Medicine at the medical center then and now: one hundred years of progress. (Wake Forest Centennial).

If we are to know our future, we must know our past.

Laura Berkson

Miriam

THE BEGINNING OF THE 20TH CENTURY saw medicine emerge with meager resources, but great promise. The days of the horse and buggy, gas lights, and nurses making rounds at night with kerosene lanterns were giving way to electricity, the telephone, and the notion that surgery could be done better in a hospital than on the kitchen table. Although herbal medicine, bloodletting, and purging were common practices, medicine began to benefit from astute observations made with the stethoscope, x-ray machine (1896), and microscope. In 1899, aspirin was introduced by Bayer of Germany, and became available in tablet form around 1915. Banting and Best discovered insulin in 1922 and, in 1928, Alexander Fleming discovered penicillin, which was first used to treat a patient in 1942. Vitamin [B.sub.12] was discovered in 1948, and pernicious anemia, a fatal disease, could be successfully treated. Although the x-ray machine was a novelty at first, it led to the development of other methods of imaging, including ultrasonography, c omputerized tomography, positron emission tomography, single photon emission computed tomography, and magnetic resonance imaging. In early 1900, laboratory medicine came into its own and, in 1953, was expanded by the discovery of the structure of DNA by James Watson and Francis Crick. (1) Today, organ transplants, stem cell transplants, telemedicine, and targeted therapies are the products of this new era of molecular and cellular medicine.

In 1892, Osler's first textbook of medicine was influential for its skepticism and its therapeutic nihilism, as this outstanding physician condemned the majority of medical treatments as useless and even harmful. (2)

What has happened to medicine over the last 100 years, and how does life today compare to that in the early 1900s? In 1900, the life expectancy for whites was 47.6 years, compared with 33.0 years for blacks. In 1997, the life expectancy for whites was 77.2 years, and 71.1 years for blacks (Fig 1). At the beginning of the 20th century, infectious diseases were a major cause of death. In 1900, the most common causes of death were pneumonia, tuberculosis, and diarrhea and enteritis. Of these deaths, 40% were among children aged < 5 years. Repeated outbreaks of cholera, dysentery, tuberculosis, typhoid fever, influenza, yellow fever, and malaria led to the high mortality rate of 1900 (Table 1). (3-5) Improved sanitation and hygiene and the success of aggressive vaccination programs contributed to the major decline in the mortality rate. The use of penicillin to treat a streptococcal infection in 1942 and the isolation of streptomycin in 1943 (effective for tuberculosis) ushered in the age of antibiotics, with fur ther success in treating infectious diseases. By 1940, the 3 most common causes of death were heart disease, cancer, and stroke. Nephritis was fourth and tuberculosis was seventh. Since that time, heart disease, cancer, and stroke have remained the 3 major causes of death, with cancer challenging heart disease as the most common. The appearance of acquired immunodeficiency syndrome (AIDS), the reemergence of tuberculosis (including multidrug-resistant strains), the origin of virulent strains of avian influenza, and Staphylococcus aureus and enterococci with reduced susceptibility to vancomycin are now presenting new challenges to the control and treatment of infectious diseases. The increasing number of deaths due to cancer, lung disease, and motor vehicle accidents is causing further adaptive changes in hospital medicine (Fig 2).

Pneumonia was the leading cause of death in 1900, and heart disease was listed as number 4. (3)

In 1949, neurosurgeons at our medical center were limited to physical diagnosis, conventional x-ray films, and performing their own ventriculograms, encephalograms, and arteriograms. There was a paucity of drugs, and psychiatric hospitals were full. Malignant hypertension was devastating, and streptomycin had just been introduced. Surgeons wore protective spectacles when tubercular meningitis was suspected, and prefrontal lobotomies for severe psychiatric problems and thoracolumbar sympathectomies for the control of hypertension were not uncommon. The use of folic acid to prevent congenital spinal disorders was unknown, and a major focus for neurosurgery was the management of myomeningoceles. Neuroscience development has led to improvement in the treatment of epilepsy and stroke. The morbidity of both conditions is diminishing, due to the use of thrombolytic therapy for cerebral vascular disease and the surgical management of epilepsy. The maternal mortality rate in 1916 was high, with 774 pregnancy-related d eaths per 100,000 live births. Today, this rate has declined to 12.3 deaths per 100,000 live births. (6)

The Wake Forest University School of Medicine (formerly the Bowman Gray School of Medicine) was founded in 1902 as a 2-year medical school on the campus of Wake Forest College.

