hyperparathyroidism
who have not been previously ex-
plored. Rather, the technique is re-
served for those patients who are un-
dergoing reexploration for hyper-
parathyroidism, and then it is used
in combination with selective su-
perior and inferior thyroid arteriog-
raphy.
We feel that this localization tech-
nique has great utility in selected pa-
tients and that it is the most accu-
rate and specific method of localiz-
ing parathyroid lesions preopera-
tively. Although the availability of
the technique is currently limited, it
is likely to assume wider usage in the
future.
References
I. Potchen EJ. Walts HG, Awwad HK: Para-
th\roid scintiscanning. Radiol Clin North
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:. Samuels BI, Dowdy AH, Lecky JW: Para-
thyroid thermotzraphv. Radiology 104; 575-
578, 1972.
3. Doppman JL. Hammond WG, Melson GL,
Evens RG, Ketcham AS: Stainmg of para-
thyroid adenomas bv selective .irteriographv.
Radiology 92: 527-5.10, 1969.
4. Shimkin PM. Doppman JL, Powell D. Mar.\
JS, Ketcham AS: Demonstration of paralhy-
[.fVEMBtR 1974, NCMJ
681
roid adenomas b\ rctro>;rade ih\roid \enoji-
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Stevens AC. Jackson CE: Localizalion ot*
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Doppman JL. Wells SA. Shimkm PM, Pear-
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Doppman JL. Hammond WG: The anatomic
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Halsted WS. Evans HM: The parathyroid
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Bilezikian JP, Doppman JL. Shimkin PM.
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Reitz RE, Pollard JJ. Wang CA, Fleischli
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O'Riordan JLH. Kendall BE, Woodhead JS:
Preoperative localization of parathvroid tu-
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14. Powell D. Shimkm PM. Doppman JL, We
SA. Aurbach GD. et al: Primary hyp-.-r
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15, Wells SA, Ketcham AS, Marx SJ. Powell D
Bilezikian JP, et al: Preoperative localiza
tion of hypverfunctioning parathyroid tissue
Radioimmunoassay of parathyroid hormone
in plasma from selectively cathelerized th
roid veins. Ann Surg 177: 93-98. 1973.
16 Wells SA. Doppman JL. Bilezikian JP
Shimkin PM. et al: :Repeated neck explora
tion in primary hyperparath>roidism; Locali
zation of abnormal glands by selective thy
roid arteriography, selective venous samplinj
and radioimmunoassav . Surgerv 74: 678-686
1973.
. . . Drs, Ret;nard and Paul Love had been present at an execution at Troyes; they even
rode in the van which carried the body from the scaffold. One hour after the execution the
heart still beat; \et this man"s existence was over; he had lost his personality, and yet his heart
was beating! Well, to us and to everyone a decapitated person is a dead man. although his
heart does continue to contract! — Dcafh and Sudden Dcatli. P. Brouardcl. 1897, p. 20.
m
]
Hi
I'd
h
Eil
Ml
p\
682
Vol. 35. No. 11
'Bli
Editorials
\ THE FALL 1974 EXECUTIVE COUNCIL
MEETING
Dr. Wingate Johnson, in his first editorial com-
mting on the role of the North Carolina Medi-
,L Journal, noted that the Journal was "a newly
rn infant" and that "its features may change greatly
dt reaches adolescence and maturity." Dr. Robert
;Lchard, 24 years later, when he became editor,
served that the prognosis of the Journal as, to
|ote Dr. Johnson, "a medium for North Carolina
ttors to use in exchanging ideas" was good because
!; changes in medicine demanded adequate means
the dissemination of information. The Journal,
w aged 35, has reached a hardy, but not overripe,
T turity by trying to identify its constituency, physi-
( n and patient, and to serve as well as possible
i a world of rapidly changing expectations brought
tout by equally rapid changes in medical knowledge
< i means.
That the North Carolina Medical Society has been
i rt to these changes and to its increasing responsi-
l ties in such a world can be confirmed by the
iiiual fall meeting of the Executive Council, with
losident Frank R. Reynolds presiding. After Mr.
I maid L. Clifford of the St. Paul Insurance Com-
f ly presented actuarial data relating to a proposed
i percent rate increase in professional liability in-
s ance. the Council voted unanimously to approve
t ; proposal as recommended by the Committee on
Il)fessional Insurance; the Council also voted to so
i; orm the State Commissioner of Insurance, Mr.
I ram, who must approve the increase. Even with
t increase. North Carolina would still have the fifth
I 'est state rates in the nation.
\ statement of the Society's financial status was
a Drded by the report of the Committee on Finance,
p sented by its chairman. Dr. T. Tilghman Herring.
Fihaps the most important of the detailed items
c sidered and approved was the establishment of an
0 rating reserve fund. The chairman of the Pro-
fi ional Service Committee, Dr. Bernard Wansker,
a Dr. David S. Johnston, immediate past-chair-
n 1 of its Blue Shield subcommittee, then discussed
p posals to improve claims adjudication, which will
b :onsidered further at the Executive Council meet-
ii in February 1975. Dr. John Glasson, speaking for
tl Council on Review and Development, described,
w 1 particular reference to the .\nnual Session, plans
fi improved coordination and increased efficiency
ii idministration — efforts designed to get rid of
excessive bureaucratic baggage, a perpetual problem
for any dynamic institution.
In a special report which, perhaps more than any
other item considered, focuses on what the state of
the art is and will be. Dr. M. Frank Sohmer, president
of the North Carolina Medical Peer Review Founda-
tion, Inc., outlined the current and projected activi-
ties of that organization. Working under a contract
with the Department of Health, Education and Wel-
fare for the development and support of the PSRO
areas in the state, the Foundation can point to sig-
nificant steps in six of these areas. It has also con-
tracted with the Social Services administration for a
twelve-month review of Medicaid involvement in ef-
fective, skilled nursing beds involving 6,000 patients.
Moreoever, the Foundation, in collaboration with the
Department of Human Resources, is concerned with
the development of a quality module which should
be of significant practical value.
More mundane, and consequently more indicative
of the scope of the Society's responsibilities, were the
Commission reports. Dr. John McCain's Public Rela-
tions Committee was concerned with such matters as
the proposed school of veterinary medicine, the
value of elective preceptorships with active practi-
tioners for senior medical students, minimum
standards of performance for ambulance drivers and
attendants, and the status of the antisubstitution law
for prescriptions. Dr. Wansker's Professional Service
Commission reported on preparations for peer re-
view, the implications of regional variations in fee
scales and the need to develop appropriate mecha-
nisms to anticipate and cope with the manifold prob-
lems presented to the committees of his commission.
Dr. Josephine Newell, speaking for the Annual
Convention Committee, won the enthusiastic con-
gratulations of the Council with her succinct presen-
tation, again proving that "brevity is the soul of wit."
Although the deliberations of the Advisory and
Study Commission did not permit such compression.
Dr. Roy Bigham nonetheless managed his Commis-
sion's report with grace and propriety. On behalf of
the Administration Commission, Dr. Hewitt Rose
noted with regret the resignation of Dr. Jesse Cald-
well, Jr., as chairman of the Retirement Savings
Plan Committee; the Executive Council expressed its
deep thanks and gratitude for the devoted and effec-
tive service performed by Dr. Caldwell during his
long tenure.
Speaking for the Developing Government Health
V,|fKMBER 1974, NCMJ
f
687
Programs Commission, in the absence of its cliair-
man, Dr. John McLeod, Jr., Dr. M. Frank Sohmer
neatly cut through jargon in outlining the implications
of Public Law 16204 which considers cost-contain-
ment, long-term planning and the development of al-
ternative systems for service in contemporary medi-
cine. He further reviewed the present status of Com-
prehensive Health Planning (CHP) and suggested
ways in which physicians can participate effectively
in this enterprise. He alluded to the gratifying re-
sults of the Henderson County Consumer Health
Survey which revealed patients' satisfaction with the
medical care in that county. The report of the Public
Service Commission, given by its chairman. Dr.
Philip G. Nelson, was the last major representation
and provided pertinent data from its many active
subcommittees.
\VILL1.\IV1 McNEAL NICHOLSON, M.D.
For manv vears the Journal and the Societv
have enjoyed the wise counsel of Dr. Nicholson.
He joined the Board in 1949, and became chairman
Emergency
Medical
Services
PROPOSED TR.\INLNG PROGRAM FOR
EMT ADV ANCED TRAINING
Rocco Morando, Executive Director
National Registry of
Emergency Medical Technicians
The National Registry of Emergency Medical
Technicians, recognizing the need for an EMT career
ladder and for registration at a higher level, is
currently developing the necessary criteria for EMT
advancement through its "Standards, Training and
Examination Committee."
The Committee, chaired b\ Kenneth F. Kimball,
M.D., of Kearney, Nebr;iska, consists of the
following:
Eugene L. Nagel, M.D., Los Angeles, California
Richard S. Scott, M.D., Los Angeles, California
Leonard Rose, M.D., Portland, Oregon
George W. Hyatt, M.D., Washington, D. C.
A. Abbatiello, Ph.D.. Chicago, Illinois
Morrie Da\idson. Ed.D.. Los Angeles, California
Joseph Kadish, Ph.D., DHEW"— Washineton,
D. C.
Mr. Robert Motlev. NHSTA-DOT— Washineton.
D. C.
Harlan Felt, R.E.M.T.A.. Riverside, Illinois
in 1959. The two editors the Journal has had thu
far fully appreciated this thoughtful, mature and de
liberate man.
The new editor will not be so fortunate, for o
September 8, 1974, Dr. Nicholson died unexpectedlj
Dr. Nicholson came to Duke when he and the schoc
were both young, and both heavily indebted to hi
alma mater, Johns Hopkins. .\ native of Bath, h
was coming back to the state he loved with the inten
tion of doing all he could to make its medical prac
tice better. In his work with diabetic patients at Dukt
in his duties in postgraduate education there, and i
his editorial board activities this objective was evi
dent. Mrs. Nicholson shared his interests, and sh
came to know as much about Journal operation a
any other member of the Board, attending the annuc
meetings faithfully.
People of broad experience and outlook are rar
in any situation; Nick's wisdom will long be missd
by his successors on the Board of this JoURNA
and elsewhere in his sphere of activity.
R.W.P.
Ed Vernoneau, R.E.M.T.A., Springfield, Mas
sachusetts
J. D. Farrington, M.D., Board Chairman (e;
officio )
Rocco v. Morando, Executive Director (e:
officio )
At a recent meeting of the Board of Directors
the National Registry has approved (in concurrent
with the U.S. Department of HEW and the Nationa.
Highway Traffic Safety Administration, DOT) tin
development of a higher level of EMTs, based upoi
the recommendation of the "Standards, Training, am- i
Examination Committee." The required level o'-
knowledge and skills will include the following:
1. Hold a current EMT-.'V rating. f"
2. Develop ad\anced abilities in triage and generaffe.
evaluation of the patient! s ). •'k
3. .Airway management
Endotracheal
Suctioning
Intubation
Positi\e pressure ventilation
Extraordinary measures (i.e. cricothyreot
omv, etc. )
V
688
Vol. 3-^. No. 1
I).
I.V. or I.M. medications
Venipuncture
Needle
Cathether
Fluids and electrolytes
Medications
Common lifesaving drugs (Digitalis and
antibiotics to be excluded )
Cardiac arrest
CPR retraining
Use of a monitor and its interpretation
Defibrillation
Telemetry
Intracardiac injection
Management of the unconscious patient
Coma
Diabetic medications
Anticonvulsants
Trauma
Sterile technique
Wound care and dressings
Head injuries
Spinal injuries
Immobilization of fractures
Anatomy and Physiology
As indicated for each of above areas to enable
the student to understand what he is doing
and why it is done this way.
The Committee, working in concert with the many
disciplines involved in advanced EMT activities, will
finalize the necessary curriculum for the identified
tasks. After pilot testing has been completed, the
National Registry will implement registration as an
EMT-Advanccd by way of appropriate examinations,
both written and practical.
Additional information relative to the progress and
status of the "Registered EMT-Advanced" will be
distributed via the Registry Newsletter and other
EMS related publications.
The Registry asks that all qualified EMTs, in-
terested in registration as an EMT-Advanced, contact
the Registry ^office, P. O. Box 29233, 1395 East
Dublin-Granville Road, Columbus, Ohio 43229.
Front "Emergency Medicine Today," Commission
on Emergency Medical Services, Volume 3, No. 8,
August 1974, John M. Howard, M.D., Editor.
Original article may be obtained from the American
Medical Association, 535 North Dearborn Street,
Chicago, Illinois 60610.
NEW MEMBERS
of the State Society
/ xander, John Eugene. M.D. (ORS), 1600 Welch PI..
;Charlotte 28216
J en. Elms Leach. M.D. (IM). 1405 Plaza Dr.. Winston-
;alem 27103
(roll, William Warren. M.D. (OPHI, 3801 Sunset .''ive..
tocky Mount 27801
( 'We, John .Mbert, Jr., M.D. (GS). 603 Beaman St..
'Hinton 28328
( rie, Donald Patrick. M.D. (U). Bowman Gray, Winston-
alem 27103
1 /is, Jerome Irvin, M.D. (Intern-Resident). 3790-H Moss
)r., Winston-Salem. 27106
I kson, Flynn Keels, M.D. (OTO), 225 Hawthorne Ln.,
:harlotte 28204
I ham. Cecil Tracy, Jr., M.D. (N), 100 Victoria Rd..
^ Lsheville 28801
I ins, Irving Barefoot, M.D. (Intern-Resident), 1287 Tred-
■ell Dr., Winston-Salem 27103
Fresca. Victor Attilio. M.D. (R), Pine Knoll Towns 32,
Morehead City 28577
Harkins, Paul Duane. M.D. (ORS), 200 E. Northwood St.,
Greensboro 27401
Harriss, William Fred. M.D. (R). 1712 Windsor Dr., High
Point 27262
Jackson. Robert Davis. M.D. (PDC). 1929 Randolph Rd.,
Charlotte 28207
Johnson. Harry Lester, Jr.. M.D. (GP). (Renewal). 210
W. Wendover Ave.. Greensboro 27401
Niemeyer, Charles John, M.D. (ORS), P.O. Box 2046,
Gastonia 28052
Pressly, James Allen, M.D. (ORS). Ste. 1 14. 1928 Randolph
Rd., Charlotte 28207
Reavis, Wilton McLean. Jr., M.D. (Intern-Resident). 28-F
Stratford Hills Apts.. Chapel Hill 27514
Rogers, Larry Arch, M.D. (NS), 1012 Kings Dr.. Charlotte
28283
Simpson. John Larry. M.D. (Intern-Resident). 710 Lance
Dr., Newport News, Va. 23601
Smith. Charles Wilson, Jr.. M.D. (Intern-Resident), B-10,
Village Apts., Carrboro
Sullivan, Raymond Charles, Jr., M.D. (IM). 3422 Deep
Green Dr.. Greensboro 27401
White, Thomas Walker. III. M.D. (FP). 905 N. Queen St.,
Kinston 28501
I ,i-i.MHhR 1974. NCMJ
1^
689
WHAT? WHEN? WHERE?
In Continuing Education
Note: (1) Programs sponsored by the Bowman Gray, Duke
or UNC Schools of Medicine are approved for "Category
I" AMA Physician Recognition Award credit, and for
AAFP "'Prescribed" continuing education credit when such
approval has been granted by the AAFP. (2) "Place"
and "Sponsor" are indicated below only where these differ
from the place and group or institution listed under
"For Information."
In North Carolina
November 15-16
Anesthesiology Fall Seminar
Place: Charlotte Memorial Hospital Auditorium
Fee: $40.0(1
For Information: Dr. H. A. Ferrari, Chairman. Department
of Anesthesiology, Charlotte Memorial Hospital, P. O.
Box 2554, Charlotte 28201
November 18
Planning Patient Care
For Information: Judith E. Wray, .Administrative Secretary.
Continuing Education Program, UNC School of Nursing,
Chapel Hill 27514
December 3-4 & 5-6
The Nursing .Audit
Place: Deer 3-4, Humanities Lecture Hall, UNC-.Asheville;
Dec. 5-6, Southwest Technical Institute, Sylva
Sponsor: Health Education Commission of Western North
Carolina
Fee: S7.00
For Information: Mrs. Marian S. Martin, P. O. Box 7607,
Asheville 28807
December 4
(changed from November 3)
Burn Symposium
Place: Babcock .Xudilorium. Time: I 2:.iO-5:30 p.m.
Fee: SI 0.00
Credit: 5 hours
For Information: Emery C. Miller, M.D., Associate Dean
for Continuing Education. Bowman Gray School of Medi-
cine, Winston-Salem 27103
December 5
American College of Physicians — North Carolina Society of
Internal Medicine, .Annual Meeting
Place: Holiday Inn Four Seasons, Greensboro
For Information: John T. Sessions, Jr., M.D., Department
of Medicine, UNC School of Medicine, Chapel Hill 27514,
or, John L. McCam, M.D., Wilson Clinic, Wilson 27893
December 5-6
2nd North Carolina Postgraduate Course on Pulmonary
Disease
Place: Velvet Cloak Inn, Raleigh
Sponsors: North Carolina Thoracic Society, North Carolina
Lung .Association and North Carolina .Academy of Family
Physicians
Fee: $25.00 — Enrollment is limited. .Applications will be ac-
cepted in order received.
Credit: This program is acceptable for ten elective hours
by the American .Academy of Family Physicians.
For Information: C. Scott Venable, Executive Director,
North Carolina Lung .Association, P. O. Box 127. Raleigh
27602 (919-832-832f))
December 6-7
What's New in Newborn Care
Place: Babcock .Auditorium
Fee: $45.00
Credit: nine hours .A.AFP credit
For Information: Emery C. Miller, M.D., Associate Dean
for Continuing Education. Bowman Gray School of
Medicine. Winston-Salem 27103
Rondomycin
(methacycline HCI)
CONTRAINDICATIONS. Hypersensilivity to any ol the tetracyclines
WARNINGS Tetracycline usage during looth development (last hall of pregnancy to eight
yearsi may cause permanent tooth discoloration (yellow-gray-brown), which is more
common during long-term use Dut has occurred after repeated shorl-lerm courses.
Enamel hypoplasia has also been reported Telracyclines should not be used in this age
group unless other drugs are not likely to be effective or are contratndicated.
Usage in pregnancy. (See above WARNINGS about use during tooth development)
Animal studies indicate that tetracyclines cross the placenta and can be toxic to the de-
veloping tetus (Often related to retardation of skeletal development) Embryotoxicity has
also been noted m animals treated early m pregnancy
Usage tn newborns, inlants. and children. (See above WARNINGS about use during
tooth development )
All tetracyclines lorm a stable calcium complex in any bone-toimmg tissue A decrease
in fibula growth rate observed m prematures given oral tetracycline 25 mg/kg every 6
hours was reversible when drug was discontinued
Tetracyclines are present in milk ol lactating women taking tetracyclines
To avoid excess systemic accumulation and liver toxicity m patients with impaired renal
function, reduce usual total dosage and. it therapy is prolonged, consider serum level de-
terminations of drug The anii-anabolic action of tetracyclines may increase BUN While
not a problem m normal renal lunction, m patients with signilicantly impaired function,
higher tetracycline serum levels may lead to azotemia, hyperphosphatemia, and acidosis.
Photosensitivity mandested by exaggerated sunburn reaction has occurred with tetra-
cyclines Patients apt to be exposed to direct sunlight or ultraviolet light should tie so ad-
vised, and treatment should be discontinued at first evidence of skm erythema
PRECAUTIONS: If supennlection occurs due to overgrowth of nonsusceptible organisms,
including fungi, discontinue antibiotic and star! appropriate therapy
In venereal disease when coexistent syphihs is suspected perlorm darklield exami-
nation before therapy, and serologically test for syphilis monthly lor at least four months
Tetracyclines have been stiown to depress plasma prothrombin activity, patients on an-
ticoagulant therapy may teguire downward adiustmeni of their anticoagulant dosage.
In long-term therapy, perlorm periodic organ system evaluations (including blood,
renal, hepatic)
Treat all Group A Oeta-hemolytic streptococcal infections for at least 10 days
Since bacteriostatic drugs may interfere with the bactericidal action of pemcitlin, avoid
giving tetracycline with penicillin
ADVERSE REACTIONS. Gastrointeslinal (oral and parenteral forms) anorexia, nausea,
vomiting diarrhea glossitis dysphagia enterocolitis, inflammatory lesions (with monil-
lal overgrowth) m the anogemtal region
Skin; nacuiopapular and erythematous rashes, exfoliative dermatitis (uncommon). Pho-
tosensitivity IS discussed above (See WARNINGS)
Renal toxicity rise m BUI^. apparently dose related (See WARNINGS)
Hypersensitivity: urlicana angioneurotic edema, anaphylaxis, anaphylactoid purpura,
pericarditis, exacerbation of systemic lupus erythematosus
Bulging fontanels, reported m young infants alter lull therapeutic dosage, have disap-
peared rapidly when drug was discontinued
Blood: hemolytic anemia, thrombocytopenia, neutropenia, eosmophilia
Over prolonged periods, tetracyclines have been reported to produce brown-black mi-
croscopic discoloration of thyroid glands, no abnormalities of thyroid function studies are
known to occur
USUAL DOSAGE: Adults-600 mg daily, divided into two or tour eguaily spaced doses
More severe infections an initial dose of 300 mg followed by 150 mg every six hours or
300 mg every 12 hours Gonorrhea In uncomplicated gonorrhea, when penicillin is con-
traindicated, Rondomycm' (methacycline HCl] may be used for treating both males and
females in the following clmical dosage schedule 900 mg initially, followed by 300 mg
g I d fora totalof 5 4 grams
For treatment of syphilis, when penicillin is contramdicated, a total ol 18 to 24 grams ot
Rondomycin' (methacycline HCl) in equally divided doses over a period of 10-15 days
stiould be given Close follow-up. including laboratory tests, is recommended
Eaton Agent pneumonia 900 mg daily lor six days
Children - 3 to 6 mg/lb;day divided into two to four equally spaced doses.
Therapy should be continued tor at least 24-48 hours after symptoms and fever have
subsided
Concomitant ttierapy: Antacids containing aluminum calcium or magnesium impair ab-
sorption and are contramdicated Food and some dairy products also interfere Give drug
one hour before or two hours after meals Pediatric oral dosage forms should not be
given with milk formulas and should be given at least one hour prior to feeding
In patients with renal impairment (see WARNINGS), total dosage should be decreased
by reducing recommended individual doses or by extending time intervals between
doses
In streptococcal infections, a therapeutic dose should be given for at least 10 days
SUPPLIED: Rondomycin' (methacycline HCl) 150 mg and 300 mg capsules, syrup con
taming 75 mg/5 cc methacycline HCl
Before prescribing, consult package circular or latest PDR information.
iffi WALLACE LABORATORIES
* ' CRANBURY,NEWJERSEY08512
Rev 6/73
^
6W
Vol. 35, No.
Is He a Source of Information?
Yes, with certain reservations.
The average sales representative
ihas a great fund of information
about the drug products he is re-
^jsponsible for. He is usually able to
lanswer most questions fully and
intelligently. He can also supply
(reprints of articles that contain a
Igreatdeal of information. Here,
too, I exercise some caution. I usu-
ially accept most of the statements
land opinions that I find in the
oapers and studies which come
Tom the larger teaching facilities,
't goes without saying that a physi-
Ibian should also rely on other
(Sources for his information on
|bharmacology.
jfraining of Sales Representatives
Ideally, a candidate for the
position as a sales representative
't)f a pharmaceutical company
Hhould be a graduate pharmacist
'vho has a questioning mind. I don't
ihink this is possible in every case,
iind so it becomes the responsibility
of the pharmaceutical company to
train these individuals comprehen-
sively. It is of very great importance
that the detail man's knowledge of
the product he represents be con-
stantly reviewed as well as up-
dated. This phase of the sales rep-
resentative's education should be a
major responsibility of the medical
department of the pharmaceutical
company.
I am certain that most of these
companies take special care to give
their detail men a great deal of in-
formation about the products they
produce — information about indi-
cations, contraindications, side
effects and precautions. Yet, al-
though most of the detail men are
well informed, some, unfortunately,
are not. It might be helpful if sales
representatives were reassessed
every few years to determine
whether or not they are able to ful-
fill their important function. Inci-
dentally, I feel the saTne way about
periodic assessments of everyone
in the health care field, whether
they be general practitioners, sur-
geons or salesmen.
Value of Sampling
I personally am in favor of
limited sampling. I do not use
sampling in order to perform clini-
cal testing of a drug. I feel that drug
testing should rightly be left to the
pharmacology researcher and to
the large teaching institutions
where such testing can be done in
a controlled environment.
I do not use samples as a
"starter dose" for my patients. I do,
however, find samples of drugs to
be of value in that they permit me to
see what the particular medication
looks like. I get to see the various
forms of the particular medication
atfirst hand, and if it is in a liquid
form I take the time to taste it. In
that way I am able to give my pa-
tients more complete information
about the particular medications
that 1 prescribe for them.
':apacity they are indeed useful;
particularly in the fact that they
iisseminate broadly based educa-
■ ional material and serve not just
,is "pushers" of their drugs.
he Other Side of the Coin
Obviously, the pharmaceuti-
al companies are not producing all
nis material as a labor of love —
'ney are in the business of selling
xoducts for profit. In this regard
ne ambitious and improperly moti-
vated sales representative can
jXert a negative influence on the
racticing physician, both by pre-
entinga one-sided picture of his
, roduct,and by encouragingthe
, ractitioner to depend too heavily
I n drugs for his total therapy. In
nese ways, the salesman has often
I istorted objective reality and
ndermined his potential role as an
'ducator.
. he Industry Responsibility
Since the detail man must be
n information resource as well as
representative of his particular
harmaceutical company, he
'iould be carefully selected and
thoroughly trained. That training,
perforce, must be an ongoing one.
There must be a continuing battle
within and with the pharmaceutical
industryfor high quality not only in
the selection and training of its
sales representatives, but also in
the development of all of its promo-
tional and educational material.
The industry must be ready to
accept constructive as wel I as cor-
rective criticism from experts in
the field and consumer spokesmen,
and be willing to accept independ-
ent peer review. The better edu-
cated and prepared the salesman
is, the more medically accurate his
materials, the better off the phar-
maceutical industry, health pro-
fessionals and the public— /.e., the
patients — will be.
Physician Responsibility
The practicing physician is in
constant need of up-dated informa-
tion on therapeutics, including
drugs. He should and does make
use of drug information and an-
swers to specific questions sup-
plied by the pharmaceutical repre-
sentative. However, that informa-
tion must not be his main source of
continuing education. The practi-
tioner must keep up with what is
current by making use of scientific
journals, refresher courses, and
information received at scientific
meetings.
The practicing physician not
only has the right, but has the re-
sponsibility to demand that the
pharmaceutical company and its
representatives supply a high level
of valid and useful information. I
feel certain that if such a high level
is demanded by the physician as
well as the public, this demand will
be met by an alert and concerned
pharmaceutical industry.
From my experience, my
impression is that sectors of the
pharmaceutical industry are indeed
ethical. I challenge the industry as
a whole to live up to that word in its
finest sense.
Pharmaceutical
Manufacturers Association
1155 Fifteenth Street, NW.
Washington, D. C. 20005
P-M-A
December 1 1-12
Hospital Emergency Room and Ambulatory Care
Place: Benton Convention Center, Winston-Salem
Sponsors: North Carolina Hospital Association and the
North Carolina Medical Society
Program: Designed for hospital administrators, trustees and
physicians.
For Information: Mrs. Diane Turner, North Carolina
Hospital Association, P. O. Bo.x 1(1937, Raleigh 2760^
Phone (919) 834-8484
Januarj 24-25
Surgical Infections
Fee: 575.00
Credit: 12 hours
For Information: Emery C. Miller, M.D.. Associate Dean
for Continuing Education, Bowman Gray School of
Medicine. Winston-Salem 27103
Januar> 31-Februarj 1
North Carolina Medical Society 1975 Conference for
Medical Leadership
Place: State Society Headquarters Building, Raleigh
Program: Designed especially for Society Officers and
other members who carry leadership responsibility. Open
to all interested Society members.
For Information: Mr. William N. Hilliard. Executive Direc-
tor, North Carolina Medical Societv, P. O. Box 27167
Raleigh 27611
February 14-15
Medical Ethics Symposium
Place: Babcock .Auditorium
Fee: S3().0O
Credit: 1 5 hours
For Information: Emery C. Miller. M.D., Associate Dean
for Continuing Education, Bowman Gray School of Medi-
cine, Winston-Salem 27103
F'ebruarj 19
Paraneoplastic Syndromes — the Wingate Johnson .Memorial
Lecture
Place: Babcock Auditorium
Time: 1 1 :00-12:00 a.m.
Speaker: Prof. A. McGehee Harvey, M.D., Johns Hopkins
Hospital, Baltimore, Maryland
For Information: Emery C. Miller, M.D.. Associate Dean
for Continuing Education, Bowman Gray School of
Medicine, Winston-Salem 27103
March 17-21
Tutorial Postgraduate Course: Radiology of the Gastroin-
testinal Tract
Place: Governors Inn. Research Triangle Park (between
Durham and Raleigh, near the airport. )
Program: Designed for radiologists, but open to other
physicians in training or practice. Emphasis on per-
sonalized, tutorial type teaching, with ample opportunity
for discussion. Two SO-minute tutorial sessions each
morning, and one in the afternoon; 12 registrants will
join one faculty member in a separate quiet room with
viewboxes for organized film reading-discussions and
case presentations. Each registrant will have a total of
14 different tutorial sessions. One hour "Panel" presenta-
tion-discussion each afternoon. Guest faculty include:
Drs. Charles A. Bream. Harley C. Carlson, Joseph T.
Ferrucci, Jr.. Roscoe E. Miller. Jerry C. Phillips.
Bernard S. Wolf. and. from Kings College Hospital.
London. England. Dr. John Laws. Chairman, Department
of Radiology.
Fee: $300; enrollment limited.
Credit: 28 hours AM.-A "Category One" accreditation
For Information: Robert McLelland. M.D., Department of
R:idio!ogv. Box 3808. Duke University Medical Center
Durham 27710
April 4-5
Pediatrics Postgraduate Course
Place: Babcock .Auditorium
Sponsors: Continuing Education. Bowman Gray School of
Medicine, and the Maternal and Child Health Section of
the State Board of Health
Fee: $35.00
Credit: 12 hours
For information: Emery C. Miller. M.D.. Associate Dean
696
for Continuing Education. Bowman Gray School of Me
cine, Winston-Salem 27103
Continuing Education via Satellite
The following programs are scheduled to be received fr<l
the ATS-6 communications satellite, by the veterans" h ^^
pitals at Fayetteville, Oteen and Salisbury on the da
indicated. Sessions are open to all physicians and oti
interested health professionals.
November 20 — 1 p.m.. "Radiology Conference"
November 27 — 1 p.m.. "Patient Histology Tissue Ci
ference"
December 4 — I p.m.. "TB.A Conference"
December 1 I — I p.m.. "Neurological Conference"
December 18 — 1 p.m.. "Psychiatry Conference"
December 25 — No program, due to holidays
.As this schedule has been subject to some change, pie;
check with one of the following before attending:
Fayetteville— Mr. Kenneth Gath (488-2120)
Oteen— Stewart Scott. M.D., or Mary Ellen Lutz. R.
(298-7911 )
Salisbury — Mr. Dante Spagnolo (636-2351 1
Programs in Contiguous States
December 5-6
46th .Annual McGuire Lecture Series — .Advances in Obst
rics and Gynecology
Sponsors: Department of Continuing Education and
partment of Obstetrics and Gynecology, and t
H. Hudnal Ware. Jr.. Society
Fee: $75.00
Credit: Nine and one-half prescribed hours .A.AFP appH tii
for; .AM.A accredited
For Information: David B. Walthall. III. M.D.. Directc
Continuing .Medical Education. Medical College of VI !;;:
ginia. Box 91. ,MCV Station. Richmond. Virginia^23298 , rj
E
December 5-8
Core Curriculum: Clinico-Pathologic Correlations in C:
diovascular Disease
Place: Williamsburg Conference Center. Williamsbui
Virginia
Fee: ACC members $125; non-memhers $175
!,\;
fe;
Credit: .Accredited by State Board of Education in Marylai ,„,,
and by .AMA Council on Medical Education.
For Information: Miss Mary .Anne Mclnerny. Director, D
partment of Continuing Education Programs. .Americ;
College of Cardioloey. 9650 Rockville' Pike. Bethesd
Maryland 20014
December 6-8
Neurologic Problems of Infancy and Childhood
Place: Cascades Meeting Center. Williamsburg. Virginia
Sponsors: University of Virginia School of Medicine. Met.
cal College of Virginia of Virginia Commonwealth Url''i
versity; Eastern Virginia Medical School ijij
Fee: $85.00 Enrollment limited to 80 registrants. l ,
Credit: 1 3 '4 prescribed hours .A.AFP credit applied for. f*
For Information: Dr. Ronald B. David. Medical College tfcr;
Vircinia.
23298
Box 211. MCV
Januarv 8.
Medical Hypnosis
Place: Porter .Auditorium (sixth floor
Time: 7-9 p.m.
Fee: $50.00
For Information: Dr. Charles E. Smith
Psychiatry. Medical College of Virginia
Station. Richmond. Virginia 23298
Station. Richmond. VirginJk;
15.22,29
Sanger Hall
ill.
Department ((18;;
Box 907. UCk.
m
January 25
Ventilatorv Problems Workshop
Place: Holiday Inn. Oak Ridge. Tennessee 37830
For Information: Doris Croley. Oak Ridge Hospital of tki"
United Methodist Church. Oak Ridce. Tennessee 37830 SHii
February 28-March 2
Annual .Meeting Virginia ( hapter .American .Academy c'
Pediatrics
Place: Colonial Williamsburg. Vircinia
Fee: $10.00
For Information: James H. Stallings. Jr.. M.D.. Secretary'
c
Ig
ih.
Vol. 35
No. If;":
ri'reasurer, Virginia Chapter American Academy of
,'ediatrics. 6503 N. 29th Street, Arlington. Virginia 22213
April 26-30
fernational Biomaterials Symposium
Snsors: Clemson University and the National Institute for
})ental Research
.': $150
1 Information: Professor J. K. Johnson, Continuing
engineering Education. 116 Riggs Hall. Clemson Univer-
ity, Clemson, S. C. 29631
■terns submitted for listing should be sent to: WHAT'.'
'lEN? WHERE?, P. O. Box 8248, Durham. N. C. 27704.
the 1 0th of the month prior to the month in which they
to appear.
I.
AUXILIARY TO THE NORTH CAROLINA
MEDICAL SOCIETY
\
AMA-ERF
ourrently within the Auxiliary — particularly dur-
|i the "giving" season of Christmas — a lot can be
rird about "amaerf."
fVm an amaerf, are you?"
in case this conjures up mental pictures of a very
^rd thing indeed, we hasten to explain that amaerf
- or AMA-ERF, as it is properly depicted — is the
/ lerican Medical Association Education and Re-
s rch Foundation. It consists of 90.000 women
V rking together with their husbands in medicine to
1 d a helping hand to making funds available so
t t many struggling young physicians can finish their
e ication. The goal for 1974-1975 is "a million
aU more," preferably as much as $2 million, fol-
I'ing on the heels of last year when AMA-ERF
b ke the million dollar barrier — the goal of last
) r"s national Auxiliary president, Mrs. Willard
S ivner.
rFhis means that every Auxiliary member should
t a fund raiser for AMA-ERF. It is the greatest
\ y' there is of showing support and interest in the
fitherance of the medical profession. It is being
I' ed that each member contribute a minimum of
3 ).00.
There are many enticing ways this can be done
c-r and beyond a check, which is always welcome.
\ :hin each Auxiliary various AMA-ERF sponsored
i i ns can be purchased :
The Groanini; Board — an excellent cookbook, a
i at gift — $5.00, 100 percent deductible;
VIedicine and Stamps — for the stamp collector —
J 00, 100 percent deductible;
f^ote paper, memo pads, postal cards— all free
:m headquarters in Chicago and the State AMA-
I F Chairman (Mrs. William Corpening, P. O. Box
n. Granite Falls, N. C. 28630). The sale of these
i lear profit for AMA-ERF;
rhristmas cards — time-tested and profitable for
y,lA-ERF; and,
Irfv'EMBhR 1974, NCMJ
Beautiful, different watches — these are ordered by
the State Chairman and shown several times a year.
There is a $10.00 profit on each watch. (The $10.00
is deductible on income tax as well. )
There are many other ideas — some very individual
ideas which might be shared with all the members.
Individual enthusiasm can be a real investment in
a young physician. Everyone is urged to encourage
the use of memorial, in honor of, thinkini^ of you and
thank you cards which can be ordered, free of
charge, from AMA-ERF headquarters in Chicago
(Mrs. Helen Mazur. AMA, Department of Circula-
tion and Records, 535 Dearborn Street, Chicago,
III. 60610) or from the State Chairman. All the
donation goes to AMA-ERF; or just send a check
to your county AM.A-ERF chairman, or state chair-
man, with instructions (name and address of the
honoree), the medical school to which the donation
shoidd go, and the chairman will handle it in a
prompt, careful and thoughtful way.
You can give to the medical school of your choice
through the AMA-ERF Auxiliary Fund, just noting
the name of the medical school on the bottom of
the check. This also can include donations to spe-
cific clubs at the school: Co-Founders at the Uni-
versity of North Carolina or the "Davidson Fund"
at Duke University, for instance. There has been
A NEW LOOK AT KEOGH COULD
BE WORTH $7,500 IN INCOME
DEDUCTIONS TO YOU THIS YEAR,
IF YOU ARE SELF-EMPLOYED!!
The new PENSION REFORM ACT became effective
on September 2nd. If you are self-employed, this
new legislation offers you substantial new benefits
in income tax deductions and in tax sheltered re-
tirement fund growth. May we assist you in improv-
ing your present plan, or in creating a new one in
time to qualify for maximum ($7,500) tax deductions
this year?
For more information, please return the attached
coupon:
KEOGH-HR-10 SERVICES
NML Associates
143 West Franklin Street
1 Chapel Hill, N.C. 27514
1 1 would like information
1 mum benefits this year
EMPLOYED PLAN.
DIRECTOR
on how to achieve max!- i
under a KEOGH SELF- 1
1
1 Name
Business
Address
1
1 City
state Zip 1
1 Telephone
MJ. 1
697
some controversy about this, but it was reascertaincd
by Mr. Robert Enlow at AMA Records Office in
Chicago on October 4, 1974. It is suggested, how-
ever, that a note be written by the physician donor
to the Dean of the medical school informing him
that his contribution will be made in this fashion.
Thus, he will not lose any privileges from donating
through these clubs.
Another choice is to give to the Loan Guarantee
Fund, a cooperative effort by American medicine
and private enterprise. Loans are issued by various
commercial banks directly to students, interns and
residents at the recommendation of tlw dean of their
medical school. For every dollar the AMA-ERF
deposits in a cooperating bank, the bank loans $ 1 2.50
to students. AMA-ERF guarantees the loans.
It is important to stress that the unrestricted grants
to medical schools are important because deans of
medical schools are always in need of flexilile finan-
cial aid. AMA-ERF funds are given with no strings
attached and can be used to solve the most pressing
problems. Loans to students at low interest rates are
one important thing, of course, but another might
afford a medical school the money to retain a valued
faculty member being sought after elsewhere at a
higher s;ilary.
Through interest in and donations to AMA-ERF,
the physicians' wives in North Carolina and all
over the United States are showing that they care
and share time, thoughts and energies, as well as
substance for medical education. That's what it takes
to be an "amaerf."
News Notes from the —
UNIVERSITY OF NORTH CAROLINA
DIVISION OF HEALTH AFFAIRS
Dr. Morris A. Lipton. professor of psychiatry at
UNC-Chapel Hill, was among 25 of the world's lead-
ing molecular biologists who met in Gottenger, Ger-
many, in September to examine the influence of genes
and biochemistry on mental illness and normal be-
havior.
Decribing the purpose of the conference. Dr. Lip-
ton said, "There is substantial evidence that a ten-
dency toward mental illness is inherited. There is a
genetic predisposition to depression and schizo-
phrenia, just as to high or low intelligence. . . . We
now believe that our understanding has advanced
far enough that we can intervene to make the or-
ganism better able to tolerate its environment."
* * *
A retired building contractor, H. D. Dickerson.
and his wife operate the H. D. Dickerson Residential
Care Facilitv on their Cvpress Lane Farm just out-
side ChapelHill.
Two-hundred persons gathered there on Septembei '*•
20 for the dedication of the new home for speechi *•
handicapped children who are being treated at UNC
in Chapel Hill.
Dr. Erie E. Peacock of Tucson, Arizona, who de-i '<^^
livered the dedication address, played a leading role
in developing the UNC program for treating speech
disorders when he was a plastic surgeon in the School Ei''
of Medicine.
For ten weeks, six to eight boys and girls fromi
throughout North Carolina will call the Dickerson B'
farm their home while they undergo treatment foii 'i^i
cleft palate-related speech disorders. Each year the •'[
UNC Schools of Dentistry and Medicine conduct! ft
three programs which include diagnostic testing,! It
treatment and clinical classroom education.
The cleft palate team includes a dozen specialists!
from the School of Dentistry and Medicine faculties.
Director of the Oral-Facial and Communicative Dis
orders Program is Dr. Robert B. Winslow.
The UNC program is unique in that it is the mosti
comprehensive clinical research cleft palate programjfci
in the nation.
lis
Alumni and former house staff of the Department
of Psychiatry at the UNC School of Medicine
gathered in Chapel Hill in September to honor Dr.
George Ham, the first chairman of the department. ■ ||
Dr. Douglas Bond, former dean of Case Western:
Reserve School of Medicine, delivered the opening!—
address. .\ contemporary of Dr. Ham's, he cited,;,
major historic events, sociological trends and scien-'i;
tific discoveries which have molded their generationf "
both professionally and personally.
Dr. David Allen, a San Francisco psychiatrist, who!;'
was the first resident in psychiatry at the University,"""'
spoke on the treatment of hysteria, and Dr. William';"
McKinney. Jr., professor of psychiatry at the Univer-f "
sity of Wisconsin School of Medicine, spoke onP
"Tough and Soft-Headed Psychiatry," which outlinedjr'
the major split in psychiatry in the United States f^
todav. , ^ r"
f
Dr. Philip T. Johnson of the UNC School of Medi- b';
cine at Chapel Hill has been named a Diplomate of jj.,
the American College of Laboratory Animal Medi-(ii\
cine.
He is campus veterinarian for the Department of
Laboratory Animal Medicine and an instructor in
the Department of Pathology at the UNC School
of Medicine.
i
Dr. Allen M. Feinberg of the UNC School of
Medicine at Chapel Hill has been elected a Diplo- '"■
mate of the American Board of Professional Psy-
chology.
Dr. Feinberg. whose specialty is clinical psy-
chology, is assistant professor of psychiatry.
* * *
Dr. Claude Piantadosi of the UNC School of
Pharmacy at Chapel Hill has been awarded a S24.344
f«
6yx
Vol . .Vv No. 11
iearch grant from the U.S. Department of Health,
ucation and Welfare,
irhe research entitled "Ether and Ketone Lipids
ring Brain Development," involves the lowering
Iserum cholesterol in the cardiovascular system.
(|Dr. Piantadosi is head and professor of the Divi-
m of Medicinal Chemistry in the School of
larmacy.
* * *
Dr. Rolf P. Lynton of the Carolina Population
jiiter and the UNC School of Public Health in
kpel Hill has been appointed dean and professor
ithe new School of Public Health of the University
ilSouth Carolina at Columbia.
pr. Lynton has been director of two international
ijects at the Carolina Population Center and asso-
fe professor of mental health in the School of Pub-
iHealth. He came to Chapel Hill in 1966.
jrhe University of South Carolina School of Public
tilth will be developed in association with the
fre's second medical school and will link up pro-
gi:ms and academic resources now located in various
f ts of the Columbia campus and across the state.
i^ews Notes from the —
DUKE UNIVERSITY MEDICAL CENTER
")r. C. William Erwin, an associate professor of
p.chiatry here, has been named the first medical
d ctor of the Durham-based National Driving
Crater.
arwin, 41, is an authority on what makes drivers
djiwsy and how to detect that drowsiness before it
le,ls to catastrophe. He received his M.D. from the
L versify of Texas in 1960.
,irwin joined the Duke psychiatric faculty five
yyrs ago. He will retain his Duke faculty appoint-
0 It in conjunction with his Driving Center position.
\t the Driving Center, now temporarily housed in
Eke's Engineering Building, he will direct research-
eiUrying to pinpoint the factors affecting a driver's
attiity.
Driver error causes most highway accidents," Er-
w" said, "but paradoxically, the thrust of safety re-
se^ch in this country has been toward improving
tfc^road or the car. In contrast, the National Driving
C ter is focusing on the driver."
oth psychology and medicine contribute to the
ounization's findings, he added.
'■ he center is a non-profit research group, funded
la.' year by the State of North Carolina, as well as
b; private sources. It is scheduled to move into
p((nanent quarters at the Research Triangle Park
n< year.
* :!: :;<
: 'ne of 19 fellowships awarded in 15 hospitals.
uii ersities and cerebral palsy centers by the United
Nl MBiR 1474. NCMJ
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Cerebral Palsy Research and Educational Foundation
has been presented to Dr. William G. Moorefield,
Jr., resident in orthopaedic surgery. The fellowship
is for $2,500.
Moorefield received his B.A., M.A. and M.D. de-
grees at Duke. He completed an internship at the
University of Alabama and an assistant residency
here. He also served two years with the U. S. Public
Health Service Hospital in Cherokee, N. C.
* * *
The urologic clinic has a new name — the Edwin P.
Alyea Urologic Clinic, named for a man who came
here at the age of 31 to establish the Division of
Urology and then headed it for the ne.\t 34 years.
The name change was made during a dedication
ceremony in the Duke Hospital Amphitheater.
Alyea drove an ambulance in World War I until
he became old enough to get into the fighting as a
lieutenant in Army heavy artillery. He had graduated
from Princeton, and after the war enrolled at the
Johns Hopkins Medical School, where he earned his
M.D. in 1923.
With internship and residency at Hopkins behind
him, he came to Duke to organize the urologic ser-
vice in 1929. The medical center opened in July
1930.
One of the leaders in his specialty. Alyea was one
of the early innovators in prostatic surgery, and his
first scientific paper recommended vasectomy. He
was a consultant to the Surgeon General in the Na-
tional Research Council during World War II.
A primary objective was the establishment of a
urologic residency, and during the time .\lyea was
chief of the service, 35 residents completed post-
graduate training here. Almost ten years ago his
former residents honored him with the establishment
of the Edwin P. Ahea X'isiting Professorship in
Urology.
Alyea relinquished his responsibilities as chief of
urology in 1963 and continued as a professor of
urology until 1969. He has been an emeritus profes-
sor since that time, but has continued to maintain
an active affiliation with the division.
* * *
Dr. Johnnie L. Gallemore, Jr., a medical center
physician-lawyer, will spend the ne.\t 12 months help-
ing Washington legislators draft health bills.
Holder of both law and M.D. degrees, Gallemore
is one of six medical educators selected recently
for the one-year assignment. A board set up by the
National Academy of Sciences and the Robert Wood
Johnson Foundation made the selections.
He will be replaced as associate director of medical
and allied health education by Dr. William D. Brad-
ford, an associate professor of pathology.
Bradford is no stranger to the post, having filled
it in an acting capacity in 1970-1971. He won the
Student .American Medical Association Golden Apple
Award in 1969 for excellence in teaching basic sci-
ences.
71)0
Duke has introduced a new program for medical '•'■'
students who want to become health policymakers. ; ■.»
Those admitted to the five-year program will Ij
study in the School of Medicine and the Institute i;;!
of Policy Sciences and Public Affairs. Both an M.D^ jjici
degree and a master of arts degree in public policy inic
sciences await those who complete it successfully. fci
The combined approach was adopted because) ^;i
"many people who are health policymakers don't ai,
have adequate medical training," explained Dr. Willis r's
Hawley, associate director of the policy sciences in-, pji
stitute. 3;tt
"Or if they do have medical training, they don't iui
have the analytical skills and knowledge of policy jjr
implementation they need," he added. i -D
The new Medicine and Public Policy Program willj guj
provide all three, Hawley noted. |i,.
The first two of the program's five years are spent r[(
with medical courses. The third year is devoted tq ,](
courses in the Institute of Policy Sciences and Public j;;;
Affairs. ifj^
There, students will learn how to analyze policy y;]
alternatives and gauge their consequences. They'll ji;,
learn how government policies are made and put
into action. They'll also learn how ethics and policy-
making dovetail.
Those students will then complete their medical,
courses during years four and five, adding health
research seminars and a master's paper.
.According to Hawley, graduates will be qualified
for positions in a variety of public and private or-
ganizations, including the National Institutes of
Health, the Office of the Surgeon General, the states
departments of human resources or public health, 'V
the regional medical programs, the American Medi
cal Association and Blue Cross-Blue Shield.
.As many as five students each year will be accepted
into the program. They may apply at the same time
they apply to the medical school, or during their
first two years.
I
News Notes from the —
BOWMAN GRAY SCHOOL
OF MEDICINE
WAKE FOREST UNIVERSITY
Thirty-one new faculty members have been ap-
pointed at the Bowman Gray School of Medicine,'
including 15 who were named to the full-time faculty.
Those appointed to the full-time faculty include:
Carol A. Appolone. instructor in pediatrics (social
work); Dr. William A. Brady, instructor in neu-,
rology; Dr. J. Edwin Byrum, Jr., instructor in sur-'
gery and instructor in medicine (emergency medical
services); Dr. Donald L. Collins, instructor in medi-
cine (rheumatolocv); James W. Fredrickson, instruc-
Vol.. .^."5. No. Iljin;
■)r in medical systems planning; David Hunter, in-
ructor in radiology (nuclear medicine technology);
)ir. James C. Leist, instructor in community medi-
jine; Dr. Michael D. Parker, assistant professor of
fiedicine (rheumatology); and William C. Park, Jr.,
iistructor in community medicine.
Also Dr. Keith M. Phillips, assistant professor of
■ediatrics (allergy and immunology); Dr. J. Baldwin
jmith, assistant professor of neurology and assistant
professor of pediatrics; Sandra E. Stoterau, instructor
i|i pediatrics (speech pathology); Dr. Wilford P.
tratten, assistant professor of physiology, section of
I'harmacology (neuropharmacology); Dr. Robert T.
Vestmoreland, assistant professor of anesthesia; and
'r. Douglas R. White, assistant professor of medicine
iihematology/ oncology ) .
Those appointed to the part-time faculty include:
T. Robert F. Blackard, clinical assistant professor
■ anesthesia; Dr. J. Frances Bounous, clinical in-
ructor in pediatrics; Dr. Paul D. Harkins, clinical
structor in orthopedics; Dr. Thomas J. Koontz,
inical instructor in surgery; Dr. James M. Marlowe,
linical instructor in orthopedics; Dr. Thomas N.
([asters, associate in physiology; Dr. H. Bryan Noah,
ttnical instructor in orthopedics; Dr. Michael J. Pol-
;k, clinical instructor in obstetrics and gynecology;
'T. Joyce H. Reynolds, clinical instructor in surgery
femergency medical services); and Dr. Keeling A.
cfarburton, clinical instructor in obstetrics and gyne-
^ogy.
In the Division of Allied Health, Dr. Victor D.
Morris was appointed associate professor. Drs.
Thomas R. Bryan, William H. Burch, James O.
Burke and Jack C. Evans were announced as clinical
instructors. ^ .^ ^
Dr. David L. Kelly, Jr., associate professor of neu-
rosurgery, has been elected secretary of the Congress
of Neurological Surgeons.
The election came during the congress's 24th
annual meeting in Vancouver, British Columbia.
Dr. Kelly, whose term as secretary runs through
1977, served as chairman of the scientific program
for the Vancouver meeting. He has been a member
of the congress's executive committee since 1971.
He also is vice president of the North Carolina
Neurosurgical Society.
* * *
Dr. John Denham, instructor in the Department of
Community Medicine, joined two residents from
North Carolina Baptist Hospital recently for a two-
week trip to San Pedro Sula in Honduras to provide
medical care for victims of Hurricane Fifi.
The residents are Dr. Michael Roberts of surgery
and Dr. Richard Sterba of pediatrics.
Their trip was taken under the auspices of the For-
eign Missions Board of the Southern Baptist Con-
vention. ^ ^ ^
Dr. Jack M. Rogers, assistant professor of psy-
chiatry, has received the first Career Teaching Award
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presented to a member of the Bowman Gray faeulty.
The three-year grant is from the National Institute
of Aleoholism and Aleohol Abuse in conjunction
with the National Institute of Drug Abuse.
Under the grant Dr. Rogers will concentrate his
efforts on helping to expand the medical school's cur-
riculum to include more training of medical students,
interns and residents in the diagnosis and treatment
of alcoholism and drug abuse. He also will be in-
volved in continuing education programs for practic-
ing physicians and paramedical personnel who come
into contact with alcoholics and other drug abusers.
Research on the causes and treatments of alcoholism
and drug abuse will be included in Dr. Rogers" work
under the grant.
His efforts will be part of a formal program within
the Department of Psychiatry and will involve several
other departments.
Dr. Rogers also will coordinate the school's work
with community agencies which deal with alcoholics
and drug abusers.
* * :■.'.
Dr. B. Lionel Truscott. professor of neurology, has
been named an alternate member of the Stroke Ad-
visory Committee of the Joint Commission on Hospi-
tal .Accreditation.
Dr. Truscott also has been nominated as the neu-
rology coordinator for Medical District No. 9. which
includes Veterans Administration hospitals in Dur-
ham. Fayetteville, Oteen and Salisbury. N. C, and tl
V. A. Center at Mountain Home. Tenn
* * *
The medical school has appointed its first traa t;
plant coordinator to assist in the growing kidn^ (i-r
transplant and dialysis effort at the medical center.
Miss Becky Norman will be the person to conta
for information about all aspects of the kidney pn
gram.
The new position is made possible by a grant froLjiii
the North Carolina Division of Human Resources. , [,j;
[:;
Dr. Alanson Hinman. associate professor of pedia
rics, has been appointed to the Council on Develoj
ment Disabilities of the North Carolina Departmei
of Human Resources.
Dr. C. Patrick McGraw. research assistant profe;
sor of neurology, has been elected to serve as a meir
ber of the Peer Review Committee for the Region;
Research Advisory of the American Heart .\ssoci;
tion. He also has been elected to the Research R(
view Subcommittee of the North Carolina Heart Ai
sociation. Inc.
pi
lUI
iieai
t!^
©.'a
Dr. I. Meschan. professor and chairman of the DtLi,,
partment of Radiology, has been appointed chairma;
of the Committee on Radiology, National Researc|r,i
Council, Assembly of Life Sciences, Division
Medical Sciences.
•Sin
Month in
Washington
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The Senate has overwhelmingly passed legislation
that would require one-fourth of all medical and
dental school graduates to spend at least two years
in the nation's slums and rural areas where there arc
shortages of physicians.
Earlier the Senate voted down a much more sweep-
ing bill sponsored by Senator Edward Kennedy that
would have required mandatory federal service for all
health professions students and national licensure and
relicensure for phvsicians and dentists.
Hours before the first Senate vote. Senator Ken-
nedy, aware that he was losing liberal support,
shelved his Health Subcommittee's S5.I billion, five-
year bill and offered a substitute measure which was
trounced 57-34. Instead, the Senate adopted a mea-
sure sponsored by Senator J. Glenn Beall. Jr.,
7(12
healtl (lid
(R-Md.). and passed a three-year. $2 billion
manpower bill by a vote of 81-7.
The bill. finall\ approved by the Senate, wa:
stripped of most of the controversial provisions o
the original Kennedy bill and was a victory for tht
American Medical .Association, the American Denta
.Association and the Association of American Medi
cal Colleges.
The Senate bill calls for a three-year e.vtensior
of present federal programs for aiding medical educa
tion at a total cost of appro.ximately $2 billion. Capi-
tation grants for medical schools would be continuec
at a high level despite the administration's reques
for a cutback.
The Beall substitute measure provides federal ar
to medical and dental schools that agree to allocatf
Vol.. }5. No. 11
TlO
li:ii
Hi;
su
iiai;
f.;i
Sffl
k
'A I
. I!
'i percent of their classroom space to students volun-
jring to serve in areas short of medical care work-
5. In return for either civilian or federal service
Wer the National Health Service Corps, the students
lould receive scholarships.
The Kennedy bill would have compelled all medi-
'l school graduates to serve in the shortage areas,
I approach labeled a "domestic draft" by Senator
[tall and his committee colleagues Senators Peter
bminick (R-Colo. ) and Robert Taft, Jr., (R-Ohio)
iio developed the substitute measure.
The Senate bill does not contain the original re-
irement for a federally appointed National Council
' Postgraduate Education with ten regional councils
!signed to deal with allocation of speciality training
bts and foreign medical graduates. The Senators
ptended that this was too heavy an involvement of
.i federal government.
'^Another casualty of the Senate voting was the
bposal for federal standards for licensing and reli-
asing physicians and dentists, a plan that stirred
de protest within the professions.
'The Maryland Senator's bill represented a middle
ound on financial help for medical schools, with
AAMC contending that the amount was too low
tjd the Administration believing it was too high.
Immigration standards would be tightened to re-
ict the number of foreign medical graduates under
Senate bill.
On the other side of the Capitol, a House sub-
immittee has approved a counterpart bill to the
aate manpower legislation that would establish
lleral scholarships intended to increase the number
! I physicians in the nation's rural areas and urban
i:ms where there are physician shortages.
I' The House subcommittee's bill authorizes $240
lllion over three years for National Health Service
|(iolarships paying $9,200 to $9,500 a year to cover
k': cost of a medical education.
i in return, the scholarship recipients would have to
|i:nd two to four years serving in areas with physi-
cin shortages. Non-scholarship students who volun-
t r to practice in areas with physician shortages
Viuld receive a guaranteed income of $28,000 a year
I til they get their practices started.
The bill would also give medical schools a grant
i$2,100 a year for each student — $400 less than the
fiools now receive.
['However, any graduate who does not practice in an
Merserved area would have to repay the govem-
'.nt the money given to the medical school.
Though the House bill differs sharply from the
late version, particularly the Senate provision fore-
medical schools to have one-fourth of their classes
federal scholarships requiring two years of prae-
; in underserved areas, the House subcommittee
airman, Paul G. Rogers, (D-Fla.), believes the
'erence can be resolved when the two bills go to
'''iference.
Undaunted by collapse of the National Health In-
surance (NHl) measure in the House Ways and
Means Committee in late summer, Senator Russell
Long ( D-La. ) is forging ahead with plans to ram a
bill through the Senate in the strained atmosphere
of a "lame duck" Congress. Long is Chairman of
the Senate Finance Committee and sponsor along
with Senator Abraham Ribicoff (D-Conn.), of an
NHI plan featuring Social Security financed and op-
erated catastrophic health insurance plan for all. The
Long-Ribicoff bill already enjoys the official support
of 25 Senators, and it rates some chance of Senate
passage.
The chances of passage of a version of such a
Senate bill by the House in a "lame duck" session
after the November elections, however, is considered
extraordinarily slim.
* * *
President Ford's long-heralded summit economic
conference produced relatively little talk about health
care costs and inflation, despite the fact that HEW
Secretary Weinberger has of late frequently sounded
such an alarm.
Nor was there any indication during the Washing-
ton parley that the Administration was considering
controls at this time, although Senate Majority
Leader Mike Mansfield (D-Mont.) urged the 800
delegates to request such controls.
However, it became clear to conference observers
that the President will ask Congress to approve cer-
tain but unspecified tax changes and to cut the federal
budget to combat inflation.
American Medical Association President Mal-
colm C. Todd, a delegate to the summit conference,
said that he agreed with the President with respect
to avoiding controls at this time — "particularly dis-
criminatory cost controls."
"Every American, every physician, has the duty to
assist in solving the number one problem of the na-
tion— inflation," Dr. Todd said, noting that the AMA
has repeatedly stressed the need for restraints by phy-
sicians in avoiding unjustifiable charges and fee in-
creases.
A summary of the earlier pre-summit session on
health was presented by Michael Zubkoff, Professor
of Health Economics at Meharry Medical College
and Vanderbilt University. He said, "It is generally
recognized that the health sector is both a hostage
and a cause of inflation."
According to Professor Zubkoff, the pre-summit
meeting had determined certain "structural defects"
in the health care delivery system which included:
( 1 ) Fee-for-service payment for physicians and cost-
plus reimbursement for hospitals . . . encourages cost
growth. (2) First dollar insurance coverage reduces
cost-consciousness by consumers. (3) Consumers
lack knowledge to become aggressive, informed pur-
chasers of health care.
According to Zubkoff, among the "common
themes" stressed at the pre-summit health conference
I'Vembhk 1974. NCMJ
705
were: that the federal commitment to health care
should not be reduced; that structural reform is
needed; and. that existing incentives and regulatory
mechanisms are inadequate.
"There was a definite lack of a widespread con-
census on solutions to cost problems in health during
the pre-summit meeting," Zubkoff told the summit
meeting.
While pleased that President Ford had not called
for wage-price clamps by the federal government.
Dr. Todd at the same time criticized the Administra-
tion for "singling out" health by "annualizing"
monthh consumer price index levels. The practice of
projecting the yearly increase on the basis of what
happens during one month or several months has
been followed only on "health" by the HEW Depart-
ment so as to bolster its contention that the health
segment should be isolated for controls. Dr. Todd
charged.
The AMA President noted that in the past three
years physicians" fees have risen 17.6 percent, com-
pared with 22.9 percent for the economy as a whole
and 32.9 percent for legal charges.
Suggested steps to curb medical costs, listed by Dr.
Todd, were preadmission testing; expansion of ambu-
latory care services; earlier discharge from hospitals;
avoidance of unnecessary hospitalization; reducing
wasteful testing, prescribing and treatment; and, de-
creasing the cost of malpractice insurance.
I
In addition. Dr. Todd explained, there must be
centives to produce more family physicians and
plan for needed specialists only.
"Perhaps physicians should attempt voluntarily
guide their fee-setting decisions by tying their char
to the consumer price index levels and not exceed
them," Dr. Todd suggested.
A wide range of health care-related subjects w
discussed at a recent meeting between an AMA de!
gation and Health, Education, and Welfare Secreta
Caspar Weinberger.
Malcolm Todd, M.D., President of the AMA, Sc
the Secretary and his aides were told that the AM
desires the best possible national health insuran
(NHI) program that can be worked out, but ca
tioned against any hurry-up approval in an em
tionally-charged Congress late in the session.
Dr. Todd said that he emphasized inflation as l
ing the number one problem facing the nation
present and, therefore, any NHI program should ha
a minimal impact on this problem. AM.A officii
urged that NHI be kept outside the Social Secur
.Administration.
The .AMA delegation urged that controls not
reimposed on the medical profession, citing t
AM.A's urging of moderation by physicians to ke
fees in line with expenses.
Other subjects at the meeting included manpow
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706
Vol. ??. N.
1
igislation and current procedural terminology.
t|The AMA delegation included, in addition to Dr.
Ddd, Richard Palmer, M.D., Chairman of the AMA
/^3ard of Trustees; Russell Roth, M.D., Past Presi-
nt; William Holden, M.D., board member; Ernest
I'vingstonc, M.D., chairman of the Council on Legis-
don; James Sammons, M.D., Executive Vice Presi-
tnt Designate; Joe Miller, Deputy Executive Vice
•esidcnt; Whalen Strobhar, Assistant Executive Vice
j'esident; and Harry Peterson, director of the legisla-
te Department.
* * *
J The Food and Drug Administratoin is planning a
cter to physicians alerting them to a series of studies,
' be published in Lancet, a British medical journal,
'at finds a higher-than-normal incidence of breast
'incer among women aged 60 and older who have
en treated with reserpine for high blood pressure.
panel of experts appointed by the HEW Depart-
fent will review the data.
1
The Food and Drug Administration has indicated
' Congress that it will order warning labels placed
oral diabetic preparations when a new study of
drug's safety and efficiency is published soon.
Alexander Schmidt, M.D., FDA Commissioner,
Id the Senate Monopoly Subcommittee headed by
Senator Gaylord Nelson that the FDA endorses a
1970 study by the University Group Diabetes Pro-
gram which found that the drugs (tolbutamide and
phenformin) were linked with a heart disease death
rate twice as high as that for diabetics taking insulin
or no drug at all through diet.
Within a few weeks, an 1 8-month audit of the 1970
study is due to be published, and apparently it backs
up the major findings of previous study. The audit
is being prepared by a special panel of the Biometrics
Society.
Lawsuits challenging the FDA's right to impose
warning labels have deterred the agency from action
to date. Dr. Schmidt told the Subcommittee. He said
that many physicians have something close to a "re-
ligious belief" that the oral diabetic preparations,
by lowering blood sugar, decrease the likelihood of
cardiovascular complications among diabetics.
The major opponent of relabeling is the Committee
on the Care of the Diabetic, composed of 180 physi-
cians. The issue is a serious controversy among
specialists in the treatment of diabetics, with experts
taking both sides.
The FD.\ is relying on the audit to strengthen
its hand sufficiently in the legal fight to allow it to go
ahead with warning labels, but the prospects are that
the actual implementation of such an order will be
tied up in the courts for some time.
Book Reviews
Stress Without Distress. By Hans Selye, M.D. 171
pages. Price, $6.95. Philadelphia and New York:
J. P. Lippincott Company, 1974.
Stress Without Distress is dedicated "to those who
' to find themselves." No matter how hard I try
have it otherwise, my prejudices begin pumping
lany mention of a book purporting to help people
Id themselves. The gaggle of these literary en-
avors which hardly ever get off the ground has
■ised me to dislike all such offerings even before
egin to read them.
Some similar prejudice must have prompted a re-
wer to produce a descriptive gem with regard to
look written by one of my colleagues. The reviewer
served that it was the "least worst" book of its
id that he had ever read. My temptation to tag
ijis Selye's Stress Without Distress with some such
icription indicates that it has mellowed my prcju-
es, but has not abolished them, as a result of read-
,l; the book.
Wembfr 1974. NCMJ
With some glaring exceptions, it is a well written
document. Chapter 2 on "Motivation" is especially
noteworthy. One of its sections, "Work and Lei-
sure," is exceptionally good, as to both content
and style. What I take to be the author's personal
charm and irrepressible good will emanate from his
writing. His ability to take justifiable pride in his own
accomplishments strikes a healthy note. Selye's genius
for communicating medical and scientific theories and
facts to laymen may constitute his finest talent as a
writer. I have no competence for determining the
validity of his medical and scientific observations, but
they are communicated with clarity and verve.
The theme of the book begins with a distinction
between stress and distress. The latter is always to be
avoided. Stress can be either good or bad, depending
upon the way the person reacts to the demands which
life makes upon him. People can learn how to react
successfully to life's stresses by taking their cues
from the way in which body cells and organs react.
707
Cells and organs have an instinct for survival, as well
as a tendency toward cooperation with one another
as a means of survival. They are sometimes syntonic
and sometimes catatonic in response to stress — the
first making for peaceful coexistence with the stress
or stressor, and the second trying to fight it off. What
is indispensable to the cells or person under stress
is the quality of homeostasis: "The body's tendency
to maintain a steady state despite external changes:
physiological 'staying power." "
"Altruistic egotism" is the best guarantor for the
homeostasis in human behavior and relationships.
This term appears to mean that a person's apparent
altruism is basically egotistical. He does good for
others in order to assure his self-fulfillment. Since I
cannot love my neighbor as myself, I should set out
to earn the love of my neighbor. I think Seyle ought
to be paraphrased somewhat like this: Because you
cannot love your neighbor as you love yourself, try
to get your neighbor to love you as he loves himself.
The flow of the book toward its central theme is
impeded b\ excessi\e repetitions and summaries, one
after the other. Thirty-five of the book's 171 pages
contain a glossary, a bibliography and an index. Selji
seems overly concerned that the reader will not re!
member what has been said in the span of 136 pages
I was somewhat irritated b\ his efforts to remind m(
many times of what had already been stated.
Although careful with a number of definitions, thi
author makes no attempt to define "altruistic ego
tism." Since the expression is certainly a contradic
tion in terms. Selye has no right to assume that th(
reader will accept it without question. Because his en
tire argument stands on the acceptance of "altruistii
egotism." Selye's failure to reconcile the two wordi
is almost unforgivable.
In a second instance, the author boldly states tha
his "code is, at the same time, both compatible with
and independent of, any religion, political system, o
philosophy." As one whose profession is linkec
with the first of these categories, I am not aware o
the facile compatibility between Selye's code anc
Christianity. Much more proof than the author sup
plies is assured!) indicated.
Most astounding is this assumption: "He who fol
lows our doctrine will ereedih hoard wealth anc
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Vol. .15. No.
4
^1 /iTength, not in the form of money or domination of
^'1 li lithe rs, but by earning the good will, gratitude, re-
^ oect, and love of those who surround him. Then,
"it iven if he has neither money nor power to com-
iiand, he will still be virtually unassailable and safe.
'.ll+jr no one would have a personal reason to attack
f? Mm." Does Selye really believe that attackers wait
'■t or reasons? As a matter of fact, 1 want to buffet
-it tim more than once simply because he appears to be
lis iooutlandishly happy with himself and the world.
iiist il Almost everything that Selye prescribes is easier
lofi jiaid than done. Therefore I suggest that the book is
ot for sinners. Selye tells us that he is not a sinner
and refuses to think of himself in that context. Since
if li am a sinner, I must declare that Selye does not
( )ipeak to my condition as cogently as does the
iVpostle Paul. His confession is mine as well: "I do
not understand my own actions. For I do not do what
II ff want, but I do the very thing I hate." I want to
|)lo what Dr. Selye prescribes, but 1 probably won"t.
Warren T. Carr, D.D.
'; The Kthics of Genetic Control: Ending Reproduc-
tive Roulette. By Joseph Fletcher, 2 1 8 pages. Price,
$1.95. Garden City. New York: Anchor Press/
Doubleday, 1974.
The moral and ethical problems posed by recent
iiscoveries in modern biology and genetics, in gen-
jral, and in human reproduction, in particular, pro-
7ide the substance of this book. As a theologian
tmeritus, now professing medical ethics. Dr. Fletcher
ippears well qualified for his task. Seven previous
'olumes on social and medical ethics attest to his
lamiliarity with the territory. In six "Some" chapters
(itarting with "Some Ideas," he considers in turn
racts. Doubts, Issues, .Answers, and Hopes. Written
n a lively style, the book explores not only what is
»iow but what may be, because, as the author argues,
(ew would have guessed a decade or two ago where
^c would be today.
I Dr. Fletcher believes that there is no logical con-
nection or scientific pathway from what is or may
ue to what ought to be. As an admitted consequential
fethicist, he asserts that "in any moral calculus human
fieed is the principal value." He opposes any universal
standard or a priori ethic other than human need,
lin his "Answers" chapter he boldly deals with the
moral and ethical aspects of adultery, artificial
i'ermination, birth defects, cloning, cost-benefit
iratios, surrogate mothering, love-making and other
iiubjects of moral and ethical concern.
' Some of Dr. Fletcher's views will prove surprising,
■f not shocking, to the reader. For instance, in a brief
((discussion of mass screening, he accepts involuntary
iterilization as a reasonable possibility when two
'People carrying the same hidden recessive gene
;hance to marry. Although such a practice would
dightly reduce the frequency of that particular gene,
he cost of making such a practice feasible might
, MsW be better borne in finding alternative solutions
to our genetic dilemma. Geneticists agree that present
medical advances which permit survival of and repro-
duction by some people who might otherwise die
prior to reproduction do not produce dramatic
changes in gene frequency. In other words, we have
time to examine various alternatives. Unfortunately,
some people will seize upon such pronouncements
as evidence of where consequential ethics may lead
us.
Since Dr. Fletcher is neither a physician nor a
geneticist, a few errors of fact in his book are not
surprising. For example, on page 61 he states that
ten percent, instead of 25 percent, is the proportion
of offspring who have sickle cell anemia from a mat-
ing of two carriers. Similarly, in answering critics of
cloning (page 75) he concludes, "All that limits
l.Q. now, as far as its neurologic apparatus is con-
cerned, is size of the pelvis." Varying from species
to species, animal intelligence appears to be corre-
lated to brain size, but among human beings brain
size is only weakly correlated to l.Q. (Jonathan
Swift's brain volume was 2,000 cc; Anatole France's
was 1,100 cc). Although eschewing pejoratives. Dr.
Fletcher slips in a footnote on page 105 in describ-
ing "nasty little seminarians." Few of us can remain
unmoved by growing public knowledge and concern
about modern medicine and, in particular, its moral
and ethical dimensions. This book provides an excel-
lent opportunity for us to examine primarily the
utilitarian or pragmatic ethic as related to some cur-
rent and future medical practices.
H. O. Goodman, Ph.D.
Handbook of Poisoning. Bv Robert H. Drieshach.
M.D. 8th ed. 517 pages. Price. $6.50. Los Altos,
California: Lange Medical Publications. 1974.
Now in its eighth edition, this handbook has 500
additional references. It maintains its traditional,
basic style and provides a concise summary of diag-
nosis and treatment of clinically important poisons.
The book is divided into six sections. The first
section deals with the diagnosis and emergency man-
agement of poisons in general. It touches on vital
subjects such as coma, convulsions, cardiac arrest,
shock acidosis and how to treat the patient in such
emergency situations. The other five sections deal
with specific poisons: agricultural, industrial, house-
hold, animal and plant, and medicinal drugs. The
main drug is briefly described regarding its primary
use, fatal dose, mechanism of poisoning, clinical
symptoms, laboratory findings and treatment.
The author has well tabulated much useful data
on many drugs and poisons. He has included infor-
mation on the availabilit\ of antisera of reptiles and
spider venoms from different sources throughout the
world.
This handbook is useful for the physician who
treats the patient and for the toxicologist who is
interested in studving toxicits' of poisons and drugs.
' Z. K. Shihabi, Ph.D.
NoviMBhR 1974. NCMJ
709
Frederick William Stocker, M.D.
Dr. Frederick William Stocker died at his home in
Durham on June 6. 1974. after an extended illness.
Dr. Stocker was born in Lucerne, Switzerland, Oc-
tober 14. 1893. He was educated in the schools of
Lucerne. He obtained his M.D. degree at the Univer-
sity of Bern. His postgraduate training was done at
the University Eye Clinic, Bern, and University Eye
Clinic, Munich. Germany. He returned to Lucerne to
practice ophthalmology. In 1941 he came to the
United States, where he was first associated with the
Institute of Ophthalmology. Presbyterian Hospital,
Columbia University, and later with the Wilmer Eye
Institute of Johns Hopkins University. In March
1942 he became affiliated with McPherson Hospital.
He later joined the staffs and faculty of Watts Hospi-
tal, Duke University Medical Center and the Uni-
versity of North Carolina School of Medicine.
Fred Stocker was a most remarkable man. He was
very proud of his Swiss heritage, but he was equally
proud of his newly adopted country. He was a warm,
gracious person who enjoyed life. He had many
varied interests, other than medicine, and was well
versed in art, music and literature. Dr. Stocker was
loved and held in the highest esteem by his students,
colleagues and patients alike.
An internationally renowned ophthalmologist, he
was the author of many publications in his specialty.
Although he was keenly interested in all phases of
ophthalmology, his special interest was in the area 0|
corneal transplantation, where he made major co:
tributions.
He was Professor Emeritus of Ophthalmology]
Duke University School of Medicine, Associate Clini
cal Professor of Ophthalmology, University of Nortl|
Carolina School of Medicine and Ophthalmic Sur
geon, McPherson Hospital. He was a member of th
.AMA, Durham-Orange County Medical Society
Southern Medical Society, American Board of Oph
thalmology, American Ophthalmological Societ\;)
American Academy of Ophthalmology and Otolarynr
gology, Swiss Ophthalmological Society (past presijj
dent), Societe Francaise d"Ophthalmologie, anc;
Chairman of the International Medical Commissioi*.
for the examination of prisoners of war (Genev;;
Convention ) in the U.S.A. during World War II.
Dr. Stocker was a member of the First Presby
terian Church, the Durham Rotary Club, and he wa
past president of the Rotary Club of Lucerne. Hi
was also a member of the Board of Directors of th
Pestalozzi Foundation of America.
Surviving are his widow, Mrs. Mary Anne Steine
Stocker, three daughters, Mrs. Maya Powell of Nor
folk. X'irginia, Mrs. Gabrielle Bouchard of San Jose
California, and Mrs. Evelyn Ireland of Seattle, Wash
ington. and six grandchildren.
McPherson Hospital Staff
7 in
Vol. 35. No. 1
\'oria
Siirji
jfllijl
dm
Oplil
HEALTH SCIENCE^JM
rhe Official Journal of the NORTH CAROLINA MEDICAL SOCIETY D D D December 1974, Vol. 35, No. 12
^ORTH CAROLINA
Medical Journa
awfN THIS ISSUE: Obstetrical and Neonatal Services in North Carolina, Edward H. Bishop, M.D., and George W. Brumley,
^""^^M.D.; An Unusual Case of Miliary Tuberculosis: Prolonged Survival with Untreated Miliary Tuberculosis, Peter W. Munt,
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l-ley, Ph.D., William E. Smith, Ed.D., A. C. Linnerud, Ph.D., William H. Sonner, M.S., Chauncey L Royster, M.D., and Al-
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somatic complaints whicli 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 frequen(
and/ or severity of grand mal seizures m;
require increased dosage of standard an'
convulsant medication; abrupt withdraw,
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) ha\'i
occurred following abrupt discontinuan ;
(convulsions, tremor, abdominal and m j
cle cramps, vomiting and sweating). Kee
addiction-prone individuals under caret J
HERE
Muscles
and joints
I Wherever it hurts, Empirin
Compound with Codeine usually
provides the symptomatic
relief needed.
HERE
Headache
In flu and associated respiratory
infection, Empirin Compound
with Codeine provides an
antitussive bonus in addition to
relief of pain and bodily
discomfort.
/^rj? prescribing convenience:
V=i up to 5 refills in 6 months,
at your discretion (unless
restricted by state law); by
telephone order in many states.
Empirin Compound with
Codeine No. 3, codeine
phosphate* 32.4 mg. (gr. Vz);
No. 4, codeine phosphate*
64.8 mg. (gr. 1) ■Warning-may
be habit-forming. Each tablet
also contains: aspirin gr. 31/2,
phenacetin gr. 21/2, caffeine
gr. 1/2.
Burroughs Wellcome Co.
Research Triangle Park
North Carolina 27709
WHEN FLU HITS AND
HURTS
Wellcome
EMPIRIN
COMPOUND
c CODEINE
#3, codeine phosphate* (32.4 mg.) gr. V2
#4, codeine phosphate* (64.8 mg.) gr. 1
®
John H. Felts, M.D.
Winston-Salem
EDITOR
John S. Rhodes, M.D.
Raleigh
ASSOCIATE EDITOR
Ms. Martha van Noppen
Winston-Salem
ACTING ASSISTANT EDITOR
Mr. William N. Milliard
Raleigh
BUSINESS MANAGER
EDITORIAL BOARD
* W. McN. Nicholson, M.D.
Durham
CHAIRMAN
Robert W. Prichard, M.D.
Winston-Salem
John S. Rhodes, M.D.
Raleigh
Louis deS. Shaffner. M.D.
Winston-Salem
Rose Pully, M.D.
Kinston
George Johnson, Jr., M.D.
Chape! Hill
Charles W. Styron, M.D.
Raleigh
• (Deceased)
NORTH CAROLINA MEDICAL JOUR-
NAL, 300 S. Hawthorne Rd., Winston-Salem,
N. C. 27103. is owned and published by The
North Carolina Medical Society under the di-
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The North Carolina Medical Society 1974.
Address manuscripts and communications re-
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South Blvd., Oak Park. Illinois 60302 and/or
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in respect to strictly local advertising. In-
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Single copies. $1.00. Publication office:
Edwards & Broughton Co.. P. O. Box 27286,
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paid at Raleigh, North Carolina 27611,
NORTH CAROLIN/
MEDICAL JOURNAl
Published Monthly as the Official Organ o
The North Carolin;
Medical Societ
December 1974, Vol. 35, No. 1
Original Articles
Obstetrical and Neonatal Services in North Carolina
Edward H. Bishop, M.D., and George W. Brumley, M.D,
An Unusual Case of Miliary Tuberculosis: Prolonged
Survival with Untreated Miliary Tuberculosis
Peter W, Munt, M.D,
A Five-Year Study of Uric Acid, Cholesterol, and Selected
Fitness Variables in Professional Men
William P. Marley. Ph.D.. William E. Smith, Ed.D.,
A. C. Linnerud, Ph.D,. William H, Sonner, M.S.,
Chaunccy L. Royster, M.D., and
Albert L'Chasson. M.D.
Editorial
Cardiac Catheterization in the Newborn
72
72
73
Correspondence
Changes in Commitment Laws
N. P. Zarzar, M.D.
Emergency Medical Services
Alternative to "91 1"
William J. Henry. M.D.
Abstracted by George Johnson. Jr.. M,D,
Bulletin Board
New Members of the State Society
What? When':' Where?
Auxiliary to the North Carolina Medical Society
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.
American ,Academy of Family Physicians
American College of Emergency Physicians,
North Carolina Chapter
North Carolina Medical Peer Review Foundation, Inc..
Month in Washington.
Book Reviews
In Memoriam
Resolution
Classified Ads
Index to .Advertisers.
Index to Volume 35..
73>
73
73l
73
73
74:
74
74
741
74!
74
751
75
75.
75
75.
75'
761
76
Contents listed in Current Contents /Clinical Practice
irolif 1
71^
Obstetrical and Neonatal Services
in North Carolina
Edward H. Bishop, M.D..* and George W. Brumley, M.D.f
TUMEROUS factors, including
high perinatal mortality rates,
5 rapidly escalating costs of medi-
1 care, and the current enthusiasm
j; :X regionalization of perinatal ser-
es, have prompted many groups
take a critical look at the status
-I maternal and newborn services of
;ir individual areas. Almost all
ch studies raise the question of the
,sdom and the necessity of main-
i:ning small obstetrical and new-
nm services. The National Study
\ Maternity Care, sponsored by the
cnerican College of Obstetricians
i.;d Gynecologists (ACOG), indi-
cted that full obstetrical services
. . can only be provided effi-
cntly when more than fifteen
I' Imdred deliveries occur a year."'
!ie ACOG study stated further.
'. . . in more sparsely populated
lAmmunities limited but adequate
1! =rvice can be provided with a rea-
nable efficiency when five-hun-
]§(ed patients are delivered at the
!fspital per year."- A subcom-
,iittee of the Michigan State Medical
ciety reported, ". . . the subcom-
ittee takes a position that no hos-
7(&,
1" Professor of Obstetrics and Gynecology, Uni-
of North Carolina School of Medicine.
'lapel HiU. N. C. 27514.
A Associate Professor of Pediatrics. Duke Uni-
1( jilsity Medical Center. Durham, N. C. 27710.
'^ileprint requests to Dr. Bishop.
-CEMBER 1974. NCMJ
pital obstetrical department should
exist unless it cares for more than
five-hundred deliveries annually."-*
The Michigan subcommittee also
made an exception by stating, ". . .
the only exception to this position
is that the smaller departments
may occasionally be justified in
Michigan on the basis of the com-
munities" geographic isolation."''
The status of perinatal hospital
services in North Carolina has re-
cently been surveyed under the aus-
pices of the Task Force on Maternal
and Infant Care, which was ap-
pointed by the Governor's Advisory
Council on Comprehensive Health
Planning.^ The Task Force Hospi-
tal Survey reconfirmed information
available from the Division of
Health Services, Department of Hu-
man Resources, for 1972. These
data are presented as a matter of in-
formation and arc available for
every hospital, community and
county in our state.
In 1972 one-hundred thirty-four
hospitals in North Carolina reported
one or more births. Distribution of
these hospitals by the annual num-
ber of births is illustrated in Figure
I. Sixty-nine (52 percent) of the
hospitals reported fewer than 500
annual births; 118 (88 percent) re-
ported fewer births than the opti-
mum number recommended by the
ACOG study. There is little question
that, from the fiscal aspect, the
smaller services find it impossible to
function as efficiently as the larger
services, but a more important ques-
tion concerns the ability of the
smaller services to provide ideal or
complete medical care. Tradition-
ally, obstetrical and neonatal results
are judged by maternal, fetal and
neonatal death rates. In the year un-
der review, too few maternal deaths
occurred to permit analysis by size
of the hospital services. Fetal death
rates, controlled by the size of the
obstetrical services, are illustrated in
Figure 2. They demonstrate that in
1972, with the exception of those in-
stitutions reporting between 1,001
and 2.000 births, there was a direct
relationship between the fetal death '
rate and the annual number of
births. When the combined data
for a five-year period were used,
this trend was less evident, but
again, in this instance, the lowest
fetal death rates were reported by
those institutions reporting more
than 2,000 births. An analysis of
neonatal death rates (Figure 3)
reveals similar trends — a direct re-
lationship between the number of
births and the neonatal mortality
rate. .Again, the most favorable rate
was reported by those institutions
which had more than 12.000 de-
liveries. This trend also was less
evident when five-year averages
were used, bi.it the highest rate was
reported by the smallest hospitals,
725
iuiL
J-IOO 101-250 251-500 50M0O0 1001-2000 2001*
NUMBER OF Births
Fig. 1
DISTRIBUTION OF 134 HOSPITALS
BY NUMBER OF BIRTHS (1972)
and the lowest rate by the largest.