The North Carolina Baptist Hospital opened in Winston-Salem in 1923, with 88 beds and 20 bassinets. During the 1929 Depression, the total census often was no more than 25 to 30 patients. Collections were difficult, and many individuals who had made pledges for the construction of the hospital were unable to follow through on their good intentions. The medical school expanded to a 4-year curriculum and moved to Winston-Salem in 1941, bringing 11 full-time members for the basic science faculty. During the first academic year in Winston-Salem, the medical faculty totaled 7 full-time and 15 part-time physicians. The post-World War II expansion created a need for increasing mutual support between the medical school and the North Carolina Baptist Hospital, and led to the extension of the fifth floor of the medical school to connect with the hospital in 1950. The need for improved clinical facilities accelerated the hospital-expansion program, and increased capacity to 270 beds and 50 bassinets.

A review of the hospital's operating log from 1925 shows a total of 1,083 cases. The top 10 procedures for that year are reported in Table 2. The procedure most often performed was tonsillectomy, with a total of 504 cases. By 1935, the total number of cases had almost doubled, and tonsillectomy still led the list at 528. An increasing number of hernia repairs, thyroidectomies, and salpingooophorectomies were performed in 1935.

Myocardial infarction was first described as a clinical entity by Dr. James Herrick in the Journal of the American Medical Association in 1912. (7) In that article, it was pointed out that a myocardial infarction was due to coronary thrombosis, which became a probable mechanism for this illness.

Although tonsillectomies still led the list of procedures in 1945, prostatectomies and thyroidectomies were increasing in frequency. In 1947, the top 10 diagnoses at Baptist Hospital were term-birth living child, phimosis (congenital), hypertensive vascular disease, anxiety state, hypertensive cardiovascular disease, jaundice of newborn, osteoarthritis, cardiac enlargement, sinus arrhythmia, and atherosclerosis of the aorta. That year, 33 patients had a breast amputation. By 1955, the total number of procedures had increased to 7,130, and the types of cases were more typical of a general surgical hospital practice. In that year, 285 prostatectomies were performed., followed, in order of decreasing frequency, by herniorrhaphy, laminectomy, cranlotomy, appendectomy, hysterectomy, reduction of fractures, thyroidectomies, cholecystectomies, and pneumonectomies. In 1965, 52 patients were admitted for mastectomies. The further increase in malignancy is evidenced by the 214 patients admitted in 1967 with a principal diagnosis of carcinoma of the cervix. In 1967, 590 patients died at the hospital, and 132 had a diagnosis of malignant neoplasm.

Heart disease became the leading cause of death in the United States in 1921, and together with stroke accounted for approximately 40% of all deaths. (8) Coronary artery disease was accelerating tremendously at that time (1930-1940), and many people died suddenly from angina or heart disease, the mechanism of which was not clearly understood.

By 1976, definite changes were noted in the types of admissions to the hospital. Admissions had increased to 23,787 (Fig 3), and the 2 most common procedures were cancer chemotherapy (690 procedures) and cardiac catheterization (505 procedures). In that same year, 337 patients were admitted with carcinoma of the breast. We begin to note a decrease in the frequency of cervical cancer in 1976, with 164 admissions that year compared with 214 in 1967.

The strong impact of cancer and cardiovascular disease on our medical center practice is seen in the data for 1986 (Table 2). Left or right heart catheterization led the list of the most common procedures for that year; close behind was the infusion of chemotherapy, with a total of 1,617. A total of 629 bypasses were done for either 1, 2, 3, or 4 coronary arteries, and the number of arteriograms performed for cerebral artery disease increased to 135. Unstable or preinfarction angina was the third most common diagnosis of patients admitted to our hospital in 1986 and the second most common diagnosis in 1992, when chemotherapy was the top admission procedure.