The frequency of prematurity is
probably the most important factor
influencing the neonatal mortality
rate. The relationship of these two
factors is shown in Figure 4. Those
institutions with the highest neonatal
mortality rate did report a dispro-
portionately higher percent of in-
fants with a birth weight less than
2.500 grams. The largest hospitals
(those with 2.000 or more births)
reported the lowest neonatal mor-
tality rate and the lowest percent of
newborns of low birth weight.
Numerous reasons justifying the
continued maintenance of the small-
er obstetrical services are often pre-
sented. Among these are previous
and current existence of facilities,
local community pride, and pres-
sures by local physicians. However,
the most important and most easily
justified reason is the necessity of
maintaining hospital services within
a reasonable distance from the pa-
BIRTH WEIGHT < 2500
101-
250
251- 501- 1001 200H
500 1000 2000
NUMBER OF Births
Fig. 4
NEONATAL MORTALITY RATE
AND PREMATURITY RATE BY
NUMBER OF BIRTHS
t 1968- ; 972
25C 500 1000 2000
NUMBER OF Births
Fig. 2
FETAL MORTALITY RATE BY
ANNUAL NUMBER OF BIRTHS
tients it serves. As will be shown
by subsequent data, in North Caro-
lina it is often difficult to dem-
onstrate this as a valid reason for the
maintenance of small services — ser-
vices which we must accept as hav-
ing certain inherent disadvantages.
Figure 5 represents the geographic
distribution of obstetrical and neona-
tal services in North Carolina in
1972. Each black circle represents
an area with a radius of appro.xi-
mately seven miles surrounding each
hospital providing maternity and pe-
diatric care. Expansion of this arbi-
trary "service area"" to a radius of
15 to 20 miles would not seem un-
reasonable and would illustrate that
almost every obstetrical patient, with
the exception of a few residing in
sparsely populated areas, is cur-
rently within one hour's transporta-
tion ( 15 to 20 miles) of an obstetri-
cal service. An even more impor-
tant obser\ation is that there is a
duplication and overlapping of com-
petitive obstetrical and neonatal ser-
vices, even when the conservative
seven-mile radius of a service area is
250 500 lOOO 2000
NUMBER OF Births
Fig. 3
NEONATAL MORTALITY RATE BY
ANNUAL NUMBER OF BIRTHS
used. The use of the larger, but st
practical, radius would make tl;
duplication even more evident ai
conspicuous. These observatioi
lead to an obvious question: Cou
not many obstetrical and neonat
services in North Carolina be coi
bined with the resultant improv
ment of both medical care and ef
ciency. without jeopardizing the ca
of patients and without imposi]
hardships on any segment of t
population?
In subsequent publications
shall discuss the utilization of ci
rent hospital facilities, distribution
manpower, and the current status
prenatal care and reproductive oi
comes in various geographic areas.
1. Bishop EH: The national study of matero
care. Int J Gynecol Obslet 8: 745-750. 1970
2. National Needs in Obstetrics and Gynecoi(
— Report of the Executive Committee. Ami
can College of Obstetricians and Gyneca
gists, 1971.
3. How to provide best care? Report of A
ternal and Perinatal Health Committee
Michigan State Medical Society. Michij
Med 72: 193-200. 1973.
4. Bishop EH: Unpublished report of T.'
Force on Maternal and Infant Care. 1974.
MILES
Fig. 5
GEOGRAPHIC DISTRIBUTION OF OBSTETRICAL AND NEONATAL SERVICES
Vol. 35, No.
An Unusual Case of Miliary Tuberculosis:
Prolonged Survival with Untreated
Miliary Tuberculosis
Peter W. Munt, M.D.
li
k ]
:o;ii
i:
E ;,
"N recent years, with the decline
' of new cases of tuberculosis,
lany other causes are now consid-
fed in the differential diagnosis of
iranulomatous diseases. Noncaseat-
.ig granulomas are usually consid-
"red more specific for sarcoidosis,
^rylliosis, syphilis, lymphoma,
Vmor-draining lymph nodes and
lyccses. However, it is often over-
'Iwked that early mycobacterial
iranulomas, especially in miliary tu-
erculosis, exhibit no caseation for
aliiany weeks prior to the develop-
lent of typical central necrosis,
^{erein is reported a third case of
aberculous peritonitis of the un-
Bual noncaseating type in associa-
tion with miliary tuberculosis. In-
iuded is an outline of the difficulties
'J diagnosing tuberculous peritonitis
nd a discussion of the dangers in-
\ f^rent in the assumption that failure
i*> 'o recover tubercle bacilli from non-
]i ^seating peritoneal granulomas cs-
1 ;ntially excludes tuberculous etiol-
/ « CASE REPORT
I A 53-year-old black man was ad-
litted to a hospital in March
972 for treatment of "pneumonia
and flu," although there was
apparent improvement. Readmission
three weeks later was necessary be-
cause of fever, sweats, a 70 pound
weight loss, and right upper quad-
rant abdominal pain. Apparently no
cause for these complaints could be
ascertained, apart from nonvisualiza-
tion of the gall bladder. A tubercu-
lin skin test PPD-S (5TU) was non-
reactive. A celiotomy performed in
May 1972 revealed diffuse, dense in-
filtrations of the entire peritoneum
with 0.5 to 1 .0 mm nodules; the liver
and spleen were not enlarged. The
histologic pattern was that of non-
caseating granulomas (Figure 1);
special stains and cultures of the
material were unrevealing for myco-
bacteria and fungi; talc particles
were not visualized. At this time the
chest roentgenogram revealed bilat-
eral diffuse miliary shadowing
(Figure 2). In addition, a review of
the chest roentgenograms of March
1972 strongly suggested a similar.
'From the Gravely Hospital and Department
,r«- Medicine, University of Nortli Carolin.i.
Ct loapel Hill. North Carolina 27514.
^ECEMBER 1974. NCMJ
Fig. 1. Peritoneal histologic .sections with
multiple noncaseating granulomas. Spe-
cial stains did not demonstrate acid-fast
bacilli. (H& E. x 185(.
Fig. 2. Classical bilateral miliarj shadow-
ing. No areas of chronic tuberculous foci
are seen.
727
albeit less distinct, pattern.
On a clinical and histological
basis it was concluded likely that the
patient had sarcoidosis, and a deci-
sion was made to treat him initially
with corticosteroids. After the ninth
day of steroids, streptomycin 1.000
mg daily and isoniazid. 300 mg daily
for ten days were administered, and
the patient showed clinical improve-
ment. He was then discharged from
the hospital on a regimen of isonia-
zid and ethambutol. Because he was
feeling quite well, the patient de-
cided to discontinue his medications.
Five weeks later (July 1972) he
awakened with a headache, malaise,
fever and profound weakness which
persisted for one week; he was ad-
mitted to the hospital because of dis-
orientation, ata.\ia. temperature of
103 F, blood pressure of 160 100,
and pulse rate of 100 beats per min-
ute. Muscular and mildly obese, he
showed marked disorientation and
delirium. Complete neurologic eval-
uation showed onl> torsion of the
neck to the right and pronounced
nuchal rigidity; no choroidal tu-
bercles were seen. The remainder of
the physical examination shov\eJ
only diffuse voluntary guarding of
the abdomen and a well-healed, right
upper quadrant laparotomy scar:
there was no hepatosplenomegaly
or ascites.
Laboratory data included a hema-
tocrit reading of 45 percent, white
blood cell count (WBC) of 8,500
per mm'' with 80 percent poly-
morphs. Urinalysis, blood urea,
serum electrolytes, calcium, and
SCOT were normal. Spinal fluid ex-
amination revealed an opening pres-
sure of 530 mm water with 128
white cells (88 percent lympho-
cytes), 304 mg dl protein, and 76
mg dl sugar. Culture of the spinal
fluid was positive for M . lubenuUi-
sis. the organisms being fully sensi-
tive to commonly used antitubercu-
losis drugs. In addition, it was dis-
covered that a gastric fluid culture,
reported two months earlier, was
positive for M. tuheiriilosis. PPD-S
( 5TU ) was 8 mm at 48 hours.
Therapy consisted of a regimen of
isoniazid. streptomycin, rifampin
and adrenal steroids. The patient's
mental status gradually impro\ed.
and eventually he was discharged on
a regimen of isoniazid, ethambutol
and pyridoxine. .\i present (January
1974) he continues to have some
neurologic sequelae (short atten-
tion span, ataxia and poor recent
memory ) although he has no further
abdominal pain and his chest roent-
genogram is normal.
DISCUSSION
This report is remarkable from
several points of view. First, it poi-
gnanth' demonstrates the pitfalls
inherent in the common misconcep-
tion that noncaseating granulomas
are usually caused by sarcoidosis or
other nonmycobacterial diseases
which may be responsive to corticos-
teroids. Indeed, in the present
study the patient had estab-
lished miliary dissemination of M.
tuberculosis for a period of more
than fi\e months, and steroids
alone would be contraindicated.
The development of tuberculous
meningitis and the probably perma-
nent neurologic sequelae in the pa-
tient discussed bespeak the dangers
at hand. With the antecedent history
of fever. 70 pound weight loss, ab-
dominal pain and a miliary pattern
on the chest roentgenogram, it was
appropriate to think in terms of tu-
berculous etiology although dissemi-
nated histoplasmosis or. rarely, sar-
coidosis' may occur with similar
findings.
Furthermore, it is unique that the
patient discussed in this report had
radiographicalh' documented, un-
treated miliary tuberculosis for more
than three months, received antitu-
berculosis therapy for only ten days,
and fortunately sur\i\ed for another
two monihs. Although documented
reports of prolonged survival with
untreated miliary tuberculosis ex-
ist.- • in general it has been un-
usual for patients to survive for more
than four to six weeks from the
asymptomatic onset. ^ This man not
only sur\i\ed with essentially un-
treated miliary tuberculosis, but he
did so while receiving corticoste-
roids— drugs which result in the
suppression of the cellular inmiune
response and other important host
defense mechanisms.
On the other hand, it must be
recognized that noncaseating gram
lomas of the peritoneum resultir
from M. tuberculosis are very ui
common. Fedotin and Brewei
have recently recorded two case
and point out the failure to previou!
ly document this pathological entit
in the literature. They point out th<
prior studies of peritoneal tuberci
losis,'''' by requiring caseatir
granulomas, positive cultures f(
M. tuberculosis, or demonstration i
acid-fast bacilli to satisfy diagnost
criteria, have thus excluded noi
caseating granulomas as a potenti
histology variant. The present ca;
is, therefore, the third report of noi
caseating peritoneal ganulomas n
suiting from tuberculosis, but it di
fers from the cases of Fedotin ar
Brewer in that it clearly occurred
association with miliary tuberculos
and no mycobacteria were recovere
from the granulomas. M. tubercuh
sis were, however, isolated from ga
trie and cerebrospinal fluids.
The usual presenting complaint
a case of peritoneal tuberculosis
abdominal distention, usually wii
chronic tenderness and pain whii.
may be sufficiently acute to mini
cholecystitis, appendicitis, or peh
inflammatory disease'' resulting :
laparotomy, as noted in the presei
ease. Most authors have agreed l\
many years that the so-calk
"doughy"" abdomen of tuberculoi
peritonitis is unreliable, uncommc
and oseremphasized as a diagnost
sign.-' ^ '" Ascites is usual, but is t
no means universal. For example. :
one study'" five of 32 patients did in
have clinical ascites except on lap;
rotomy. Tuberculous peritonitis m;:
be easily overlooked in patients wii
hepatic cirrhosis and ascites, esp'
cially since there may be no feve
the chest roentgenogram may I:
normal, and the tuberculin skin te
ma\ be negative. Fever is usual, ai"
not uncommonly an abdominal m;i
ma_\ be present as a result of adhe
ent bowel and omentum.
Most cases of peritoneal tuberci
losis represent disseminated or mil
ary forms of tuberculosis as exen
plified by the present case and :
suggested by others.'' " .Appro ■;
mately one-third of these patien
ha\e evidence of pulmonary tub^
728
Vol.. -VS. No.
[iiulosis, often of the pleuritic
"lit jype.'^' •* However, a normal chest
poentgenogram is common despite
jecovery of tubercle bacilli from
* ijputum antemorten or at autopsy in
i». jniliary tuberculosis.'
ii It is not surprising that the tuber-
culin skin test has varying positivity,
;lepending on the duration and se-
al j'erity of the tuberculous disease. In
\ prior study of miliary tuberculosis
||y this author' only 52 percent of
(he patients had positive tuberculin
iifoeactions to the equivalent of 5 TU
lif PPD-S; similarly, studies of peri-
ci aoneal tuberculosis have recognized
« d high degree of tuberculin negativ-
siity.-'' "• "
i ( In summary, this patient had an
ni»ccult illness, a negative tuberculin
Wn test, a normal chest roentgeno-
i i(;ram, no ascites, and noncaseating
til i
granulomas on peritoneal biopsy
which were negative on stain and
culture for mycobacteria, and yet he
hud tuberculous peritonitis in asso-
ciation with miliary tuberculosis.
SUMMARY
The rare occurrence of noncaseat-
ing granulomas of the peritoneum
caused by M. tuberculosis was deter-
mined in a patient who had miliary
tuberculosis. This unusual entity and
its diagnostic pitfalls have been ex-
emplified and discussed. Unusual al-
so was the well-documented, pro-
longed survival (for more than five
months ) with essentially untreated
miliary tuberculosis culminating in
tuberculous meningitis.
References
1. Becker WF, Coleman WO: Surgical sig-
nificance of abdominal sarcoidosis. Ann Surg
15.1: 9S7-995, 1961.
2. Fenichel NM: Fever of seven months dura-
tion due to subacute miliary tuberculosis. —
Clinical arrest with antituberculous drugs.
NY Stale J Med 54: 2987-2990. 1954.
^. Munt PW; Miliary tuberculosis in the chemo-
therapy era: With a clinical review in 69
American adults. Medicine 51: 139-155,
1972.
4. Muschenheim C: Disseminated hematogenous
tuberculosis: Miliary tuberculosis, in Beeson
PB. McDermott W (eds): Cecil-Loeb Text-
book of Medicine, ed 12. Philadelphia: WB
Saunders Co, 1967. pp 291-29.1.
5. Fedotin MS. Brewer DL: Noncaseating tu-
berculous peritonitis. Arch Intern Med 130:
920-922. 1972.
6. Hughes HJ, Carr DT, Geraci JE: Tubercu-
lous peritonitis: A review of 34 cases with
emphasis on the diagnostic aspects. Dis Chest
38: 42-50, 1960.
7. Singh MM, Bhargava AN. Jain KP: Tubercu-
lous peritonitis: An evaluation of pathoge-
netic mechanisms, diagnostic procedures and
therapeutic measures. N Engl J Med 281:
1091-1094, 1969.
8. Borhanmanesh F. Keyoumars H. Vaezza-
deh K.. Rezai HR: Tuberculous peritonitis:
Prospective study of 32 cases in Iran. Ann
Intern Med 76: 567-572, 1972.
9. Sochocky S: Tuberculous peritonitis: A re-
view of liKi cases. Am Rev Resp Dis 95:
398-401, 1967.
10. Burack WR. Hollister RM: Tuberculous
peritonitis: A study of forty-seven proved
cases encountered by a general medical unit
in twenty-five years. Am J Med 28: 510-523,
1960.
1 1. Johnston FF. Sanford JP: Tuberculous peri-
tonitis. Ann Intern Med 54: 1125-1133. 1961.
I i
111
SB
1 1
(1.
Il
i
,!
f
I
«
y
When you have not a scientific demonstration of the facts, always say. in giving your opinion,
that you do not know. Not only will you be speaking the truth, but it is much better to say
at the preliminary examination. "I do not know." than to he forced at the trial to say. "1 did
not know." — Dealli and Sudden Death, P. Brouardel, 1S97, p. 20.
teCEMBER 1974. NCMJ
729
)
A Five-Year Study of Uric Acid, Cholesterol,
and
Selected Fitness Variables in Professional Men
William P. Marley, Ph.D., William E. Smith, Ed.D., A. C. Linnerud, Ph.D.,
William H. Somier, M.S., Chauncey L. Royster, M.D.,* and Albert L. Chasson. M.D.^
P VIDENCE has accumulated
which links serum cholesterol
(SC) with cardiovascular disease. No
lipid or battery of lipids appears to
be more useful than an accurate SC
value for the purpose of predicting
coronary heart disease (CHD) in
men and young women. This is true
despite uncertainty concerning the
regulation of cholesterol in the body,
its optimal range of values, details
of its involvement in pathogenesis,
and its determinants within popula-
tions.' For instance, there is no
■■normal"' SC reading, but risk ap-
pears to increase exponentially as SC
rises in linear fashion. A person with
an SC of 260 mg/dl is at an approxi-
mately five times greater risk than
one whose SC is 200 mg/dl. Those
people having readings higher than
400 mg/dl rarely live to the age of
fifty.-
Recent research has provided
some elegant explanations of the
modus operandi by which choles-
terol may promote atherogenesis.
Shimamoto and his colleagues ■ have
From the Department of Physical Education.
Physical Fitness Laboratory. North Carolina
Stale University. Ralcii;h. N- C. 27607 (Drs.
Marley. Smith, and Linnerud; W. H. Sonner).
" Attending physician. Rex Hospital. Raleigh.
N. C.
t Director of Laboratories, Rex Hospital, Ra-
leigh, N. C.
Reprint requests to Dr. Marley,
extended the findings of Anitsch-
kow^ who produced experimental
atherosclerosis by daily oral admin-
istration of cholesterol to rabbits.
A single dose of cholesterol appears
to permit infiltration of substances
such as lipoproteins,' fibrinogen,"
and cholesterol" into the subendo-
thelial space and medial layers of an
artery. The platelet-repelHng func-
tion of endothelial cells is also re-
duced,' thus initiating viscous meta-
morphosis.
Studies of SC levels, after patients
had a strenuous bout of exercise,
have presented conflicting find-
ings — some indicating increases "■'"
and others indicating no change."' '-'
Chronic (long-term) physical train-
ing, however, appears to be capa-
ble of lowering SC, provided that
the SC level is high at the start of
the program and that the exercise is
sufficiently vigorous. '■'■■ '^
Systems for uric acid regulation
are clinically relevant in man be-
cause excessive retention can lead
to the precipitation of crystals which
may initiate acute and chronic gouty
arthritis'' and may be related to
systolic blood pressure"' and hyper-
tension.'"- '■■ In addition, some
studies of patients with known CHD
showed that these patients had high-
er levels of serum uric acid (SUA
than SC.'-' -" Finally, Moore aiP
Weiss-' suggest that uric acid m;
damage the vascular intima, predi
posing it to cholesterol deposition.
An association has been reportt.
between hyperuricemia and hype-
cholesterolemia.-- -'-' Pincherle
has suggested that the association
hyperuricemia with increased levc
of coronary thrombosis is attributt
to their common association wi
raised SC levels. This association
also indicated by the Framingha
study--' which yielded a significa
relationship between gouty arthrii
and CHD. Kohn and Prozan-- cc
eluded that hyperuricemia appea
to be a concomitant of myocardi
infarction with approximately tl
same degree of frequency as h
percholesterolemia. The work
Schoenfeld and Goldberger--' leni
further support to the suppositit
of a fundamental link between the
substances; they report a positi'
correlation between absolute levi
and the direction and magnitude
diurnal change in SC and SL
levels. Gertler and associates-" :i
tempted to clinically apply this a
parent relationship by incorporati ;
SUA levels into a ratio with S
levels and phospholipid levels. The
730
Vol. 35, No.
^arpose was to assess individual
IHD risk.
' The increase in SUA resulting
|iom a strenuous bout of exercise
ias been well documented.-"
ihanges in SUA with training are
*ss consistent. Studies have shown
icreases,-** decreases,-"' and no
jTiange.''"
i The purpose of the present study
'as to examine the effects of train-
ig on SC, SUA and selected fitness
'ariables in professional men during
ifive-year longitudinal exercise pro-
ram. The interrelationships of these
fariables were also examined.
PROCEDURE
The exercise program was initi-
ited in October 1961 as a service to
!ie community, and although re-
Earch is secondary to this original
iiurpose, two papers'*'' ^- have re-
lorted findings from subsequent in-
estigations. All variables, except
le 1.5 mile run and SUA, were as-
issed from the beginning. The 1.5
eifciile run was begun in 1968 and the
djT/UA collection in 1967, the year in
irt yhich the present study was initi-
- ted. Calisthenics of high duration
i,r nd intensity comprised the exercise
tij, (fogram during the first three years.
^i; logging was introduced in the fourth
r jear, and the duration and intensity
. ., f calisthenics were lowered accord-
:?. I'lSly-^
I V Thirty-one professional men were
,,,, [[elected for the study. Five were re-
,y. ;eased from the program because
': ledication which had been pre-
;[)[ jicribed for them affects SC and
. yUA. The remaining 26, from the
1 .iges of 36 to 70, included business-
. pen, bankers, lawyers, professors,
,iditors, physicians, dentists and
, government officials. They partici-
j^ lated in three formal exercise ses-
ijj -ions each week for nine months
,,|, i,i each of five years (1967 to
,|,,g'972). The exercise sessions were
j[ j onducted on a gradually progres-
,,j ive basis by trained instructors, and
jjuicluded calisthenics, rope skipping
5[Und bench stepping. In addition, all
(Jiubjects ran or jogged for at least
.,U0 minutes, twice and usually three
jijirmore times weekly. Subjects exer-
I Wsed on an individual basis during
fjiiummer months. All exercise repeti-
tions and running mileage were
recorded on individualized forms
kept in a locker room file. The fol-
lowing data were obtained in the fall,
winter and spring of each year:
height, weight, body fat measured by
skinfolds, 1 .5 mile run time, bent
knee sit-ups, chin-ups, lateral jump
over a 15-inch rope, resting pulse,
pulse after three-minute modified
Harvard step test on a 17-inch
bench, SC, and SUA.
Skinfolds were assessed by the
method of Brozek and Keys'''' and
converted to percent body fat by the
Rathbun and Pace formula.''^ The
1.5 mile run was completed on a
quarter-mile track. Bent knee sit-
ups, chin-ups, and lateral jumps
were the maximum number that
could be achieved. Resting heart rate
was recorded in the supine position
after a five-minute rest prior to the
modified Harvard test. From ante-
cubital blood samples, both the SC
and SUA were calculated with stan-
dard colorimetric methods-*'' ■'" by
means of a Technicon Auto An-
alyzer at Rex Hospital chemistry
laboratory.
Coefficients of variation for the
six-year period, 1967-1972, inclu-
sive, were calculated to be four per-
cent and 1.7 percent for SC and
SUA, respectively.
RESULTS AND DISCUSSION
Group SC values decreased from
fall to spring in every year but 1971-
1972 (Table 1). The increase in
1971 may be related to an aging
effect; that is, the liver is known
to metabolize lipids less effectively
with age.'"* Further indication of
the effects of age is provided by the
significant (P<0.01) correlation
between SC and age (Table 2). Al-
though the rise in SC with age is
well known, most studies show a
plateauing near the age of 50, which
may be the result of a survivor ef-
fect. That is, men with high SC and
a high coronary risk tend to die
earlier, thus reducing the mean cho-
lesterol of the survivors.-^ Some
research'" -"' has shown that partici-
pation in regular, vigorous exercise
may possibly help in resisting this
natural tendency of SC to increase
with age. It is possible, in this re-
spect, that a training effect may have
been obscured, in the present study,
by individual differences in time of
entrance into the program. For in-
stance, ten subjects had participated
in the program for six years prior
to the start of the program, and five
entered the program in 1967. How-
ever, in this context, all group SC
means except two (fall and winter,
1969-1970) were lower than the ini-
tial group mean of 237 mg/dl (Ta-
ble 1 ) .
Similar results appear in Table 3
which lists annual group values. Pre-
vious studies of men in the North
Carolina State Fitness Class have
shown significant decreases in SC
with training" and have indicated
that their SC was lower than usual
for men in the fourth and fifth de-
cades.''- Scrutiny of individual data
yields findings similar to those of
Golding'-' who observed reductions
in SC during the first, second and
third years. During the fourth and
fifth years, however, the SC level in-
creased. A plateau was achieved in
the sixth year and, although it had
increased, it was still significantly
below original levels. A secondary
reduction occurred in the seventh
Table 1
Group Five-Year Seasonal SC and SUA Values
SC
Fall
SUA
SC
Winter
SUA
Spring
SC SUA
1967-68
199
7.00
204
6.50
195
6.91
1968-69
229
6.66
212
6.62
214»
6.94
1969-70
239
6.57
247
6.32
226"
6.26
1970-71
212
6.62
216
6.21
207
6.74
1971-72
209
7.50
219
6.62
220"
6.62"
Group mean
Group mean
a. P <;0.01
SC upon entry to program =
SUA at first measurement —
for difference from fall value
237
7.00
mg, dl
mE dl
b. P <;0.05
for
diffe
ence
from
fall value
IJecember 1974, NCMJ
731
'/
Table 2
Five Year Correlations
HT
STEP
REST
WEIGHT
^WT
BODYFAT
CHINS
JUMPS
SITUPS
1.SM RUN
TEST
T-SCORE
PULSE
sc
SI
AGE
-0.359'
-0.124»
0.243»
-0.359'
-0.272>
-0.257-
0.616-
0.505-
-0.414-
0.133-
0.2U-
0.1)
TIME IN
-0.266"
-0.044
-0.158'
0.130"
-0.348-
0.152"
0.1231'
0.106"
0.232-
-0.015
0.201-
0.2;
HEIGHT
0.690-
0.205'
-0.106"
0.077
0.131-
0.169-
-0.418- -
-0.410-
0.204"
-0.288-
-0.169-
-o.o:
WEIGHT
-0.091
O.303>
-0.182-
-0.063
-0.210"
-0.313- -
-0.169-
-0.062
-0.238-
—0.044
-0.0
HT
-0.125"
-0.005
0.161-
0.217-
0.056
-0.138"
0.105
0.013
0.282-
0.01
X/V/J
BODYFAT
-0.602-
-0.509-
-0.495-
0.447-
0.492-
-0.619-
0.198"
0.179-
0.1
CHINS
0.508-
0.385"
-0.361- -
-0.280-
0.757"
-0.094
0.048
0.1
JUMPS
0.499»
-0.555- -
-0.420-
0.774-
-0.222-
-0.011
0.0
SITUPS
-0.421- -
-0.519-
0.680-
-0.243-
-0.183-
-0.1
1.5 M RUN
0.563'
-0.596-
0.321-
0.371-
0.1
0.21
STEP TEST
-0.566-
0.582"
0.304-
T-SCORE
-0.216-
-0.073
0.0
REST PULSE
0.049
0.1
SC
0.2
' P ^0.01
" P <0.05
year, coinciding with the national in-
terest in jogging and the program's
addition of increased running.
Pincherle-^ witnessed seasonal
variations in SC. Values were high-
est in the winter, fell during the
spring, reached minimum in the
summer, and rose again in the fall.
.A similar trend, which may be at-
tributable to an inverse relationship
between SC and air temperature, is
seen in the present study during
1967-1968, 1969-1970, and 1970-
1971.
The changes in SUA from fall to
spring (Table 1) were not as con-
sistent as those exhibited by SC. This
lack of consistency, however, may
be spurious. For example, all blood
samples were obtained in the post-
absorptive state, and Ogryzlo" has
shown that, in the fasting patient,
uric acid excretion diminishe-s on the
first day. Obsei"vations of diurnal
variation in uric acid excretion show
that the normal increase in excretion
which occurs during the afternoon
period disappears completely if the
morning and noon meals are
omitted^--^^ A decreased excretion
of uric acid can therefore be detect-
ed within 12 hours of commencing a
fast; this effect has been attributed
to the mobilization of fatty acids
and a consequent ketonuria. The ef-
fects of a high fat diet are compar-
able, although less dramatic. No at-
tempt was made to control diet in
this study. As mentioned previously,
SUA analysis was not initiated until
1967. Therefore, some training ef-
fects may have been obscured. Every
Table 3
Annual Group Profiles
1967-1968
1968-1969
1969-1970
1970-1971
1971
-1972
Age (months)
47.8 = 7.4
48.4
i
7.2
49.5
±
7.2
50.5
±
7.2
51.4
± 7.2
Months in
Program
49 ± 26
55
^
30
69
i
30
80
±
30
92
* 30
Height
69 ± 3
69
±
3
69
±
3
69
*
3
69
± 3
Weight
168 = 21
170
±
20
170
±
20
171
±
20
171
It 20
Ponderal
Index
12.35 i 1.30
12,31
±
1.24
12.30
±
1.24
12.30
i
1.23
12.29
* 1.24
Bodyfat
7.5 i 3.3
8.4
^
3.2
8.2
±
3.0
8.3
±
3.1
7.9
:t 2.8
1.5m run
not
(minutes)
employed
U.4
±
2.6
11.5
=
2.5
11.4
It
2.3
11.8
= 2.6
Step Test
51 ~ 10
47
^
11
48
rt
10
47
It
10
47
i 11
T-Score
62 = 15
62
±
15
63
±
15
66
It
12
67
= 13
Rest Pulse
30 ± 3
29
—
5
29
±
4
29
It
4
29
± 4
SC
199 -± 33
218
±
40
237
±
43
212
:t
38
216
± 42
SUA
6.83 i 1.24
6.74
±
1.35
6.38
zt
1.29
6.52
±
1.29
6.91
It 1.45
Group mean SC upon entry to program — 237 mg, dl
Group mean SUA at first measurement — 7.00 mg/dl
group mean except one (fall 197
1972) is lower than the initial groi
value of 7 mg/dl, the value also coi
sidered hyperuricemic in males. ^'
The professional responsibiliti
of all subjects involved executi'
and administrative duties which r
quired the subjects to make dec
sions and meet deadlines. This r
quirement is relevant in that mo
previous studies have shown SU
levels to be highest in well-educatt
professionals or executives.^''
Brooks and Mueller^^ suggest th
the high values of SUA observed
these people are related to the
drive and competitive nature. Tt'
influence of psychologic stress h,
also been noted on SC, having bet
observed in patients following
stressful interview,""'' accountants b
fore tax deadlines,'"' and in medic
students at examination time.'^
Subjects were then divided in
subgroups (Tables 4-7) for pu
poses of more detailed analysis. Tt
first four groups were formed wi
the criteria of training frequenc
running mileage, observed moti\
tion and physical fitness test pe
formance. Group five was compos,
of four postcoronary subjects ai
one who had angina pectoris. Tab
4, with three exceptions, shows c
creases for every subgroup from f
to spring in the first four years >
the study. During 1971-1972. ho.
ever, increases in SC were present,
by every group, similar to changi
732
Vol. 35. No.
exhibited by the group mean dis-
cussed previously. These changes
may result from a change in the SC
standards employed in the Rex Hos-
feipital chemistry laboratory. Figure 1
t. ^appears to provide some support for
' hthis contention. Comparison of
I'mean SC values of each group upon
t nentrance into the program with
spring values of each year — those
J: ['most likely to reflect the effects of
u jtraining — yields only two spring
•; [(Values higher than those initially ob-
j Itained. Further examination of Ta-
li ilbles 4 and 5 shows that the three
*; [most active groups (1-3) exhibited
newer SC than groups 5 and 6 in all
testing periods while group 4, the
least active, presented the highest
- jSC and SUA of all groups in every
testing period except one (i.e., winter
1968-1969, group 5 SC was higher
"jthan that of group 4). This same
pattern is reflected in the five-year
seasonal values (Table 6). These
■ kiata appear to dramatize the efficacy
•* bf exercise in controlling SC and
SUA.
Correlations (Table 2) between
'^ SUA and age, time in program, step
j'.est, resting pulse, chin-ups, and SC
'■'were significant at the 0.01 level.
Body fat, sit-ups, and 1.5 mile
"un were related to SUA at the
i).05 level. Significant correlations
M ■
I ( 400 r
.!!«% t
380^
iill
Table 4
Subgroup Yearly Seasonal SC Changes
Year
1967.68
1969-70
1970-71
1971-72
Entrance
ubgroup
SC
1
236
2
201
3
202
4
278
5
281
1
236
2
201
3
202
4
278
5
281
1
236
2
201
3
202
4
278
5
281
1
236
2
201
3
202
4
278
5
281
1
236
2
201
3
202
4
278
5
281
Fall Wintei
192 197
184 170
187 195
226 247
214 219
230 213
188 176
204 195
272 231
253 252
225 241
204 210
227 238
286 285
257 274
196 207
183 184
198 197
257 252
231 243
192 210
179 182
191 201
253 269
236 239
Spring
184
162
196*
231*
207
209
177
204 1
245
236
217
196
210t
263
248
198*
179
193
245
223
209*
188*
201*
264*
241*
* Higher than fall value.
t Higher than entrance SC value.
(P<0.01) were also observed be-
tween SC and age, time in the pro-
gram, height, ponderal index, body
fat, sit-ups. 1.5 mile run and step
test.
The significant positive relation-
ship between SC and SUA is in
agreement with findings from previ-
ous research with coronary pa-
tients,-- -'' hypercholesterolemia, ^-
stress,''-' and gout."'^ Klein's study*"'
of 2,530 white and black males
and females, however, presents
360-
340^
320-
300^
i i I 280-
ff^ 260-
IP* i
M I
Till
240-
220-
200-
180-
160-
140-
120-
F W S F W S F
flT-ra S7-68 S7-6B 66-68 68-69 66-66 69-70
[IFlg. 1. Subgroup SC seasonal fluctuations
.iSnbgroup 2: © O i Subgroup 3
iSubgroup 5! Q Q ; Group msan
jJECEMBER 1974. NCMJ
//
W S F W S
(-70 69-70 70-71 70-71 70-71
Subgroup 1
Subgroup
-72 71-72 71-
Fable 5
Subgroup
Yearly
Seasonal
SUA Chan
ges
Year
Subgroup
Fall
Winter
Spring
1967-68
1
6,63
6.95
6.80
2
6.60
5.43
6.50
3
6.92
6.47
7.16
4
8.78
7.54
8.00
5
6.83
5.88
6.08
1968-69
1
6.80
6.10
7.65
2
6.07
6.18
6.04
3
6.58
6.77
7.08
4
8.09
7.80
8.40
5
5.93
6.48
5.69
1969-70
1
6.55
5.64
6.07
2
6.35
5.93
5.86
3
6.73
6.61
6.47
4
7.19
8.18
7.30
5
6.09
5.31
5.72
1970-71
1
6.46
6.18
6.52
2
5.95
5.56
5.90
3
6.68
6.28
7.10
4
8.41
7.60
7.70
5
5.79
5.60
6.28
1971-72
1
7.20
6.22
6.02
2
6.92
5.72
5.82
3
7.06
6.68
6.75
4
9.33
8.40
8.68
5
7.06
6.44
6.14
733
Table 6
Subgroup Five Year SC and SUA Seasonal Values
Fall
Winter
Spring
Subgroup
N
SC
SUA
SC
SUA
SC
SUA
1
6
207
6.73
214
6.22
203
6.61
2
5
188
€.37
185
5.78
181
6.00
3
6
202
6.79
205
6.57
201
6.90
4
4
259
6.49
256
7.90
205
8.02
5
5
239
6.32
247
5.92
232
5.98
Table 7
Subgroup Five Year Profiles
Subgro
up 1
Subgroup 2
Subgroup 3
Subgroup 4
Subgroup 5
Age (months)
44.3
=
4.4
48.3
=
3.8
47.3
—
2.3
59.5 ^
6.8
51.5
IT 7.6
Months in
73
i
32
65
i
27
48
zt
29
98 It
17
63
It 36
Height
71
i
2
71
±
2
68
^
4
68 ±
2
68
t: 1
Weight
175
=
18
181
±
18
174
±
25
164 ±
22
158
± 12
Pondera!
index
12.78
-+-
.45
11.61
^
2.27
12.24
±
.24
12.40 It
.19
12.50
± .37
Bodyfat
5.5
^
3.0
9.3
i:
1.8
8.4
±
2.5
10.4 ±
2.7
8.6
i 2.6
Chinups
14
i
4
11
It
3
9
±
3
9 It
5
11
^ 3
Vertical
Jumps
109
-1-
38
63
:*:
23
61
±
28
53 ^
18
47
± 14
Situps
162
±
102
107
:t
55
76
±
33
57 *
24
96
= 49
1.5m run
(minutes)
9.1
-^
.7
10.8
^
.5
11.5
^
.6
14.1 :t
1.1
13.8
- 3.0
Step test
39
:r
7
48
=
6
45
=
8
51 i
7
52
^ 7
T-Score
76
±
10
65
=
10
59
=
12
54 =
14
51
= 10
Rest pulse
27
^
2
29
~
3
29
:t
2
31 *
6
30
= 4
SC
204
^
30
197
~
33
192
±
35
255 =
44
239
= 32
SUA
6.40
-
1.06
6.62
—
1.36
6.33
—
1.05
8.09 =
1.33
6.07
It .95
data showing no significant rela-
tionship between these variables.
These same investigators also made
observations regarding SUA and
age. They suggest that several fac-
tors are involved with significant
roles probably being played by
changes in dietary habits and physi-
cal activity. These findings are at
variance with Montoye et al''"' who
concluded, as a result of their study
of 167 business executives ranging
in age from 30 to 59 years, that SUA
is not related to age. Mikkelsen et
al"'" present similar results.
The inverse relationship between
height and SC duplicates the findings
of Pincherle.-* As a result of his
findings, he postulates that the great-
er coronary risk observed in short
people may be accounted for by
their common relationship with SC.
The lack of association observed be-
tween ponderal index and SUA is
at variance with results from pre-
vious research by Gertler et al-'' and
Klein et al''"' who reported a signifi-
cant association between increased
ponderosity and hyperuricemia. The
relationship between SC and body
fat is well documented.'' ''■" Indeed,
previous studies indicate an associ-
ated rise of serum lipids with weight
gain"'-' and a decrease concomitant
with a decrease in weight.''" Strong
correlations between SUA and mea-
sures of body weight,'''- ''- obesity,''"'
and body size-'' also have been re-
ported.
CONCLUSIONS
1 . The chronic effect of regular,
vigorous exercise is a decrease in
both SC and SUA concentrations.
2. There is a relationship between
SC and SUA concentrations.
3. Serum cholesterol and SU.A
concentrations are age-related.
4. Serum cholesterol concentra-
tion varies with body fat, as does
SU.A. concentration to a lesser de-
gree.
References
1. Kannel Vt'B: Lipid profile and the potential
coronary victim. Am J Ciin Nutr 24: 1074-
1081, 1971.
:. Eliol RS. Mathers DH: Sudden death . . .
are there anv real warnings'? Consultant 12:
61-6.1, 1972.
.1. Shimamoto T, Numano F: Contraction and
relaxation of endothelial cells covering
atheroma and their significance. Proc Japan
."iicad 49: 77-81. 197.1.
4. Anitschkow N: Ueber die Veranderungen
der Kaninchenaorta hei expenmenteller
Cholesterinstealose. Beitr Pathol Anat 56:
379-404. 191.1.
5. Shimamoto T: New concept on atherogenesis
and treatment of atherosclerotic diseases. Jap
Heart J 11: 517-.562. 1972.
6. Adams CW: Lipids, lipoproteins and alhero-
sclerotic lesions. Proc R Soc Med 54: 902-
905, 1971.
7. Shimamoto T: The relationship of edematoui
reaction in arteries to atherosclerosis and
thrombosis. J Atheroscler Res 3: 87-102,
1963.
8. Sannersledt R. Sanbar SS. Conway J: Me-
tabolic effects of exercise in patients with
tvpe IV hvperlipoproteinemia. Am J Cardiol
25: 642-648, 1970.
9. Naughton J. Balke B: Physical working ca-
pacity in medical personnel and the re-
sponse of serum cholesterol to acute exercise
and to training. Am J Med Sci 247: 286-
292. 1964.
10. Fitzgerald O. Heffernan A. McFarlane R:
Serum lipids and phvsical activity in normal
subjects. Clin Sci 28: 83-89, 1965.
11. Jarvonen MJ. Rautanen Y. Rikkonen P,
Kihlberg J: Serum cholesterol of male and
female champion skiers. Ann Med Intern
Fenn 47: 75-82. 1958.
12. Carlson LA. Mossfeldt F: Acute effects of
prolonged, heavy exercise on the concentra-
tion of plasma lipids and lipoproteins in
man. Acta Phvsiol Scand 62: 51-59. 1964.
13. Cureton TK: Physiological Effects of Exer
cise Programs on Adults. Springfield. Illi
nois: Charles C Thomas. 1971. pp 52-55.
14. Golding LA: Serum cholesterol levels in
adult men as effected bv prolonged exercise
Fed Proc 21: 96-101. 1962.
15. Simkin PA: Uric acid binding to serum pro-
teins: differences among species 136196).
Proc Soc Exp Biol Med 139: 604-606. 1972.
16. Sive PH. Mcdahe JH. Kahn HA. Neufelc
HN. Riss E: Distribution and multiple re
gression analysis of blood pressure in lO.OOC
Israeli men. Am J Epidemiol 93: 317-327
1971,
17. Kahn HA. Medalie JH. Neufeld HN. Riss E
Goldbourt U: The incidence of hypertensior
and associated factors: the Israel ischemic
heart disease studv. Am Heart J 84: 171
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18. Garrick R. Ewan CE. Bauer GE. et al
Serum uric acid in normal and hypertensivt
.Australian subjects. Aust NZ J Med 2: 351
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19. High level of txith uric acid, cholestero
raises heart risk, Ini Med Ne^'s, Nov 15
1971, p 3,
20. Serum uric acid and CHD. Lancet 1: 358
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21. Moore CB. Weiss TE: Uric acid melabolisn
and myocardial infarction, in James TN
Keves JW (eds): The Etiology of Myo
cardial Infarction, Boston: Little, Brown
and Co,. 1963. pp 459-479.
22. Kohn PM. Prozan GB: Hyperuricemia-
relationship to hypercholesterolemia ant
acute myocardial infarction. JAMA 170
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23. Schoenfeld MR. Goldberger E: Serum cho
lesterol — uric acid correlations. Metabolisn
12: 714-717. 1963.
24. Pincherle G: Factors affecting the meai
serum cholesterol. J Chronic Dis 24: 289
297. 1971,
25. Hall AP: Correlations among hyperuricemia
hypercholesterolemia, coronary disease, am
hypertension. Arthritis Rheum 8: 846-852
1965,
26. Gertler MM. Gam SM. Levine SA: Seruc
uric acid in relation to age and physique ii
health and in coronary heart disease. An:
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27. Bosco JS. Grcenleaf JE: Relationship be
tween hyperuricemia and gout, hereditar
and behavior factors, and CV disease — wit
special emphasis on the role of acute an'
chronic phvsical exercise, in Franks BI
led): Exercise and Fitness, Chicago: At!
letic Institute. 1969, pp 83-95.
28. Mann GV. Garrett HL. Farhi A. Murray H
et al: Exercise to prevent coronary heai
disease. Am J Med 46: 12-27, 1969.
29. Bosco JS. Greenleaf JE, Kaye RL. Averki
EG: Reduction of serum uric acid in youn
men during phvsical training. Am J Cardit
25: 46-52. 1970.
30. Calvv GL. Cady LD. Mufson MA, et al
Serum lipids and enzymes: Their levels aftf
high-caloric, high-fat intake and vigoroi
exercise regimen in Marine Corps recru
personnel, JAMA 181: 1-4. 1963,
II, Smith WE. Sonner WH: A study of physici
fitness in middle-aged men. Presented at Ri
search Section, Southern District. AAHPE
Convention. Knoxville. Tennessee. Feb 2:
1963, (Unpublished),
32, Pollock ML. et al: Physiological findings i
v^ell-trained middle-aged American men. Pn
senled to the .Will World Congress c
Sports Medicine. Oxford. England. Sept
1970. (Unpublished).
33. Brozek J. Keys A: The evaluation of le.
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12,
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position. I. The determination of total body
fat by means of the bodv specific gravity.
J Biol Chem 158: 667-676, 1945.
Levine J, Morgenstern S, Vlastelica D: A
direct Liel>ermann-Burchard method for
serum cholesterol, in Automation in Analyti-
cal Chemistry. White Plains, New York:
Mediad Inc. 1968, pp 25-28.
Musser AW, Ortigoza C; Automated de-
termination of uric acid bv the hvdro.xvla-
mine method. Techn Bull Regist Med Techn
36: 21-25. 1966.
Nishi HH: Determination of uric acid: an
adaptation of the Archibald method on the
autoanalyzer. Clin Chem 13: 12-18, 1967.
Iron-prolein improves lipid metabolism. Sci-
ence Ne<ii 102: 238-243. 1972.
Golding LA: Cholesterol and exercise — a ten-
year study, in (special report) National
YMCA Physical Fitness Consultation, edited
by Myers CR, J Phys Educ, March-April:
106-110. 1972.
MD's running for their lives in race with
heart disease. Med Trib 14: 47. 1973.
Ogryzio MA: Hyperuricemia induced by high
fat diets and starvation. Arthritis Rheiim 8:
799-822, 1965.
Lennox WG: A study of the retention of
uric acid during fasting. J Biol Chem 66:
521-572. 1925.
Lewis HB. Dunn MS. Doisy EA: Studies in
uric acid metabolism. II. Proteins and amino-
acids as factors in the stimulation of endo-
genous uric acid metabolism. J Biol Chem
36: 9-26. 1918.
Neuwirth I: The hourlv elimination of cer-
tain urinary constituents during brief fasts
J Biol Chem 29: 477-484, 1917.
45. Klein R. Klein BE. Cornoni JC, Maready J.
ct al; Serum uric acid: Its relationship to
coronary heart disease risk factors and car-
diovascular disease. Evans Countv. Georgia.
Arch Intern Med 132: 401-410, 1973.
46. Dunn JP, Brooks GW, Mausner J, Rodnan
GP, Cobb S: Social class gradient of serum
uric acid levels in males. JAMA 185: 431-
436. 1963.
47. Mueller EF. KasI SV, Brooks GW, Cobb S:
Psvchosocial correlates of serum urate levels.
Psychol Bull 73: 238-257, 1970.
48. Brooks GW, Mueller E: Serum urate con-
centrations among university professors.
JAMA 195: 415-418. 1966.
49. Wolf S. McCabe WR. ■^amamoto J, et al:
Changes in serum lipids in relation to emo-
tional stress during rigid control of diet and
exercise. Circulation 26: 379-387, 1962.
Frideman M. Rosenman RH. Carroll V;
Changes in the serum cholesterol and blood
clotting time in men subjected to cyclic varia-
tion of occupational stress. Circulation 17:
852-861, 1958.
51. Grundy SM. Griffin AC: Relationship of
periodic mental stress to serum lipoprotein
and cholesterol levels. JAMA 171: 1795-
1796. 1959
52. Harris-Jones JN: Hyperuricaemia and es-
sential hvpercholesterolaemia. Lancet 1 : 857-
860. 1957.
53. Rahe RH, Rubin RT, Arthur RJ, Clark BR:
Serum uric acid and cholesterol variabilitv.
JAMA 206: 2875-2880. 1968.
54. Prior lAM, Rose BS, Harvey HPB, David-
50
son F: Hyperuricaemia, gout, and diabetic
abnormality in Polynesian people. Lancet 1 :
333-338, 1966.
55. Montoye HJ. Faulkner J A, Dodge HJ, et al :
Serum uric acid concentration among busi-
ness executives: with observations on other
coronarv heart disease risk factors. Ann In-
tern Med 66: 838-850, 1967.
56. Mikkelsen WM, Dodge HJ, Valkenburg H:
The distribution of serum uric acid values
in a population unselected as to gout or
hyperuricemia: Tecumseh, Michigan 1959-
1960. Am J Med 39: 242-251. 1965.
57. Montoye HJ. Howard GE, Wood JH: Ob-
servations of some hemochemical and
anthropometric measurements in athletes.
J Sport Med 7: 35-44, 1967.
58. Miettinen TA : Cholesterol production in
obcsitv. Circulation 44: S42-850, 1971.
59. Walker WJ. Weiner N, Milch LJ : Differ-
ential effect of dietary fat and weight reduc-
tion on serum levels of beta lipoproteins.
Circulation 15: 31-37, 1957.
60. Ahrens EH: Nutritional factors and serum
lipid levels. Am J Med 23: 928-952, 1957.
61. Myers AR. Epstein FH. Dodge HJ. Mik-
kelsen WM: The relationship of serum uric
acid to risk factors in coronarv heart disease.
Am J Med 45: 520-528, 1968.
62. Hall AP. Barry PE. Dawber TR, Mc-
Namara PM: Epidemiology of gout and hy-
peruricemia: A long-term population study.
Am J Med 42: 27-37, 1967.
63. Acheson RM: Epidemiology of serum uric
acid and gout: an example of the complexi-
ties of multifactorial causation. Proc R Soc
Med 63: 193-197. 1970.
6 !
r ■
■J I
t
r
i i
1
I
r
is. i.
To the medical jurist the study of the causes of death, of the phenomena which precede the
examination of the corpse, is of great importance: in more than half of the medico-legal e.xami-
nations that you will be called upon to make, whether the question raised is one of suicide,
murder, sudden death, or survivorship, it is with the study of the dead body that you will
have to begin.
Activity does not entirely cease at the instant of death. Vital phenomena are replaced by
cadaveric phenomena: it is requisite that you should become familiar with these last, for in-
experienced medical men have ascribed to poisoning lesions which have been really produced
after death by the normal processes of decomposition. — Death ami Sudden Death, P. Brouardel.
1897. p. 2.
IBl
is 1
» 'I
fflSl!
S5
[k i<
jlECEMBER 1974, NCMJ
//
735
'
Editorials
CARDIAC CATHETERIZATION
IN THE NEWBORN
It is a well known fact that during the past four
decades, cardiac surgery has made tremendous strides
in correcting inborn anomalies of the child. Much less
has been said, however, about the large percentage
of those children born with hcmodynamically signi-
ficant cardiac disease who die within the first 12
months of life because either the complexity of the
anomaly or the small size of the patient made surgi-
cal intervention inadvisable.
Having now reached a point when more and more
complex congenital cardiac lesions are falling prey
to the advancement of medical and surgical manage-
ment, the days of benign neglect and watchful waiting
for the newborn in cardiac distress have passed. To
interrupt the sorrowful train of cardiac deterioration,
which most of the time leads to the demise of these
unfortunate children, the following steps are manda-
tory:
( 1 ) Consider the possibility of congenital heart
disease in the newborn in cardiopulmonary distress.
(2) Establish an accurate diagnosis using all neces-
sary means, including cardiac catheterization.
(3) Institute medical or surgical therapy, or both,
as soon as possible.
It is evident that the primar\ physician, who sees
the newborn after delivery and who follows him dur-
ing the first days and weeks of life, holds the key
position in this process.
When should we consider the necessity of hemo-
dynamic studies? The principal indication for such
studies in the newborn and very young infant is con-
gestive heart failure or cyanosis, or both, usually
caused by one of the following conditions: hypoplas-
tic left heart including coarctation of the aorta, trans-
position of the great vessels, obstruction to the pul-
monary flow, and large left-to-right shunts.
The clinical appearance of the newborn with a
hypoplastic left heart is one of shock secondary to
poor cardiac output. This may be confused with hy-
povolemia, sepsis or adrenal insufficiency. The
clinical constellation is one of congestive failure, poor
peripheral pulses in both the upper and lower ex-
tremities, mottled appearance of the skin and a large
heart on roentgenographic examination. Since the
outcome for these infants is almost uniformly fatal,
they should be studied primarily to rule out other
correctable conditions.
Symptomatic coarctation of the aorta in the new-
736
born period usually implies the presence of associate*;
intracardiac pathology, e.g., left heart hypoplasia anc
endocardial fibroelastosis or a ventricular septal de
feet. The well known clinical "giveaway" is the ab
sence of pulses in the lower extremities. Newborn:
suspected of having aortic coarctation should under
go catheterization for congestive heart failure, witl
or without response to medical therapy, if left ven
tricular outflow obstruction is present. Since this i
an extracardiac lesion, it may be repaired even in thi
newborn period if indicated by closed heart surgery.
Transposition of the great vessels is an anomal;
second in frequency only to hypoplastic left heart a
a cause of heart failure in the newborn. In thi;
disease congestive failure and cyanosis are usuall
present. The patient seldom has a significant murmur
the chest roentgenograms may or may not demon
strate the typical findings of an egg-shaped hear
with increased pulmonary vascularity, and the elec
trocardiogram may be within the range of the norma
for a newborn. These children frequently present
problem as to whether their cyanosis is cardiac o
otherwise, e.g.. pulmonary. The adjunct of blood ga
determinations can be helpful in this regard; persis
tenth' low arterial pO- while the infant breathes 10(
percent oxygen indicates a large right-to-left shunl
which is usually intracardiac. This simple laborator
test lends support to the old clinical observation tha
the newborn with pulmonary disease usually "pinks
up" while oxygen is being administered, in contrast ti
the "cardiac-baby," who does not. Infants suspectei
of transposition should be immediately referred t
the cardiologist, not only because catheterization i
diagnostic but also because balloon atrial septostom
done during catheterization can be lifesaving fo
these children.
The primary symptom in newborn infants wit
ohstriiction to pulmonary blood flow is cyanosis, bu
congestive heart failure also may occur. The lattei
however, is less frequent than in transpositior
Anatomically, they may have tetralogy of Fallol
atresia of the pulmonary artery, significant valvula
pulmonic stenosis with intact ventricular septum d
tricuspid atresia. On roentgenographic examinatioi
the child's heart is usually small and the lung field
appear normal or avascular. The electrocardiogran'
except in those patients suffering from a hypoplasti
right heart (tricuspid atresia or pulmonary atres
with intact ventricular septum), shows right ventricU
lar preponderance. Infants belonging to the "low pi;
Vol. 35. No.
■
nonary flow" group should undergo cardiac cathe-
;rization in order that their cardiac anatomy be
iehneated and the necessity and feasibility of cura-
ive or palliative surgery be studied.
Left-to-right shunts are less frequent causes of car-
'iac distress in the immediate newborn period, but
■hey may be present in the first few weeks or months
if life, when the pulmonary vascular resistance dc-
lines. Atrial septal defects are rarely present with
longestive heart failure; however, one out of ten in-
ants with a ventricular septal defect develops con-
gestive failure, usually at six to eight weeks of
"ge. A patient ductus arteriosus in the newborn or
iifant may mimic closely a ventricular septal de-
£Ct with the diastolic component of the continuous
'nurmur entirely missing. A history of prematurity,
'eonatal respiratory distress or maternal rubella sug-
ests the presence of a patent ductus arteriosus. The
ommon denominator of increased pulmonary blood
low, regardless of the site of the shunt, may be
lemonstrated on the chest film.
Cardiac distress in the newborn caused by a left-
3-right shunt should be treated promptly and ener-
getically with appropriate drugs. If the infant fails to
respond adequately to medical therapy, cardiac cathe-
terization should be done without delay, since a
number of anomalies belonging to this category can
be dealt with effectively by corrective or palliative
surgery. There is nothing more tragic than to lose
an otherwise healthy child from an overlooked or
misdiagnosed patent ductus arteriosus, which can be
repaired with a minimal operative risk.
This sketchy overview is intended to assist primary
physicians in their decision as to when to refer very
young infants for cardiac catheterization, .\lthough
the risk of mortality and morbidity from hemody-
namic studies is extremely low in both the adult
and the child, it may be appreciable in the newborn
in severe cardiopulmonary distress. In spite of this
somewhat increased risk, the procedure should be
performed without hesitation if the necessity arises.
Not doing so would deny the benefits of an accurate
diagnosis and effective medical or surgical manage-
ment of a child born with a cardiac defect who
may be salvageable.
Robert D. Jackson, M.D.
Hi I
1 u
m (
k E
eli ;
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k 1
Correspondence
Changes in Commitment Laws
ijjjj'o the Editor:
jl 1 I read with interest the article by Drs. Raft, Wer-
aan and Spencer, "To Commit or Not to Commit,
B i' Continuing Dilemma: Some Guidelines," in the
,} ipptember issue of the Journ.IlL. It is an interesting
Ijiii jlrticle, and in many ways illuminating.
0 1 Your readers should know, however, that the ad-
:| jiissions statutes quoted and explained were replaced
l^^ ly the 1974 Session of the General Assembly, with
jj, , nportant modifications in procedure. Judicial com-
,,5 j'litment now is initiated, not by a law enforcement
1(1 ilfficer, but rather by a relative or other person
gj i.rho files an affidavit with a magistrate or clerk of
p]jj iiourt, stating that the person is believed to be men-
0 ^lUy ill, or inebriate, and imminently dangerous to
iW
jimselt or to others. The clerk or magistrate may
jtien issue an order for a law enforcement officer
(iF.CEMBER 1974. NCMJ
to take the person into custody for examination by a
physician. Subsequent events arc similar to those that
took place under the 1973 Act. It should also be
noted, however, that the term "gravely disabled" has
been eliminated. A part of the definition of "danger
to self or others," is that the person is unable to
"provide for basic personal needs for food, clothing
or shelter."
The emergency procedure described in the article
remains in force essentially as described, but can be
invoked by a law enforcement officer only if a per-
son is "violent and requires restraint, and delay in
taking him to a qualified physician for examination
would likely endanger life or property. . . ." The
clerk or magistrate may then order the person taken
directly to a mental health facility (State of North
Carolina Session Laws, 1973 (Second Session 1974).
Chapter 1408. Senate Bill 981).
737
The law governing voluntary admissions was
changed also by the 1974 Legislative Session, but
does not invalidate the comments included in the
article.
It is essential that North Carolina physicians he
cognizant of the laws governing admissions to mental
health facilities, and also of some practical conse-
quences of statutory changes. The authors" case re-
port and comments remain valid and offer valuable
insight into the clinical management of various de-
Emergency
Medical
Services
ALTERNATIVE TO '911"
William J. Henry, M.D.
Twisp Medical Center
Twisp, Washington
In order to gain entry into the emergency medical
systems, the "9 11" concept has been introduced in
large metropolitan areas. This gives the caller the
ability to talk to a central dispatcher for fire, police,
ambulance or physician.
In rural areas, primarily because of the expense,
the '^ir" concept has been impractical. In a rural
community in north central Washington, a system
has been installed using the number 7111. Five tele-
phones were installed answering to this number:
one at the medical center, one at a physician's home,
one at a registered nurse's home, and two in ambu-
lance attendants' homes. The list of on-call physi-
grees of behavior disorders, and the way in whicf
such management is affected by the relevan
statutes.
N. P. Zarzar, M.D., Director
Mental Health Services
North Carolina Department of Human Resources
Division of Mental Health Services
Albemarle Building
325 N. Salisbury St.
Raleigh, North Carolina 2761 1
cians. ambulance attendants and nurses is available
so that rapid response can be obtained.
Installation charges were approximately S150.0(
and the monthly service charges are about $25.00
This has been paid for from gifts from the com
munity. In the two and one-half months since its in
stallation, the community has been pleased with th
practicality and operational aspect of the system,
With continued publicity, it is anticipated that its usi
will increase.
— .Abstracted by George Johnson. Jr.. M.D
From "Emergency Medicine Today," Vol. 3, No
9, September 1974. John M. Howard, M.D., Editor
Original article may he obtained from Commission oi
Emergency Medical Services, American Medical Asi
sociation. 535 North Dearborn Street, Chicago, llli
nois 60610.
738
Vol. 35, No.
ires
Bulletin Board
NEW MEMBERS
of the State Society
uchanan, Robert Auaustus, Jr., MD (CD), 1200 Broad
St., Durham 27705
;rawford. Robert Cecil. Jr., MD (OBG), 227 Prestwick
J Dr., Rt. 2, High Point 27262
i:ulley, James Paul, MD (GS), 506 Wood St., Troy 27371
'iarnest, Robert Rhea, MD (PD), 2436 Asheville Rd.,
i' Waynesville 28786
lernandez. Hector Rene, MD (Intern-Resident), 1036 Lake-
\ side Dr., Rt. 8, Durham 27704
I'rothingham, Thomas Eliot, MD (PD), Box 3937, Duke
'' Med. Ctr., Durham 27710
Sibbs, James Samuel. MD (IM), 2240 Cloverdale Ave..
' Winston-Salem 27103
torelson. John Miles, MD (ORS), 2019 Wilson St., Dur-
I ham 27705
Cjerring. Rufus McPhail, Jr., MD (PD). 403 Fairview St..
( Clinton 28328
|teff, Peter Brynan. MD (GE). 2240 Cloverdale Ave..
'' Winston-Salem 27103
<iempert, Kenneth D. (Student), R-5 Kingswood Apts..
,( Chapel Hill 27514
:,utz, Charles Larry, MD (IM), 315-A Mulberry St., SW.
^'- Lenoir 28645
iilcDonell, Charles Franklin, Jr., MD (OBG), Rt. 11, Box
^j 465, Hickory 28601
iJeale, Spottswood Pryer, MD (PTH), Rt. 9, Box 816,
Bi 1 Morganton 28655
'hillips, Daniel Gordon. MD (OBG). 2400 Wayne Me.
1 Dr. Ste. K. Goldsboro 27530
?ierson. Steven Scott. MD (EM), 709 W. End ,A.ve.,
; Statesville 28677
father, Edwin Pratt, MD (D). Ste. 301, 1200 Broad St.,
i Durham 27705
iichards, Frederick, IL MD (IM). Bowman Gray, Win-
ston-Salem 27103
icott, John Layne, MD (DR), 305 Edwards Rd.. Apt.
1 B-1, Greensboro 27410
imith. Timothy Carl. MD (IM), 1042 Sycamore St.,
, Rocky Mt. 27801
;tevenson, John Samuel, MD (R). 926 Biags Blvd., Rock-
ingham 28379
Thomas, Colin Edward, MD (U), 3115 Hickory Hill Rd.,
Hendersonville 28739
iTiomason. Henry Clayton. Jr., MD (IM), 1045 Nottine-
■ ham Dr., Gastonia 28052
/est. Howard Ryland, Jr., MD (AN). 529 Edgewood Rd.,
Asheboro 27203
(ill. \
WHAT? WHEN? WHERE?
In Continuing Education
December 1974
fete: ( 1 ) Programs sponsored by the Bowman Gray,
)uke or UNC Schools of Medicine are approved for "Cate-
ory I"' M<.\.\ Physician Recognition .Award credit, and for
lAFP "Prescribed" continuing education credit when such
I^ECEMBER 1974, NCMJ
N.
C.
N.
C.
N.
C.
approval has been granted by the A.AFP. (2) "Place" and
"sponsor'' are indicated below only where these differ from
the place and group or institution listed under "For in-
formation."
Programs in North Carolina
January 22-24
North Carolina's Alcoholism Awareness Week — 1975
Place: Sheraton Crabtree Motor Inn, Raleigh
Sponsors: N. C. Alcoholism Research Authority,
Center for Alcohol Studies at UNC-Chapel Hill:
Department of Human Resources, N. C. Jaycees;
State Medical Society, N. C. Neuro-Psychiatric Associa-
tion
Program: Respective topics for the three days will be as
follows: 22nd — Medical Health for the Alcoholic. At
7:30 p.m. Mrs. Marty Mann, founder of the National
Council on Alcoholism, will speak in Christ's Episcopal
Church, Raleigh, on ".Alcoholism and You." 23rd —
Alcoholism — The Search for the Sources. At the 7:00
p.m. banquet the main address will be given by Secre-
tary David Flaherty, N. C. Department of Human Re-
sources. 24th — First Annual North Carolina .Alcoholism
Researchers' Forum
Fee: $30 in-state; $45 out-of-state. Pre-registration by Janu-
ary 7 is requested
Credit: 13 hours AAFP continuing education credit ap-
plied for
For Information: John A. Ewing, M.D., Executive Secre-
tary, Alcoholism Research Authority, 623 E. Franklin
Street, Chapel Hill 27514
January 24-25
Surgical Infections
Fee: $75
Credit: 12 hours
For Information: Emery C. Miller. M.D., Associate Dean
for Continuing Education, Bowman Gray School of Medi-
cine. Winston-Salem 27103
January 31-February I
North Carolina Medical Society 1975 Conference for Medi-
cal Leadership
Place: State Society Headquarters Building, Raleigh
Program: Designed especially for Society Officers and
other members who carry leadership responsibility. Open
to all interested Society members.
For Information: Mr. William N. Hilliard, Executive Di-
rector, North Carolina Medical Society, P. O. Box 27167,
Raleigh 27611
February 7-8
Current Topics in Occupational Health
Place: Carolina Inn. Chapel Hill
Sponsors: Dept. of Community Health Sciences, Duke Uni-
versity Medical Center; Carolina Industrial Medicine As-
sociation: N. C. .Association of Industrial Nurses
For Information: Leonard J. Goldwater, M.D.. Dept. of
Community Health Sciences, Duke University Medical
Center. Box 2914, Durham 27711)
February 14-15
Medical Ethics Symposium
Place: Babcock Auditorium
Fee: $30
Credit: 15 hours
For information: Emery C. Miller, M.D., .Associate Dean
for Continuing Education, Bowman Gray School of
Medicine, Winslon-Salem 27103
739
February 17-18
Recional Diabetes Teaching Nurse Workshop
Fee: S50 . ^
For Information: Judith E. Wray. Administrative Secretary,
Continuinc Education Program, UNC School of Nursing,
Chapel Hill 27514
February 19
Paraneoplastic Syndromes— the Wingate Johnson Memorial
Lecture
Place- Babcock Auditorium. Time: 11:00-12:00 a.m.
Speaker: Prof. A. McGehee Harvey, M.D., Johns Hopkins
Hospital, Baltimore, Maryland
For Information: Emery C. Miller, M.D., Associate Dean
for Continuing Education, Bowman Gray School of Medi-
cine, Winston-Salem 27103
March 3-4
Nutrition in Mothers, Infants, and Pre-School Children
Place: Carolina Inn, Chapel Hill
For Information: Dr. John J. B. Anderson, Department
of Nutrition, School of Public Health, UNC, Chapel
Hill 27514
March 12 & May 7
(two different workshops)
Toward More Effectise Diabetic Teaching
Practical approaches to diabetic care, including some
newer developments and less well-known aspects
Place: March 12— Reidsville: May 7— Raleigh
Fee: S20
For Information: Judith E. Wray, Administrative Secre-
tary, Continuing Education Program, L'NC School of
Nursing, ChapefHill 27514
March 17-21
Tutorial Postgraduate Course: Radiology of the Gastro-
intestinal Tract
Place: Governors Inn, Research Triangle Park I between
Durham and Raleigh, near the airport)
Proeram: Designed for radiologists, but open to other
physicians in' training or practice. Emphasis on person-
alized, tutorial tvpe teaching, with ample opportunity for
discussion. Two' I hour 20 minute tutorial sessions each
mornins;, and one in the afternoon; 12 registrants will
join one faculty member in a separate quiet room with
view boxes for organized film reading-discussions and case
presentations. Each registrant will have a total of 14 dif-
ferent tutorial sessions. One hour "Panel" presentation-
discussion each afternoon. Guest faculty include: Drs.
Charles .A. Bream, Harlev C. Carlson, Joseph T. Fer-
rucci, Jr., Roscoe E. Miller, Jerry C. Phillips, Bernard S.
Wolf, and, from Kings College Hospital, London, En-
gland, Dr. John Laws. Chairman, Department of Radi-
ology
Fee: S3()(); enrollment limited
Credit: 28 hours AM A "Category One" accreditation
For Information: Robert McLel'land, M.D., Department of
Radiologv, Bo.\ 3808, Duke University Medical Center,
Durhanr27710
March 25-26
Problem-Oriented Medical Record System
Through a video-tape simulated case presentation, par-
ticipants will be involved in learning to use the POMR
throimh actual insolvement
Fee: $50
For Information: Judith E. Wray. .-Xdministrative Secre-
tary, Continuinc Education Program, UNC School of
Nursing. ChapefHill 27514
March 27-28
The Nursing .Audit
Designed to assist nursing administrative personnel in
evaluating the quality of patient care through the use of
a systematic auditing technique
Fee: $50
For Information: Judith E. Wray, Administrative Secretary,
Continuinc Education Proeram. UNC School of Nursing,
Chapel Hill 27514
April 4-5
Pediatric Postgraduate Course
For Informatron: Emery C. Miller, M.D., Associate Dean
Rondomycini
(methacycline HCI)
CONTRAINDICATIONS: Hypersensitivity to any of the tetracyclines
WARNINGS Telracycline usage during tootfi development (last half of pregnancy to eigi
years) may cause permanent tooth discoloration (yeltow-gray-brown), which is met
common during long-term use bul has occLirred after repeated stiort-term courses
Enamel hypoplasia has also been reported Tetracyclines should not be used in this agi
group unless other drugs are not likely to be effective or are contraindicated
Usage in pregnancy. (See above WARNINGS about use during tooth development.
Animal studies indicate that tetracyclines cross the placenta and can be toxic to the de
veiopmg tetus (often related to retardation of skeletal development) Embryotoxicity ha;
also been noted m animals treated early m pregnancy
Usage in newborns, infants, and children. (See above WARNINGS about use dunni
tooih development )
All tetracyclines form a stable calcium complex in any bone-lormmg tissue A decreasi
m (ibula growth rate observed in prematures given oral tetracycline 25 mg/kg every I
hours was reversible when drug was disconitnueO
Tetracyclines are present m mtik of lactatmg women taking tetracyclines
To avoid excess systemic accumulation and liver toxicity m patients with impaired rena
function, reduce usual total dosage and, it therapy is prolonged, consider serum level de
terminations of drug The anti*anabolic action of tetracyclines may increase BUN Whiii
not a problem m normal renal function, m patients with significantly impaired function
higher tetracycline serum levels may lead to azotemia, hyperphosphatemia, and acidosis
Photosensitivity manifested by exaggerated sunburn reaction has occurred with letra
cyclines Patients apt to be exposed to direct sunlight or ultraviolet light should be so ad
vised, and treatment should be discontinued al first evidence ol skin erythema
PRECAUTIONS: It supermlection occurs due to overgrowth of nonsusceptibie organisms
including tungi, discontinue antibiotic and starl appropriate therapy
In venereal disease when coexistent syphilis is suspected, perform darkfield exami
nation before therapy, and serologically test tor syphilis monthly for at least four monthsl
Tetracyclines have Seen shown to depress plasma prothrombin activity, patients on ai
ticoagulant therapy may require downward ad|ustmeni ol their anticoagulant dosage
In long-term therapy perform periodic organ system evaluations (including blood
renal, hepatic)
Treat all Group A beta-hemolylic streptococcal infections for at least 10 days
Since bactenostahc drugs may interfere with the bactericidal action of penicillin, avoit
giving tetracycline with penicillin
ADVERSE REACTIONS: Gastrointestinal (oral and parenteral forms) anorexia, nausea
vomiting diarrhea, glossitis, dysphagia, enterocolitis, inflammatory lesions (with monil
lai Overgrowth) m the anogeniial region
Skin: maculopapuiar and erythematous rashes, exfoliative dermatitis (uncommon). Pho
icsensit-viiy IS discussed above (See WARNINGS}
Renal loxicity rise m BUN apparently dose related (See WARNINGS)
Hypersensitivity: urticaria, angioneurotic edema, anaphylaxis, anaphylactoid purpura
pericarditis, exacerbation ot systemic lupus erythematosus
Bulging fontanels, reported m young infants after full therapeutic dosage, have disap
peared rapidly when drug was discontinued
Blood: hemolytic anemia, thrombocytopenia, neutropenia, eosmophilia
Over prolonged penods, tetracyclines have been reported to produce brown-black mi
croscopic discoloration ol thyroid glands, no abnormalities of thyroid function studies ar
known to occur
USUAL DOSAGE: Adults-600 mg daily, divided into two or four equally spaced doses
More severe infections an initial dose of 300 mg tollowed by 150 mg every six hours c
300 mg every 12 hours Gonorrhea In uncomplicated gonorrhea, when penicillin is ccn
traindicaied, Rondomycm (methacycline HCI) may be used for treaiing both males ai
lemales in the following cimical dosage schedule 900 mg initially, followed by 300 n
q I d fora total of 5 4grams
For treatment of syphilis when penicillin is contramdicated, a total of 18 to 24 grams c
Rondomycm imeihacycime HCl) m equally divided doses over a period of 10-15 da/
should be given Close follow-up. including laboratory tests, is recommended
Eaton Agent pneumonia 900 mg daily for six days
Children - 3 to 6 mg/lb.day divided into two to four equally spaced doses
Therapy should be continued for at least 24-48 hours alter symptoms and fever hav
subsided
Concomitant therapy: Antacids containing aluminum, calcium or magnesium impaired
sorption and are coniramdicated Food and some dairy products also mterlere Give drj
one hour before or two hours alter meals Pediatric oral dosage lorms should not 3
given with mitk formulas and should be given at least one hour prior to feeding
In patients with renal impairment (see WARNINGS), total dosage should be decrease
by reducing recommended individual doses or by extending time intervals betwe^
doses
In streptococcal infections, a therapeutic dose should be given tor at least 10 days.
SUPPLIED: Rondomycm (methacycline HCI) 150 mg and 300 mg capsules, syrup ccr
taming 75 mg,'5 cc methacycline HCI.
Before prescribing, consult package circular or latest PDR information.
ifli WALLACE LABORATORIES
* - * CRANBURY, NEWJERSEY08512
'fif.
a
740
Vol, 35, No, l]
Is He a Source of Information?
Yes, with certain reservations.
The average sales representative
has a great fund of information
about the drug products he is re-
sponsible for. He is usually ableto
answer most questions fully and
intelligently. He can also supply
reprints of articles that contain a
great deal of information. Here,
too, I exercise some caution. I usu-
ally accept most of the statements
and opinions that I find in the
papers and studies which come
from the largerteachingfacilities.
It goes without saying that a physi-
cian should also rely on other
sources for his information on
pharmacology.
Training of Sales Representatives
Ideally, a candidate for the
position as a sales representative
of a pharmaceutical company
should be a graduate pharmacist
who has a questioning mind. I don't
thinkthis is possible in every case,
and so it becomes the responsibility
of the pharmaceutical company to
train these individuals comprehen-
sively. It is of very great importance
that the detail man's knowledge of
the product he represents be con-
stantly reviewed as well as up-
dated. This phase of the sales rep-
resentative's education should be a
major responsibility of the medical
department of the pharmaceutical
company.
I am certain that most of these
companies take special care to give
their detail men a great deal of in-
formation about the products they
produce — information about indi-
cations, contraindications, side
effects and precautions. Yet, al-
though most of the detail men are
well informed, some, unfortunately,
are not. It might be helpful if sales
representatives were reassessed
every few years to determine
whether or not they are able to ful-
fill their important function. Inci-
dentally, I feel the saTne way about
periodic assessments of everyone
in the health care field, whether
they be general practitioners, sur-
geons or salesmen.
Value of Sampling
I personally am in favor of
limited sampling. I do not use
sampling in order to perform clini-
cal testing of a drug. I feel that drug
testing should rightly be left to the
pharmacology researcher and to
the large teaching institutions
where such testing can be done in
a controlled environment.
I do not use samples as a
"starter dose" for my patients. I do,
however, find samples of drugs to
be of value in that they permit me to
see what the particular medication
looks like. I get to see the various
forms of the particular medication
at first hand, and if it is in a liquid
form I take the time to taste it. In
that way 1 am able to give my pa-
tients more complete information
about the particular medications
that 1 prescribe forthem.
capacity they are indeed useful;
particularly in the fact that they
* disseminate broadly based educa-
i tional material and serve not just
'; as "pushers" of their drugs.
(The Other Side of the Coin
' Obviously, the pharmaceuti-
tcal companies are not producing all
this material as a labor of love —
'i they are in the business of selling
;products for profit. In this regard
: the ambitious and improperly moti-
ii i/vated sales representative can
lexert a negative influence on the
^practicing physician, both by pre-
isentinga one-sided picture of his
:product, and by encouragingthe
': practitioner to depend too heavily
."■on drugs for his total therapy. In
'■these ways, the salesman has often
i-distorted objective reality and
lundermined his potential role as an
e. ^educator.
IThe Industry Responsibility
■ Since the detail man must be
5an information resource as well as
aa representative of his particular
[-pharmaceutical company, he
^should be carefully selected and
//
thoroughly trained. That training,
perforce, must be an ongoing one.
There must be a continuing battle
within and with the pharmaceutical
industry for high quality not only in
the selection and trainingof its
sales representatives, but also in
the development of all of its promo-
tional and educational material.
The industry must be ready to
accept constructive as well as cor-
rective criticism from experts in
the field and consumer spokesmen,
and be willing to accept independ-
ent peer review. The better edu-
cated and prepared the salesman
is, the more medically accurate his
materials, the better off the phar-
maceutical industry, health pro-
fessionals and the public— /.e., the
patients — will be.
Physician Responsibility
The practicing physician is in
constant need of up-dated informa-
tion on therapeutics, including
drugs. He should and does make
use of drug information and an-
swers to specific questions sup-
plied by the pharmaceutical repre-
sentative. However, that informa-
tion must not be his main source of
continuingeducation. The practi-
tioner must keep up with what is
current by making use of scientific
journals, refresher courses, and
information received at scientific
meetings.
The practicing physician not
only has the right, but has the re-
sponsibility to demand that the
pharmaceutical company and its
representatives supply a high level
of valid and useful information. I
feel certain that if such a high level
is demanded by the physician as
well as the public, this demand will
be met by an alert and concerned
pharmaceutical industry.
From my experience, my
impression is that sectors of the
pharmaceutical industry are indeed
ethical. I challenge the industry as
a whole to live up to that word in its
finest sense.
Pharmaceutical
Manufacturers Association
1155 Fifteenth Street, N.W.
Washington, D. C. 20005
P-M-A
for Continuing Education, Bowman Gray School of
Medicine, Winston-Salem 27103
April 7-11
Practical Approaches to Diabetic Care
Program especially suitable for nurses caring for large
numbers of diabetic patients. Emphasis on teaching needs
of diabetic patients and how to meet them
Fee: $125
For Information: Judith E. Wray, Administrative Secre-
tary, Continuing Education Program. UNC School of
Nursing. Chapel Hill 27514
April 11
North Carolina Diabetes Association Eighth Annual Scien-
tific Session
The program will include a scientific session for physicians
and a separate and concurrent session for laymen
Place: Babcock Auditorium
For Information: Emery C. Miller, M,D.. .Associate Dean
for Continuing Education, Bowman Gray School of
Medicine, Winston-Salem 27103
April 21-22
Primary Nursing
Participants will explore the use of the primary system
and its relationship to other systems, and identify its
influence on the nursing process, patient care and staffing
Fee: $50
For Information: Judith E. Wray, Administrative Secretary,
Continuing Education Program, UNC School of Nursing,
Chapel Hill 27514
April 23-25
Maternal Health and Family Planning
Designed to assist nurses to conduct classes for parents
in prepared childbirth
For Information: Judith E. Wray, .Administrative Secretary,
Continuing Education Program, UNC School of Nursing.
Chapel Hill 27514
May 13-14
Breath of Spring, '75 — Respiratory Care Symposium
Place: Babock Auditorium
Sponsors: Division of Continuing Education, Bowman Gray
School of Medicine: Northwestern Lung Association
Fee: $25
Credit: 12 hours Category 1 .AMA; .A.AFP applied for
For Information: Emery C. Miller, M.D., .Associate Dean
for Continuing Education, Bowman Gray School of Medi-
cine, Winston-Salem 27103
Continuing Education via Satellite
The following programs are scheduled to be received from
the .ATS-6 communications satellite, by the veterans" hospi-
tals at Fayetteville. Oteen and Salisbury on the dates indi-
cated. Sessions are open to all physicians and other inter-
ested health professionals.
December 18 — 1 p.m., "Psychiatry Conference"
December 25 — No program, due to holidays
January 1 — No program, due to holidays
January 8 — 1 p.m., "Cardiology Conference"
January 15 — 1 p.m., "Radiology Conference"
January 22 — 1 p.m., "TBA Nuising Conference"
January 29 — 1 p.m.. "Pathology, Histology Tissue"
.As this schedule has been subject to some change, it might
advisable to check with one of the following before at-
tending:
Fayetteville— Mr. Kenneth Gath (488-2120)
Oteen — Stewart Scott, M.D. or Mary Ellen Lutz. R.N.
(298-7911)
Salisbury — Mr. Dante Spagnolo (636-2351 )
Programs in Contiguous States
December 16-20
Team Leadership in Community Health Nursing (nurses')
For Information: Mrs. Helen O'Toole, Medical University
of South Carolina, Division of Continuing Education. 80
Barre Street, Charleston, S. C. 29401
744
January 8, 15, 22, 29
Medical Hypnosis
Place: Porter Auditorium (sixth floor), Sanger Hall. Time
7-9 p.m.
Fee: $50
For Information: Dr. Charles E. Smith, Department of
Psychiatry, Medical College of 'Virginia, Box 907, MCV,
Station, Richmond, Virginia 23298
January 20-23
The Alton D. Brashear Postgraduate Course in Head and
Neck Anatomy
Sponsors: Department of .Anatomy, in cooperation with the
Division of Continuing Education, School of Medicine
and School of Dentistry.
Program: The primary teaching method of this course is the
dissection of the head and neck. Fresh specimens (unpre
served), when available, are used to be as life-like as
possible. Individual, surgical approaches and manipula
tions are welcomed. Lectures and demonstrations will
augment the laboratory dissections.
Tuition: $180; $95 for students in residency programs. Lim
ited to 32 registrants.
Credit: 40 hours: Academy of General Dentistry; AAFP
For informaton: Dr. Hugo R. Seibel, Department of
.Anatomy, Medical College of 'Virginia. MCV Station,
Richmond. Virginia 23298
January 25
Ventilatory Problems Workshop
Place: Holiday Inn, Oak Ridge, Tennessee
For Information: Doris Croley, Oak Ridge Hospital of the
United .Methodist Church. Oak Ridge, Tennessee 37830
February 16
Cancer of the Breast, a postgraduate course
Place: Hyatt Regency .Atlanta Hotel, Atlanta, Georgia
For Information: A. Hamblin Letton, M.D., Secretary'
Treasurer, the Southeastern Surgical Congress, 340 Boule^
vard N.E., Atlanta, Georgia 3031 2
February 17-20
Southeastern Surgical Congress. 43rd Annual Assembly, foi
Doctors & Nurses
Place: Hyatt Regency Atlanta Hotel, Atlanta, Georgia
For Information: A. Hamblin Letton, M.D., Secretary
Treasurer, the Southeastern Surgical Congress, 340 Boule
vard N.E., .Atlanta, Georgia 30312
February 28-\rarch 2
.Annual Meeting Virginia Chapter .American Academy ol
Pediatrics
Place: Colonial Williamsburg, Virginia
Fee: $10
For Information: James H. Stallings. Jr., M.D., Secretary
Treasurer, Virginia Chapter .American Academy ol
Pediatrics. 6503 N. 29th Street, .Arlington, Virginia 22213
April 26-30
International Biomaterials Symposium
Sponsors: Clemson University and the National Institute
for Dental Research
Fee: $150
For Information: Professor J. K. Johnson. Continuing Engi-
neering Education, 116 Riggs Hall, Clemson University
Clemson, S. C. 29631
May 12-15 '
Cardiology for the Internist
Place: Royal Coach Motor Hotel. Atlanta. Georgia
Sponsors: .American College of Cardiology; Council or
Clinical Cardiology. American Heart Association; De
partment of Medicine. Emory University School of Medi
cine, .Atlanta, in cooperation with Georgia Heart As
sociation
For Information: Miss Mary .Anne Mclnerny, Director
Department of Continuing Education Programs, Ameri
can College of Cardiology? 9650 Rockville Pike. Bethesd;
Maryland 20014
Vol. 35. No. 1
Li! i
Rehabilitation of Stroke Patients
\ series of workshops on rehabilitation of strolce patients
will be conducted as a special project of the South
Carolina Heart Association. The overall goal of the
project, entitled "Regionalization of Specialized Nursing
Home Services," is to upgrade the care of geriatric
patients through the latest methodology in stroke patient
care. Each workshop will consist of a two-day training
session and a one-day follow-up session for review and
evaluation. Dates and locations of the workshop sessions
are as follows:
January 14-15 & March 20— Rock Hill, S. C.
January 21-22 & March 6 — Aiken. S .C.
January 28-29 & March 5 — Orangeburg, S. C.
February 1 1-12 & April 8— Sumter, S. C.
February 18-19 & April 3— Columbia, S. C.
February 2.'i-26 & April 9— Florence, S. C.
March 11-12 & May 1— Myrtle Beach, S. C.
March 18-19 & May 6— Spartanburg, S. C.
'or Information: Mrs. Dolores J. Wilkie, P. O. Box
5937, Columbia, S. C. 29250
Sesquicentennial Seminars for Physicans
irhe programs will be presented by "world renowned medi-
cal teachers"
tredit: Continuing education credit for the AMA Physicians
'' Recognition Award
3ates, department presenting the program and speakers are
as follows:
January 6-7, Anatomy — ^Dr. Charles P. Leblond of Mc-
: Gill University, Montreal, Canada
! January 16-17, Physical Medicine — Dr. John V. Bas-
I majian of Emory University
: January 23-24, Laboratory Medicine — Dr. J. Roger Ed-
son, University of Minnesota, Mayo Graduate of Medi-
cine
February 10-11, Anesthesiology — Dr. Charles Ronald
Stephen of Washington University, St. Louis
. February 20-21, Biochemistry — Dr. Sidney Udenfriend of
I the Roche Institute of Molecular Biology
February 27-28, Biometry — Dr. Cling Chun Li, Univer-
sity of Pittsburgh
-'or Information: Department of Continuing Medical Edu-
cation, Medical University of South Carolina, 80 Barre
I Street, Charleston, S. C. 29401
items submitted for listing should be sent to: WHAT?
, WHEN? WHERE?, P. O. Box 8248, Durham, N. C.
27704, by the 10th of the month prior to the month in
' which they are to appear.
AUXILIARY TO THE NORTH CAROLINA
MEDICAL SOCIETY
TELL IT AND SELL IT
Communicate! This is what the marriage coun-
elor tells the couple and what the child psychiatrist
rt£lls the parent and child. And it is is exactly what
ihe AMA Medical Auxiliary is telling its members.
The Auxiliary this year is adding a new meaning to
the word "communication." As we have indicated,
t should encompass the whole world of public re-
(.ations.
' Mrs. T. S. Cheek of Smithfield, the State Auxil-
ary Chairman for Communications and Public Re-
itt cations, attended the AMA Auxiliary Southern Re-
Wonal Workshop held in New Orleans, October
M-ZS. She brought back a number of definitive point-
liiJ '
ers for the improvement of public relations in con-
nection with the North Carolina Medical Auxiliary
on the county and the state levels.
First and foremost, it is urged that we have new
ideas and that we do not hesitate to discard ideas
long since dead. A good test of what is "dead" is
seeing how new members respond to a so-called "es-
tablished idea." If the response is negative, or one of
bewilderment, then perhaps the idea should be scm-
tinized.
Wc should learn how to use our publications to
the fullest to do the job of communicating. The Auxil-
iary's state and national publications tell a story,
and they tell it well. The articles from these publica-
tions, full of new ideas and experiences, can be used
in every chapter's program. It is suggested that the
communications chairmen meet with their respective
presidents and vice presidents in planning their pro-
grams for the year.
The national office of the Auxiliary can only guess
at individual community needs, so rather than cater-
ing solely to national needs, it urges that those of
the individual community be met primarily.
Small communities usually know when a new
prospective member has moved into town, but large
medical groups must make a special effort to keep in-
formed of new residents. In small or large communi-
ties, prospective new members should be asked to
A NEW LOOK AT KEOGH COULD
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DEDUCTIONS TO YOU THIS YEAR,
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The new PENSION REFORIVI ACT became effective
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new legislation offers you substantial new benefits
in income tax deductions and in tax sheltered re-
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time to qualify for maximum ($7,500) tax deductions
this year?
For more information, please return the attached
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on how to
under a
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KEOGH
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SELF- 1
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MJ. 1
UDecember 1974, NCMJ
745
attend the meetings, and hopefully they will get in-
volved.
We should encourage all members to make use
of their talents. Members of the auxiliaries are volun-
teers, and interest wanes fast when volunteers are
routinely asked to function outside their areas of ex-
pertise.
The Auxiliary recommends rapport with the Medi-
cal Society. We should report to the Medical Society
on the Auxiliary's activities, and we should make
projects community oriented in order to get the So-
ciety's backing.
Establish a two-way channel — better known as
"feedback." The Auxiliary, both state and national,
wants to hear about the results of projects. Communi-
cate in any and every way that it can be done. A good
slogan to remember is this: "You can't sell it if you
don't tell it!"
The NCMA Mid-Winter Conference, with the
theme "Leadership and Communication," to be held
at the NCMS Headquarters in Raleigh. February 1,
will afford the opportunty to "tell it and sell it."
County auxiliaries are urged to put this date on their
calendars and to make certain that representatives
attend.
News Notes from the—
BOWMAN GRAY SCHOOL
OF MEDICINE
WAKE FOREST UNIVERSITY
Dr. William M. McKinney, associate professor of
neurology, is the new president of the American
Institute of Ultrasound in Medicine (AIUM). He
was installed as president at the organization's Oc-
tober meeting in Seattle, Wash. Dr. Ralph Barnes,
research assistant professor of neurology, has begun
a three-year term as a member of the AIUM execu-
tive board. James W. Willard, research associate
in urology, was awarded second prize by the Ameri-
can Society of Ultrasound Technical Specialists
(which met along with the AIUM) for his paper
entitled "Ultrasonography of the Prostate and Re-
lated Structures."
The 1975 meetings of AIUM and ASUTS were
held in Winston-Salem Oct. 4-9.
* * *
Dr. Clark E. Vincent, professor of sociology and
director of the Behavioral Sciences Center, has re-
ceived a special award from the California .Associa-
tion of Marriage and Family Counselors for his liter-
ary contributions in the field of counseling.
The award was presented during the 33rd annual
meeting of the American .Association of Marriage
and Family Counselors.
Dr. \incent just completed his term as president
746
of the AAMFC, and is continuing to serve on the'
board of directors. He is the first person ever to
have served as head of all four major marriage and
family organizations in the nation.
* * *
Bowman Gray has signed a contract with the Uni-
versity of North Carolina School of Medicine, accept
ing responsibility for developing an Area Health Edu-
cation Center program in a 16-county region of
northwest North Carolina.
Dr. Richard Janeway, Bowman Gray dean, and
Dr. Christopher Fordham, dean of the UNC medica
school, signed the contract, which sets into motion
a planning phase, lasting until July 1, 1975.
Under the AHEC, Bowman Gray is developing
a Department of Family medicine and will start 75
new residencies in primary care fields over a three
year period. As part of the new department's creation,
Bowman Gray has recently signed an affiliation
agreement with Forsyth Memorial Hospital and the
Family Health Center of Reynolds Memorial Hospi
tal.
The AHEC program will also involve an outreach
effort, touching as many of the 30 community hospi-
tals in the 16-county region as wish to participate.
Bowman Gray will be offering continuing education
programs for physicians and those in allied health
fields, as well as helping in the development of com-
munity health centers.
The new AHEC program has the cooperation of
the UNC-G School of Nursing and the schools oi
dentistry, pharmacy and public health of the Univer-
sity of North Carolina.
* * *
Dr. Ernest H. Stines of Canton has been elected
president of the Alumni Association of the Bowman
Gray School of Medicine, Dr. Giles L. Cloninger ol
Hamlet is the association's new president-elect.
Drs. George H. Armstrong of Mount Gilead
Len D. Hagaman of Boone, Dewitt Trivette ol
Hickory, Erich W. Schwartze of Waco, Tex., anc
Betsy A. Parsley of Winston-Salem have been elected
to the association's alumni council.
Dr. Jean Baily Brooks of Greensboro, retiring
president of the alumni association, was presentee
an award for distinguished service to the associatior
during the association's annual dinner recently.
* * *
Dr. Timothy Pennell, associate professor of sur-
gery, recently began a three and a half week assign-
ment in Africa and India under the auspices of th£
Foreign Missions Board of the Southern Baptis;
Convention and the medical school.
His responsibilities included teaching at universi-
ties and medical schools, observing health care pro-
grams in the mission hospitals and e\aluation of the
hospitals.
* * *
Dr. James F. Martin, professor of radiology, has
Vol. .vs. No. i:
Oi f-
jen elected secretary of the American Roentgen
t^y Society.
* * *
Three Bowman Gray and Baptist Hospital physi-
luis recently returned from Honduras, where they
bvided medical care to victims of Hurricane Fifi.
,^ \Dt. John Denham, instructor in community medi-
ae, joined Dr. Richard Sterba, a resident in pcdiat-
ts, and Dr. Michael Roberts, a resident in surgery,
making the two-week trip under the auspices of
e Foreign Missions Board of the Southern Baptist
invention.
' The three physicians spent their time in rural areas
ound San Pedro Sula, a particularly hard-hit coastal
wn. They provided basic medical care in field hos-
ital-type units.
I * * *
Dr. B. Lionel Truscott, professor of neurology,
s been named advisory consultant to the Office
', Biometry, Collaborative and Field Research Pro-
am of the National Institute of Neurological
iseases and Stroke.
* * *
I Dr. Walter A. Ward, assistant professor of
jjOlaryngology, was elected secretary/treasurer of
e American Society of Ophthalmologic and Oto-
.^ngologic Allergy at an October meeting of the so-
.Ety in Dallas, Tex.
il^ews Notes from the —
UNIVERSITY OF NORTH CAROLINA
DIVISION OF HEALTH AFFAIRS
u
(Dr. Lewis Thomas, author of "Lives of a Cell,"
i'esented the McNair Lecture at UNC-Chapel Hill
I October 31 in Memorial Hall. Dr. Thomas, presi-
;nt of the Memorial Sloan-Kettering Cancer Center
New York City discussed "Biological Aspects of
lilfness."
* * +
/After an extensive 18-month study into the feasi-
^lity of developing a Health Maintenance Organiza-
pn (HMO) in Chapel Hill, the Steering Committee
the project has decided that further planning ef-
irts cannot proceed until questions concerning the
lancial support for start-up costs and the avail-
'•ility of local leadership for such a venture are
iiswered. However, because recent events, such as
e enactment of federal legislation aiding HMO de-
lopment, might lead to the resolution of these local
fficulties, the Steering Committee intends to re-
^amine the Chapel Hill HMO effort within the year.
Dr. Cecil G. Sheps, vice chancellor for health
iences at UNC-Chapel Hill, is chairman of the
iering committee of the Chapel Hill HMO Plan-
ing Project. Funded by a $125,000 grant from
;rEW, the project was organized in January 1972
liCEMBER 1974. NCMJ
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to determine the feasibility of using existing health
care resources here for development of an HMO.
Patients who suffer serious injury, or trauma, and
those who undergo major operations often are sad-
dled with lung complications which might result in
respiratory failure, causing their lungs to stiffen and
making them work harder to breathe.
Dr. Enid Kafer, associate professor of anesthe-
siology at the UNC School of Medicine, is studying
how the respiratory system adjusts to increased work-
loads. Working under a $65,000, three-year grant
from the National Heart and Lung Institute, she
hopes to discover the e.xact factors involved in
respiratory failure and to define better indices for
deciding when a patient is able to breathe on his
own.
* * *
New faculty members include the following:
Robert E. Cross has been appointed assistant pro-
fessor in the Departments of Medicine, Biochemistry
and Nutrition, and Pathology, and associate director
of the Clinical Chemistry Laboratory. He has been a
postdoctoral fellow at the University since 1972. His
B.S. and M.S. are from the University of Toledo
and his Ph.D. is from the University of Florida.
Laurence Ray McCarthy has been appointed as-
sistant professor in the Departments of Bacteriology
and Immunology, and Pathology. He has been as-
sociate director of the Diagnostic Microbiology
Laboratory at the Memorial Sloan-Kettering Cancer
Center in New York since 1972. A graduate of
St. Anselm's College, he earned his Ph.D. at the
University of New Hampshire.
Gerhard W. D. Meissner has been appointed as-
sistant professor in the Departments of Biochemistry
and Nutrition, and Physiology. A research assistant
professor at Vanderbilt University since 1972. he re-
ceived the B.S. and M.S. degrees from the Free
University of Berlin and the Ph.D. from the Techni-
cal University of Berlin.
Lee O. Stang has been appointed assistant profes-
sor in the Division of Ph\sical Therapy. She has
been director of Physical Therapy Services with the
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^ ^ 3^
Noel A. Mazade, assistant professor, Departmei
of Psychiatry, is on a one-year leave to serve s
project director of the Pilot Model Area Progran
with the North Carolina Division of Mental Healj
Services until July 31, 1975.
Glenn J. Martin, chief of the Program Exper
mentation Branch in the Social Security Administr;
tion's Bureau of Health Insurance, has been named
visiting fellow in the Department of Health Admit
istration (HADM) in the UNC School of Publ
Health at Chapel Hill.
The Faculty Field Exchange Program develope
last year is designed to encourage HADM faculi
to gain field experience in the operation and managi
ment of health and human service programs and I
encourage high-level practicing professionals to coi
tribute to research and teaching.
During his stay in Chapel Hill, Martin will exploi
payment systems, new coverage provisions with co
containment potential, innovative systems of payir
for physician's extender services and the determin
tion of problem areas in extended care benefit pn
visions. He also will be available as a consultat
and advisor to interested students, faculty and heall
agencies.
News Notes from the —
DUKE UNIVERSITY MEDICAL CENTER
748
Four medical center faculty members have bee
promoted to full professor. Ten others were promote
to associate professor, and six were named assistai
professors.
Promoted to professorships are Dr. Walter 1
Floyd, medicine; Dr. Irwin S. Johnsrude, radiolog
Dr. Robert E. Whalen, medicine; and Dr. Robe
Wayne Wheat, microbiology.
The ten faculty members awarded associate pn
fessorships include Dr. Darell D. Signer, patholog
Dr. Matthew Cartmill, anatomy and anthropolog
Dr. John H. Grimes, urology; Dr. William L. H
lander, anatomy and anthropology; Dr. Char!
Johnson, medicine; Dr. Jack L. Nichols, microb
olog\; Dr. Lois A. Pounds, pediatrics; Dr. .Arvin I
Robinson, radiology; Dr. Ralph E. Smith, virologi
and Dr. Thomas C. V'anaman, microbiology.
The six new assistant professors are Elaine Eckc
physical therapy; Dr. James Clifford Green, psychi
try; Dr. Jarlath Mackenna. obstetrics and gym
Vol. 35, No.
logy, and Linda W. Craig, Jane S. Kaufman and
incy F. Woods, ail from tiie Sciiool of Nursing.
* * *
Dr. William G. Anlyan is the new national presi-
'at of the Association for Academic Health Cen-
s (AAHC).
'Anlyan, vice president for health affairs, was in-
'iUed as the organization's fourth president at its
mual meeting in West Palm Beach, Fla.
(The AAHC membership is made up of persons at
i; vice president or chancellor level who have senior
ministrative responsibilities for academic health
liters.
* * *
jDr. John L. Weinerth, assistant professor of uro-
)ipc surgery, has been named associate director of
k jaduate medical education.
P«l [^Announcement of the appointment came from Dr.
raid W. Busse, director of medical and allied health
loilijucation, and J. P. Gibbons, Professor of Psychia-
a 1'.
a; ll'Weinerth succeeds Dr. M. S. Mahaley, Jr., associ-
^ professor of neurosurgery, who has given up the
jsition to devote more time to his clinical practice
d research interests. Mahaley has held the post
piliice June of 1972.
u .Weinerth's responsibilities will include coordinat-
; all educational activities related to residency
i|riining and managing the hospital's house staff of-
e. In addition, he will supervise the matching pro-
ijm through which graduating medical students are
i (iced in internships and residencies across the
untry and serve as a liaison between Duke Hospi-
. and the School of Medicine.
^A 1963 graduate of Bucknell University in Lewis-
irg, Pa., Weinerth received his medical education
(Harvard Medical School. Upon graduation from
arvard in 1967, he began a surgical internship at
iike and completed his urologic surgery residency
quirements, also at Duke, in 1973.
jFrom September 1969 to September 1970, he
aded the Tissue Bank in the Laboratory Services
apartment at the Naval Hospital in San Diego, and
ice August of 1972, he has been chief of the Renal
Irfusion Unit here in the Department of Surgery's
,|l/ansplantation Service.
of) * * *
John D. Shytle, a former controller of the Veterans
dministration in Washington, has been named as
iistant vice president for health affairs.
He will be responsible for medical center admin-
1 iration and will report to Dr. William G. Anlyan,
111 re president for health affairs.
Shytle was controller of the Veterans Administra-
in from 1963 until 1972. From 1972 until his
[tpointment at Duke he was director of the Veterans
^ministration Hospital in Richmond.
J>A native of Shelby, Shytle, 56, was a cost ac-
cl iuntant at Dover Mills in Shelby prior to Worid
oj: rar IL During the war he served as a captain with
CEMBER 1974, NCMJ
V
the 14th Air Force in China, earning a Distinguished
Flying Cross with three Oak Leaf Clusters.
Following the war he joined the Veterans Admin-
istration, leaving for two years to serve as a senior
cost analyst for U. S. Steel in Pittsburgh.
Shytle rejoined the VA in 1949, serving consec-
utively in the Budget Service, Department of Vet-
erans Benefits and the Department of Medicine and
Surgery. In 1961 he was named Budget Officer of
the VA, holding that position until being named
controller.
Shytle holds a B.S. degree in business administra-
tion and M.S. degree in management from George
Washington University.
:i= * *
More than 40 Japanese and American investiga-
tors studied the cellular make-up and natural de-
velopment of the heart muscle in Tokyo in mid-
October, thanks largely to the foresight and interest
of a Duke physiology professor.
The bilaterally-sponsored seminar, "Developmen-
tal Aspects of Cardiac Cellular Physiology," was
planned and established by Dr. Melvyn Lieberman,
in cooperation with Dr. Toyomi Sano, a professor
at Tokyo's Institute for Cardiovascular Diseases.
AMERICAN ACADEMY OF FAMILY
PHYSICIANS
Dr. Carl B. Hall of Charleston, West Virginia,
was recently named president-elect of the American
Academy of Family Physicians at the medical group's
Congress of Delegates.
Among other new officers elected by the Congress
was Dr. George Wolff of Greensboro, elected to
serve a three-year term on the Board of Directors.
AMERICAN COLLEGE OF EMERGENCY
PHYSICIANS
North Carolina Chapter
The North Carolina Chapter of the American Col-
lege of Emergency Physicians has elected the follow-
ing officers: president, Dr. George Podgorny of
Winston-Salem; vice president. Dr. William Barry of
Fayetteville; secretary-treasurer. Dr. David S. Nelson
of Winston-Salem; councillor. Dr. George Podgorny
of Winston-Salem; alternate, Dr. Thomas Berner of
Asheville; 2nd alternate. Dr. R. Tempest Lowry of
Raleigh.
The following were elected to the Board of Direc-
tors: Dr. William Barry of Fayetteville; Dr. Thomas
Berner of Asheville; Dr. Hugh Fitzpatrick of High
Point; Dr. Frederick W. Glass of Winston-Saleiji;
Dr. Robert S. Jacques of Pittsboro and Pinehurst;
Dr. R. Tempest Lowry of Raleigh; Dr. Morton
Meltzer of Durham; Dr. Wayne Stockdale of Golds-
boro and Smithfield.
749
NORTH CAROLINA MEDICAL PEER
REVIEW FOUNDATION. INC.
The North Carolina Medical Peer Review Founda-
tion, Inc. (NCMPRF). was formed in February
1973 at the direction of the E.xecutive Council of
the North Carolina .Medical Society, and is dedicated
to developing and promoting methods of peer review
applicable to all aspects of medical care in the state.
Membership in the Foundation is open to any phy-
sician licensed to practice in North Carolina, and
nearly one-third of all North Carolina's physicians
are already members.
NCMPRF, Inc., was formally established in Febru-
ary 1974. M. Frank Sohmer, M.D., Winston-Salem,
was elected president and is Acting Medical Direc-
tor as well, and Dan Mainer, formerly Assistant Ex-
ecutive Director of the North Carolina Medical So-
ciety, is Executive Director of the Foundation. The
executive offices of the Foundation are located in the
Medical Society Building at 222 North Person Street
in Raleigh. The telephone number is 919-828-7306.
As part of its continuing obligation to both prac-
titioners and providers of medical care in North
Carolina, the Medical Peer Review Foundation is
actively developing various kinds of review programs
to help ensure that the responsibility for the review
of medical services remains with practicing physi-
cians, not with governmental agencies.
The first program undertaken by the Foundation
was educational and was funded by a grant from the
North Carolina Regional Medical Program; it was an
attempt to familiarize North Carolina physicians
with the provisions of the PSRO Law. Physician
members of the Foundation's Board of Directors pre-
sented a series of seminars throughout the state. The
well attended seminars seemed to answer mri '
physician's questions about PSRO. Under this gra
the Foundation has also formed a committee of pi
sicians whose responsibility it is to make fom
recommendations concerning criteria for the asse
ment of the quality of medical care in North Ca
lina. Its work is expected to take some time, a
the committee plans to evaluate pertinent informati
from the medical staffs of many of the hospit
in the state before making its final recommendatio
On March 28, 1974, the Foundation entered ii
a contract with the State Department of Human I
sources to provide periodic medical review servi
for Medicaid patients in skilled nursing faciliti
psychiatric and tuberculosis hospitals, as required
45 Code of Federal Regulations 250.23. Under t
Program, four Foundation Review Teams, with et c.
team composed of a review physician, nurse a
medical social worker, will evaluate the quality e
patient care and appropriateness of the level of ca
Each eligible patient will be reviewed two or th
times a year.
On July I. 1974. the Foundation was designa'
as a statewide PSRO Support Center, by contr
with the United States Department of Health, Edui -
tion, and Welfare (HEW). There are eight des
natcd PSRO areas in the state. In this role.
Foundation proposes to undertake further edu
tional programs concerning the PSRO Law for pi
sicians and other health professionals, and to id'
tify organizations to perform Professional Standa
Review in those areas where no appropriate org;
zation has yet emerged. .As PSROs are identifiedl
each of these areas, the Foundation is provid
professional and technical assistance to these
:aj
PSRO DESIGNATION'S FROM
MWC.H IS, 19:'4 FIZDEJIU REGISTER
750
NORTH CAROLINA
Vol. 35, No.
nizations, as they request it, so that each progresses
gTi^im the planning phase to conditional operational
(itUS.
iC* Areas— (8)
iE'Area
riiiaii:Area
1,;. Area
■WArea
BtioWArea
■ed hi Area
, „ Area
'"^ H Area
mi
I
II
III
IV
V
VI
VII
VIII
TOTAL
MDs
518
665
454
1,012
375
459
867
432
4,791
DOs Hospitals
28
27
19
9
8
12
23
22
14
134
Hospital
Beds
2,421
2,745
1,698
1,823
1,586
2,115
4,102
2,235
18,725
ierti At present, NCMPRF, Inc., is assisting with or-
ik eiinizational activities in eight of the eight designated
5e acKRO Areas in North Carolina. Area I had an or-
iliti'mizational meeting in late October, inviting chiefs
icas hospitals staffs of all hospitals in the area, as
niiiHl as presidents of county medical societies, for
air initial discussion of the approach to organizing
a non-profit corporation. Area II has received a plan-
ning grant from HEW for a six-month period, which
began July 1, 1974; it is making preparations for
applying to HEW as a Conditional PSRO, known
as the Piedmont Medical Foundation, with headquar-
ters in Winston-Salem. Area III has had several or-
ganizational meetings and has formed a corporation
known as the North Central Peer Review Founda-
tion, headquartered in Greensboro, and NCMPRF,
Inc., is assisting this organization in applying for a
planning grant at the time of the next contract award
period. Area VI has had two organizational meetings
and formed the Northeastern North Central Medical
Peer Review Foundation, headquartered in New
Bern, North Carolina. NCMPRF, Inc., is assisting
this corporation in making preparations to apply for
a planning grant. Area VII had one organizational
meeting, and another was scheduled for late October
to formally organize a non-profit corporation for
seeking a planning grant. Area VIII has completed an
initial organizational meeting and scheduled another
for their corporate organization in late October.
ity, program and environment
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jlCEMBER 1974, NCMJ
r
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Nature Trail
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FOR ADMIHANCE CALL
JAMIE CARRAWAY
EXECUTIVE DIRECTOR
919-621-3381
Recognized by:
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• Pilot Life Ins. Co. • Aetna Life & Casualty
• John Hancock Mutual Life Ins. Co • Kemper Ins,
• Metropolitan Life Ins. Co. • United Benefit Life Ins. Co
• Security Life & Trust Co,
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p. 0. BOX 6928 • GREENSBORO, N. C. 27405
Member of;
« N. C. Hospital Association
The Alcoholic & Drug Problems
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» American Hospital Association
FOR MEDICAL INFORMATION CALL
J. W. WELBORN, JR., M.D.
MEDICAL DIRECTOR
919-275-6328
Located off U.S. Hwy. No. 29 at Hicone Road Exit,
6% miles north of downtown Greensboro, N. C.
Convenient to 1-85, 1-40, U.S. 421, U.S. 220,
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FELLOWSHIP HALL WILL ARRANGE CONNECTION WITH COMMERCIAL TRANSPORTATION.
7.^1
Month in
Washington
Though Senator Russell Long (D-La.) may make
an attempt to win Senate approval of his social
security-catastrophic national health insurance pro-
posal when the Congress returns in late November,
most Capitol Hill observers believe such legislation's
chances of passage are less than that of Henn,' Menc-
ken's snowball in hell.
+ ^ *
The American Medical Association is now in the
process of reviewing and updating its position on na-
tional health insurance, Malcolm C. Todd, M.D.,
has told Washington groups.
"Our objective is to make the AMA's national
health insurance proposal more flexible, while at the
same time maintaining certain basic precepts." Dr.
Todd said.
"If necessary, we may compromise on the method
of financing we adopt. But we are not willing to
fund national health insurance through an increase in
Social Security taxes; nor are we willing to see the
program administered by the Social Security Ad-
ministration.
"We want a financing mechanism for comprehen-
sive health insurance that will do the most at the least
cost. This could involve: increase employer-employee
contributions for private health insurance; the use of
general tax revenues; or, an individual tax credit to
he applied toward full health care protection. This
latter method was, of course, the method employed
in Medicredit.
"The important point is that we cannot counte-
nance greater fiscal and bureaucratic authority for
the Social Security .Administration or an increase in
the Social Security tax.
"Any payroll tax, whether collected under Social
Security or not, constitutes the most insidious form of
taxation that can be invoked by government. It is a
totally regressive tax that weighs heavily on low and
middle income workers and lightly on the affluent.
"Finally, the measure that emerges will provide
comprehensive health care benefits as well as protec-
tion against the catastrophic costs of prolonged ill-
ness for every American," Dr. Todd said.
* * *
.\ batch of major health bills is hanging afire for
the "lame duck" session of Congress starting Nov. 1 8.
Comprehensi\e health planning bills have cleared the
Senate but not the House. Though no public utility-
752
type regulation is in prospect, other measure
strengthening government planning authorit
abound.
Health manpower legislation with provisions fo
federal service in shortage areas is through Senati
House action is expected shortly after Congress re
turns. There is a possibility that one or both ma
be stalled in conference as the Administration no\
wishes simple extension of present programs.
A health revenue sharing bill will be taken u
again by a House-Senate conference. This measur
extends state health block grants, community mentc
health centers, family planning, migrant health an
neighborhood health center programs. It should sc
cure Congressional enactment this year.
The Health Education and Welfare appropriation
bill still has to be completed.
No chance is seen for passage of the Omnibii
Drug amendments bill that would provide Medicare
outpatient drug benefits, a Federal Formulary, an
the Administration's low-cost drug plan for Med
care-Medicaid patients.
* * *
The Health Education and Welfare Departmer
has issued final regulations on benefits and structur
of Health Maintenance Organizations, giving th
green light to federal grants launching the progran
The regulations set forth the rules, restriction
and benefits that must be followed in order for o
ganizations to qualify as HMOs and receive federj
aid. The $325 million HMO program was approve
by Congress in 1973.
Grants can now be made among the 125 group
that have applied for funds to conduct feasibilit
studies, planning and development.
The HMO Act authorizes federal support for fiv
years "to demonstrate more broadly the concept
organizations delivering comprehensive health cai
services on a prepaid basis." Last year Congre;
appropriated 561 million. The Administration sougl
560 million this year, but the Senate approved on
518 million because of a delay due to the develop
ment of the complicated regulations.
The regulations specify basic services to be pn
vided in return for fixed payments made on a period
basis without regard to the frequency, extent, or kin
of services provided, with the payments set on
community rating system. These may be suppl
Vol. 35, No.
iSUI
IS I
nted by what the regulations call "nominal co-
yments" limited under a variety of formulas.
Before the HMO program can be launched, still
ire regulations will have to be completed. The
ist important is the statutory requirement that
ployers with more than 23 workers offer the em-
•yees the option of joining a qualified HMO if
; is available. These proposed regulations are
.ted to be issued soon, but final ones are some
>nths off.
Though suggestions were made to exempt HMOs
^,m Professional Standards Review Organization
SRO) authority, HEW rejected them, declaring
t there is a need "to assure that suitable proce-
jes are applied to HMO services to assure they
'Worm to appropriate professional standards for the
wision of health care applicable to other pro-
bers."
"Basic HMO benefits must include: physician ser-
es (including consultant and referral services by a
ysician); outpatient services and inpatient hospital
Jvices; medically necessary outpatient and inpatient
^li 'ergency health services; short-term (not to exceed
visits), outpatient evaluative and crisis inter-
^ htion mental health services; medical treatment and
'erral services (including referral services to ap-
jpriate ancillary services) for the abuse of or ad-
:ition to alcohol and drugs; diagnostic laboratory
i diagnostic and therapeutic radiologic services;
nit ime health services; and preventive health services
iLcluding voluntary family planning services, ser-
i les for infertility, preventive dental care for chil-
ite )sn, and children's eye examinations conducted to
termine the need for vision correction) .
* * *
sThe General Accounting Office (GAO) has
a larged that per capita payments for Medicaid pa-
: : Ints enrolled in prepaid health plans in California
II Eeeded average fee-for-service costs on one of two
(Ot projects studied.
ri [fin a report to the Senate Finance Committee, the
i AO also said that Medicaid enrollees in the prepaid
ins "have made many complaints about the quality
medical care," especially the lack of a personal
,nily physician.
(About three percent of the Medicaid patients in
:al 1972 dropped out of the plans each month
th the exception of the Sacramento Foundation
timmunity Health plan where the rate was only .3
" xcent, a difference attributed by GAO probably
the fact that the Foundation allows most en-
lees to remain with their family physicians.
jHowever, GAO, Congress' watchdog on federal
oenditures, said the Foundation was paid $406,000
)re for Medicaid patients than per capita fee-for-
"vice estimates for the group.
The agency recommended that the HEW Depart-
mt establish surveillance mechanisms to insure that
;5ts of HMO do not exceed the costs of fee-for-
"vice.
fCEMBER 1974, NCMJ
A controversial draft report that showed two Blue
Cross Medicare intermediaries with substantially
lower administrative costs than those of the Social
Security Administration's Bureau of Health Insur-
ance ( BHI ) has been pulled back by the General Ac-
counting Office and is being redone, according to the
Washington Report on Medicine and Health. BHI
has objected to the comparison as invalid and GAO
has protested Blue Cross use of the draft which had
been put out on a confidential basis.
* * *
Physicians, patients and fellow workers have re-
acted favorably to the Physician Assistants (PA)
employed in a pilot experiment by Kaiser Founda-
tion Health Plan, according to a report on the pro-
gram.
At present, seven PAs are on duty at Kaiser. The
first was hired in 1970, a graduate of the Duke Uni-
versity PA program and a former military corpsman.
There was concern by some physicians and ad-
ministrators, but "the greatest resistance came from
the nursing department," writes Kaiser official Paul
Lairson, M.D., in Inqidry. the Blue Cross Associa-
tion magazine.
As the nurses began to work with the PA and
learned from experience that there was more of an
"equal relationship" with him than with the physi-
cians, they became a "traditional team," Dr. Lairson
declared. Furthermore, "all but one of the physicians
who worked in the clinic with the PA came to favor
expanding the program," he said.
The PA saw approximately 20 patients each day
at the Vancouver, Washington, clinic. He was given
three physical examination appointments, and the
rest of his time was rapidly filled with the "treat-
ment of relatively minor medical and surgical prob-
lems, whether by appointment or on a 'drop-in'
basis." More severe or chronic problems were trans-
ferred to the internist or other specialist.
The tax reform bill before the House Ways and
Means Committee has a provision to discourage pro-
fessional conventions by American organizations in
foreign countries.
Exempted would be Canada, Mexico, Bermuda
and the Caribbean. The taxpayer must show that it
was "more reasonable for the meeting to be held
outside North America," to secure a business expense
deduction. Not affected would be meetings an-
nounced before September 1 1, 1974.
The amendment is aimed at national conventions
being held in faraway tourist attractions where at-
tendees deduct their travel and other expenses as
business-connected.
* * *
The Department of Health, Education and Wel-
fare has announced that, commencing with the first
of the new year, the Medicare hospital deductible
will jump to $92. The present deductible is $84.
HEW said that the $92 deductible is equivalent
753
to the average cost of one day of hospitalization.
The increased payment was brought about by rising
hospital costs, according to HEW.
The Medicare law requires an annual review of
hospital costs under Medicare and an adjustment of
the portion of the bill for which a Medicare bene-
ficiary is responsible, if the costs have risen sub-
stantially.
When the hospital deductible amount changes, the
law requires comparable changes in the dollar
amounts that a Medicare beneficiary pays toward a
hospital stay of more than 60 days, or an Extended
Care Faciiitv (ECF) stay of more than 20 days.
When a Medicare beneficiary has a hospital sti
of more than 60 days, he will pay $23 a day f
the 61st through the 90th day, up from the prese
$21 per day. If he has a posthospital stay of ov
20 days in an ECF, he will pay $11.50 per d;
toward the cost of the 21st day through the 100
day, up from the present $10.50 per day.
If a beneficiary uses his "lifetime reserve" daj
the extra 60 hospital days a beneficiary can u
when he needs more than 90 days of hospital ca
in the same benefit period will cost him $46 f
each reserve day used, instead of the present $'
per day.
Book Reviews
Emergency Medical Services: Behavioral and
Planning Perspectives. John H. Noble. Jr., Henry
Wechsler, Margaret E. LaMontagne, and Mary
Anne Noble (eils). 595 pages. Price, $24.95. New
York: Behavioral Publications, 1973.
Over the years, all hospitals have had great diffi-
culty in coping with the onslaught of patients in
their emergency departments. "Without design, emer-
gency departments have taken on, in addition to
their traditional role, the buffering function of regu-
lating the imbalance of the overall health care sys-
tem."
The preceding quotation (from the foreword by
Dr. James D. Mills, president of the American Col-
lege of Emergency Physicians) succinctly states the
basic theme of this compendium of articles on
Emergency Medical Services. The editors selected the
articles from the literature of the past 15 years.
They grouped them into four sections and introduced
each with a brief review of each article.
The first section is on systems of emergency medi-
cal care and comprises five articles: the first article
analyzes emergency medical care problems as part
of the general crisis of health care and the inac-
cessibility of health care to many Americans; the
second is the only known nationally representative
study of hospital emergency facilities (written in the
late 1950s); the third analyzes the highly successful
network of emergency st;Uions in San Francisco;
the last two. examples of systems analysis, utilize
analytic models of community emergency care.
The articles in the second section relate to pat-
terns of utilization. These articles analyze either (1)
the types of patients who use the emergency room
for emergency or nonurgent care, and relate income.
754
living area and relationships with private physicia
or hospitals to such use, or (2) the interrelatio
ships between physicians, patients and outpatie
medical care.
Section three, which comprises seven articles (
transportation and communication, concerns tl
means of conveying (recovering) patients to tl
emergency room and the costs and efficiency
various "recovery" systems and disaster plans. Tl
section is the most cohesive of the four and it mc
clearly concerns true emergency care.
Section four contains a potpourri of articles (
standards and policies. It covers ( 1 ) the failure
many hospitals to meet the emergency needs of t
public, even when adequate guidelines have bei
given, (2 ) the problems of staffing emergency roor
with "moonlighting" interns and residents, (3) t
professional and legal responsibilities of nurses ai
physicians in emergency rooms and the related i
sponsibilities of hospital trustees and administratoi
(4) the emergency room's responsibilities to t
press, particularly regarding legal aspects versus t
public's "right to know," and (5) a planning ■pt
spcctive for communities that must integrate t
many components of emergency health care.
Because of the incredibly rapid expansion of inte
est and activity in emergency care programs, tl
book is already outdated. It makes little referenc
for example, to the many recently established re
dency training programs for full-time emergency ph
sicians. It offers very few solutions to the maj
problems that relate to emergency versus prima
care.
Despite the foregoing deficiencies, however, tl
compilation of articles, accompanied by pertine
Vol. 35, No.
IF A
DISABILITY
CLOSED THE
DOOR ON YOUR
PRACTICE...
WOULD IT ALSO
CLOSE THE
TTTTlTriTTT;
FAMILY'S
FUTURE?
Disabilities are something a
doctor deals with every day.
Certainly no one is more aware of
how much a life can be affected by
a disabling sickness or injury.
Sometimes, though, a doctor can
become so involved in the
treatment of these disabilities that
it becomes easy to put aside
thoughts of what might happen to
you and your family if that
disability struck you down and
you were unable to continue your
practice.
Now, a Disability Income
Protection Plan, especially
designed for younger doctors, is
available for members of the
North Carolina Medical Society.
This Plan can help see to it that
your family's future will be
protected if you should become
sick or hurt and are unable to
continue your practice. This
monthly benefit is payable directly
to you for use as you see fit.
Furthermore, these are tax-free
benefits and are payable whether
you are confined to the hospital or
are at home recovering.
If you are under 55 years of age,
just fill out the coupon below and
mail it today. There is no
obligation to learn more about the
benefits of this Plan to you.
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 rode
Mutual^
People i/au can count an...
Life Insurance Affiliate: United of Omaha
MUTUAL OF OMAHA INSURANCE COMPANY
HOME OFEICE- OMAHA, NEBRASKA
editorial comments, is an excellent source book of
information on emergency medical services in this
country.
James T. McRae, M.D.
Essays on Longevity. By Samuel Kahn, M.D. 198
paces. SlO.fJO. New York: Philosophical Library,
1974.
Essays on Loiii^evity is essentially a spiel, eluci-
dating the obvious or oversimplifying the compli-
cated. It reads as if the author believed he has dis-
covered eternal life.
For example. Dr. Kahn says:
Posture is very important. The man or woman who
carries the head high, the chin up, shoulders straight
and chest out is on the right road to a long life. The
resistance of the lungs is lowered when the posture
is bad, and you may invite diseases in the chest,
pelvic or abdominal muscles. Long life and poor pos-
ture are not good friends. The lazy carriage bespeaks
a lazy body and a lazy body bespeaks a lazy mind.
Either or both may be fatal to longevity. When you
walk, sit, play or work, always remember good pos-
ture— it will prolong your life and add to your per-
sonality.
He suggests we, "Eat the following fish: coc
mackerel, haddock, halibut, blue fish, bass an
Hounder" to help prevent cardiovascular renal dis
ease.
After reading such instructions for 200 pages,
cannot help thinking of my uncle who died at 8
after smoking three packages of cigarettes a da
for 70 years. Each in his own way. Dr. Kahn an
Uncle Bill seem foolish.
William D. Poe, M.D.
The Doctors' Guide to Better Tennis and Health.
Claude A. Frazier, M.D. (ed). 126 pages. Price,
$5.95. New York, N. Y.: Funk & Wagnalls Pub-
lishing Co., 1974.
This small book, edited by tennis enthusiast Di
Claude A. Frazier of .'\sheville. North Carolina, i
both readable and concise. The chapters are writte
by experts in their chosen fields. Although there i
little in the way of new information for the physi
cian, the book should be a helpful reference sourc
for the tennis-playing family.
C. Glenn Sawyer, M.D.
J
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.
Accredited by the Joint Commission on Accreditation and
Certified for Medicare
James Asa Shield, M.D.
James Asa Shield, Jr., M.D.
Catherine T. Ray, M.D.
Weir M. Tucker, M.D.
George S. Fultz, Jr., M.D.
Graenum R. Schiff, M.D.
756
Vol. 35, No.
In JHpttwrtam
James Breckinridge Loundsbury, M.D.
James Loundsbury, M.D., died June 20, 1974, at
je age of 65 years. He was born in Wilmettc, Illi-
)Ois, and completed primary schooling there. He at-
^nded the Hotchkiss School, Lakeville, Connecti-
ut, and Yale undergraduate school. He graduated
•rem Yale Medical School in 1935 with the M.D.
'egree. Dr. Loundsbury then served a rotating intem-
'nip at University Hospital, Ann Arbor, Michigan,
lor one year, after which he served two years at the
IJniversity of Michigan as a lecturer in Public Health
|nd Hygiene. He spent one year as surgical resident
It the University of Michigan and served as resident
1 Obstetric /Gynecology at the University Hospitals
1 Cleveland, Ohio. He served his final year at
Voman's Hospital, Detroit, Michigan, finishing his
raining in 1941.
Dr. Loundsbury married Beatrice Thomen and
ame to Wilmington in 1941 where he was on the
itaff of James Walker Memorial Hospital prior to
£rving in the Navy Medical Corps during World
Var IL At the end of his service he returned to
V'ilmington where he stayed until his death. In addi-
lon to being a member of the attending staff of the
Jew Hanover Memorial Hospital, he was on the
iourtesy staff of Cape Fear Memorial Hospital and
iie consulting staff of Dosher Memorial Hospital at
iouthport. North Carolina.
Dr. Loundsbury served the community for many
ears as chief obstetrician of the Maternity Clinic
f the New Hanover County Health Department. He
i/as a member of the American Medical Association,
idedical Society of New Hanover County, American
uollege of Surgeons, American Gynecological So-
dety. North Carolina Obstetrical and Gynecological
iociety, American College of Obstetrics and Gyne-
)ology, and was a Diplomate of the American Board
if Obstetrics and Gynecology.
I>ECEMBER 1974, NCMJ
Besides his many medical accomplishments. Dr.
Loundsbury enjoyed several hobbies, but he pri-
marily loved to play golf. He became interested in
boating after his retirement in 1969, and served as
a lieutenant in the local chapter of the Power
Squadron and was treasurer for the five years pre-
ceding his death.
Jim Loundsbury was a true friend and accom-
plished physician. He will be sorely missed and
fondly remembered.
Surviving are his widow, two daughters, Barbara
and Jean, four grandchildren, and a brother, Rich-
ard C. Loundsbury of Sherman, Connecticut.
New Hanover-Pender-Brunswick County
Medical Society
Luther W. Kelly, Sr,, M.D.
Dr. Luther W. Kelly, Sr., died on August 23, 1974.
He received his Doctor of Medicine Degree from the
University of Virginia and served his internship and
medical residency at Boston City Hospital. Dr. Kelly
came to Charlotte in 1928.
Dr. Kelly was born on April 14, 1896, in Phila-
delphia and moved to Williamsburg, Virginia, at the
age of 12. He joined the Nalle Clinic in 1929 where
he continued his medical practice until 1971, at his
retirement. He was chairman of the Department of
Medicine at Charlotte Memorial Hospital when it
first opened its doors. He was president of the Meck-
lenburg County Medical Society in 1947 and was an
organizing member of the Charlotte and North Caro-
lina Societies of Internal Medicine.
Dr. Kelly was a colleague and friend who exem-
plified the fine things we mean when we say that
he was a gentleman and physician.
Mecklenburg County Medical Society
757
SUBJECTS
Alcoholism research in North Carolina (Ewing) 421-C Commitment laws, changes in (Zarzar) 737-C
Allergy in children, insect sting (Frazier) 358
Apnea, postanesthetic, pseudocholinesterase abnormali-
ties as a cause of (James) 607
Asthma in children, the role of gastroesophageal reflux
in nocturnal (Dees) 230
Biomedical research, certain ethical aspects of: evolu-
tion of concepts of ethical standards (Toole) 475
Book Reviews
Abse W: Speech and Reason: Language Disorder
in Mental Disease ( Ewing) 190
American National Red Cross: Advanced First Aid &
Emergency Care (Shaffner) 56
American National Red Cross: Standard First Aid and
Personal Safety (Shaffner) 56
Behrman RF (ed): Neonatology: Diseases of the Fetus
and Infant (Smithson) 324
Blau SP, Shultz D: Arthritis. Complete. Up-to-Date
Facts for Patients and Their Families (Muse. Turner)
576
Carter WA ( ed ) : Selective Inhibitors of Viral Func-
tions (Kucera) 39
Davis L: A Surgeon's Odyssey (Alexander) 506
Delacato CH : The Ultimate Stranger ( Hinman ) 576
Driesbach RH : Handbook of Poisoning (Shihabi) 709
Fletcher J: The Ethics of Genetic Control: Ending
Reproductive Roulette (Goodman) 709
Frazier CA: Annual Review of Allergy, 1972 (Hunt-
ley) 259
Frazier CA (ed): Dentistry and the Allergic Patient
( Beavers) 453
Frazier CA: Faith Healing: Finger of God or Scien-
tific Curiosity? ( Hackett) 3S0
Frazier CA: Parents Guide to AUercv in Children
(Ward) 507
Frazier CA ( ed ) : The Doctor's Guide to Better Tennis
and Health (Sawyer) 756
Ganong WE: Review of Medical Physiology, ed. 6
(Hutchms) 5(1
Goldberser E: Treatment of Cardiac Emereencies
(Head ley) 506
Hamburger J: The Power and the Frailty (Felts) 119
Harper HA: Review of Phvsiolocical Chemistrv ( De-
Chatelet) 381
Kahn S: Essays on Longevity ( Poe ) 756
Kempe CH, Silver HK,"0'B'rien D: Current Pediatric
Diagnosis and Treatment (Simon) 453
Krupp M, Chatton MJ : Current Diagnosis and Treat-
ment (Kaufmann) 259
Krupp M, Chatton MJ (eds) : Current Medical Diag-
nosis and Treatment (Almkuist) 638
Luskin AL Lechevalier HA (eds): Handbook of
Microbiology, Vol. L Organismic Microbiology
(Wasilauska's) 576
Mule SJ, Brill H (eds) : Chemical and Biological As-
pects of Drug Dependence (Pearson) 324
Noble JH, Jr., Wechsler H, LaMontagne ME, Noble
MA (eds): Emergency Medical Services: Behavioral
and Planninc Perspectives (McRae) 754
Phibbs B: The Cardiac Arrhvthmias (Edmonds) 453
Selye H: Stress Without Distress (Carr) 707
Stephenson HE, Jr. (ed): Immediate Care for the
Acutely 111 and Injured (Glass) 639
Carolinas' camp for diabetic children: descriptive fea-
tures of a camper population with emphasis on com-
plications (Sk\ler, Ellis, Bivens) 29
Carpal desmotomy:
Meagher) 415
764
technical note ( Banerjee.
Community of care, a ( Lee ) 96
Congenital neuroblastoma presenting as hydrops fetalis
(Johnson, Halbert) 289
Control of diseases preventable by active immunization
in North Carolina — past, present and future (Mac-
Cormack. Koomen) 411
Cvstosarcoma phvlloides in a twelve-year-old girl
'(Kelsh) 295
Diabetes
Carolinas' camp for diabetic children: descriptive
features of a camper population with emphasis on
complications ( Skyler, Ellis, Bivens) 29
diabetic microangiopathy, the etiology of: a review of
the recent literature (Smith) 354
Doctor, what did you say? (Matthews) 297
Education, survey of health, in the North Carolina
public schools (Martinat) 614
Emergency medical services (Abstracts from Emergency
Medicine Today)
Activities of tfie public health service in emergency
medical services ( Wagner) 174
Alternative to "91 1" (Johnson) 738
A mobile system of acute cardiac care (Becker) 362
A "new role" for the emergencv department nurse
(Davison) 240
Categorization of hospital emergency departments:
how it was done in Ohio (Johnson) 100
Historical background of the AMA Committee on
Community Emergency Services (Johnson) 44
Organizing and establishing a rural emergency medical
s>s"tem (Johnson) 488
Proposed training program for EMT advanced train-
ing, 688
"STATES" keeps an eve on highway safety (Johnson)
420
The scene of an accident (Johnson) 305
Trauma can be conquered ( Proctor) 620
Emergency medical services in North Carolina: a propo-
sal for the organization of a statewide emergency
services system in North Carolina (Cordle) 535
Drug deaths in North Carolina: a brief survey of deaths
attributed to drugs in North Carolina, 1973 ( McBay.
Hudson) 542
Endobronchial disease, an improved approach to the
diagnosis of: fiberoptic bronchoscopy (Taylor,
Evangelist, Phillips) 667
Experience with a skin cancer detection clinic at a state
fair (Kanof) 159
Family practice: one answer (Jordan) 612
Fiberoptic bronchoscopy: an improved approach to the
diagnosis of endobronchial disease (Taylor, Evange-
lisel, Phillips) 667
Folk medicine in North Carolina ( Betts) 156
Hand, initial care for lacerations of, flexor tendons of
the (Winslow. Bevin) 38
Health education, survey of, in the North Carolina pub-
lic schools ( Martinat ) 614
Hvdrops fetalis, congenital neuroblastoma presenting as
■(Johnson, Halbert) 289
Vol. 35, No. K
E..
»■
yp)erparathyroidism
iithe preoperative localization of hyperfunctioning
Jparathyroid tissue utilizing parathyroid hormone
! radioimmunoassay of plasma from selectively cathe-
Iterized thyroid veins (Wells. Johnsrude, Ellis, Bilezi-
ikian, Johnson. Peete. McPherson) 678
itial care for lacerations of flexor tendons of the hand
KWinslow, Bevin) 38
1
jsanity defense, recent developments on the (Rollins)
356
isect bites (Frazier) 365-C
lacMillan. Louise Fant (Alexander) 306-C
Radical and surgical complications of therapeutic ter-
tminations of pregnancy ( Evans, Gusdon) 87
>edical-ethical issues, personal testimonies on (Frazier)
306-C
ijorth Carolina
alcoholism research in (Ewing) 421-C
control of diseases preventable by active immuniza-
tion in, past, present and future (MacCormack,
fKoomen) 41 1
drug deaths in: a brief survey of deaths attributed to
drugs in 1973 (McBay, Hudson) 542
;emergency medical services in: a proposal for the
.organization of a statewide emergency services system
•iin (Cordle) 535
I folk medicine in (Betts) 156
I health education, survey of, in the public schools
((Martinat) 614
'ineed for more and better distributed primary physi-
(Cians in, 234-C&0
^obstetrical and neonatal services in (Bishop, Brumley)
primary medical care and group practice in (Allcott,
t Madison, Sheps) 33,725
arathyroid tissue utilizing parathyroid hormone radio-
i immunoassay of plasma from selectively catheterized
I thyroid veins, the preoperative localization of hyper-
i functioning (Wells, Johnsrude, Ellis, Bilezikian, John-
jsson, Peete. McPherson) 678
V ■ w
■jtiysical iitness
ia five-year study of uric acid, cholesterol, and selected
il fitness variables in professional men (Marley, Smith,
Linnerud, Sonner, Rovster, Chasson) 730
Physicians' assistant program of the Bowman Gray
School of Medicine, the present status of the (Wilson)
292
Pediatrics
allergy in children, insect sting ( Frazier) 358
asthma in children, the role of gastroesophageal re-
flux in nocturnal (Dees) 230
Poisons that killed (Whitener) 364-C
Poisons that killed: an analysis of 300 cases (Fatteh,
Hayes) 227
Pregnancy
medical and surgical complications of therapeutic
termination of (Evans, Gusdon) 87
Prescription drug prices, variability of (Hayes, Whalley)
351
President's farewell address (Gilbert) 405
President's inaugural address ( Reynolds) 469
President's Newsletter — See Organizations & Institutions
Primary care physicians in North Carolina, need for
more and better distributed (North Carolina Medical
Society Committee on Medical Care) 234-C&0
Primary medical care and group practice in North Caro-
lina (Allcott, Madison, Sheps) 33
Pseudocholinesterase abnormalities as a cause of post-
anesthetic apnea (James) 607
Psychopharmacological treatment of disorders of
senescence (Fann, Wheless, Richman) 672
Reimplantation of extremities by microvascular suture
(Boyes) 479
Skin cancer detection clinic at a state fair, experience
with a (Kanof) 158
State mental hospital referrals: patient abandonment by
local medical resources (Edwards, Gowitt, Rollins)
151
Tail is wagging the dog, the ( Wansker) 91
To commit or not to commit, a continuing dilemma:
some guidelines (Raft, Werman, Spencer) 545
Tuberculosis, an unusual case of miliary: prolonged sur-
vival with untreated miliary tuberculosis (Munt) 727
EDITORIALS
luthors, suggestions for, 41, 418
lardiac catheterization in the newborn, 736
river licensing, medical evaluation for, 482
>'irugs, regulation and progress, 238
iditor, a new, 554
xecutive Council, midwinter meeting, 162
(cecutive Council, spring meeting, 361
xecutive Council, the fall 1974 meeting, 687
3lk medicine, 162
ox. Dr. Myron L. and Dr. Thomas More. 300
tiouse of Delegates, transactions of. 418
ow to know what is going on. 99
ij.iacMillan. Louise Fant. 238
ledical evaluation for driver licensing. 482
:(ecEMBER 1974. NCMJ
Medicine, folk, 162
More. Dr. Thomas and Dr. Myron L. Fox. 300
Neglected disease of modern society, the, 554
Nicholson, Dr. William McNeal, 688
North Carolina Regional Medical Program, 239
Prescription PSRO, 162
Prevention, an ounce of? 619
Problem-oriented records, 361
PSRO, prescription, 162
Records, problem-oriented. 361
Right physician at the right time.
Suggestions for authors. 41. 418
Will sickness become illegal? 620
239
765
ORGANIZATIONS AND INSTITUTIONS
American Academy of Allergy, 319
A.merican Academy of Facial Plastic and Reconstruc-
tive Surgery, 447
American Academy of Family Physicians. 748
American Board of Dermatology, 187
American College of Obstetricians and Gynecologists.
502
American College of Emergency Physicians. North
Carolina Chapter, 749
American Medical Association Council on Constitution
and Bylaws. 254
Bowman Gray School of Medicine of Wake Forest
University, 51, 104, 184. 252, 318, 369. 440, 501.
560.631.700. 746
Boy Scouts of America. 447
Duke University Medical Center, 47, 110, 182, 251,
312, 372, 438, 499, 570, 629, 699, 748
Joint Commission on Accreditation of Hospitals. 319
Month in Washington. 53. 112. 188. 255. 319. 375.
448. 503, 572, 636, 702. 752
North Carolina Heart Association, 502
North Carolina Medical Society
ad hoc Committee to Study and Recommend a Salary
or Increase in Allowances for the President. 245
Auxiliary to the. 559. 628. 697. 745
Committee Advisory to Crippled Children's Program,
177
Committee and Commission Appointments (1974-
75). 423
Committee on Chronic Illness. TB and Heart Disease,
100
Committee on Community Medical Care. 234
Committee on Medical Education. 489
Committee on Medicare, 422
Committee on Public Relations. 422
Committee on Peer Review. 100
Committee to Work with the N. C. Industrial Com-
mission. 177
Insurance Industry Committee. 306
New Members, f79. 245, 307, 365, 437. 490, 555.
621.689, 739
President's Newsletter, 17, 77, 137, 221. 281
Report to the Committee Liaison to the Pharmaceu-
tical Association. 1 77
1 20th Annual Session
Preliminary program. 168
Transactions — Supplement
Roster of Members — Supplement
North Carolina Medical Peer Review Foundation. 750
North Carolina Society of Internal Medicine. 187
Pre-PSRO Education Seminars. 187
University of North Carolina Division of Health Affairs
47, 109, 186, 250, 310, 371. 445. 493. 565. 632. 698
747
What? When? Where? 45. 102. 180. 246. 307. 366. 437
490. 555. 621.690.739
Bell. L. Nelson, 640
Boyette, Dan Parker, Jr., 382
Bullard, George M., 120
Coxe, Joseph Wentworth. 325
Chandler. Weldon Parten. 260
Crump. Cecil L., 640
Frye, Glenn Raymer, 58
IN MEMORIAM
Hamilton, Joseph Franklin, Jr.. 260
Hardin. Eugene Ramsey. 191
Hedrick. Clyde R.. 454
Hornowski. M. J.,578
Kapoor. Shankar Nath. 382
Kelly. Luther W.. Sr.. 757
Loundsburv. James Breckinridge. 757
Lyda. Edgar Witherly. 260
McGuffin. William Christian. 326
Palumbo. Leonard. 578
Stocker. Frederick William. 710
Thomas. Charles Darwin. 325
Wolfe, Nathan Carl, Sr., 508
766
Vol. 35. No. I
NORTH CAROLINA MEDICAL JOURNAL
SUPPLEMENT.
RRARY
S^LTH SCIENCK.S r,T
NORTH CAROLINA MEDICAL
SOCIETY
TRANSACTIONS
One Hundred Twentieth Annual Session
held at
Pinehurst, North Carohna
May 18-22, 1974
Briefed and Abridged by
William N, HiUiard, Executive Director
North Carolina Medical Society
222 North Person Street, Raleigh, North Carolina 27611
i
NORTH CAROLINA MEDICAL
SOCIETY
TRANSACTIONS
One Hundred Twentieth Annual Session
held at
Pinehurst, North Carolina
May 18-22, 1974
Compilation of Annual Reports 4
Auditor's Report 7
Executive Council Meetings
Fall Meeting. September 30, 1973 43
Mid-Winter Meeting, February 3, 1974 46
Annual Meeting, May 5, 1974 48
House of Delegates Meetings
Sunday, May 19, 1974 50
Constitution and Bylaws 56
Reports of the Executive Council 59
Budget Estimates 59
Resolutions 69
Election of Officers 55
Tuesday, May 21, 1974 75
Reference Committee I 75
Reference Committee II 80
President's Dinner, May 21, 1974 87
General Sessions
First General Session, Monday, May 20, 1974 91
Second General Session, Tuesday, May 21, 1974 94
Third General Session, Wednesday, May 22. 1974 96
Conjoint Session — Medical Society and State Board of Health 96
Medical Awards:
Moore County Medical Society 98
George Marion Cooper (Wake County) 98
Historical Data 99
Roster of Members of State Board of Health 100
Roster of Members of Board of Medical Examiners 100
r
OFFICERS— 1974-1975
President Frank R. Reynolds, M.D., 1613 Dock St., Wilmington 28401
President-Elect James E. Davis, M.D., 1200 Broad St., Durham 27705
First Vice-President Jack Hughes, M.D., 923 Broad Street. Durham 27705
Second Vice-President M. Frank Sohmer, Jr., M.D., Professional Bldg., Winston-Salem 27103
Secretary E. Harvey Estes. Jr.. M.D.. Duke Univ. Med. Ctr., Durham 27710 (1976)
Speaker Chalmers R. Carr, M.D., 1822 Brunswick Avenue, Charlotte 28207
Vice-Speaker Henry J. Carr, Jr.. M.D., 603 Beamon St., Clinton 28328
Past-President George G. Gilbert, M.D.. 1 Doctors Park. Asheville 28801
Executive Director William N. Hilliard. 222 N. Person St., Raleigh 27611
COUNCILORS AND VICE-COUNCILORS
First District: Edward G. Bond, M.D., Chowan Med, Ctr.. Edenton 27932 ( 1977)
\'ice-Coiincilor: Joseph A. Gill. M.D., 1202 Carolina Ave., Elizabeth City 27909 (1977)
Second District: J. Benjamin Warren, M.D., Box 1465, New Bern 28560 ( 1976)
Vice-Councilor: Charles P. Nicholson. Jr., M.D., 3108 Arendell St., Morehead City 28557 (1976)
Tliird 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: Harrv H. Weathers, M.D.. Central Medical Clinic. Roanoke Rapids 27870 (1977)
Vice-Councilor: Robert H. Shackleford. MD. 115 W. Main St., Mt. Olive 28365 (1977)
Fijtii District: Albert Stewart, Jr., M.D.. 114 Broadfoot Ave.. Fayetteville 28305 (1975)
Vice-Councilor: August M. Oelrich. M.D,. Box 1169, Sanford 27330 (1975)
Sixth District: J. Kcmpton 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: Jesse Caldwell, Jr., M.D.. 114 W. Third Ave.. Gastonia 28052 (1975)
Vice-Councilor: William T. Raby, M.D.. 1012 Kings Drive, Charlotte 28283 (1975)
Eighth District: Ernest B. Spangler, M.D.. Drawer X3, Greensboro 27402 (1976)
^Vice-Councilor: James F. Reinhardt, M.D.. Cone Hospital. Greensboro 27402 (1976)
Mnth District: Verne H. Blackwelder. M.D.. Box 431. 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 (1975)
Vice-Councilor: Otis Bentley Michael. M.D.. Suite 208. Doctors Bldg., Asheville 28801 (1975)
SECTION CHAIRMEN— 1974-75
Anesthesiology: Merel H. Harmel. M.D.. Duke University Medical Center, Durham 27710
Dermatology: Charles M. Howell. Jr.. Bowman Gray School of Medicine. Winston-Salem 27103
Family Physicians: C. O. Plyler. Jr.. M.D.. 1025 Randolph Road. Thomasville 27360
Internal Medicine: W. W. Fore. M.D.. 1705 W. 6th Street. Greenville 27834
Neurology & Psychiatry: Marianne S. Breslin. M.D.. Duke University Medical Center, Durham 27710
Neurosurgery: Ira M. Hardy, II, M.D., 1709 W. 6th Street, Greenville 27834
Obstetrics & Gynecology: C. T. Daniel, Jr.. M.D., 1641 Owen Dr., Fayetteville 28304
Opiuhalmology: E. Randolph Wilkerson. Jr., M.D., 1012 Kings Drive, Charlotte 28207
Orthopaedics: James R. Dineen, M.D., 1616 Medical Center Drive, Wilmington 28401
Otolaryngology: Nathaniel L. Sparrow. M.D.. 3614 Haworth Dr.. Raleigh 27609
Pathologx: W. Harley Davidson, M.D., Scotland Memorial Hospital, Laurinburg 28352
Pediatrics: Eugene B. Cannon, M.D., 135 McArthur St.. Asheboro 27203
Public Health & Education: W. Burns Jones. M.D., 500 Pittsboro Road. Chapel Hill 27514
Radiology: Julius A. Green. Jr., M.D., 3821 Merton Dr., Raleigh 27609
Surgery: Robert W. Youngblood, M.D., 1201 Brookside Drive. Wilson 27893
Urology: P. G. Fox. Jr.. M.D., 1 1 10 Wake Forest Road. Raleigh 27604
Students. Medical:
DFXEGATES TO THE AMERICAN MEDICAL ASSOCIATION
Donald B. Koonci-. M.D., 1833 S. Live Oak Parkway, Wilmington 28401 —
2 year term (January 1, 1975 to December 31, 1976)
John Glasson, M.D., 306 S. Gregson St., Durham 27701 — 2 year term (Janu-
ary 1, 1975 to December 31, 1976)
David G. Welton, M.D., 3535 Randolph Road, Charlotte 28211 — 2 year term
(January 1, 1974 to December 31, 1975)
Edgar T. Beddingfield, Jr., M.D., Wilson Clinic, Wilson 27893 — 2 year term
(January 1, 1974 to December 31, 1975)
ALTERNATES TO THE AMERICAN MEDICAL ASSOCIATION
James E. Davis, M.D., 1200 Broad St., Durham 27705 — 2 year term (January
1, 1975 to December 31, 1976)
Louis deS. Shaffner, M.D., Bowman Gray, Winston-Salem 27103 — 2 year term
(January 1, 1975 to December 31, 1976)
Charles W. Styron, M.D., 615 St. Mary's St., Raleigh 27605 — 2 year term (Janu-
ary 1, 1974 to December 31, 1975)
D. E. Ward, Jr., M.D., 2604 N. Elm St., Lumberton 28358—2 year term
(January 1, 1974 to December 31, 1975)
STAFF OF HEADQUARTERS OFFICE
Executive Director — Mr. William N. Hilliard -
Assist, to Ex. Dir. & Convention Coordinator — Mrs. LaRue A. King
Controller — Mr. Garland R. Pace
Director, Field Service — Mr. Gene Lane Sauls
Director, Governmental Affairs — Mr. Stephen C. Morrisette
Field Representative. Media Relations — Mr. John M. Evenson
Field Representative — Mr. Michael F. Gates
Graphics Technician — Mr. Bill Ennis
Receptionist — Mrs. Ginny Nichols
File Clerk — Mrs. Mary H. Gordon
SECRETARIES:
Membership — Mrs. Deanna Godwin
Advertising — Mrs. Katherine Moore
Headquarters — Mrs. Linda Blanton
Field Service — Miss Martha Floyd
Field Service — ^Mrs. Kay Hinsley
Auxiliary and NCSIM — Mrs. Jackie Cutrell
STAFF (Outside Headquarters Office)
John H. Felts, M.D., Editor — North Carolina Medical Journal
Winston-Salem
Ms. Martha van Noppen, Acting Assistant Editor, Winston-Salem
Ron W. Davis, Ed.D., Consultant, Medical Education, Regional Medical Program,
Durham
1974
Compilation of Annual Reportj
INDEX TO REPORTS
Constitutional Secretary 5
Executive Director 5
Auditor's Report 7
Auxiliary President 17
First Medical District 18
Second Medical District 18
Third Medical District 18
Fourth Medical District 18
Fifth Medical District 18
Sixth Medical District 19
Seventh Medical District 19
Eighth Medical District 19
Ninth Medical District 19
Tenth Medical District 19
Administration Commission 19
Advisory and Study Commission 19
Annual Convention Commission 19
Professional Ser\ice Commission 20
Public Relations Commission 20
Public Service Commission 21
Developing Government Health Programs
Commission 21
Auxiliary & AMA-ERF 22
Anesthesia Study 22
Arrangements 22
Association of Professions. 22
Audio- Visual Programs 23
Archives of History-NCMS 23
Blue Shield 23
NCBCBS, Inc., Board of Directors 24
Cancer 25
CHAMPUS 25
Child Health & Infectious Diseases 26
Chronic Illness 26
Community Medical Care 28
Comprehensive Health Ser\ices Planning 28
Constitution & Bylaws 28
Credentials 28
Crippled Children's Program 28
Council on Review & Development 28
Disaster & Emergency Medical Care 29
Drug .Abuse 29
Eye Care & Eye Bank 30
Finance 31
Health Care Delivery 30
■A I'.
.ii
-3 1
IF
Governor's Coordinating Council on Aging 3 it
Hospital & Professional Relations &
Liaison to NCHA
Insurance Industry
Legislation
Marriage Counseling & Family Life Education.
Maternal Health
Mediation
Medical Aspects of Sports 3
Medical Education 3
Medical-Legal 3
Medicare 3
Medicine & Religion 3 r?
Mental Health
A-Alcoholism
B-Mental Retardation & Children's Services...
Memorial Services 2
Nominations
N. C. Association of Medical Assistants
N. C. Industrial Commission
N. C. Dept. of Motor Vehicles
N. C. Pharmaceutcal Association
Occupational & Environmental Health...
Peer Review
Personnel & Headquarters Operations
Physical & Vocational Rehabilitation
Physicians on Nursing
Medical Society Consultant on Podiatry
Professional Insurance
Programs for General Sessions
Public Relations
Radiation
RMP. Advisory Group
Relative Value Study '^i
Retirement Savings Plan
Scientific Awards
Scientific Exhibits
Social Services Programs '
Advisorv' to Medical Students %
ad hoc Committee on Constitution & Bylaws
Revision
ad hoc Committee to Study and Recommend a
Salary' or Increase in Allowances for the
President '
Board of Medical Examiners '
Commission for Medical Facility, Services, and
Licensure
1 •;:
i.
K-i
V'
COMPILATION OF ANNUAL REPORTS
Compilation of Annual Reports
CONSTITUTIONAL SECRETARY
The North Carolina Medical Society continues to
lerience a healthy growth. We have experienced a
growth of 175 members in the past year. Again the
hest percentage of growth was in the student member
egory.
The membership figures are as follows:
December 3 1
tal Members 4.122
■ e Members 257
Ident Members 57
ern-Resident
Members 20
1972
December 3 1 ,
4,297
286
108
1973
This years has seen serious discussion of some very
I idamental issues, which will be difficult to resolve to
1 satisfaction of all. An effective system of peer re-
1 w of the quality of care and an effective system of
] itgraduate education seem to be the most pressing
) :ds arising from these discussions.
The impact of these activities on the membership and
I enthusiasm of the individual members will be inter-
( ng to observe. My prediction is that the effect will
I a positive one in both areas.
E. Harvey Estes, Jr., M.D., Constitutional Secretary
REPORT OF THE EXECUTIVE DIRECTOR
William N. Hilliard
Vlembership in the North Carolina Medical Society
( itinues to grow at a moderate but steady rate during
t 1973-74 Society year. The 1974 Budget, however,
I ects a reduction from the 1973 Budget as a result
{ the bulk of the membership having completed the
f ; year period of increased dues, with the 1974 budget
t mates reflecting the adjustment back to the regular
S i annual dues. New members and others who have
I completed the five year payment of increased dues
\ ' continue being billed at the increased amount until
t ir five year payment is completed.
^ copy of the Auditor's Report is contained in
t compilation of Annual Reports reflecting that all
fids and assets of the Society have been properly
i ounted for on the books of the Society in con-
f iiity with generally accepted accounting principles
f non-profit organizations. The Audit Report as sub-
r ted by A. T. Allen & Company, dated January 18,
i '4, stands as a self-explanatory report of my re-
s nsibility as Treasurer for the calendar year 1973
; I is recommended to you for approval.
'he Audit Report also reflects the 1973 management
c the North Carolina Medical Journal and this por-
t I of the Audit Report is offered as a report on the
b iness affairs of the Journal as the Business Manager.
i lecrease in advertising revenue was experienced dur-
i 1973 of approximately $5,000.00, reflecting a na-
t al trend of pharmaceutical manufacturing firms to
a ertise more in specialty and national magazines
r ler than the State magazines.
"he Medical Journal Editorial Board. Staff and many
r nbers of the State Society were saddened by the
death of Miss Louise MacMillan, Assistant Editor, on
March 2, 1974. She had served as Assistant Editor
for more than 23 years.
On December 31, 1973, the total membership in
the State Society stood at 4.297 as compared with
4,122 on that same date for 1972. As of April 1, 1974,
there were 4,059 members of the State Society after
taking into account deceased members during the past
year and members who have moved out of state. There
are, admittedly, a few slow paying members who we
do hope to collect dues for within the next few weeks
so that we will undoubtedly continue to show a net
gain in membership before too much more of 1974 has
elapsed. On April 1, 1973, there were 3,912 members of
the State Society. Including student and intern-resident
members. 207 new members have already joined the
Society this year.
Most annual projects and activities of the Society
have continued in a manner similar to previous years.
Among the more important of the continuing projects
is, of course, the arranging and staging of the Annual
Meeting of the Society, including two meetings of the
House of Delegates, General Sessions on three days.
Scientific Specialty Section Meetings, Reference Com-
mittee Hearings and related functions of the meeting.
Other projects include the Annual Conference of County
Medical Society Officers and Committeemen as a Con-
ference on Medical Leadership; the Annual Committee
Conclave held at Mid Pines Club in Southern Pines;
publication of the North Carolina Medical Journal and
the Public Relations Bulletin; the presentation of First
Aid competition trophies to the North Carolina As-
sociation of Rescue Squads; a County Medical Society,
"Secretary's Check List"; and a two-day Speech Train-
ing Session for Society leaders in November; and liaison
with many State governmental agencies.
There has been major Society and staff involvement
in activities relating to Professional Standards Review
Organizations (PSRO) and concern with Federal regu-
lations implementing this feature of Public Law 92-
603. A separate organization was formed to deal with
this problem, entitled the North Carolina Medical Peer
Review Foimdation, Inc. Space in the Medical Society
building has been leased to that organization and Mr.
Dan I. Mainer, a former member of the Headquarters
staff, was employed as Executive Director of the Peer
Review Foundation.
A member of the Headquarters staff attended a com-
bined total of thirty-one County Medical Society meet-
ings during the year, in addition to two District Medical
Society Meetings. The staff stands ready to assist any
county medical society in its local efforts insofar as
staff time permits.
The State Medical Society is fortunate in having a
capable and energetic staff, to assist your Executive
Director, all of whom have participated fully and will-
ingly in the various projects assigned to them. In most
cases they were completely responsible for various
projects, but where more than a single staff person was
involved they worked together with a high degree of
teamwork.
Mr. Garland Pace, as Controller, administers most
SUPPLEMENT TO N. C. MEDICAL JOURNAL
financial affairs of the Society, preparation of Annual
Budget estimates, preparation of Technical Exhibit
Prospectus for the Annual Meeting as well as assign-
ment of Exhibit space allocation and management of
the Exhibit area during the Annual Meeting. He super-
vises the operation and maintenance of the Headquar-
ters Building, leasing and purchase of office equipment,
and liaison responsibility with the building janitorial ser-
vice and tenants. He is also responsible for staff sup-
port for six committees.
Mrs. LaRue King. Assistant to the Executive Direc-
tor, handles the major preparation of the Annual Meet-
ing Program and supporting materials for the House of
Delegates, the compilation of Annual Reports, and meet-
ings of the Executive Council. She handles correspond-
ence relative to the Scientific Exhibits for the Annual
Meeting, along with meeting room assignments and spe-
cial luncheon affairs. She provides the staff support
for 10 committees and prepares the schedule for meet-
ings at the Annual Committee Conclave.
Mr. Gene Lane Sauls. Field Representative, con-
tinues to assume increasing responsibilities on the staff
in both areas of administrative services provided by the
Society staff and in Field Service effort. He also is
responsible for the staff support of 1 1 Committees,
and has provided administrative services for the Fourth
District Medical Society's Annual Meeting. He edits
the monthly Piihlic Relations Biillelin, is responsible
for all audio-visual equipment requirements provided at
the Annual Meeting, and attends national AMA Meet
ings in his State Society area of responsibility such a
the National Rural Health Conference.
Mr. Stephen C. Morrisette, Field Representative
works primarily in the field of Legislative activities
This year he has initiated a weekly legislative news
letter to all county society presidents and legislativ.
chairmen. He continues to review all bills introduce(
in the General Assembly which have any importance ti
the medical profession and works with the Society Lega
Council in contacting physicians about matters bein
considered by the General Assembly of interest to th
membership. He also provides staff support for 14 Com
mittees and for the North Carolina Society of Interne
Medicine.
The Administrative Staff meets periodically to discus
projects and activities that each staff member will b
involved with or assigned to in order to assist wit
production and finalization of the various function
scheduled. These meetings enable the staff assistants t
be familiar with each other's work schedule in additio
to offering assistance to each other and further th
teamwork concept within the office.
In closing, the membership should certainly be mad
aware of my appreciation and gratitude to all the secrt,
tarial staff for loxal and efficient efforts on behalf c
the Society. They and the staff assistants serve the Sc
ciety well and do deserve your support and appreciatior
William N. Hilliard, Executive Directc
f
1 1:».
K
COMPILATION OF ANNUAL REPORTS
\
AUDITOR'S REPORT
NORTH CAROLINA MEDICAL SOCIETY
Raleigh. North Carolina
12 Months Ended December 31, 1973
George G. Gilbert, M.D.
Frank R. Reynolds, M.D.
D. E.Ward, Jr., M.D.
Vacant
E. Harvey Estes, Jr., M.D.
James E. Davis, M.D.
Chalmers R. Carr, M.D.
John Glasson, M.D.
William N. Hilliard
OFFICERS
President
President-Elect
First Vice-President
Second Vice-President
Secretary
Speaker of the House
Vice-Speaker of the House
Past President
Executive Director-
Treasurer
Asheville, N. C.
Wilmington, N. C.
Lumberton. N. C,
Durham, N. C.
Durham, N. C.
Charlotte, N. C.
Durham, N. C.
Raleigh, N. C.
EXfflBITS AND SCHEDULES
1.
lairman and Members of the Finance Committee
i rth Carolina Medical Society
IJeigh, North Carolina
(-ntlemen:
I'ursuant to engagement, we have audited the books
a^l records of the North Carolina Medical Society, Ra-
Ir h. North Carolina, for the period beginning Janu-
s'. 1, 1973, and ending December 31, 1973, and present
tewith our report.
I
■ in presenting our findings, as the result of the audit,
•R'have prepared four E.xhibits and four Schedules, as
c lined in the Inde.x, which are attached hereto as a
f t of this report.
I ance Sheet — Exhibit "A":
'he first statement is a list of the Assets, Liabilities,
E erves, and Fund Balances, which we designate as
Eance Sheet, December 31, 1973, Exhibit "A". This
St ement has been divided into two sections. One con-
tt s the Current Operating Fund, which represents
tl Current Assets, Liabilities, and Reserves. The other
h been designated as a Capital or Non-Operating Fund
C' iaining the office equipment, real estate and capital
SI ik owned and used by the Medical Society.
:'he Cash on Hand and in Bank is made up of
$ 5.00 Petty Cash Funds and $349,059.47 in a check-
it account at First-Citizens Bank & Trust Company,
R ;igh. North Carolina. Also, there was $103,491.43
ii sgular savings account, and $20,000.00 in a savings
b<i with the same Bank, There was $40,000.00 in
rt: local Savings and Loan Associations. The Cash in
B k was verified through reconciliations of the bal-
aij s as shown by the records of the Medical Society
W confirmations obtained independently from the
b| Ics, See Schedule 1 of this report for details.
' ccounts Receivable — Regular in the amount of $3,-
7! 92 are shown on the Balance Sheet. The balance
K esents the total of several uncollected balances due
fc local advertising in the State Medical Journal, and
0 r miscellaneous receivables.
ccounts Receivable — National Advertising in the
ai unt of $3,932.98 represent November and Decem-
ber 1973 National Advertising in the State Medical
Journal.
Accrued Interest Receivable on three savings certifi-
cates totals $1,159.00.
Air Travel Deposit of $425.00 is cash deposited
with Eastern Airlines for air travel credit cards.
The Medical Society has a Notes Receivable and Deed
of Trust, with balance due. of $190,653.75 from Inter-
national Developers, Inc., dated December 20, 1972, due
each ninety (90) days for ten (10) years, at IVi per-
cent interest, payments at $7,330.62 including interest,
beginning March 20, 1973. This note came from the
sale of land on Raleigh-Durham Highway.
The real estate, capital stock and office equipment
and furniture shown on the Balance Sheet in the amount
of $1,345,055.02, is listed in detail in Schedule— 2.
The items shown represent cost value of the equipment
to the Medical Society as no depreciation has been re-
corded.
Under the "Liabilities" section, we have listed those
accounts, expenses, etc., incurred prior to December 31,
1973, for which statements or accounts were rendered or
payment was due.
The Accounts Payable — Trade, in the amount of
$1 1.247.90, represents unpaid accounts at December 31,
1973. Most of these items were paid during the course
of the audit.
The $3,993.00. Dues to be Refunded, represents State
dues collected which are refundable to the members.
The $130,795.00, "Due American Medical Association,"
is 1974 A.M. A. dues collected in 1973. The $430.00
"American Medical Association Dues in Escrow," repre-
sents dues paid to the State Society, but which cannot
be remitted to the National Society at the time due to
diverse disqualifying reasons. At December 31, 1973, the
Society had collected, from members $8,800.00, for
MEDPAC contributions and $53,428.00 for county
dues. These items will be remitted to the respective or-
ganization in regular course. The payroll taxes, $4,-
299.58, were paid during the course of the audit.
The deferred credits of $149,737.09 are for payments
of $4,080.00 received on technical exhibits space for
the 1974 Convention, and $144,515.00 on 1974 mem-
bership dues, and $1,142.09 on 1974 tenant's rent.
//
8
SUPPLEMENT TO N. C. MEDICAL JOURNAL
These remittances were received in 1973. and will he
transferred to the income accounts in 1974.
The Reserve accounts set forth on Exhibit "A" are
for specific purposes or specific projects, which normally
last for periods longer than one year; therefore, special
provisions are made to set aside funds for these speci-
fied Reserves. A new Reserve for Operating Reserve
for $92,900.00 was established this year. This new Re-
serve account is intended to eventually equal one year's
operating co.Us.
The Ftmd Balance section of the Balance Sheet is
comprised of two figures. S249.796.51 being the surplus
of the Current Operating Ftmd at the year-end. and
$1,345,055.02 representing the balance of Capital Fund.
It should be ob.served that all surplus in the Current
Operating Fund would not be available for immediate
use. since a material amount is made up of the $190,-
653.75 Note Receivable from International Developers,
Inc.
Statement of Fund Balances — Exhibit "B":
The second statement is an anahsis of the changes in
Fund Balances during the sear and is detailed on Ex-
hibifB."
Statement of Income and Expenses — Exhibit "C":
A statement showing a budget comparison of the in-
come and expenses for the twelve months period is
given in Exhibit "C" This statement is. in effect, a
statement of operations for the year, and by examination
it may be observed that the Income of $692,163.14
e.xceeds the Expenses of $542,166.79 by $149,996.35.
There was included in the expenses $3,827.53 in Capital
Expenditures, and $105,200.00 loan repayments. Elimi-
nating these, we show a margin from operations of
$259^023.88.
Comparing with the Budget, we see that actual income
was more than anticipated. The main items accounting
for this was the interest income received and the large
increase in annual dues.
Further comparisons reveal that the total actual ex-
penses were $93,189.21 less than the budget provision.
Cash Receipts and Disbursements — Exhibit "D":
A statement showing m detail the cash receipts and
disbursements of the Societ\ during the \ear under re-
view is shown on Exhibit "D."
We made a careful analysis of the cash transactions
and. where practicable, traced the receipts to their origi-
nal source. Disbursements for expenses were supportai
b>' cancelled checks and invoices issued in the regula
course of business. We believe the funds have all beei
accounted for.
GENERAL COMMENTS
A surety bond covering faithful performance of Mi
William N. Hilliard. Executive Drector, in the amoun
of $50,000.00, is in force, held by the Medical Societ:
and was examined by us. We also examined and founi'
in force a Primary Commercial Blanket Honesty Bom
in the amount of $50,000.00; a fire insurance polic
covering fire loss on new building of $1 ,000.000.()C
all office contents incidental to the use of the Societ)
in the amount of $70,000.00; glass coverage is includei
under separate coverage; a Non-Automobile Schediil
Policy; a standard Workmen's Compensation and En>
ployer's Liability Policy; a Comprehensive General Lia
bility Policy and Catastrophic Liability Polic\'; and a
Accident Policy on Officers, Delegates, and .Staff.
We were extended every courtesy and cooperatio
during the course of the audit and we experienced n
trouble in obtaining the necessary information for thi
report.
SCOPE OF EXAMINATION AND OPINION
We have examined the balance sheet of the Norti(
Carolina Medical Society- as of December 31, 1973. an
the related statements of income and expense and fun
balances for the year then ended. Our examination wa
made in accordance with generally accepted auditin.*!
standards, and accordingly included such tests of the .k
counting records and such other auditing procedures .
we considered necessary in the circumstances.
In our opinion, the accompanying balance sheet an
statements of income and expense and fund balancf
present fairly the financial position of the North Care
lina Medical Society at December 31. 1973, and the n
suit of its operations for the year then ended, in coi
formity with generally accepted accounting principlt, ,
for non-profit organizations applied on a basis consistei
with that of the preceding year.
Respectfully submitted.
A. T. ALLEN & COMPANY
CERTIFIED PUBLIC ACCOUNTANTS
Raleigh, North Carolina ' 'l
Januiu-v 18, 1974
^^
COMPILATION OF ANNUAL REPORTS
NORTH CAROLINA MEDICAL SOCIETY
Raleigh, North Carolina
EXHIBIT "A"
BALANCE SHEET
Deccmher 31, 1973
ASSETS:
?1RRENT OPERATING FUND:
;i:ash on Hand and in Banks — (Schedule— 1 ) $ 512,875.90
(iccounts Receivable — Regular 3,790.92
liccounts Receivable — National Advertising 3,932.98
jiccriied Interest Receivable — On Savings Certificates 1,159.00
^ur Travel Deposit 425.00
.■Jotes Receivable — International Developers. Inc 190,653.75
rOTAL CURRENT OPERATING FUND $ 712,837.55
( PITAL OR NON-OPERATING FUND— (SCHEDULE— 2):
Leal Estate — Land— Lane and Person Streets, Raleigh, N. C $ 227,733.90
—Headquarters Building— Raleigh, N. C 1,042,394.56
I )ffice Furniture and Fixtures 74,726.56
.'apital Stock — Common — State Medical Journal Advertising Bureau, Inc 200.00
OTAL CAPITAL OR NON-OPERATING FUND 1,345,055.02
^TAL ASSETS $2,057,892.57
'<i
LIABILITIES, RESERVES, AND FUND BALANCES:
ABILITIES:
ccounts Payable— Trade $ 11,247.90
smes to be Refunded 3,993.00
, lue American Medical Association 130,795.00
Jue American Medical Association — Dues in Escrow 430.00
Me County Medical Associations -...- 53,428.00
,^iue MEDPAC 8,800.00
'ederal and State Income Tax Withheld 3.487.81
^ ay roll Taxes Payable 81 1.77
iOTAL LIABILITIES $ 212,993.48
INFERRED CREDITS:
Idvance Payments on Technical Exhibit Space at 1974 Convention $ 4,080.00
i.ldvance Payment on 1974 State Membership Dues 144,515.00
Idvance Rent from Tenant on 1974 Rental Income 1,142.09
OTAL DEFERRED CREDITS 149,737.09
R IIERVES:
sserve for Traffic Liability Safety Program $ 135.28
eserve for Section on O & 0 432.40
eserve for Mental Health State Conference Programs 3,302.87
sserve for Mental Health Contactorama Programs 3,539.92
eserve for Operating Reserve -- - 92,900.00
OTAL RESERVES 100,310.47
F WD BALANCES:
jrrent Operating Fund— ( Exhibit "B") $ 249,796.5 1
ipital Fund— (Exhibit -B") 1,345,055.02
3TAL FUND BALANCES 1,594,851.53
1 AL LIABILITIES, RESERVES, AND NET WORTH $2,057,892.57
//
10
SUPPLEMENT TO N. C. MEDICAL JOURNAL
92,900.00
3.827.53
616.31
EXHIBIT "B"
STATEMENT OF Fl ND BALANCES
Deccinhtr 31. 1973
Cl'RRENT OPERATING FllND:
Balance— January 1. 1973
ADD: Net Profit From Operations.