In 2001, coronary atherosclerosis was the most common diagnostic category, but unstable angina or preinfarction angina was not listed in the top 25 diagnostic categories. This dramatic decline is a reflection of the improved accuracy of diagnosis and a decided change in the management of coronary artery disease.

The capacity of the medical center is being constantly challenged. Hospital admissions totaled 23,304 in 1992, and 31,107 in 2001 (Fig 3). Further, outpatient facilities at the Wake Forest University Baptist Medical Center are also fast reaching capacity as a greater number of procedures are performed on an outpatient basis. The number of visits to Wake Forest University Physicians outpatient facilities increased 14.7% from 1996 to 2001. There has also been a noted shift from inpatient to outpatient surgery. Based on year-to-date data for 2002, outpatient surgeries now comprise 55.8% of all surgeries performed at the Medical Center. This trend is expected to continue. Table 3 reviews the type and number of day-hospital procedures, and lists the top 10 diagnoses of patients admitted to the day hospital in 2001. Major trends in health care, such as minimally invasive surgery centers, continue to influence medicine at the medical center. Minimally invasive surgery is typically laparo-scopic or endoscopic. These techniques utilize small incisions through which video cameras and lens systems permit visualization of the operative region. Patients undergoing minimally invasive surgery have reduced postoperative pain, shorter hospital stays, quicker recovery times, and less infection and scarring.

In 1954, it was recognized that a laboratory diagnosis of myocardial infarction could be determined by enzymatic analysis. Twelve-lead electrocardiograms were being done, but required at least 24 hours for interpretation. (9)

CARDIAC CARE

The leading cause of death in the United States since 1921 has been heart disease, and stroke has been the third leading cause since 1938. (8) Age-adjusted death rates for coronary artery disease, which is the major cause of cardiovascular deaths, peaked at 307.4 per 100,000 population in 1950, and continued to show an increase into the 1960s. Since 1950, the mortality rate from heart disease has declined 56% overall, with coronary artery disease showing a rate of 134.6 deaths per 100,000 population in 1996. The identification of major risk factors, such as high blood pressure, increased cholesterol, smoking, and exercise and dietary factors, has had an important role in the major decline in cardiovascular disease mortality and morbidity rates. The recognition that individuals with myocardial infarctions had arrhythmias and that ventricular fibrillation was a major cause of death led to improved clinical care and decreased mortality rates. The first coronary care unit at the North Carolina Baptist Hospital, w ith 16 beds, saw the mortality rate decrease to 20%, from the previous rate of 40% to 50%. A 22-bed coronary care unit opened in 2000. The medical center's reputation for innovative cardiac care began in the late 1940s, when it helped to pioneer open heart surgery. The cardiology program was ranked 20th in the US in 1999, and mortality rate is now less than 10% for patients admitted to our coronary care unit with acute myocardial infarctions. Our cardiology group was the first in North Carolina to open blocked arteries with laser surgery, and was the first to use ultrasound probes to get an inside view of blockages in the coronary arteries. We now have the capability to use a dual chamber defibrillator for patients with both atrial and ventricular arrhythmias. The Cardiothoracic Surgery Department developed a highly effective coronary bypass program, and has led the way in the use of arteries, rather than veins, for this type of surgery. Ours is one of the first centers in the country to offer a new, natural valve replacement to patients with diseased or damaged aortic valves. In addition to our 22-bed coronary care unit, we have 60 dedicated beds for less-intensive management of patients with myocardial disease.