LESS: Transfer to New Reserve for Operating Re.^erve $
Office Furniture and Equipment Transferred to Capital Fund
Construction in Progress — Completion of Drug Authority
Rental Space
TOTAL CIRRENT OPERATING FUND— TO EXHIBIT "A"
CAPITAL FUND:
Balance — January 1. 1973
ADD: Capital Expenditures From Current Operating Fund
Construction in Progress — From Current Operating Fund
TOTAL CAPITAL FUND— TO EXHIBIT "A"
TOTAL FUND BALANCES— DECEMBER 31. 1973
EXHIBIT 'C"
STATEMENT OF INCOME AND EXPENSES
12 Months Ended December 31, 1973
Budsct
Provisions
INCOME:
Membership Dues— Current and Prior Years $ 52().(IO().0(l
Sales of Journals. Rosters, and Value Scales 3..s00.00
Revenue Unexpected 3.000.00
Sales of Technical Exhibit .Space 10.000.00
Journal .'Sidvertising — Local 10.000.00
Journal Advertising — National 35.000.00
Commission ( Kf ) from AMA for Dues Collected 3.700.00
Commission ( Ki) from MEDP,A.C for Dues Collected 220.00
Rental Income 49.936.00
Interest Income from Note .00
Interest Income from Savings .00
Book Proceeds — "Medicine in North Carolina" .00
TOTAL INCO.ME $ 635.356.00
EXPENSES:
Executive Budget:
A-1 Expense — President
A-2 President's Secretarial Assistance
A-3 Travel — Secretary
A-4 Salary — Executive Director — Treasurer
A-5 Travel — Executive Director — Treasurer
A-6 Executive Office — Secretarial and Clerical .Assistance..
A-7 Executive Office — Equipment and Replacements
AS Expenses — Executive Office
A-9 Bonding— (In Effect to 1975)
A- 10 Auditing
A-11 Taxes — (Salary Taxi
A- 12 Insurance
A-1 3 Membership Record System and Machine Rental
A-14 Publications. Reports, and Executive Aids
A-1 5 Salary — .-\ssistant Executive Director
A-16 Travel — Assistant Executive Director
A-1 7 Salary — .Assistant to Executive Director
A-22 Salary — Controller
A-23 Salary — Field Representative No. 1
7
.s
1
24
6
45
4
18
000.00
,0(10.00
.000.00
000.0(1
000.00
.000.00
,000.00
000.00
.00
,000.00
.440.00
.200.00
.600.00
300.00
,200.00
000.00
900.00
400.00
500.00
88,116.47
259.023.88
(97.343.84)
"$ 249.796.
n. 340.611. 18
3.827.53
616.31
,345.055.(
$1,594,851
Actual
548.412.00
4.487.56
5.531.02
10.970.00
8.605.10
29.964.67
3.661.10
213.75
50.627.72
14.977.75
11.503.02
3.209.45
Difference
Over
(I nder)
; 28.4 12.(
987
2,531.(
970.(
(1,394.
(5,035.
(38.
(6.
691.
14.977.
11.503.(
3.209
$ 692,163.14 $ 56,807.
$ 6,230
2,458
24,000
4.263
40.624
3.827
18.203
2.223,
6,575
2.039,
9.077,
295.
17.200.
2.328.
12.900.
15.400.
12.500.
.39
80
00
00
.80
.57
.53
.40
,00
,96
.65
,50
,68
12
,00
75
00
00
00
(769.(
(2.541
( I.000.(
.(
(1.736..
(4,375
(172
203
.(
223
135.(
(160
477.(
(4.jilili
(671.
[tto
D-;
Io(
• Total Current Operaliny Fund includes a long-term note receivable from International Developers. Inc.. for $190,653.75 at December 31. 1
therefore, this figure should be deducted when computmg available cash surplus.
C-2
C-3
C-4
C-5
'■<f > C-7
iC-8
iC-9
COMPILATION OF ANNUAL REPORTS
A-24 Salary — Field Representative No. 2
A-25 Travel — Field Representatives No. 1 &
Budcet
Provision.s
9.60().()()
5,000.00
Actual
9,600.00
3,925.58
11
Difference
Over
(Under)
.00
(1,074.42)
Total ExecuHve Budget $ 205,140.00 $ 193,674.73 $ (11,465.27)
lurnal Budget:
B-1 Publication of Journal _ $
B-5 Expenses — Editorial Office
B-6 Expenses — Business Manager's Office
B-7 Equipment — Business Manager's Office
B-8 Travel for Journal
B-9 Payroll Taxes
B-10 Sales Tax on Journal and Roster Sales
B-1 1 Journal Salaries
59,800.00 $
62,360.79 $
2,560.79
850.00
721.22
(128.78)
1,000.00
793.54
(206.46)
100.00
.00
( 100.00)
200.00
.00
( 200.00 )
1,052.00
1,136.41
84.41
2,200.00
2,140.03
(59.97)
17,050.00
17.758.00
708.00
Total Journal Budget $ 82,252.00 $ 84,909.99 $ 2,657.99
Itra-Functional Activity Budget:
I C-1 Expenses — Executive Council $
Expenses — Publication Council Minutes
Expenses — Legislative Committees
Expenses — Maternal Health Committee
Expeases — Drug Abuse Committee
Expenses — Scientific Exhibits Committee
Expenses — ^Mental Health Committee
Expenses — Mediation Committee
(C-10 Expenses — Chronic Illness Committee
.1 C-1 1 Expenses — Committees in General
.iC-15 Expenses — Relative Value Committee
.1 C-17 Expenses — Student ,AMA Committee _
.iC-18 Expenses — Disaster Emergency Medical Care Committee
.1 C-20 Expenses — Constitution and By-laws Committee
J(C-24 Expenses — Anesthesia Study Committee
tC-30 Expenses — Liaison to Insurance Industry Committee
.lC-3 1 Expenses — Community Health Committee.
.JC-36 Expenses — Family Marriage Counseling Committee
,iC-37 Expenses — Medicine and Religion Committee
■(C-48 Expenses — Medicare Committee
■<C-49 Expenses — Medical Education Committee
^C-50 Expenses — Comprehensive Health Service Planning Committee
■iC-51 Expenses — Medical .Aspects of Sports Committee _
3!C-53 Expenses — Physicians on Nursing Committee
(C-56 Expenses — President's Communications Program
(C-58 Expenses — Peer Review Committee
lC-59 Expenses — Health Care Delivery Committee
4,600.00 $
4,146.14 $
(453.86)
6,500.00
5,703.14
(796.86)
5,000.00
4,297.04
(702.96)
600.00
600.00
.00
1,000.00
.00
( 1 ,000.00 )
1,225.00
907.80
(317.20)
400.00
256.01
(143.99)
400.00
229.06
(170.94)
400.00
.00
(400.00)
4,500.00
4,337.06
(162.94)
600.00
123.50
(476.50)
1,060.00
628.65
(431.35)
600.00
.00
( 600.00 )
500.00
258.88
(241.12)
365.00
314.79
(50.21 )
800.00
838.45
38.45
500.00
386.08
(113.92)
300.00
5.95
( 294.05 )
350.00
69.00
(281.00)
200.00
.00
(200.00)
1,000.00
.00
( 1,000.00)
250.00
.00
(250.00)
1,000.00
814.77
(185.23)
200.00
43.96
(156.04)
1,200.00
1,121.59
(78.41 )
200.00
154.52
(45.48)
1,000.00
.00
( 1,000.00)
.ITotal Intra-Functional Activit> Budget $ 34,750.00 $ 25,236.39 $ (9,513.61
Ktra-Functional Activitj Budget:
ID-l Expenses — Delegates to AMA..
!D-2 Expenses — Conference Dues ....
D-3 Expenses — Woman's Auxiliary ..
9.700.00
$
6,782.56
$
(2,917.44)
200.00
232.50
32.50
4,260.00
4,260.00
.00
Total Extra-Functional Activity Budget $ 14,160.00 $ 11,275.06 $ (2,884.94)
iblic Relations Budget:
E-3 Committee Chairman — Out of State Travel..
E-10 Educational Distributions — Materials
E-11 News and Press Releases
E-I2 Public Relations Bulletin
E-13 State High School Science Fair Program
E-14 Exhibits and Displays
E-15 Conference for Medical Leadership
|E-17 "Today's Health" Magazine Subscriptions....
500.00 $
.00 $
(500.00)
500.00
21.89
(478.11)
200.00
105.08
(94.92)
3,500.(.)0
3.761.55
261.55
160.00
1 00.00
(60.00)
350.00
362.29
12.29
1,500.00
1,392.27
(107.73)
850.00
.00
(850.00)
//
12
SUPPLEMENT TO N. C. MEDICAL JOURNAL
Budget
Provisions
E-18 Collateral Public Relations 500.00
E-19 N. C. Revenue Squad First .Aid Trophies 200.00
Total Public Relations Budget S 8,260.00
.\nnual Sessions (n9th) Convention Budget:
F-l Program Production S 2.000.00
F-2 Hotel and Auditorium Expense _ 4,700.00
F-3 Expenses — Publicity Promotion 600.00
F-4 Entertainment 1.200.00
F-> Orchestra and Floor Entertainment 2.500.00
E-6 Guest Speakers 900.00
F-9 Booth Installation and Supplies 4,500.00
E-10 Projection Expense 1,300.00
F-l I Badges . 250.00
F-I2 Transactions Reporting Service 2,500.00
F-l? Rental— Extra Facilities _ 200.00
F-14 Exhibitors Entertainment 850.00
F-15 Banquet Expense 200.00
F-I6 Police Security 360.00
Total Annual Sessions (119th) Convention Budget ...S 22,060.00
Miscellaneous Budget:
G-1 Legal Counsel Retainer S 11,300.00
G-2 Reporting— ( Executive Council, Etc.) 2,000.00
G-3 Fifty ^'ear Club— (Pins, Etc.) 300.00
G-4 Contingency and Emergency 4,174.00
G-5 Employees Retirement System 19.175.00
G-6 .'Kdvalorem Taxes — (Personal Property I 960.00
G-7 .Association of Professions 200.00
G-IO Expense of Commissioners 1.500.0;)
G-1 1 Expenses of Executive Committee 300.00
G-1 2 Expenses of Officers to National Meetings 2,000.00
G-1 3 Travel and Maintenance, Expense of Essential Staff —
Out-of-State Sessions __ 1,700.00
G-14 Sales Tax — "Medicine in North Carolina" .00
Total Miscellaneous Budget S 43,609.00
Difference
Over
Actual
(I nder)
41.90
(458.10
117.85
(82.15
S 5,902.83
S ( 2.357. r
S 1,655.96
S (344.(4
4,858.03
158.()3
511.64
(88.36
1,133.37
(66.63
1,983.78
(516.::
348.30
{551.70
3.938,64
(561.36
550.45
(749.55
365.00
115.(>r
2,316.13
(183.,^-
110.73
(89.:-
804.42
(45.'^
198.93
(l.C
360.00
.( 1
S 19.135.38
s (:.924.f:
S 12.530.85
1.230.8;
1.805.31
( 194.65
415.28
115.:^
3.964.27
(209.':
18.643.50
(531.5t
837.72
(122.:^
200.00
.(1(
1.095.48
(404.?;
.00
(300.(i(
4.304.78
2.3{M."J
2.154.00
454.((
103.94
103.9^
•s 46.055.13
S 2.446.1:
Headquarters Facility Budget:
Capital Investments:
M-1 .Application to Construction and or .Mortgage
Payments — Estimated .Available $ 162,261.00 S 100.000.00 $
M-3 Mortgage Payable on Greenfield Property — !'"( Interest
and Unpaid Balance of S5. 200.00 2.964.00 5.442.64
M-4 Estimated Interest Cost on Mortgage or Construction Funds 7.000.00 415.26
Operating Costs:
M-5 Utilities _ _ 13.800.00 14.223.44
M-6 Insurance _ 1 .700.00 1 .754.00
M-7 Taxes 16.700.00 16.183.95
M-8 Water 500.00 363.40
M-9 Janitorial Services _ 15.000.00 12.900.00
M-IO Groimds Maintenance 1.000.00 984.73
M-11 Building Repairs and Mamtenance 1.200.00 1.045.24
M-12 Heating. .AC Repairs and Maintenance 3.000.00 2.664.62
Total Headquarters Facility Budget S 225.125.00 S 155.977.28 S (69.147.7:
TOTAL EXPENSES $ 635.356.00 S 542,166.79 S 93.189.2
SL'MMARY:
TOTAL INCOME $ 692.163.1
LESS: EXPENSES:
Executive Budget _ $ 193.674.73
Journal Budget 84.909.99
Intra-Functional .Activity Budget 25.236.39
COMPILATION OF ANNUAL REPORTS 13
i Difference
Budget Over
Provisions Actual (I'nder)
f,xtra-Functional Activity Budget 1 1,275.06
lublic Relations Budget 5.902.83
jjinual Sessions (119th; Convention Budget _ 19.135.38
liscellaneous Budget 46,055.1 3
.Jeadquarters FaciUty Budget 155,977.28 542,166.79
? J CESS OF INCOME OVER EXPENSES _ $ 149,996.35
.D: Capital Expenditures From Current Funds 109,027.53
r MARGIN FROM OPERATIONS $ 259,023.
EXHIBIT "D"
CASH RECEIPTS AND DISBURSEMENTS
12 Months Ended December 31, 1973
jSH ON HAND AND IN BANKS— JANUARY 1. 1973 $ 264,079.05
I): CASH RECEIPTS:
'bcome From Operations — ( E.xhibit "C") _ $ 692,163.14
jjecrease in Accounts Receivable — Regular 1,885.00
iecrease in .Accounts Receivable — National 752.49
Receipts on Notes Receivable — International Developers, Inc. — Principal 14,346.25
iicrease in Refunds Payable 2,309.00
UVIA Dues Collected 413,275.00
i'ounty Dues Collected 157,966.00
;IEDP.\C Dues Collected 24,740.00
Qcrease in Payroll Taxes Unremitted 446.28
idvance Payments — Technical Exhibit Space — 1974 4,080.00
Idvance Payments — State Membership Dues — 1974 144,515.00
idvance Payments — Rent from Tenant — 1974 1,142.09
.LESS): Accrued Interest Receivable on Savings Certificates _ (1,159.00)
'OTAL CASH RECEIPTS 1,456.461.25
1 TAL FUNDS TO ACCOUNT FOR _ $1,720,540.30
( 5H DISBURSEMENTS:
xpenditures From Operations — (Exhibit "C") $ 542,166.79
tisbursements — Construction in Process — 1973 616.31
-.ccounts Payable— Trade— 12/31/72— Paid in 1973 23,441.20
tecrease in AM.A Escrow Funds 60.00
MA Dues Remittances 364.875.00
ountv Dues Remittances 136.753.00
^lEDPAC Dues Remittances 20,970.00
.dvance Payments — Technical Exhibit Space — 1973 — Transferred to 1973 Income.- 4,560.00
dvance Payments — State Membership Dues — 1973 — Transferred to 1973 Income 125,470.00
!lESS): Accounts Payable— Trade— 12/31/73— Unremitted ( 11,247.90)
OTAL CASH DISBURSEMENTS $1,207,634.40
( SH ON HAND AND IN BANKS— DECEMBER 31, 1973 _ 512.875.90
PAL FUNDS ACCOUNTED FOR $ 1 ,720,540.30
14
SUPPLEMENT TO N. C. MEDICAL JOURNAL
SCHEDll.E— 1
CASH ON HAND AND IN BANKS (INCLLDING SAVINGS)
December 31, 1973
FIRST-CITIZENS BANK & TRUST COMPANY— RALEIGH, N. C:
Checking Account — Number 1 2-03-643 - $ 349.059.47
Savings Account — Number 0861010544 103.491.43
Savings Bond — Number 39270 — N 20.000.00 S
FIRST FEDERAL SAVINGS & LOAN ASSOCIATION— RALEIGH, N. C.
Certificate of Deposit — Number 141,851
RALEIGH SAMNGS & LOAN ASSOCIATION— RALEIGH, N. C:
Certificate of Deposit — Number 5931 _
PETTY CASH FUND— OFFICE
TRAVEL ADVANCE FIND— FIELD REPRESENTATIVE
TOTAL CASH $
Quantity Item Date
OFFICE FURNITl RE AND FIXTURES:
1 Steel Filing Cabinet
2 Gray Steel Filing Cabinets..
1 Four Drawer Steel
Filing Cabinet
1 Remington Rand Electric
.Adding Machine
1 Metal Storage Cabinet
1 Metal Filing Cabinet
1 Metal File and Sections
2 Typewriters — Large
Type (Bulletin)
1 Metal File and Frames
1 Portable Lectern
1 Metal File
1 Five-Drawer Letter File
2 Five-Drawer Files
1 A. B. Dick Offset
Duplicator
2 Four-Drawer Durable Files
1 Postage Mailing Machine...
1 Book Case Section
No. 813 Walnut
3 Letter Size Files
1 TU-24 Star Tube Roll File..
1 122 H Steel Cart W/ 3
Shelves
6 Four-Drawer Letter Size
Files
1 Electric Projection Pointer..
1 Toledo Postage Scale
(Used)
1 Three Section Book Case....
1 Divisumma 24 Calculator...
1 Walnut Dictionary Stand....
4 Side Chairs
1 Premier Ream Cutter.
1 No. 1900 Addressograph...
1 Carrying Case for
.Adding Machine
1 Four-Drawer Letter File...
1 Four-Drawer No. 24-.-\
File Cabinet
1 Remington Typewriter
No. 3064244
SCHEDILE— 2
SCHEDL LE OF C APITAL ASSETS
December 31, 1973
Cost Quantitj Item
I Hand Truck
$ 71.75 1 Section Steel Shelving
103.00 1 Scriptor 13" Elite Electric
Typewriter No. 9709767
78.03 4 No. 8 B 51 Five
Drawer Files
215.01 1 Electric Pencil Sharpener....
78.28 1 Feeder Unit for
92.76 .Addressograph
68.55 1 Scriptor Electric
Typewriter No. 1089421..
321.23 2 Fi\e-Drawer Files — Gray ..
93.07 I Storage Cabinet
29.93 l.B.M. Equipment:
114.33 17 Control Panels
122.78 1 Sorter Rack
245.56 5 Sets Manual Wire
Complements
3.204.53 I Twent\-Drawer Card File
61.70 1 Control Panel Cabinet...
855.70 1 Mosler Fire-Proof File—
Four-Drawer
2y.26 3 Cory Five-Drawer
103.72 Letter Files
40.00 1 Cosco Secretarial Chair
I Combo Binding Machine....
35.76 1 Model L-H Letter Opener..
1 18" Pendaf lexer—
199.31 Two-Drawer
77.15 7 Four-Drawer Files
I L'nderuood Electric
154.50 Typewriter— 700
137.61 TW No. 9694676
^-'■'" I Projection Pointer
''"'■"'^ 2 Shelving Units
~,/n_y, 1 Eight Station Collator —
1 3 .M Portable Co.Tipact
KS 49 Copier
l7-,'(,f, I Tu-DROR Pendaflevor
File
41 y; 1 Electrosumma 20 .Adding
Machine No. 6638949...
388.90 1 Dual Purpose Hand Truck..
Date
184 8
47 5
COMPILATION OF ANNUAL REPORTS
lontity Item
I 1 F & E Checkwriting
Machine
Desk — Walnut Finish
Remington Electric
Typewriter No. 634800..
Remington Electric
Typewriter No. 635838..
Four-Drawer File
(Dr. Styron)
Used Copying Machine —
A. B. Dick No. 675
Supply Cabinet
Storage Cabinet
Metal Letter File with Lock
Storage Cabinet
Royal Typewriter
No. 4132-506
Four-Drawer Metal File...
Two-Drawer Metal File
Supply Cabinet
Metal Storage Cabinet
Folder Machine and
A. B. Dick Stand
Model DLS Screen
Record Player
Microphone and Stand
Slide Projector — With Case
Lectern Mike
Camera & Flash
Metal File
Four-Drawer Files
Underwood Scriptor
Electric Typewriter
No. 21-8721980
Crestline Delii.xe Projector..
Carri-Voice and Revere
Tape Recorder
No. 3001 312
8 B 51 Gray File Cabinets..
8 B 51 Gray File Cabinet..
Five-Drawer Gray
File Cabinet
Bell & Howell Projector
Four-Drawer File
Cory Five-Drawer Files
Olympia Electric Type-
writer No. 27-494032
Steel File
Four-Drawer Files
Portable Lectern
Eight Yard Dempster
Dumpmaster
Sanco Corporation
Floor Ash Trays —
Duk-It— ROS
Dual Receptacle Duk-It
Duk-lt Black Letter Trays..
No. 1605 Ash Trays
Duk-It Waste Baskets
Duk-It Calendars
and Bases
No. 1607 Ash Trays —
Duk-It
Duk-It Ice Water
Pitcher & Tray
No. 6023 Chairs — Serapi
Blue — Navaho Fabrics
No. 6023 Chairs— Soot
Black — Navaho Fabric. 3
No. 6055 UA Chairs-
Ebony — Navaho Fabric.
Date
Cost
' 3
I 5
-42
I 6
8
3/19/71
115.88
1 18.97
424.01
424.00
88.60
1.000.00
37.00
37.00
61.60
37.00
133.31
69.49
18.36
75.00
57.29
397.88
32.45
101.25
19.40
94.47
56.85
88.98
95.79
194.47
337.64
79.26
480.00
236.66
100.57
100.48
175.00
63.86
228.66
431.05
88.27
63.86
29.67
528.37
10
3/24/71
96.00
3/24/71
1 17.00
3/24/71
37.50
3/24/71
126.00
3/24/71
66.60
3/24/71
21.60
3/24/71
31.20
3/24/71
126.00
3/24/71
497.88
/24/71
165.96
3/24/71
1,940.40
Quantity Item Date
22 No. 1086 Howe
Folding Tables 3/24/71
4 2530 Bench— DG 3/24/71
3 19-12 Pot Cover 3/24/71
1 67 BC Sofa 3/24/71
2 65 BC Chairs 3/24/71
1 252 Coffee Table 3/24/71
3 19-12 Pot Cover 3/24/71
1 8623 Ash Tray 3/24/71
150 1601-G Stacking Chair 3/24/71
8 1600-1 Dolly 3/24/71
4 309 F-2 Table 3/24/71
16 1601 Stacking Chair 3/24/71
2 72 UBC Chairs 3/24/71
4 72 US-BS Chairs 3/24/71
6 1514 WRC Desks... 3/24/71
1 1519 WRC Table Desk 3/24/71
1 1546 WRC Secretarial Desk 3/24/71
6 541 WRC Credenzas 3/24/71
1 541 WRC Credenza 3/24/71
1 541 Credenza 3/24/71
8 72 UBC Chairs 3/24/71
6 72 UBC Chairs 3/24/71
2 72 UBC Chairs 3/24/71
8 10 N-10 Waste Baskets 3/24/71
8 2 W Letter Trays 3/24/71
2 72 US-BS Chairs 3/24/71
1 1503 WRC Desk 3/24/71
2 72 UBC Chairs 3/24/71
1 1590 Table. 3/24/71
4 68S— BS Chairs 3/24/71
1 8623 Ash Tray 3/24/71
1 10 N-10 M Waste Basket.... 3/24/71
1 2-W Letter Tray 3/24/71
1 19-9 Pot Cover 3/24/71
1 1503 WRC Desk 3/24/71
1 541 WRC Credenza 3/24/71
2 72 UBC Chairs 3/24/71
1 704 BC Sofa Bed 3/24/71
I 65 ABC Chair 3/24/71
1 2511 Table 3/24/71
1 10 N-10 M Waste Basket.... 3/24/71
1 2-W Letter Tray 3/24/71
19 1258 DS Chairs 3/24/71
12 1255 Chairs 3/24/71
2 544 WR Wall Cabinets 3/24/71
1 19-12 Pot Cover 3/24/71
2 65 BC Chairs 3/24/71
1 2562 WRBC Table 3/24/71
4 72 USES Chairs 3/24/71
1 Frigidaire Refrigerator —
futile 4/15/71
1 Frigidaire Range 4/15/71
2 Royal Metal 30 x 75 4/30/71
1 Conference Table 4/30/71
6 Alma Book Cases 4/30/71
4 Wall Poles 4/30/71
2 File Units 4/30/71
1 Sliding Door Cabinet.. 4/30/71
6 Alma Shelves 4/30/71
1 Cory Library Table 4/30/71
6 All Steel Black Desks—
A. Williams 4/30/71
1 All Steel Black Table
36 X 36 4/30/71
1 Lectern 4/30/71
1 Chalkboard 4/30/71
1 Conference Table — Oil
Walnut Finish 4/30/71
1 Lectern — Oil Walnut
Finish 4/30/71
15
Cost
2.640.00
940.36
49.59
613.87
487.13
242.46
49.59
12.67
2,295.75
132.25
262.30
238.05
138.32
349.37
1,384.28
215.47
367.55
1,776.66
333.38
409.43
585.25
457.09
179.64
193.97
163.11
188.74
312.45
141.63
234.19
662.40
12.67
24.25
20.39
8.82
312.45
285.44
138.31
472.52
262.58
159.80
24.25
20.39
2.946.30
1,509.92
548.85
16.53
436.43
67.77
349.35
349.68
246.17
228.50
104.22
495.72
3 1 .44
175.22
53.35
47.17
195.77
1,602.54
66.31
68.22
67.06
3.982.50
239.99
//
16
SUPPLEMENT TO N. C. MEDICAL JOURNAL
Quantity Item Date
2 Tables— White— 16.^ F .... 4/30/71
i: I 2.'i8 DS Chairs-
Red Fabric 4/30/71
3 Clocks— .HM Black Case—
Storr Sales 4/30/71
Draperies — Weaver Textile 5/28/71
7 An Metal Bookcase
Sections— Storr Sales 6/25/71
1 Vogel Peterson Costumer.
Wall Shelf & Coat
Hangers 6/25/71
1 Chair and Table— ROS 6/25/71
1 Toro Lawn Mower — Flythe 7/09/71
2 1-W Letter Trays— D.G 7/09/71
2 72 USBS Chairs 7/09/71
1 10-N Waste Basket.. 7/09/71
1 2562 WR/BC TABC 7/09/71
4 Bookcase Sections and one
End Panel No. 2118—
Storr Sales 9/07/71
6 No. 800 Walnvit Oil
Shelves— E & B 10/21/71
4 Lockers— Gray Finish 12/23/71
I 560 R Pedestal Desk and
Chair— Storr Sales 11/23/71
1 Twenty-Drawer Card
File— Clyde Rudd 2/11/71
1 Drain Board for Printing
Room — Montgomery-
Green .'... 5/12/71
1 Control Panel Cabinet —
Tab Products 5/12/71
1 Edison- Voicewriter —
T. A. Edison Ind. 7/19/71
1 File Cabinet— W. B. Bunn..l 1 /23/71
1 Bates Electric Stapler —
# 56 3/08/72
2 IBM Selectric II
Typewriters 5/15/72
1 IBM Selectric U
Typewriter 12/08/72
2 IBM Selectric II
Typewriter 4/26/73
2 Stencraft Storage Cabinets.. 8/17/73
1 Bookcase— Oil Walnut 9/13/73
5 Panasonic Tape Recorders. 10/08/73
1 Ricoh Electronic
Calculator 12/21/73
1 NuArc Light Table—
(Lay-out) 11/28/73
1 IBM Electric Typewriter.... 12/3 1/73
I Envelope Detacher 12/31/73
1 Sonyo Recorder 12/31/73
TOTAL OFFICE
FURNITURE AND
FIXTURES
REAL ESTATE:
Land — Lane and Person
Streets, Raleigh. N. C. —
(Schedule— 3)
Cost
100.29
1.863.78
139.21
6.620.21
551.06
80.42
152.98
124.58
20.59
201.32
17.73
78.06
342.31
63.65
186.70
395.30
210.73
72.10
87.86
1.548.46
150.00
72.28
1.268.80
634.40
1,268.80
133.12
101.09
389.64
462.80
182.00
717.60
281.33
291.15
$
74.726.56
27,733.90
New Headquarters Facility
Building. Raleigh, N. C.
— (Schedule — 4)
:()i
1,042,394.51
OTHER ASSETS:
Capital Stock — State
Medical Journal
.Advertising Bureau, Inc..
TOTAL CAPITAL ASSETS—
TO EXHIBIT "A"
2OO.0
I'
JI
$1,345,055.0!!
SCHEDULE— 3
SCHEDULE OF BUILDING SITE COSTS-
PERSON AND LANE STREETS. RALEIGH
December 31, 1973
Land Purchase — Person and Lane Streets-
Raleigh. North Carolina
Legal Services
Survey and Map of Property
.■\rchitect Service
.•\ppraisal Fees
Photos
Cleaning Lot
Lot — 217 North Bloodworth Street —
Raleigh. North Carolina
Lot — 222 North Person Street —
Raleigh, North Carolina
.$ 175,1
14.252.:
36.358. '
TOTAL TO SCHEDULE— 2 $ 227,733.9
SCHEDl LE— 4
NEW HEADQUARTERS FACILITY BU
Decemper 31, 1973
Worthy and Company — Consulting Services. .$
J. .A. Edwards — Engineering
Geotechnical Engineering Company —
Soil Borings
Miscellaneous — Maps. Printing.
Lot Cleanings. Etc
Grading Services. Inc. —
Demolition of Buildings
G. Milton Small — .Architects
Carl A. Mims — General Contractor
Stahl-Rider. Inc.—
Heating and .Air Conditioning
Bryant-Durham Electrical Contractors —
Electrical
Mechanical .Associates — Plumbing
Froehling & Robertson, Inc. —
Structural Testing
Various — To Complete Construction on
Drug .Authority Rental Space
Tenant Reimbursements
ILDING
HI
sij
SI
23.234.45
699.78
1.143.50fc,
377.99,1
5.000.00
59,857.5'^
728.678.2')
121.225.14
86.317.00
21,366.8:
2,763.2^
6 16.3 if
( 8, 885.55' *■
Sll,
TOTAL TO SCHEDULE— 2 $1,042,394.51
Si
t
:t.
COMPILATION OF ANNUAL REPORTS
17
1
REPORT FROM THE WOMAN'S AUXILIARY
O THE NORTH CAROLINA MEDIC AL SOCIETY
"Service to Medicine and Humanity"
IThe year of 1973-74 began our second fifty years.
e know we cannot rest on our past achievements but
ust continue to recognize the everchanging conditions
I our society and respond to them. By doing this.
Jr Auxiliary will continiic to grow and develop so that
;. our one hundredth year, we will be a stronger and
bra viable organization. It has been my distinct
jiivilege and pleasure to have been President at the
jitiation of the ne.xt half century of service. In my
levels to County and District meetings, I have observed
.'genuine warmth and enthusiasm among our members,
aey are engaged in many projects that bring credit
!l the medical profession. The work of doctor's wives
\ North Carolina compares very favorably with those
(Other states across the nation and 1 am indeed proud
I be their representative for this year.
iDr. George Gilbert. President of the North Carolina
Jedical Society, has been most generous in the giving
i his time to speak to us and to advise me in regard
j Auxiliary matters. The Auxiliary is most grateful
^d appreciative for all the support given by the Medical
ciety as a whole. The Headquarters Staff has been
Soperative and helpful and very prompt in complying
,1th our requests. We have enjoyed using the Auxiliary
pee for several committee meetings during the year
well as the Council Room for our Mid-Winter Con-
rence. Dr. Gloria Graham. Chairman of the Advisory
i>mmittee, has been extremely interested and en-
.'jsiastic over AiLxiliary accomplishments and has been
ost helpful with her guidance and suggestions.
[Our theme for this year is "Service to Medicine and
nmanity." We have projected our theme into the areas
"'health and service in our communities.
;Our first Program Planning Workshop was held in
injunction with our Annual Convention. It was de-
fined to aid and assist incoming County Officers in
mning their years' work and carrying out the years"
'.'me. We specifically focused on six areas of interest,
■ey were: AMA-ERF. Health Manpower, Safety, Nu-
^tion. Blood Donor, and Legislation.
jIn the Fall, a series of Regional Workshops were held
Hickory, Fayetteville. and Greenville to again em-
[lasize our areas of interest.
'AMA-ERF — The American Medical Association
'jiucation and Research Fund continues to be our only
■'ilanthropic endeavor sponsored by the Woman's
.ixiliary to the American Medical Association. Over
^! past eleven years, the Auxiliary has been increasingly
j-.ponsible for the designated funds returned to North
Carolina. In its initial year, 1962. the Auxiliary con-
_butions that were designated, represented 6 per cent
. the funds returned to North Carolina medical schools.
1973. this figure had increased to 51 per cent. Vari-
s methods of fund raising have been used besides
; direct contribution. This year a cookbook. Tlie
oaning Board, is the most popular item. It was put
;ether by the wives of the Officers and Board of
Listees of the American Medical Association and
derwritten by the Board itself. As of January 1, 1974,
have become part of "Project Credit" where all
nations from North Carolina received in the AMA-
'F office in Chicago, will go on record for our
Auxiliary. With this project, we hope some of our hard
work will receive National recognition. Donations to the
Davison Fund at Duke University and the Co-Foun-
ders Club at the University of North Carolina can now
also be donated to AMA-ERF and ear marked for these
funds with our Au.xiliary receiving the credit. At the
writing of this report, donations "totaled $10,070.24.
It is hoped that we can pass the $1 1,000.00 mark.
This year, a handbook for fund raising, compiled by
our state AMA-ERF Chairman, Mrs. Joe"(Jean) Frazer
of Greensboro, was so well received by the WA-AMA,
that they reproduced it and distributed it on a National
level.
At our Mid-Winter Conference, Mrs. Cliff (Frankie)
Moore, Jr. of Rome, Georgia, our Southern Regional
AMA-ERF Chairman, gave an informative presenta-
tion. She also brought with her items for display that
could be sold with the proceeds going to AMA-ERF.
HEALTH EDUCATION— Several counties have
purchased the film. VD — A New Focus, and made it
available to their school systems at a junior high level.
Some have been very successful while others continue
to press for its use. Our state Health Education Chair-
man, Mrs. Edwin (Martha) Martinat, is in the process
of completing a survey that will give us a good idea
just what kind and how much health education is being
taught in the schools and by whom. The report is not as
yet complete.
Mrs. John (Betty) McCain wrote an article for
M.D.'s Wife entitled "The Sick Physician Needs Help."
Betty is the Mental Health Chairman for the WA-AMA.
CHILD ABUSE — This has been one of our main
areas of interest with several county Auxiliaries pre-
senting programs on it. At our Mid-Winter Conference,
Dr. Minta Saunders spoke to us about their program
in Greensboro.
BLOOD DONOR PROGRAM— Our involvement
in the Blood Donor Program continues to be an area
of frustration and we have not been able to come up
with a satisfactory answer. We do have many Auxiliary
members who volunteer their time to this program.
HEALTH MANPOWER— The Auxiliary has spon-
sored many Health Fairs. These allow young children to
appreciate thru the senses of touch and feel, the exami-
nation equipment found in a physician's office and hos-
pital setting. At times we have worked with other re-
lated groups who also explain their equipment and the
role which they play in providing health care.
LEGISLATION — As there continue to be many
pieces of legislation dealing with health affairs, the
Auxiliary has attempted to keep abreast of these propos-
als. We encourage all our members to support candi-
dates sympathetic to the cause of Medicine. We are
currently in the middle of a LEGS Alert, (Legislative
Effort Group System) where everyone is asked to write
to their congressmen in regiu"d to Phase IV.
HEALTH SERVICES— Some of our Auxiliaries are
bcoming active with other community groups in the
"Meals on Wheels" project. It provides one hot nu-
tritious meal a day to a shut-in or elderly person.
Due to the increase and interest in cycling, some em-
phasis has been put on Bicycle Safety as well as Safety
on the Streets. This pertains to safer procedures to fol-
low while on the streets.
In addition to the projects listed and enumerated
L
20
SUPPLEMENT TO N. C. MEDICAL JOURNAL
consist of a strong program of continuing medical
eJncation wiiich will revolve around a central
theme which crosses specialty lines.
4. Such programs will be planned and executed in
cooperation with the faculties of the Medical
Schools.
5. Because of the length of the Annual Meeting and
the required sessions, some specialty sections must
meet concurrenth' with the General Sessions. It
was felt that this could be worked out to prohibit
a conflict of interest.
T he Committee on Arrangements was in accord with
the foregoing and farther recommended to the Executive
Council that Memorial Services be united with a Prayer
Breakfast, to be planned through the cooperative efforts
of the Memorial Committee and the Committee on
Medicine .ind Religion. The Auxiliary will be invited to
participate.
Josephine E. Newell. M.D.. Chairman. Commission III
PROFESSIONAL SERVICE COM.MISSION
Si.x committees met on schedule and had a busy and
productive year. The Blue Shield committee had its regu-
lar meetings, which v\ere open to all. and its subcom-
mittee on claims adjudication was highly effective. The
committee on Hospital and Professional relations met
and approved in principle the N. C. Society of Internal
Medicine's request to study methods of improving medi-
cal records, recommended gnidelines regarding profes-
sional remuneration of interns and residents, and re-
quested a legal ruling on the rights and hazards of ob-
taining blood alcohol levels. The committee to work with
the Industrial Commission met at the Conclave and rec-
ommended May 1975 as the time for updating the N. C.
Workman's Compensation Fee Schedule, with subse-
quent updating e\'ery two years thereafter. The Insur-
ance Industr\ committee met periodically, adjudicated a
large number of claims, recommended that insurance
carriers provide maternity benefits for unmarried minor
females, voted to oppose Senate Bill No. 932 which
would eliminate "coordination of benefits" in group in-
surance contracts in effect in North Carolina, and ap-
pointed a subcommittee to define and develop guidelines
tor the determination of "custodial care." The committee
on Ph\sical and Vocational Rehabilitation nominated
Dr. William B. Hall. Jr.. FayetteviUe. N. C.
as Phvsician of the Year for the Governor's Com-
mittee on Employment of the Handicapped. The
Committee .Advisory to Crippled Children's Program
met. and its consensus was that the State Board
of Health should draft certain criteria and guidelines,
noting the number of physicians, as well as specialties,
and set forth certain criteria b\' which an institution
could be measured in order to receive certification for
pa>ment. The full reports of these committees will ap-
pear elsewhere in this compilation. The support from
and the cooperation of these committees are greativ
appreciated.
W. Howard Wilson. M.D.. Commissioner
PUBLIC RELATIONS COMMISSION
All of the committees of the Public Relations Com-
mission met in Southern Pines diirina the Committee
Conclave in September 1973. Several of the committeesijg
ha\'e met since then. With few exceptions each of thete
meetings were well attended and productive, as indi-||
cated by the reports of the committee chairman listed '
separately. Some of the activities of the committee are
outlined below.
Medical-Legal Committee: Julius A. Howell. M.D.J'
Chairman j|
1 . Plans were made to distribute questionnaires re-
garding medical conditions in jails to county au-
thorities, i
2. Members of the legal and medical professions wereL.
encouraged to follow the Medico-Legal Code of"
U ndersianding for problems that arise in the mal-jj'
practice area. I
Eve Care and Eye Bank Committee: Paul McB. Aber- -
nath\. M.D.. Chairman i
1. Assistance was given the Department of Social
Services in managment of some of the professional .
reimbtirsement problems associated with the pro-l'
vision of optical services to North Carolina recipi-!'
ents under Title XIX.
2. Recommendations were made to the Committee ■
on Relative Value Study that as soon as possible
more descriptive procedures be added to the RVS.—
Ilh
Committee Liaison to the N. C. Pharmaceutical Associa-. i
tion: Charies W. Byrd. .M.D.. Chairman
1. .Assistance in an advisory capacit\' was given Paid
Prescriptions, Inc. in North Carolina as employed
b\ t.'-.e Department of Social Services to administer
the Medicaid program for prescriptions in North
Carolina.
2. In cooperation with the N. C. Pharmaceutical
Association and the N. C. Board of Pharmacy, a
program was undertaken to asstire continued high
quality prescription priorities in North C;trolin,i.
3. Support was given behind House Bill 156 to re-
quire labeling of prescriptions.
Committee on Disaster and Community Medical Care: .:.
George A. Watson. M.D.. Chairman jJBll
1 . .Assistance was gi\'en in an advisory capacity
through an expanded committee with representa-
tives from other interested state agencies, to thejisi
new program by the Emergency Medical Servicesfea
Division with the Dept. of Social Services. W*
2. Expansion of the Good Samaritan Law was recom-*ii
n-.e..ded to co\er all emergencv situations. f '
Committee on Association of Professions: Thomas Ci.
Thurston. M.D.. Cnairman
1. Happenings of joint professional concern were
reviewed by the committee and recommendations were
made as to how we can more effectiveh' work together.
Committee on Legislation: H. David Bruton. M.D .
Chairman
1. Continuing surseillance was provided state and
national health legislation and reported to the Ex-
ecutive Council.
2. Effective efforts were made to present the offici.il
position of organized medicine to the legislature
1 bmmiftee on Community Medical Care: J. Kempton
; ines, M.D., Chairman
COMPILATION OF ANNUAL REPORTS
21
i^
Endorsement was given the Governor's Riiral
Health Program as an example of an experimental
model health care system. Close followup evalua-
tion was recommended to determine effectiveness.
A position paper on the Need for More and Belter
Distribution of Primary Care Physicians was pre-
pared with assistance of other concerned groups
for presentation to the House of Delegates.
ommittce on Public Relations: John L. McCain, M.D..
"hairman
,ilL An AM A Medical Leadership Seminar was con-
ducted with Dr. Marshall Redding. M.D., as Pro-
gram Coordinator.
1 2. Conference for Medical Leadership was sponsored
on the topic of "Practicing Physician Pressure
Point" at the Headquarters Office Building in Ra-
leigh.
To help increase physician productivity, a pro-
gram on "Train Your Own Assistant" was pre-
pared and made available to the membership.
I For detailed accounts of committee actions and delib-
|ations. please refer to the respective committee chair-
man's report.
II would like to commend the committee chairmen
Tid the headquarters staff for the excellent service per-
i>rmed and the leadership given and accomplishment
thieved in the Public Relations Commission.
John L. McCain. M.D., Commissioner
\
PUBLIC SERVICE COMMISSION
Ijllt is rather difficult for me to know exactly what to
jrite in my first report as Chairman of Public Service
lommission. I did meet with all of the nine (9) com-
jlittees and I was deeply impressed with the dedication
each chairman and with the obvious concern of the
Members of these committees. Summaries of each com-
ittee's work will be printed elsewhere in this issue so I
jail not repeat what each chairman has said. I think
Jaat my main job is to recognize the tremendous amount
■f work which these committees have done.
[The President of North Carolina Medical Society
jppointed an Ad Hoc Committee on Mental Health to
Wiew the current salary schedule for physicians within
^e mental health system and make recommendations as
1 how to make these salaries competitive and enable the
.pparment to recruit qualified physicians into the sys-
hm. It was pointed out by Dr. Zarzar that salaries avail-
We for physicians working in the mental health system
sere well below what the physician could earn in private
L'actice. He requested that the State Medical Society
jpipport a 30 per cent increase for physician's salaries
™iithin the mental health system as proposed by the De-
lartment to the Advisory Budget Commission of the
egislature. He also pointed out that Medicaid receipts
3w go to the general fund. He felt that these receipts
■iiould go back to the mental health system in order to
irovide funds to up-grade services provided. It was
ointed out by Dr. Lowenbach that 80 per cent of the
'.sychriatrists in the United States practice in towns
^ere the population is 500,000 yet they treat only 8
per cent of the patients, It was resolved that "base sala-
ries for physicians in the mental health system should
be raised by 15 per cent and that an additional 15 per
cent should be paid to attract physicians to less popular
positions."
It was also the con.'ensu^ of the committee that Presi-
dent. George G. Gilbert, M.D. should send a question-
naire to all members of the North Carolina Medical
Society asking them if they would be willing to work as
a consultant in the mental health system, and what they
would consider as a reasonable daily fee for such work.
This was done by the President and as of the time of this
writing only one reply has been received.
Philip G. Nelson. M.D.. Commissioner
DEVELOPING GOVERNMENT HEALTH
PROGRAMS COMMISSION
The Committees under this Commission have had a
very active year. Each met during the September Con-
clave with good attendance. The members of the Com-
mittees were interested. Special guests with information
necessary for the Committees added valuable in-put into
the sessions of the Committees.
The Committees with their respective Chairman cur-
rently on the Commission are:
1. Comprehensive Health Service Planning. Com-
mittee On — Robert C. Moffatt, M.D.
2. Medicare, Committee On — William T. Raby, M.D.
3. Peer Review. Committee On — M. Frank Sohmer,
M.D.
4. Social Services Programs, Committee On —
James S. Mitchener, M.D.
5. Health Care Delivery, Committee On — Patrick
Kenan. M.D.
The activities of these Committees is contained in
reports submitted by the Chairmen and will be found
in the compilation of reports.
The Committee on Peer Review activities again merits
particular mention. The report of M. Frank Sohmer,
Jr. M.D. who is Chairman of the Medical Society Com-
mittee is also head of the North Carolina Peer Review
Foundation reflects the constant activity of this group.
The increasing communication between the Social
Services Programs Committee and officials of the de-
partment of Social Services reflects a spirit of coopera-
tion which has gradually developed. This is particularly
helpful to both parties in problem cases.
The Committee on Comprehensive Health Services
Planning is in the process of developing new gtiidelines
for the various State planning areas to outline the plan-
ning areas where physicians are most needed and should
be involved. When these guidelines are developed, they
are to be presented to the Executive Committee for re-
view and further disposition.
The Committee on Health Care Delivery is awaiting
to study the results of a survey questionnaire concerning
accessibility to medical care which was taken in Dur-
ham-Orange Counties. If the results show a clear pattern
or develop valid trends, the Committee will recommend
that a similar study be done statewide. It was felt
strongly by tiie members of this Committee that the
State Society must address itself to the problems of ac-
cessibility to health care.
John A. McLeod, Jr., M.D., Commissioner
SUPPLEMENT TO N. C. MEDICAL JOURNAL
REPORT ON COMMITTEES
COMMITTEE ON AUXILIARY & AMA-ERF
No report.
COMMITTEE ON ANESTHESIA STUDY
The Committee on Anesthesia Study convened on
the evening of September 2S. 1973 at the Mid Pines
Club in Southern Pines. North Carolina. Chairman Dr.
Bechtoldt reported on the continuing progress of the
new Medical Examiner system. Of the twenty one deaths
considered at the meeting to be related to anesthesia in
some way. several deaths were picked up by the Medi-
cal Examiner s\stem and not by the Death Certificate
system. On the other hand, there were several operating
room deaths not reported to the Medical Examiner.
Therefore, it was felt that the dual system should be
continued. The Medical Examiner system adds to the
number of reported operating room deaths, while the
Death Certificate s\'stem adds the dimension of Re-
covery Room and Intensive Care Unit deaths related to
an anesthetic as these deaths might not be reported to
the Medical Examiner.
It was emphasized that all of the hospitals in North
Carolina should be reminded again of the Medical Ex-
aminer system. This will be done through ( 1 ) the ques-
tionnaires routinely sent out. (2) the "Public Relations
Bulletin." and (3) a letter by Dr. Page Hudson sent
through Mr. Milliard's office to all of the hospital admin-
istrators.
There followed at the meeting individual considera-
tion of cases.
Albert A. Bechtoldt. Jr.. M.D., Chairman
COMMITTEE ON ARRANGEMENTS
The Committee met in Southern Pines on September
27, 1973. with excellent attendance. Three major topics
were considered and acted upon. The committee recom-
mended that the Auxiliary and the Society jointly spon-
sor a Memorial Service, combined with a Prayer Break-
fast. The Committee endorsed the idea of devoting two
general sessions to coordinated postgraduate educational
programs, prepared by the faculty of the medical
schools. The Committee discussed the expressed desire
of the Society for a Thursday night to Sunday meeting,
and how this could be accomplished in the face of prior
commitments of the hotel management for available
days. Some support emerged for a September meeting,
and this possibility will be further explored.
E. Harvey Estes. Jr.. M.D . Chairman
COMMITTEE ON
ASSOCIATION OF PROFESSIONS
Opportunity has been afforded the North Carolina
Association of Professions this past year, to gain the
attention of KEY State Agency Heads and legislators b>'
expressing views and concerns of our professional prac-
titioners which have been passed on to our members.
Beginning with our 1973 Tenth Anniversary Meet-
ing last March. Senator Herman Moore of Mecklenburg
was invited to speak to the Board of Directors on his
Tax Exemption proposals. The Association members
were primarih' concerned with the INTANGIBLE TAX: 1'-
LAWS and stated their reasons for promoting exemption!]
from the current law. Senator Moore took note of this
request and attempted to include this in his bills, then
before the General Assembly. No action was taken dur-i
ing the 1973 session, and these issues were promised t(
come before the 1974 session.
David Flaherty. Secretary of the .State Human Re-J^';
souces Department, received many questions from th^i^.
group when he addressed the membership meeting dur-L,,
ing the afternoon session. He agreed that private anc|,,
public agencies and leaders working together to provideTj^,
service and protection to the citizens of North Carolinaij,
can do a better job more efficiently and effectively, ash-
less cost to the taxpayer. Flaherty, being a business mani
knows the importance of business and professiona
leader support for state government programs, and hii
was pleased to hear practitioners speak out for anciCt
against specific tax-fimded services — that could bes
be carried out b\' private enterprise.
li IS with pride that the Association recoanized Dff',"
''11*
John S. Rhodes at the 1973 annual meeting with i!'
SPECIAL AWARD for his ten vears of leadership antf,'
service to the objectives and purposes of NCAP. Repf
Bund\' of Pitt County was the dinne"
re>entati\e
speaker.
During the summer and fall, all professional licensmiji;
boards were called before a sub-committee, appointee
b\ the 1973 General Assembly, to report their finances*
regulations; methods for licensing: and appointments o'
selection of board members. All 32 separate funde/r'
licensing boards were given a written questionnaire t(|
complete and called in for public hearings. Severa
questions were common to all Boards: fees, board ap
pointments: duties of board members: compensatioi:
for members: rules and restrictions, if any. for licensing!
investiizative services performed on behalf of the boards pi
and tenure ot office for members.
The results of these hearings were reviewed with Rep
resentative Foyle Hightower. of Anson, chairman o
the sub-committee charged with the responsibility foily
reviewing all licensing boards, at an Association meetjjjj,
ing held in Charlotte on October 4th. At that timejf^i
NCAP members were quite open with their support oji_^.^
the present operation of the professional licensing boardjijj
and urged that they remain as "peer member groupSjC
and allowed to serve the purposes for which they wer[,(
created and charged by the professional practice acti,L,;
In February. 1974 — a battery of bills were introduce^L
by the Hightower sub-committee and referred to th|j,
House Finance Committee. All NCAP members hav
received a copy of these bills. Results are not known :
this point. NCAP has been recorded by the commitie
as objecting to one or more of these bills and is awaitin _
further opportunity to be heard. jy
The March 6. 1974 Annual Meeting will be anothef"
forum at which time these bills will be reviewed.
Officers who have ser\'ed the Association the p.i;
\ear are :
President: William B. Gibbs, P.E.. Burlington
Vice-President and president-elect: A. W. Smith
D.V.M.. Farmville
Second Vice-President: B. Cade Brooks. P. Ph., Fajl
etteville
^^
COMPILATION OH ANNUAL REPORTS
23
^Secretary: E. A. Pearson, D.D.S.. Raleigh
Treasurer: Thomas O. Thurston, M.D.. Salisbury
Immediate Past-President: John F. Wicker, A. I. A.,
Greensboro
Mrs. John B. Chase, chairman of the House Health
ammittee, has been invited to address the dinner meet-
;g on March 6. 1974 of the 1974 annual meeting to be
lid in Raleigh at the Velvet Cloak Inn. Mrs. Chase has
ayed an important role in many of the study efforts
ncerning professional manpower; financing of health
rvices; and educational training programs. The asso-
''jtion is honored by having her accept its invitation for
arch 6th.
'New Officers will be elected and installed March 6th
th Dr. A. W. Smith to serve as the 1 2th President for
■}74-75.
Thomas G. Thurston, M.D., Chairman
:
if COMMITTEE ON AUDIO- VISUAL PROGRAMS
The Committee on Audio-Visual Programs met dur-
ig the Committee Conclave in September.
An interesting audio-visual program has been planned
r the Annual Meeting in May for Monday, May 20th
J 00 a.m. to 12:00 Noon p.m. and 2:00 p.m. to 5:00
im.; and Tuesday, May 21st, 9:00 a.m. to 12:00 Noon
lid 2:00 p.m. to 5:00 p.m. Members of the Committee
lill serve as moderator each session.
The full program of films will be listed in the official
;ogram copy, and this program will also be distributed
1 the membership in the April issue of the Public Rela-
ons Bulletin.
I G. P. Henderson, Jr., M.D., Chairman
i
COMMITTEE ON ARCHIVES
OF HISTORY— NCMS
jlNo report
COMMITTEE ON BLUE SHIELD
'Your Blue Shield Committee held five scheduled
Meetings of the full membership during the past year.
Itiese meeting dates were established in advance; and the
Wire Society membership notified of the meeting
•'ihedule through bulletin of the Headquarters Office
^'ad informed that any member could present matters
•r Committee consideration. In addition the Claims
' 3view Subcommittee met monthly and there were sev-
' al called meetings of Ad Hoc Committees appointed
consider special issues.
Vacancies in the pediatrics, obstetrics and surgical
ctions were tmfilled through the summer months due
' the resignation of a surgical member for health rea-
ns, and the inability of representatives from the
;diatric and obstetric sections to serve on the Commit-
e. The Executive Council, at the September meeting,
)pointed Doctor J. H. Monroe for the obstetric sec-
m. Doctor William W. Farley for the pediatric sec-
)n. Doctor Marshall Morris as a surgical consultant,
octor H. V. Bullard, Jr. as an internist consultant,
I id Doctor John Wooten as an orthopedic consultant.
For the future, your committee respectfully suggests
at nominees for Blue Shield Committee membership
■ contacted prior to election by the House of Dele-
gates to determine that conflicts of responsibilities do not
prevent willingness to .serve.
The meetings of the Committee during the past year
were characterized by progress in understanding between
members of the Society and Blue Cross and Blue Shield.
During the March meeting of the Committee, repre-
sentatives from the North Carolina Society of Internal
Medicine presented a statement of concerns. Blue Cross
and Blue Shield representatives, including Corporation
physician trtistees, responded to their concerns; and as-
sured these doctors and the Committee that the Cor-
poration had and would continue to direct its sincere
effort to work cooperatively to find viable solutions
to problems and seek better commimication with physi-
cians and subscribers. Discussions between the North
Carolina Society of Internal Medicine and the Cor-
poration through the channel of the Blue Shield Com-
mittee have continued throughout the year. A special
Ad Hoc Literature Committee has been appointed under
the chairmanship of Doctor C. A.. Hoffman, Jr. to meet
with appropriate staff members of the Corporation and
committee members and consultants. This is to help
development of Blue Cross and Blue Shield booklets
and literature that most accurately describe to subscrib-
ers the benefits, limitations, and exclusions of their
coverage.
The correlation of the opinions, advice, and decisions
of this and previous Blue Shield Committees has kept
the formal activities of the Committee to a bearable
level. One reasonably successful telephone conference
was tried in December as an experiment for claims re-
view in case the fuel shortage restricts travel to meet-
ings. Specialty members have actively served in a liaison
capacity between the Committee and specialty groups
to help resolve problems involving new or unusual ser-
vices. Among many matters involving problems or spe-
cial consideration were the establishment of benefit
guidelines for private duty nursing services, psychiatric
care involving paramedical personnel, administration
of inhalation therapy benefits, duplication of pre-surgi-
cal diagnostic services, the proliferation of diagnostic,
laboratory panel screening, and utilization of laboratory
services. Committee actions continue to contribute to
Blue Shield policy decisions and maintain effective com-
mimications between the Corporation and the Medical
Society.
Serving on the Claims Review Subcommittee were
Doctors Vatz, Robertson, McCutcheon. Johnston,
Langley, and Morris. During the twelve meetings ap-
proximately 315 cases were formally adjudicated, from
which important precedents and general guidelines re-
lating to charges and customary medical practice
emerged and were referred to the full Committee for
final determination. Claims were reviewed at the request
of individual physicians or the Corporation when there
was a question about the type and amount of benefits
applicable, or when a procedure or service was provided
for which benefits had not been established.
Committee members and consultants have given gen-
erously of their time serving as advisors in problems
relating to their specialty. There have been approxi-
mately 1,500 communications with the Corporation
about customary medical care and Blue Shield profes-
sional benefits. The three year terms enable members
of the Committee to become familiar with the problems
of physicians and the Corporation and aware of the
/,
24
SUPPLEMENT TO N. C. MEDICAL JOURNAL
rapid developments and changes of common concern
in the delivery and fimding of health services. However,
the diversity and scope of activities of major concern
to the medical profession result in heavy responsibilitie>
and time demands on the Chairman. Some problems
and issues require more than one year to resolve. In
the future, it may be desirable for the Society to allow
flexibility of tenure to permit a member to serve two
years as chairman, while a designated vice chairman
is developing the experience and training to succeed
him.
North Carolina Blue Cross and Blue Shield has been
cooperative and responsive at all times and the Com-
mittee is grateful for the active support of Committee
functions by Mr. Thomas A. Rose, President, and to
Mr. K. G. Beeston, Vice President of Blue Shield
Activities, for his continued help in the capacity of
secretary and staff support.
The Committee is appreciative of the interest, parti-
cipation, and frequent meeting attendance of Doctor
G. G. Gilbert, President; Doctor F. R. Reynolds, Presi-
dent Elect: Doctor John Glasson, Past President. Doc-
tor Howard Wilson. Commissioner, and Mr. William N.
Hilliard, Executive Director of the North Carolina
Medical Society.
David S. Johnston. M.D.. Chairman
REPORT OF PH^ SICI AN TRUSTEES
NORTH t AROLINA
BLUE CROSS AM) BLUE SHIELD. INC.
TO NORTH CAROLINA MEDICAL SOCIETY
The year 1973 was a very eventful one for North
Carolina Blue Cross and Blue Shield, Inc. Two signi-
ficant events having much to do with the future of
North Carolina Blue Cross and Blue Shield, Inc.. oc-
curred during the year. The first was the assumption
of the duties of President by Mr. Thomas A. Rose.
The second was the long anticipated move into the
new Service Center on the Chapel Hill-Durham
Boulevard.
The Board of Trustees met monthh' with Physician
Trustees as well as other Trustees having almost perfect
record of attendance. Dr. David S. Johnsion. Chairman
of the Blue Shield Committee, and Dr. Frank R. Re\ n-
olds, President-Elect of the North Carolina Medical
Society, met with the Board as ex officio members and
contributed greatly to the deliberations of the Board.
A Corporate Plan for 1974 was completed in mid-
December 1973 imder the giudance of President Rose
and after much time and effort at all levels of the Cor-
poration. The Corporate Planning Committee developed
and implemented a two-phase corporate planning
process. This process required that each division formu-
late a statement of assumptions on anticipated events,
as based on the purpose and objectives of the Corpora-
tion, and prepare a statement of programs for 1974
charting directions the Corporation will take.
During the last two weeks in July 1973 approximateh
850 Durham and Chapel Hill employees moved into
the new Blue Cross and Blue Shield Service Center on
the Chapel Hill-Durham Boulevard. Nine of eleven
former offices in Durham and Chapel Hill were closed.
This long-needed facility enables the Corporation to
establish and maintain more effective and economical
Il<
administration of an expanding business, which grewl
by close to 400,000 members since 1967, Even more
important, the Service Center, as its name implie.s,i|
enables the Corporation to improve and expand service
to subscribers, doctors and hospitals, and the public we
serve. 1
The Blue Cross and Blue Shield Service Center was
officiaIl>- dedicated Friday, October 19, 1973. President
Thomas A. Rose presided at the ceremony on the east
plaza that was attended by some 300 invited guests
and hundreds of employees. Principal dedication speaker'
was Marshall I. Pickens. Chairman of the Trustees offc
of The Duke Endowment. Is
The Blue Shield Activities Division issued a newjf
Doctors" Manual in late 1973 to replace one whichf''
had been well received and much used since 1969.|
Professional Relations Representatives distributed copiesj
of the mantial to doctors and clinics at workshops andj
during personal visits to doctors" offices. The manual!'^'
is intended to acquaint doctors with information about''.
Blue Shield benefits, indentification card explanation,!*'
and claim form preparation and in so doing improvesjP''
and expands our service to our subscribers. F
Enrollment in the Teachers and State Employeesf.
group increased to 140.000 certificates in 1973 with overj
273.000 participants. Two important benefit changes!
were an increase in in-hospital medical benefits undeL
High Option from S5 per day to 100 percent VCR,.
and an increase in surgical benefits and in-hospital medi-
cal benefits under Low Option to 80 percent UCR.
During 1973 the Corporation processed a record higbtei
of 1,880,528 Blue Cross and Blue Shield claims. This
\y.
reflected an increase of 234,759 claims. A record benei|t!i;
fii
fit payment of $158,513,167 was recorded for Bluef
Cross and Blue Shield claims. These plus Medicare Parllie
A and CHAMPUS claims brought total claims tojtt
2.345.400 claims and paid $290,744,047 in benefits un-k
der all underwritten and administered programs. m
.Additional detailed information concerning opera*
tions of Blue Cross and Blue Shield of North Carolina]'''
is available b\ reference to the Corporate annual report,';™
The Claims Processing Task Force continued its work|t,
throughout the \ear to alleviate service problems relatiagjj^
to claims processing. Efforts were concentrated in majoijjjj
areas such as prompt and accurate processing, thereb);^,
reducing inventories, and establishing an ongoing pro-L
gram of quality control. The Blue Shield Activities|j^
Division continues to establish a line of communicatioDifjij
and to carry out an ongoing liaison between the Cor-L
poration and the medical profession through plannedlu
personal contact and prompt Corporate attention anfflj
response to questions raised by the medical professioaLj
The cooperation of all trustees. Physicians. Hospitafir
Administrators and Public members as well as Manag<w
ment was excellent. The Board is especially gratefaics
to Senior Vice President Rogers C. Wade who servecfe.
as Acting President prior to the arrival of Presiden«ll,
Rose. Mr. Wade retired on August 10, 1973, after 280:
\ears of dedicated service to Blue Cross and Blue Shield.'*.
11
President Rose has already established contacts wittj
main' members of the Medical Societ\ as well as witl;
public leaders and subcribers throughout the State
The Physician Trustees are grateful for the privUegajf
(Dr.
^^
COMPILATION OF ANNUAL REPORTS
25
K serving on the Board and have been accorded lit-
est cooperation b\- management and other trustees.
5j Frederick A. Blount. M.D.. Roy S. Bigham, M.D.
fl James E. Davis. M.D.. H. Fleming Fuller, M.D,.
iidfred T. Hamilton, M.D., Marvin N. Lymberis. M.D.
Joseph B. Stevens. M.D.. Kenneth D, Weeks. M.D.
COMMITTEE ON CANCER
rhe Committee on Cancer met on September 27.
|73 in Southern Pines with e.xcellent committee at-
ijdance and with the support of ten resource people
ibse help was invaluable.
pT. Isa Grant, State Board of Health, reported the
.jiiual summary of the cancer three-da\' diagnostic and
]|,i day treatment program. She reported that the 19
Cjjcer clinics and 30 multiphasic screening clinics have
Ij formed a total of 23. .366 Pap smears with 44 cases
(^cancer detected in addition to other findings. The
{,te Board of Health performed 109.000 Pap smears
c,- which 475 were positive. Statistics for Pap smears
{. formed by private pathologist were not available.
Vir. Jim McCormick reported for the Central Cancer
I gistry and an annual symposium held in March.
f ; Registry was depicted as a going concern with its
a'uial report due in the next few weeks. Five primary
s'r'S were concentrated on in this report. There are
rv over 22,300 cases in the registry.
Mrs. Edna Raynor showed transparencies of the
t ast cancer data report. It was pointed out that in
s ie of advancement in therapy we still have the same
ju-centage of female breast cancer deaths that we had
t' years ago with the rate going up but the percentage
rSiaining stable.
Pive hospitals were granted approval for participation
i; he Cancer Diagnostic and Treatment Program. These
T:e Martin General Hospital. Williamston. Chowan
(jjnty Hospital. Gordon-Crowell Hospital, Lincolnton.
( lawba Memorial Hospital, Hickory and the Sea
I|f'el Hospital was approved for Diagnostic Program
j^fter a report by Dr. Grant on Certified Home
I ilth Agencies a motion was made recommending that
t' State Medical Society emphasize and call attention
t'the value of the State Board of Health's Certified
I-ime Health Agency Services so that physicians in dif-
f-;nt counties, particularly the sparsely settled areas
c' be informed of the various functions and encourage
iy use of the Certified Home Health Agency Services
v';ch can be made available to the physicians in the
Sie. Also, that the State Society might send out ne-
t's particularly to the small counties to make the doc-
t , aware of these services and what can be done to
Id them.
jn response to continued inquiry about the liberaliza-
tji of guidelines in regard to chemotherapy, a commit-
ti' chaired by Dr. Jim Maher of Goldsboro. was ap-
plied to study this subject with the hope that some
Ejre definitive action could be taken.
)r. Simmons Patterson reported for the Regional
Jldical Program that it would be viable until June 30.
1: 4 and its future after that is uncertain. Certain
F' grams of the Regional Medical Program related to
c cer are continuing and have been very successful.
)r. Warren Cole reported for the N. C. Division
c: the American Cancer Society. He particularly re-
ported the Uterine Task Force Program and the con-
tinuing efforts to establish a breast cancer study pro-
gram at Duke Hospital. This effort is coordinated and
supported by the American Cancer Society.
It was reported that the N. C. Cancer Institute in
Lumberton had 65 beds with average occupancy of 62
and has recently purchased new equipment. They have
a full time medical director and administrator and are
doing a splendid job in supplying terminal care.
It was reported by Dr. Max Scheibel that the Gov-
ernor's Cancer Commission expired on June 30, 1973
and its future was uncertain. Ten thousand copies of the
cancer resource booklet had been printed and distributed
with excellent reception.
Lewis S. Thorp, M.D.. Chairman
ANNUAL CHAMPUS REPORT TO
STATE MEDICAL SOCIETY
The Dependent's Medical Care Act of 1956 became
the founding block for the Civilian Health and Medical
Program of the Uniformed Services, a comprehensive
health program commonly known as CHAMPUS.
The CHAMPUS provides coverage to the dependents
of active duty personnel, retirees and their dependents,
and dependents of deceased personnel who seek medical
care outside of military facilities.
However, the scope of the CHAMPUS has been ex-
panded. Through the passage of the Veterans Health
Care Expansion Act of 1973 (P.L. 93-82). the spouse
or child of a veteran with a total permanent disability
(service connected) or the surviving spouse or child of a
veteran who dies from a service connected disability is
entitled to receive hospital and medical care benefits.
The law authorized the Veterans Administration to pro-
vide for care in the private sector, as well as in VA
facilities.
The law became effective on September 01, 1973
and a contract between the Department of Defense
(OCHAMPUS) and the Veterans Administration has
been signed. In effect, the VA decided to contract with
the Department of Defense to provide civilian medical
care to its' beneficiaries using OCHAMPUS and the
CHAMPUS System of Fiscal Agents. The Veterans Ad-
ministration has named the new program CHAMPVA
(Civilian Health and Medical Programs of the Veterans
Administration).
The CHAMPUS Program is administered by Blue
Cross and Blue Shield of North Carolina, the fiscal
agent for the Office of Civilian Health and Medical
Program of the Uniformed Services. Claims are
processed in accordance with the usual, customary and
reasonable fee concept with pa>ments made to the phy-
sician or to the patient. The usual, customary and rea-
sonable concept, as administered under the CHAMPUS.
has continued to be widely accepted by North Carolina
physicians with few exceptions. However, if a physician
does not desire to participate in the CHAMPUS Pro-
gram or does not want to be subject to the usual and
customary allowance determinations, our office can
reimburse the patient in an amount not to exceed that
which would have been paid to the physician.
Present trends indicate a reduction in the population
of dependents of active duty servicemen. However,
the number of retired military personnel and depen-
dents will likely increase since the Armed Services are
ly
26
SUPPLEMENT TO N. C. MEDICAL JOURNAL
allowing for early retirement. Secondly, the emergence
of CHAM PUS increases the number of beneficiaries
eligible to receive civilian medical care. More important,
however, is the drastic cut back of active duty physicians
who are "base connected." Therefore, it appears that
care of dependents and retired service personnel in
North Carolina will continually he the responsibility of
the practicing physician and other medical communit\
services.
In its seventeenth \ear as fiscal administrator for the
CHAMPUS Program. Blue Cross and Blue Shield of
North Carolina made pa\ment of S4.549.34 1 .Z.'i to ph\-
sicians in the state for 48.348 cases. This represents
an average payment of !s94.10 per case for outpatient
and inpatient care. .Since 1957 CHAMPUS has made
payment of $27,483,380.00 for 284.111 cases— a
significant factor in support of free choice medical
care in North Carolina.
We wish to express our sincere appreciation and
thanks to the North Carolina Medical Society for their
continued support and guidance in the administration
of this Procram.
CO.VIMITTEE ON
CHILD HEALTH AND INFECTIOUS DISEASE
The Child Health Committee met at Pinehurst on
Friday. Sep;ember 28. 1973. A considerable number of
topics were discussed and two recommendations were
referred to the Executive Council.
The status of sickle cell screening was discussed h\
Dr. Ted Scurletis. It was generally agreed that this is a
very sensitive area and progress must he very care-
fully planned and implemented.
Dr. Will London discussed earh and periodic screen-
ing, diagnosis and treatment of Medicaid patients. There
was considerable response from most of the committee
members regarding this, and all agreed that intensive
efforts at the state le\el should be made to clarify and
help implement this program.
A trial immunization program against Hemophilus
Influenzae. Type B and Neisseria Meningitis Group
C Meningitis in Mecklenburg County was mentioned
b\ Dr. O. F. Roddev. .After discussion on this. Dr.
Paul Glezen made the recommendation and it was un-
animously agreed that Hemophilus Influenzae Meningi-
tis be made a reportable disease. This is for the two-
fold purpose of helping to decide on the use of the \'ac-
cine on a state-wide basis, and because of the frequency
and seqtielae of this serious disease.
Dr. Ted Scurletis discussed regional care centers for
neonates and their transportation to these centers, and
the Committee recommended that the principle of re-
gionalization of newborn care as being presented h\
Dr. George Brumley to the Committee on Legislation
be pursued and implemented.
O. F. Roddev. Jr.. NLD.
COMMITTEE ON CHRONIC ILLNESS. TB, AND
HEART DISEASE
The Committee on Chronic Illness. TB. and Heart
Disease met on September 2h. 1973 at the Annual Con-
clave of Committees in Soiuhern Pines. North Carolina.
I. Dr. \V. G. Steinincer, Medical Director, McCain
Hospital, discussed "Current Trends in the Manaj
ment of Tuberculosis Patients; Shorter Duration ok,\
Hospitalization; Emphasis on Home Care." Dr. Steinin
ger also indicated that North Carolina has the 12tl
highest new tuberculosis case rate in any state in thi
nation. 22% ahead of the national average. During tb
last three years, there has been no appreciable declim
and therefore we have to realize that tuberculosis ii'
North Carolina is still a major problem. In view of this'
case finding remains an important endeavor and in or
der to avoid increased spread of disease, active treat
ment programs should be maintained under the besj^
possible circumstances and supervision. The followia
recommendation is therefore made to the Executiv
Council:
"3.
se.
'I
IH
WHEREAS IN CALENDAR YEAR 1972 REn.;
PORTS WERE MADE TO PUBLIC HEALTH AlJ '
THORITIES OF 996 \EW ACTIVE CASES
TUBERCULOSIS WITH SIXTY PERCENT BEIN
OVER THE AGE OF FORTY-FIVE AND SEVE^L
TY PERCENT BEING MALE. 130 REACTIVy* ^
TiONS OF TUBERCULOSIS AND 113 DEATH]^
ATTRIBUTED TO TUBERCULOSIS IN NORTl
CAROLINA.
AND WHEREAS IN 1972 NORTH CAROLIN.
HAD THE TWELFTH HIGHEST NEW ACTIV
TUBERCULOSIS CASE R.ATE IN THE NATIOI
(19.1 PER 100.000 POPULATION COMPARE!
TO U.S. RATE OF 15.8 PER 100.000), TH
CHRONIC ILLNESS COMMITTEE OF THE N. (
MEDICAL SOCIETY RECOMMENDS:
1. A RENEWED EFFORT TO IDENTIFY AN]
BRING TO TREATMENT CASES AND P(
TENTIAL CASES OF TUBERCULOSl
AMONG THE POPULATION.
2. THAT WHERE TREATMENT IS IND
GATED EVERY ATTEMPT BE MADE T
SELECT. WITH APPROPRIATE CONSUI
TATION AND LABORATORY INVESTIGi*
TION AS NECESSARY. AN ADEQUAT
REGIMEN OF ANTITUBERCULOSIS
DRUG THERAPY FOR A MINIMUM 0
TWO YEARS OF UN INTER RUPEE
TREATMENT IN THE CASE OF ACTIV
OR PROBABLY ACTIVE DISEASE.
3. THAT THE INITIAL PHASE OF TREA'
MENT OF ACTIVE CASES COVERIN'
THE PERIOD OF POSSIBLE INFECTIOU;
NESS SHOULD IN MO.ST CASES TAK
PLACE IN A HOSPITAL HAVING TH
NECESSARY .MEDICAL. LABORATOR
AND SUPPORTING FACILITIES FO
FULL EVALUATION AND FORMULA
TION OF OPTIMUM DRUG THERAP
PLANS.
4. THAT RESPONSIBILITY FOR SUPERVI
ING THE CARRYING OUT OF TREA'
MENT AT HOME AND EPIDEMIOLOG
CAL INVE.STIGATION OF CASES INCLUl
ING THE REPORTING OF NEW CASES E
.ACTIVELY SHARED WITH PUBLl
HEALTH .AUTHORITIES.
N. B. THE TUBERCULIN SKIN TEST IS REfl
OMMENDED AS THE INITIAL SCREENIN
COMPII ATION OF ANNUAL REPORTS
27
^'ROCEDURE OF CHOICE IN TUBERCULOSIS
:ASE FINDING.
j The Recommendation was seconded and carried
inimously)
II. The Committee discussed the "Statement Regard-
Preventive Use of Isoniazid" as a public health
Ijasure that was adopted by the Committee and pre-
ted to the Executive Council last year. Reference
mmittee #1 recommended and the House of Dele-
jjes approved that the report be referred back to the
(,ronic Disease Committee for re-evaluation.
The Committee discussed the recommendation at
1 gth and decided to re-submit the recommendation as
i igain to the E.xecutive Council as they agree unanim-
( ;ly with its contents:
^THE COMMITTEE ON CHRONIC ILLNESS EN-
^30RSES THE PREVENTIVE USE OF ISONIA-
UD IN THOSE SITUATIONS WHERE, IN THE
'OPINION OF THE INDIVIDUAL'S PHYSICIAN.
|l)R ONE OR MORE PHYSICIANS EXPERI-
iNCED IN TUBERCULOSIS. SUCH WOULD BE
' N THE BEST INTEREST OF THE HEALTH OF
VhE INDIVIDUAL. HIS FAMILY OR COMMUN-
TY FROM THE POINT OF VIEW OF PREVENT-
NG FURTHER SPREAD OF INFECTION.
THOSE INCLUDED MAY FALL INTO ONE OF
'PHE FOLLOWING GROUPS:
J
I
\ 6
\ 7
^1'.
1. INFANTS AND YOUNG CHILDEN WITH
A HISTORY OF HOUSEHOLD EXPOSURE
TO AN INFECTIOUS CASE OF TUBERCU-
LOSIS.
2. RECENT CLOSE HOUSEHOLD OLDER
CHILD AND ADULT CONTACTS OF AN
INFECTIOUS CASE OF TUBERCULOSIS
WHO HAVE SIGNIFICANT TUBERCULIN
HYPERSENSITIVITY.
3. PREVIOUSLY UNTREATED CHILDREN
TWENTY YEARS OF AGE AND UNDER
WHO HAVE SIGNIFICANT TUBERCULIN
HYPERSENSITIVITY.
4. CERTAIN RECENT TUBERCULIN CON-
VERTERS OF ANY AGE WHO HAVE SIG-
NIFICANT TUBERCULIN HYPERSENSI-
TIVITY.
5. CERTAIN MEDICAL SITUATIONS IN-
VOLVING UNCONTROLLED DIABETES
MELLITUS. SILICOSIS. AND THOSE WITH
PEPTIC ULCER ABOUT TO UNDERGO
PLACED ON CORTICOSTEROID THERA-
HAS SIGNIFICANT TUBERCULIN HYPER-
SENSITIVITY AND FOR THOSE WHO ARE
PLACED ON CORTICOSTEROID THERA-
PY.
CERTAIN PREVIOUSLY UNTREATED OR
INADEQUATELY TREATED, INACTIVE
OR QUIESCENT CASES OF TUBERCULO-
SIS.
THE COMMITTEE RECOMMENDS IN
EACH SITUATION THAT THE RISK OF
KOWN SIDE EFFECTS OF ISONIAZID BE
EVALUATED AGAINST THE POSSIBLE
ADVANTAGES TO THE INDIVIDUAL
AND COMMUNITY BEFORE DECIDING
TO INSTITUTE THERAPY. AND THAT
WHEN ISONIAZID IS PRESCRIBED, RE-
MADE OF PATIENTS RECEIVING IT IN
ORDER TO DETECT OCCURRENCE OF
ANY ADVERSE SIDE EFFETS AS EARLY
AS POSSIBLE.
THE ABOVE SHOULD RECEIVE THE CONSID-
ERATION AND ENDORSEMENT OF LOCAL
MEDICAL SOCIETIES.
( Recommendation was seconded and unanimously
carried )
III. A progress report on Home Health Care was
given by Dr. Thomas D. Long and Mr. lim Boehm.
Chairman of the Home Health Services Committee. In
general, the Home Health Care programs are well re-
ceived and in September. 1973. there were 50 Home
Health Agencies in 63 counties. The majority of these
are based in the Health Department, but there are six in
general hospitals, 10 are independent, and one is in the
Department of Social Services. Mr. Boehm discussed
with the Committee DHS Form 1500. the Patient's
Discharge/ Referral Form. The use of this form has
been very satisfactory; it has also been well accepted
by physicians and nurses. The committee made the fol-
lowing recommendation to the Executive Coimcil :
THE COMMITTEE ON CHRONIC ILLNESS RE-
VIEWED AND APPROVED THE "REFERRAL
AND TREATMENT" FORM (DHS- 1500) OF THE
DEPARTMENT OF HUMAN RESOURCES, DI-
VISION OF HEALTH SERVICES. AS WAS PRE-
SENTED.
THE COMMITTEE ON CHRONIC ILLNESS REC-
OMMENDS TO THE EXECUTIVE COUNCIL
THAT THE NORTH CAROLINA MEDICAL SO-
CIETY CONTINUE TO ENDORSE HOME
HEALTH SERVICES AND RECOMMEND THE
DEVELOPMENT AND EXTENSION OF HOME
CARE TO AREAS NOT HAVING THESE SER-
VICES AT THE PRESENT TIME.
( Both these recommendations were seconded and
carried imanimously)
IV. Mr. Ernest Phillips. Special Assistant. Medicare-
Medicaid Program. Division of Health Services, gave a
report on New Federal Regulations Affecting Nursing
Homes:
a. Uniform Standards for Skilled Nursing Facilities
under Medicare and Medicaid
In the past. Medicare certified "extended care fa-
cilities" and Medicaid certified "skilled nursing
home." The new amendment establishes a single
"skilled nursing facility" definition and a single
set of health, safety, environmental, and staffing
standards for such institutions. A single determi-
nation of compliance for Medicare would also
qualify a facility for Medicaid.
This is effective Iiily 1, 1973.
b. Implementation of ICE Programs
While not a part of the 1972 amendments, the
implementation of an intermediate care facility
program began in North Carolina on luly 1, 1973.
ICF care is paid for only imder Medicaid but
the inclusion of ICF payments does add a different
type of care to our state programs. It is intended
to serve those patients who need some skilled nurs-
ing services but not on a 24-hour basis. An ICF
28
SUPPLEMENT TO N. C. MEDICAL JOURNAL
provides skilled nursing 8 hours per da\ . 7 days
per week on the da\ shift,
c. Reorganization of State Government:
As a part of reorganization, all licensure and cer-
tification of health facilities and services have been
placed in a new division of the Department of
Human Resources — the Division of Facility Ser-
vices. This Division will handle all matters involv-
ing health facilities. Previously these functions
were scattered throughout five or si.\ state agen-
cies."
V. Dr. Abram L. Van Horn. UNC School of Medi-
cine. Department of Hospital Administration. ga\e a
brief report on "The Role of the Medical Director in
Long-Term Care Facilities":
He reminded the committee of the requirements under
Federal jurisdiction with respect to physicians services in
long-term care institutions. The health care must con-
tinue under the supervision of a physician and the
facilitv must have a physician available to furnish neces-
sary medical care in the case of an emergencx .
The AMA this past \ear decided to hold several
seminars throughout the coimtry on the subject of the
"Medical Director in Long-Term Care Facilities." Dr.
Van Horn passed out reports of what came out of these
conferences. The Committee discussed the desirability
to have a Medical Director for Long-Term Facilities
and came up with the following recommendation for
the E.xecutive Council:
THE COMMITTEE ON CHRONIC ILLNE.SS REC-
OMMENDS TO THE EXECUTIVE COUNCIL
THE N. C. MEDICAL SOCIETY ENDORSE THE
PRFNCIPLE THAT LONG TERM CARE FACIL-
ITIES IN NORTH CAROLINA EMPLOY THE
SERVICES OF A PHYSICIAN TO SERVE AS
MEDICAL DIRECTOR.
( Recommendation seconded h\ Dr. Long and carried
unanimously)
Dr. Van Horn disjussed the AMA qualitications of
the function of a Medical Director in a Long-Term Care
Facilitv. The following recommendation was made to
the Executive Council:
TH.AT THE NORTH CAROLINA MEDICAL SO-
CIETY ENDORSE THE "GUIDELINES FOR A
MEDICAL DIRECIOR IN A LONG TERM CARE
FACILITY" AS ADOPTED BY THE A. MA. AND
THAT COPIES OF THESE GUIDELINES" BE
FORWARDED TO THE N. C. DEPARTMENT OF
HUMAN RESOURCES AND TO THE N. C.
HEALTH FACILITIES ASSOCIATION WITH
THE RECOMMENDATION THAT THESE RE-
SPECTIVE AGENCIES AND ORGANIZ.ATIONS
TAKE SIMILAR ACTION OF ENDORSEMENT.
( Recommendation seconded b\ Dr. Long and carried
unanimously 1
VI. The Committee reviewed the Chronic Illness
Committee Gtiidelines as presented to them before the
meeiinc and accepted them as written.
Dirk Verhoeff. M.D.. Chairman
COMMITTEE ON COMMUNITY MEDICAL
C.\RE
The Committee on C'ommunity Medical Care has had
a busy year. During the summer of "73 we helped
draw up a program that would take residents in prima' •
care programs out into communities which are in ne<
of such care. They would practice with establishi
physicians and hopefully would be inspired to set i'
permanent practices of their own there. Money w
appropriated by the last legislature for this purpose.
At our September meeting and subsequently \
worked out details of a proposal which would rota
medical students in the schools of our state out in
communities across the state. They would precept und
a chosen panel of physicians in primary care practic
A subcommittee did much of the work of this projei
Another subcommittee is working on a position pap
to be presented to the North Carolina Medical Society
the need for more and better distributed primary ca
physicians in North Carolina.
Mr. Jim Bernstein who is heading the Governor's C
fice of Rural Health Services Program met with us
September and a dialogue was established which h
continued concerning the progress of this program.
Implementation and development of all of these pla
will have our continued concern and attention duri
the coming year.
J. Kempton Jones. M.D.. Chairm
COMMITTEE ON COMPREHENSIVE HEALTI
SERVICES PLANNING
(Report not received April 10, 1974)
COMMITTEE ON CONSTITUTION & BYLAWS
Annual Report to be presented in the HOUSE (
DELEGATES Sunday. May 19. 1974. Cardinal Bu
room. Pinehurst Hotel. Pinehurst.
Henrv J. Carr. Jr.. M.D., Chairm
COMMITTEE ON CREDENTIALS
Certification of Delegates and report to the HOU:
OF DELEG.ATES at opening session. Sunday. May
1974. Cardinal Ballroom. Pinehurst Hotel. Pinehui
Charles B. Wilkerson. Jr.. M.D.. Chairm
ADVISORY COMMITTEE TO THE CRIPPLED
CHILDREN'S PROGRAM
The only action to come before the .Advisory Co
mittee to the Crippled Children's Program occurred
the .September 26th Annual Meeting held at the N
Pines Club. Southern Pines. N. C. There was only c
person absent from the meeting.