The mortality rate of acute coronary myocardial infarctions in the first 4 weeks of illness was about 40% to 50% in the period from 1950 to 1970. About half of those deaths occurred within the first 2 hours of the onset of symptoms. (10)

We now have 5 coronary angiographic laboratories for the evaluation of patients with myocardial disease. The coronary care unit has the capability for special procedures, such as pericardiocentesis, cardioversion, temporary pacemaker insertion, and angiography. The medical center has extended its care from coronary artery bypass surgery to the further utilization of angioplasty, particularly stent angioplasty. We performed more than 2,000 angioplasties in 2002. Documenting the increasing excellence of the center in coronary care is the fact that, in 1992, 10,020 patients were discharged from our medical center with a diagnosis of unstable, crescendo, or preinfarction angina. By 2001, patients were being discharged with a specific diagnosis of coronary atherosclerosis and definitive therapy having been applied, either by angioplasty, stent angioplasty, or coronary bypass surgery. Patients quickly diagnosed with infarctions or impending infarctions have decreased cardiac damage and improved quality of life.

In 1967, Dr. Bernard Lown published a landmark article, "The Coronary Care Unit," in the Journal of the American Medical Association. (11) This was followed by a Public Health Service directive that hospitals initiate coronary care units. The North Carolina Baptist Hospital established its first coronary care unit in 1972 with 16 beds. Mortality rates for myocardial infarctions decreased from 46% to 20%.

Cardiothoracic Surgery

Interest in cardiothoracic surgery was evident immediately after the medical school was moved to its present campus in the 1940s. After some years of laboratory research in this rapidly evolving cardiac surgical field, the first few open cardiac procedures were done in 1957 and numbers grew rapidly over the ensuing 10 to 15 years. Improvements in perfusion technology, surgical techniques, and effective postoperative care allowed an increase to over 1,200 open procedures by 1990. Coronary bypass surgery, prosthetic valve insertion, and techniques of valve repair contributed to that number. Pediatric cardiac surgery also constituted a major portion of the early cases when surgery was done in older children. More recently, procedures have been done in the neonatal or very young patient with improved results. The demonstration of the aortic root replacement technique is of particular interest and offers excellent and natural valve function in the aortic position, and has led to a large series of patients in whom allografts and porcine roots have been successfully completed with low mortality. Four operating room capability, twelve bed intensive care units, and ample step-down monitored beds allow increased overall capability in this specialty.

The new Brenner Children's Hospital provides a seven bed intensive care area and twelve step-down beds for pediatric cardiac patients. Approximately 150 open pediatric cardiac cases are done annually at this time. The multitude of advances in patient care for cardiac surgery have led to a steadily decreasing morbidity and mortality rate in all age groups.

PEDIATRIC CARE AT THE MEDICAL CENTER

The United States infant mortality rate (number of deaths of infants < 1 year of age per the number of live births) (3) was 180 per 1,000 live births in blacks and approximately 100 per 1,000 live births in whites in 1915. In 1900, 30.4% of all deaths occurred among children aged < 5 years. (12) Vaccination campaigns have virtually eliminated diseases that were common in the US during these early years, including diphtheria, tetanus, poliomyelitis, smallpox, measles, mumps, rubella, and Haemophilus influenzae diseases (including meningitis). The introduction of the Salk poliovirus vaccine in 1955 has virtually eliminated a disease that was a major health care factor in our hospitals in the 1930s through the 1950s. The overall infant mortality rate in 1998 was 9.3 deaths per 1,000 live births. (13)

In the early 1940s, the department of pediatrics started with 2 full-time pediatricians. The original pediatric wards were on the second- and third-floor wings of the hospital. The second floor, for older children, had room for 13 patients, and the third floor, for infants and younger children, had room for 15 patients. In 1955, the fifth floor of the hospital was renovated to provide adequate quarters for up to 19 older children and 31 infants. The original nurseries for the healthy newborns, located on the fourth floor, were always inadequate, and in 1955 were expanded to hold 48. The premature infant program, partially supported by state and federal funds, was opened in 1949, with a maximum capacity of 16 patients; the usual load was between 10 and 12. The Brenner Center for Adolescent Medicine opened in 1981, and was established as a hospital-within-a-hospital in 1986. The new 160-bed Brenner Children's Hospital opened in 2002, providing a full continuum of care, with a pediatric emergency department; ped iatric and neonatal intensive care units; infant, child, and adolescent inpatient units; and outpatient clinics. The Brenner Children's Hospital is staffed by more than 70 full-time pediatric faculty representing all pediatric subspecialties. The pediatric intensive care unit is staffed by critical care experts, and is equipped with state-of-the-art technology. The intermediate-care unit provides a facility for patients whose condition does not warrant a stay in the pediatric intensive care unit, but who are not ready to be moved to a general pediatric room. Extensive supportive resources are available for children hospitalized in the Brenner Hospital and their families.

The first manuscript showing that a treatment was effective in altering the natural history of myocardial infarction was published in the New England Journal of Medicine in 1981. (14) This study showed that treatment with a [beta]-blocker reduced the mortality rate and incidence of reinfarction in patients surviving an acute myocardial infarction. Subsequent studies have confirmed this observation.

TRAUMA CARE AT THE MEDICAL CENTER

Mortality from all accidents was the seventh leading cause of death in 1900, the sixth in 1940, and the fourth in 1960. In 1998, it was the seventh leading cause of death for North Carolina residents, but was ranked as the major cause of death in those aged 1 to 4 years and those aged 5 to 14 years. The location of our medical center on the Interstate-40 corridor with close access to Interstate 85, and the associated increase in the number and speed of automobiles, have made trauma an increasing focus. In 1982, a level I trauma center was established at the hospital, and helicopter-based AirCare was established in 1986. Full designation as a level I trauma center occurred in 1990, and was affirmed by the American College of Surgeons in 2000. Trauma patients are now consolidated in a dedicated intensive care unit and medical/surgical area. The number of level I trauma cases increased from 1,727 in 1988 to 2,809 in 2001. In 1998, the age-adjusted male death rate per 100,000 population was 30.8, more than twice the female death rate of 13.1. Although teenagers constitute 10% of the total population, they account for 15% of deaths from motor vehicle accidents. Increased mechanization and mobility of our citizens will lead to a corresponding need for level I trauma care at our medical center.

Coronary artery bypass surgery became an important surgical procedure at the North Carolina Baptist Hospital in late 1970. Performing 1-, 2-, 3-, and, on occasion, 4-vessel bypass surgery became a daily event.

CANCER CARE AT THE MEDICAL CENTER

Cancer and other malignant tumors were the eighth leading cause of death in the US in 1900. By 1940, cancer and other malignant tumors had become the second leading cause of death. This distinction was maintained through the year 1998. (15) While the age-adjusted death rate for heart disease has declined steadily during the past 20 years, death rates for cancer remain relatively unchanged. In 1998, 15,327 North Carolinians died of cancer and 19,441 died of heart disease; cancer is gaining on heart disease as the leading cause of death (Table 4).

Major changes in the management of neo-plastic disease have occurred since both radiation therapy and chemotherapy became available at the medical center in the mid-1950s. In 1967, carcinoma of the cervix was the sixth most common malignant diagnosis, and approximately 174 deaths per 100,000 population occurred in North Carolina as a result of cervical cancer in that year. This total decreased to 124 deaths in North Carolina in 1998. Hodgkin's disease was a frequent admission diagnosis in the 1970s and 1980s, and laparotomies were frequently performed for accurate staging and treatment. Today, patients with Hodgkin's disease are primarily treated with outpatient therapy, and staging laparotomies are rarely performed. It was not unusual to have 1 to 3 patients on old 3rd West dying from the complications of hairy cell leukemia in the 1960s and 1970s. Today, 80% to 90% of these patients are treated with cladribine as outpatients, and more than 80% of them have prolonged remissions. The medical center was design ated a specialized clinical cancer research center in 1972, one year after the National Cancer Act was signed by President Nixon. By 1976, the most common procedure performed in our hospital was the administration of cancer chemotherapy, and this has remained either the first or second most common procedure. Further distinction was given to the cancer center in 1990, when it was recognized by the National Cancer Institute as a Comprehensive Cancer Center. This recognition applies to clinical centers that not only conduct basic research and clinical trials, but also engage in cancer control, provision of cancer information, education services, and education outreach activities. We now have 1 of only 37 cancer centers in the nation designated by the National Cancer Institute as a Comprehensive Cancer Center. The medical center is developing a new outpatient Comprehensive Cancer Center that will consist of 4 floors, comprising 172,512 square feet. The Comprehensive Cancer Center will house Centers of Excellence in most oncology specialties.