Details of the Meeting are present in the minutes
the meeting on file in the Medical Society office.
No other business activities were performed by I k
throughout the remainder of the year.
Robert G. Underdal. M.D.. Chaim
COUNCIL ON REMEW DEVELOPMENT
The Council on Review and Development met on StI
tember 29. 1973 and February 1. 1974. Quorums w|ie
present at each meeting.
The Handbook on Committee Guidelines was tk
ished prior to and discussed at the February meeit|
The work was done by Ron Davis. Ed.D.. through rii
ords research and bv direct contact with officers, cc fc
COMPILATION OF ANNUAL REPORTS
29
nissioners. committee chairmen, the Executive Director,
■ ■leadquarters Staff, and members of committees. The
fiandboolv was approved by the Council on Review and
■Development.
I The Handbook on Committee Guidelines consists of a
isting of committees, committee membership, commit-
;3e charges, and operating methods. The book will prove
Laost helpful to the Societ\' and to the officers, com-
fHiissioners, and committee chairmen in particular. Two
r^undred copies will be printed. Complete copies of the
ijOok will go to committee chairmen, commissioners.
fficers, and the Coimcil. Each committee member wil
ave a copy of that portion related to his committee
nly.
The Council on Review and Development com-
lended highly Dr. Davis of his excellent production, a
)'ork that in fact required several years to prepare, and
fproject that has been discussed for ten years at least.
|in official letter of commendation was sent to Dr.
lavis over the signature of the President and the Com-
;jiittee Chairman. It is our hope that the Committees of
e Society will revise the Handbook each year in order
maintain a worthy document. The Committee ad-
fsed the Executive Director to oversee the various
^cessary revisions in the future as charges to commit-
es change.
iProper cataloguing and filing of the Medical Society
'pers, documents, meeting reports, historical material,
,;., is a problem that the Society must face in the fu-
re. The Committee felt that expert advice must be
I'ught on this matter and accordingly a request was
ide that Mr. Hilliard, Executive Director, and Drs.
,h.n Rhodes and Charles Styron arrange a conference
ith a staff member of the Department of Archives and
iStory to discuss the available materials and the proper
^ \y to use them for the benefit of the Societ\'.
The Commit:;ee on Archives and History previously
i requested that the Committee be disbanded. After
jch discussion and in view of the request such action
s recommended in the February meeting of the Coun-
The Council received a request that the Committee
'Auxiliary and AMA-ERF be discontinued. The Coun-
! therefore recommended that the Commitee on Aux-
ry and AMA-ERF be renamed the Committee Ad-
lory to the Auxiliary, and that this Committee be
igned responsibility for the AMA-ERF activities.
The Committee on Health Care Delivery expressed
desire to have as its primary activity in the corn-
year "accessibility of medical care." The Council
rroved this request but expressed the opinion that
;ific activity of committees is the committee prero-
= ve in the absence of specific instructions from the
iety.
■'he Committee Advisory to the Department of Motor
licles recommended a name change to the Committee
Traffic Safety. This recommendation was approved,
he North Carolina Medical Foundation in accor-
:e with its bylaws meets at the first regular meet-
of the Executive Council which is held at the Fall
clave. Sentiment was expressed that the time allotted
le meeting is insufficient to consider the many prob-
; of the Foundation. It was suggested that the Board
,3 lie Foimdation consider a regularly scheduled meet-
jA'ith sufficient time to consider its business.
J the Council on Review and Development recom-
-1 jded strongly to the Committee on Personnel and
r
Headquarters Operation and to the Finance Committee
that an additional Headquarters Staff executive be au-
thorized. Ihis has become necessary because of the
probabilit\- that one staff executive will be assigned full
time to legislation and that much time will be required
of the Headquarters Staff in PSRO activities.
The Chairman of the Council on Review and Devel-
opment recommended that any change in objectives or
name change of a committee should be formally re-
quested by the Chairman of that Committee to the
Council on Review and Development by letter.
The Council on Review and Development next re-
\iev\ed the entire committee structure of the Society
with regard to Commission assignment and Committee
name and content. The above recorded actions are in
part an outgrowth of this discussion. An additional ac-
tion was a majority vote to drop the Committee on
Medicare and add its function to the duties of the In-
surance Industry Committee.
Charles W. Stvron. M.D., Chairman
COMMITTEE ON DISASTER AND
EMERGENCY MEDICAL CARE
During the spring months committee members met
with Mr. Billy Talbert who was then formulating his
final draft for The Comprehensive Emergency Medical
Services Enabling Act. Three recommendations were
made to Mr. Talbert. 1 ) That at least three physicians
be included as members of the council. 2) That physi-
cian members be those licensed to practice medicine in
North Carolina 3) That the chairman of the E.M.S.
Advisors' Council be elected by the members of the
council in lieu of being appointed h\ the Secretary of
the Department of Hiunan Resources.
With the formation of the State Council during the
summer the committee met at Southern Pines Fall Con-
clave. Mr. O'Neil Jones an ex State Senator, now Chair-
man of the Council, Mr. David "Warren, the legal coun-
sel and newly employed members of the Division of
E.M.S. were in attendance. Although the staff had not
been completed, envisioned policies were discussed.
This new division of the Department of Himian Re-
sources had been established by a S750.000 appropria-
tion from The General Assembly.
There was disagreement by the ph>sicians as to the
proposed designation of "Trauma Centers" and the ten-
tative proposal of patient placement. Since the division
had just been formed any definitive action was post-
poned with the understanding that the Division of
Emergency Medical Services would make a report to
the committee ever\- six months so that they could con-
tinually monitor the progress of the program.
A motion was made, seconded, and duly passed to
the effect that: "The Committee on Disaster and Emer-
gency Medical Care Request the Legislative Committee
of The North Carolina Medical Society to use all avail-
able means to have the Good Samaritan Law expanded
to cover all Emergency Situations.
Georae A. "Watson. M.D.. Chairman
COMMITTEE ON DRUG ABUSE
The Committee on Drug Abuse of the North Caro-
lina Medical Society had one regular scheduled meet-
30
SUPPLEMENT TO N. C. MEDICAL JOURNAL
ing at Pinchurst. North Carolina on September 28.
1973. Ihe concerns and activities of the Committee
durini; the past \car are reflected in the contents of
the minutes. Ihe Committee has maintained communi-
cation and collaboration with the North Carolina Drug
Authority in the effort to implement the State Plan
and to disseminate information about drug abuse to
interested parties. Another concern of the Committee
has been to see that adequate procedures are available
and in use to deal with drug abuse by physicians. Other
matters of lesser concern have been the subject of com-
munications b\ various members of the Committee with
those of both inside and outside the Medical Society.
Kenneth E. Rockwell. M.D.. Chairman
COMMITTEE ON EYE CARE AND EYE BANK
The Committee on Eye Care and Eye Bank held its
regular meetings as in years past.
No unusual happenings other than being able to
handle legislation of the optometrists which we felt was
detrimental to medicine, in our favor.
Paul M. Abernethv. M.D.. Chairman
CO>!.MrrTEE ON FIN.4NCE
The Finance Committee met as usual in September,
and prepared the budget for 1974. which was approved
by the Council, and is in your Delegate's package. In
order to balance the budget it proved necessary to take
into account certain items which have heretofore been
ignored — such as increase in dues from anticipated
increase in membership. This means that we are un-
likely to have in 1974 a budget surplus comparable to
the approximately $60,000.00 operating surplus which
we had for 1973.
We were able in 197.^ to put into an operating re-
serve fund, as the Council instructed us. monies equal
to ( 1 ) the original cash payment for the airport prop-
erty (2) the quarterly payments made on the mortgage
for the airport property. (3) the investment income
realized from money in the reserve fund, and (4) 5Cf
of the operating budget. Into this fund in addition are
to go the excess dues colected from new members who
have not paid the extra $50.00 dues for five years with
which we financed the headquarters building. We have
not provided in the 1974 budget for the 5^r of the
operating budget for this reserve fund but the other
amounts wil be automatically available as they are not
taken into account in the budgeted income.
The Society has prepaid tb.e mortgage on the Green-
field property — which is the last purchased piece of the
headquarters site and the building and grounds are free
and unencumbered. The socicts is free of debt and our
reserve fund at vear"s end amounted to slightly less
than $93.0(10.00. '
T. Tilghman Herring. M.D.. Chairman
COMMITTEE ON HEALTH CARE DELIVERY
The Committee on Health Care Delivery has. since
its inception in 1971. had some difficulty defining what
its role or mission was to he. Certainly, in the delivery
of health care, there arc a number of identifiable factors
or problems which might concern this committee.
Some of these factors might be cited as follows: 1)
Problems of accessibility 2) Problems of quality coi
trol 3) Problems of cost containment 4) Probleni
of health manpower availability 5) Problems of maldi
tribution 6 ) Relationship with third party carriers 7
Relationship with present and planned government
programs S) PSRO 91 Health education 101 Preventiv
care and health maintenance 1 1 1 Development of ne
sN'stems of health deliverv' 1 2 1 Need for primary cai
providers.
Though all of these factors are justifiable concer:
for the Committee on Health Care Delivery, it has bea
conceded that involvement in all of these areas is to
broad, too impractical, and in most instances overl
with concerns of other standing committees. Howeve
in studying the missions of other committees of tl
North Carolina Medical Society, it seems obvious thj
no one committee has been specifically charged wi
studying the problems of accessibility into the heal
care system
At the Fall 1972 conclave of the N. C. Medic
Society, the Committee on Health Care Delivery a''
proved the following resolution: — "that the prima
mission of the Committee on Health Care Delivery 1
to concern itself with the problems of health care a
cessibility." Though not mentioned specifically, it
possible that at some future dale this committee m,
wish to be renamed more in keeping with its prima
mission of accessibility.
The committee spent much of its allotted time
the Fall Conclave discussing and studying a questio
naire circulated by the Durham-Orange County Medic
Society which polled the licensed physicians of tr
two county area on the problems of health care acct
sibility and possible solutions. There was unanimo,
agreement by the committee that a similar study be u
dertaken in a broader sense by separately structiir
questionnaire sent to every licensed physician in Not
Carolina. However, the feeling was expressed that tl
should be undertaken after completion of the Durhai
Orange County study, in order to best utilize the U,
sons and trends learned from this information sampli
technique.
Accordingly, the following resolution was approv
b\- the committee: — "that we finish out score count
in Durham-Orange and if it looks like a fairly cle^
cut direction is emerging from that, this Committee
Health Care Delivery will sponsor the design of a qui
tionnaire having to do with problems of accessibility ir
the system and with the proper staff support from t
State Medical Society, this will be sent out to all
censed physicians with a North Carolina address."
1 he Durham-Orange County project is nearing co
pletion. and the staff of the North Carolina Medii
Society has been alerted that we can soon concern oi
selves with designing and circulating a state wide phy
cian questionnaire exploring the problems of hea
care accessibility.
The important point to stress regarding this co
mittees" concerns and activities is that after more th
two \ears trying to identify a specific mission not o
lapping concerns of other committees, pursuing t
problems and solutions of accessibility into the hea
care system has emerged as the primary concern of t
Committee on Health Care Delivery. The questionn:i
technique of information sampling is intended as
COMPILATION OF ANNUAL REPORTS
31
ferst method of carrying out the mission of this com-
itrmittee.
i|il Patrick D. Kenan, M.D., Chairman
■f
GOVERNOR'S COORDINATING COUNCIL
,; ON AGING
i|' This newly reconstituted committee is heing buffeted
li)y variable Federal regulations and directives, an in-
iiecure position in the Department of Human Resources.
ind an uncertainty in the appropriations to be made by
ihe present session of the State Legislature.
Despite this, the Staff of the Governor's Coordinating
tbOcaincil on Aging has been providing technical as-
illistance to prospective projects in the field of both Title
lill and Title VII of the Older Americans Act of 1965,
li'S amended.
Thirteen new Title III projects consisting of twelve
lome Health Service projects (which will be of particu-
■jiT interest to the State Medical Society) and one li-
rary project have been approved by the Staffs Tech-
ical Review Committee and approval by the Regional
)ffice in Atlanta is expected. These new projects
present a total Federal amount of funding, coupled
lith local matching funds, to total $305,008.00. These
ijifWards are no longer available for a five year period
Q a sliding scale but are for a period of one year
1 1 which time a full review will be required. Seven
/antinuation projects under Title III have been pro-
,'i/;ssed, representing Federal funds and local matching
, mds of $239,573.00. Title III programs consist of
' ' )mprehensive planning, coordination and direct ser-
_ice projects.
""The nutritional program under Title VII of the
' Ider Americans Act of 1965 came to a halt when funds
ere frozen. There has been re-application and grants
ive been issued as of 31 December 1973 for a total
4.493 meals per day, five days per week. These
ograms which are ongoing in scattered regions
roughout the State are not totally successful and in at
' ,ast one instance have been widely resisted, possibly
■cause of lack of information being conveyed to the
der citizens, lack of "grass roots" initiation for the
■''''Ogram, and probably lack of coordination with other
"'.igoing programs of similar aims. In this area. Federal
• Jnds will amount to $2,050,156.00. Coupled with
■ m Federal matching will amount to $2,277,95 1 .00.
• jThe total for all projects under Titles HI and VII
':luding both Federal and non Federal shares will
lount to $2,822,531.00. The recommendation for dis-
'bution of these fimds is the responsibility of this
mmittee.
ra JiBackground information, allocations, and projected
,|(it lldgets concerning the above notations are on file at
Raleigh office of the North Carolina State Medical
ciety.
lis (The uncertainties of the committee status and future
;dvities has not changed during this interval.
(-■, Thomas R. Nichols. M.D.. Representative
iiei
" COMMITTEE ON HOSPITAL & PROFESSIONAL
"■ IIELATIONS TO N. C. HOSPITAL ASSOCIATION
The Committee held its annual meeting at 2; 00 p.m.,
aursday, September 27, 1973 in Southern Pines during
Medical Society's Committee Conclave and made
fii
several recommendations to the E .xecutive Council
of the State Medical Society. The committee attendance
was excellent and a very worthwhile exchange of ideas
was conducted. Several resolutions and recommenda-
tions were adopted which are detailed in the minutes
of that meeting.
The Committee has had only two complaints in the
field of Hospital & Professional Relations. One of
these involve the question of detailed delineation of
privileges thought to be required by the JCHA. raised
by the District Memorial Hospital at Andrews. North
Carolina. After conferring with the representative of the
JCHA and several phone calls to Mr. Mashburn. the
administrator, and Dr. Clark, the Chief of Staff of
the hospital concerned, it was possible to relieve some
of their anxieties. Since I have heard no more from
them, I assume that the problem has been resolved satis-
factorily.
The Committee would again like to urge the Medical
Society to take the initiative in conjunction with the
North Carolina Hospital Association to act upon the
recommendation made in Paragraph II in our Commit-
tee minutes of September 27, 1973. I have had letters
and oral communication from several members of the
Society saying that they were pleased that this recom-
mendation had been made and looked forward to the
development of some better and more efficient means
of documenting good medical care. This could be in
the form of a workshop with hospital staff physicians,
administrators and medical records personnel invited
to attend.
J. M. Van Hov. M.D., Chairman
INSURANCE INDUSTRY COMMITTEE
The Insurance Industry Committee has had a very
busy year. We continue to have an increasing number
of problems involving retrospective peer review of ser-
vices; less so of fees. (See the February 1974 issue of
the North Carolina Medical Journal for further details. )
Bernard A. Wansker, M.D., Chairman
COMMITTEE ON LEGISLATION
The work of your legislative committee continues to
expand at an exponential rate. Our society is fortunate
to have the effective and dedicated service in the legis-
lative area of our attorney Mr. John Anderson and the
staff assistance of Mr. Steve Morrissette.
The hills with importance to medicine considered by
The General Assembly and by the U. S. Congress are
too numerous even to list by title for this report. Be-
low is a brief summary of the first session of the 1973
Assembly in those areas most directly effecting our
membership.
ABORTION (HB 615) The abortion law in North
Carolina was rewritten to comply with the U. S. Su-
preme Court decision.
AMBULANCE ATTENDANT (HB 1079) The
ambulance law was amended to require a certified
ambulance attendant plus the driver during emergency
missions.
APPROPRIATIONS (HB 50) The appropriations
bill called for a imiform rate of reimbursement for state
programs at the same level as the medicaid program.
32
SUPPLEMENT TO N, C. MEDICAL JOURNAL
CERTIFICATE OF NEED ( HB 648) The certificate
of need program was repealed following the determina-
tion b\ the N. C. Supreme Court that the law was
unconstitutional.
EMERGENCY MEDICAL SERVICES PROGRAM
(SB 592) Established comprehensive programs within
the Department of Human Resources.
INSURANCE COVERAGE (SB 669) Insurance
coN'erage for newborn infants from the moment of birth.
INSURANCE COVERAGE (HB 743) Allows com-
panies to make pa\'ments for disabilities upon certifi-
cation of chiropractors.
INSURANCE COVERAGE (HB 744) The bill adds
■"a dulv licensed chiropractor" within the definition of
■'medical service plan."
MENTAL HEALTH (HB 373) This act amended
Chapter 122 of the General Statutes relating to the
rights of patients at treatment facilities for the men-
tally ill and retarded.
MENTAL HEALTH There were 16 bills in all in
this group, each making significant changes in our men-
tal health laws.
NURSES EXPANDED ROLE (HB 168. HB 169)
The Boards of Nursing and Medical Examiners to work
together in developing rules and regulations governing
the performance of medical acts by registered nurses.
OCCUPATIONAL AND SAFETY HEALTH (SB
342) Act provides for the state to take over the occu-
pational and safet\ health program in North Carolina.
OPTO.METRY BOARD OF EXAMINERS (SB
844) Revised the General Statutes relating to the
powers and duties of N. C. State Board of E.xaminers
in Optometry.
PHYSICIAN SHORTAGE ( HB 512) Appropriated
S 100. ()()() for mcentive payments to doctors who will
practice in medicalK deprived areas.
(HB 1123) Established a S7.5 million reseri'e fund
for an additional degree granting school of medicine.
(HB 1237) Appropriated S456.000 for the ■■Gov-
ernor's Rural Health Program."
PUBLIC HEALTH Eight bills having to do with
changes in the laws affecting public health departments
were made law.
STATE GOVERNMENT REORGANIZATION The
Department of Human Resources was extensiveh' re-
organized.
NATIONAL LEGISLATION The N. C. Medical
Society is indeed fortunate to have Ed Beddingfield
serving on the AMPAC Board and the AMA Legisla-
tive Council. Space will not permit a national legisla-
tion review. The membership is referred to the AMA
News where excellent accoimts of this legislation is
presented weekh'. It is fair to say that the Congress
and the American people now seem ready to establish
a national health insurance program. Our job as phv-
sicians is to get out and help get elected to Congress
men and women who have the kind of judgment re-
quired to develop a health care system that preserves
the great strengths of our present system, and protects
our patients from a massive imfeeling. inefficient
bureaucracy.
H. David Bruton, M.D.. Chairman
P
E
COMMITTEE ON MARRIAGE COUNSELING Xfi
FAMILY LIFE EDUCATION
The Committee on Marriage Counseling and Fam?
Life Education met on Thursday. September 27. 19''
in the sunroom at Midpines Club. Southern Pines, N.
from 2:00 to 5:00 p.m. The first item on the ageni
was a program for the annual meeting in May. Tl
program had been proposed for the meeting last ye;
but was not put on because of a problem of securi
a room. It was suggested that a similar program of tl
nature be planned for the annual meeting in 19"
The following recommendation was made, seconded, a
passed. It was recommended that this committee
on a two hour program on sex education at the
nual meeting in May, open to the members of the SU
Society, wives, and guests, which may be addressed
some of the common marital se.xual difficulties a phy
cian sees in daily practice with allotted time at the e
of the program for possible anonymous questions frc
the people screened and selected at random for bi
representation. Dr. John Reckless agreed to chair tl
program. It was suggested that Dr. Robert Bran
Chairman of the Section of Obstetrics and G\necolo!
be contacted to see if possibly this could he work!
into his program and also, it was suggested that t3
possibility of the Women's Auxiliary could be contactl
for some help on implementing this program. A let r
to Dr. Robert Brame. Chairman of the Section of ( -
stetrics and G\'necoIog\ Committee, has been writti,
but to date, we have not received an answer.
The second item on the agenda was a resolution )
Dr. Ethel Nash who died earlier this year. Dr. Re^-
less made the following motion which was duly secontll
and passed to the effect that "be it resolved that t;
North Carolina Medical Society and its Committee i
Marriage Counseling and Family Life Education recois
with deep and sincere regret the untimely death of M .
Ethel Nash early in 1973. Mrs. Nash, through ir
pioneer work with sex education, brought to Ncii
Carolina and its universities a wealth of knowle. :
and vision from which sprang a number of ediicatioT
and treatment facilities. Her death represents a loss )
her family, her patients, and her many friends and l -
leagues in medical and allied professions in the ful
of marital and sex counseling."
On the Budget request for 1973 which allocail
three hundred dollars, a letter was written to incrc ;
that budget from three hundred to one thousand doll :.
From the informal conversations with many of i;
members of the committee, there appeared to be soii-
what of a blase attitude and ineffectualness of the -
pact of this committee, in particular on the whole Sr:
Medical Society in general. It would seem that the Mi -
cal Society has never taken any action on support ig
the law to give contraception to minors, nor have t >
made any effort in recent months to support the '-
preme Court's decision on January 22. 1973. for le:-
izing abortion. However, every effort will be contin 1
to be made, to begin infusing the Medical Societx' \ i
information on human sexuality, sex counseling, ni-
riage counseling, abortion counseling, and contracep,
counseling. A letter to Dr. Rachel Davis has been sij
mitted concerning her part to tr\- to get the La
■Auxiliary to sponsor an evening or breakfast sessij
on human sexuality.
Althotigh I keep hearing time and time again fr
COMPILATION OF ANNUAL REPORTS
33
*pi5hysicians across the state that something needs to be
j lone in the areas of sex education, family life educa-
jdon, abortion counseling, contraceptive counseling. I
fiee little enthusiasm and support in terms of financial,
political, educational to meet the needs of the requests
^'rom our physicians,
r Takev Crist. M.D., Chairman
^ COMMITTEE ON MATERNAL HEALTH
IT The Maternal Health Committee does not have a
ijtfomplete report on maternal deaths for the year 1973
[t| s of the date of this report. There has been a change in
.;he recovery system of data on maternal deaths from
;t;(he State Board of Health and they are obtainable
1 Jnly on a quarterly basis. This report includes ma-
iiremal deaths through October 31. 1973. There was a
fisotal of 33 maternal deaths. Twenty-one of these deaths
ifj'fere remote or non-obstetrical deaths, three were due
tjo hemorrhage, two to infection, four to toxemia, two
tjio embolism, and one to cardiac failure.
iiiil The last three years have shown a steady decline
Mill maternal deaths, which indicates that the continued
iljtrong interest in maternal and child health in our
|,ate is beginning to show favorable results. The mater-
iii:il death workload for the Chairman has decreased.
Irtiowever. as the Society gets more involved in social
(;>edicine. the Committee seems to have more and more
njiquiries locally and abroad in the country for input
.to planning and programming of maternal and infant
ipif'ojects.
(iji-'Much time has been spent during the last year by the
iflj^hairman and other interested members of the Com-
i| ittee in pursuing the work of the Governor's Task
sliiorce for the Development of Regionalization of Ma-
jifirnal and Infant Care. A very significant document has
\..jlminated from this work and is now in the hands of
1 ' ; State Legislature, having been voted out of the Fi-
V;:ince Committee. The Executive Council of the State
;; ,?edical Society has endorsed this project.
The Chairman wishes to express his appreciation for
i cooperation and continued support of the Executive
.jifejiuncil of the State Medical Society. Listed below is a
fljisakdown of the expenditure of the $600 allowance
Mn the State Medical Society which is used to defray
otjfcsretarial. mailing and publishing expenses incurred in
itij )! course of conducting the work of the Committee
lol ^Maternal Health by the Chairman:
January 1, 1973-Deceinber 31, 1973
ipenditures
Secretary's salary ($41.66 2/3 per month)....$500.00
jt jTelephone 16.70
p postage 25.30
[jl lOupIicating charges 8.00
iIj Office supplies 50.00
Total $600.00
W. Joseph May, M.D., Chairman
MEDIATION COMMITTEE
^I'he Mediation Committee has met periodically during
year to consider cases referred to it by the North
Ijblina Medical Society. In view of the number of
patients treated by North Carolina physicians every day.
the number of problems which have been brought to
the attention of this Committee has been small. The
Committee continues to be an effective mechanism for
resolving problems between North Carolina physicians
and their patients. Those problems involving primarily
the matter of fees and third party reimbursements have
been referred to appropriate committees of the Society.
In the remainder of the cases, certain patterns have
been noted. First, the Committee has considered sev-
eral instances in which problems arose in the Emergency
Room setting, particularly with non-resident and tran-
sient patients injured in accidents. It was very important
that in such cases the physicians rendering service in
Emergency Rooms pay particular attention to attitude,
thoroughness, and consideration for the wishes of the
family and the patient, remembering the increased
stress of being injured when away from one's home.
Second were problems which apparently developed
as a result of inadequate or faulty communication be-
tween the doctor and the patient, and between the doc-
tor and the patient's family, especially in the case of
severe and potentially fatal diseases or injuries.
The third problem area which emerged was the mat-
ter of billing procedLires. and in particular, problems
created by requiring that a patient's bill be paid before
an insurance form was completed. The Committee has
succeeded in modifying these procedures in some in-
stances so that they are more satisfactory to the patient.
The Committee format and size appear to be quite
satisfactory in terms of achieving the Committee's prop-
er objectives.
David G. Welton, M.D.. Chairman
John Glasson, M.D., Secretary
COMMITTEE ON THE MEDICAL ASPECTS
OF SPORTS
Two committee meetings were held during 1973.
The first was on July 4 in Wrightsville Beach. North
Carolina. Members present were Wilson. Bassett. Bow-
man. Boyd. Clippinger. DeWalt. Jennette. Reibel, Taft,
Rhodes, Proctor, Mainer, and Sauls (guest). Absent
were Dineen. Hiller, James, Montgomery, Wrenn, and
Harris. The main agenda item was a presentation by
Mr. Al Proctor, Coordinator for the Sports Medicine
Program in the Department of Public Instruction who
presented a report on the activities presently underway
in his program. The major thrust of his section presently
is to develop a system of teacher-athletic trainers to
serve the high schools of the state to help with preven-
tion, treatment, and rehabilitation of sports injuries in
public schools. Ways in which the Committee on the
Medical Aspects of Sports and the Department of
Public Instruction might better coordinate their activities
were discussed. Continued liaison between these groups
is planned for the future. The Committee also consid-
ered legislation passed by the House of Delegates of the
North Carolina Medical Society at its annual meeting
in May, 1973 relative to condition of public school
athletes. It was recommended that the issues raised re-
ceive further consideration by the Advisory Committee
on Sports Medicine in the Department of Public In-
struction before being implemented. The Committee also
approved a recommendation to request the President of
the North Carolina Medical Society to communicate
34
SUPPLEMENT TO N. C. MEDICAL JOURNAL
with each County Medical Society President requesting
that they designate or appoint a committee of physicians
to be responsible for the medical aspects of sports in
the county area. Such a letter was subsequently written
by Dr. Gilbert, the Society President.
The second meeting of the Committee was held Oc-
tober 12, also in Wrightsville Beach. The final draft of
the Athletic Participation Form was approved and it
was recommended that this form be forwarded to Dr.
Gilbert who should direct it to the Chairman of the
State Board of Education requesting that completion
of this form prior to participation in organized athletics
be a requirement in each system as opposed to being
on a voluntary basis. Stich a recommendation was writ-
ten by President Gilbert to Dr. Craig Phillips on De-
cember 10. 1973. As yet the result of this correspon-
dence are imknown.
I believe our State is in the forefront in the planning
and development of programs to prevent and treat in-
jury to public school athletes. 1 appreciate very much
the opportunity to he part of this commitment.
Frank C. Wilson. M.D.. Chairman
COMMITTEE ON MEDICAL EDUCATION
In 1973 the House of Delegates approved a resolu-
tion calling for documented participation in continuing
education as a requirement for continued membership
in the North Carolina Medical Society. This committee
was charged with implementation and administration of
this proposed program.
Considerable discussion has taken place regardmg
compulsory continuing education. To have a strong pro-
gram will require a minimum budget of $40,000 per
year. Ths iestmate is based in large part on budgets ob-
tained from states which already have continuing edu-
cation programs in operation.
Several tentative programs are under consideration.
Hov\e\er it seems clear that further planning on the part
of this committee will be dictated by the e.xtent of the
financial commitment the society is prepared to make.
Richard H. .Ames. M.D.. Chairman
MEDICAL-LEGAL COMMITTEE
Review of work done to date.
A joint meeting of the Medical-Legal Committee of
the North Carolina Medical Society and the Medical-
Legal Committee of the North Carolina Bar Association
was held on April 29. 1973 in Pinehurst. North Caro-
lina. DiscLission covered areas of court appearance on
the part ot physicians, fees for expert medical testi-
mony, suits involving professional liabilit\ and health
care in penal institutions. The Bar group signified their
intention to ask their parent group to consider the
matter of fees.
In regard to m.ilpractice it was pointed out that in-
formed consent is becoming increasingh important.
It was the con-ensus of the joint committee that a
further survey of health care in jails in North Carolina
should be conducted. This has alreads been initiated.
A meeting of the committee was held on Septem-
ber 26. 1973. at Midpines. The matter of certain attor-
neys asking the committee members to review malprac-
tice claims was discussed at length and it was the feel-
ing of the committee that the Medical-Legal Commit
should not provide review assistance in malpractice ca
but should encourage the attorney to obtain professioi
review on his own.
The report of the Presidential Commission on M
practice was noted and it was the consensus that vi
little of a constructive nature could be expected from t
review.
The Chairman attended a meeting of the Amerit
College of Legal Medicine in Cleveland. Ohio, on Si
tember 9. 1973. and a critique of the report of the Pn
dential Commission on Malpractice was given.
Joint meetings were held in approximately 24 coi
ties.
The committee is now in the process of contact
authorities in all the counties of North Carolina in
gard to health care in their jails.
No instance of alleged imethical action on the part
ph\sicians has been reported to this committee.
Julius A. Howell. M.D., Chairn
COMMITTEE ON MEDICARE
The Committee held one meeting on September
1973 with nine out of twelve members present. Gui
of the Committee included representatives from
Medicare Division of the Prudential Insurance Comp;
of America and the Department of Social Servi(
Clarification was sought by the Committee as to
status of payment of physicians for concurrent
rendered the same patient. The representative of
Prudential Insurance Company of America reported t
his company after investigation felt that there v.
some 40 cases per week receiving medically unnecess
concurrent care. This figures out to be less than .'
per cent of claims handled. He further estimated that
half of these cases of medically unnecessary concuna
care are patient induced rather than doctor indued
Since the meeting onh' one phssician complaint l!
been directed to the Medicare Committee. This
handled to the phvsician's satisfaction.
William T. Rabv. M.D.. Chair:
COMMITTEE ON MEDICINE & RELIGION
(Report not received .\pril 10, 1974)
COMMITTEE ON MENTAL HEALTH
The year 1973 has been a very busy one for
Mental Health Committee. We have all been dec
concerned with the problems surrounding the o
mitment procedures and at the time of this writing
proposed acts are being considered by the Legislati
These acts may very well not prove to be per
hut it is the opinion of the chairman that they re|
sent a tremendous amount of work on the part of th
concerned and that they also represent a very consic
able improvement in the commitment procedures
Committee has been deeply concerned by what set
to be the constitutional issue in that we are unabU (I
wa\s to commit patients who perhaps need to be i^o
mitted and who would benefit from commitmeriii
the sense that they could then be forced to tat
medication which would be of great help to them
COMPILATION OF ANNUAL REPORTS
35
liipould reduce their symptomatology considerably. A
iiatient under the new laws cannot be committed if he
'm merely suffering from a mental illness and is not a
ranger to himself or to others. The chronic schizo-
i'll'hrenic who would benefit from medication which we
>1 ow have available could not be committed as we imder-
liiiland the law. This in reality perhaps represents a con-
iict between the rights of an individual as an individual
n.i^d his rights to treatment. As physicians we have
Sieen deeply concerned with his rights as a patient
°'jiut we also recognize that we must live within the Con-
ines of the constitution.
(. The Committee has also been concerned and engaged
I the AMA-Southeast Regional Mental Health Con-
'cjijrence to be held in Atlanta on April 5-6. 1974. The
itle of it is "Public and Private Mental Health Care
I'uo Vadis" chosen at a meeting held in Raleigh
ir.^i September of representatives of seven ( 7 ) southeast-
m state medical societies. Dr. E. William Busse, Duke
ittiBy'niversity Medical Center where he is Chairman of the
lepartment of Psychriatry will be one of the main
leakers. An effort is being made to encourage residents
\ North Carolina to attend this meeting.
There has also been an effort established to bring
-J )Out a closer cooperation between the Medical So-
ety's Mental Health Committee and the North Caro-
Jia Neuropsychiatric Association which is also the
orth Carolina District Branch of the American Psy-
I, iiatric Association. Tentative plans were made for
e chairman of the North Carolina Medical Society
ental Health Committee to meet with the E.\ecutive
,j, ijuncil of the Psychiatric Association and it is also
{,»ped that we can arrange for the President and the
j-esident-EIect of the Psychiatric Society to serve on
,e Mental Health Committee.
,11 )It has been a busy and we hope a productive year.
jini Philip G. Nelson, M.D., Chairman
4. ii
il 1
SUBCOMMITTEE ON ALCOHOLISM
[The Subcommittee on Alcoholism met at the North
lai^Tirolina Medical Society Headquarters Building on De-
mber 16, 1973. The disadvantages of the existing
mmitment laws were noted, and it was considered
lOvkit especially in the case of alcohol related problems,
s unfortunate that family members are unable to initi-
: the commitment procedure so that in effect both
! alcoholic and those persons close to him are denied
less to treatment programs. It has been the experience
rally as well as elsewhere that enforced treatment
the alcoholic may in fact often have a very favor-
k 5e outcome and patients often express their gratitude
le ipa later date that those around them were concerned
iiJugh to take the necessary steps on his behalf. There
jslJlp seems to be a general lack of awareness on the
pa let of those responsible for this type of legislation
t commitment to an out-patient treatment facility can
t Ii to equally favorable results as those obtained in
irin-patient setting.
Ooncern was expressed about the lack of adequate
itsildical involvement in planned detoxification programs
i h alcoholics, where emphasis is being placed on a so-
tiei >:ed social model. It is clear that when dealing with
■0 )[ problems of alcoholism, social, vocational, physical,
emotional factors must be taken into account in
Ii rehabilitation process, and to ignore the medical
hen
aspects of alcoholism is again to deny patients adequate
treatment. The Committee passed a resolution that ade-
quate medical back-up should be available in any detoxi-
cation program for alcoholics.
D. E. Macdonald. M.D., Chairman
SUBCOMMITTEE ON MENTAL RETARDATION
& CHILDREN SERVICES
(Report not received .\pril 10, 1974)
COMMITTEE ON MEMORIAL SERVICES
The memorial services for decreased physicians will
be combined with a Prayer Breakfast, Monday morn-
ing. May 20, 1974. in the Crystal Room, Pinehurst
Hotel. Pinehurst.
W. Otis Duck, M.D.. Chairman
COMMITTEE ON NOMINATIONS
Report of the Committee on Nominations will be
given in the HOUSE OF DELEGATES, opening ses-
sion, Sunday, May 19, 1974, Cardinal Ballroom, Pine-
hurst Hotel, Pinehurst.
J. Elliott Dixon, M.D.. Chairman
ADVISORS TO NORTH CAROLINA ASSOCIATION
OF MEDICAL ASSISTANTS
This has been an unusual year inasmuch as three
persons have served as President.
This Association's House of Delegates voted in No-
vember 1972 to institute the annual year that most
states found best to their organization, namely April
to April, The annual National meeting is in October
each year and this means changes and information dis-
seminated from AAMA can be passed on to states at
the April meeting rather than a state meeting in No-
vember. This meant that the President who was elected
in November 1972 was to serve 18 months and her
successor's term would begin April 1974. Mrs. Ottilie
Kirb>' served from November 1972 to July 1973, when
she left the medical profession and the Presidency was
assumed by Mrs. Barbara Godwin of Fayetteville. On
January 7, 1974, Mrs. Godwin resigned by mail due to
family reasons and Mrs. Ruby Guigou of Morganton
was elevated to the presidency.
Mrs. Guigou had the winter Board meeting in Win-
ston-Salem in January.
Total county chapters in the State now is 18. an in-
crease of 7 in 18 months. Contacts at the North Caro-
lina Medical Society annual meeting in Pinehurst in
May 1973 netted several new chapters.
The annual state educational workshop was held in
the North Carolina Medical Society building in Raleigh
on Saturday, September 15, 1973. One half day was
spent with Professional Management representatives and
one half day was spent with a Credit & Collections
firm — one of the best workshops in recent years.
Ten of the State members attended the 17th Annual
meeting of the American Association of Medical As-
sistants held in Washington. D. C. October 21-27. 1973.
This was the first international convention with medical
assistants from London, Scotland, Ireland and Canada.
The Annual State Convention will be held at the Hil-
ton Inn, Winston-Salem, North Carolina, April 26-28,
i6
SUPPLEMENT TO N. C. MEDICAL JOURNAL
1974. The theme of the Convention is: ITS WHO'S
OUT FRONT THAT COUNTS!
The membership committee is actively engaged in
entering counties where no organization exists and any
help from the Medical Society members would certainly
be appreciated b> this organization.
Advisors:
Emmett S. Lupton. M.D., Greensboro
William H. Shaia, M.D.. Charlotte
COMMITTEE TO \\ ORK WITH THE
NORTH CAROLIN.A INDUSTRIAL COMMISSION
The Committee has had an active \ear. New members
to the Committee this year are Doctors Leonard Gold-
ner of Durham and Robert Miller of Charlotte. Doctor
John W. Morris. Mediciil Director as well as the entire
staff of the North Carolina Industrial Commission have
been most helpful m cooperating with our Committee
members. Doctor Morris and Mr. Forrest H. Shuford II
of the Commission staff attended the Spring Meeting
of the Committee at Pinehurst.
The new fee guide was received b\ most of our mem-
bers in the late spring and most comments in regards to
this schedule have been favorable. The Committee has
informed the Commission that it will work with them
so that a new fee guide will be published on an every
two year basis. The members of our Society are again
urged to document any charge in excess of the maximal
allowable charge provided b\' the fee schedtile. b\' a de-
tailed description of the extraordinary service rendered
so that the Commission and your Committee will he able
to more fairh ascertain a reasonable fee.
Ernest B. Spangler. M.D.. Chairman
COMMITTEE ADVISORY TO N. C. DEPT. OF
MOTOR ^EHKI ES
(Rtport not rictived April 10, 1974)
COMMITTEE LIAISON TO NORTH CAROLINA
PHARMACEUTICAL ASSOCIATION
During the year I have attended several joint meet-
ings with members of the Medical Society and with
members of the Pharmaceutical Association in regard
to prescription refills and drug labeling bills. The first
meeting was held on 1 iiesday. September 11. 1973
in Southern Pines with Dr. David Bruton and repre-
sentative members of the Pharmaceutical Association
concerning the drug labeling bill, which was House Bill
No. 156. ^
On .September 27. 1973 the Committee Liaison to the
North Carolina Pharmaceutical Association held its
meeting at the regular Committee Conclave. Highlights
of this meeting were:
I. Mr. Clarence B. Ridout of the North Carolina
Department of Social Services reviewed all the
doctors dispensing under Medicaid. The follow-
ing physicians were approved for dispensing
drugs under Medicaid: Physicians in: Moyock,
Hatteras. Gatesville. Sunbury. Englehard. Jack-
son and Richlands.
II. Mr. Frank Yarborough. Paid Prescriptions. Inc..
gave a Report to the Committee, stating that Paid
III.
Prescriptions was employed by the Departme
of Social Services to administer the Medic;
program for prescriptions in North Carolii
Under this program, drug utilization is co;
puted for Medicaid patients and then submittl
to four district Peer Review Committees of ph\"
cians and pharmacists. The Committee revies
exceptions identified by parameters developed i
these committees. These committees have nt
twice to date and reviewed 896 questional}
drug prescription practices. After the review s
completed, the Committee will send out a let r
to the pharmacists or physician dealing with c>;
of three general areas. They are: uneconomi>l
continuous refills; apparent over utilization; al
patient using multiple providers of drugs. 1 ;
Committee Liaison to the North Carolin,
Pharmaceutical Association has reviewed the -
port of Paid Prescriptions and feels it is a wor -
while service. The Committee has requested tit
Mr. Yarborough prepare a report on n
operations of Paid Prescriptions and make i s
available to the North Carolina Medical Joiirn.
Mr. Yarborough also pointed out that there Is
been a savings in the 585 prescriptions review f
$91,495.46 over a year's period.
The Committee discussed a variety of prohlc s
associated with prescribing practices in No i
Carolina. A problem that has caused some o -
cern in recent months is the practice of le
pharmacists calling a phvsician's office to .i
permission to give a refill to a patient and havig
the nurse or secretary give him the okay, le
pharmacist is put in the position of not knowig
positively if the physician has. in fact, given s
permission to refill that drug. Also a short i -
cussion concerning the problems of nurse prai-
tioners dispensing drugs in rural clinics was »-
cussed. It was the concensus of the Commii e
that a subcommittee should be appointed y
the Chairman with representatives from e
North Carolina Pharmaceutical Association .id
the Medical Society to prepare an update of e
N. C. Physician-Pharmacist Code of Unil-
standing.
IV.
There was also a discussion of House Bill 1
which concerns the labeling of prescriptio
The bill requires that a prescription be labe
unless otherwise specified by the physici
The Pharmacy Association has found some c
ficulty in supporting the bill because they f
that it will increase drug abuse. The meml
of the Committee felt very strongly that Ho
Bill 156 should be supported and that it \
a good bill. Mr. John Anderson pointed out 1
the bill could be amended so that the pen;:
for violation of the Act would be determir
by the N. C. Board of Pharmacy.
On October 25, 1973. Dr. George Gilbert. Presid.
of the North Carolina Medical Society. Dr. H. D;i
Bruton and I met with the North Carolina Phari
ceutical Association with regards to prescription
fills. This meeting was held at the Institute of Pharmi
in Chapel Hill. As a result of this meeting, it was
cided that the Pharmaceutical Association submit
COMPILATION OF ANNUAL REPORTS
37
'"'sac'h physician in North Carolina information form as
'••'to prescription instructions.
'■li I have also received as chairman of this committee
'I'll great deal of correspondence and information pertain-
■■ng to drug problems in North Carolina.
(' Charles W. Bvrd. M.D.. Chairman
m
COMMITTEE ON OCCUPATIONAL AND
ENVIRONMENTAL HEALTH
The Committee met on September 28, 197.S at
([iouthern Pines. N. C. At that time. Dr. Harold Imhus
jjij.ock over as chairman of the committee succeeding Dr.
iJohn Brockman who had served for many years as
[ihairman. A vote of thanks was given to Dr. Brock-
jflan for his long and very fine service.
Mr. John Lumsden of the Division of Health Ser-
jryices. Occupational Health Branch, State of N. C. spoke
l|iD the committee about the current status problem and
ji.eeds in occupational health in the State of N. C.
.Lie outlined the role of his division in conducting occu-
jiational health surveys in plants at the request of the
)ccupation:iI Safety and Health Act function of the
(itate Department of Labor. He also outlined that his
ivision provides many services to industry in occupa-
lonal health.
[ The Committee discussed its future role in occupa-
lonal and environmental health in the State of N. C.
'(he group recommended the following three major
unctions for the Committee;
;l I. That we endorse strongly and support the develop-
I ■ ment of speakers and assistance to the local
County Medical Society toward educational infor-
mation on occupational health.
,1^2. Support similar programs on occupational health
at the annual meeting at the State Medical Society
when it can be accomplished.
3. The Committee urges the State Medical Society
to endorse occupational health information to be
u disseminated in the curricukmi of the medical
,j ; schools in the State of N. C.
o' ^.Accordingly, a subcommittee to develop the occu-
t* 'jltional health speakers bureau was appointed. ]t con-
8ted of Dr. Mario Battigelli as Chairman, Dr. James N.
adson. Dr. Emil Beyer, and Dr. John Brockman.
i|r. Bernard Greenberg from the UNC School of Public
,ealth indicated a willingness to assist in the develop-
,;3nt of educational programs for physicians.
\\A subcommittee on environmental health was ap-
rinted consisting of Dr. Carl Shy and Dr. Emil Beyer.
j'Prior to and subsequent to the meeting the Chair-
H;jj;in contacted the program committee asking for con-
j(i:eration of time to present several occupational health
,j|.jji)jects at the annual meeting in May. This was denied,
^(jlf'it has been several times in previous years. This has
Ljiil'a a great concern in that there does appear to be
ilack of official interest in providing information to
' ysicians in occupational health. This is of even more
' ' icern in view of the fact that physicians are increas-
ly being called upon to service occupational health
:ds in communities for employers and employees.
thout adequate participation and interest on the part
physicians, the vital decisions so critical to the health
■ds of a large percentage of our population are being
de outside of the medical profession.
We hope to have the speakers and environmental
subcommitee active and ready to report to the Fall
meeting of the Committee.
Harold R. Imbus, M.D., Chairman
COMMITTEE ON PEER REVIEW
The activities of the Committee on Peer Review have
been covered in the minutes of the Council meeting
in September. The full Peer Review Committee met
at the Committee Conclave in September at which time
joint meeting with the Committee on Social Services
and consultants from the Social Services Department
of North Carolina was held regarding two particular
problems.
The principal other activities have been for the most
part directed to the North Carolina Medical Peer Re-
view Foundation and no further meetings of the com-
mittee have been held.
M. Frank Sohmer. M.D., Chairman
COMMITTEE ON PERSONNEL &
HEADQUARTERS OPERATION
Parking lot repairs have been accomplished. Mileage
reimbursement has been increased from 10 cents to 15
cents per mile. Hospitalization insurance for the NCMS
headquarters staff has been increased from half to full
single unit coverage. Authorization has been obtained
for the addition of a file clerk. The Medical Peer Re-
view Foundation has leased space on the top floor of
our building. Mr. Dan Mainer has been offered the job
of executive director of that organization. Maximum
accumulation of sick leave for employees has been ex-
tended from 30 to 90 days. Vacation for employees
has been somewhat liberalized.
A. Hewitt Rose, Jr., M.D., Chairman
COMMITTEE ON PHYSICAL & VOCATIONAL
REHABILITATION
(Report not rt'ccived April 10, 1974)
COMMITTEE OF PHYSICIANS ON NURSING
The committee of Physicians on Nursing met at the
Holiday Inn. Burlington. N. C. on March 1. 1973.
The committee reviewed proposed rules and regulations
that would be u.sed as guidelines by the Board of
Medical Examiners to approve nurses in the expanded
role. The following motion was passed: ANY RULES
AND REGULATIONS ADOPTED BY THE BOARD
OF MEDICAL EXAMINERS FOR THE PURPOSE
OF REGULATING THE EXPANDED ROLE OF
THE NURSE SHOULD INCORPORATE WORDING
SIMILAR TO THE RULES AND REGULATIONS
PERTAINING TO PHYSICIANS ASSISTANTS.
A request by the North Carolina Nurse Anesthetist
Association that the North Carolina Medical Society
support a bill slating qualifications for a nurse to ad-
minister anesthetics was deferred due to lack of informa-
tion.
Followina much discussion the following motion was
made: PHYSICIAN'S ASSLSTANTS LICENSED BY
THE BOARD OF MEDICAL EXAMINERS UNDER
38
SUPPLEMENT TO N. C. MEDICAL JOURNAL
EXEMPTION 13 WOULD BE EXTENDED AN IN-
VITATION TO ATTEND THE MEDICAL SO-
CIETY'S ANNUAL MEETING AND BE GIVEN A
SPECIAL COLOR GUEST BADGE. No further action
regarding associate membership in the Societ\ will be
taken pending development of paramedical associations.
Mrs. Mary Piner of Onslow County was selected
Nurse of the Year and was appropriately honored at
the annual meeting of the Society at Pinehurst in May.
The committee met at Pinehurst. N. C. on Septem-
ber 29. 1973. The implementation of the legislation
calling for an expanded role of the nurse by the Board
of Medical E.xaminers and the Board of Nursing was
discussed The followinu motion was passed: IT IS THE
SENSE OE THIS CONIMHTHE THAT EACH EX-
TENDER OE HEALTH CARE OF EACH APPLI-
CANT UNDER EXEMPTION 14 BE CONSIDERED
INDIVIDUALLY AND BE RE-REGISTERED PERI-
ODICALLY.
The ongoing activities of the Joint Practice Commit-
tee of Medicine and Nursing were discussed. The fol-
lowini; recommendation was made: THE COMMIT-
TEE RECOGNIZES THAT ANY CARE RENDERED
BY PROVIDERS OF ALLIED HEALTH SERVICES
BE RENDERED UNDER THE DIRECT AND RE-
SPONSIBLE SUPERVISION OF THE PHYSICIAN,
AND THAT ANY OTHER SYSTEM PROPOSED IS
CONSIDERED TO BE EXPERIMENTAL AND SUB-
JECT TO REVIEW AND EVALUATION.
Upon further disctission and consideration the fol-
Iowuil; resolution was passed: THE COMMITTEE HAS
CONSIDERED THE CONCEPT OF INDEPEN-
DENT FEE-FOR-SERVICE FOR CARE REN-
DERED BY PHYSICIANS ASSISTANTS. NURSE
NURSE PRACTITIONERS AND ASSISTNATS.
SIMILAR INDIVIDUALS AND REJECTS THIS
CONCEPT AS INVALIDATING PHYSICIAN RE-
SPONSIBILITY FOR MEDICAL CARE.
Consideration was given to changing the name of the
Committee of Phvsicians on Nursing. COMMITTEE
ON ALLIED HEALTH PROFESSIONALS was ac-
cepted, and was to be recommended to The Council.
Guidelines for the Committee were then approved.
Upon motion duly made and passed, the Nurse of
the Year Award was discontmued for the coming year.
A new educational T.V. film "Train Your Own As-
sistant" was reviewed. The committee recommended its
distribution to interested parties.
W. Benson McCutcheon. Jr.. M.D.. Chairman
CONSULTANT ON PODIATRY
As the Medical .Society Consultant on Podiatry. I
have not been approached by any problems relative
to this subject nor have I been aware of any new busi-
ness being brought to my attention on this matter during
the past year of 1973.
Donald B. ReibeL M.D.. Consultant on Podiatry
COMMITTEE ON PROFESSIONAL INSURANCE
The Professional Insurance Committee of the North
Carolina Medical Societs meets quarterly to consider
inquiries concerning all types of professional insurance
for phxsicians. The majority of the committee's time
is spent in reviewing malpractice claims. The committee
enjo\s an excellent working relationship with the Soci
approved professional liability insurance carrier — a n
jor factor in the North Carolina Medical Society me
bers experiencing the second lowest malpractice
surance rate in the countrv.
John C. BurweU. M.D., Chairm
COMMITTEE ON GENERAL
SESSIONS PROGRAM
The General Sessions Committee proposed a
organization of the General Sessions Program based n
the following considerations.
1. Professional excellence through continuing edu.-
tion is a priority concern of organized medic e
at all levels. It was the concensus of this comn:-
tee that the North Carolina Medical Society shoid
upgrade its scientific program and thereby py
some part in the continuing education of prim.y
care physicians in this state.
1. Our three excellent medical schools should beco e
more active in North Carolina Medical Soci^y
affairs and should particularly share the societ's
re>ponsibility for continuing education.
3. An upgraded scientific program would imprie
attendance to the state meeting and hopefiy
thereby stimulate general interest of members n
the affairs of our medical society.
The reorganized format of the General Sessions \Q
therefore be planned as follows:
Monday — 9 a.m. -12:30 p.m. — Scientific Surgiil
Program presented by the University of Chapel 1 11
Medical School.
Tuesday — 9 a.m.- 1 2: 30 p.m. — Scientific Mediil
Program presented by Bowman Gray Medical School
VVednesday — 9 a.m.- 12 p.m.— Socio Economic P-
gram. Conjoint session with Department of Piii c
Health. Address by Dr. Russell Roth, President Am>.-
can Medical Association. Address by Incoming Pru-
dent of the North Carolina Medical Society. Infon J
talk by Dr. Edward R. .Annis.
A special seminar entitled. "Sex after Supper" > 1
be presented at 9:30. Monday evening sponsored b\ e
Committee on Marriage Counselling and Family 1 e
Education.
Kenneth E. Coscrove. M.D.. Chairnn
COMMITTEE ON PUBLIC RELATIONS
The Committee on Public Relations met at the \
Pines Club in Southern Pines on September 27. 19'
and planned the vear's activities as listed below.
1. Continue the PUBLIC RELATIONS BULU
TIN with periodic review of its format, cont'd
and presentation to maintain relevance and rea.-
bilit\'.
2. Continued the exhibit at the 1973 N. C. Si e
Fair.
3. Continued the High School Science Fair pro t
for the winner to receive a S50 award at the 1''3
Fair and a certificate at a meeting of the U 1
county medical societx'.
4. Performed periodic review evaluation of the "t
FORMATION PACKET FOR PHYSICIA "
for distribution to new members.
5. Continued the project to give an award to
COMPILATION OF ANNUAL REPORTS
39
laii I
Buii ;
cot 1
diss
winner of the N. C. Rescue Squad First Aid
competition, presented by a member of the Com-
mittee.
6. Conducted an AMA Leadership Seminar under
the direction of Marshal Redding, M.D., for de-
velopment of current and future leaders of the
Society.
7. Provided foUowup on the recommendations of
the Conference on Access to Health Care. All
agencies involved in the recommendations were
contacted with appropriate secondary foUowup to
manifest our intent and concern. To enhance
physician productivity a TV tape on "Train Your
Own Assistant" was prepared by the committee
with supportive questionnaires.
8. Conducted a Conference for Medical Leadership
on February 1-2, 1974, on the topic of "Practic-
ing Physician Pressure Points." The first of such
meetings held at the Headquarters Office Building
wtih 115 physicians in attendance. Chiefs of
Medical Staffs of Hospitals, youthful physicians
with leadership potential, plus Auxiliary, commit-
tee chairmen and county medical society officers
were invited. The Conference was well received in
Raleigh according to the evaluation reports com-
pleted by those in attendance.
9. Continued the previous policy of distributing
Today's Health magazine to the Governor" Su-
preme and Superior Court Judges and members of
the N. C. General Assembly while considering the
feasibility of changing to American Medical
News at a later date. A decision will be made at
the Committee's next meeting.
10. Sponsored planning for an AMA Practice Man-
agement Workshop for physicians soon to go into
practice scheduled to be held in February but
c ancelled because of transportation problems as-
sociated with the energy crisis.
11. Began preparation of a brochure in "How to Be
a Good Doctors Good Patient" with Dr. Eliza-
beth Kanof editor.
12. Prepared for distribution Joint Statement of
Policy on Donation of Human Tissue for Trans-
plantation approved by the North Carolina Medi-
cal Society and the N. C. Hospital Association.
13. Planned on followup meeting of the Public Re-
lations Committee in March or April to undertake
with the assistance of an AMA Consultant on
indepth evaluation of the existing external public
relations program of the North Carolina Medical
Society and to prepare recommendations as to how
the North Carolina Medical Society can communi-
cate more effectively with the public.
Appreciation is expressed to the members of th Com-
:{tee. President George Gilbert, Mr. William Hilliard.
^: Dan Mainer, Mrs. LaRue King, Mr. Gene Sauls,
,. Steve Morrisette, and Mrs. Jackie Cutrell and
^'■er members of the Headquarters Staff for the help
jsn in the performance of the activity of the Public
lations Committee. The Chairman is indebted to those
; folks for the program of this Committee.
I, John L. McCain, M.D., Chairman
COMMITTEE ON RADIATION
All physicians, whether they are radiologists,
urologists, orthopaedists or general or family practi-
tioners must keep permanent records of total body ir-
ration that wc or our employees receive. These records
must be passed on to other employers and in turn we
shall receive total body irration records from previous
employees. These rules are set down by federal law.
W. C. Sternberg. M.D., Chairman
NORTH CAROLINA REGIONAL MEDICAL
PROGRAM
The year 1973 has indeed been an eventful one for
the North Carolina Regional Medical Program. Al-
though President Nixon requested no funds for the
Regional Medical Program for the period July 1, 1973
through June 30, 1974, we decided to prepare an appli-
cation for future activities in hopes that the legislation
would be extended. Diiring the first three months of
1973, in spite of the fact that our Program had been
directed to phase out by July 1, 1973. as were all other
Regional Medical Programs, projects were solicited, ob-
tained and carefully reviewed by the Regional Advisory
Group. In March 1973 an application was approved
for submission to RMP offices, and this was done. Be-
cause of the uncertainty of the future of the Program,
many of our key staff personnel resigned and accepted
positions elsewhere. However, a dedicated group re-
mained, and we pursued our activities in spite of the
gloomy outlook. In June 1973, several weeks prior to the
termination of the RMP legislation. Congress approved,
and President Nixon signed, a bill extending the RMP
legislation for one year. Funding was to be on the
basis of a continuing resolution, i.e., to continue at the
same level as the previous year.
Although our Program application for 1973-74 was
approved, the first three months of the fiscal year (be-
ginning July 1, 1973) were difficult ones because no
funds for activities were released. We were able to sup-
port our Program Staff on the basis of carry-over funds
from the previous year due to the termination of some
projects on July 1, 1973. Finally, in the latter part of
September we were notified of our funding level for
the period for the first six months of the fiscal year.
This level was roughly one-half of what we were sup-
posed to receive. In spite of these difficulties we were
able to implement the projects that had been submitted
in our application of Februar\' 1973, emphasis being
placed on hypertension, emergency medical services,
kidney disease, quality of care and health manpower.
In November 1973 we submitted another application
for the period January 1, 1974 through July 1, 1974.
This was approved at the funding level granted us. In
December 1973 President Nixon signed the Fyi974
HHW Appropriations Bill that had been passed by Con-
gress. This meant that $36 million more was due to
the Regional Medical Programs for this year, but as of
January 1 these funds had not been released. Like-
wise, funds in the amount of ,$89 million plus that
had been impounded from FY 1 973 RMP funds, al-
though ordered released b>' President Nixon, still remain
impounded.
In summary, this past year has been a difficult one
because of the uncertainty concerning legislature and
40
SUPPLEMENT TO N. C. MEDICAL JOURNAL
funding ;it the National level. During this period of time
the North Carolina Medical Society has supported us
at all times. Our Regional Advisory Group has guided
us widely. Dr. E. Harvey Estes is Chairman of this
Regional Advisory Group, and there are six representa-
tives-at-large from the Medical Society of the State of
North Carolina that were appointed by Dr. John Glas-
son. These individuals are Dr. Edgar T. Bcddingfield.
Jr.. Dr. Joseph G. Gordon. Dr. John A. Brabson. Dr.
John R. Chambliss. Dr. George W. Paschal. Jr.. and Dr.
Louis deS. Shaffner. There are 1 1 other physicians on
our Regional Advisory Group which has a total mem-
bership of 49. The loyalty and dedication of these phy-
sicians as well as their fellow members on the Regional
Advisors' Group has been a great factor in the con-
tinued operation and success of the NCRMP.
In addition, through the efforts of Dr. Ron Davis,
the NCRMP has supplied information monthly to the
North Carolina Medical Society via the Nonh Caroliiui
Medical Journal a summary of continuing education
activities in North Carolina and neighboring states.
This information is entitled "What? When? Where?
In Continuing Education." Furthermore. Dr. Davis has
worked closely with the staff of the Medical Society
at its office in Raleigh.
The future of our Program is undoubtedK question-
able since the legislation expires on July 1. 1974. The
likelihood is that the Program will be extended at
least until July 1. 1975. A far-reaching bill (HR 12053)
was introduced into Congress in Januarx 1974 trans-
ferring the functions of Regional Medical Programs.
Comprehensive Health Planning and Hill-Burton to new
entities called Health Service Agencies. This proposal
will warrant heated debate, and I doubt if the transition
will occur before January 1. 1975 even if the bill is
passed bv Congress and signed b\ the President.
F. M. Simmons Patterson. M.D.. Executive Director
COMMITTEE ON REI ATI> E VALUE STUDY
(Rt'port not received .\pril 10. 1974)
COMMITTEE ON RETIREMENT SAVINGS PLAN
The Committee on the Retirement Savings Plan is
pleased to present its report for the year 1973. During
the >'ear the Committee met at the conclave in Mid
Pines and all members were present with the exception
of one. At that time the Committee heard a report on
the operation of the NORTH CAROLINA MEDICAL
RETIREMENT SAVINGS PLAN from two trust of-
ficers from Wachovia Bank & Trust Compan\. the
Trustee. Other routine business was transacted.
As is apparent to all investors the stock market
equities dropped sharply in 1973 and most retirement
plans were affected adverseU' in some way. On the other
hand the decrease in stock prices provided the oppor-
tunity for suitable acquisitions which were made during
the \ear. Although the market value of the stock port-
folio dropped considerably during the year we are
pleased to report that the assets of the Plan continued
above two million dollars at the end of 1973 and in-
come on the diversified portfolio was over $75. 000. 00.
At the present time onh a few physicians are taking
down benefits from the Plan. Apparently because of the
good performance in 1972 we have enrolled a numl r
of participants who have switched to the NORII
CAROLINA MEDICAL RETIREMENT SAVIN(3
PLAN from other Keogh plans.
The Committee wishes to advise the membersfi
again about the insured savings portion of the Pli
which provides a method of saving for retiremit
which would not fluctuate with the stock market.
Jesse Caldwell, M.D., Chairmi
COMMITTEE ON SCIENTIFIC AWARDS
Following the annual meeting of the North Caroli
Medical Society in May 1973. the scientific papers
lected by the various specialty organizations were
cured and distributed to the members of the Commit
on Scientific Awards. On September 28. 1973, I
Scientific Awards Committee met at Mid Pines a
made the following selections for awards:
"An Experience with a Skin Cancer Detect
Clinic at A State Fair" by Dr. Elizabeth Kanof
the Wake County Award
"The Role of Gastroesophageal Reflux in Nocti
nal Asthma in Children" by Dr. Susan Dees, for t
Moore Cotmty Award
The Conmiittee reaffirmed its previous approval
principle of the Durham-Orange County Annual Scit
tific Award for the outstanding clinical paper si
mitted yearly by a medical student or house offic
David S. Citron. M.D.. Chairm
:
I
COMMITTEE ON SCIENTIFIC EXHIBITS
The members of the Committee on Scientific Exhib
were well pleased with the group of exhibits which wt
assembled for the 1973 Annual Session. Our trial
fort at a competitive exhibit, in order to stimulate
tendance, was moderateh' effective.
A news letter of appreciation was circulated to b
scientific and technical exhibitors shortly after the A
nual Meeting.
Invitations have been issued to scientific exhibiK
for the 1974 Annual Session. We hope to have a w
rounded group of exhibits and are striving to att;
greater attendance.
Josephine E. Newell, M.D., Chairm
COMMITTEE ON SOCIAL SERVICE PROGRAM
The Committee on Social Service Programs dun
the past \ear has been concerned primarily with Med
aid. The-e claims have been handled entirely by
Department of Social Services this past year and
change in the handling of these claims on the wh
has gone smoothly. There have been some instances,
over-utilization which are in the process of review. T
committee held onh' one meeting, this being at 1
Committee Conclave at Mid Pines in September. 19
In the interim liaison has been maintained by the co
mittee chairman with Mr. Sellers of the Departnii
of Social Services and Dr. Watson of the profession
staff of this department.
J. S. Mitchencr. Jr.. M.D.. ChairiT
COMPILATION OF ANNUAL REPORTS
41
r
COMMITTEE ADVISORY TO MEDICAL
STUDENTS
h At the annual mee;ing of the N. C. Medical Society
i[ay 19-23, 1973, a change in the Constitution was
Tassed by the House of Delegates — to wit: "any student
fiho is regularly enrolled as a candidate for the degree
T| Doctor of Medicine in a school in the state of North
harolina shall be eligible for Student Membership."
'Phis eliminates the previous requirement of SAMA
embership as a prerequisite. Final action on this
I lange will be in 1 974.
I: During the 1973 meeting at Pinehurst, an informal
ijj|incheon was arranged for students and practicing phy-
ijcians. This was an unqualified success! Students at-
, Lnded many specialty sections as well as the general
jAiSsions and actively participated. Delegates from Duke.
jowman Gray, and UNC participated in the dclibera-
:j|;i)ns of the House of Delegates.
[There continues to be increasing interest in the N. C.
ledical Society by students. The student members are
Lxious to serve on committees and to contribute to
e advancement of the Society.
i Oscar L. Sapp, III, M.D., Chairman
dti
'AD HOC COMMITTEE ON CONSTITUTION &
BYLAWS REVISION
iNothing to report at this time
Louise deS. Shaffner. M.D,, Chairman
AD HOC COMMITTEE TO STUDY AND
^ RECOMMEND A SALARY OR INCREASE IN
ALLOWANCES FOR THE PRESIDENT
"liThe full committee met at Mid Pines on September
, 1973 for the consideration of its charge.
jlThis committee was appointed by President John
asson at the direction of the House of Delegates of
)ifll North Carolina Medical Society at the annual meet-
t;in Pinehurst in May, 1973.
This was the result of action taken relative to Resolu-
iSlii No. 3 introduced by the Pitt County Medical So-
ai ')ty which provided "that the President of the North
tolina Medical Society will be paid a salary of $25,-
) per year" and that the President will continue to
Bpaid all reasonable expenses incurred in performing
Irth Carolina Medical Society duties,
following consideration and discussion before Ref-
Hjfcace Committee II. the House of Delegates received
m them a substitute resolution in which it was re-
I'ed "that a method be made to increase the allow-
es for the President of the Society" and "that this
cter be referred to an ad hoc committee appointed
[he President for further study and recommendation."
,111 developing our recommendations we prepared and
'. a questionnaire to each of our fellow State Medical
ieties to determine what is being done in other states.
iDformation received covered:
. the number of full-time and part-time employees
. size of annual budget
. does the President receive a s;dary, and if so, how
much?
I does the President receive pay for outside secre-
1/
if
t \
;i
It
0
%
111!
\&
V
tarial and/or office expenses, either on a fixed or
reimbursable basis
5. does the President receive travel expenses and if
so is he paid on a fixed annual or monthly al-
lowance or on an actual reimbursement basis?
Of the 44 responses we learned that we were among
the 12 responding states with a budget in excess of
$500,000. Only eight per cent of the states pay their
President compensation, ranging from $1,000 to $10,-
000. Ten of the states provided states fimds for secre-
tarial help and nine states pay for secretarial help on a
reimbursable basis. Only four states do not pay for travel
expenses. The Charter of the North Carolina Medical
Society does not prohibit it from paying the President
for services rendered. Such payment does require that
he come under the same provisions of any other of its
employees.
The recipient of funds would be required to treat such
monies as income. Here in North Carolina we feel that
with our coverage for travel and costs incurred plus the
provision for secretarial help that we actually exceed
the $10,000 salary provided by some states.
We find complete agreement within the committee
that the President should receive a generous allowance
for expenses incurred, but that a definite salary should
not be provided.
Based on these and other considerations, we submit
the following statement for the information of the Coun-
cil. This same statement will be forwarded to the Speaker
of the House of Delegates for con.sideration by them at
the next annual meeting:
We recommend that the Society continue to pay re-
imbursable expenses attendant to the President includ-
ing necessary travel, housing, food, communications,
and out-of-pocket secretarial expenses; and that in
addition, the Society pay a per diem at the rate of
$25 per day for days or parts of days spent by the
President outside of the home town on Society busi-
ness.
We further recommend in alleviating the burden of
assuming the Presidency that the President-elect and
the immediate past President be reimbursed for their
travel and living expenses when by virtue of their
office they are involved in official Medical Society
functions.
We estimate that the cost incidental to the implemen-
tation of the first recommendation will be about $2,500
and of the second, about $1,500.
Edgar T. Beddingfield, Jr., M.D.
LouisdeS. Shaffner, M.D.
T. Tilghman Herring, M.D.
George W. Paschal, Jr., M.D., Chairman
NORTH CAROLINA BOARD OF MEDICAL
EXAMINERS
STATISTICS
November 1. 1972-October 31, 1973
Total number of applicants granted license 722
By endorsement of credentials 486
By written examination 236
Examination failures 60
42
SUPPLEMENT TO N. C. MEDICAL JOURNAL
LiniLed licenses 92
Hospital residents 5
C ountv or counties 87
Re idenfs training license 296
Applicants rejected license by endorsement of
credentials 3
Did not meet requirements of the Board
Applicants declined permission to take written
examination 0
Hearings 31
Drug addiction -'■
Mishandling of drugs 19
Petitioning for reinstatement of narcotic
registration - 3
Over-utilization of Medicaid billings 1
Routine follow-up 6
Licence to practice medicine revoked 0
Surrender narcotic tax stamp 0
Declined reinstatement narcotic tax stamp 2
License to practice medicine reinstated 0
Investication b\ SBI 2
COMMISSION FOR MEDICAL FACILITY
SERVICES AND LICENSURE
Report on Activities for the Calendar Year Ending
December 31. 1973
Medical Facility Planning and Construction
During 1973. 28 medical facility projects receiving
State and Federal aid were underway. Total cost for
these projects is $139 million; they will provide 1.800
additional beds. The 28 projects involved \5 hospitals.
3 nursing homes. 2 mental health centers. 2 facilities
for the mentally retarded, and 1 rehabilitation facility.
In addition to these, the Construction Section has been
readying during the year 4 other health facility projects,
estimated to cost more than S18 million that can be
initiated when and if Federal appropriations are re-
leased. This represents a decline in activity from the
previous vear when the staff was readying 7 construc-
tion projects estimated to cost S36 million. This de-
crease is due to the Federal cutback in grant fimds to
health care facilities.
Norih Carolina ranks second among all the states in
the niimher of health facility projects constructed tinder
tlte Hill-Burton Act.
Scholarships for Medical and Related Health Studies
Recipients of the Division's educational loans agree
upon completion of their training to repay their loans
by one calendar \ear of service for each year they re-
ceived funds. In 1473. 402 applicants were approved.
The vear"s new participants bring the current in-school
total to 677. An additional 171 recipients are in a de-
ferred status (postgraduate training, military service or
sick leave) providing a potential manpower contribution
of 848. Of the 848. 286 are in nursing, and 242 aren
medicine. During 1973. 108 recipients entered practie
arrangements consistent with the needs of the St.;.
making a total of 269 practitioners currently pro\|-
ing service in 13 different health professions. Five )f
those beginning practice this year were physicians — eh
with four-year commitments.
Physician Recruitment 1
A pilot program was authorized by the 1973 legi i-
ture to offer incentives to physicians who would pi;-
tice in medically deprived areas. Two measures h'e
been authorized by the Commission for Medical j-
cility Services and Licensure. One is the provision )f
stipends for residents whose field practice is in a rial
community or a medically deprived area. The seciid
measure involves the partial reimbursement of costs a-
curred by a community in recruiting a physician, is
the program has been in existence for only a v>.
months, and is obviously somewhat dependent on le
restructuring of medical training programs, it was i-
possible to place any physicians in 1973. Communi;s
and residents have demonstrated interest in both p-
grams. however, and a number of areas should obir.
medical services through these efforts in 1974.
Hospital Licensure and Medicare Certification
During the year. 156 hospitals involving 31.505
were licensed as meeting the Commission's standi
for patient care and safety. Many of these received
siiltation from the Commission to help them retain e^
bilitv to admit patients under the Medicare and Mec-
aid programs. The number of hospitals complying \tf
Federal criteria represents 97 of the total in operatn
Economic Stabilization Program
Appointed by the Governor as the State Advii
Board for North Carolina during Phase II of the I
nomic Stabilization Program, the Division reviewed
quests from hospitals and nursing homes for incre:
in charges in excess of limitations set forth in Cos
Living Council health regulations. The Division a<
on 27 applications for exceptions in 1973 as comp^
to 26 application reviews in 1972.
Administrative Reorganization
The administrative staff of the Commission for M
cal Facilitv Services and Licensure has been combia
with several other administrative units of the Depi
ment of Human Resources to form the Division o
Facility Services. Consolidated in this Division f>
those activities relating to licensing, certification, r
lation. inspection, and registration of health and so
service facilities and organizations. The Divison alsq
eludes the newly created Emergency Medical Ser\-
and Rural Health Sections.
I. O. Wilkerson. Jr.. Executive Secre
43
Executive Council
\ Summary of Minutes of Meetings of tlie Executive Council
lOTE: As recommended by the Finance Committee, the Executive Council authorized that just the salient actions
of the Executive Council will be reported in brief form.
The verbatim transcript of the Executive Council minutes are on file in the Headquarters Office and may
be reviewed or pertinent portions excerpted on request.
FALL EXECUTIVE COUNCIL MEETING
September 30, 1973
-The
(Morning Session)
Fall meeting of the Executive Council con-
aied at 9:10 a.m. in the Meeting House of the Mid
fties Club, Southern Pines. N. C, Dr. George G. Gil-
,rt, President, presiding. Past President Dr. John Glas-
ji(i gave the invocation, following which Dr. Gilbert
i: cognized new Councilors in attendance and also new
(jiMnmissioners.
— President Gilbert announced with regret that First
ce-President Dr. Michael F. Releher. had had to
.;ign all extracurricular activities because of health,
rjiduding the vice-presidency of the State Society. So
that token and in keeping with the Constitution.
D. E. Ward is automatically the First Vice Presi-
:it. Secretary Dr. E. Harvey Estes. Jr., called the
J and declared a quorum present.
— Mrs. J. Benjamin Warren, representing the Airxili-
' President, Mrs. J. Elliott Dixon, preiented a brief
iiort on the Auxiliary activities for the year 1973-74.
— Dr. William F. HoUister, Chairman. North Caro-
1 Medical Education and Political Action Committee
tsented a brief report on the current activities of
dPac and AmPac. urging support of the Society
(Jership and encouraging the membership to join the
organization and participate in its activities.
-Dr. T. Tilghman Herring, Chairman, Committee on
lance, presented the propo.sed budget for 1974. as a
anced budget, which was approved and adopted by
Executive Council. See separate REPORT A —
PORT OF THE EXECUTIVE COUNCIL. Paue
HOUSE OF DELEGATES, May 19. 1974.
—The Executive Council approved a motion that
■ ad hoc liaison committee be appointed to meet
'i a similar subcommittee of the North Carolina
■;;e Board of Medical Examiners to discuss the prob-
s of dealing with those physicians who appear to
'engaged in deviant or inappropriate practice of medi-
in North Carolina and that the joint committee
iiiiinnstructed to report back to the Council at its next
SePfitting."
-The Executive Council appointed Dr. John H.
aroe of Winston-Salem, to fill the tmexpired term
)Dr. Joseph B. McCoy. Jr.. on the Committee on
Shield representing the Section on Obstetrics and
necology. the term expiring in 1976.
-The Executive Cotmcil appointed Dr. William W.
ley of Raleigh to fill the unexpired term of Dr.
Jam R. Purcell, on the Committee on Blue Shield
resenting the Section on Pediatrics, the term expir-
nn 1976.
rThe Executive Coimcil appointed Dr. John Glas-
son of Durham to fill the unexpired term of the late
Dr. Frank W. Jones, as a Delegate to the American
Medical Association, a term expiring December M
1974.
— The Executive Council appointed Dr. Charles W.
Styron of Raleigh to fill the unexpired term of Dr.
John Glasson, as an Alternate Delegate to the American
Medical Association, a term expiring December 31,
1975.
— The ad hoc Committee to Study and Recommend
a Salary or Increase in Allowances for the President
recommended that in addition to paying the reimburs-
able expenses that the Society pay a per diem of $25
per day for days spent on Society business, and at-
tendant to the President further recommended in al-
leviating the burden of assuming the Presidency that
the President-Elect and the immediate Past President
be reimbursed for their travel and living expenses when
involved in official Medical Society functions. See
separate REPORT B— REPORT OF THE EXECU-
TIVE COUNCIL, Page 63. HOUSE OF DELEGATES,
May 19, 1974.
— The Committee on Peer Review recommended to
the Executive Council that the Committee on Peer Re-
view serve as a coordinating body to meet at frequent
intervals with the review committees involved with
claims review to coordinate problems. The Committee
on Peer Review would make certain educational ef-
forts as are deemed necessary in particular cases. If
the Committee cannot correct the problem, it would
refer it as a profile to the Mediation Committee for
whatever action they deemed necessary. A motion that
these recommendations be incorporated in the com-
mittee charges was amended to refer them to the
Council on Review and Development and was then
passed by the Executive Council.
— The Executive Council approved a motion that the
State Society approves the North Carolina Medical Peer
Review Foimdation, Inc.. presentation appealing for one
statewide PSRO in the state and go on record as sup-
porting the statewide PSRO concept.
— Past President Charles W. Styron. M.D.. for the
CoLincil on Review and Development, reported that the
Council planned to write to the Committee on Per-
sonnel and Headquarters and to the Committee on Fi-
nance recommending that the Society engage an addi-
tional headquarters staff member by reason of the heavy
workload of the headquarters staff. In addition, he re-
ported, it is hoped that a staff member can be as-
signed full\' to legislative matters since it is one of
the most important activities of the Society. He also
44
1974 TRANSACTIONS
viid the Council on Review .ind Development will
recommend that the North Carolina Medical Society
Foundation arrange a separate meeting during the
year since the Foundation now meets for such a short
mee:ing and has no opportunity to discuss the problems
of the Medical Foundation.
(Afternoon Session)
The Executive Council considered and recom-
mended to the House of Delegates approval of a re-
quest from the Section on Ophthalmology and Oto-
laryneologv to form a ■separate section for each as
follows: A Section of Ophthalmology and a Section
on Otolarvnaoloizv. See separate REPORT C— RE-
PORT OF fHE EXECUTIVE COUNCIL. Page 63.
HOUSE OF DELEGATES. May 19. 1'574.
The Executive Council approved a recommenda-
tion of the Committee on Chronic Illness that the North
Carolina Medical Societv endorse the principle that
lona-term care faciliiies in North Carolina employ the
services of a phvsician to serve as Medical Director.
It also recommended and the Council approved, that
the Sociely endorse the -Guidelines for a Medical Di-
rector in a Long-Term Care Facility" as adopted by the
American Medfcal Association. See separate REPORT
D— REPORT OF THE EXECUTIVE COUNCIL. Page
M. HOUSE OF DELEGATES, May 19. 1974.
On recommendation of the Committee on Chronic
Illness, the Executive Council approved that the North
Carolina Medical Society continue to endor-e Home
Health Services and recommends the development and
extension of Home Care to areas not having these
services at the present time. Implementation of this
recommendation to be encouraged through county medi-
cal societies.
The Executive Council accepted as information the
recommendation from the Committee on Chronic Ill-
ness for approval of the Statement regarding preventive
use of isoniazid as a public health measure. The State-
ment had been recommended for approval by the Com-
mittee one year ago. was submitted to the House of
Delegates, but the Reference Committee recommended
that Instead of adoption it be re-referred to the Com-
mittee for further consideration on the basis of some
evidence presented at the Reference Committee having
to do with the toxicity of certain drugs, etc. However,
the Committee on Chronic Illness again recommended
approval of the Statement.
Approval was voted for a Committee on Chronic
Illness recommendation for a renewed effort to identify
and bring to treatment cases and potential cases of
tuberculosis amona the population. See separate RE-
PORT E— REPORT OF THE EXECUTIVE COUN-
CIL. Page 64. HOUSE OF DELEGATES. Mav 19.
1974.
— Council approval was vo:ed for a request from
the Committee on Mental Health that the Reserve Funds
for Mental Health purposes be used to pav expenses
for key people to attend the Southeastern Regional
Mental Health Meeting at .-Xtlanta. Georgia.
— Recommendations from the Committee on Drug
.Abu^e concerning proposed amendments to General
Statutes were referred to the Committee on Legislation
for their perusal.
— A recommendation from the Committee on Mar-
riage Counseling and Family Life Education that a two-
hour program on sex education be held at the anr 1,
meeting was referred to the Annual Convention C(
mission.
— The E.xecutive Council adopted a resolution, fri
the recommendation of the Committee on Marri>e
Counseling and Family Life Education, recording djp
and sincere regret at the untimely death of Mrs. E el
Nash early in 1973. a pioneer with sex education f-
forts and marital and sexual counseling in North C.o-
lina.
— The Committee on Child Health recommended »o
the Executive Council approved that in light ot t
common occurrence and serious complications in e-
gard to mortalitv and permanent brain damage, a
hemophilus influenza meninuiiis be named a report .k
disease. See separate REPORT F— REPORT OF II
EXECUTIVE COUNCIL. Page 64. HOUSE ff
DELEGATES. May 19. 1974.
— A recommendation from the Committee on c
cupational and Environmental Health for strong r
dorsement and support for the development of spe.i r
and assistance to the local county medical socite
toward educational information on occupational hi. tt
was referred to the Committee on Medical Educatn
A Committee recommendation urging the supporiol
similar p.ograms on occupational health at the an ;
meeting of the Medical Societv in .Ma\ when it ca .
accomplished was referred to the Committee on j
rangement;:. A motion from the Committee urging ht
State Societv' to endorse occupational health info: a
tion to be disseminated in the curriculae of the met a
schools of the State was received as information.
— The Committee on Legislation recommended n
the Executive Council approved that the Societv .n
tinue its current way of operating in the implemt.:a
lion of PSRO's that the Society not join in an\ e:)r
to have PSRO repealed in the U. S. Congress. b<
Committee al:o recommended and the Executive Cl
cil approved that the Society continue its suppoi o
AMA Medicredit legislation with the addition of di:£
services to the proposed legislation.
— The Executive Council passed a motion appn o
of the actions of the Committee on Legislation in :;i
interest in possible legislation that would make rei. d
of peer review committees, non-discoverable in )i
proceedings.
— The Executive Council approved the recomnii .
tion of the Committee on Legislation that the t r
cil approve the Committee's continued oppositio:
Senate Bill 556. having to do with the definition,
optometry.
— Approval was given to participation with the Sr^
Rline and French pharmaceutical firm in a prog
called Practical Politics Seminar, a program whei
the Society invites the health leaders in the Gen
.•\ssemblv to a weekend seminar about the poll
process with the expenses of the legislators being ;
b\ the pharmaceutical companv .
— It was reported as information that the Med
Legal Committee, as a follow up to the AMA met
survev on medical services in jails, will send a n
comprehensive questionnaire to each Chairman ol
Board of County Commissioners with copies to the
ficers of the countv medical society.
— The Committee on Eye Care and Eve Bank bro
several items as information to the attention oi
Council. The Committee recommended to the s'
1974 TRANSAC TIONS
45
phthalmologists and to the Department of Social Ser-
vices that a prior approval policy for Medicaid recipi-
nts he implemented hy the Department for routine
ye examination for fitting eye glasses to prevent dupli-
ation of services. It was also pointed out that there
a remarkable shortage of eye descriptive procedures
1 the RVS as it exists at the present time limiting
'iimbursement for services provided. The Committer
rj^lso recommends approval for use of soft contact lenses
i limited to therapeutic use and onl\ then with prior
.pproval in order to limit indiscriminate use of soft
,,ontact lenses.
' — The Committee Liaison to the North Carolina
Jiarmaceutical Association reported as information that
f subcommittee with representatives from the Phar-
laceutical Association will begin work on an updated
jrsion of the booklet. "Phvsician-Pharmacy Code of
'nderstanding."
— The Committee on Public Relations reported a
amber of items as information, inckiding the follow-
g: A Synopsis and Recommendations for Improve-
ent of Medical Services in North Carolina has been
stributed; Recommendations for initiating a program
periodic news releases has been planned; A Joint
latement of Policy on Donation of Himian Tissue for
ransplantation, as approved by the Society, has been
.iproved by the N. C. Hospital Association and is to
''"; printed and distributed; The Conference on Medical
eadership is to be held on February 1st and 2nd in
-aleigh and the Committee recommends that an in-
i;pth review and analysis of the existing external pub-
'c relations programs by the Society' be undertaken.
— The Committee on Disaster and Emergency Medi-
1 Care reported as information that a new Division is
ring established in the N. C. Department of Human
'^sources to be known as the Emergency Medical
'^rvices Division and members of the Medical Society
-ommittee are assisting in the implementation of the
lOgram.
The Committee on Association of Professions noted
i information the need for increased participation by
lysicians in the Association of Professions organiza-
I
ft C
m.
— The Committee on Community Medical Care re-
tried as information that it endorsed the Governor's
nral Health Program as an example of an experi-
ntal model health care system: that the Committee
5d prepared suggested guidelines for a program funded
the last Legislature whereby residency programs in
imary care in communities across the state would
""' 'od the students translocation expense for the period
I time the student is to spend in the community to
le electives in community medicine; and expressed
; need for a comprehensive plan by the Medical So-
'ty for meeting the problem of maldistribution of
"^ iysicians and too few primary care physicians.
— The Insurance Industry Committee recommended
d the Executive Council voted approval, that the So-
'ty go on record as opposing Senate Bill 932 before
! General Assembly, a bill which would remove the
'ijuirement of coordination of benefits from health
^jurance coverage.
' — The Insurance Industry Committee reported as in-
irmation. its recommendation that the Society go on
pord supporting the concept of insurance carriers pro-
tto i;
jiing maternity benefits for unmarried female minors,
jalso reported that the committee has appointed a
subcommittee to develop a proposed definition and
guidelines for "'custodial care."
— As an information item, the Committee to Work
with the N. C. Industrial Commission recommends
May 1975 ;;s the date when the N. C. Workmen's
Compensation Fee Schedule should be updated and
that it should be updated every two years thereafter.
— The Executive Council approved a motion to refer
to the Committee on Hospital and Professional Rela-
tions to serve as the coordinating representative of the
State Medical Society with the North Carolina Hospital
Association relative to a recommendation from the
Committee on Hospital and Professional Relations that
this Committee approves in principle the request of the
North Carolina Society of Internal Medicine to study
methods of improving medical records and that the
North Carolina Medical Society and North Carolina
Hospital Association should in consultation form a
committee to sttidy and demon ;trate solutions to this
problem and employ professional consultants if neces-
sary.
— The Committee on General Sessions Program pre-
sented a progress report, as information, on its efforts
to present a strong program of continuing medical
education at the first and second general sessions and
that the third general session be socio-economic in
content.
— The Committee on Arrangements reported as in-
formation a number of changes in the program format
being planned for the Annual Meeting including: ( 1 ) a
strong scientific program for the first and second gen-
eral sessions with a socio-economic program for the
third general session, (2) the Memorial Service to be
united with a Prayer Breakfast, ( 3 ) pins and certifi-
cates for the Fifty Year Club to be presented at each
member's respective county society, (4) AMA-ERF
checks to be presented to their recipients during the
Auxiliary program, (5) the Nurse of the Year Award
to be made at the annual meeting of the N. C. Nurses'
Association and presentation of awards of the Moore
and Wake Count\' medals will be made by the Com-
mittee on Awards in an appropriate manner via the
respective county societies of the recipients.
— The Committee on Arrangements recommended
that the Executive Council approve September dates
for the annual meeting beginning in 1975 or as soon
thereafter as possible. The Executive Council voted ap-
proval of the motion. A following motion passed by
the Executive Council instructed that the Executive
Director and staff prepare a questionnaire to the mem-
bership concerning the question including choice of
dates as May opposed to September. See separate RE-
PORT G— REPORT OF THE EXECUTIVE COUN-
CIL, Page 65, HOUSE OF DELEGATES. May 19,
1974.
— The Committee on Cancer recommended that the
State Society emphasize and call attention to the value
of the State Board of Health's Certified Home Health
Agencies services so that the physicians in different
counties might be aware of these services. This being
a concurring recommendation with an earlier recommen-
dation from the Committee on Chronic Illness, no ac-
tion was deemed necessary.
— The Committee on Medical Education recom-
mended implementation of a program of compulsory
continuing education, including four points in their rec-
ommendations, which were approved by the Executive
46
1974 TRANSACTIONS
Council. Principle ;imong them was "that a minimum of
fifty hours of continuing education per year be re-
quired of each member of the State Society. " See
separate REPORT H— REPORT OF THE EXECU-
TIVE COUNCIL. Page 65. HOUSE OF DELEGATES.
May 19. 1974.
— The Committee on Constitution and Bvlavvs recom-
mended that the Executive Council establish a format
and policy for the correct submission of resolutions.
However the discussion seemed to indicate a con-
sensus that this could be handled administratively so
no action was taken.
— The Committee on Relative Value Study is ap-
proaching proof form. Final drafts will be reviewed
by the committee as soon as practicable.
— The Committee Advisory to the Department of
Motor Vehicles reported as information that it wished
to change its name to Committee on Traffic Safet\
inasmuch as it now has a broader scope of activity
more in keeping with the new name.
— The Committee of Physicians on Nursing expressed
a desire to change its name to Committee on Allied
Health Professionals since it is now involved with areas
other than nurses. It also reported as information
that "the committee has considered the concept of in-
dependent fee-for-service for care rendered by physi-
cians" assistants, nurse assistants, nurse practitioners
and similar individuals and rejects this concept as in-
validating physician responsibility for medical care." It
was also reported that the Committee voted to drop
the Nurse of the Year Award for next year.
— The Committee on Comprehensive Health Service
Planning recommended follow up effort by the Soc
in two particular areas: { 1 ) that the physicians be
couraged to participate in the various subdivisions
t.isk forces on Comprehensive Health Planning agen^
and ( 2 ) that the Society follow up in its efforts
get practicing physicians on the Governor's Advis,
Commisson on Comprehensive Health Planning.
— The Executive Council approved a motion requ
ing the Committee on Constitution and Bylaws to j
pare a suggested change to the Constitution and
laws regarding local membership in a medical stuc
bod\' organization in lieu of Student American M^
cal Association membership as a prerequisite to m<
bership in the State Society.
— The approval was voted for a Committee on
sonnel and Headquarters Operation request that the
ing of an additional headquarters staff person to se
as a file clerk be approved.
— Tentative dates for the September Committee C
clave were announced for future vears as folio
September 25-29. 1974; September 24-28. 1975;
tember 22-26, 1976; September 28-October 2. 19
and September 27-October 1, 1978, all scheduled to
held at the Mid Pines Club. The Executive Cou
voted confirmation of the 1974 dates.
— The Executive Council approved a motion that
Secretary write a letter of sincere appreciation
Joseph J. Combs, M.D., for his faithful service o
the many years that he has served as Secretary of
Board of Medical E.xaminers of the State of Nc
Carolina.
MIDWINTER EXECUTIVE COUNCIL MEETING
Febrtiarv 3. 1974
(Morning Session)
— The Mid-Winter Meeting of the Executive Council
convened at 9:00 a.m. in the Executive Council Room
of the Medical Society building, Raleigh, N. C, Presi-
dent George G. Gilbert presiding. Vice-Speaker of the
House of Delegates, Chalmers R. Carr, gave the invo-
cation. In the absence of the Secretary, the Executive
Director, Mr. William N. Hilliard, called the roll and
declared a quorimi present.
— Dr. T. Tilghman Herring, reporting for the Com-
mittee on Finance presented the Audit for the 1974
calendar year and reported that the remaining portion
of the mortgage on the Greenfield property was paid
off ahead of schedule and it was also possible to pay
off the loan for building the Society building. The
Council voted approval of the Report of the Committee
on Finance.
— Dr. H. David Bruton, Chairman, Committee on
Legislation, reported on current status of various meas-
ures before the 1974 General Assembly. Approval was
voted for a motion that the Committee on Legislation
be instructed in whatever manner they deem necessar\
to oppose Senate Bill 1014 and identical House Bill
1450, a health reimbursement plan that payment by in-
surance carriers and third parties be determined on a
usual, customary and reasonable basis with respect to
the entire state and not made on geographical basis.
Opposition to Senate Bill 932. a Bill which would
eliminate coordination of health insurance benefits,
also approved b>' the Executive Coimcil. The Cou
voted to instruct the Committee on Legislation to )■
pose .Senate Bill 1002, a bill requiring that there k:
suspicion that criminality exists before the Med 3
Examiner's autopsy can be ordered. Support was >
proved for House Bill 1303 and Senate Bill 913 wl
would remove the thirty day waiting period for ste
zation. The Executive Council voted to support :
bills on mental health, one regarding voluntary cc'
mitment and one regarding involimtarv commitmi
Senate Bill 981 and 990.
— A motion was passed that a letter be written
the Department of H.E.W. in support of the A!^
position protesting the proposed regulation requir
precertification for hospitalization except in cases
emergency, A motion was also passed to send a t(
gram to each North Carolina .Senator urging that ti
vote against extension of an extension of econoi
stabilization act, a copy of the telegram to be sent
the .Senate Banking Committee.
— The Executive Council considered a resolu
from Wake Count) which requested proposing legi;
tion regarding protection for physicians with regard
"Informed Consent," however the discussion seemed
indicate that this subject was not one lending iti
readily to a legislative solution. As a result the Co
cil approved a motion that a letter be written to '\\ ,
lea
EXECUTIVE COUNCIL MEETINGS
47
"PCounty Medical Society giving them the benefit of this
* 'discussion and ask them to either withdraw the resolu-
M'ion or it will be presented to the House of Delegates.
'"]" — A resolution from the Edgeeombe-Nash County
^''Medical Society, proposing repeal of the Professional
'"■'.jtandards Review Organization (PSRO) legislation, was
;eceived and will be passed on to the House of Dele-
i|tii|»ates. See separate Resolution No. I.
);|i — A resolution from the Fifth District Medical So-
1 :iety on the subject of "Increased Activity in the Area
iicj)f Public Relations and Legislative Contact," however.
M It was the consensus of the Executive Council that it
nijivould be better form if a component society (county
.ociety) or an individual delegate were to submit the
ilf.esolution since a district society has no delegate in the
li ilouse of Delegates to speak on behalf of the proposal.
S(,;t was suggested that the District Councilor seek to
\ave the resolution introduced by a county in the dis-
.(srict or by an individual delegate.
IIjjJ- ■ — The Executive Council considered a legislative pro-
u'Osal submitted by Pitt County Medical Society, a
lojample bill, which would require that anyone seeking a
...cense to practice in several health related professional
„ [reas listed in the bill would have to be a graduate of
,i
school which has been accredited by a recognized
xrediting agency. A motion was passed referring the
'Troposed bill to the Committee on Legislation for fur-
ther study.
•'!' A request from the Vital Statistics Division of the
department of Human Resources for State Medical So-
tety support for changes in the death registration sys-
m was presented by Dr. Jacob Koomen, Director,
ivision of Health Services, and the Executive Council
ml on record as supporting the proposed changes and
lat a letter be written to the appropriate department
ivising of the fact that the Executive Council endorsed
e proposal.
— The Executive Council voted approval of two meas-
les having to do with traffic safety, the first Senate
■(jljll 89 and the comparable bill in the House which
ibkes blood alcohol of .10 prima facie evidence of
jtoxication. The Council also passed a motion reaf-
j(( iming its support of mandatory seat belt legislation.
■The Executive Council approved the recommenda-
ji'n of the Chairman of the Committee on Public
iijjilations that future meetings of the Conference on
edical Leadership held near the last of January be
dd in Raleigh again next year and that the dates in
jlj -lOuary held at the Pinehurst Hotel be released.
— Approval of a direct State Society Membership
■ Dr. James J. Richardson, was disapproved, but
|th the recommendation that he be instructed that
application will be reconsidered contingent upon
1 renewal of his membership in the Scotland County
udical Society in compliance with the State Society's
requisite of Coimty Society membership to be elig-
:i for State Society membership.
p — Approval was given for accepting former student
imber, Colin Douglas Jones, as an out-of-state Intern-
isident member in the State Society, in order for him
[continue his membership.
1=— A motion was approved by the Executive Council
I t the Committee on Constitution and Bylaws be re-
'«ted to consider a change in the Bylaws whereby
I'sicians in postgraduate training in accredited institLi-
. is outside North Carolina be admitted to Intern-
i'' , );ident membership.
A' /'
)»
lal
— The Executive Council considered Resolution No.
12 (1973 Annual Session) which was referred to the
Executive Council for further consideration. In connec-
tion with the referral back to the Coimcil, a letter
from Past President Louis Shaffner commenting on
the resolution was reviewed along with this suggestion
for its handling. After discussion, the Council approved
a motion that the Council accept Dr. Shaffner's rec-
ommendation and take no further action, but report
his statements to the House of Delegates along with
the fact that the UNC Board of Governor's Study ful-
fills the request of the Forsyth County Medical So-
ciety. See separate REPORT I— REPORT OF THE
EXECUTIVE COUNCIL, Page 65, HOUSE OF
DELEGATES. May 19, 1974.
— Affiliate membership status was approved for Jo-
seph M. Hitch, M.D.. on the recommendation of the
Wake County Medical Society.
— Reappointed to the Board of Directors of the
North Carolina Association of Professions, representing
the Medical Society, were the following: Thomas G.
Thurston. M.D.. of Statesville; Edward K. Isbey, Jr..
M.D.. of Asheville; and George G. Gilbert. M.D.. of
Asheville.
— The Executive Council received a request from
the newly organized North Carolina Neurosurgical So-
ciety that a Section on Neurological Surgery be formed
in the State Medical Society. The request was approved
by the Council and recommended to the House of
Delegates for approval. See separate REPORT J — RE-
PORT OF THE EXECUTIVE COUNCIL, Page 65.
HOUSE OF DELEGATES. May 19. 1974.
(Afternoon Session)
— Secretary of the Board of Medical Examiners.
Charles B. Wilkerson. Jr.. M.D.. reported as informa-
tion that the Board of Medical Examiners has set up
rules, regulations and procedures whereby the so-called
outpatient or out-of-hospital based nurse practitioner
can apply for registration in that category, and he also
reported that the University of North Carolina nurse
practitioner training has been approved by the Board.
On another subject, he reported that it is not legal for a
foreign doctor who is not licensed in the State to
serve as a medical assistant or doctor under the spon-
sorship of another doctor. Finally, he reported that
the Medical Practice Act states that when a licensed
doctor of medicine in the State has been adjudged
guilty of a felony that he may be investigated, called
on to explain the situation and that his license may
be considered for revocation. At the present time there
are two instances where licensed doctors of medicine
have been convicted of a felony and are now serving
time, but while a person is incarcerated the Board
has no access to him and since state law prevents re-
voking a license without giving the individual a hearing
these cases are being kept under consideration.
— Dr. W. Joseph May. Chairman. Committee on
Maternal Health, presented a report on behalf of the
Governor's Task Force on Regional Planning for Ma-
ternal and Infant Care. The regionalization plan is
proposed, he said, in large part because there is an
excess of delivery facilities in North Carolina, so the
regionalization concept is proposed in an attempt to
bring about a gradual volimtary program of consolida-
tion. The I, II, and III classes of stratification of hos-
48
1974 TRANSACTIONS
pituls is in accord with the National Task Force on
Perinatal Health and has the endorsement of the Ameri-
can College of Obstetrics and Gynecology, the Ameri-
can Academv of Pediatrics, and the American Academy
of Family Phssicians. The Executive Council endorsed
the proposal and voted to send that endorsement to the
North Carolina Legislature with a request for funding
and implementation.
— Dr. J. Benjamin Warren. Vice President of the
North Carolina .Medical Peer Review Foundation, re-
ported on the highlights of a meeting, the day before,
of the Board of Directors of the Peer Review Founda-
tion. The principal actions reported included: (1) a
report from the President of the Foundation on his
trip to Washington along with Medical Society Attor-
ney Mr. John Anderson to explore the chances of
North Carolina being designated a statewide single
PSRO area. It was pointed out that four PSRO's of
the size now proposed would not be manageable so it
is being recommended that the .State be divided into
eight or more PSRO's; (2) the Peer Review Foundation
apply for and assume the role of a medical resource
center (MRC) to help the PSRO's set up and become
functional: ( .^ ) a Committee on Norms was estab-
lished: and (4) action was taken to employ Mr. Dan
Mainer. the Society's Assistant Executive Director, on a
full-time basis as Executive Secretary and to establish
a fringe benefits package which would be equal to the
North Carolina Medical Society package. On the fringe
benefits package portion of the last item, the Execu-
tive Council passed a motion authorizing M hn-r-
derson to implement an amendment to the 'efca'-}
ciety plan whereby a transfer of retiremel te" '
between the Medical Society and the Peer Rete« 'I'ltii
dation would be possible. *'''
— The Executive Council considered a m ''
participate with four other southeastern statesti.
ing a jet airplane for travel to the AM|ti
Meeting in Honolulu. Hawaii, in 1975 and liiiiQ
the Executive Director to book forty seats ;!I^
Carolina.
— A proposed position paper on "Need forta
Better Distributed Primary Care Physicians'ws
sented from the Committee on Communit Me
Care by Dr. John L. McCain, as Commissicir. i
considerable discussion, the Executive Coutil i
to commend the Committee on Communit Me
Care for doing an outstanding job and thane
poied position paper be widely publicized an|refi
to the House of Delegates at the Annual Neiir
Mav. See separate REPORT K— REPORT F '
EXECUTIVE COUNCIL. Page 65. HOKE
DELEGATES. May 19. 1974. j
— Approval was voted for a motion to wrila
to Mr. John Ketner. of the North Carolinaflos
.Association staff expressing appreciation and tin
edgement of the fine service he has provided |rb
health in North Carolina in bringing hospitalind
.Medical Society closer together.
ANNUAL EXECUTIVE COUNCIL MEETING
Mays, 1974
(Morning Session)
— The Annual Meeting of the Executive Cotincil
convened at approximately 9:00 a.m. in the Executive
Council Room of the Medical Society Building. Raleigh.
N. C. President George G. Gilbert presiding. Past
President John Glasson gave the invocation, and in the
absence of the Secretary, the E.xecutive Director Mr.
William N. Hilliard called the roll and declared a
quorum present.
— The Council reviewed the lettered reports "A"
through "K" and "M" as contained in the delegates
kits which were accepted for referral to the House of
Delegates, all having been developed on the basis of
previous Council action.
— The Council reviewed the numbered Resolutions 1
through 1.^ and approved that the\' be accepted for
referral to the House of Delegates as presented.
— The Council reviewed a resolution, on the subject
of "Delineation of Hospital Privileges by Specific Pro-
cedure." submitted by the Beaufort-Hyde-Martin-Tyr-
rell-Washington County Medical Society and received
after the normal deadline for acceptance of resolutions
by the Headquarters Office. A motion was approved that
this resolution be accepted and referred to the House
of Delegates for co.isideration by Reference Committee
II. to be considered along with Resolution No. 4. and
that it be listed as Resolution Number 4-A. See separ-
ate RESOLUTION 4-A. Page 70. HOUSE OF DELE-
GATES. May 19. 1974.
— The Council approved acceptance of the Annual
Committee Reports as submitted in the Compiiic
.Annual Reports dated 1974. See separate cop
printed reports.
— .Approval was voted for the purchase of
and lot adjacent to the Medical Society parkjg
fronting on Bloodworth Street, on the reconii
tion of the Chairman of the Committee on Pji
and Headquarters Operation and the Chairmaiio
Committee on Finance. Identified as the pror
Mrs. N. G. Fonville. the propertv is 5.943 squ.e
See separate REPORT N— REPORT OF TI'i
ECUTIVE COUNCIL. Page 69. HOUSE OF)
GATES. May 19, 1974.
— On the recommendation of the Chairman:
Committee on Personnel and Headquarters Op'
approval was given to several proposals submi
the Executive Director to the Chairman of tht
mittee concerning Headquarters Staff personnel
ments and job titles with appropriate salary increa
— A motion was approved that the members
Executive Council and members of the N. C
Pac Board be given a specific invitation by the
MedPac Board to become sustaining members
North Carolina Medical Education and Politii.
tion Committee and that the Executive Coimcil
record as supporting this endeavor.
— The Council approved a resolution enco
N. C. MedPac membership on the part of mem
the House of Delegates and that the resolution
warded to the House of Delegates for consid
EXECUTIVE COUNCIL MEETINGS
49
Ci'
ith(
iis'j.r I
Mitfohihe appropriate Reference Committee. See separate
MdiciOLUTION 14, Page 72. HOUSE OF DELE-
W! bcfES. May 19. 1974.
w 'Mominees for the North CaroHna MedPac Board
irectors were received and the following were
i|j'pr«ili:
Ernest W. Larkin, M.D.
Marshall Redding. M.D.
Edgar T. Bcddingfieid. Jr.. M.D.
John Watson. M.D.
JohnT. Dees. M.D.
Robert H. Shackleford. M.D.
James E. Davis. M.D.
Archie T. Johnson. M.D.
T. Lacy Stallings, M.D.
David Nelson. M.D
JohnH. Hall, M.D.
Charles Hoffman. M.D.
William P. Hollister. M.D.
Lloyd H. Robertson. M.D.
Joseph Dameron. M.D.
John Henry Early Woltz. M.D.
A. Ledyard DeCanip. M.D.
R. Spencer Eaves. M.D.
T. Reginald Harris. M.D.
Wilburn Oscar Brazil. M.D.
Kenneth Cosgrove, M.D.
telon
os'Was
nilsJiMi
isioirr.
'ourtii
liiikMt
fcirhe
;Cf,ret
I M^stii
!t:if
HOilSE
la
bilo)
larkll;
I- I
ftn( Auxiliary
Mrs. J. Elliott Di.xon
Mrs. A. J. Crutchfield
Mrs. Edna Hoffman
— The Executive CoLincil approved in principle, a
oposed Plan of Assistance to Hospitals and Medical
affs for Developing Full Time Emergency Room
)verage as presented by Mr. William F. Henderson,
alth Care Systems Constiltant. former Executive
cretary of the North Carolina Medical Care Com-
ission.
^ — The Executive Council approved the recommenda-
apicic
copic'
ha
m of an ad hoc Liaison Committee between the Board
Medical Examiners and the Medical Society, after
■:.,i
praft
IB
OF 3i
nor word changes in the recommendation, to the
'feet that the House of Delegates be requested to
endorse an amendment to the North Carolina Medical
Practice Act that the Board of Medical Examiners
may revoke or restrict a license to practice medicine
for lack of professional competence. See separate RE-
PORT O — REPORT OF THE EXECUTIVE COUN-
CIL. Page 69, HOUSE OF DELEGATES, May 19,
1974.
— The Executive Council voted approval to recom-
mendations of the Committee on Constitution and By-
laws concerning proposed changes in the Constitution
and Bylaws. See separate REPORT P — REPORT OF
THE COMMITTEE ON CONSTITUTION & BY-
LAWS. Page 57. HOUSE OF DELEGATES. May
1974.
— The Executive Council discus.sed the problem of
implementing a change in the Constitution in regard
to the compulsory continuing education as a require-
ment for membership in the Society approved by the
House of Delegates in 1973. The Chairman of the Com-
mittee on Constitution and Bylaws indicated that it
had not been possible for the Committee to meet on
this subject but that he had some tentative Constitu-
tion and Bylaws wording regarding the compulsory con-
tinuing education as a requirement for membership for
consideration by the House of Delegates in case they
want to take action on this subject at this Annual
Meeting. See separate REPORT Q — REPORT OF
THE COMMITTEE ON CONSTITUTION AND BY-
LAWS, Page 58, HOUSE OF DELEGATES. May
19. 1974.
— The Executive Council approved a recommenda-
tion from the Chairman of the Annual Convention Com-
mission that the Committee on Memorial Service be
dissolved and that the duties of the Committee be as-
sumed by the Committee on Medicine and Religion,
and that the Committee on Constitution and Bylaws
prepare the amendment to the Bylaws to effect the
elimination of the Committee on Memorial Service.
— Dr. John W. Watson moved, and the Executive
Council approved a Resolution to commend President
George G. Gilbert for doing a fine job during the past
year as President, since this was the last meeting of
the Council over which President Gilbert would pre-
side. The membership of the Council gave Dr. Gilbert
a round of applause.
ijanff
;Op(\ii'
jtaiu'
iM'j
iters 1
f,C.
,'lie
tes
*ic|il
.)•*
iitoiW
[im t '
50
1974 TRANSACTIONS
Abridged Minutes of the Meetings of tlie House of Delegates
SUNDAY AFTERNOON SESSION
May 19. 1974
The First Meeting of the House of Delegates at the
120th Annual Meeting of the North Carolina Medical
Society convened at t\vo-twent\-one o'clock in the Cardi-
nal Ballroom of The Pinehurst Hotel. Pinehurst. North
Carolina.
DR. GEORGE G. GILBERT [President of the
Medical .Society]: Hear ye! Hear ye! The 120th Annual
Session of the North Carolina Medical Society is now-
declared in order and I will turn the podium over to
our esteemed Speaker of the House of Delegates. Dr.
James Davis.
DR. JAMES E. DAVIS [Speaker of the House of
Delegates of the Medical Societv 1 : Thank you. sir.
(The invocation was given by the Reverend Martin
Caldwell. Rector of Emanuel Episcopal Church. South-
ern Pines. )
SPEAKER DAVIS: We welcome our visitors today,
I'm delighted to see that there is a good number of
them. We appreciate your being with us to make this
120th annual session and the annual meeting of the
House of Delegates the valuable and memorable oc-
casion we trust it will be.
With special pleasure. I now present to \ou \our
very able Vice Speaker. Dr. Chalmers Carr.
[Whereupon Dr. Chalmers R. Carr. Vice Speaker of
the House of Delegates of the Medical Societ>. stood up
to be recognized.] [Applause]
I realize also that your other officers are also known
to vou. not only by their appearance but b\ their good
work, but I will ask our Vice President. Dr. D. E. Ward
to stand and be recognized.
[Whereupon Dr. D. E. Ward. Jr.. First Vice Presi-
dent of the Medical Societv'. stood up to be recog-
nized.] [Applause]
And. our Secretar\ . Dr. Harvey Estes!
[Whereupon Dr. E. Harvey Estes, Jr.. Secretary of
the Medical Society, stood up to be recognized. 1 [.Ap-
plause]
RECOGNITION OF PAST PRESIDENTS
Everv organization owes a debt of gratitude, lasting
gratittide. to its past leaders. Organizations, just as
individuals, have become what the\ are because of and
as a resLilt of the past.
Most importanth', we are what we are because of
the people who have influenced our lives, have changed
and molded us into our present being.
So. It is with trtie delight tod:i>' that we have with
us. not really as guests because as \'ou recognize these
men are lifetime delegates to this House, but have
with us as honorees men who have been so instru-
mental in changing and molding this Society into its
present form.
Now. we have not suddenly nor recenth become the
organization which you and I know, a soundK struc-
tured, financially solvent Society of more than 4300
physicians, which not only speaks authoritatively for
medicine in North Carolina, but constantly and con-
scientiously strives for more and better health care for
all the people of North Carolina.
So it is with pride and humilitv that we present to
\ou our living Past Presidents of this Society. The
accomplishments, of course, are legion, probably ir
possible to calculate and certainly 1 shall not attempt
enumerate them.
As each is presented. 1 will ask him to please stan
to remain standing and I'll ask the House to withho'
their applause until all have been presented.
Paul F. Whitaker. M.D., internist, Kinston, Pres
dent in 1945.
Fred C. Hubbard. M.D.. surgeon. Wilkesboro, Pre*
dent in 1952.
Donald Brock Koonce, M.D.. surgeon. Wilmingto
President in 1957.
Edward William Schoenheit. M.D.. internist. Ash
ville. President in 1958.
John Conklin Reece. M.D.. pathologist. Morganto
President in 1960.
Amos Neil Johnson, M,D.. famih' physician. Ga
land. President in 1961.
John Sloan Rhodes. M.D.. urologist. Raleigh. Pre*
dent in 1964.
George Washington Paschal. Jr., M.D.. surgeon. R
leigh. President in 1966.
David Goe Welton. M.D.. dermatologist, Charlott
President in 1969.
Edgar Theodore Beddingfield. Jr.. M.D.. famih' ph
sician. Wilson. President in 1970.
Louis deSchweinitz Shaffner. M.D., surgeon, Wi
ston-Salem. President in 1971.
Charles Woodrow Styron. M.D.. internist, Raleig
President in 1972,
John Glasson, M.D.. orthopaedist, Durham, Preside
in 1973.
[As each past president's name was called each stoi
up at his place on the stage to be recognized.]
Gentlemen, we again recognize your past and yoi
continuing contributions to our Society and the socie
at large. We express our gratitude to you and we trii
that the good Lord will continue to bless you with goi
health, and longevity for many \ears to come.
[Whereupon the entire assemblage then accorded tl
Past Presidents a standing ovation.]
PRESIDENTS MESSAGE
It is most appropriate that we now recognize ar
hear from our inctmibent President.
All of us who have been privileged to work wi
George Gilbert over the past and previous years, ar
I think that this now must represent a large segme
of our total membership, all I believe have been in
pressed with his sinceritv, his conscientious approac
to the duties of his office and to the problems of th
Society and impressed that he is without doubt a m
of conscience.
This past year must have been one of the busie
and most troubled years that medicine has seen so f;
but through it all George has maintained his calmne
and his quiet efficiency.
Wherever he has appeared as our spokesman, ar
Em sure at this point it must appear to him to hai
HOUSE OF DELEGATES
51
been endless, his quiet dignity, his thoroughness and
his clear thinking have earned respect not onl>' for
■ ihimself but for our Society.
It is a genuine pleasure to present to you our Presi-
,dent. Dr. George G. Gilbert.
[Whereupon the entire assemblage then accorded
j-;President Gilbert a standing ovation.]
3,1' PRESIDENT GILBERT: For once I don't have an
^appropriate joke like people often do after they get a
Iblow-up like that, so I'll proceed with my little offering.
dii Mr. Speaker, Officers of the Society, Past Presidents,
i jiMembers of the House of Delegates:
[Whereupon President Gilbert then read his pre-
Ptlspared Message of the President to the House of Dele-
gates, which was printed in the North Carolina Medi-
kica! Journal. Vol. 35. No. 7. July 1974. p. 409) [Ap-
Iplause]
t.a SPEAKER DAVIS: Thank you. very much. Dr. Gil-
bert and this address, of course, will be referred to the
\iiH|Cominittee on the President's Addresses.
A i MESSAGE OF THE PRESIDENT OF
! THE AUXILIARY
ri
" ' Just as the past year has been a busy and trying one
ifor the Society. I'm sure the same has been true for
"' 'i;he Au.\iliary to the Society.
As many of you will recaU, they celebrated their
■'fetieth anniversary last year and, so, the Au.xiliary like
I I few of us present are now in the second fifty and
'''Wjrying hard to make it as good as the first fifty.
I Fortunately for the Au.xiliary, they have this past
P-P^ear had a very dynamic leader and at this time
, .ve will hear from her with her report from the Auxili-
'iry, Mrs. Elliott DLxon. and I'll ask our Secretary, Dr.
^stes. to escort Mrs. Dixon to the podium.
'•'-■ [Whereupon Mrs. J. Elliott Dixon. President of the
Auxiliary to the Medical Society, was accorded a stand-
'"f ng ovation.]
AUXILIARY PRESIDENT DIXON: Dr. Gilbert.
At. Speaker, Dr. Carr and Members of the House of
delegates:
I would like to thank you for the opportunity of
peaking to you this afternoon on behalf of your
Auxiliary.
The activities of the Auxiliary during the past year
ire set forth in some detail in the Compilation of Re-
iiorts, which you have already received. Therefore. I
/ill not repeat that information.
I would like to go over a project that I personally
;ave been interested in over the past three \'ears. It
;iiii;as been presented in several areas of the state with
lery good response.
wli I am referring to the concept of the mini-health
, anirs. It comprises of a series of exhibits which are
jiBilsimed at children from first through the fifth grades
a tjti'ith the purpose of teaching the students some knowl-
i[Oj,)idge of their physical self and of those persons and
lituations in which he receives health care.
B^i These have been exhibits using plastic models of the
lye, the ear, joints, kidneys, skeleton, and in some a
iiisitieinonstration of a fresh beef heart has been used.
:' The instruments a physician uses in conducting a rou-
uiiiiacie physical examination have also been available for
eie children to touch and demonstrations of their use
limve been conducted.
6 Two fairs included the equipment usually found in a
ilO K
hospital room and operating room setup. X-rays were
on display which showed a fracture film, a chest film,
a skull film and a ftill term intrauterine pregnancy.
Our dental friends cooperated in providing an ex-
hibit on dental hygiene and a variety of other areas of
interest were included that related to health care.
In each area where the-e have been given, there has
been overwhelming response by the students and a genu-
ine interest and enthusiasm displayed.
In all of these. Auxiliary members have been re-
sponsible for initiating, gathering the materials to be
used and were present to explain the demonstrations.
You may be approached by someone to use the mod-
els that are gathering dust in your office. Please al-
low their use and give whatever assistance you can to
someone who wishes to put on a mini-health fair.
There are a few places in this state where this type
of exhibit is on permanent display. While this is the
ultimate, these temporary exhibits help to fill the gap.
This type of exhibit makes children more familiar
with health related subjects and. hopefully, stimulates at
an early age an interest in health careers.
Along the same line. I would also like to point out
our efforts on behalf of AMA-ERF have been more
successful this year than any one previous. So far. over
$14,000 has been raised for these funds and they will
be distributed among the state's four medical schools.
The AiLxiliary looks forward to continuing to work
in the interest of organized medicine. Although the
Auxiliary has its own role to play, we realize that
we are only an integral part and hope that we can
continue to represent its interests and aims whenever
we have the opportunitv. Thank vou. [Applause]
SPEAKER DAVIS: Thank you, Betty, very much,
and I hope you will once again remind all the mem-
bers of the Auxiliary how much we appreciate and
value their continued work in our interests.
HOUSE OF DELEGATES
Will the Hou.se please be in order'.'
Would Dr. Wilkerson please approach the podium'?
In looking for people to be honored, we have recog-
nized one more and we would now like to recognize
and congratulate the man who has termed himself the
lifetime Chairman of the Credentials Committee. Dr.
Charles Wilkerson.
We've got a red carnation for him and after pinning
that on him. we will ask him for this year's report
from the Credentials Committee.
Dr. Wilkerson!
[Whereupon Speaker Davis then pinned a red car-
nation onto Dr. Wilkerson's jacket lapel.] I Applause]
DR. CHARLES B. WILKERSON. Jr. [Chairman,
Credentials Committee]: Mr. Speaker, you have 176
duly certified delegates on the floor.
SPEAKER DAVIS: Thank you. Dr. Wilkerson. for a
lifetime of duty!
As we get down to business, may I take just a moment
to comment on the pamphlet that I hope all of you
have received and I hope you have had a chance to
review and you have with you.
This is simply guidelines compiled by your Speakers
to help the House in smoothness and effectiveness of
our actions.
I think that all of you realize that by bylaw require-
ment, followina Sturgis's Rules and Reaulations these
52
1974 TRANSACTIONS
are simply abstracts which we think might be more
readily referred to.
It is your Speat;ers' feeling that since this is a Compi-
lation of rulings of abstracts from Sturgis bylaw re-
quirements that it is unnecessary for the House to adopt
this officially, simply because it is subject to correction
or change at any time that you wish.
If >ou notice inside the back cover, there is a change
by addition even before it got out of the pres^. so please
don't feel that this limits or restricts you in anything
that this House wants to do. This is only suggestions.
The question of a time limit on debate has also been
raised and it again is our feeling that the procedure
that we have followed, and that is to allow any speaker
a reasonable period of time, certainly five minutes, and
then allow him a second opportunity to speak if he so
desires after everybody has had an initial opportunity,
is a fair and equitable way of dealing with this without
having a time kept on each speaker.
Again, we suggest that we continue to follow this,
but this as any other rules of this House are subject
to your judgment.
i should also like to point out that our session today
for the first time has delegates from the specialty sec-
tions. In addition to the component county or hyphen-
ated societies, many specialties, and they are listed in
your handbook, have specialty representatives here and.
therefore, when they speak will identify themselves as
representing that specialty section rather than a com-
ponent county society.
[Whereupon at this time Vice Speaker Carr as-
sumed the Chair.]
VICE SPEAKER CARR: Mr. Speaker. Members of
the House:
It is my duty to first introduce two speakers for short
informal reports for information, not for action, and
not for debate at this time.
First is Dr. Frank Sohmer who will speak on the
current status of PSRO.
He is speaking to u^ as Chairman and Medical Di-
rector of the North Carolina Medical Peer Review Foun-
dation.
DR. M. FRANK SOHMER. Jr. [President. North
Carolina Medical Peer Review Foundation. Inc.]:
Thank you, Mr. Speaker. Ladies and Gentlemen, it is
with pleasure that I report to \ou as President of the
North Carolina Medical Peer Review Foundation. Incor-
porated.
This organization was established with the endorse-
ment of the E.xecutive Council of this Medical Society
in February of 1973.
The intent at that time was to respond to the PSRO
legislation.
I have had the pleasure of serving as President of
this organization since that time and with the very e.\-
cellent Board, composed of many of the officers of this
Medical Society, the following actions have taken place:
In September 1973 we made application to HEW for
a single state PSRO designation. At no time have we
changed our stance. We have been to Washington, we
have talked to people in Atlanta. We continue to main-
tain this stance and as Dr. Gilbert has said, we now
have eight PSRO's in this state. We have eight geo-
graphic designations. We do not have eight PSRO's.
An additional activity of this North Carolina Medical
Peer Review Foimdation has received an RMP grant
and this was for educational seminars which we have
had fourteen — or. we're in the process of having fou
teen. We have accomplished thirteen of these at th
time.
In addition, we are establishing a Committee q
Norms and this committee will develop criteria fc
standards for each PSRO to use only as guidelines, (
be altered to implement each PSRO's activities.
It is not a cookbook that you're all going to ha\
to practice by. It's only a guide to help you in the dl
velopment of a program as required bs' the law.
I might say that copies of the presentation that \\
made with the educational seminars are at the desk
any of you are interested in seeing the presentatic
that was made, this talk is available to you at the re
istration desk.
In addition, as Dr. Gilbert referred to earlier, v
contracted with the Department of Human Resourc<
to provide a quality of care review on all Medica
patients in skilled nursing home facilities, psychiatr
hospitals and tuberculosis center sanitoria.
We signed a >ear's contract in March of this ye;
We have been developing a program. The first actu
on site review will take place on May 28th.
As many of you are aware, we have solicited phy^
cians in the state to find out who's interested in servi:
on the review team. There will be four review tear
in the state. The review teams will consist of a nur
and a social worker.
We envision using man\', many physician review<
to do on site review.
We have had over five hundred physicians respo:
and express interest in participating in this program.
In addition, we have made application to HEW f
designation as a statewide support center and I mig
say there will be a statewide council. The statewii
support center has nothing to do with the council.
Where there are three or more PSRO's. geograph'
designations, or potentially three or more PSRO's in
given state, HEW has seen fit to establish the desigr^
tion as a statewide support center.
Our initial efforts, if we are approved and apparent
we will be, will again be in an educational effort
make physicians aware of what the requirements of tl
law are and, in addition, in an organizational effc
in the eight areas to aid those interested individui
and groups in establishing a non-profit corporation
establish a PSRO.
We will continue to aid until that organization h
made application for a planning grant.
Following this, after the organization has been
veloped and has made application for a planning gra^
we would then only serve at the request of the indi
dual PSRO as a service organization. We will provi
administrative data, etcetera.
We would in no way have anything to do with loQ
review, would have nothing to do with the directjii
of the individual PSRO and its activities.
We're hopeful that each individual PSRO organiz
tion i;s it develops will see fit to utilize the statewi
support center for these purposes.
There has been no funding from the North Carolii
Medical Society for this Foundation from its inceptin
None of your dues, no money has been received fro
the Medical Society for this Foundation.
We, at the present time, are renting space in t
Medical Society building in Raleigh. We are paying tl
going commercial rate for this. We have paid the Me
a
\:\
HOUSE OF DELEGATES
53
cal Society for all services that they have rendered
;tO the Foundation.
All fLinds that have been received for this Founda-
!;tion have been received from grants such as the RMP
grant and from contracts such as the Medicaid nursing
home contract.
Membership in the statewide Foundation is open to
any licensed physician in this state, or to any doctor
of osteopathy. We encourage your membership. We en-
courage your participation. We need your support. We
■need your input and applications are also available for
membership at the desk.
Thank you, very much. [Applause]
VICE SPEAKER CARR: Thank vou. Dr. Sohmer.
urti)
kk We wil
iat il
REPORT ON N. C. MEDPAC
now hear from Dr. Hollister on Med-Pac.
DR. WILLIAM F. HOLLISTER: [Chairman,
(North Carolina Medical Political Education and Action
ijCommittee.] Mr. Speaker, Members of the House and
icii|iiGuests:
I welcome this opportunity to bring you a message on
Ai'l'lthe activities of MedPac and the activities which have
ntliibeen going on in this past year.
leiji Your MedPac Committee has been very active during
Hithis past year. The 24-member Board of Directors has
i met five times and will meet again this coming Monday
e«tpinight.
I'm pleased to report to you that your membership
\<so far this year has already exceeded our total of last
year by some 250 members.
iVj When I became Chairman of the MedPac Board last
™,|May, one of my goals was to see to it that MedPac was
wfiknown to every member of the North Carolina Medical
Society.
■jpjii At our first Board meeting, I asked each member
5 unto participate in a Speakers' Bureau so that any county
siffeiiociety that requested a program concerning MedPac
;ould have a member of the Board available to speak
cto their medical society at any designated meeting.
Also, Mr. Steve Morrisette of the headquarters staff,
f:ias spoken to several county medical societies and aux-
iUiary groups.
I would like to have Steve rise. He's in the back of
ihe room, because I want every member of the House
bf Delegates as well as members of the Medical Society
1x0 know Steve if you don't already.
Steve has been doing a great job in governmental
ind legislative affairs and the Executive Council has re-
sillteently seen fit to allow an increase in his activities
jiin governmental affairs, so that we hope that he will
ae your governmental and legislative liaison man be-
tween each component medical society and that you will
loe seeing more of him personally this coming year
Sand in years to come.
Steve has been working very closely with Mr. John H.
iinijti^nderson to develop an expertise in governmental and
(legislative affairs. John has been very helpful to him
ii ind will continue to do so.
jtiilfl John has given me permission to tell you that two
eplitjiinembers of his firm, Henry Mitchell and John Jerni-
iirjp'i;an. will also be working with the Medical Society in
1
. I (A copy of the N. C. MedPac reporl. filed with [le appropriate su-
'b lervisory office is available for purchase from the Superintendent of
documents. United States Government Printing Office, Washington,
|i. C. 20402.)
legislative affairs and governmental affairs these coming
years.
Mr. Anderson has done a magnificent job this year,
as Legal Counsel for the Medical Society, as always.
So, there, you have the beginning of a new team which
can more closely coordinate our governmental and
legislative affairs with the affairs of your component
societies.
We need the input of your component societies which
I realize we have not had. We've not had the com-
munications with the MedPac Board which we should
have, but I can assure you that we have been working
hard in that direction.
I feel that this initial begmning of communications
on an eyeball to eyeball basis will cause the members
of the North Carolina Medical Society to see the neces-
sity for political action through your designated organi-
zation, MedPac.
In September we held our first workshop in conjunc-
tion with the Committee Conclave of the Medical So-
ciety. Those who attended the workshop felt it was
most beneficial and we hope to have regional workshops
in the coming year.
These workshops will provide physicians with back-
ground knowledge of the political process which is
so vitally needed in our profession today.
We have also arranged with the headquarters office
for a more efficient way of handling our membership
and it will be possible in the next few months to get
a print-out of all MedPac members in any given
county medical society.
We feel that this will aid us in increasing our mem-
bership.
We also plan to establish a quarterly newsletter for
MedPac members. This Newsletter will keep them in-
formed of what's going on in the organization.
The MedPac Board voted at its last meeting to ap-
propriate funds from our educational account for the
purpose of producing a film about the state political
action committee. This film has been completed and
will be shown at the MedPac banquet tomorrow night,
which I hope you will all attend. This film will be
available to any county society or anyone else in the
Medical Society who would like to use it. We have two
copies of the film. We plan at this time to use the
film as part of our presentation when we speak at
county society meetings and at auxiliary meetings.
I would remind you t'lat MedPac dues are only $20
a year or $100 a year for sustaining membership.
I would hope that every member of the Medical
Society and particularly members of this House of Dele-
gates would become members of MedPac and support
your medical political action and edticational organiza-
tion.
Thank you very much for this opportunity to present
this report to you.
[Applause]
VICE SPEAKER CARR: Thank you. very much. Dr.
Hollister. We hope that your words will be heeded.
ANNUAL REPORTS
The next order of business is acceptance of the An-
nual Reports. The Annual Reports are contained in the
Compilation which you have in your packet, the 1974
Compilation of Annual Reports. They emanate from
various committees, commissions, boards, etcetera, in-
56
1974 TR.\NSACTIONS
a motion that the slate as presented to you be accepted
bv acclamation.
' DR. GEORGE W. PASCHAL: So moved.
(The motion was se\erall\' seconded from the floor.)
All those in favor please say "aye"; opposed "no."
The motion carries. The slate is elected.
SPE.AKER D.AVIS: I think you also recall that the
b\laws pro\ide that the Nominating Committee will also
circulate to you as voting delegates of this House at
least thirty days in advance of our session a list of
nominations for committee members of the Society and
I'll ask at this time Dr. Elliott Dixon to come forward
and place these nominations before vou.
DR. J. ELLIOTT DIXON (Chairman. Nominating
Committee): Mr. Speaker. Members of the House of
Delegates:
We present to \ou the following names for nomina-
tion:
North Carolina Board of Medical Examiners, six year
terms:
David S. Citron of Charlotte: James Jerome Pence
of Wilmington; and Jack Powell of .Asheville.
AM A DELEG.ATES:
John Glasson of Durham; Donald Koonce of Wil-
mington.
AM A Alternate Delegates:
James E. Davis of Durham: Louis Shaffner of Win-
ston-Salem.
Medical Care Commission, four year term:
Hugh F. McManus of Raleigh.
Editorial Board. North Carolina Medical Journal.
four year terms:
George Johnson of Chapel Hill;
Robert W. Prichard. of Winston-Salem.
Board of Directors of North Carolina Blue Cross
Blue Shield, three \ear terms:
Roy S. Bigham. Jr.. of Charlotte;
James E. Davis of Durham.
Retirement Savings Plan Committee, three \ear terms:
,A. Hewitt Rose. Jr.. of Raleigh;
George W. James of Winston-Salem.
Committee on Blue Shield, three \ear terms;
Gloria Graham of Wilson;
Meh in P. Eserman of Lincolnton:
Carl Warren of Charlotte;
Thomas Fox. Jr.. of Charlotte;
Robert M. Gay of Greensboro:
Angus McBryde of Charlotte:
Victor G. Herring of Tarboro;
R. Bertram Williams of Wilmington:
Irvin P. Plaisance of ,Ashe\ille.
Thank \ou.
SPEAKER D.A\ IS: Thank you. Dr. Dixon.
These names ha\e now ofhcially been placed in nomi-
nation and the floor is open to other nominations.
(The Speaker called for nominations from the floor
for each of the positions listed by the committee on
Nominations without a response from the floor. )
May I ha\e a motion then?
DR. DIXON: I mo\e that the nominations be closed
and that the slate as submitted be elected.
DR. CHARLES W. STYRON: Second.
SPE.AK.ER DAVIS: Those favoring this motion
please say "aye"; opposed "no."
This slate is elected.
Thank vou. \er\ much. Dr. Dixon.
I would like to remind the House what a time co
suming and difficult job the Nominating Committee h;
I think \ou are aware of the fact that it excludes tl
members of this committee from any other positio
within the Society. It requires a great deal of time ai
conscientious thought.
We appreciate ver\ much the work your committ
has done. Dr. Dixon.
VICE SPEAKER CARR: The next order of busine
is the report of the Committee on Constitution ai
Bylaws. In your packets this concerns Reports "M
"P". "Q" and "R" in case \ou want to refer to them.
Dr. Henry Carr. your newly elected Vice Speak*
is also Chairman of the Committee on Constitution at
B>laws. I present him to \ou at this time for action c
his report, or various parts of it.
CONSTITUTION AND BYLAWS
DR. HENRY J. CARR [Chairman. Committee c
Constitution and Bylaws]: Mr. Speaker. President G
berl. Members of the House of Delegates:
Report "M" is the first item of business today.
REPORT M
Subject: Proposed Change in The Constitution
Referred To: Reference Committee I
At the 1973 House of Delegates, the following pn
posed Constitution change was accepted by a majori
of the House of Delegate members. Final action on th
Constitution change will be made by the 1974 Hou
of Delegates.
ARTICLE 11'. Seciion 1. page 4 of the Constitutii
regarding student members, the first sentence now rea
as follows:
"Any student who is regularly enrolled as a
candidate for the degree of Doctor of Medicine in
a School in the State of North Carolina and who
is an active member of his local Student American
Medical Association Chapter shall be eligible for
Student Membership."
The proposed change would delete the phrase "ar
who is an active member of his local Student Americc
Medical Association Chapter"
The new first sentence would then read as follows:
"Any student who is regularly enrolled as a candi-
date for the degree of Doctor of Medicine in a
school in the State of North Carolina shall be
eligible for Student Membership."
The remainder of Section 7 of ARTICLE IV of tt
Constitution, page 4. v\ould remain unaltered.
The Committee on Constitution and Bylaws recor
mends this change.
The Committee on Constitution and Bylaws recor
mends this change, and final action on this propose
constitutional change can be made toda\.
VICE SPEAKER CARR: You have heard the repo
of the committee on this proposed change in the consi
tution. It was received by \ou last \ear for consideratii
It is now in order that it be approved or disapprove.
Ratification will take tv\o-thirds of the membe
present, or delegates registered.
DR. LOUIS SHAFFNER: Mr. Speaker. I move it I
approved.
[The motion was seconded from the floor.]
.An\' further discussion of this constitutional amem
ment proposal?
HOUSE OF DELEGATES
57
p-r
» i All of those who approve, or are in approval of
til his report of the constitutional amendment, say "aye":
'(iipposed "no."
tic I rule two-thirds carries the amendment and it is
pproved.
DR. HENRY CARR: Reports "P". "Q" and "R"
r|'iertain to constitution and bylaws changes that are
Ubmitted to this House of Delegates for consideration.
1 Report "Q" regards a constitution or bylaws change
sgarding compulsory continuing education as a require-
'aent for membership in the Society.
This proposed change was submitted as a constitu-
,;i)Onal change. However, this could be made a bylaws
:ihange rather than a constitutional change and there-
ore could become effecti\e at this annual meeting
ither than waiting for the 1975 annual meeting if it is
jade a constitutional change.
Constitutional changes must wait over for one year
br final action and bylaw changes can become effec-
[|jive the same year, laying on the table for one day and
iceiving an approval vote.
The bylaws change would be to add the sentence as
,reviously proposed as a constitutional change, to Chap-
r I. Membership, of the bylaws, page 13. making a new
3ction 5 with the proposed sentence. This suggestion
at the discretion of the House of Delegates.
VICE SPEAKER CARR; Since the^last one involves
ill change of status, a proposed constitutional change to
t If bylaws change. I will take it up first as it requires
decision whether it goes to a Reference Committee
a bylaws change or as a constitutional change.
utilDR. SHAFFNER: I move that this proposed change
considered as a bylaws change and so submit it
the Reference Committee.
B [The motion was severally seconded from the floor.]
I'No further discussion.
All those in favor of this motion say "aye"; all op-
iMsed "no."
I [The motion carried.]
iYou have heard the other two plus this one which
6! as I understand for bylaws change, and will be re-
jirred to Reference Committee 1.
DR. J. BENJAMIN WARREN: 1 move that they be
cepted for consideration by this House.
I'he motion was seconded from the floor.]
j^Any discussion?
Mil those in favor say "aye": all opposed "no."
IThey have been accepted for consideration and I will
w refer them to Reference Co:nmittee 1.
REPORT P
'bject: Proposed Changes in the Constitution and
(Bylaws
ferred To: Reference Committee No. I.
The May .5. 1974. meeting of the E.xecutive Council
isidered and approved the following proposed changes
the Constitution and Bylaws submitted by the Com-
ttee on Constitution and Bslaws. to be submitted to
: House of Delegates.
PROPOSED CHANGES IN THE
CONSTITUTION AND BYLAWS
re: :
in'
i»
lit
. Chapter IV — House of Delegates: Chapter IV.
I'.tion 2, page 16, line 3. now reads: "A list of such
■agates shall be certified officially by the secretary of
\h component county medical society or in the case
of student delegates by the Chief Executive Officer (or
his designee) of each medical school in the State of
North Carolina, to the Executive Director of The Society
on forms furnished by the Secretary of The Society,
who shall issue an official certificate to each delegate."
The proposal is to delete the phrase, "or in the case
of student delegates by the Chief Executive Officer (or
his designee) of each medical school in the State of
North Carolina." and insert after the sentence ending
"who shall issue an offical certificate to each delegate.",
on line 8. the following sentences: "In the case of student
delegates, the student members of The Society at each
medical school in the State of North Carolina shall
hold an election on or before December one of each
>ear for the purpose of electing delegates and alternate
delegates to the House of Delegates. This election and
these delegates and alternate delegates shall be certified
by the Chief Executive Officer (or his designee) of each
medical school in the State of North Carolina to the
Executive Director of The Society in the same manner
as provided above for reporting component county
medical society delegates. An official certificate shall be
issued to each student delegate by the Secretary of The
Society."
The remainder of the paragraph would continue as is
for the next two sentences (lines 8 through 15). In
lines 15 through 17 which now reads: "Every delegate
shall be a voting member of The Society and a com-
ponent county medical or hyphenated society or Student
American Medical Association Chapter." delete the
phrase. "Student American Medical Association Chap-
ter." and insert the phrase "student member of The So-
ciety."
It would then read as follows:
"A list of such delegates shall be certified officially
by the Secretary of each component county medical
society to the E.xecutive Director of The Society on
forms furnished by the Secretary of The Society, who
shall issue an official certificate to each delegate. In
the case of student delegates, the student members of
The Society at each medical school in the State of
North Carolina shall hold an election on or before De-
cember one of each year for the purpose of electing
delegates and alternate delegates to the House of Dele-
gates. This election and these delegates and alternate
delegates shall be certified by the Chief Executive Of-
ficer (or his designee) of each medical school in the
State of North Carolina to the Executive Director of The
Society in the same manner as provided above for re-
porting component county medical society delegates. An
official certificate shall be issued to each student dele-
gate by the Secretary of The Society. In the esent that
the regular delegate is unable to attend, he shall endorse
his certificate in favor of his alternate delegate. If
neither the delegate nor the alternate delegate is able to
attend the meeting of the House of Delegates, the dele-
gate may designate some other member of his society
or hyphenated society, or in the case of the Student
delegates, the delegate may designate some other student
member from his medical school, to attend the sessions
of the House of Delegates. Every delegate shall be a
voting member of The Society and a component county
medical society or hyphenated society or student mem-
ber of The Society."
II. Chapter XI — Sections: Chapter XI. Section 1.
page 54. line 18. now reads: "The following Sections
58
1974 TRANSACTIONS
shall constitute the regular scientific program: Surgery,
Internal Medicine. Obstetrics and Gynecology, Public
Health and Education. Pediatrics, Ophthalmology and
O.olaryngology, Family Physicians, Neurology and Psy-
chiatry, Radiology. Pathology. Anesthesiology. Ortho-
paedics. Student Member. Dermatology and Urology."
The proposal is to delete the "and"" between Oph-
thalmology and Otolaryngology and inserting a comma
in lieu thereof; delete the "and"' between Dermatology
and Urology, and to insert after "Neurological Surgery"
and "Urology.""
The sentence would then read as follows:
"The following Sections shall constitute the regular
scientific program: Surgery. Internal Medicine. Obste-
trics and Gynecology. Public Health and Education,
i'ediatrics. Ophthalmology. Otolar\ngology. Family Phy-
sicians. Neurology and Psychiatry. Radiology. Path-
ology. Anesthesiology. Orthopaedics. Student Meri^ber.
Dermatology. Urology, and Neurological Surgery.""
III. Article IV — Membership of The Society: Article
IV. Section 6, page 3. line 16, now reads: "Intern-
Resident Training Members: Physicians who are in
training in hospitals in the State of North Carolina,
which are accredited by the Joint Accreditation Com-
mission on Hospitals for the contmuing education of
interns or residents licensed to practice in North Caro-
lina may be admitted to membership in The Society
without becoming a member of a component countv'
society for and during the period of time in which they
are engaged in such training.""
The proposal is to change "in the State of North
Carolina"" to "in the United States"" and inserting the
phrase "and certify their intention, to the best of their
knowledge at that time, to practice medicine in North
Carolina."" after the phrase "licensed to practice in North
Carolina"" and before the phrase "may be admitted to
m.embership. . . .""
The first sentence of Section 6 would then read as
follows:
"Intern-Resident Training Members: Ph\sicians who
are in training in hospitals in the United States, which
are accredited by the Joint Accreditation Commission
on Hospitals for the continuing education of interns or
residents and who are licensed to practice in North
Carolina and certify their intention, to the best of their
knowledge at that time, to practice medicine in North
Carolina, may be admitted to membership in The
Society without becoming a member of a component
county medical society for and during the period of
time in which they are engaged in such training."
REPORT Q
Subject: Constitution and Bylaws Change Regarding
Co:nipulsory Continuing Education as a Requirement
for Membership in the Society
Referred to: Reference Committee I
The May 5. 1974. meeting of the Executive Council
discussed the problem of implementing a change in the
Constitution in regard to the compulsory continuing
education as a requirement for membership in the So-
ciety approved by the House of Delegates in 1973. The
Chairman of Committee on Constitution and Bylaws
indicated that It had not been possible for the Com-
mittee to meet on this subject but that he had some
tentative Constitution and Bylaw wording regarding the
compulsory continuing education as a requirement f(]
membership for consideration by the House of Del
gates in case they want to take action on this subje(
at this Annual Meeting.
The suggested wording, by adding a sentence in t\
Constitution under the Section on Membership of tl
Society, is as follows:
"Completion and certification of a program of
continuing medical education on a periodic basis by
the members of the Society as specified by the
House of Delegates shall be a requirement for
continued membership.""
The Executive Council passed a motion to the effe
that this part of the report of the Chairman of tf.
Committee on Constitution and B\laws be accepted
principle with the wording to come from the Committe
This wording was suggested and approved by tl
Executive Council, but at this writing has not offic
ally been considered by the Committee on Constitutic
and Bylaws. It is anticipated, however, that this wordii
would be approved by the Committee.
Upon introduction of this Report Q before the fir'
meeting of the House of Delegates on Sunday. Mj,
19. 1974. the House of Delegates approved making tb
amendment a b\law change instead of a constitution
change by adding the above proposed sentence to Cha
ter I. Membership, as a new Section 5 with the Pn
posed sentence becoming the new Section 5 on page 1
REPORT R
Subject: Proposed Change in the Constitution at
Bylaws
Referred to: Reference Committee No. I
The May 5, 1974. meeting of the Executive Coun(
approved a recommendation from the Chairman of tl
Annual Convention Commission that the Committee (
Memorial Services be dissolved and that the duties
the Committee be assumed by the Committee on Mec
cine and Religion, and that the Committee on Co;
stitution and Bylaws prepare the amendment to tl
Bylaws to effect the elimination of the Committee o
Memorial Services.
The Committee on Constitution and Bylaws in co
formity with this request therefore recommends that tb
can be accomplished by deleting the phrase, Committ
on Memorial Services in Section 2. page 33. Chapt
10 — Committees, in section on Bylaws and also by d
leting the section on Committee on Memorial Servid
on page 37. Section 6. Chapter 10 — Committees. T|
whole paragraph that forms Section 6 shall be deleti
and the other sections will be numbered appropriate
after that with the next printing of the ConstitutH
and Bylaws.
SPEAKER DAVIS: Thank you. Drs. Carr, yo
new Speaker and Vice Speaker! They certainly work
gether well and Em certain they will in the years
come.
Just a word about Reference Committees. These iter
will, of course, be brought up b\ the committee. 1
floor will be open for discussion by an>one. any met
ber of the Society, whether he be delegate or not ai
anyone interested in testifying as to any of these res
lutions is welcome and even non-members of the S
ciety. at the discretion of the Chairman, if they af
f
1
HOUSE OF DELEGATES
59
' Ifclt to have input as a resource person, will be allowed
■I h speak.
M These reports as you have seen have been culled
bt of the reports of the three sessions of the Execu-
i live Council and since this House has the authority
li 1) accept or reject the actions of the Executive Council,
DU are the ultimate authority of this Medical Society.
l All of the reports emanating from the Council must
|B presented to you.
f I will now recognize Dr. Gilbert, Chairman of the
'xecutive Council of course, to submit the other reports
om the Council, those not relating to changes in
jnstitution and bylaws.
J
1 REPORTS OF THE EXECUTIVE COUNCIL
|,,j) PRESIDENT GILBERT: Each of you have received
' your packets, summaries of the actions of the Execu-
ve Council at its sessions on September 3()th, 1973;
ebruary 3rd, 1974; and. May 5th. 1974.
■; These three summaries represent actions by the Ex-
I mtive Council which it was felt did not require spe-
,al reports, but which are submitted in summary form
' , r your consideration and hopefully your approval.
You have also in your delegate packet Reports "A"
rough "R" which originated from actions of the Coun-
1 at these three meetings. There is no Report "L" be-
|,use that letter was accidentally overlooked in the
iping of the reports.
IThe Chairman of the Committee on Constitution and
/laws has already reported on "M." "P," "Q" and
i I, therefore, move that these lettered reports as
inted, with the exception of "L," "M," "P," "Q" and
it*
"R" be received at this time for consideration by the
House of Delegates and referral to the Reference Com-
mittee as indicated, without being read at this time or
further identified.
|1 he motion was severally seconded from the floor.]
SPEAKER DAVIS: The motion was to refer all
of the other reports Dr. Gilbert has mentioned. Ques-
tions regarding these reports are in order, debate is not,
but as I've indicated open debate will be available in
the Reference Committees. These committees consisting
as you see of three delegates will then bring in a recom-
mendation to the House on Tuesday.
Again, if you have not foimd satisfaction in your
discussion at the Reference Committee, the floor will be
available for further discussion and a vote at that lime.
So. we are then back to the motion to refer the re-
ports as listed by Dr. Gilbert.
Any discussion on this?
[No response]
Those favoring this motion for referral, please say
"aye"; opposed "no."
They are referred as indicated and we will not read
the specific Reference Committee numbers.
REPORT A
Subject: The Annual Budget Estimates for 1974
Referred to: Reference Committee No. 1
The Executive Council, at its September 30, 1973
meeting, considered the proposed budget for 1974 as
recommended by the Committee on Finance.
On motion duly made and seconded, the budget esti-
mates for 1974 were adopted by the Council.
The Budget Estimates for 1974 are as follows:
■
BUDGET ESTIMATES
January 1, 1974 to December 31, 1974
1973
jl^eCEIPTS: (ESTIMATED)
'.Estimated balance January I, 1974 NIL
iAnnual Dues, paying members $520,000
[Sales — Rosters, Journals 3,500
iRevenue Unexpected 3,000
itlfTechnical Exhibits 10,000
nil Journal Net Advertisement — Local 10,000
ii IJoumal Net Advertisement — National 35.000
)**AMA Remittance Hi of dues processed — plus interest 3,700
MEDPAC Remittance \^'c of dues processed 220
en|tlRental Income (New Headquarters Facility) 49,936
interest Income — Operating Funds — 0 —
II
$635,356
i#i:PENDITURES: (ESTIMATED)
A $205,140
B 82,252
C 34,750
D 14,160
E 8,260
F 22,060
G 43,609
M 225,125
>5chedule
'Schedule
ijchedule
(Schedule
schedule
jchedule
;ichedule
(ichedule
ml
$635,356
1974
NIL
$376,000
5,600
4,500
10,560
10,000
35,000
7,500
220
50,936
6,000
$506,316
$228,910
86,425
34,790
18,100
8,610
21,490
52,541
55,450
$506,316
fo be appropriated to Secretarial Budget A-6.
'//
60 1974 TRANSACTIONS
1973 1974
EXCESS OF RECEIPTS OVER EXPENDITURES —0— — 0-
EXCESS OE EXPENDITURES OVER RECEIPTS —0— — 0-
RESERVES: (Estimated Cash Reserves— 560,000)
SUBMITTED TO COMMITTEE ON FINANCE September 16. 1973
SUBMITTED TO EXECUTIVE COUNCIL FOR APPROVAL September 30. 1973
SUBMITTED TO HOUSE OF DELGATES FOR APPROVAL May 19, 1974
A. EXECUTIVE BUDGET
A- 1 President, expense of (travel & communications) * $ 7.000 5
A- 2 President's secretarial assistance 5,000
A- 3 Secretary, travel of* 1.000
A- 4 Executive DirectorTreasurer. salary of 24,000
A- 5 Executive DirectorTreasurer. travel of* 6,000
A- 6 Executive Office. Secretarial & Clerical Assts.** 45,000
A- 7 Executive Office, equipment-replacements - 4.000
A- 8 Executive Office, expense of (communications, printing, and supplies, repairs &
replacements of expendables) 18.000
A- 9 Bonding (m effect to 1975) — 0—
A-10 Audit (Quarterly & Annual) 2.000
A-l 1 Taxes (salary tax).. 6.440
A-12 Insurance: fire, liability & compensation 2.200
A-l 3 Membership Record. Acctg.. IBM Machine Rental, Forms 8,600
A-14 Publications, reports & executive aids 300
A-13 Assistant Executive Director, salary of 17.200
A-16 Assistant Executive Director, travel of 3.000
A-17 Assistant to Executive Director, salary of 12.900
A-22 Controller, salary of 1 5.400
A-23 Field Representative, salary of 12.500
A-24 Field Representative, salary of 9,600
A-25 Field Representatives, travel of* 5,000
$205,140 $228,9
B. JOURNAL BUDGET
B- 1 Journal, printing and mailing. $ 59.800
B- 3 Editor, salary of ^ B-llt
B- 4 Assistant Editor, salary B-llt
B- 5 Editorial Office, expense of ( 12 months rent, communications, printing and
supplies, repairs and replacements) 850
B- 6 Journal Business Manager's Office expense of ( 12 months communications.
printing and supplies, repairs, and replacements) 1,000 9'.
B- 7 Business Manager's Office, equipment for 100 U
B- 8 Journal, travel for (Local and National) 200 U
B- 9 Taxes (salary tax) 1.052 l.2(
B-10 Sales tax on Journal subscriptions and Roster Sales 2.200 2,41
B-ll Journal Salaries 17,050 18,8)
B-13 Advertising Secretary, salary of B-llt B-ll
S 82,252 S 86.4
C. INTRA-FUNCTIONAL ACTIVITY BUDGET
C- I Executive Coimcil expense of and travel of Councilors including district travel 5 4,600 S 4,5
C- 2 Publication of Executive Council Minutes, Transactions, Annual Reports 6,500 5,5'
C- 3 Legislative Committee, expense of ( Local and National activity) 5,000 6,5j
C- 4 Maternal Health Committee, expense of (secretarial, communications.
printing and supplies) 600 3l
C- 5 Committee on Drug Abuse 1.000 :
C- 6 Committee on Arrangements C-l 1 C-1
C- 7 Committee on Scientific Exhibits, expense of (including S200 for Scientific
Exhibit Awards and S2()l) for Student Scientific Exhibit Award ) — Committee
' Basis: Real for personal ni.iirUcnanLe and Iravel 'n 15c- per mile .'ind or common carrier r.ile .md lor olficial purposes.
' Any revenue derived (roni collection ellorls related to Americin Medical Association dues .ind processing of same shall accrue to this item oi i
Budget.
■ Transferred to B-ll.
HOUSE OF DELEGATES
61
1973
1974
^:-
M.
- 9
-10
-11
-12
-13
-14
-15
-16
';-i7
;-i8
;-i9
;-20
-21
:-22
>23
''i24
^1^-25
;f;-26
■r-27
|'-'.28
■ |-,29
'■i ^.-30
*.31
SJ !
ill
'■-32
34
36
37
38
39
|40
Ul
42
.43
1.45
146
48
is
150
f'51
'•52
'53
■>4
55
()6
on Audio-Visual Programs transferred to separate line item C-61 $
Committee on Mental Health
Committee on Mediation
Committee on Chronic Illness. TB & Heart Disease
Committees in general, expense of (including committees imder $100 allocations)
Committee on Nominations
Committee on Occupational & Environmental Health
Committee on Professional Insurance
Committee on Relative Value Studies
Committee on Negotiations
Committee on Student AMA [Section & Transportation & Delegate to SAMA
one each Medical School Chapter (3)1-
Committee on Disaster Emergency Medical Care
Committee on Industrial Commission
Committee on Constitution and Bylaws
Committee on Medical-Legal
Committee Advisory to N. C. Department of Motor Vehicles
Committee on Cancer
Committee on Anesthesia Study
Committee on Child Health & Infectious Disease
Committee on Blue Shield
Committee on Hospital and Professional Relations
Committee on Social Services Program
Commitee on Memorial Services (Necrology)
Insurance Industry Committee
Committee on Community Medical Care, sponsorship of 4-H Health activity for
trip to National 4-H Club for State Health Winner, and "Today's Health"
subscription to 4-H Health winners; Dues Rural Health Safety Council;
Miscellaneous expense
Committee on Retirement Savings Plan
Committee on General Sessions Program (Scientific Works)
Committee on Marriage Counselling & Family Life Education
Committee on Medicine and Religion
Committee on AMA-ERF (Chairmanship includes Auxiliary under item D-3)..-.
Commtitee on Credentials
Committee on Scientific Awards
Committee on Physical and Vocational Rehabilitation
Committee on Eye Care and Eye Bank
Committee on CHAMPUS
Council on Review & Development
Committee on Finance
Committee on Medicare
Committee on Medical Education
Committee on Comprehensive Health Service Planning
Committee on Medical Aspects of Sports
Committee on Association of Professions
Committee on Physicians on Nursing
Committee Liaison to N. C. Pharmaceutical Association
Committee on Personnel & Headquarters Operation
President's Communications Program (Newsletter)
1,225
.$ 1 ,220
400
400
400
500
400
C-ll
4.500
4,500
C-ll
C-ll
C-11
200
c-ll
C-ll
600
600
C-ll
discontinued
1 ,060
2,000
600
600
C-ll
C-1 1
500
500
C-ll
C-ll
C-ll
C-ll
C-Il
C-ll
365
320
C-ll
C-ll
C-ll
C-ll
C-ll
c-ll
c-ll
C-l 1
c-ll
c-ll
800
800
500
C-ll
c-ll
300
350
C-ll
C-ll
c-ll
c-ll
c-ll
C-ll
c-ll
C-l I
200
1 ,000
250
1,000
C-ll
200
C-ll
C-ll
1 ,200
'«7 Advisory Committee on the Crippled Children's Program C-l I
'8 Committee on Peer Review 200
19 Committee on Health Care Delivery 1,000
iO Committee on Archives of History-NCMS C-ll
111 Committee on Audio-Visual Programs (Combined with item C-7 in 1973) combined
with C-7
$ 34,750
I EXTRA-FUNCTIONAL ACTIVITY BUDGET
I I Delegates to AMA, expense of (8 including alternates to each Annual and
Clinical Session) $ 9.700
|2 Conference Dues 200
500
C-ll
1,500
500
350
C-ll
C-l I
C-ll
C-l I
C-ll
discontinued
C-ll
C-ll
C-ll
1 ,000
c-ll
1 ,000
c-ll
200
C-l I
C-ll
transferred
to item D-5
C-ll
200
750
C-ll
150
$ 34,790
1.100
250
62 1974 TRANSACTIONS
1973
D- 3 Woman's Auxiliarv (contribution to entertainment, travel to National Auxiliars'
for 1 and productions) $ 4,260
D- 5 President's Communication Program (Newsletter) ( transferred from item C-56).... See C-56
S 14.160
E. PUBLIC RELATION.S BUDGET
E- 3 Committee Chairman, out of State travel..... $ 500
E- 9 .Audio-Visual depiction, photography, radio-motion pictures, production.
distribution and printing, purchase of films, etc.. — 0 —
E-10 Educational distribution; reprints, periodicals, press materials, pamphlets, and
dodgers for educational purposes; production, distribution and printing,
binding, stuffing and mailing " 500
E-1 1 News and press releases, production and printing of 200
E-12 Public Relations Bulletin, production and printing of 3,500
E-13 State High School Science Fair Program, Award for 160
E-14 Exhibits and Displays; Purchase, rental, production, fabrication and
transportation of - 350
E-1 5 Conference for Medical Leadership 1.500
E-17 Today's Health Magazine Subscriptions 850
E-1 8 Collateral Public Relations with other committees 500
E-19 N. C. Rescue Squad First Aid Trophies 200
$ 8.260
F. ANNUAL SESSIONS (12{)th) CONVENTION BUDGET
F- 1 Program, Production of S 2.000
F- 2 Hotel and Auditorium expense 4,700
F- 3 Publicity promotion, expense of (reporters and expense) 600
F- 4 Entertainment (general in\ol\ing personnel) 1.200
F- 5 Orchestra and Floor entertainment 2.500
F- 6 Guest Speakers expense and or honorarium 900
F- 8 Electric Amplification, operators, installations and screening auditorium — 0 —
F- 9 Booth installations, supplies, expense signs (Scientific and Technical ) including
exhibit expense & promotion 4,500
F-IO Projection, expense of (service rentals) 1.300
F-1 1 Badges (members, guests, exhibitors, auxiliary) 250
F- 1 2 Reporting Service for Transactions — ( House of Delegates. General Sessions and
Reference Committees) 2.500
F-1 3 Rental, extra facilities, trucks for sections and, or exhibits 200
F-1 4 Exhibitors entertainment 850
F-1 5 Banquet expense 200
F-16 Police Secuiity 360
S 22.060
G. MISCELLANEOUS BUDGET
G- 1 Legal Counsel, retainer fees for S 11.300
G- 2 Reporting. Executive Council Meetings 2.000
G- 3 Fifty Year Club Pins and Certificates, and President's Jewel 300
G- 4 Contingency and Emergenc\ --.- 4,174
G- 5 Retirement Sxstem for Societ\ Employees 19.175
G- 6 Advalorem Taxes (Personal Property) 960
G- 7 Association of Professions 200
G-10 Commissioners, expense of 1,500
G-11 Executive Committee, expense of 300
G-12 Officers, expense of 2,000
G- 1 3 Travel and Maintenance, expense of essential Headquarters Staff for out-of-state
meetings and in-state conferences 1.700
G-14 NCMS Headquarters Staff Hospitalizaion and Insurance Coverage charged
to G-4
S 43.609
J
s
21.',
s
16.;
2.1
3.:
21,1
1
1,)
2,1
2.1
2.
s
52 „
'|.M.
M-
■■ \m-
HOUSE OF DELEGATES
HEADQUARTERS FACILITY BUDGET 1973
Capital Investtnenis
1 Application to Mortgage Payments — estimated available $162,261
3 Mortgage Payable on Greenfield Property (a 1/5 of $13,000 plus 7% interest
on unpaid balance of $5,200 ($2,600 plus $364 interest) 2.964
4 Estimated Interest Cost on Mortgage ($100,000 (a 7%) 7,000
Sub-total $172,225
Operating Costs
5 Utilities $ 13,800
6 Insurance 1,700
7 Taxes (Real Property) 16,700
8 Water 500
9 Janitorial Services 1 5.0(J0
10 Grounds Maintenance 1,000
11 Building Repairs and Maintenance 1,200
12 Heating A/C Repairs & Maintenance. Elevator Maintenance 3,000
63
1974
-0—
-0—
$225,125
$ 15,000
1,750
16.200
500
13,500
1 .500
4,000
3,000
$ 55,450
REPORT B
Subject: Report of the ad hoc Committee to Study and
Recommend a Salary or Increase in Allowances for
the President
deferred to: Reference Committee No, 1
The ad hoc Committee to Study and Recommend a
alary or Increase in Allowances for the President
yas appointed by President John Glasson, M.D., at the
irection of the May 1973 meeting of the House of
, delegates. This was the result of House approval of
'.eference Committee II's substitute resolution for Reso-
ition No, 3 (1973) introduced by Pitt County Medi-
kl Society. The substitute resolution resolved "that a
lethod be made to increase the allowances for the
iresident of the Society" and "that this matter be re-
birred to an ad hoc committee appointed by the Presi-
ent for further study and recommendation."
The committee sent a questionnaire to each State
ledical Society. The information received covered ( I )
.le number of full-time and part-time employees: (2)
ze of annual budget: (3) does the President receive
i salary, and if so how much: (4) does the President
:ceive pay for outside secretarial and/or office ex-
enses, either on a fixed or reimbursable basis; and
:)') does the President receive travel expenses and if
;- is he paid on a fixed annual or monthly allowance
1 OD an actual reimbursement basis?
illt was found that of the 44 response. N, C. is
Jnong 12 states responding with a budget in excess
$500,000, Only eight percent of the states pay their
■esident compensation, ranging from $1,000 to $10.-
10. Ten of the states provide funds for secretarial
ilp and nine states pay for secretarial help on a re-
rlibursable basis. Only four states do not pay for travel
penses.
■iThe Charter of the North Carolina Medical Society
es not prohibit it from paying the President for ser-
i;es rendered, however such payment would require
at he come under the same provisions of any other
I its employees. The recipient of funds would be re-
lired to treat such monies as income. The Committee
t that with the coverage for travel and costs in-
^Ted plus the provision for secretarial help that the
Society actually exceeds the $10,000 salary provided
by some states.
The Committee agreed that the President should re-
ceive a generous allowance for expenses incurred, but
that a definite salary should not be provided. Based
on these and other considerations the Committee;
RECOMMENDED THAT THE SOCIETY CON-
TINUE TO PAY REIMBURSABLE EXPENSES AT-
TENDANT TO THE PRESIDENT INCLUDING
NECESSARY TRAVEL. HOUSING. FOOD, COM-
MUNICATIONS. AND OUT-OF-POCKET SECRE-
TARIAL EXPENSES: AND THAT IN ADDITION,
THE SOCIETY PAY A PER DIEM AT THE RATE
OF $25 PER DAY FOR DAYS OR PARTS OF
DAYS SPENT BY THE PRESIDENT OUTSIDE OF
THE HOME TOWN ON SOCIETY BUSINESS,
AND FURTHER RECOMMENDED IN AL-
LEVIATING THE BURDEN OF ASSUMING THE
PRESIDENCY THAT THE PRESIDENT-ELECT
AND THE IMMEDIATE PAST PRESIDENT BE
REIMBURSED FOR THEIR TRAVEL AND LIVING
EXPENSES WHEN BY VIRTUE OF THEIR OFFICE
THEY ARE INVOLVED IN OFFICIAL MEDICAL
SOCIETY FUNCTIONS.
It was estimated that the cost incidental to the im-
plementation of the first recommendation will be about
$2,500 and of the second, about $ 1.500.
REPORT C
Subject: Request that the Section on Ophthalmology
and Otolaryngology be divided into a Section on Oph-
thalmology and a Section on Otolaryngology
Referred to: Reference Committee I
A May 30, 1973, letter from Lee A. Clark. Jr..
M.D., 1973 Chairman of the Section on Ophthal-
mology and Otolaryngology advised President George
Gilbert that the Section had voted to split into separate
sections and requested the creation of a Section on
Ophthalmology and a Section on Otolaryngology. The
letter also requested that the old Section on Ophthal-
mology and Otolar\ngology be discontinued.
At its September 30, 1973, meeting, the Executive
M
1974 TRANSACTIONS
Council considered and recommended to the House of
Delegates approval of the request from the Section on
Ophthalmology and Otolaryngology.
REPORT I)
Subject: Guidelines for a Medical Director in a Long-
Term Care Facility
Referred to: Reference Committee No. II
The September ?<0. 1973. meeting of the Executive
Council approved a recommendation of the Committee
on Chronic Illness that the North Carolina Medical
Societv endorse the principle that long-term care fa-
cilities in North Carolina employ the services of a phy-
sician to serve as Medical Director. It also recommended
and the Council approved, that the Society endorse the
-Guidelines for a Medical Director in a Long-Term
Care Facility." as adopted by the American Medical
Association, as follows:
1. Assist in arranging for continuous physician cov-
erage for medical emergencies and in developing proce-
dures for emergency treatment of patients.
2. Participate in development of a system providing
a medical care plan for each patient, which covers
medications, nursing care, restorative services, diet, and
other services, and. if appropriate, a plan for discharge.
3. Be the medical representative of the facility in the
community.
4. Develop liaison with attending staff phvsicians in
efforts to ensure effective medical care.
5. In the absence of an organized medical staff, be
responsible for the development of written bylaws, rules
and regulations applicable to each physician attending
patients in the facility .
6. If there is an organized medical staff, be a mem-
ber, attend meetings and help assure adherence to medi-
cal staff bylaws, rules and regulations.
7. Participate in developing written policies govern-
ing the medical, nursing and related health services
provided in the facility.
8. Participate in developing patient admission and dis-
charge policies.
9. Participate in an effective program of long-term
care review.
10. Be available for consultation in the development
and maintenance of an adequate medical record sys-
tem.
11. .Ad\ise the administrator as to the adequacy of
the facility's patient care services and medical equip-
ment.
12. Be available for consultation with the admin-
is:rator and the director of nursing in evaluating the
adequacy of the nursing staff and the facility to meet
the psvchosocial as well as the medical and physical
needs of patients.
13. Be available for consultation and participation in
in-service training programs.
14. Advise the administration on employee health
policies.
15. Be knowledgeable concerning policies and pro-
grams of public health agencies which mav affect pa-
tient care programs in the facility .
REPORT E
Subject: Treatment of Tuberculosis Cases and Potenti
Cases
Referred to: Reference Committee No. II
The September 30, 1973. meeting of the Executiv
Council voted to approve the recommendation of th
Committee on Chronic Illness as follovss:
WHEREAS, in calendar year 1972, reports we
made to public health authorities of 996 new activ
cases of tuberculosis with sixty per cent being over tl
age of 44 years and seventy per cent being male, L3
reactivations of tuberculosis and 113 deaths attribute!
to tuberculosis in North Carolina, and
WHEREAS, in 1972 North Carolina had the twelff
highest new active tuberculosis case rate in the natici
( 19.1 per 100.000 population compared to U.S. rate (
15.S per 100,000) the Committee on Chronic Illness (
the North Carolina Medical Society recommends:
( 1 ) a renewed effort to identify and bring to trea
me.nt cases and potential cases of tuberculosis amot
the population
(2) that where treatment is indicated every attem]
be made to select, with appropriate consultation ar
laboratory investigation as necessary, an adequate ree
men of anti-tuberculosis drug therapy for a minimui
of two years of uninterrupted treatment in the case
active or probably active disease
( 3 ) that the initial phase of treatment of active cas
covering the period of possible infectiousness should
most cases take place in a hospital having the nece
sary medical, laboratory and supporting facilities for ft
esaluation and formulation of optimum drug thera[
plans
(4) that responsibility for supervising the carryi
out of treativ.ent at home and epidemiological inves:
gation of cases including the reporting of new cas
be actively shared with public health authorities.
NOTE: The tuberculin skin test is recommended
the initial screening procedure of choice in tuberculoi
casefinding.
REPORT F
Subject: Recommendation that hemophilus influen
meningitis be made a reportable disease
Referred to: Reference Committee No. II
The September 28, 1973, meeting of the Committi
on Child Health and Infectious Diseases discussed tl
Flu Meningitis problem in the Charlotte area. It was
ported that^ there had been 8-10 cases in the Chariot
area during the year. Following the discussion the Coi
mittee recommended:
In the light of its common occurrence and serious
complications both in the regard to mortality and
permanent brain damage, we feel that we should
strongly express the feeling that Hemophilus In
fluenza Meningitis be named as a reportable dis
ease. This is particularly apropos at the moment
in that vaccines may be available in the near future
to prevent this disease and a large clinical trial on
the vaccine is being performed in Mecklenburg
County.
The September 30. 1973 meeting of the Executi
Council, approval was voted for approval of the Col
mittee recommendation.
X
HOUSE OF DELEGATES
65
REPORT G
eili iiubject: Change in Dates of Annual Meeting and Survey
of tlie Membersliip Regarding Clioice of May or Sep-
tember
■jieferred to: Reference Committee No. I
i'l The September 30, 1974. meeting of the Executive
:3ouncil approved a recommendation of the Committee
m Arrangements for approval of September dates for
jhe Annual Meeting beginning in 1975 or as soon there-
fter as possible.
However, a following motion passed by the Execu-
kj:|)jive Council instructed that the Executive Director and
taff prepare a questionnaire to the membership con-
(Aerning the question including choice of dates as May
apposed to September.
A Survey was mailed to the membership on April 1.
1974. and by April 26. 1974. 1500 responses had been
eturned to the Headquarters Office.
Pinehurst received more than a four to one vote as
he preferred location in contrast to the other cities
isted which appear to have adequate facihties at present
or holding the Annual Meeting.
''"' An overwhelming majority voted for an Early or
''/lid May time of year for the Annual Meeting with
'nly slightly over 400 voting in favor of a September
aeeting time.
A majority of those responding expressed a willing-
ess to pay a registration fee of from $10 to $25 at the
Junnual Meeting if this became necessary, with 903
f those responding indicating a willingness to pay a
egistration Fee.
I
REPORT H
ubject: Compulsory Continuing Education as a Re-
quirement of Membership
deferred to: Reference Committee No. I
■ The September 30. 1973, Executive Council voted
ipproval of the Committee on Medical Education
tecommendation for implementation of a program of
liompulsory continuing education as follows:
( 1 ) that a minimum of fifty hours of continuing
Iducation per year be required of each member of the
late Society.
' (2) that wide latitude be allowed in the manner in
^'hich the required time is spent. Attendance at scientific
tieetings. participation in clinical conferences, perusal of
"iie scientific literature, etcetera, are all recognized as
'orthwhile forms of continuing education and credit
■I'ill be given for time so spent.
(3) that each physician keep and submit such records
's will enable him to certify each year that he has met
lie minimum requirement of fifty hours.
(4) that a form for certifying compliance with the
bove requirement be included with the annual notice
f dues sent each physician. This form could then be
jSturned along with payment of dues.
t\
REPORT I
Subject: Resolution Regarding the Delivery of Primary
Medical Care for Winston-Salem. N. C. (Resolution
12 — 1973 Annual Meeting)
eferred to: Reference Committee No. II
i Resolution 12 (Annual Meeting 1973) was intro-
duced by the Forsyth County Medical Society on the
jllbject: "Suggested Resolution Regarding the Delivery
of Primary Medical Care for Winston-Salem. North
Carolina."