The first of 4 floors will house the radiation oncology department. The addition of a Leksell gamma knife in 1999 moved the neuro-oncology team to the forefront of brain tumor treatment in this country. Supporting facilities consist of 7 computed tomography scanners, 5 linear accelerators, and accessible laboratory services.

The Comprehensive Cancer Center is further supported by the 830-bed tertiary-care teaching hospital. Major programs for the prevention and early detection of cancer and specific molecular therapies, such as the use of tyrosine kinase and farnesyl transferase inhibitors, are revolutionizing the management of malignant disease, leading to significant changes in our management of patients.

By 1992, the procedure most frequently performed at the North Carolina Baptist Hospital was single-vessel percutaneous transluminal coronary angioplasty, and in 2000, we performed 2,701 coronary angiograms with 637 stent insertions and 115 angioplasties. By 2001, the mortality rate for acute myocardial infarction in our institution was less than 10%. The average length of hospital stay for an acute myocardial infarction has decreased from 4 weeks to 4 days.

SUMMARY

The health and life expectancy of persons residing in the United States has improved dramatically during the 20th century. The average life span in the US has increased by more than 30 years since 1900. This significant gain is attributable to improvements in both public health and medical care. Tempering this notable achievement is the observation that the mortality rate per 1,000 population, although showing a significant decline in the era from 1920 to 1940, has now plateaued, and may be showing a slight increase. Our scientists and physicians have appropriately exploited the scientific discoveries of the 20th century and are poised as a medical tour de force for the 21st century. The decline in deaths from coronary artery disease and stroke has resulted from risk-factor modification and the innovations of surgeons and physicians who have dedicated themselves to early detection and better treatment of these cases. During the 1960s, patients admitted to our medical center with advanced Hodgkin's disease, ha iry cell leukemia, and the acute leukemias had a life expectancy of < 1 year. Today, even advanced Hodgkin's disease and hairy cell leukemia are curable, and many patients with other acute leukemias respond to therapy and have very durable remissions. The rate of maternal mortality has shown a dramatic decline, and many childhood diseases have been eradicated or reduced to infrequent occurrences. Our public health scientists and physicians are joining forces to further diminish the morbidity and mortality rates for many of our common diseases. The achievements of our past afford us the vision for what we can become.

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TABLE 1

Leading Causes of Death by Year

     1900 (3)                1940 (3)           1960 (3)

Pneumonia               Heart disease      Heart disease
Tuberculosis            Cancer             Cancer
Diarrhea and enteritis  Stroke             Stroke
Heart disease           Nephritis          Accidents
Stroke                  Pneumonia          Childhood diseases
Nephritis               Accidents          Pneumonia (excluding MVAs)
All accidents           Tuberculosis       General arteriosclerosis
Cancer                  Diabetes mellitus  Diabetes mellitus
Senility                Premature birth    Congenital malformations
Diphtheria              MVAs               Cirrhosis of liver

     1900 (3)                1990 (4)              1997 (3)

Pneumonia               Heart disease         Heart disease
Tuberculosis            Cancer                Cancer
Diarrhea and enteritis  Stroke                Stroke
Heart disease           Accidents             Lung disease
Stroke                  Lung disease          Accidents
Nephritis               Pneumonia, influenza  Pneumonia, influenza
All accidents           Diabetes mellitus     Diabetes mellitus
Cancer                  Suicide               HIV infection
Senility                Liver disease         Suicide
Diphtheria              HTV/AIDS              Chronic liver disease

MVAs = Motor vehicle accidents

HIV = human immunodeficiency virus

AIDS = acquired immunodeficiency syndrome.
TABLE 2

Most Common Procedures Performed at North Carolina Baptist Hospital by
Year

1925 (N = 1,083)

Procedure                             No.