Resolution 12 (A-73) was referred to Reference
Committee No. I which recommended that this resolu-
tion be referred to the Executive Council for further
consideration.
The Executive Council, at its February 3. 1974. meet-
ing in Raleigh, further considered Resolution 12 {A-73)
and after a review of suggestions by interested parties
recomended the following report to the House of
Delegates:
Since the purpose of the original resolution was
to assure a study that would aid the Board of Gov-
ernors of the University in making a realistic
recommendation to the Legislature, it would seem
that the study which the Board of Governors
themselves had done by a Panel of Medical Con-
sultants (September 21. 1973) has accomplished
the purpose of the original resolution from For-
syth County.
It was the suggestion of the Executive Council,
therefore, that the attention of the House of Dele-
gates and the Membership be called to this study
as an authoritative, unbiased, and lucid one which
fulfills the intent of the original resolution.
REPORT J
Subject: Request for the Establishir.ent of a Section on
Neurological Surgery
Referred to: Reference Committee No. I
A January 25. 1974. letter to President George G.
Gilbert from Ira M. Hardy. II, M.D., acting chairman
of the newly organized North Carolina Neurosurgical
Society, requested that a Section on Neurological Sur-
gery be formed in the North Carolina Medical Society.
As its February 3, 1974, meeting, the Executive Coun-
cil considered the request and recommended to the
House of Delegates approval of the request.
REPORT K
Subject: Proposed Position Paper "Need for More and
Better Distributed Primary Care Ph\sicians"
Referred to: Reference Committee No. II
At the February 3, 1974, meeting of the Executive
Council, a proposed position paper on "Need for More
and Better Distributed Primary Care Physicians" was
presented from the Comn-ittee on Community Medical
Care by Dr. John L. McCain. Commissioner on behalf
of Committee Chairman, Dr. J. Kempton Jones.
After considerable discussion, the Executive Council
voted to commend the Committee on Community Medi-
cal Care for doing an outstanding job and that the pro-
posed position paper be widely publicized to the mem-
bership and referred to the House of Delegates at the
Annual Meeting in May.
The proposed position paper is as follows.
NEED FOR MORE AND BETTER DISTRIBUTED
PRIMARY CARE PHYSICIANS IN
NORTH CAROLINA
Comniitlee on Coniniiinity Medical Care,
North Carolina Medical Society
The North Carolina Medical Society is vitally con-
cerned with every aspect of the medical care of the
66
1974 TRANSACTIONS
people of North Carolina. Of particular concern are
the deficiencies in the delivery of primar\ medical care
to the people of North Carolina in rural and less ur-
banized areas of the state.'
In keeping with the leadership that has become ex-
pected of the North Carolina Medical Society and as
evidence that our present medical care system is con-
cerned and responsive, the following position paper has
been prepared on the need for more and better dis-
tributed primary care physicians. The Committee on
Comnumity Medical Care is comprised predominantly
of primary care physicians who. by interest and practice
characteristics, are knowledgeable of the problems in-
volved.
PROBLEM DESCRIPTION
Distribution
It is desirable that physician services in North Caro-
lina be evenly accessible to the population in all geo-
graphic settings in relation to demand. Until now. such
accessibility has not been possible because physician
distribution, as that of many segments of the popu-
lation, has been markedly influenced by economic and
social conditions and by urban and rural dynamics. Such
factors include the prevalence of poverty, age. and acci-
dents, and the availability of communication, transpor-
tation, educational, cultural, and recreational resources. -
The result has been a dramatically disproportionate con-
centration of phv'sicians in various population areas.
Primary medical care
Of equal importance is the problem of having the
right physician in the right place at the right time. The
distribution of physicians by medical specialty is com-
parable in importance to the total number of physi-
cians and their geographic distribution.
Health care manpov\er is a special and acute problem
in North Carolina, particularly with respect to primary
care which includes the full spectrum of basic services
needed to maintain and restore health. Primary care
services are called for in 80 to 90 percent of all
patient needs. Yet the predominance of the effort is
focused on the other 10 to 20 percent — training special-
ists and subspecialists who are increasingly less trained
for handling the problems of primary care.-
The modern personal physician considers the ex-
panded health care team and diverse communit\- re-
sources as an extension of himself. This type of team
can be the most efficient and flexible means of assur-
ing comprehensi\e primary health care made a\ailable
to the rich or poor in rural or urban settings. -
Part of the dilemma of underserved areas is that there
has not been an advocate with responsibility for allocat-
ing health care manpower for primary and rural health
care. Until recently medical schools have not been ac-
countable for producing the numbers and kinds of phy-
sicians that society needs. The types of educational pro-
grams offered have led to a migration of medical man-
power from rural areas to more urban areas where the
more sophisticated facilities have been located. Their
efforts, quite understandably, have been directed toward
developing programs that would attract federal monies
available at the time which, unfortunately, were mostly
ear-marked, until recently, through government desig-
nation for other than primary care services. -
Financing rural care is a most difficult problem. A '!^
tual cost per unit of service is frequently higher
rural areas, especially if an attempt is made to provi
a broad spectrum of health care. Many rural an
are unable to support even a rudimentary public hea
care system, let alone one directed toward providi
comprehensive care. The financial incentives are oft
inadequate, and discriminatory reimbursement practi(
by third party payors for rural physicians compou
the problem. -
SUPPORTING DATA
Geographic distribution
The geographic distribution of physicians by popu
tion in North Carolina is as follows: In rural Not
Carolina there are 1,737 people to each physician; the
are 760 people to each physician in urban North Cat
lina. In rural North Carolina there are 2.3 times m
people per physician than in urban areas of the state
In the six most populated counties in North Caroliri
the population physician ratio is 859:1. The popul
tion/physician ratio is 2.396:1 in the six least pop
lated counties. ■•
Graduating physicians
Between 1958 and 1972 North Carolina had a tot
of 2.983 physician graduates."' Bowman Gray Scho
of Medicine had 776 (26 percent); Duke Univers
Medical School had 1.226 (41 percent); and the Ut
versity of North Carolina School of Medicine had 9
( 33 percent ) .
Retention rates
I
:
II
Retention of North Carolina medical school graduate
for practice in North Carolina allows three years
placement.'' Because of internship, residency, and mil
tary obligations, there is frequently a time lag of f
to seven years between the time of graduation and e
tablishment in practice. From 1955 to 1964, the nun
ber of physicians who graduated from North Caroli
medical schools was 1,869; of these, 40 percent h
settled in North Carolina as of 1967.
The retention rates for each of the schools are
follows: Bowman Gray School of Medicine — 37 pe
cent; Duke University Medical School — 29 percen
University of North Carolina School of Medicine —
percent.
Primary care physicians in North Carolina
Of the 1.869 graduates from North Carolina Medic
schools between 1955 and 1964. four hundred and tw
(22 percent! were practicing in North Carolina in tf
primary medical care specialties by the year 1972
The breakdown from the three schools is as follows
Bowman Gray School of Medicine — 22 percent of 49
graduates; Duke University Medical School — 13 pe
cent of 782 graduates; University of North Carolin
School of Medicine — 32 percent of 594 graduates.
Of the 5.964 non-federal physicians practicing i
North Carolina in 1971. 45 percent (2.583) were i
the primary medical care specialties: 19 percent wet
in family medicine; 13 percent were in internal med
cine; six percent were in pediatrics; and seven percen
were in obstetrics-gynecology.^
HOUSE OF DELEGATES
67
i|'Trainiiig programs for primary care specialties in North
Carolina
In 1972 there were 703 residents in training in North
Carolina, of whom 27 pereent were in training in the
primary care specialties."
Relationships can be seen between the 45 percent of
non-federal physicians practicing in North Carolina in
the primary medical care specialties in 1971, the 27
percent of total residents in training in North Carolina
in primary medical care specialties in 1972. and the re-
cently adopted AM A goal that at least 50 percent of
all medical graduates enter residency training in the pri-
mary care specialties in the coming years.
PREVIOUS STUDY REPORTS
The North Carolina Medical Society has long been
^interested in promoting realistic solutions to meet the
iproblems of medical manpower, as evidenced by two re-
ports in 1972 regarding "Medical Students and Medical
■ i^iManpower" by the Joint Conference Committee, and the
"Recommendations from the Conference on Access to
Health Care" by the Public Relations Committee. Rec-
ommendations regarding these problems, including the
need for more medical school graduates in North Caro-
lina, have been made in the "Report of the Statewide
'^Plan for Medical Education in North Carolina" by a
panel of medical consultants to the Board of Governors
;of the University of North Carolina. The UNC Board
of Governors has prepared Recommendations Consistent
with the Report of the Panel of Medical Consultants
on a Statewide Plan for Medical Education in North
Carolina. Separate recommendations have been prepared
by the Medical Manpower Commission of the North
(Carolina State Legislature which call for the gradua-
ition of an increased number of physicians in North
Carolina and the addition of a second year to the ECU
iMedical School,
1
RECOMMENDATIONS
s. L^Ieviating maldistribution
The scholarship or loan funds administered through
Khe North Carolina Department of Human Resources to
support medical education, with forgiveness of indebted-
iQess if the student ultimately practices for a short
length of time in rural areas, should be continued and
enlarged.'"
Medical school admission and recruitment criteria
Ishould be altered in favor of those factors in the ap-
iplicant's background which might encourage him to
eiS|ipractice in an underserved area. Medical students should
>be more oriented to the needs of medically deprived
areas."
Admission committees to medical schools should in-
Ijl^blude as full active members independent primary care
■^physicians. Since this service can be very time consum-
ing for a busy practitioner, reimbursement for time spent
1 should be provided. '-'
•' In the selection criteria for scholarship recipients in
!".he proposed scholarship program for undergraduate
imedical students, to be implemented by the Board of
hGovernors of UNC for financially disadvantaged stu-
.dents, high priority should be given those applicants
ivho express an interest in entering a primary care
^specialty and serving in an underserved area.i"*
The Resident Physician-Preceptor Field Training Pro-
gram for Primary Care-Family Practice Residents, being
implemented by the North Carolina Department of
Human Resources, should be supported and expanded.
This program provides opportunities for primary care
residents to receive part of their training in rural com-
munities with selected medical practitioners.'-'
The statewide network for decentralization and co-
ordination of medical and health professional educa-
tion through development of Area Health Education
Centers in North Carolina should be encouraged. The
decentralization of undergraduate and graduate medical
education through the greater use of community hos-
pitals for intern and residency training will also be bene-
ficial.'-'
Expansion of transportation and communication capa-
bilities between rural areas and larger medical centers,
presently in the planning stage by the Emergency Medi-
cal Services Network, should be accomplished, making
adequate provision for appropriate reimbursement for
medical services to be provided. Such reimbursement
will be vital to the success of this program.'-'
The enhanced use of allied health professionals to in-
crease the productivity of physicians, particularly those
in rural areas, can be a beneficial influence. A program
to help accomplish this, although not in itself a sub-
stitute for increased production of primary care phy-
sicians, is being implemented by the North Carolina
Medical Society."'
The proposal to establish a network of primary medi-
cal care clinics throughout the state, as a cooperative
endeavor between the community and the state, with
supervision and backup by physicians and hospitals in
nearby towns and cities, is an experimental program
that deserves continuing support and guidance by the
North Carolina Medical Society. The support of backup
physician coverage will be vital to its success.'"
Consideration should be given, with assistance from
the interested agencies available, to expanding the func-
tion of the North Carolina Medical Society's Physician
Placement Service to include development of demo-
graphic profile data on communities seeking a physician
and active contact with physicians on behalf of such
commimities.'"*
New physicians moving into underserved areas should
be allowed fee reimbursement for services provided,
similar to those in other areas, and should not be
limited for reimbursement to previously e.xisting re-
gional, prevailing fee schedules. These new reimburse-
ment allowances should be included in determining
prevailing fee schedules.'''
Efforts such as job fairs, similar to the 1973 Student
Physician Community Fair by the North Carolina
Academy of Family Physicians, to bring physicians and
rural leaders together should be supported and encour-
aged. Advance planning by representatives of parties
involved and widespread publicity are important for the
success of these programs.'" -"
Correlating medical education with function
In the de\elopment of new curricula for medical stu-
dents, further relevance should be sought by increased
emphasis on performance criteria including task analysis
and team concepts." There should be greater interrela-
tionship of training programs for medical and allied
health professionals. Core courses in geographic proxi-
68
1974 TR.\NSACTIONS
mity of the training programs to areas of need, as
tiiat envisioned in the expanded AHEC program, is
one way to accomplish this."
The professional associations should provide pro-
grams to interest medical students in selecting primary
care specialty, such as that provided by the North
Carolina Family Practice Club of Medical Students.-"
Attractive credit-bearing electives in community pri-
mary medical care, using practicing physician preceptors
(not Imiiled to the .AHEC affiliated community hospitals
mentioned in the preceding recommendation) should
be developed so that, as a goal. 25 per cent of
senior medical students" available elective time can be
spent in rotations off university medical center cam-
puses. Full reimbursement of student translocation ex-
penses and appropriate preceptor reimbursement should
be provided. Utilization of model medical practices,
vsith physician preceptors who successfully demonstrate
for medical students how underserved areas can ef-
fectively be served, should be given highest priority."' -'
To promote appropriate orientation as the programs
of the medical schools move further into communities,
it is recommended to the Chairman of the Board of
Governors of UNC that a practicing physician, named
by the North Carolina Medical Society, be added as
an ex officio member of the proposed health subcom-
mittee of the Committee on Educational Planning. Pol-
icies and Programs of that Board.' ■
Increased funding should be provided for primary
care physician training in North Carolina. Ihis might
include grants to departments for graduates after four
years of practice in North Carolina as primary care phy-
sicians.--
The general requirements for all residencv programs,
as enforced through the AMA Medical Specialtv Re-
view Teams, should be broadened and super\ ised to as-
sure increased emphasis on the exposure of house of-
ficers to meaningful experiences in health and medical
service outside the university medical center: orienta-
tion to the social and economic aspects of medical prac-
tice should be included. -■•
It is important, in keeping with a recently adopted
AMA goal, that at least ?0 percent of all medical
graduates enter residency training in the primary care
specialties in the coming years. -■*
Health care delivery sjsteius
The Office of Comprehensive Health Planning in the
North Carolina Department of Administration has
the responsibility of planning to meet the health needs
of the people in North Carolina. Inadequate primary
care services ha\e been identified as a major health
problem; \et. there are no primary care practicing
physicians on the Comprehensive Health Planning Ad-
visory Committee. There should be at least five prac-
ticing physicians on this Committee.-''
County medical societies, as far as possible, should
consider taking on a "population frame of reference"
in which physicians accept not only an individual re-
sponsibility to individual patients but also cooperate b\
establishing responsibility to the geographic areas. -^' The
regional approach for underserved areas, using satellite
clinics which are staffed by health care teams composed
of an allied health professional under physician super-
vision, is being implemented in North Carolina. '''
Additional studies should be undertaken to deter-
mine newer methods of transportation to bring th
needy to areas of existing health services."'
Efforts underway by the Emergency Medical Servic
Program to centralize the provision of emergency med
cal services in the community and to eliminate dupl
cate staffing of emergency rooms in hospitals which ar
close together are important. Efforts should be continue
to find more efficient and less costly ways to provid
non-emergency, unscheduled care than by use of hospit;
emergency rooms."''
Community responsibilitj'
There is an urgent need today for citizens in com
munities to examine their medical services" strength
and deficiencies. The people must establish the mean
for planning to assure optimum quality and continuit
of comprehensive health services, working through th
designated regions of the Office of Comprehensi\
Health Planning in cooperation with county medical as
sociations. Every effort should be made on a regions
and geographic basis to develop not only this entn,- poin
and access to primary care, but also the necessar
secondary care in rural areas and backup tertiary can
in strategically located medical centers. It is importan
for each community health planning committee witi
leadership from community physicians to establish lonj
term goals to be accomplished in a stepwise fashion.-
These goals should be as follows:
To make qualits health care available for all peopl
in the region: ( 1 ) Start with improvements in the area
transportation system to bring people to available phy
sicians and hospitals in the region: (2) Secure coopera
tion of community colleges to train medical and den
tal assistants: (3) Contract with health departments tc
provide public health nurses: (4) Develop plans fo:
providing new medical dental clinics to help in recruit-
ment of health personnel: (5) Seek to enlist the coi
operation of medical and dental societies to provide
added services: (6) Contract with local hospitals tc
establish emergency services: and (7) Establish im
proved ambulance services with better training anc
equipment for ambulance attendants.-"
To improve the family's ability to handle health prob
lems: ( 1 ) Health education courses in schools foi
adults and children should be improved: (2) First aii
courses for each family should be emphasized: (3) Self
help courses should be taught: and (4) Rural safety
and accident prevention programs should be made
available.-''
References
1, Forsyth County Medical Society Resolution to the 1973 NC MediJ
cal Society House ol Delegates . . . referred to the Executi\e
Council for consideration.
2. Rural Heullh Care Seeds, address by Len Hughes Andrus. MriJ
Professor and Chairman of Department of Family Practice. School
of Medicine. University of Calif. 12-10-7,^.
.^. Distrihiilion of Physicians in the United Slates. 1971. AMA,
Chicago, 1972. ("Rural" refers to AMA county classifications 1-4;
"urban" refers to classification 5-9. The US figures refer to the
US, excluding North Carolina.)
4. Population f.iiures from 1970 Census of Population. Advance Re-
port PC (VI)'-35. US Department of Commerce. 1970. (Total phy-
sicians, non-federal, from Roster of Registered Physicians in the
State of North Carolina) Bo.ird of Medical Examiners of the
State of North Carolina. March 1. 1972. (Six most populous coun-
ties were Cumberland. Fors>th. Gaston. Guilford. Mecklenburg,
and Wake. Six least populous were Tyrrell. Clay. Camden, Hyde
Graham, and Currituck.)
5. Report of the Committee to Study the Request of East Carolina
University for a Second ^'ear of Medical Education, Report lo
the UNC Board of Governors. December 29. 1972. p 67. Supple-
mented bv telephone communications with medical schools f<r
graduates 1958-1960,
6. Medical School .Ahimni. 1967. AMA. Chicago. I96S, pp 528-53".
7. Derived from computer analysis of 1972 AMA Master File com-
puter tape for North Carolina by Division of Education and Rf-
HOUSE OF DELEGATES
69
39.
,2.
(|l|3.
4.
5.
6.
1
^7.
jS-
n.
,f
(ill,
^\.
a'-
search in Community Medical Care, UNC School of Medicine.
Heciltli Resources Statistics, Health Manpower and Health Fa-
cilities, ;v7-'-/97.i. US Department of Health, Education, and Wel-
fare, 197J. pp 192. 196, 197.
Telephone survey of Sept 1, 1972, residency positions filled by
Division of Education and Research in Comnnmity Medical Care,
University of North Carolina at Chapel Hill, 1973.
A Statewide Plan for Medical Education tn North Carolina —
Report of the Panel of Medical Consultants to the Board of Gov-
ernors of the University of North Carolina (9^21 73).
ExpatidinK the Sufply of Health Servicer in the 1970s. Report of
the National Congress on Health Manpower, sponsored by The
Council on Health Manpower of the AM A (10 22-24 701.
Actions of NC Medical Society House of Delegates, May 1973.
Recommended Actions Consistent with the Report of the Panel of
Medical Consultants on a Statewide plan for Medical Education
in North Carolina, UNC Board of Governors.
Senate Bill 301, General Assembly of North Carolina, 1973 Session.
Statement by State Emergency Medical Services Advisory Council,
NC Department of Human Resources (9 20 73 ) .
Outhne of Proceedings — Conference on Access to Health Care. By
NC Medical Society and NC Regional Medical Program (9 9-
10,/73).
NC Medical Society Executive Council (10 73).
Priorities for Increasing AvailabiUty of Health Services in Rural
Areas — AMA House of Delegates, 6/12.
Written communication to LH Fountain from RM Ball, Com-
missioner for Social Security, US Department of HEW, 3/22/73.
(Resource information only.)
Written communication from Dr. Alleson M Alderman, President,
NC Academy of Family Practice (1210 73).
Medical school expands off campus. American Medical News,
10/ 1 73. ("For each of the past four years, more than 50 percent
of the senior medical students time was spent in rotations off the
Indianapolis campus" — University of Indiana),
Senate Bill 858, General Assembly of NC, 1973 Session.
AMA Council on Medical Education. Essentials of Approved Resi-
dences, p 351.
AMA House of Delegates, June, 1973.
Membership C~omprehensive Health Planning Advisory Committee,
NC Department of Administration.
Fenderson DA: Special Communications — Health manpower de-
velopment and rural services. JAMA 225: 1627-1631, 1973.
Guidelines: Community Organization for Health Services in Rural
Areas. AMA Council on Rural Health (4/16/71),
REPORT N
ilibject: Purchase of Property AtJjacent to the Medical
i' Society Parking Area on Bloodworth Street in Raleigh
T.ef erred to: Reference Committee No. I
: The May 5, 1974, meeting of the Executive Council
Died approval of the purchase of property adjacent
)i) the Medical Society parking area fronting on Blood-
^J|r^o^th Street in Raleigh. The action was based on the
^commendation of the Chairman of the Committee on
iii|)lersonnel and Headquarters Operation and the Chair-
»an of the Committee on Finance.
cl Price of the house and lot. encompassing 5,943 square
3set and identified as the property of Mrs. N. G. Fon-
llleof Raleigh, is $16,000.
REPORT O
hbject: Amendment to the Medical Practice Act
,;eferred to: Reference Committee No. 1
^ The May 5. 1974, meeting of the E.\ecutive Council
pproved a recommendation of an ad hoc Liaison Com-
littee between the Board of Medical Examiners and
jj lie Medical Society that the House of Delegates be re-
:^aested to endorse an amendment to the North Caro-
ja Medical Practice Act.
The Executive Council made minor word changes in
;e recommendation of the ad hoc Committee so that
^e recommendation now reads as follows:
The Executive Council requests the House of
|| Delegates to endorse an amendment to the Medi-
iiCal Practice Act to the effect that the Board of
Medical Examiners may revoke or restrict a license
,ito practice medicine for lack of professional com-
ipetence and that such amendment be incorporated
'i in Section 90-14 of the Medical Practice Act.
3llt was also the recommendation of the Council that
'f. is ad hoc Committee be continued by the incoming
President so that they might continue to meet for the
purpose of making further recommendations to imple-
ment the recommendation if necessary.
SUMMARIES OF EXECUTIVE COUNCIL
MINUTES
You have also received in your packet a summary of
the three sessions of the Executive Council throughout
the year. Dr. Gilbert and members of the Council stand
ready to answer questions if you have them.
Are there questions concerning the other actions
of the Executive Council?
Lest you be confused, the reports are lifted from the
summaries. The summaries do contain some actions of
the Executive Council but not necessary to be approved
by the House of Delegates.
DR. WILLIAM ROMM: 1 move that these sum-
maries be accepted.
DR. PASCHAL: Second.
SPEAKER DAVIS: Discussion of the motion?
[No response]
If not, those favoring the motion please say "aye":
opposed "No."
The summaries of the sessions of the Executive
Council are accepted.
RESOLUTIONS
We move now to the resolutions and again you have
copies of them, of course, in your packets on yellow
sheets.
Now. you will notice and 1 think you have it in your
packets but not listed on your agenda, a Resolution 4-A
has been submitted and Resolution No. 14 came from
the Executive Council, but has been circularized. It is
not listed on your agenda.
Resolution: I
Introduced by: Edgecombe-Nash County Medical So-
ciety
Subject: Professional Standards Review Organizations
(PSRO)
Referred to: Reference Committee No. II
WHEREAS, Part B, Title XI of the Social Security
Act as amended by P.L. 92-603 (known as PSRO)
will allow government snooping into the files of private
patients as well as into the files of those receiving as-
sistance through Social Security, such as Medicare and
Medicaid, causing the harassment of physicians, and
WHEREAS, it will result in standardization and
mediocrity in the practice of medicine by setting up
national norms of diagnosis and treatment implemented
through the use of computers, and
WHEREAS, enforcement of PSRO would destroy the
freedom of phvsicians to exercise independent judgment
in caring for Medicare and Medicaid patients by forcing
them to conform to government-imposed "norms'" of
diagnosis and treatment, and
WHEREAS, standardization of medical care will
seriously impair the quality of medical care to the
detriment of these patients by restricting a physician's
liberty to use his own judgment, skill and knowledge,
freely and without interference from government bu-
reaucrats, and
WHEREAS, physicians who deviate from go\ern-
ment's arbitrary "norms'" will be subject to punishment.
70
1974 TRANSACTIONS
no matter how much harm to the patient might result
from adherence to the norms, and
WHEREAS, this unjust law could be employed to
subject physicians to public scorn and ridicule and
thereby undermine public confidence in the medical
profession, and
WHEREAS, justification for the PSRO law is based
on the f.ilse assumption that government can effecti\ely
improve medical quality and costs and the misrepresen-
tation that physicians are responsible for rising health
care costs whereas the blame actually lies with recklessly
extravagant government, and
WHEREAS, Congressman John R. Rarick ( D-La. )
has introduced H.R. 9375 calling for repeal of the PSRO
provisions of P.L. 92-603.
THEREFORE. BE IT RESOLVED that the members
of the Edgecombe-Nash Medical Society in regular ses-
sion this 14th day of November 1973 request and peti-
tion their fellow physicians, the North Carolina Con-
gressional delegation, every member of both Houses of
the United States Congress and both Houses of the
North Carolina Legislature to work for the passage of
the aforementioned Rarick bill calling for repeal of
PSRO. and that copies of this resolution be forwarded
to the aforementioned individuals, to all District Coun-
cilors and component county societies of the North
Carolina Medical Society and submitted to the North
Carolina Medical Society as a Resolution for action at
the Annual Meeting in Mav 1974.
Resolution: 2
Introduced by: Scotland County Medical Society
Subject: Repeal of PSRO Act
Referred to: Reference Committee No. II
RESOLVED, that the Scotland County Medical So-
ciety supports the efforts of 30 U.S. Representaiises in
obtaining the repeal of the PSRO Act.
RESOLVED, that the Scotland County Medical So-
ciety urges the North Carolina Medical Society to intro-
duce such a resolution at the AM A House of Delegates.
Resolution: 3
Introduced by: Pitt County Medical Society
Subject: Professional Standards Review Organization
Referred to: Reference Committee No. II
WHEREAS. PSRO empowers government agents to
inspect clinical records, thereby destroying the patient's
right to privacy, and
WHEREAS, the PSRO empowers go\'ernment to take
control of clinical and administrative aspects of patient
care from doctor and patient, conferring it upon gov-
ernment, and
WHEREAS, rising costs, brought about b\ a deliber-
ate government policy of a managed economv and
inflation (increasing minimum wage, deficit spending!
doom cost control to failure, and
WHEREAS, the inevitable failure of PSRO to con-
trol medical care costs will be blamed on the practicing
phvsician and on medical societies.
THEREFORE. BE IT RESOLVED that the Pitt
Counts Medical Societs :
1. Opposes PSRO.
2. Instructs its delegates to the annual meeting of the
N. C. Medical Society to initiate and support
resolutions and actions in opposition to PSRO.
And. THEREFORE, BE IT FURTHER RE
RESOLVED:
1 . That the House of Delegates, acting for the meq
bers of the State Society, make its resolution i
opposition to PSRO and initiate appropriate meas
ures in support of this position.
2. That the N. C. State Medical Society not lend it
support to the appropriation by the government i
the name of PSRO of functions belonging h
physicians, patients, medical societies. Boards o
Medical Examiners, and local administrative age
cies.
il
Resolution: 4
:;
Introduced by: Pitt County Medical Society
Subject: Requirement of Joint Commission on Ai
creditation of Hospitals for Detailed Delineation q
Hospital Staff Pri\ileges
Referred to: Reference Committee No. II
WHEREAS, the Joint Commission on Accreditatioi
of Hospitals has directed that hospital staffs describ
in minute detail each surgical procedure and each med
cal treatment that each of its staff members is qualifiei
to perform, and
WHEREAS, this cataloging of allowable treatment
will tend to be restrictive and intimidating to the con
scientious practitioner as his skills, technique and mode
of treatment are constantly changing. Further the nee(
for this self-imposed regulation has not been show
and under the present system there has been a constan
and steady impro\emenI in the skill of hospital staf
members, and
WHEREAS, the ultmiate aim of this ruling is to fu
nish a technique of our ov\n making that will make
easy for third parties, lawyers and hospital administrd
tors to coerce or restrict a physician's activities: there
fore be it
RESOLVED, that the Pitt County Medical Societ
go on record opposing the detailed delineation of hosp
tal staff privileges: and be it further
RESOLVED, that the North Carolina Medical So
ciety go on record opposing this ruling.
Resolution: 4-A
Introduced b\ : Beaufort-Hyde-Martin-Tvrrell-Wash
ington County Medical Society
Subject: Delineation of Hospital Prixileges by Specific
Procedure
Referred to: Reference Committee No. II
WHERE.AS. within the framework of the concept o
the PSRO Law. Hospital bylaws would be requested ti
delineate privileges within a specialty by specific proce
dures: and
WHEREAS, such a policy would be unjustly bindin,
to community hospitals with limited staff and mak
them unjustly open to litigation:
THEREFORE. BE IT RESOLVED that the Beaufort
H\de. Martin. Tyrrell. Washington County Medical So
ciety go on record as considering such action impraq
tical and unjust:
And. THEREFORE. BE IT FURTHER RB
SOLVED: that the North Carolina Medical Society ac
against implementation of such requirements.
II
t
I
HOUSE OF DELEGATES
71
Resolution: 5
itroduced by: Moore County Medical Society
bbject: Increased Activity in tile Area of Public Rela-
I tions and Legislative Contact
"deferred to: Reference Committee No. I
WHEREAS, the private practice of medicine is at
ne of its most crucial crossroads today, and
J WHEREAS, inflation is rapidly eroding into the dol-
! 'rs that the State Medical Society has to spend, and
. WHEREAS, we have just paid out final assessment
)r an appropriate Medical Society headquarters build-
ig, and
' WHEREAS, we need added monies for public rela-
ons and legislative contact,
I BE IT RESOLVED that the North Carolina Medical
'ociety increase its activity in the area of public rela-
ons and legislative contact: and, further, that the North
arolina Medical Society dues be raised as necessary
1 support this increased activity.
Resolution: 6
Nash-Edgecombe County Medical So-
litroduced by:
•^i ciety
libject: Resolution on Creating Improved Communica-
1*1 tions Between Hospital Staffs through County and
B! (! State Medical Societies
i« tieferred to: Reference Committee No. I
K 1 WHEREAS, the rapid pace of change in the prac-
ce of medicine and the continuing attempts at impos-
i|g controls on physicians make it imperative that all
iiysicians be informed about changes or contemplated
langes in order to implement them or take action
?ainst them, and
3 WHEREAS, an individual hospital staff might be
ngled out as a test case for proposed changes without
iher hospital staffs having knowledge of the action
hich might later affect them, and
3 WHEREAS, a broader base of experience can be
awn upon in arriving at solutions if all are informed,
erefore.
BE IT RESOLVED that the North Carolina Medical
jciety inform every member of the Society through
e President's monthly message or a letter from the
secutive Secretary whenever there are attempts by a
ospital administrator, the Joint Commission on Ac-
editation of Hospitals, or a federal agency to impose
'.w regulations or controls over a hospital staff if the
iquest is made through a county medical society.
Resolution: 7
troduced by: Nash-Edgecombe County Medical So-
ciety
ibject: Dissolution of the North Carolina Medical Peer
Review Foundation, Inc.
jferred to: Reference Committee No. II
'WHEREAS, Congress passed Public Law 92-603 in
t-fstober of 1972, Section 249(f) of which calls for
i establishment of a network of Professional Standards
'I'jview Organizations, and
jI* '\ WHEREAS, the Executive Council of the North
'irolina Medical Society has appro\ed Articles of In-
fporation for a Statewide Eoimdation for Peer Review
\WHEREAS, we believe private physicians and sur-
Dns should re-declare their continued dedication to:
1 . The high ethics of our profession, and
2. The free and complete exercise of our independent
medical judgment solely in the service of our
individual patients.
IHEREFORE, BE IT RESOLVED that:
1. We will not collaborate with any scheme that im-
pairs in any manner the conscientious, confidential.
loyal, and mutual responsibility between patients
and their personal physicians, and
2. Accordingly, we will not collaborate with Profes-
sional Standards Review Organizations, since this
scheme inherently conflicts with the best interests
of patients, and
3. That all component societies of the North Carolina
Medical Society join in our refusal to collaborate
with political medicine, and
4. That the North Carolina Medical Society by ac-
tion of the House of Delegates withdraw its sup-
port and dissolve the North Carolina Medical Peer
Review Foundation. Inc.
Resolution: 8
Introduced by: Nash-Edgecombe County Medical So-
ciety
Subject: Resolution on Delineation of Privileges
Referred to: Reference Committee No. II
WHEREAS, the State Board of Medical Examiners
is the legal examining and licensing body for physicians
in the State of North Carolina, and
WHEREAS, attempts by the Joint Commission on the
Accreditation of Hospitals and hospital administrators
to require delineation of privileges for physicians be-
yond the customary departmental requirements as a re-
quisite for staff privileges is an infringement upon the
authority of the State Board of Medical Examiners,
and
WHEREAS, the specific delineation of privileges
could create new avenues for medico-legal problems for
physicians in this time of increasing medico-legal aware-
ness, and
WHEREAS, the highest standard of medical care the
world has ever known has been attained by cooperation
between the medical profession and the Joint Commis-
sion on the Accreditation of Hospitals, but specifically
not by regulation of the medical profession by the Joint
Commission on the Accreditation of Hospitals, therefore
BE IT RESOLVED that the members of the Edge-
combe-Nash County Medical Society will not be regu-
lated by and controlled by the Joint Commission on the
Accreditation of Hospitals to the extent of submitting
to a requirement for the delineation of privileges be-
yond that which has been customary in a departmental-
ized hospital in order to secure hospital staff privileges.
Resolution: 9
Introduced by: Cleveland County Medical Society
Subject: Professional Standards Review Organization
Referred to: Reference Committee No. II
RESOLVED that the North Carolina Medical Society
should instruct its delegates to the AMA to introduce a
resolution instructing the AMA to actively work for the
repeal of the present PSRO amendment to the Social
Securitv Act.
72
1974 TRANSACTIONS
Resolution: 10
Introduced b\': Cleveland County Medical Society
Subject: Chiropractors on the Board of the North Caro-
lina Division of Health Services
Referred to: Reference Committee No. II
RESOLVED that the North Carolina Medical Society
request Governor Holshouser to remove chiropractors
from the North Carolina Disision of Health Services.
Resolution: 1 1
Introduced by: Anson County Medical Society
Subject: Opposition to Chiropractic School Accredita-
tion and Repeal of Legislation Recognizing Chiro-
practors as being Eligible for Medicare and Medi-
caid Funds
Referred to: Reference Committee No. II
WE. the Anson County Medical Society of Anson
County. North Carolina, go on record as not lending
support to any legislation which would give recognition
to any chiropractic school regarding accreditation. We
further believe recognition of chiropractors as being
eligible for Medicare and Medicaid funds for treatment
or X-rays of patients is unjustified and the State Medical
Society should work tov\ard repeal of this legislation
by any manner possible.
Resolution: 12
Introduced by: Anson County Medical Society
Subject: Ending Cost of Living Council Controls and
Expiration of the Present Economic Stabilization Act
Referred to: Reference Committee No. II
WHEREAS. Phase ill of the economic control pro-
gram has been directed only to a limited segment of
the economy and others have been permitted to be de-
controled causing an unfair hardship on the medical
profession, WE. the Anson County Medical Society sup-
port and encourage effects to have those controls re-
scinded immediately. We further support measures to
end all controls on all areas of the economy with the
expiration of the present Economic Stabilization Act.
April 30. 1974.
We believe that since enactment in November of
1971 there has been no evidence that such controls have
been fair or have slowed inflation of our econon.x in
general.
If these controls are in fact allowed to be extended
to physicians after April 30. 1974. we contest this to
be discrimination and against the U.S. Constitution as
our rights as individual citizens.
Resolution: 13
Introduced by: Mecklenburg County Medical Society
Subject: Membership of the Council on Medical Educa-
tion of the AMA
Refererred to: Reference Committee No. II
WHEREAS, the Bylaws of the .AMA provide that
the Council on Medical Education shall consist of ten
acti\'e members, at least one of whom shall be from
practice and ha\e no academic connections, and
WHEREAS, this has been taken literally over a period
of many \ears with the result that the Council has
become dominated by academicians to the point that it
is virtually a A.A.M.C. appendage, and
WHEREAS, the community hospital graduate educa-
tion programs, where a substantial number of traine
are and a substantial number of physicians are. ha'
all but been excluded from having a voice in medic
education during these critical times, and
WHEREAS, the Council on Medical Education
deepK invoked not only in graduate medical educatio!
allied health personnel, and either directly or indirectj
with certification, re-certification, licensure and mai
other areas which affect the practicing physician ar
his daih acti\ ities; therefore be it
RESOLVED that the Mecklenburg County Medic
Society feels that there should be more balance :
the Council of Medical Education of the AMA betwet
men in practice and A.A.M.C. members: therefore be
further
RESOLVED that the Mecklenburg County Medic
SocietN' proposes that the Council on Medical Educ.
tion shall consist of ten active members of which n(
less than one nor more than five shall be members of
medical school faculty.
Resolution: 14
Presented by: President George G. Gilbert, for th
Executive Council
Subject: Encouraging Membership in N. C. MEDPA
Referred to: Reference Commtitee No. I
WHEREAS. Government encroachment into the pr
vate practice of medicine increases daily at all levels c
government; and
WHEREAS, there is an ever increasing need to elei
candidates to political office whose beliefs reflect thoi
of physicians and represent the free enterprise systei
of health care delivery: and
WHEREAS, more and more physicians are seekiri
PAC dollars for candidates at all levels; and
WHEREAS. MEDPAC can only meet these demanc
through increased memberships and dues monies;
THEREFORE. BE IT RESOLVED that the Hou!
of Delegates of the North Carolina Medical Society e
on record as favoring the following:
1. Every member of this House become a dues pa;
ing member of MEDPAC
2. Strongly recommend that e\ery member of th
North Carolina Medical Society and Auxiliai
members become dues paving members of MEE
PAC
3. Urge the Executive Council and all State an
County leadership of the North Carolina Medic
Societ\ to become sustaining members of MEC
PAC;
And. THEREFORE. BE IT FURTHER RE
SOLVED: that the North Carolina Medical Societ
delegates to the American Medical Association Hous
of Delegates introduce a similar resolution at the ne:
Annual Meeting of the American Medical Associatio
House of Delegates and actively work for its passag
in support of AMPAC so as to enhance medicine
political acti\ ities on the national le\el.
There is one change in Reference Committee assigi
n-ent. This relates to Resolution No. 8 and we woul
like to change that and refer it to Reference Commi
tee 11 simply because its composition is consistent wit
other items to be discussed by that Reference Con
mittee.
HOUSE OF DELEGATES
73
( li Would the committee chairman please tatce note of
i jhat.
. 1 Resolution No. 8 to Reference Committee II rather
han to Reference Committee I.
Again, questions concerning these resolutions are in
nrder, but no debate. If not, may I have a motion
: that these resolutions be accepted as the property of
the House of Delegates and be referred to the Refer-
Jjijnce Committees as indicated?
[The motion was made and seconded from the
loor. ]
If there is no discussion, all those in favor say
saye"; opposed "no."
p These resolutions are accepted and are referred.
it )i NOMINATING COMMITTEE
" At this time, we will again have about a ten minute
^ecess for the purpose of the Third, the Fifth, the
eventh and the Ninth Districts caucusing to nominate
member from their District as their representative on
le Nominating Committee.
Why only these four Districts? Simply because we
re now in our second year of staggered terms on
le Nominating Committee, being that the terms of of-
• ce of the representatives of these Districts have ex-
ired. new members should be nominated only from
lese Districts.
As you realize we are getting to a three year term
I n the Nominating Committee and the man nominated
'ad elected subsequently by the House today to the
f ilominating Committee will serve a three year term.
1 The question comes up. those who are going off of
le committee who have not served a full three year
(Vm as to their eligibility for re-election — they are
igible.
,( One must serve a full three year term to lose his
dgibility so current members or any member who
,4S not served a full three year term is eligible for
ijmination to the committee. Are there questions con-
;rning this procedure?
DR. PHILIP NAUMOFF IMecklenburg County]:
r. Chairman, in order to be a member of the Nomi-
uting Committee you must be a delegate to this House,
that correct?
;i SPEAKER DAVIS: That is correct.
^DR. NAUMOFF: Suppose a man is elected today for
three year term and then after a year or two is not
tSected back as a delegate to the House, what happens
iii this nomination?
SIfpSPEAKER DAVIS: I would think that all of us
alize if this matter is contested the Executive Council
S.s to make the ultimate judgment on it. However, in
fling over the bylaws I think it is more likely one would
ilerpret that a member of the Nominating Committee
ust be a delegate at the time of election and so I think
: should follow that policy unless a matter does be-
; me contested. It would then go to the Executive
fjuncil.
Is there any contrary opinion? Any discussion?
,' [No response]
^So, a ten minute recess and could I ask the Third,
'iFth, Seventh and Ninth Districts to forward their
(iif *ime of their nominee immediately to the podium.
aey must then be elected by the House. We stand in
^ess.
//
■h
(Whereupon there followed a twenty minute recess
for the purpose of District Caucuses.]
SPEAKER DAVIS: Will the House please be in or-
der? We now have nominated for a position on the
Nominating Committee:
From the Third District, Dr. Thomas Craven of Wil-
mington.
From the Fifth District, Dr. Charles T. Johnson, Jr.,
of Red Springs.
From the Seventh District, Dr. James Greenwood of
Charlotte.
And. from the Ninth District, Dr. James H. Segars
of Lenoir.
May I have a motion that these men be elected
to the Nominating Committee.
[The motion was made and seconded from the
floor.]
Those in favor of the motion please say "aye"; op-
posed "no."
These men are elected for a three year term to the
Nominating Committee and 1 vsould ask that they and
the continuing members of the Nominating Committee
meet on the podium immediately following adjournment
of this meeting to meet with the Secretary for organi-
zation of the Nominating Committee.
Is there New Business to come before the House?
DR. JOHN L. McCAIN: Mr. Speaker!
SPEAKER DAVIS: Would you state the reason for
your rising?
DR. McCAIN: I would like to present a late resolu-
tion.
SPEAKER DAVIS: Would you briefly outline the
resolves of this?
DR. McCAIN: There are three brief whereases that
will make the resolve a little more understanding if I
could have permission to read this briefly.
SPEAKER DAVIS: All right, sir. just a minute for
an explanation of procedure.
As you know, late resolutions must be accepted by
two-thirds vote of the House; before we get into any
discussion of the resolution we need to know the nature
of it and if you will please read the resolves.
Just the resolves if you will.
DR. McCAIN: Therefore, be it.
RESOLVED, that it be urged that medical specialty
examining boards articles of incorporation and bylaws
restrictions for membership that are contrary to the
"peer" concept be removed, and be it further,
RESOLVED, that this resolution be referred to the
AMA House of Delegates.
SPEAKER DAVIS: You have heard the substance of
Dr. McCain's proposed resolution. He moved that the
House accept this late resolution and have it referred
to a Reference Committee.
Is there a second to his motion?
[The motion was seconded from the floor.]
Is there any discussion on acceptance of this late
resolution? [No response]
If not, those favoring acceptance please say "aye":
opposed "no." Ifs the feeling of the Chair that two-
thirds are in favor.
Would those favoring the motion please raise your
hand. [Whereupon there followed a showing of hands.]
Those opposed please raise your hands. [Whereupon
there followed a showing of hands.]
It is still the strong impression from the podium
74
1974 TRANSACTIONS
that the motion is carried. The resolution is accepted
and it will become Resolution No. 15 and will be
referred to Reference Committee II.
Resolution: 15
Presented by: Wilson County Medical Society
Subject: Medical Specialt\' Examining Boards
Referred to: Reference Committee No. II
WHEREAS, plans for recertification are being under-
taken by man>' of the medical specialty examining
hoards, and
WHEREAS, this House of Delegates has approved
the desirability of the membership of these boards being
peers of those they seek to examine, and
WHEREAS, in some instances, the legal instruments
setting up these boards are contrary to this concept,
despite this expressed desirability,
THEREFORE, BE IT RESOLVED that it be urged
that medical specialty examining boards" articles of in-
corporation and bylaws restrictions for membership th
are contrary to the "peer'" concept be removed, and
BE IT FURTHER RESOLVED that this resolutiq
be referred to the AM A House of Delegates.
SPEAKER DAVIS: It is accepted and it is referre
One other word of explanation. I've been told that tl
Commission for Medical Facility Services and Licensu
has gone back to its former term of Medical Care Cor
mission and it is that commission that we have tod:
elected Dr. Hugh McManus to.
Is there other business to come before the Housi
[No response]
Prior to adjournment, let me with all sincerity thar'
you for your cooperation todav'. I ask that all of yi
possible attend the Reference Committee sessions t
morrow at two o'clock and we will reconvene bac
here on Tuesday at two o'clock. We stand adjourns
until two o'clock on Tuesday.
[The meeting adjourned at four-twenty o'clock.]
lili
Its
rit
■:*
HOUSE OF DELEGATES
75
Abridge Minutes of the Meetings of tlie House of Delegates
TUESDAY AFTERNOON SESSION
May 21, 1974
A The Second Meeting of the House of Delegates at
le 120th Annual Meeting of the North Carolina Medi-
ji ^al Society convened at two-fifteen o'clock. Dr. James E.
)avis. Speaker of the House of Delegates, presiding.
SPEAKER DAVIS: Will the House please be in or-
er? First of all, I would like to recognize our Presi-
ent who has a message for the House.
PRESIDENT GILBERT: This represents a little good
':,ews for a change. This is a telegram that was sent
esterday from Dr. Russell Roth. President of the AMA
"3 me in behalf of the State Society and I will read it:
DEAR DR. GILBERT;
IT IS ALWAYS A PLEASURE TO BE THE
DFFICIAL BEARER OF GOOD TIDINGS. IT IS MY
i:HEERFUL PRIVILEGE TO INFORM YOU THAT
IKE NORTH CAROLINA MEDICAL SOCIETY
(ACHIEVED THE DISTINCTION OF BECOMING
PHE THIRD STATE MEDICAL SOCIETY TO
iTRENGTHEN THE AMA MEMBERSHIP THIS
I'EAR. THIS MARKS THE FIFTH CONSECUTIVE
I'EAR THAT NORTH CAROLINA HAS EX-
CEEDED THE AMA DUES PAYING MEMBER-
HIP THAT IS RECORDED FOR THE PRECEDING
FEAR. THIS INDICATES THE IMPORTANCE
rHAT NORTH CAROLINA PHYSICIANS PLACE
UPON THE AMA.
CONGRATULATIONS TO YOU. THE OTHER
UORTH CAROLINA MEDICAL SOCIETY OFFI-
CERS AND TRUSTEES AND TO YOUR FINE
TAFF FOR EXHIBITING THE LEADERSHIP
HAT HAS PERPETUATED A UNIFIED PROFES-
UON IN THIS TARHEEL STATE.
CORDIALLY YOURS, RUSSELL B. ROTH.
I thought you ought to hear this! [Applause]
SPEAKER DAVIS; Thank you. Dr. Gilbert.
May we please have a report from the Credentials
'ommittee. Dr. lohn Payne.
DR. JOHN PAYNE: Mr. Speaker, we have 133
lualified delegates.
SPEAKER^DAVIS: 133! Thank you, sir.
So a quorum is in the House and the House is ready
) do business.
I would first of all like to appoint tellers in case
iiey are needed this afternoon and I will ask Dr.
oy Bigham to serve as chief teller and with him
iir. Philip Pearce, Dr. Shahane Taylor, Dr. Ben War-
im and Dr. Walter Burwell.
As we proceed with the reports of the Reference
ommittees, a simple reminder if I may, please keep
mind that the primary issue under discussion and
iader vote as we go along is the basic resolution.
The Reference Committee may amend or offer a sub-
litute resolution to this, but when they make a rec-
inmendation it is only that and so when we are voting
I you desire to vote or when you're voting keep the pri-
iiary issue in mind.
"We will proceed with the report of Reference Com-
iiittee I and I'll ask the members of this committee
to please come forward and ask Dr. John McCain to
assume the podium.
REFERENCE COMMITTEE I
DR. McCain [Chairman, Reference Committee
I]: I'd like to introduce the two other members of the
committee. Dr. Thomas Dameron and Dr. E. T. Marsh-
burn.
The committee report and recommendations are as
follows:
REPORT A
Report "A," Subject; The Annual Budget Estimates
for 1974 from the Executive Council.
The Reference Committee recommends approval of
Report "A."
SPEAKER DAVIS; All of you have a copy of Re-
port "A" before you. The Reference Committee, of
course, has three members on it so when they move or
recommend, it comes with a second.
This has to do with the annual budget, so it has
been moved and seconded that this report on annual
budget be adopted.
Are there any questions concerning the budget? Any
discussion on the motion?
If not, those favoring adoption of Report "A" please
say "aye"; opposed "no."
It is adopted.
REPORT B
DR. McCain : Report "B, " subject: Report of the ad
hoc Committee to Study and Recommend a Salary or
Increase in Allowance for the President from the Ex-
ecutive Council.
The Reference Committee recommends approval of
Report "B."
SPEAKER DAVIS: Report "B " is before you with a
recommendation for its adoption.
Are there questions or is there discussion?
AH those in favor of adopting Report "B" please
say "aye"; opposed "no." It is adopted.
REPORT C
DR. McCAIN; Report "C." Subject: Request that
the Section on Ophthalmology and Otolaryngology be di-
vided into a Section on Ophthalmology and a Section
on Otolaryngology, from the Executive Council.
The Reference Committee recommends approval of
Report "C. "
SPEAKER DAVIS: Report "C" which simply separ-
ates these two sections and makes individual sections
is before you with a recommendation for adoption.
Is there discussion? [No response]
If not, those favoring adoption please say "aye";
those opposed "no." It is adopted.
REPORT P
DR. McCAIN; For continuity of concern we would
like to have Report "P" considered next.
Report "P," Subject: Proposed changes in the Con-
76
1973 TRANSACTIONS
stitution and Bylaws from the Executive Council.
It's divided into three parts.
Part 1 has to do with Chapter IV. Section 2. page
16. regarding student membership and provides tor
election of their o\\n delegates.
The Reference Committee recommends approval of
this portion of Report "P."
SPEAKER DAVIS: As you notice. Report "P" is in
three sections. The Reference Committee has a recom-
mendation concerning each part. The Chair thinks it bet-
ter to consider this one part at a time unless there is
disagreement.
Part one concerning election and certification of stu-
dent members is before you with a recommendation
for adoption.
Is there discussion? [No response]
If not. those favoring adoption, please say "aye";
opposed "no." Part one is adopted.
DR. McCAIN: Part two: Chapter XI. Section 1.
page 54. addition of Sections on Neurological Surgery.
Otolaryngology and Ophthalmolog\ as editorially cor-
rected during the first session of the House of Delegates.
The committee recommends approval of part two of
Report "P."
SPEAKER DAVIS: Part two and I hope all of you
have a copy of this, is before \ou. It is recommended
to be adopted.
Are there questions or discussion? [No response]
If not. those favoring adoption, please sav "aye";
opposed "no." Part two is adopted.
DR. McCAIN: The committee concurs that with the
addition of new Sections, alterations should occur in the
composition of the Blue Shield Committee as indicated
in Chapter X. Committees, Section 16 of the Com-
mittee on Blue Shield in the Constitution and Bylaws.
Part three: Article IV. Section 6. page 3 — Intern-
Resident Training Members.
This pro\ides opportunity for membership in the
North Carolina Medical Societ\ for those in training
outside of North Carolina.
The committee recommends approval of this change
with the following editorial correction:
That on lines 134 and 136 and lines 156 and 158
"Joint Accreditation Committee on Hospitals" be
changed to 'Joint Co.nniission on .Accreditation of Hos-
pitals."
The committee recommends approval of Report "P"
as amended.
SPEAKER DAVIS: Part three of Report "P" is be-
fore you with a grammatical change and the Refer-
ence Committee recommends approval.
Is there discussion'.' I No response]
If not. those favoring approval say "aye"; opposed
"no."
Part three is approved and if I may have a motion
that the entire Report "P" as amended be adopted.
Ed appreciate it.
[The motion was niade and seconded from the
floor. 1
Those favoring adoption of the amended Report "P"
please say "aye"; opposed "no." Report "P" is adopted,
as amended.
REPORT J
DR. McCAIN: Report "J": Subject: Request fort!
establishment of a Section on Neurological Surgei
from the E.xecutive Council.
The committee recommends that Report "J" be file
The action item in this resolution has already bee
approved by this body.
SPEAKER DAVIS: Report "J" is before you.
The Reference Committee recommends that this t
filed. Is there discussion? If not. those favoring filir
of Report "J" please say "aye"; opposed "no." It
filed.
REPORT Q
DR. McCAIN: Report "Q." Subject: Constitutio
and Bylaws change regarding compulsory continuin
education as a requirement for membership in the S(
ciety. It is from the Executive Council.
It was reported that many other state medical societic
are in various stages of implementation of continuir^
education as requirement for membership.
The committee commends the action of the fin
session of the House of Delegates in its decision Sunda
to have this incorporated as a change in the bylav\|
rather than a change in the Constitution, as this v>
allow subsequent changes to be accomplished by th
House of Delegates more easily on a yearly basis t
assure compliance to the will of the membership.
The commtitee recommends approval of Report "Q,
SPEAKER DAVIS: Report "Q" is before you.
The mechanism as outlined was adopted on Sunda
to consider that as a bylaw change and its adoptio
as a bylaw change is recommended by the Referenc
Committee.
Those who might be following this will find i
Chapter 1. page 13, Section 5.
Is there any discussion of Report "Q"? [No n
sponse]
If not. those favoring adoption of Report "Q" the b;
law change please say "aye"; opposed "no." Repoj
"Q" is adopted.
REPORT H
DR. McCAIN: Report "H." Subject: Compulsor
Continuing Education as a Requirement of Membci
ship from the Executive Council.
Considerable discussion was heard, both pro and cor
concerning the desired hours to be required, differer
categories of credit, methods of keeping records, er
forcement of requirements, cost of staff time and pre
vision for hardship allowances.
The committee recommends that Report "H" b'
amended by substitution of item No. 1 as follows:
That a minimum of 150 hours of continuing educ
tion per three years be required of each member o
the State Medical Society, reportable on an anniiE
basis.
It is felt that instead of making it 50 hours on a:
annual basis that by extending it to 150 hours in thre
years it gives more flexibility.
And, furthermore, the committee reconimends tha
Report "H" be amended by substitution of item No. '
by replacement of the second sentence of this item.
Item No. 4 would then read as follows:
That a form for certif>ing compliance with the abovi
requirement be included with the annual notice of due
HOUSE OF DELEGATES
77
then be returned
with the 1976
i(
i ;ent each physician. This form would th
L, ilong with the dues payment beginning
dues.
The time of applicability of continuing education
;ould not be had until January I, 1975 and would be
,-eportable at the time that statements are sent out in
iDecember, 1975 for the 1976 dues.
It is anticipated that a program of membership edu-
cation would be imdertaken to alert them that the time
B. jfor initiation of measurement begins in January 1975 to
je reported in December 1975.
And. furthermore, the committee recommends that
■leport "H" include the recommendation that the Com-
nittee on Medical Education be requested to study and
"■■econimend methods of awarding credits, processing and
icecording replies, managing cases of hardship and non-
■'|<:ompliance and report their findings to the House of
Delegates next year.
'" I' The committee recommends approval of Report "H"
'"^is amended.
SPEAKER DAVIS: Report "H" is before you. The
ommittee has recommended three different changes. It
f vould appear advantageous to consider these separately.
nnless 1 hear objection.
So we will go first to item one which changes the 50
tours per year to 150 hours per three years reportable
in an annual basis.
Approval of this has been recommended. Is there
''iiscussion? Is it understood?
DR. BRUCE BLACKMON [Harnett County]:
'Dr. Blackmon from Harnett!
. Em concerned about what we're doing to our retired
ihysicians in this. I don't believe it's clear to me just
I/hat happens to a fellow when he gets 62. 65 or 67 and
etires.
Does he get to the point in three years where he
an't write a prescription for the neighborhood young-
jter?
DR. McCain : This was brought out in the discus-
ion. This would be categorized as a hardship case.
Another hardship case would be where a physician
lad a heart attack or a case where it might be con-
idered one of his partners left and you had the whole
bad to carry by yourself.
The description of hardship cases should be studied
ind brought back so that consideration of these items
iDuId be included.
Another reason for starting when it does, beginning
■ext January as beginning to count the time, this will
lUow consideration and study by the House of Dele-
.ates and would be available for consideration with the
pport from the Committee on Medical Education at the
[ouse of Delegates meeting next year to consider in
tore depth the items that you mentioned.
And, I would think the Committee on Medical
Jducation would welcome your comments and sugges-
,ions if this is approved, that anyone would like to
lake.
I DR. BLACKMON: Are we anticipating that this re-
(ired physician will lose his license to practice after
|iiree years if he has not kept up his traninig?
DR. McCAIN: This does not apply to his license.
iihis applies to membership in the Medical Society.
II' SPEAKER DAVIS: Is there further discussion?
*
We're considering the substittite motion for item one
of Report "H."
Those favoring adoption of the substitution please
say "aye"; opposed "no." Item one is adopted.
We now move on to item four, again a substitute
motion, that would remove item four and substitute for
it the words that you see at the bottom of the page 3 of
your Reference Committee report.
Is there discussion?
DR. MELVIN W. WEBB [Anson County]: Under
number two. who will judge scientific literature reading?
DR. McCAIN: I hope this body right here will when
the results — when it acts on the report of the Com-
mittee on Medical Education to the House of Dele-
gates meeting next year.
SPEAKER DAVIS: We are considering item four
and its substitution. Are there further questions or dis-
cussion?
If not. those favoring adoption please say "aye"; op-
posed "no." [There were a few dissenting votes.]
It appears that item four is adopted.
Then the paragraph at the top of page 4. your Ref-
erence Committee makes a recommendation that might
be considered as item four of Report "H."
Acceptance of this and addition to Report "H" has
been recommended by your Reference Committee.
Is there discussion? If not. those favoring adoption
of item five please say "aye"; opposed "no." Item five
is adopted.
The Reference Committee has recommended adoption
of this entire Report "H" as amended. Discussion?
Those favoring please sav "aye"; opposed "no."
Report "H" as amended is adopted.
REPORT O
DR. McCAIN: Report "O. " Subject: Amendment to
the Medical Practice Act.
This provides for revocation or restriction of a license
for the lack of professional competence. It's from the
Executive Council.
The committee recommends approval of Report "O."
SPEAKER DAVIS; Dr. McCain, this is of such im-
portance, can you elaborate a little bit of what this en-
tails and how it will be enforced?
DR. McCAIN: This gives the Board of Medical Ex-
aminers the authority to revoke or restrict a license of a
physician for the lack of professional competence. If
hj's not measuring up to what should be done why this
allows them to consider him in this light.
SPEAKER DAVIS: Heretofore, it has been on mis-
conduct. Any questions on Report "O"?
DR. BLACKMON: I again, sir. would like to know
if professional competence be tied in with his hours of
study. We have a physician in the state who has had
over 1200 deliveries since he was aged 70. I doubt
seriously if this man is going back to school, yet I
think he's doing a good job in what he's doing. Are we
going to penalize this type of individual is what I'm
concerned about?
DR. McCAIN: I would not think if he was pro-
viding good service that continuing education would
be a component of this, as at the present time this is
not included under the purview of the Medical Practice
Act.
If he were providing inferior care or if there was a
78
1974 TRANSACTIONS
lack of competence. I would think they v\ould care to
insert this as one of his criteria for continued licensure.
DR. RALPH V. KIDD [Mecklenburg County];
Ralph V. Kidd. Mecklenburg Count\ !
1 would like to know if we could define lack of
professional competence in these others such as moral
turpitude or criminal charges or criminal actions as
stated against the physician during the act of profes-
sional competence and ability?
SPEAKER DAVIS: Dr. McCain!
DR. McC.AlN: Can we defer to counsel.
MR. JOHN ANDERSON [Legal Counsel]: The
present Medical Practice Act referred to as General
Statute 90-18 describes and provides the grounds on
which the Board of Medical Examiners may revoke or
rescind a license.
This provision would clarif) the power of the Board
to mean that the Board could restrict or revoke a li-
cense for lack of professional competence, notwithstand-
ing the doctor may in good faith or may have good
morals or not be involved in any moral turpitude.
As to the matter of how do you determine his medical
competence, the Board of Medical E.xaminers has a
n-.echanism for doing this, for granting due process in
doing it and it would be. of course, up to this group of
physicians to make this determination, but once it's
made this amendment in the Medical Practice Act
would require legislative action and would make it
easier to deal v\ ith this problem in our state.
SPEAKER DAVIS: Is there further discussion on
Report -O"?
Adoption is recommended. Those favoring adoption,
please say "aye"; opposed "no."
Report "O" is adopted.
REPORT N
DR. McCain ; Report "N." Subject; Purchase of
Property Adjacent to the Medical Society parking area
on Bloodworih Street in Raleigh. It's from the Executive
Council.
The committee felt that purchase of a rentable
house in the middle of Raleigh for $16,000 next to
our Medical Society building was a good bargain.
The committee recommends approval of Report "N."
SPEAKER DAVIS: Report "N " is before you. The
Executive Council has approved the purchase and Re-
port "N" would approve the action of the Executive
Council.
Is there any discussion? [No response]
Those favoring adoption of Report "N" please sav
"aye"; opposed "no." It is adopted.
REPORT R
DR. McCAlN: Report "R." Subject; proposed
change in the Constitution and B>laws regarding the
Committee on Memorial .Services.
This will allow services to be conducted by the Com-
mittee on Medicine and Religion. It's from the Execu-
tive Council.
The committee recommends approval of Report "R."
SPEAKER DAVIS; Report "R" actually eliminates
the Committee on Memorial Services. Its adoption is
recommended by the Reference Committee. Are there
questions or is there discussion?
If not. those favoring adoption of Report "R" pleasi
sa\- "aye"; opposed "no." It is adopted.
RESOLUTION NO. 5 i
DR. .\lcCAIN; Resolution No. 5. Subject; Increasec
activity in the area of public relations and legislatix
contact. It's from the Moore County Medical Society
The committee recommends approval by subslitutioi
of the following resolve:
Be it.
RESOLVED, that the North Carolina Medical So
ciety increase its activity in the area of public relation?
legislative contact and governmental relations.
The second sentence recommending a dues increas
was not felt necessary at this time as program enhance
ment was alread\' being accomplished within the presen
budget.
The committee recommends approval of Resolutioi
No. 5 as amended.
SPEAKER DAVIS; Resolution No. 5 is before yoi
with a substitute motion which will eliminate the sec
ond part of the single resolve, that having to do with ;
dues increase, but contains the substance of the firs
part of the resolve.
Is there any question about this?
!f not. those favoring the adoption of Resolution N<
5 as amended please say "aye"; opposed "no."
The amended resolution is adopted.
RESOLUTION NO. 6
DR. McCAIN; Resolution No. 6. Subject; Resolutio:
on creating improved communications between hospita
staffs through county and state medical societies. It'
from the Edgecombe-Nash County Medical Society.
The committee commends the Edgecombe-Nas!
Counts Medical Society for their concern in the need fo
improved communications between the hospital staff,
and county and state medical societies.
As the recommendations are already being carrie^
out via the President's Newsletter, the committee rec,
ommends that Resolutoin No. 6 be filed.
SPEAKER DAVIS: Resolution No. 6 is before yoi
with a recommendation that it be filed.
DR. LLOYD BAILEY [Edgecombe-Nash County
I would like to move that we vote on this resoiutioii
We felt that this is necessary because there are ia
stances where individual hospital staffs apparently an-
being singled out for action or treatment, one way o
another, by various groups and it would be nice if al
the members of the Society are informed at the sann
time when these things happen instead of hearing abou
an action six months later.
We felt that this resolution would set up a manda|^'.i
tory mechanism for improving communications acros
the state so that all of us could be informed in
timely manner about things that are important to all o^
us.
This doesn t change anything perhaps that's beinj
done right now. but it does require the State Medica
Society to distribute this information.
SPEAKER DAVIS: Resolution No. 6 we're consid
ering the recommendation of the Reference Committee
that this be filed.
Dr. Baile\' could accomplish his desire if this motiot
h
SPf
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HOUSE OF DELEGATES
79
ivere defeated. We would then resort to the basic
resolution. He states against filing.
(After further discussion and a voice vote which
failed to indicate a clear decision, the speaker called for
a standing vote.)
Now. will those favoring filing of Resolution No.
5 please stand.
Those against filing of Resolution No. 6 please
itand.
DR. ROY S. BIGHAM. Jr.: (Chief Teller) Mr.
speaker, for filing 76. those against filing 61.
SPEAKER DAVIS: Resolution No. 6 then is filed.
■» f
RESOLUTION NO. 14
111 li
•i;
"5 DR. McCAlN: Resolution No. 14. Subject: Encour-
'* 'iging membership in North Carolina MedPac. It's from
he Executive Council.
"' " Discussion was presented about the need for wide-
ipread support of the North Carolina MedPac. In the
liscussion of this resolution, it was pointed out that
h included no inference of mandate or coercion.
The committee recommends approval of Resolution
«Jo. 14.
SPEAKER DAVIS: Resolution No. 14 is before you
■ vith the recommendation of the Reference Committee
or its adoption.
DR. NAUMOFF: [Mecklenburg County] I am in
avor of the resolution to encourage that every member
if the North Carolina Medical Society become dues
laying members of MedPac. But I object to two of
ihe statements in the resolution on a basic principle.
First of all, number three which urges that the Ex-
cutive Council and all state and county leadership of
he North Carolina Medical Society become sustaining
'*4«riembers of MedPac.
I am well aware of the fact that there is no coercion
■r mandate in this resolution. For those people who
o not know what sustaining membership means, it
neans that instead of contributing S20 per year, you
■re contributing $100 per year.
I am opposed to anything that tells our county so-
'dety leadership or presidents, or secretaries, or other
arson of leadership in the county as well as the state,
s well as telling members of our Executive Council
aat we by urging them to become sustaining members
ve in effect are telling them that we expect them to
'ccome sustaining members of MedPac. I think this
(lould be voluntary.
I also object to number one which says that every
'iiember of this House become a dues paying member
f MedPac on the same basis. Here again, I think
elegates to this House should have the right to decide
3r themselves whether or not they want to become dues
-aying members of MedPac.
I therefore urge that we vote down the recommenda-
on of Reference Committee I and that we approve a
jsolution amendiT.ent to read that, therefore, be it.
RESOLVED, that the House of Delegates of the
''orth Carolina Medical Society go on record as favoring
ae following — just including number two which says,
ifil'l-e strongly recommend that e\ery member of the North
'.larolina Medical Society and Auxiliary become dues
laying members of N. C. MedPac.
iiKl'i SPEAKER DAVIS: Dr. Naumoff speaks against ap-
proval of Resolution No. 14 and offers a substitute
motion: Therefore, be it,
RESOLVED, that the House of Delegates of the
North Carolina Medical Society go on record as favor-
ing the following:
strongly recommend that every member of the North
Carolina Medical Society and Auxiliary members be-
come dues pa\ing members of MedPac.
SPEAKER DAVIS: Is there a second to this sub-
stitute motion?
[The motion was severally seconded from the floor.]
The substitute motion that you have just heard is
before you for discussion.
DR. J. ELLIOTT DIXON [Pitt County]: Di.xon
from Pitt! I would just like to ask Dr. Naumoff if he
would consider striking Auxiliary members from that.
We are speaking here of the Medical Society and we
are asking our Auxiliary to do something that I think
can be done very directly to the Auxiliary so I wonder
if you would agree to striking the words "Auxiliary
members"?
DR. NAUMOFF: Yes, I would and I even brought
this up at the Reference Committee meeting that I didn't
think we really had the right to tell the Auxiliary
members what to do.
SPEAKER DAVIS: Substitute motion then has
stricken from it "and Auxiliary members," from second
line of number two.
Is there further discussion of the substitute motion?
DR. JOHN H. HALL [Guilford County]: Mr.
Speaker. I oppose the substitute motion — I oppose the
substitute motion and speak in favor of the original
resolution. It is not telling, in my opinion, what the
county officers have to do or what the Auxiliary mem-
bers have to do, but rather is putting this House on
record as favoring something which is long overdue.
As a matter of fact, the Auxiliary has already rec-
ommended the same for its members.
SPEAKER DAVIS: He speaks against the substitute
motion.
Is there further discussion of this motion? If not,
those favoring the substitute motion please say "aye";
opposed "no."
It appears that the "ayes" have it and the substitute
motion carries.
REPORT G
DR. McCAIN: Please see the attached addendum re-
garding Report "G."
Report "G," Subject: Change in dates of annual meet-
ing and survey of the membership regarding choice of
May or September. It's from the Executive Council.
The committee felt that this report contained no ac-
tion items.
The committee recommends that Report "G" be
filed.
SPEAKER DAVIS: Report "G" is before you with
the recommendation that it be filed.
Is there discussion? If not, those favoring filing of
Report "G" please say "aye"; opposed "no."' Report
"G" is filed.
DR. McCAIN: I think that concludes my report. I
would like to comment that the discussions during the
hearings were very similar to that we've heard here to-
day; views on both sides were presented and the com-
mittee attempted to steer a middle of the road course
80
1974 TRANSACTIONS
about the comments and suggestions that were made.
I'd like to express my appreciation to Dr. Dameron
and Dr. Marshburn for serving on this committee.
Thank you.
SPEAKER DAVIS: I'd like to express the apprecia-
tion of the House to Drs. McCain. Dameron and
Marshburn for a very fine job and we are most grate-
ful to you.
May I please ha\e a motion that the report of
Reference Committee 1 as amended be adopted.
[The motion was severally made and seconded
from the floor.]
Any discussion? Those favoring adoption of the
amended Reference Committee report I please say
""aye"; opposed "no." It is adopted. [Applause]
I now recognize President Gilbert for another intro-
duction, please.
PRESIDENT GILBERT: Last fall. 1 had the honor
of being invited to the annual convention of the Vir-
ginia State Medical Society and they treated me \ery
royally, so I am proud to tell you that the President
of the Virginia Medical Society, in turn, is now here as
our guest and if you will just rise I want you to join
me m welcoming Dr. James Martin, President of the
Virginia Medical Society.
[Whereupon Dr. James Martin, President of the
Virginia Medical Society stood up to be recognized and
was accorded a standing ovation.]
REFERENCE COMMITTEE II
VICE SPEAKER CARR: Mr. President, Mr. Speak-
er. Members of the House of Delegates:
It is now my duty to turn to Reference Committee
II and I'll ask Dr. Stewart and his committee members
to please come forward to the podium.
Dr. Stewart, will you please stick to the ground rules
that Dr. Davis set.
DR. ALBERT STEWART [Chairman. Reference
Committee III: Mr. Speaker, Reference Committee II
met as scheduled on the 20th.
The meeting was well attended. The discussions were
lively and informative. I want now to thank all those
who came for their remarks. It was of tremendous
help to us in making decisions about our recommenda-
tions.
I also would like to recognize and thank Dr. David S.
Citron and Dr. Jack Hughes for their help on this
committee.
The business before this committee consisted of five
reports from the E.xecutive Council and thirteen resolu-
tions from various county societies.
We will begin with the reports.
REPORT D
Report "D": Guidelines for a medical director in a
long-term care facility.
Your Executive Council has approved recommenda-
tions from the Committee on Chronic Illness that the
North Carolina Medical Society endorse the principle
that long-term care facilities should employ the ser-
vices of a medical director, and that the Society endorse
the guidelines for a medical director in a long-term
care facility as adopted by the American Medical As-
sociation.
The Reference Committee understands that a long-
term care facility refers to an extended care facilit|
and offers skilled nursing services on a continuini
basis.
Realizing that in some areas the acute shortage o'
physicians would create problems of procurement for
facility. Reference Committee II amends this resolutior
by adding the words "where available," after the won
"physician" in line 7 and recommends the approva
of the amended report.
VICE SPEAKER CARR: Report 'D" is before yoi
for consideration to vote on Report "D" as amended
Is there discussion?
All in favor of Report "D" as amended please sa
"aye"; opposed "no."
The "ayes" have it and Report "D" as amended i
accepted.
REPORT E
Treatment of tubercu
DR. STEWART: Report 'E
losis cases and potential cases.
The report is from the Executive Council which ha
approved the recommendation of the Committee oj'-
Chronic Illness, that renewed effort be made to identif
and bring to treatment cases and potential cases, treat
n-.ent be continued for at least two years for active o
probably active disease, that the initial infectious phasi
be treated in a hospital, that the responsibility for out
patient treatment and epidemiologic investigation bi
shared with public health authorities and that the tu
berculin skin test be recommended as the initial screen'
ing procedure of choice in tuberculosis case findings
Reference Committee II recommends approval of thi
report.
VICE SPEAKER CARR: Is there any discussion o:
Report "E" or of the Reference Committee's recommen
dation?
All those in favor of Report "E" please say "aye'
opposed "no."
Report E is approved.
REPORT F
DR. .STEWART: Report 'F." report of the Executive-
Council: Recommendation that hemophilus influenz;
meningitis be made a reportable disease
The Executive Council has approved the reconi
mendation of the Committee on Child Health and In
fectious Diseases that hemophilus influenza meninigiti:
be made a reportable disease.
Reference Committee II recommends approval ol
this report.
VICE SPEAKER CARR: You have heard the recom
mendation of the Reference Committee. Is there any dis
cussion of the report or the recommendation?
If not, we will vote on the report as presented anc
approved by the Reference Committee.
All those in favor say "aye": opposed "no."
The "ayes" have it and Report F is approved anc
adopted.
REPORT I
DR. .STEWART: Report -1." resolution regardinc s;
the delivery of primary medical care for Winston-Saleir
in the State. This formerly was Resolution No. 12 a
the 1973 meeting.
The 1973 resolution called for a study to be made by
the Council on the deliver\' of primar\- medical care.
In this report. Council reports that the study made by
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11
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HOUSE OF DELEGATES
81
:s
the Board of Governors of the University in Septem-
j(ber 1973 accomplished the purpose of the original
Forsyth resolution and the Council calls our attention
ito the report.
Reference Committee II recommends approval of this
report.
VICE SPEAKER CARR: You have heard the resolu-
(ition and the report of the Reference Committee upon
Ithe resolution. Is there any discussion?
ij Hearing no discussion, we will vote on the report and
iJi^'the recommendation of the Reference Committee.
All those in favor say "aye"; those opposed "no."
The "ayes" have it and Report I is adopted.
REPORT K
DR. STEWART: Report "K, " a proposed position
paper on the "Need for More and Better Distributed
,'Primary Care Physicians."
Council received a proposed position paper on the
jneed for more and better distributed primary care phy-
isicians from the Committee on Community Medical
jjCare by Dr. John McCain acting for Dr. J. Kemp-
Ij. ,|ton Jones.
The Council voted, one, to commend the committee
for an outstanding job and, two, to publicize the paper
and refer it to the House of Delegates.
Mr. Speaker, there are some 25 recommendations in
Ijthis position paper all of which the Reference Com-
;[(i jmittee approved. There was no statement in opposition
jjj jlo any of them at our meeting on the 20th.
1 The Reference Committee II recommends approval
Of this report and compliments Dr. Jones's committee
and Dr. McCain's subcommittee for an e.vcellent paper.
5 VICE SPEAKER CARR: You have heard the report
of the Reference Committee. The Chair would call for
.discussion upon this, with the observation that if adopted
represents the position of the Hou.se of Delegates of
North Carolina Medical Society.
Is there any discussion? If not, all those in favor
tay "aye"; opposed "no." The "ayes" have it and the
feport is adopted.
I DR. STEWART: We now come to the resolutions.
.X RESOLUTIONS NO. 1. NO. 2, NO. 3, NO. 7
AND NO. 9
jis|>i We would like first to take up Resolutions No. 1
■'rom Edgecombe-Nash, No. 2 from Scotland, No. 3
■'rom Pitt, No. 7 from Edgecombe-Nash and No. 9
Tom Cleveland.
1 These five resolutions are concerned with repeal or
opposition to the so-called PSRO law or the PSRO
provisions of Public Law 92-603.
i Reference Committee II considered these resolutions
ogether at its meeting. There was lively discussion.
!*lost of those heard favored the concept of peer review,
iiiut many had misgivings about the PSRO law.
The committee was impressed with evidence indicat-
ing, or statements indicating the futility of persuading
[ihe congress to repeal the law so far untried.
; We also were impressed with statements from our
delegates to the AM A that amendments to the PSRO
uw have brighter prospects.
Reference Committee II makes the following substi-
ijjte resolution for Resolutions Nos. I, 2, 3, 7 and 9,
||s follows:
'/
RESOLVED, that although the North Carolina Medi-
cal Society strongly supports the concept of peer review
having improvement of the quality of medical care as
its goal, we are opposed to many aspects of PSRO
legislation; and, be it further
RE.SOLVED, that in view of the fact that repeal of
PSRO is not practicable at this time, we support the
intent of the American Medical Association to have the
law amended.
The committee recommends approval of this sub-
stitute resolution.
VICE SPEAKER CARR: You have heard the report
of the Reference Committee.
Inasmuch as this is a consolidation of several resolu-
tions, the consolidated substitute resolution becomes
the business of the House and the main motion at this
time.
Is there any discussion?
Microphone number two. Dr. Bailey!
DR. BAILEY: Mr. Speaker. I would like to request a
separate vote on number one and number seven, that
they be taken separately.
Number one, it would be in order to make a couple
of remarks. We, in medicine, appear to be in the posi-
tion of a condemned man who is afraid to offend his
executioner lest we make him angry,
I think all of us recognize that PSRO is a bad law
and it will decrease the level of medical care available
to the population of this country and I think we are
therefore obligated to oppose something which we know
is bad and therefore should work for its repeal.
Even though the chances may not be good, we can
still stand for what we know to be correct and things
we know will help medical care in this country.
It's good at the same time to work for amendments
if it's more practicable, but I think we should take the
position of being for repeal of the law.
VICE SPEAKER CARR: Is there further discussion?
The parliamentary situation at the moment is that there
is a substitute motion offered by the Reference Com-
mittee which is the business of the House and there
are two ways to handle it.
The easiest and simplest way is to defeat it if that
be the will of the House, the substitute motion and
address ourselves back to the original resolutions.
DR. BEDDINGFIELD: I rise to support the work
of the Reference Committee and presentation of the
substitute motion. I don't agree with some of the
premises advanced by Dr. Bailey. There are many de-
ficiencies or many objectionable features of the PSRO
law.
I believe there is no chance whatever and I base
this on, what I believe to be good authority to as re-
cently as last week in personal discussions with mem-
bers of the Finance Committee of the United States
Senate which is the power structure controlling this leg-
islation, and I would tell you very frankly there is no
way this legislation can be repealed until it's a proprie-
tary law.
I think it's an exercise in futility for this House
to pass a repeal amendment.
I would further disagree with Dr. Bailey in his
premise that PSRO will necessarily lead to poorer quality
of medical care. Indeed, I think there's a chance it can
improve medical care if PSRO is properly applied.
82
1974 TR-\NSACTIONS
There are patients in North Carolina who are in an
inappropriate institution, who stay an inappropriate
length of time, who have inappropriate studies done on
them and in an inappropriate manner.
PSRO. as judged by one's peers, would strive to
correct those deficiencies.
I think it's better for us to do it than for others to
do it.
I think the people who advocate repeal of PSRO
must present a \iahle. workable alternative and under
the present law. Section 249-F of Public Law 92-603.
which is the Bennett PSRO amendment, if it is re-
pealed then other portions of the Social Security Act
coir.e into plav which provide for review by others who
are not our peers.
1 sirongh support the committee's position.
VICE SPEAKER CARR: Is there further comment
or discussion of the substitute motion?
DR. BAILEY: Mr. Speaker, as PSRO is written, even
though peers may do the inspecting, the Secretar\ of
Health. Education and Welfare is still the final au-
thoriiv .
No matter how we look at it. he's the one who
makes the decisions and Dr. Beddmgfield and I are
certainly in basic disagreement on many parts of this
and 1 recognize what he said is right about other parts
of this overall law being more objectionable perhaps
than PSRO. In that case, we should actualh' be op-
posed to the entire thing.
We are the one.-> who are practicing medicine, pro-
viding quality medical care, and we should be the ones
who direct the progress of medicine rather than gov-
ernment.
All of us know. 1 think, that any time government
gets into anvthing it becomes inferior. Regulation by
government leads to people trying to avoid regulations
and increases costs and there are many reasons I
could name and I just do not want to take the time of
this House to go into all of them.
VICE SPEAKER CARR; Is there further discussion'.'
DR. GL.^SSON: I would simply like to reiterate
what Dr. Beddingfield has pointed out and that is in
this instance repeal turns us back to already existing
regulations under the Social Security Act through the
Bureau of Health Insurance which all of the things
PSRO can't be done other than our peers.
I would point out further that the Finance Commit-
tee and the Congress in doing this have \iewed as giving
doctors a chance to do peer review.
The fundamental concept is that the professional de-
cisions are made locally by the local PSRO. As far as
we have been able to see, they are sticking to this
and the professional decisions regarding patient care are
not. in my view, made by the Secretary of HEW.
The norn:s are also not made by the Secretary of
HEW. They are mandatory to be made by the local
peer review organization. It's a local effort and there is.
as has been mentioned, a provision that in January
1976 it could indeed be done by the Secretary in desig-
nating another organization to do it.
DR. KIDD: [of Mecklenburg] I would like to have
a little information that would support the intention of
the AMA to have the law amended.
What are these amendments that are being offered
by the American Medical Association?
DR. STEWART; At the Reference Committee meet-
ing yesterday, we were given a list of some 19 amend
ments which the AMA is sponsoring to be put intc
Congress to amend the present law.
What the status of these amendments are at thd
moment. I do not know. Perhaps Dr. Beddingfield couk •''
tell us.
VICE SPEAKER CARR; The Chair would recognizs
Dr. Beddingfield to answer a portion of Dr. Kidd's
question, as is well within his province being on the
AMA's subcommittee on PSRO legislation.
DR. BEDDINGFIELD: Mr. .Speaker, the reason tha
I was asked to do this, on Wednesday of last week
on behalf of the AMA I presented these amendment^
to the Senate Finance Committee in Washington.
The reason for this presentation was that following
the AMA's clinical sessions at Anaheim last December
acting under mandate of AMA House of Delegates
the leadership of the AMA approached the leadershif f
of the Congress and tried soundings on the chances ol
repeal and the results 1 have previously enunciated.
However, there are still some reasonable minds and
reasonable men in Congress and in the appropriate
committees that compose these. 1 don't mind mention
ing some of these by name; Senator Talmadge, Senatot
Long, and a long conference was held with these mer
as part of the committee on finance and committee or
health, and they felt if this law could be improved sc
that it would be tolerable, workable b\' physicians a
they had intended, they had invited us to suggest meth-
ods and they accepted these amendments.
They were presented to them in oral and documen
tary form on Wednesday of last week. They are undei
study by the Senate Finance Committee at this time
and I can report to you. unofficially, that the Secretary
of HEW told me following this presentation that a gooc
number of these amendments he thought were good an
that the Secretary and the Department of HEW coul
support a good number of these amendments we haq
suggested.
So I think some of them will not have strenuous
opposition.
Now. many of these are technical. If you want m«
to go into them I will because that really was the ;,
thrust of the question.
Ma\be I could quickl> glean out the more important
things, if this is the pleasure of the House.
The salient features of these amendments are aA-
follows:
The first one involves a change of definition unde^ ..
a section of this law so that we could perhaps have jj
a medical society in those states having a single stat^
PSRO without having a separate foundation set up,
that the Medical Society itself could become a PSRO
That is not possible under the act until after Senatoi
Bennett leaves the Senate which is on January 1.
One of the more important amendments was a re-
quest for an extension of time past the deadline ot
Januar> 1. 1976. which by the time the Congress passes
the law which seems in the future, which now is i
difficult task of organizing PSRO's and making thert
operative, it becomes more and more evident tha*
January I, 1976, is going to be tomorrow so an eigh-
teen month extension of time was requested.
There is an amendment regarding the structure anc
form of professional participation of the National '^
PSRO Council which is an eleven man national counci
HOUSE OF DELEGATES
83
3(
omposed exclusively of physicians and it was felt
tjhat the walled intention of this was that it should be
rimary practicing physicians.
We have a question whether or not a practicing
[fihysician or physicians are adequately represented on
he eleven man council and we have asked Congress to
Uave oversight hearings on this and determine whether
heir congressional intent has been fulfilled.
There is another amendment which attempts to
trengthen the fact that the norms that will be applied
Jj/ill indeed be norms developed within a given PSRO
[.'irea. that they could use guidelines developed by others
]([ ^nd modify them for the local situation, but that the
linal authority for this will be with the local PSRO.
J We have asked that the law state specifically that
guidelines whether they are called norms, criteria, or
tandards are to be guides only and cannot be sub-
|itituted for individual professional judgment.
We have an amendment which would clearly exclude
re-admission certification relying instead on concurrent
jCview after 48 hours after a patient has been admitted.
We have a provision to enunciate clearly every single
ijase, but it does not have to be reviewed, allowing for
eview on u random, or sample basis, or diet constant
inergy basis where the probability is very evident and
iji/ill be completely diagnosed.
Some of the more objectionable features of PSRO
1 Section 1 1 60 provide for financial penalties. We have
fied to soften this somewhat by saying a system of
raduated sanctions clearly stating the maximum applic-
able penalties such as suspension of thirty days. He
hould be suspended rather than requiring a physician
D reimburse the government for his patient's hospital
lill when he thought he had actually been acting in good
laith.
!i We've got another amendment.
I The law presently calls for reporting by PSRO to
lie Secretary for certain violations on the part of indivi-
!Ual doctors. We felt it was not the intent of the law
lat every single technical violation be reported and
lis amendment would clarify that and would require
lat it be reported only when a pattern of practice
'squired such attention, or the provider practitioner has
rossly, flagrantly and repeatedly violated the obliga-
ons imposed under the act.
We have an amendment to require that written rec-
ords of the PSRO shall not be subject to subpoena
r discovery proceedings in any civil action, a non-
■iscoverability clause which we feel is essential to pre-
ent a lot of dissent and professional liability litiga-
on problems.
We have another amendment to repeal a section and
) make it clearer to limit the liability of an individual
irnishing items or services when such individual has
cted in compliance with the norms or care applied
y a PSRO, provided that he exercised due care in
is conduct.
' This language in the provision could have an unde-
rrable effect of pressuring practitioners to adhere to the
iorms.
t
„ This provision is at best meaningless because on its
lice it is applicable only when the practitioner has
^ercised due care, so we're just asking that that be
ipealed.
i The language I was reading would be the amend-
0
ment instead of the present language of the law which
we're asking for that to be repealed.
There is a provision for an appeal of area designa-
tion mechanism. These are areas that have been pres-
ently designated and do not work, this provides they
can go ahead and be appealed.
There's a very interesting one here, which provides
for PSRO review of governmental and federal hospitals
such as the VA and public health .service hospitals.
It's the feeling that seeing that this is for civilian popu-
lation there should certainly be review of VA hospitals
as well.
One of the present requirements of the law requires
that PSRO inspect all hospitals within a given PSRO
area. It is the feeling that hospitals are subjected almost
daily to a given set of inspectors — the JCAH, Medical
Care Commission, and now the Fire Marshals and so
the AMA would not want on-site inspection by PSRO
to be a duplication.
There is a request to repeal Section 1155 (b) (3)
which would cut out a lot of paperwork for doctors
and patients and to minimize such documentation.
There is a request that we seek repeal of the present
utilization review procedures now under Medicaid in-
asmuch as PSRO would be applicable to do this.
There is another amendment that would strengthen
the confidentiality portion of the law that providing
information with regard to patients and with regard to
activities of PSRO, review committees would not be
available to agencies or arms of government.
And, that's a very brief summary,
DR. S. P. BASS, JR. [Edgecombe-Nash County]:
I question whether "practicable" is the right word in
there. Wouldn't it be better to say that repeal is not
likelv or probable rather than practicable?
Whv not say likely or probable?
VICE SPEAKER CARR: It's in order, sir. to offer
an amendment by deletion or addition of a word, if
you wish to do so.
DR. BASS: Well, I offer the use of the word
"likely."
VICE SPEAKER CARR: Is there a second to that?
DR. STEWART: We will accept that as an editorial
correction.
VICE SPEAKER CARR: The Chairman of the Ref-
erence Committee states that rather than go through the
process of amendment by deletion or addition, he will
accept that as an editorial correction. So we will accept
it.
DR. STEWART: The word he wanted was what?
1 didn't hear it.
VICE SPEAKER CARR: "Likely."
(After considerable further discussion the question
was called and the House of Delegates voted to termi-
nate debate and vote on the previous question.)
VICE SPEAKER CARR: We will now vote on the
question which is the substitute motion of the Refer-
ence Committee.
All in favor of that please say "Aye"; all opposed
"No."
[There were several dissenting votes.]
The "ayes" have it unless there be reason to contest
it on the part of anyone. The Reference Committee's
substitute motion is passed and the resolutions to which
it pertains have been adequately covered.
84
1974 TRANSACTIONS
RESOLUTIONS NO. 4, NO. 4-A, and NO. 8
DR. STEWART; Reference Committee II would now
like to consider Resolutions Nos. 4, from Pitt County,
No. 4-A from Beaufort-Hyde-Martin-Tyrrell-Washing-
ton counties and Resolution No. 8 from Edgecombe-
Nash.
The resolves of these three documents call for the
North Carolina Medical Society to oppose the require-
ment of the Joint Commission on Hospital Accredita-
tion that hospital staff privileges be delineated in minute
detail.
Information was offered at our Reference Committee
meeting yesterday that the Joint Commission has re-
lented temporarily but is expected to return to the con-
cept and make it a requirement.
Reference Committee II has consolidated Resolutions
Nos. 4, 4-A and .S. substituting the following resolu-
tion:
RESOLVED, that the North Carolina Medical So-
ciet\ believes that hospital staff privileges should be
delineated in a manner which is specific enough onK
to insure that the professional activities of each phy-
sician are consonant with good medical care as prac-
ticed in his medical community; and. be it further.
RESOLVED, that the North Carolina Medical So-
ciety express to the Joint Commission on Accredita-
tion of Hospitals and to the House of Delegates of
the American Medical Association its opposition to de-
lineation of hospital staff privileges in minute detail.
The committee recommends approval of the substitute
resolution.
VICE SPEAKER CARR: As stated in the foregoing
question, the business before the House now is the ap-
proval or disapproval of the substitute resolution offered
by the Reference Committee II.
Is there any discussion of this?
DR. DONALD B. KOONCE: [New Hanover Coun-
ty] I rise to speak in favor of the report of the
Reference Committee but to object to what the Chair-
man said about the Joint Commission. The Joint Com-
mission has not relented in its stand. Its stand has never
been adamant as seems to be the understanding of the
committee and it's not going to change and go back.
It can't go back because it's never been there, to being
adamant.
VICE SPEAKER CARR; Is there further discussion?
[No response]
All those in favor of the substitute motion please
say "aye"; all opposed "no."
The "ayes" have it and the resolution as amended
and consolidated is approved and adopted.
RESOLUTION NO. 10
DR. STEWART; We now take up Resolution No.
10 from Cleveland County which states;
RESOLVED, that the North Carolina Medical So-
ciety request Governor Holshouser to remove chiro-
practors from the North Carolina Division of Health
Services.
At the Reference Committee meeting, it was interest-
ing to learn that the chiropractor appointed to the
Board was appointed as a citizen and not as an indivi-
dual who represents chiropractic. However, the point
remains the same.
Reference Committee II amends the resolution as fol
!ov\s;
RESOLVED, that the North Carolina Medical Sc
ciety request the present and future Governors to re
frain from appointing chiropractors to the North Caro
lina Division of Health Services.
The committee recommends approval of this amende^
resolution.
VICE SPEAKER CARR; You have heard th
amended resolution as offered by the Reference Com
mittee. Is there further discussion? [No response]
Hearing none. I'll call for the question.
All those in favor of the amended resolution pleas
say "aye"; opposed "no."
The amended resolution is adopted.
t
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11
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RESOLUTION NO. 11
DR. STEWART; Resolution No. 1 I from AnsoX.,
County.
The resolution calls for the North Carolina Medica
Society to work for repeal of legislation accreditin
chiropractic schools or that which allows disbursal a
funds of Medicare or Medicaid for chiropractic ser
vices.
Statements made at our meeting indicated that
rumor existed that if an accredited school accepteiL,
academic credits on transfer from an unaccredited
school then the unaccredited school and its graduate
might be made eligible for benefits otherwise not attain
able.
Reference Committee II amends the resolution alj
follows;
RESOLVED, the North Carolina Medical Soceit;
goes on record opposing any legislation which wouU
give recognition or accreditation to any chiropracti^
school; and, be it further,
RESOLVED, that the North Carolina Medical So
ciety voice its opposition to the granting of eligibilit;
to chiropractors or other cultists for Medicare am
Medicaid funds in the performance of their services ,,.
and. be it further.
RESOLVED, that the Executive Council of the NortI
Carolina Medical Society determine whether any legall
constituted educational institution in North Carolin:
has accepted academic transfer credits from any schoo
of chiropractic and express our disapproval of sucl
practices if found.
The committee recommends approval of this amendei
resolution.
VICE SPEAKER CARR; You have heard th(
amended resolution of the Reference Committee. I'
there further discussion? [No response]
Hearing none, all in favor of the amended resolii
tion please say "aye"; opposed "no."
The "ayes" have it by unanimous vote and it i.'
adopted.
RESOLUTION NO. 12
DR. STEWART; Resolution No. 12 from Ansor
County.
This is concerned with the ending of the cost of living
council controls and expiration of the present economic
stabilization act.
Since this resolution is no longer timely. Referen;t
Committee II recommends that this resolution be r.'-
ceived and filed.
I
HOUSE OF DELEGATES
85
i VICE SPEAKER CARR: You have heard the report
of the Reference Committee that this resolution be
'received and filed.
Is there any discussion? [No response] There
aeems to be no discussion. We will then call for a
vote.
|J All those in favor of filing this resolution please
isay "aye"; opposed "no."
fj The resolution is filed.
I
RESOLUTION NO. 13
I DR. STEWART: Resolution No. 13 from Mecklen-
ourg County. Subject is membership of the Council
3n Medical Education of the American Medical As-
isociation.
Statements were offered at the committee meeting
:hat membership on the Council stands at eleven mem-
bers instead of ten; one student, one private practi-
tioner and nine medical school faculty members.
' The resolution calls for more equitable membership
'oetween private practitioners and medical school faculty
nembers.
Reference Committee II amends this resolution as
rollows:
' RESOLVED, that the North Carolina Medical So-
",;iety believes there should be more balance in the
ouncil on Medical Education of the AM A; that it be
Vurther,
RESOLVED, that the North Carolina Medical So-
;iety proposes that the Council on Medical Education
'.hall consist of eleven active members of whom not
ewer than one nor more than five shall be full-time
nembers of a medical school faculty; and be it further,
RESOLVED, that this resolution shall be transmitted
'o the House of Delegates of the American Medical
Association.
Reference Committee II recommends approval of this
imiended resolution.
' VICE SPEAKER CARR: You have heard Dr. Stew-
art's report for his committee. Is there any discussion
of this amended resolution? [No response]
If not, all those in favor of the amended resolution
^l)lease say "aye"; opposed "no."
[There were a few dissenting votes.]
The Chair rules that the "ayes" have it and the
"imended resolution is adopted.
' RESOLUTION NO. 15
.. The next one. Resolution No. 15. is the one that is
low being passed out to you. It was the resolution
vhich by your affirmative vote at our first session
j,!)n Sunday was accepted as a late resolution by the
lecessary two thirds of you. It was considered by the
leference Committee.
It may not have been read in detail other than
he resolves which were presented.
. DR. STEWART: Resolution No. 15 from Wilson
■^Dounty.
Subject: Medical Specialty Examining Boards.
WHEREAS, plans for recertification arc being under-
fliaken by many of the medical specialty examining
Iwoards, and
WHEREAS, this House of Delegates has approved
".he desirability of the membership of these boards being
►>eers of those they seek to examine, and
WHEREAS, in some instances, the legal instruments
setting up these boards are contrary to this concept,
despite this expressed desirability, therefore, be it,
RESOLVED, that it be urged that medical specialty
examining boards articles of incorporation and bylaws
restrictions for membership that are contrary to the
"peer" concept be removed, and be it further,
RESOLVED, that this resolution be referred to the
AM A House of Delegates.
Reference Committee II recommends approval of this
resolution.
VICE SPEAKER CARR: Are there further questions
or discussion on this resolution which are in order inas-
much as it was a late resolution? It's in order and
it is legal. INo response] Since there seems to be
no discussion, we will have the usual vote.
All those in favor say "aye"; opposed "no."
The "ayes" have it and the resolution is adopted.
I would now entertain a motion for acceptance of
the entire report of Reference Committee II, as
amended, and before the acceptance of such a motion
to thank Dr. Stewart, Dr. Hughes and Dr. Citron for
their diligent performance of their quite exacting task
yesterday afternoon.
[The motion was made and seconded from the
floor.]
May I have an affirmative vote unanimously by
saying "aye";
[Applause]
SPEAKER DAVIS: I now recognize Dr. Edward
Bond, Chairman of the Committee on Messages of the
President.
DR. EDWARD G. BOND [Chairman, Committee
on President's Addresses]: Mr. Speaker, other Mem-
bers of the Committee on the President's Addresses
were Dr. Margaret McLeod of Sanford and Dr. Wil-
liam Romm of Moyock.
At the outset, Mr. Speaker, and Fellow Delegates,
this committee would like to make it perfectly clear
that we had no trouble — I repeat — no trouble at
all getting transcripts of our President's spoken words —
[laughter] — and with no deletions! [Laughter]
The focus of this statement, returning to the serious,
does keynote the emphasis on communications that
our President, George Gilbert, has so well expressed in
his remarks.
As President and in his addresses, his communica-
tions have been open, grassroots in approach, "telling it
like it is" and for this, we commend him and express
our thanks.
In addition. President Gilbert has especially reminded
LIS of the continuing dedication and plain, plain hard
work of our headquarters staff and manv of our mem-
bers in their Society duties.
At no time in the past have these efforts been so
needed as now. Finally. Dr. Gilbert has stressed that
organized physician involvement must continue and. in
fact, be an integral part of our practice of medicine
if we as physicians are to meet our charge.
Mr. Speaker, it is our privilege to commend and en-
dorse our President's Addresses and I so move.
SPEAKER DAVIS: It has been moved and seconded
by Dr. Bond's committee that this report be adopted.
Is there discussion? [No response]
86
1974 TRANSACTIONS
If not. those in favor of adoption please say "aye";
opposed "no."
It is adopted with OLir thanks. Dr. Bond, to you and
to ti.e other members of your committee. Dr. McLeod
and Dr. Romni.
The House is now ready for New Business.
I would like to take this opportunity to express what
I think all of us feel and that is great satisfaction in
the way that our experimental sessions in medical edti-
cation proceeded both this morning and yesterday and
to commend Dr. Josephine Newell and Dr. Kenneth
Cosgrove who were in charge of this responsibility and
whose work this really is.
Id also like to belatedly — because I haven't had
a chance earlier in the session — to thank our head-
quarters staff. I think all of you would agree with me
that not only do we perhaps have the best staff in the
country, but they could not be more cooperative and
more agreeable in all the hard work that they do and I
would like to have a round of applause for the good
work that they do for us. [Applause]
Dr. Hughes, are vou rising for New Business?
DR. JACK. HUGHES [Durham County]: Mr.
Speaker. 1 have an item of New Business concerning
the exemplary administrative activities of the Speakers.
Does that require a vote or mav I present that?
SPEAKER DAVIS: I think you may present that!
[Laughter]
DR. HUGHES: I would move you. sir, that the
House of Delegates compliment the Speaker and the
Vice Speaker for another excellent performance in con-
ducting the affairs of the House of Delegates again
this year.
Further, that the House recognize Dr. Davis for a job
well done during the five years he has served as
Speaker of the House, particularly for his successful
efforts in increasing the efficiency of the meetings of
this House while increasing participation by the indivi-
dual members.
[The motion was immediately severally seconded
from the floor.]
[Whereupon the entire assemblage then accorded
Dr. Davis a standing ovation.]
M
..
SPEAKER DAVIS: I'm sure that both Dr. Carr and
I appreciate that more than you realize and as this is
my "Swan Song." I particularly appreciate it and would
like to take just a moment to express to this House
my sincere appreciation for what I consider a real privi-
lege for having served as your Speaker
As I trust you know, this has been a very stimulatina
and rewarding experience for me and I think you knowi
it has been fun all the way, even when Shaffner gets
up to object to every ruling — [laughter] — and Bed
dingfield skims in at the last minute and that boy never
misses a deadline — [laughter].
It has been fun and I am most grateful to you. You
have been most courteous, most kind and I appreciate
your helpful cooperation
I need not emphasize what great help Dr. Chalmers
Carr has been throughout this five year tenure. Thi:
House, I think as all of you realize, is a truly great
institution and it can only get greater.
You have chosen \our new Speaker and \our new
Vice Speaker exceedingly well
In these days of energ\' shortage, you have taken
care of everything. You have two Carrs — you've got a
big Carr and you've got a little Carrll [Laughter]
And. certainly, they can only succeed and I wish
them well, I thank you for all the help you have given
me and I now turn the podium o\er to your Speaker
Dr. Chalmers Carr. for adjournment. [.Applause]
SPEAKER CARR: I wish to personally thank Dr.
Davis — Jim, as I'\e known him for many years — for
showing me the ropes of this office which I have en
joyed, and I hope that I shall be able to carry it on in
the tradition which he has established
I have no prepared speech, nor shall I make one
now. I'm in the position of saying that since \ou have
chosen a Vice Speaker who happens to have my same
surname, though we would have to go way back into the
roots of Duplin County to find a cross connection, but ,,.,
I'm sure there's one somewhere as my paternal ances-
tors originated in Duplin County from which he comes
With that, we adjourn the House. \,
[The meeting adjourned at four-ten o'clock.] i eij
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PRESIDENT'S DINNER MEETING
President's Dinner
TUESDAY EVENING SESSION
May 21, 1974
87
ilii 1 The President's Dinner Meeting of the 12()th Annual
(/leeting of the North Carolina Medical Society con-
icned at nine o'clock in the Main Dining Room of
il'he Pinehurst Hotel, Pinehurst. North Carolina, Dr.
lames E. Davis, Speaker of the House of Delegates of
he Society, acting as Master of Ceremonies,
r MASTER OF CEREMONIES: "Will the House please
l|iome to order'? [Laughter] Will the House please be
1 order'.' [Laughter]
II I'm sorry, it must be a habit!
This is really the President's Dinner and right away
;i want to put you at ease because I know you're
itting back there with your tiny little heads saying,
.(What is he doing up there tonight'?"
; You know I'm not George Gilbert and you know and
. know I'm not President — but I'm working on it!
jLaughter] And, I'll tell you the reason I'm here is
:mply because we've got a very kind and considerate
'resident.
I.'
It's sort of like this — shortly after I was impeached
lis afternoon by the House of Delegates — [laughter]
'-and George came by and said. "Yes, I think I can
inderstand because tomorrow I'm going to be in the
ame boat!", but he said. "I think I can help you out
^I'ith a temporary job if you can work tonight!"
JLaughter]
So I'm here to welcome you here tonight to Katie and
iJeorge Gilbert's Presidential Dinner.
' First of all, I would like to present to you those
'ifting at the head table and I'll ask you to withhold
^our applause until all have been recognized.
^ On my far right are Dr. and Mrs. Elliott Dixon;
''.ietty of course is the President of the Women's Aux-
■Jary and Elliott has been Chairman of the Nominating
''ommittee.
Next is Ella Glasson, of course the wife of our im-
iiediate Past President, John Glasson.
And, next is Katie Gilbert and I will ask her not to
■ se if you will.
And, on my far left Margaret Hilliard, wife of course
f our Executive Director, Bill Hilliard.
Next, Mrs. Russell Roth and Dr. Roth the President
f the American Medical Association, whom we will
ear from tomorrow.
And, next. Marguerite Reynolds, wife of our incoming
resident.
And. then the most important person here, the most
aluable player received in my league, my wife, Mar-
aret.
[As the Master of Ceremonies introduced each per-
)n, they stood to be recognized and were applauded
y the audience at the conclusion of the introductions.]
We have so many other dignitaries seated throughout
le hall that I would not attempt to recognize all of
lem, but we're particularly glad to have with us to-
ight one of George Gilbert's associates and I'll ask
■r. George Coughlin and his lovely wife, Jean, to
ease stand.
Mrs. Ruth Scrivner, the President of the National
luxiliary is with us. We regret that Dr. Scrivner could
not be here. He is a Past President of the Illinois State
Medical Society and is also a member of the PSRO Ad-
visory Committee. Mrs. Scrivner, we're delighted to have
you with us.
And, also. Dr. Ed. Annis, a Past President of the
American Medical Association, whom we will also hear
from tomorrow morning.
[As each of the additional persons were recognized,
they stood at their place in the audience and were ap-
plauded at the conclusion of the introductions.]
I think you will all agree that George Gilbert has
run a very tight ship this year, has had a very thor-
ough, far-reaching administration. In fact, this morning
he pointed out to us in his Presidential Address all the
innovations he has brought about. He has enlarged the
staff. He has shuffled them around. He has raised all
the salaries. He's after the "bad apples" in the member-
ship and it was only after my experience with the House
of Delegates this afternoon that I found out what he
meant by "bad apples"! [Laughter] He certainly got
rid of me in a hurry! [Laughter].
But in his retinue is something that other past Presi-
dents have not had — King George had a court jester,
if you will, through the year and I will now recognize
Josephine Newell — [laughter] — to please come and
pay her final respects to King George of Gilbert!
[Applause] [Cheers]
DR. JOSEPHINE E. NEWELL: Dear friends!
[Laughter]
Everybody knows that Jim is desperate!
I'll tell you what's the truth, you look in your folders
you'll see I'm listed for Moderator tomorrow and the
day they told me I was the moderator — there I am in
print — they said, "The great dignitaries from the AMA,
Dr. Annis and Dr. Roth, and Jo we know we've got
some explaining to give to the AMA" — [laughter] but
I want to tell you that I love "em all, every one of you,
and particularly George Gilbert: George Gaylord Gil-
bert.
And, 1 was thinking about that as I was walking up
here, just a few short seconds, he's the gayest lord I've
ever seen in my life! [Laughter]
But, LaRue King told me that "gay" meant some-
thing else all together and I didn't even know it —
[laughter] O Lord!
You know, they sic her on me day and night and
tell her, "Watch her! Don't let her say anything out of
place!" By golly, and she watches me.
They send me to the AMA meeting to pick up the
scientific exhibits and they said, "You've got to live in
a room with LaRue and she'll watch you like a hawk!"
and she does! [Laughter]
But I did want to tell you this, that one of the greatest
experiences of my life has been this year when Katie
Gilbert has tried and has gone every time and joined
George in his escapades all over the United States and
everywhere else he has gone, in spite of a broken hip
and her other infirmities.
She has been really the First Lady of the Land and
88
1974 TRANSACTIONS
1 ask you for \our appluase for Katie, the great lady!
I Applause I
For George, for Frank Reynolds to whom we are
going to be greatly indebted — we're already indebted
but he's going to be one of the greatest Presidents
we've ever known — in our fight for private enterprise
and for personal endeavors.
1 can be serious at times and I am serious. I have
to make a living, just like the rest of you fellows!
ILaughterl Ain't nobody going to buy bread for me
when I get home! 1 just have to get out and make it and
I ha\e to make it just like you do and I do appreciate
this and I do want to render a service, just as you do.
And. I am opposed to all this socialized stuff and I
am working with you and for you.
And. the thing is. nobody can tell me about Women's
Liberation. You don't have to be liberated. All you have
tO do is work with those men and stand your ground
ai.d they'll help you stand it and you can help them
stand theirs: we're all working for one comn-.on t'.iing
— the he.t thing for American medicine and American
health.
And, that's what these three great fellows are fighting
for — George Gilbert. Frank Reynolds and Jim Davis
and all of the AM A and 1 ask your support and thank
you 'o kindly for putting up with me.
I admire every last one of you. You're great fellows.
You've always produced great presidents. They have
produced for you and these are three of the greatest!
And. thank you so much. [Applause 1
MASTER OF CEREMONIES: As always. Josephine
Newell!
George has agreed to work some this evening and at
this point he is slated to install the newly elected of-
ficers and so I will ask the First Vice President-elect.
Dr. Hughes; Second 'Vice President-elect. Dr. Sohmer:
the Speaker and the Vice Speaker, the Carr boys, to
please come forward and the President will administer
the oath of office.
[Whereupon the newly elected officers then came
forward to the podium. 1
PRESIDENT GILBERT; I should mention that our
esteemed Master of Ceremonies is also President-elect
and he's going to get sworn in too, whether he likes it or
not.
Repeat after me. this oath of office.
(Whereupon each newly elected officer then re-
peated his oath of office as President Gilbert recited; ]
I SOLEMNLY SWEAR THAT I WILL CARRY
OUT THE DUTIES OF MY OFFICE TO THE BEST
OF MY ABILITY. I SHALL UPHOLD THE CON-
STITUTION OF THE UNITED STATES OF AMERI-
CA AND THE CONSTITUTION AND BYLAWS OF
THE NORTH CAROLINA MEDICAL SOCIETY AT
ALL TIMES. I SHALL CHAMPION THE CAUSE OF
FREEDOM IN MEDICAL PRACTICE AND FREE-
DOM FOR ALL MY FELLOW AMERICANS.
What Say You'.'
rWhereupon the nevsly elected officers responded
in unison.]
I Do'
MASTER OF CEREMONIES; I now recognize John
Glasson. immediate Past President.
DR. JOHN GLASSON: Thank you. Mr. President-
elect.
f.-:
llf;t
Distinguished Guests of the Society. Dr. Roth, Di
Gilbert. Ladies and Gentlemen;
It has been my privilege to work very closely witl ',"
George Gilbert in the work of the Society for the pas
ten years and as tradition would have it. it is my privi '*
lege at this time to share with you some of the observa
tions and e.xperiences which do not always come into th
spotlight in connection with the official meetings an^''|'
functions of the Society.
George Gilbert's official biography is in the prograri
of the meeting. Additional facets of his life are familia
to many of you and to others, perhaps not.
No man was ever more conscientious, devoted ti
duty, or more effective as a professional man. as
leader in organized medicine and. indeed, as Presiden
of the North Carolina Medical Society, than Georgi •
Gilbert.
When the nionth of July rolls around, however, a
surely as the swallows go back to Capistrano. Georg
Gilbert and his family retreat to the family summe
place in the mountains of New Engalnd. where, afte' ■'"
some forty years, they are beginning to get almost oi
speaking terms with some of the true natives of thi
area.
.Many years of exposure to these fine people and ti
the fine people of the mountains of Western Nortf
Carolina tend to mold even a person with the stronj
character of this minister's son into a rugged indivi
dualist who is honest to a fault.
George tempers his honesty with kindness on all oc'
casions. but without too much prompting if he is at al
goaded by his friends, me included, he will come ou;
with such things as. "Go to (expletive deleted). John
[Laughter]
Whereupon he will calmly resume the topic of conver
sation or will resume one of literally thousands o!
good stories which he has at his command, many o
which as you can well imagine, are related to hi
held of primary professional endeavor as a urologist.
He spends more time by far than the average docto
talking with his patients on a one-to-one basis evaluatin]
their opinion on the broad subjects of delivery of healtl
care, insurance and other items of general interest U'
all American citizens.
He has used all types of air transportation coverini
the breadth of the good state of North Carolina in con
nection with his assigned duties as a leader in the Nortl
Carolina Medical Society and his early training as ;
pilot has enabled him on some of these occasions h
take a turn at the controls.
As one might expect from a native of the Nortl
Carolina mountains, he has a healthy and somewha
suspicious respect for all "revenooers" and Feds, undo,
whatever guise! [Laughter]
Like all Presidents of our Society, his commitmen .
to this job has also been a commitment shared with th(
other members of his professional partnership and htg
never fails to recognize the contribution which they o:
make in behalf of the work of organized medicine ir
our slate through their sponsorship of his participatior
in this important work.
As I noted last year. George came through Hopkiai.,
with many of the giants of American medicine todayj
and like Russell Roth, our honored guest, Rollins Han''"
Ion. and as he says. Willie Longmire and others whc
t
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Sc,
F;
SOI
PRESIDENT'S DINNER MEETING
89
}/ere his classmates. He is evolving as a giant in his
■wn right though he would, I am sure, view this state-
lent with obvious disgust and great reservation.
1 am sure you have all enjoyed with me the smooth,
onest, sincere and conversational style of his writing in
.lie monthly President's Newsletter this year.
For mc. his effort in this publication has been one
jf constant concern for the timely presentation of cur-
,3nt legislation, federal regulations and, as he expresses
.j, whatever has been the latest thing to hit the fan —
II
[e brings to us his greeting.
:'s the "Doc from the hills" who brings us the thrills
..t the Annual Medical Meeting.
),
jie can stop all pollution, he can solve distribution
^s he travels by plane or by Hertz.
Je deciphers the role of Price Control
i,o keep it from driving us "Nertz."
•f
fe is truly the Scion from Buncombe to Tryon
s he works out the guides with the "Blues"
ijrom Raleigh to Sidney, it's our Captain Kidney
'ho will stop the next raise in the "dues."
'1
;iS he flies like an eagle, he is handsome and regal
; e has a firm hand at the helm.
i'hether it's problems of health or the spread of the
wealth,
■e is known throughout all the realm.
jB's the son of a preacher and he's known as a teacher
, e can handle a pain in the flank.
'e will bring you new hope with his trusty old scope
Dr in this he is rated "Top Rank."
■aughter] — which is important to his fellow North
arolina physicians.
So, George, before you turn over your responsibilities
Frank Reynolds, we would ask you to hear this little
■jem by an anonymous author:
"' It's called:
CAPTAIN KIDNEY
or our President here, the man of the year
e gather to honor tonight.
i-e turns gloom into cheer, he leads without fear
5 he gives all those feds a real fright.
; the old North State the Watergate
ill make us all wiser but sadder.
0 to George at the Mission, assume the position
nd "Presto" you'll have a new bladder.
s can start a Foundation, he can clean up the Nation
') we tool up for PSRO:
X the Medicare forms or develop the Norms
' jr big man puts on quite a show.
; is the "Pilot at the Wheel." he carries on with lots
of zeal.
ith faultless propriety, he leads the Society
hether it's reading a tough I.V.P.,
■ reading the Blips or washing out chips
s performance is something to see.
iw — expletive deleted — as is oft-times repeated,
-■'s a master behind anv "mike"
For a union physician he takes the position
You can fuss, but you dasn't not strike.
He promotes legislation to require education
And for us all he made it a rule
That we accomplish a pass in a medical class
Or get ourselves back to the school.
For the states and possessions, he leads the "Profession,"
He has solved all our problems with fuel.
There can be little doubt as you start to go out
That he really deserves this fair "Jewel"!
George, here it is!
[Whereupon Dr. Glasson then pinned on the Presi-
dent's Jewel to Dr. Gilbert's coat lapel.] [Applause]
PRESIDENT GILBERT: I just said, "You — ex-
pletive deleted!" [Laughter]
It is now my duty, probably the most enjoyable duty
Eve had all year now that I think of it, to swear in
my successor, so Dr. Frank R. Reynolds, please come
to the podium.
[Whereupon as President Gilbert recited the oath of
office of the President. Dr. Reynolds repeated it after
him as follows: ]
L FRANK REYNOLDS, SOLEMNLY SWEAR
THAT I SHALL CARRY OUT THE DUTIES OF
THE OFFICE OF PRESIDENT OF THE NORTH
CAROLINA MEDICAL SOCIETY TO THE BEST OF
MY ABILITY. I SHALL STRIVE CONSTANTLY TO
MAINTAIN THE ETHICS OF THE MEDICAL PRO-
FESSION AND TO PROMOTE THE PUBLIC
HEALTH AND WELFARE. I SHALL DEDICATE
MYSELF AND MY OFFiCE TO IMPROVING THE
HEALTH STANDARDS OF THE AMERICAN PEO-
PLE AND TO THE TASK OF BRINGING
INCREASINGLY IMPROVED MEDICAL CARE
WITHIN THE REACH OF EVERY CITIZEN. I
SHALL UPHOLD THE CONSTITUTION OF THE
UNITED STATES AND THE CONSTITUTION AND
BYLAWS OF THE NORTH CAROLINA MEDICAL
SOCIETY AT ALL TIMES. I SHALL CHAMPION
THE CAUSE OF FREEDOM IN MEDICAL PRAC-
TICE AND FREEDOM FOR ALL MY FELLOW
AMERICANS.
I SOLEMNLY SWEAR THAT I WILL DIS-
CHARGE THE DUTIES OF OFFICE TO THE BEST
OF MY ABILITY. SO HELP ME GOD.
[Whereupon the entire assemblage then accorded
newly elected President Reynolds a standing ovation.]
PRESIDENT REYNOLDS: The buck stops here!
[Laughter]
Dr. Roth, Dr. Annis. Distinguished Guests:
I do consider this the highest honor that our Society
can bestow on any of its members. I realize fully that
one cannot accept this honor without also accepting the
responsibilities that accompany it.
Our Society has been extremely fortunate in the past
in having leaders with dedication, ability and stature
and I shall try to follow in their footsteps.
As you noticed on the program, fortunately, there's
not an acceptance speech, just acceptance "remarks,"
so if you'll bear with me for a few minutes I just
have a few remarks Ed like to make.
First, about the onlv difference I noticed in getting
90
1974 TRANSACTIONS
older is. first, that one appreciates the family n-.ore.
seeond. one appreciates their friends a great deal more
and. thirdly, one gets more garrulous! [ Laughter 1
With this in mind. I would like to take this oppor-
tunity to mtroduce my family to you.
All of vou know my long-suffering wife. Marguerite!
1 would like to introduce my children to you.
Our oldest son. Frank. Jr.. is working for the Health
Department down in South Carolina and he had to go
to an EPA meeting of all things in Atlanta, so he
couldn't get here.
But my oldest daughter, Margo!
My next daughter. Lindsay, who will be a freshman
at St. Mary's next year!
And, my second son. Fairfax, who will be a senior
in premed at Chapel Hill this year.
[Whereupon each member stood as he or she was
introduced, following which their recognition was ap-
plauded.]
Now. secondK. 1 would like to thank all of Mar-
guerite's and my friends who have come to Pinehurst
for this occasion. I want them all to know that we ap-
preciate it more than they will ever know.
When I look around I see a great many of them
from home and it really has meant a lot to me to see
them here tonight.
The last thing, if you could bear with me a few
moments. I just have a few words Ld like to say.
A lot of my friends and other people have said.
■"Frank, how in the world have you been interested in
the Medical Society for so long? How can a pediatrician
down there on the coast get up to Raleigh?" My only
answer to them has been that Lve been extremely
fortunate in having very, very dedicated friends.
It all started back in \'^51 when we had a \er\ special
le:
man from Wilmington who was President of the Stat
Medical Society. Dr. Donald Koonce. [Applause]
Dr. Koonce asked me if I would work and I toh
him. yes. I certainly would, so he put me on the Legisia
tive Committee. Then I had several trips to Washingtoi
with them and then when they had a meeting at Pine
hurst, Donald would call and say, "Come on, Frank, let'
go to Pinehurst!" and I would say, "All right!"
I was also fortunate v\hen I got up here, I had th
opportunity of playing golf with some of Donald'tf'
friends. If any of you have ever played golf witl iiir
"Pot" Poteat and Charlie Styron and Alfred Hamiltoi
and some of those, it's worth the price of admissio: sia
up here just to hear them! [Laughter]
So, anyway, buddy, it seems to me that every tim
that I would get a little slack or something. Donaf
was always there and anything about the State Medics K'
Societ\ \ ou could always ask him. I don't know any as
body who knows any more about medicine in Nort mi
Carolina than Donald Koonce and I would just like t set
say that if it wasn't for Donald, I don't think I woulJUf
be here tonight. I certainly appreciate it.
The other thing, if you noticed on your program
after we leave here, the President's Ball is over in thiM
Cardinal Ballroom and I want to tell all of you tha
we certainly do appreciate your coming and as yo la
leave here, if we adjourn, and go right down the ha! "
the orchestra is going to start playing and we want t
assure you that the party is just starting! Thank yoi .
again.
[Applause]
MA,STER OF CEREMONIES: Have a nice eveninf-"
We stand adjourned. Good night! '"
[The meeting adjourned at nine-thirty o'clock.] t*
oil
91
General Sessions
MONDAY MORNING SESSION
May 20, 1974
' The First General Session of the 120th Annual Meet-
ling of the North Carolina Medical Society convened at
'nine-five o'clock in the Cardinal Ballroom of the Pine-
hurst Hotel, Pinehurst, North Carolina, Dr. George G.
Gilbert, President of the Medical Society, presiding.
PRESIDENT GILBERT: Would everybody that's
going to come to this session come on down on the
floor and have a seat up front, preferably, so we can
(get this show on the road!
Well. I believe it is up to me to initiate the cere-
imony for the first general session of this, the 120th meet-
ing of the State Medical Society. So, with this, I will in-
HToduce our Moderator who is Chairman of the Depart-
sTient of Surgery at the University of North Carolina.
jiFhese good people have gone to great trouble to prepare
heir papers which I'm sure will be fabulous and I think
[ive're all going to learn an awful lot. Thank you for
: ;oming.
DR. COLIN G. THOMAS. JR. [Professor and Chair-
7 nan of the Department of Surgery, University of North
iTarolina School of Medicine, Chapel Hill, N. C.]: Let
ne thank you all for being here. I'd like to introduce
our Dean, Christopher C. Fordham, III, who will have
I few comments to make.
DR. CHRISTOPHER C. FORDHAM, III [Dean,
JNC School of Medicine, Chapel Hill]: Mr. Chair-
, nan, Mr. President, Fellow Members and Guests: It's
I pleasure to participate in this program and comment
!)n the new format. I hope it will prove to be successful.
.Ve are certainly pleased that our Department of Sur-
;ery is beginning the general sessions this year in the
lew format.
There are important new trends in medicine. I thought
might spend a minute before we start the formal
irogram addressing a few comments to the role of the
.urgeon and the surgical sub-specialist in some of these
iiew trends because I believe the surgeon has a critical
o\e to play and it may not appear that at the surface.
One of the important new trends in medicine and
medical practice, medical education, is the great empha-
is in our society now along more generalists. more
primary care physicians; physicians trained in family
medicine, general internal medicine, general pediatrics,
rnd I think it's very clear, judging from what's happen-
ing all across the country and in the State of North
Carolina, that this trend is with us.
I That the trend in a sense swims against the natural
■volution of specialization when knowledge and tech-
' ology burgeon as they have in the medical field.
In other fields, specialization is the inevitable conse-
,iuence of the growth of knowledge, but it's very clear
' ihat in our society there is a cry among governmental
gencies. professional groups and the general public for
etter accessibility to comprehensive care embodied in
le primary care physician.
What's the role of the surgeon in this changing scene?
I It's quite likely as we see medical schools grow and
i'raduating classes from medical schools grow, we're
jOing to see an increasing proportion of those gradu-
ates going into primary care specialties and not into
the sub-specialties of medicine and surgery.
So there will be proportionately fewer surgeons com-
ing from the e.xpanding generation of medical students.
I would present the thesis that the surgeon never-
theless has an important role to play.
We have in the State of North Carolina embarked
upon a major new effort — the profession of medicine,
the medical schools, the State of North Carolina, the
Board of Governors — to make health education as
fully responsive to serving the needs of the state as it
can possibly be.
And, this is exemplified with the Area Health Edu-
cation Center Program which I talked about in this
forum last year and will not belabor this morning.
It does address itself to several of the key problems
in our state, the number of physicians, the distribution
geographically, and a key part of it is the distribution
of physicians in our state by specialtv with the major
emphasis and the major thrust in the primary care field.
As we proceed attempting to mount these residencies,
working with our colleagues in practice, in hospitals
across the state, several critical items need attention and
deserve attention which I think perhaps haven't had a
sufficiently careful analysis in our country.
One of the difficulties is that we're such a large
country and the states and the variations within the
states are so great in terms of health care needs.
But, North Carolina is an entity with a responsibility
and it just may be possible for us to come up with a
rational approach to improving access to services.
Now, the issues to which I refer have to do first
with some kind of effort to define the content of the
practice of medicine, that is the generalist practice of
medicine in the future, based on an analysis of the
clinical problems which come to the physician.
I believe this is an effort which has not been satis-
factorily accomplished in our society and it must be a
joint effort; it must be an effort between the academic
medicine, the organized practice of medicine including
the surgeons and the surgical sub-specialists, the medi-
cal sub-specialists and those who plan to be generalists
and those who are now serving as generalists.
I do believe that the glamor and the additional prere-
quisites and esteem and prestige issues are pretty much
behind us, so that we can look upon all trainees as in
fields of worthy endeavor. The pay differentials under
the VA and the military no longer exist and so it's not
a matter of what's better than something else. It's really
a matter of how do we train men and women to each
kind of practices they want to do and that's needed in
given areas of our state.
So for example, the orthopaedic surgeon needs to help
us define what the generalist can properly do in a set-
ting in the State of North Carolina that will not com-
promise the outcome to the patient.
Should the generalist. for example, set a Colles frac-
ture?
I think we need to do a lot of work on this matter
r
92
1974 TRANSACTIONS
of content of practice and we need to do it togetiier.
Secondly, arising from this analysis should be an
improvement in our training programs for generalist
physicians.
We only ha\e three years at the present time to train
a family physician, for example. Many people ha\e com-
mented that the family phvsician needs to be trained
much longer than many of the sub-specialists because
of the breadth of his challenge. Therefore, we must
make that three \ear training program as effecti\e as
possible.
Teach that trainee v^hat he or she needs to know
and not spend a lot of time teaching things that he or
she will not be doing except insofar as they contribute
to the total capability.
But we need to use that time well.
And. thirdly, we need to articulate these training pro-
grams and this definition of clinical content with the
assured specialts backup across the State of North
Carolina in those areas where the generalist is not
tramed in special techniques and capabilities and so on.
Now. I would simply conclude by saying that the
surgeon has a very important role to play in the changing
scene. I think it's clear that the Department of Surgery
at Chapel Hill is very concerned about the training of
future generalists. their own role in this and I'm very
pleased with their approach to it. We've got a long ways
to go to deal effectively with the issues and translate
them into training programs.
This collaborati\e effort though with the profession
is. I think, just one area of an example where the
medical schools and the organized profession are grow-
ing closer together in dealing with the problems that
we face and the understanding of the public of our ef-
forts to serve them and our own understanding of what
they view their problems to be.
We've had that experience in developing our affili-
ated hospital programs, our associated hospital programs
now. our care of individual patients from all hundred
counties each year that goes b\' and the development of
the exciting new area health education centers program
this year, which the General Assembly as you know
has generoush funded. The partnership that ue ha\e.
though, with the practicing profession is critical if
we're to sohe these problems.
The medical schools certainly can't do it. but they can
help the profession do it and in this vein I want to
pay especial thanks to the leadership of the Society in
the past several \ears. I'll only go back to the year
before last when Dr. John Glasson was President, to
this year with Dr. George Gilbert, and look forward
to next year with Dr. Frank Reynolds.
We certainh' have had a very close relationship and
the constituent societies within the Medical Society
ha\e been of inestimable value in working with us to
develop teaching programs out of the state.
Finally. I'd like to make a couple of comments and
express a few words of appreciation to my colleagues
in the Department of Surgery who will be delivering
the more formal part of this program.
To Dr. Thomas, the Chairman, to Dr. Murray. Dr.
Fagelman, Dr. Croom. Dr. Biggers. Dr. Bevin, Dr.
Preston. Dr. Avis who will be giving the talk originally
scheduled for Dr. Cole, Dr. McDevitt and Dr. Mandel.
This is a mixture of junior and senior faculty of great
capability and dedication.
As we all know but need perhaps to be reminded on
occasion, the academic surgeon like his community
based counterpart is a ver\' special kind of individual.
Even in the teaching setting, dedication to patient care
must come first on his list.
The teaching surgeon functions as a multiplier by
serving as an example, as well as teaching b\ precept
and he also has responsibility for the advancement of
knowledge, understanding and skill in the surgical care
of patients.
Our surgeons are dedicated to the State, to the Uni-
versity Medical School, but most of all to their pa-
tients and their trainees. On all these counts, I believe
my colleagues merit high marks and I'm grateful to be
associated with them.
1 conclude by saying how much I appreciate the
privilege of opening this session and of working with
the Society as a member.
MODERATOR; Thank you. Dean. Mr. President,
Members and Guests:
The Department of Surgen, is honored and delighted
to have this opportunity to present to you the topic of
■'Conte.Tiporary Surgical Management."
Our objectives are to bring to you some recent ad-
vances in surgen.- covering common medical problems
that, hopefully, will provide you with a better under-
standing of the type of care that is available and in-
dications for its application.
This knowledge should, directly or indirectly, enable
you to provide better care for your own patients. As
Dean Fordham has mentioned, you'll notice that our
faculty that we've selected are relatively young.
They're in the forefront of medicine. They're imagi-
native, critical thinkers with a high degree of intellectual
curiosity. They're not willing to accept the imperic ap-
proaches of the past.
.All of them, as has been indicated, are involved in
active care of patients, the teaching of our medical stu-
dents and house staff, as well as conducting investiga-
tive programs.
.Although we have no formal question and answer
period, perhaps at the end of each individual's presenta-
tion, if there's time, we can entertain one or two ques-
tions.
In presenting new information, I'm reminded of the
co.iiments of a speaker at a graduating medical class
indicating that he had both good news and bad news
for the graduates.
The good news was that despite the rapid advances
in medical knowledge, at least half the information that
they had been presented with was absolutely true.
The bad news was that each wasn't sure which half!
Now, today we're going to present you with the half
that is true and will remain so.
Our first speaker is Dr. Gordon Murray, Assistant
Professor of Surgery of the Division of Cardiovascular
and Thoracic Surgery.
Dr. Murray is a graduate of the University of Mich
gan and joined us two years ago after completing his
graduate education in surgery at Johns Hopkins.
Dr. Murray 's topic is "Cancer of the Lung."
DR. GORDON F. MURRAY [Assistant Professor
of Surgery, Division of Cardiovascular and Thoracic
:.:
T
\
■a:
E
8'
k
D
Ik;
\\k
i
linn
D
iN
GENERAL SESSIONS
93
Surgery. UNC School of Medicine. Chapel Hill.
N.C.I:
[Whereupon Dr. Murray presented his paper which
liwill be submitted to the North Carolina Medical Jour-
inal for possible publication.]
1 MODERATOR: Our ne,\t speaker is Dr. Fredric
Fagelman. Assistant Professor of Surgery in our Divi-
:!5ion of Neurosurgery.
J Dr. Fagelman is a graduate of the University of Ver-
mont and he continued his graduate education in sur-
gery and neurosurgery at the University of Vermont.
This is his first year on our staff.
( Neurosurgeons as you know have for a long time
;(oeen interested in pain control which is one of his
/:opics. He is also going to bring to us some of the newer
^aspects of micro-neurosurgery.
DR. FREDRIC I. FAGELMAN [Assistant Profes-
fior of Surgery. Division of Neurosurgery, UNC School
ipf Medicine. Chapel Hill N. C] :
[Whereupon Dr. Fagelman presented his paper
Q,vhich will be submitted to the Norih Carolina Medical
Journal for possible publication.]
jj MODERATOR: Our next speaker is Dr. Robert D.
,rroom. III. Dr. Croom is one of our own graduates,
laving finished at Chapel Hill several years ago with his
;ubsequent graduate education at Johns Hopkins. North
-Tarolina Memorial Hospital and Walter Reed.
: He has been a member of the general surgical staff
:or two years.
Dr. Croom brings to us a topic. I think, which
-Joes represent a real advance in medicine and has
application in both medicine and surgery. The topic.
.'Improved Nutrition — Parenteral Alimentation and
elemental Diet."
= DR. ROBERT D. CROOM. Ill [Assistant Professor
jof General Surgery, UNC School of Medicine. Chapel
Hill. N.C.]:
[Whereupon Dr. Croom presented his paper which
vill be submitted to the North Carolina Medical Jour-
nal for possible publication.]
; MODERATOR: Our next speaker is Dr. Paul Big-
;ers. Associate Professor of Surgery in our Division of
"Otolaryngology.
■ All of us I think have been concerned about the
5inability to communicate defining extirpational surgery
md other more subtle injuries to the larynx.
i; Dr. Biggers today will bring us the exciting topic of
i''Surgical Restoration of the Voice."
' DR. W. PAUL BIGGERS [Associate Professor of
Jurgery, Division of Otolaryngology. UNC School of
;vledicine. Chapel Hill. N. C.]:
i [Whereupon Dr. Biggers presented his paper which
vill be submitted to the North Carolina Medical Jour-
h'lal for possible publication.]
I MODERATOR: The next speaker is Dr. A. G. Bevin.
\.ssociate Professor of Surgery in our Division of Plastic
jJurgery.
; Dr. Bevin is a graduate of Yale and continued his
;raduate education in surgery at Yale and the Depart-
inent of Surgery at UNC.
■' His topic today is "Treatment of the Burn Injury."
DR. A. G. BEVIN. JR. [Associate Professor of Sur-
;ery. Division of Plastic Surgerv. UNC School of
Medicine. Chapel Hill. N. C] :
: [Whereupon Dr. Bevin presented his paper which
will be submitted to the North Carolina Medical Jour-
nal for possible publication. 1
MODERATOR: I'd like to introduce the next
speaker. Dr. Edwin Preston. Associate Professor of Sur-
gery and Orthopaedic Surgery.
Dr. Preston is a Duke graduate and had his subse-
quent graduate education in surgery at the Children's
Hospital in Boston and The Brigham.
He has been on our staff in the Division of Ortho-
paedic Surgery since 1969 and will bring new develop-
ments in Orthopaedic Surgery.
DR. EDWIN T. PRESTON [Assistant Professor of
Surgery and Otrhopaedic Surgery. Division of Ortho-
paedic Surgery, UNC Medical School, Chapel Hill,
N.C.]:
[Whereupon Dr. Preston presented his paper which
will be submitted to the North Carolina Medical Jour-
nal for possible publication.]
MODERATOR: The next speaker is Dr. Fred Avis,
who is a graduate of the University of North Carolina
School of Medicine and continued his education in sur-
gery.
During his second year as a surgical resident he was
in the tumor clinic and developed a keen interest in
tumor immunology.
He has pursued that now a couple of years in the
laboratory and will be joining us next year as a current
member of the staff.
Dr. Avis will speak on "Immunological Advances in
Urological Tumors."
DR. FRED AVIS [Instructor. Department of Sur-
gery, UNC School of Medicine, Chapel Hill, N. C.]:
[Whereupon Dr. Avis presented his paper which will
be submitted to the North Carolina Medical Journal
for possible publication.]
MODERATOR: The next speaker is Dr. Noel
McDevitt who again is a graduate of the University of
North Carolina and continued with his graduate surgi-
cal education in our Department of Surgery.
He joined us this year as an Assistant Professor of
Surgery in the Division of Vascular Surgery.
It has always impressed me that with the availability
to provide new techniques and in this instance restore
blood flow, how many patient problems we then see.
and obviously there's a need to evaluate peripheral blood
flow and Dr. McDevitt is going to bring to us today,
a "Non-Invasive Estimate of Peripheral Blood Flow."
DR. NOEL B. McDEVlTT [Assistant Professor of
Surgery. Division of Vascular Surgery. UNC School
of Medicine, Chapel Hill. N. C] :
1 Whereupon Dr. McDevitt presented his paper which
will be submitted to the North Carolina Medical Jour-
nal for possible publication.]
MODERATOR: Our final speaker is Dr. Stanley
Mandel, Associate Professor of Surgery, again in the
Division of Vascular Surgery, Trauma and Transplan-
tation.
Dr. Mandel is a graduate of the University of Vir-
ginia and had his graduate education at Duke and also
the University of Virginia.
He has been on our staff since 1969 and has had
an interest in transplantation. He brings to us the role
of the community hospital in end stage renal disease.
DR. STANLEY R. MANDEL [Associate Professor
of Surgerv. Division of Vascular Surgery, UNC School
of Medicine, Chapel Hill. N. C] :
f
94
1974 TRANSACTIONS
[Whereupon Dr. IVhindel presented his paper which
will be submitted to the Narlh Carolina Medical Journal
for possible publication. I
MODERATOR: Dr. Cosgrove has advised me that
we may all receive five hours of continuing education
credit for this session.
I'd like to thank the audience for being so patient
and staying beyond the scheduled time and, hopefully,
we have presented something to \ou that will be of some
help in your patient management. I think Dr. Gilbert
would like to make a few comments before closing.
PRESIDENT GILBERT: First of all. as I mentioned
at the beginning, with this innovation. I think youVe
all seen that this program has been fabulous and I think
a tremendous success and we sure want to thank Dr.
Thomas and his colleagues from the University of North
Carolina School of Medicine for making this presenta-
tion.
I think all this augurs well for our future, gentlemen,
as far as general sessions.
ri he meeting adjourned at twelve-thirty o'clock.]
TUESDAY MORNING SESSION
May 21, 1974
The Second General Session of the 120th Annual
Meeting of the North Carolina Medical Society con-
vened at nine-ten o'clock. Dr. D. E. Ward. Jr., First
Vice President of the Medical Society, presiding.
CHAIRMAN WARD: Good morning.
I want to welcome you to the Second General Ses-
sion of the North Carolina Medical Society meeting.
Today, it's my pleasure to act as presiding officer
for the Medical Session which is the Bowman Gra\'
Medical Session Program put on by the faculty of the
Bowman Gray School of Medicine.
This morning I'd like to introduce to you the Dean
of Bowman Gray School of Medicine, Dr. Richard
Janeway, and in turn. Dr. Janeway will introduce to
you Dr. Joseph Johnson, Professor and Chairman of the
Department of Medicine, who. will in turn, introduce his
own faculty members who are on the program this
morning.
Dr. Janeway was born and reared in California, at-
tending Colgate University and graduated from the
University of Pennsylvania School of Medicine and I
interned at Philadelphia General which is just over a
stone wall from Pennsylvania and up there ail these
men are referred to being at THE university, just like
there was no other one in the country and all of us at
Philadelphia General always sort of ganged up at the
university graduates when they started coming out with
this business of THE university, but it is referred to as
THE university up in Pennsslvania.
He took his graduate education as a Public Health
Fellow in Research Pathology, interned at the University
of Pennsylvania, also at School of Aerospace Medicine
in Texas and came to North Carolina as a resident in
neurology at the Baptist Hospital.
From here he was appointed to the faculty and was
first a neurologist and then he did such a good job in
this hard and complicated field, they decided that he
would make a good dean, so they took him out of
neurology and they made him Dean of the Bowman
Gray School of Medicine.
He is certified by the American Board of Psychia-
try and Neurology and if he limps when he comes up
here, it is not that he was wounded in the line of action
as the dean, it was a wound received legitimately not
jumping out of a second story window but on a tennis
court running back to get a lob and he pulled a liga-
ment in his leg so he has a cast.
DR. RICHARD JANEWAY [Dean, Bowman Gray
School of Medicine. Winston-Salem, N. C] :
I found out I was one year older and one step slower
on the tennis court and I guess it's been that kind of a
year.
I very much appreciate your attendance for this brief
introduction to "What's New at Bowman Gray" and
there's a great deal that is new as well as a great bit that
is old and traditionally present.
The class size had just gone from 46 to 54 when I
arrived in Winston-Salem in 1963. We will enter 89 stu-
dents this September and in cooperation with the state,
approximately 98 students in 1973 entering class.
Perhaps the newest thing at Bowman Gray, after pro-
longed discussion among the faculty at our retreat that
we have at Pottstown, West Virginia, last June and then
with a formal vote of the faculty executive council on
Friday, the Department of Family Practice was estab-
lished at the Bowman Gray School of Medicine as an
academic department of the institution.
One of our new people who is heading up the De-
partment of Medicine has been with us since October of
I 972. He's Dr. Joe Johnson who comes to us via Vander-
bilt where he received his undergraduate medical train-
ing and then to the Hopkins for residency training and
then was at the University of Florida Gainesville as
head of the Section of Infectious Disease and Professor
of Medicine there.
He has now been with us approximately a year and a
half, has a very strong Department of Medicine, in the
process of continuing growth and we would anticipate
that it will approximately be 1-3/4 going on twice the
size of what it was when Joe came to us in October .i
year ago.
And. I'll introduce Joe now to the audience to moder-
ate the program. We certainly are pleased that you're
all here for the session this morning.
DR. JOSEPH E. JOHNSON tProfessor and Chair-
man. Department of Medicine. Bowman Gray School of
Medicine I :
Well, we're pleased to be able to join you this morning
and to present a program on what we think is a very
important topic.
Now, the Department of Medicine at Bowman Gra\.
as he told \ou. is in the process of growth and develop-
ment.
We will have added about 35 per cent more faculty
members as of this summer and in the last year approxi-
mately and we are growing in addition beyond that
with a number of other people that we are in the process
of recruiting.
GENERAL SESSIONS
95
The house staff has essentially doubled in size now
<i and we have a fairly active and highly competitive
t. staff training program now and fellowship training pro-
gram.
The Department of Medicine is now sectionalized
formally with each of the sub-specialty sections being
formally constituted as a section so that all of these
things we think are indicative and supportive of the
growth and development of the department and of the
institution.
I think we"re very much conscious of our triple
role in medicine and in the institution, in teaching of
course, our students and house staff, and in the new
programs that we're developing in primary care, for ex-
ample, in conjunction with pediatrics and the new De-
partment of Family Practice and in the role of continu-
ing education and. of course our role in research, which
we're pleased to say is progressing with such counter-
current phenomena as a recent funding of a large pro-
gram project grant in lung disease being somewhat
against the trend of the federal subsidies at the moment.
Our cancer center is in the process of further growing
and enlarging and as a referral center we are extremely
conscious of the importance of filling our role as a re-
ferral center and in further improving and maintaining
better communications with the referring physicians.
We are certainly conscious of the fact that this is an
, area, particularly in the area of house staff trainees
and students sometimes falls down and we are working
" very hard to maintain our communications with all of
! our referring physicians on whom we are extremely
j dependent and with whom we hope to work more and
more closely in the future.
Now. my talk this morning as you see is billed as an
, "introduction" and I was preceded by the Dean who
told you what's going on that's new and I'm going to be
succeeded by one of our faculty members who's going to
give you an "Overview of the Subject of Hypertension,"
so it was not absolutely clear what I was supposed to do.
[Laughter]
' So, I'm not going to speak on hypertension. Rather.
: we've marshalled the strength of our department to cover
this very important subject for you.
J Hypertension is the most common condition seen in
: adults today probably in that perhaps 15 to 20 per cent
ji of the adult population is said to have hypertension at
the present time.
However, whatever the precise statistical position it is
=, an extremely common and important disease and one
■ which is incredibly treatable in many of its forms.
For that reason, it is clear to us it's one that needs
1 to be widely appreciated by physicians of all kinds what-
I • ever their areas of interest.
' It is a disease that has a lot for everybody in it in
II the sense that it involves the heart, kidneys, the brain.
I It involves in one way or another the endocrine system.
the cardiovascular system. It gets involved throughout
, the body in producing manifestations of diseases.
jl So the theme of our program this morning is to sur-
'"vey the areas in which hypertension gets involved in the
'. body and in producing disease.
Accordingly, we want to start with an overview of
ii the subject and we are pleased that the first speaker
- will be Dr. Robert Headley.
Dr. Headley is a long standing member of our de-
partment of medicine at Bowman Gray, having come
from Maryland where he got his B.S. degree and sub-
sequently his M.D. degree and was AOA student leader
in those days.
He trained at the University of Virginia in Charlottes-
ville and subsequently took training at Bowman Gray
in Cardiology and has been with us ever since.
He has progressively succeeded to positions of in-
creasing importance including Directorship of the Out-
Patient Department and subsequently is in charge of the
coronary care unit and most recently, in addition to
being promoted to full professor, he is also associate to
the chief of professional services for the Baptist Hospi-
tal.
DR. ROBERT N. HEADLEY [Professor of Medi-
cine. Department of Medicine, Bowman Gray School of
Medicine.] :
[Whereupon Dr. Headley presented his paper which
will be SLibmitted to the North Carolina Medical Jour-
iiiil for possible publication.]
MODERATOR: Our next speaker is Dr. John Ed-
monds. He is a graduate of Gastonia High and Wake
Forest University and of the Bowman Gray School of
Medicine and did his training, part of it at Wayne
County General Hospital up in Michigan but then came
back to Bowman Gray by way of Georgia.
He finally came back to the faculty of Bowman
Gray where he is Professor of Medicine and among
other things, runs the heart station and is the resident
EKG expert.
With that preamble. I'd like to introduce Dr. Ed-
monds who is going to talk about "Hypertension and
the Heart."
DR. JOHN H. EDMONDS, Jr. [Professor of Medi-
cine, Bowman Gray School of Medicine]:
[Whereupon Dr. Edmonds presented his paper
which will be submitted to the North Carolina Medical
Journal for possible publication.]
MODERATOR: Its always good to have a versatile
dean and at this point the dean is going to take off his
hat as dean and talk from the point of the view of the
neurologist.
DR. RICHARD JANEWAY [Dean. Bowman Gray
School of Medicine] :
(Whereupon Dr. Janeway presented his paper which
will be submitted to the North Carolina Medical JoHr~
nal for possible publication.]
MODERATOR: Well, we will now proceed having a
look at the more interesting and newer developments in
hypertension and then follow that with consideration of
treatment, which is after all. an extremely important
part of the whole process.
Our next speaker is Dr. Vardaman Buckalew who is
Professor of Medicine at Bowman Gray and he, al-
though coming from Mobile, Alabama, I think origi-
nally, managed to get up to Chapel Hill where he took
his undergraduate training and then went on up to what
Dr. Ward referred to as THE university in Pennsyl-
vania, the one in Philadelphia there, and took his
training — a good bit of his training subsequently at
that institution, finally going to Emory, the university
in Atlanta, from whence last year he joined us and is
now taking a leading role in the development of our
nephrology section at Bowman Gray.
96
1974 TRANSACTIONS
Dr. Biickalew is going to tulk about "Renin. Aldo-
sterone and the Kidney."
DR. VARDAMAN BUCKALEW [Professor of
Medicine, Bowman Gra\ .School of Medicinel:
[Whereupon Dr. Buckalevv presented his paper
which will be submitted to the North Carolina Medical
Journal for possible publication.]
MODERATOR: Our next speaker is Dr. John Kauf-
mann who is Assistant Professor of Medicine and
Pharmacology at Bowman Gray.
He is a Wake Forest graduate and a Bowman Gray
graduate as well and also managed to get up to the
hospital in Pennsylvania for part of his training and
came back to Bowman Gray and subsequently got a
Ph.D. in addition to his M.D.. this Ph.D. is in phar-
macology, also did work at Vanderbilt in clinical phar-
macology and now heads our Clinical Pharmacology
Unit in the Department of Medicine.
Dr. Kaufmann is going to talk about "Pheochro-
mocvtoma."
DR. JOHN S. KAUFMANN [Assistant Professor
of Medicine and Pharmacology. Bowman Gray School
of Medicine] :
[Whereupon Dr. Kaufmann presented his paper
which v\ill be submitted to the Norlh Carolina Medical
Journal for possible publication.]
MODERATOR: The final speaker on our program
this morning is Dr. John Felts, who began his under-
graduate education in South Carolina and then came to
Bowman Gray where for a number of \ears he has
pioneered in the establishment of the discipline of
nephrology in our institution.
Dr. Felts is Professor of Medicine and he will ad-
dress himself at this time to the "Therapy of Hyper-
tension."
DR. JOHN H. FELTS [Professor of Medicine.
Bowman Gray School of Medicine] :
[Whereupon Dr. Felts presented his paper which
will be submitted to the North Carolina Medical Jour-
nal for possible publication. I
CHAIRMAN WARD: Ed like to thank each one of
the staff of the Medical Department of the Bowman
Gray School of Medicine, all six. for their fine presen-
tations this morning.
We want to thank Dr. Ken Cosgrove and his com-
mittee on the general sessions program for their change
in format and for the innovation they have used this
year in the surgical and medical sessions. He also re-
minded me to remind \ou that each of the sessions
will give you five hours credit so please don't forget
that, those of you who are interested in continuing
medical education.
At this time, it gives me great pleasure to introduce
to you the President of our Medical Society, Dr.
George G. Gilbert.
Dr. Gilbert was born in Massachusetts, went to public
school in New Jersey, attained a B,S, degree at Kenyon
College in Ohio and an M.D. degree from Johns
Hopkins.
After graduatmg. he had one year of internship in
urology at Hopkins and he came to Duke University
for internship in pathology and a residency in urology.
Following this, he had active duty in the naval reserve
in World War II.
He came to North Carolina to practice in 1946, es-
tablished his practice in Asheville and has been in
the practice of private urology in Asheville since then.
He has been President of the Carolina Urological
Association and the North Carolina Association of Pro-
fessions.
They have tv\o sons, both living in Western North
Carolina and working with the Carolina Caribbean
Corporation. Mrs. Gilbert sustained a fracture of the
hip three weeks ago, but is here at this meeting with her
husband and following last night's discussion with Dr.
Reckless. I'm sure he would be pleased to see such de-
votion.
It is my pleasure to present to you your President,
Dr. George G. Gilbert!
[Whereupon the entire assemblage then accorded
President Gilbert a standing ovation.]
PRESIDENT GILBERT: I want to thank all of you
that have the courage to stay here. Most of you have
heard me so many times you can almost anticipate
what I'm going to say, I'm sure.
Mr. Vice President. Members of the Society and
Guests:
[Whereupon President Gilbert then read his pre-
pared address entitled "The President's Address: Where
We Stand" which was published in the North Caro-
lina Medical Journal. July 1974. Vol. 35, No. 7, page
405, Following Dr. Gilbert's address he was again ac-
corded a standing ovation.]
CHAIRMAN^WARD: Thank you. Dr. Gilbert, for
that excellent presentation and also in behalf of the So-
ciety, for a most fruitful and rewarding year.
At this time, this concludes our morning session,
[The meeting adjourned at twelve-thirty o'clock.]
WEDNESD.W MORNING SESSION
Mav 22, 1974
The Third General Session of the 12()th Annual Meet-
ing of the North Carolina Medical Society convened at
nine-ten o'clock, Dr, George G. Gilbert. Immediate Past
President of the Medical Society, presiding.
CHAIRMAN GILBERT: I guess we might as well
get started.
Every one of our previous sessions has been a success
as far as crowds go and 1 do want to thank the few
of you who are here for coming.
I really do wish there were more here, just because
the Medical Society's association with this gentleman
on m\ right and we are mutually proud of the interdigi-
tation between the State Medical Society and the now
called Division of Health Services and of course I'm
speaking of Jake Koomen.
So, here he is!
[Whereupon Dr. Jacob Koomen, Director, North
Carolina Division of Health Services, Department of
Human Resources, presented his prepared annual
address to the Medical Society which will be submitted
to the North Carolina Medical Journal for possible
publication.]
GENERAL SESSIONS
97
1 CHAIRMAN GILBERT: I just told our two famous
s speakers that here is the highUght of our whole meeting.
I have iooi^ed forward for a long time to this moment,
■' and it's a real privilege to be in the position of being
on the same podium with them.
I started admiring Ed Annis way back yonder and I'm
sure most of you are aware of his fabulous contribu-
t- tions to American medicine.
'I I am going to recall in introducing him however one
meeting, the only meeting, although I've heard him
" speak many times, that was small enough, sort of like
this, where you could have a real viable question and
answer period where there weren't thousands of people
- to hear him speak and I don't know whether he will
remember this or not. but it was a small MedPac meet-
-jing that was held in Boone, North Carolina, I don't
riknow how many years ago, but as far as political
i| progress goes, this was before Robert Kennedy was
li assassinated and among others who appeared with Dr.
- Annis, was Senator Sam Ervin. He was on the program.
He wasn't quite as well known in those days.
■ Anyway, this was the first chance that I had had
uto really quiz Dr. Annis and I was as I am still periodi-
s cally discouraged about the future of the practice of
!'. medicine.
I have heard him go all over the country, on tele-
ivision and everywhere else in our battle against Medi-
xare and he was indeed our best spokesman in this
-regard.
But we had lost and we had been told ever since
'the days of Harry Truman and compulsory health in-
surance that once the government got the foot in the
I'door. we'd had it and in many respects this is true.
* However, the thing that surprised me in Dr. Annis's
Wajor speech at that meeting was that he was still
optimistic and so I asked him how come?
J We've had it! They've got us!
And, he said, "Well," and this may sound and they
'were at the time corny answers, but he said, "Every-
?where I go in this country, I talk to people — cab drivers,
'lairline stewardesses, plumbers, whoever and, first of all,
'jl think they're wonderful people and, secondly I think
'they like their doctors and they are our tremendous
'bulwark of basic strength, right down at the grassroots
for our system of medicine!"
The second thing he said, and I don't know what
the percentages are today, that over 80 per cent of the
idoctors of this country were in private practice and he
ijave the opinion that he didn't think the American doc-
cors would stand still to let the government take over.
I So, with that introduction, here is Dr. Annis!
;; DR. EDWARD R. ANNIS [Physicians Planning Ser-
I'/ice Corporation, New York. New York; Past President
af the American Medical Association]: To begin with,
iiTiy optimism is just as great today as it was ten years
ngo.
S It hadn't occurred to me why that's the case, why
i' have encouraged two of my sons who are now doctors.
,ii third who's on the way to continue with the practice
hf medicine.
I' [Whereupon Dr. Annis presented his address which
'^vi\[ be submitted to the North Carolina Medical Jour-
pal for possible publication.]
P CHAIRMAN GILBERT: If there are any of you here
!j/ho have never heard Dr. Annis before, I'm sure you
will sec why he's one of the great leaders of our medical
generation.
I have waited a long time also to introduce Russ
Roth to you, and there are many, many anecdotes I
could tell you that would be embarrassing to him and he
could tell many that would be embarrassing to me.
Just like beginning this morning with Jake Koomen
and with Dr. Annis, Dr. Roth doesn't need any introduc-
tion otherwise, so with that I'll let him take the podium.
[Whereupon the entire assemblage then accorded
Dr. Roth a standing ovation.]
DR. RUSSELL B. ROTH [President, American
Medical Association]: 1 think there's something worth
mentioning as the two of us stand here at this podium
before you.
Obviously, while George and 1 were together at Johns
Hopkins, there was something in the drinking water at
our fraternity house. We didn't use a lot of it, but it
must have been effective because in our small group,
in this one fraternity house, at one time living there,
we had Tom Ballantine, Chief of NeurosLirgery at Mas-
sachusetts General and immediate past president of the
Massachusetts Medical Society; Freddie Webber, recent
past president of the Connecticut Medical Society; Bob
Derbyshire who was sort of congenital secretary and
president of the Federation of State Boards of Medical
Licensure; Freddie Merchant who was the congenital
treasurer for that organization; Russ Nelson who be-
came president of the American Hospital Association
among many other things; Bill Longmire, past president
of the American College of Surgeons; John Atwater, a
perennial delegate to the AMA from Georgia; George
Gilbert and myself.
1 don't know how you account for it but it seems
to me that it was an extraordinary variation on the theme
when one considers that in our day of medical school
none of us were very much concerned with the socio-
economics of medicine and few of us knew that the
AMA existed or that the Medical faculty of Maryland
was our locally active state agency.
[Whereupon Dr. Roth presented his address which
will be submitted to the North Carolina Medical Journal
for possible publication.]
[Whereupon the entire assemblage then accorded
President Roth a standing ovation.]
CHAIRMAN GILBE^RT: I'm sure that all of you
would agree that these are two highlights of our meeting,
these two speeches, and in a way I have seen this pro-
gram and felt a little sorry for my successor, Frank
Reynolds, because you talk about two tough acts to fol-
low, he really is in that spot.
Frank R. Reynolds was born in Wilmington in 1920.
He's a graduate of the Universits' of North Carolina
anc* got his M.D. at the University of Pennsylvania,
his internship at the Medical College of Virginia and
residency. Children's Hosptial in Philadelphia,
You know he practices pediatrics in Wilmington, so
that he has been around North Carolina most of the
time.
He was in the army from 1946 to 1948 and certified
by the American Board of Pediatrics,
He has been through a number of offices in our
association, has done a whale of a lot of very valuable
work for us and highly deserves the position as President
of our Society.
98
1974 TRANSACTIONS
So. with that. I present your new President, Dr.
Frank R. Re\nolds.
] Whereupon as President Reynolds came up to the
poditim. the entire assemblage accorded him a standing
ovation.]
PRESIDENT REYNOLDS: I donl know how many
of you were able to sta\ up late enough last month to
watch the Emmy Awards, but if you remember, dif-
ferent celebrities presented different categories of excel-
lence and one of the celebrities was Elizabeth Taylor
and she was walking up onto the stage, and as she was
walking up to the stage about that time a streaker went
across the stage and of course after the uproar died
down, she got up to the stage and her comment was the
same thing that I'm going to say. "That's a hell of an
act to have to follow!"
[Laughter]
Dr. Roth. Dr. Annis. Dr. Marden, Members of the
North Carolina Medical Society. Au.xiliary Members,
Guests and Friends:
(Wtiereupon President Reynolds then presented his
prepared address which was printed in the North Caro-
lina Medical Journal Vol. 35. No. 8. August 1974,
page 469. Following his address, he was accorded a
standing ovation.]
CHAIRMAN GILBERT: To continue the nautical
image that Frank made, I'm sure you can see we've got
a whale of a captain for our ship for this coming year!
The meeting adjourned at eleven-thirty, o'clock.
c:
Kb
Ice
MEDICAL AWARDS
Moore County Medical Society Medal
In 1927 the Moore Counts Medical Society estab-
lished a fund, the interest from which is used to pay
for a medal to be given for the best paper read at the
State Society meeting each year. No one is eligible to
receive this medal except Fellows of the Medical Society
of the State of North Carolina in good standing; no
invited guest is allowed to complete.
Each Section Chairman selected a committee of three
to decide on the best paper in their section. The win-
ning papers are then turned over to the State Com-
mittee, who select the one to receive the medal. The
following award was made:
1971— Herbert J. Procter. M.D.. Chapel Hill
"POST TRAUMATIC PULMONARY IN-
SUFFICIENCY"
(Section on Surgery. May 17. 1971 )
1972— Donald C. Mullen. M.D.. Charlotte
■CURRENT CONCEPTS IN THE MAN-
AGEMENT OF ABDOMINAL AORTIC
ANEURYSMS. "
(Section on Surgery. May 2.^. 1972)
1973 — Susan C. Dees. M.D.. Durham
■THE ROLE OF GASTRO-ESOPHAGEAL
REFLUX IN NOCTURNAL ASTHMA IN
CHILDREN "
(Section on Pediatrics. May 22. 1973. Pine-
hurst)
The George .Marion Cooper Award
The Fellows of the Wake Coimty Medical Society
present the George Marion Cooper Award established
in honor of George Marion Cooper, physician and
health benefactor.
The medal is awarded by the Fellows of the Wake
County Medical Society as a token of appreciation and
esteem in recognition of the eminence of an essay con-
tributing to the knowledge and advancement of the
science of medicine in the field of Preventive Medicine.
Public Health, or Maternal and Infant Health Care.
presented before the Medical Society of the State of
North Carolina. The following award was made:
1971— Takev Crist. M.D.. Chapel Hill
■ABORTION— WHERE HAVE WE BEEN?
WHERE ARE WE GOING.'"
( Section on General Practice of Medicine,
May 18. 1471)
1972— John L. McCain. M.D.. Wilson
•TRAIN YOUR OWN ASSISTANT"
(Section on Internal Medicine. May 23. 1972)
1973— Elizabeth Kanof. M.D.. Raleigh
■SKIN CANCER — EDUCATION AND
DETECTION AT A STATE FAIR "
(Section on Dermatology — May 20, 1973,
Pinehurst)
ci
D,
D;
99
HISTORICAL DATA
n the interest of economy the lengthy Historical Data
)rinted in the Transactions will only be printed every five
^ears. Only the information relating to recent years is
'ncluded here.
Ihould any member desire additional Historical Data, he
may request the information for earlier years from the
Medical Society Headquarters Office at 222 North Person
Street, (Mail address: P. O. Box 27167) Raleigh, North
Carolina 27611.
HISTORY OF THE NORTH CAROLINA MEDICAL SOCIETY ANNUAL MEETINGS
I
Date
Place of Meeting
President
President-Elect
Vice Presidents
Sec.-Treas.
c:
o
t
<u o
O OJ
1,811
7
1,939
6
2,191
7
2,298
8
2.318
5
2,283
5
2,341
5
2,326
5
2.673
5
2,801
6
2.896
6
3,058
7
3,127
8
3.171
9
3,211
10
3,247
12
3,248
12
3,339
9
3.491
9
3,473
8
3,516
8
3,597
12
3,606
14
3,642
13
3.674
13
3.711
14
3,765
14
4,059
15
4,123
15
4.294
15
1945
^2 1946
'^93 1947
1p94 1948
95 1949
■ 96 1950
'^97 1951
It
98 1952
^'lOl 1955
^102 1956
''i03 1957
-<04 1958
05 1959
,' 06 1960
]iD7 1961
38 1962
1:39 1963
10 1964
; 11 1965
.12 1966
-13 1967
'14 1968
Cd5 1969
46 1970
■n 1971
iS 1972
'j,9 1973
',0!O 1974
No meeting because
of O.D.T. restrictions
Pinehurst
Virginia Beach. Vs
Pinehurst
Pinehurst
Pinehurst
Pinehurst.
Pinehurst
Pinehurst
Pinehurst
Pinehurst
Pineliurst
Asheville
Asheville
Asheville
Raleigh
Asheville
Raleigh
Asheville
Greensboro
Charlotte
Asheville
Pinehurst
Pinehurst
Pinehurst
Pinehurst
Pinehurst
Pinehurst
Pinehurst
Pinehurst
444
920
998
947
938
969
1,016
1,077
991
1,022
867
781
651
848
636
745
714
677
738
545
644
623
577
580
575
543
562
623
Paul F. Whitaker
tOren Moore
tWm. M. Coppridge. . . .
tFrank A. Sharpe(J). . . .
James F. Robertson. . .
tG. Westbrook Murphy
Roscoe D. McMillan. . .
Frederic C. Hubbard..
J. Street Brewer
tJoseph A. Elliott
Zack D. Owens
t James P. Rousseau. . . ,
Donald B. Koonce
Edw. W. Schoenheit- . .
Lenox D. Baker
John C. Reece
Amos N. Johnson
tClaude B. Squires
John R. Kernodle
John S. Rhodes
tT. S. Raiford
George W. Paschal, Jr. ,
tFrank W. Jones
Robert A . Ross
David G. Welton,.
Edgar T.
Beddingfield, Jr.
Louis deS. Shaffner. . .
Oren Moore.
Charles W. Styron.
John Glasson
George G. Gilbert.,
Frank A. Sharpe
James F. Robertson. . .
G. Westbrook Murphy
Roscoe D. McMillan . .
Frederic C. Hubbard.
J. Street Brewer
Joseph A. Elliott
Zack D. Owens
J. P. Rousseau
Donald B. Koonce. . . .
Edward W. Schoenheit
Lenox D. Baker
John C. Reece
Amos N. Johnson
Claude B. Squires
John R. Kernodle
John S. Rhodes
T. S. Raiford
George W. Paachal, Jr. .
Frank W. Jones
Robert A. Ross
David G. Welton...
Edgar T.
Beddingfield, Jr. . ,
Louis deS. Shaffner. .
Charles W. Styron
John Glasson
George G. Gilbert. .
Frank R. Reynolds . . .
Wm. H. Smith
Zack D. Owens
JWm. H. Smith
Zack D. Owens
G. E. Bell
J. B. Bullitt
V. K. Hart
J. G. Raby
Joseph J. Combs
Joseph A. Elliott. . . .
Ben F. Royal
Joseph A. Elliott
Joseph A. Elliot
Henderson Irwin. . .
Forest M. Houser
Arthur Daughtridge.
George W. Paschal
John R. Bender. . .
John F. Foster
Julian A. Moore
George W. Paschal, Jr. ,
Elias S. Faison
E. W. Schoenheit
Milton S. Clark
John S. Rhodes
O. Norris Smith
George W. Holmes
Amos N. Johnson. . .
Amos N. Johnson
Kenneth B. Geddie.
Chas. M. Norfleet. Jr.
W. Walton Kitchin. .
Theodore S. Raiford.
Charles T. Wilkinson
John A. Payne. HI
J. Sam Holbrook. . . .
H. Fleming Fuller
Jacob H, Shuford , .
Wm. F. Hollister
F. G. Patterson
Hubert McN. Poteat,
Wavne J. Benton. . .
W. Otis Duck
John L. McCain, . .
David G. Welton
Daniel A. McLaurin.
E.T. Beddingfield. Jr..
James S. Kaper
John Glasson
Mark McD. Lindsey.
Robert P. Crouch
Rose Pully
George G. Gilbert
James G. Jones
Kenneth E. Cosgrove
William H. Romm..
Frank R. Reynolds .
Harry H. Summerlin
"Michael F. Keleher
^D E. Ward, Jr. . .
Roscoe D. McMillan. . .
Roscoe D. McMillan. . .
Roscoe D. McMillan. . ,
Roscoe D. McMillan. . .
Roscoe D. McMillan. . .
Millard D. Hill
Millard D. Hill
Millard D. Hill
Millard D. Hill . ..
Millard D. Hill
Millard D. Hill
Millard D. Hill
Millard D. Hill
Millard D. Hill
John S. Rhodes
John S. Rhodes
John S. Rhodes
John S. Roodes
Charles W. Styron
Charles W. Styron
Charles W. Styron
Charles W. Styron
Charles W. Styron
Charles W. Styron
Charles W. Styron.....
Charles W. Styron ....
E. Harvey Estes, Jr. , .
E. Harvey Estes, Jr...
E. Harvey Estes, Jr. .
E. Harvey Estes, Jr. .
383
397
404
407
405
455
469
476
507
561
522
542
251
472
438
425
431
398
390
339
302
298
298
289
287
267
;- Deceased.
Died during term of office; succeeded by James F. Robertson, president— elect.
Jl^Resigned as First Vice-President.
I '1 Became First Vice-President at resignation of Dr. Keleher.
r
100
HISTORICAL DATA
ROSTER OF MEMBERS OF COMMISSION FOR HEALTH SERVICES
(Formerly Slate Board of Health!
Name
Address
Appointed by
Medical Society
Medical Society
Gov. Dan Moore
Gov. Dan Moore.
Medical Society...
Medical Society
Gov. Robert W. Scott
Gov. Robert W. Scott
Gov. Robert \V. Scott
Gov. Robert W. Scott
Medical Society
Medical Society
Governor Robert W. Scott
Governor Robert W. Scott
Medical Society
Medical Society
Gov. James E. Holshouser, Jr.
Gov. James E. Holshouser, Jr
Gov. James E. Holshouser, Jr
Gov. James E. Holshouser. Jr
Gov. James E. Holshouser, Jr
Term
James S. Raper, M.D..
Paul F. Maness. M.D
Ben W. Dawsey. D.V.M
Ernest A. Randleman. Jr.. PhG..
Joseph S. Hiatt. Jr., M.D
Jesse H. Meredith, M.D
Lenox D. Baker, M.D. (1)
J. M. Lackey
Charles Barker, D.D.S
Ralph W. Coonrad. ^^D. (2)
James S. Raper. M.D
Paul F. Maness. M.D
Ernest R. Randleman, Jr.. PhG...
Donald W. Lackey. D.V.M
Jesse H. Meredith, M.D
Maurice A. Kemp, M.D
Richard T. Belton. D.D.S.
Faye B. Eagles, D.C
Grady Hunter
Buford W. Kidd. CD
Clvde W. Kiker
Asheville
Burlington
Gastunia ---
Mount .Airy
Southern Pines...
Winston-Salem..
Durham
Hiddenite
New Bern.-
Durham
Asheville
Burlington
Mount Airy
Lenoir
Winston-Salem
Charlotte
Gastonia...
Rocky Mount....
Boonville
Greensboro
Greensboro
1967 to 1971
1967 to 1971
1967 to 1971
1967 to 1971
1969 to 1973
1969 to 1973
1969 to 1973
1969 to 1973
1969 to 1973
1971 to 1973
1971 to 1975
1971 to 1975
1971 to 1975
1971 to 1975
1973 to 1977
1973 to 1977
1973 to 1977
1973 to 1977
1973 to 1977
1973 to 1977
1973 to 1977
( 1 ) Resigned when appointed Secretary, Department of Human Resources.
(2) Fill unexpired term Dr. Baker.
ROSTER OF .MEMBERS OF BOARDS OF MEDICAL EXA.MLNERS
Name
Address
Term
Bryant L. Galuska. M.D., President
Charlotte
1968 to 1974
Charles B. Wilkerson. Jr.. M.D.. Secretary
Raleigh
1972 to 1978
Frank Edmondson. Jr.. M.D
Ashehoro
1970 to 1976
Joseph W. Hooper. Jr.. M.D
Wilmington
1968 to 1974
Cornelius T. Partrick. M.D.
Washington . .
1968 to 1974
E. Wilson Staiib. M.D
Pinehurst
1972 to 1978
Vernon W. Tavlor, Jr.. M.D.
Elkin
1970 to 1976
*Joseph J. Combs. M.D..
Exectitive .Secretarv
Raleigh
David S. Citron. M.D
Charlotte
Wilmington
1974 10 1978
James Jerome Pence. M.D
1974 to 1978
Jack Powell. M.D
Asheville
1974 to 1978
Bryant D. Paris. Jr.,
Executive Secretary
Raleigh
1973 to
Ret:red October 31. 1973
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