Tonsillectomy                         504
Appendectomy                          126
D & C                                  73
Cystoscopy                             28
I & D                                  23
Mastoidectomy                          19
Fracture reduction                     13
Cast change                            13
Cholecystectomy                        12
Hysterectomy                           10

1935 (N = 1,997)

Tonsillectomy                         528
Appendectomy                          376
Cystoscopy                            186
Cast application/change               120
D & C                                 114
I & D                                  90
Hernia repair                          54
Thyroidectomy                          48
Salpingo-oophorectomy                  42
Salpingectomy                          42

1945 (N = 1,925)

Prostatectomy                         152
Appendectomy                          151
Thyroidectomy                         121
Hernia repair                         111
Hysterectomy                          100
Craniotomy                             82
Salpingectomy                          81
Enterostomy                            78
Fracture reduction                     58
Thoracotomy                            58

1955 (N = 7,130)

Prostatectomy                         285
Herniorrhaphy                         247
Laminectomy                           226
Craniotomy                            198
Appendectomy                          184
Hysterectomy                          152
Fracture reduction                    152
Thyroidectomy                         139
Cholecystectomy                       130
Pneumonectomy

1963 (N = 7,353)

Hysterectomy                          311
Prostatectomy                         242
Herniorrhaphy                         233
Laminectomy                           154
Cholecystectomy                       150
Craniotomy                            109
Fracture reduction                    107
Appendectomy                          100
Intestine resection                    99
Thyroidectomy                          75

1976 (N = 17,003)

Cancer chemotherapy                   690
Cardiac catheterization               505
Circumcision                          453
Episiotomy                            319
D & C                                 227
Intracapsular lens extraction         225
Low forceps & episiotomy               99
Cystourethroscopy                     190
Hysterectomy                          187
Heart revascularization               150

1986 (N = 23,192)

Left or right cardiac               1,683
catheterization Injection/          1,617
infusion chemotherapy
Aortocoronary                         629
by pass of 1 (n=139),
2 (n = 180),
3 (n = 188), or
4 (n = 122) CA
Removal of CA obstruction             245
Arterial catheterization              188
Excision/destruction of               160
intervertebral disk
Cholectomy                            154
Hysterectomy                          144
Arteriography of cerebral arteries    135
Fracture reduction                    115

1992 (N = 23,223)

Chemotherapy infusion               1,800
Left heart catheterization          1,037
PTCA                                  509
Continuous mechanical ventilation     455
  < 96 hr (260)
  > 96 hr (195)
CA by pass                            419
Excision of intervertebral disk       404
Excisional debridement of wound,      262
  infection, or burn
Combined right and left cardiac       248
  catheterization
TAH                                   195
Insertion of vascular access          194
  device

2001 (N = 31,098)

PTCA                                1,480
Infusion cancer chemotherapy          955
Left heart catheterization            553
Hemodialysis                          553
Continuous mechanical                 446
  ventilation < 96 hr
Tracheostomy                          364
Excisional debridement of wound,      348
infection, or burn
TAH                                   213
Total knee replacement                213
Total hip replacement                 199

D & C = Dilatation and curettage, I & D = incision and drainage, PTCA =
percutaneous transluminal coronary angioplasty, CA = coronary artery,
TAH = total abdominal hysterectomy.
TABLE 3

Day-Hospital Statistics for 2001

       Most Common Procedures Performed         No.

Cardiac catheterization                         710
Cardiac electrophysiologic stimulation and      155
  recording studies
Arteriovenostomy for renal dialysis             145
Cerebral arteriography                          127
Renal biopsy                                    124
Aortography                                     115
Therapeutic infusions                           108
Cardioversion (atrial)                           97
Contrast myelography                             60
Percutaneous coronary angioplasty                60

       Most Comon Surgical Procedures           No.

Myringiotomy with tube insertion                615
Phacoemulsification and aspiration of cataract  572
Tonsillectomy with adenoidectomy                330
Excision of semilunar cartilage of knee         260
Vitrectomy                                      214
Excision of laryngeal lesions                   206
Excision of lesion of knee joint                200
Carpal tunnel repair                            198
Hernia repair                                   190
Excision of breat lesion                        187

       Most Common Diagnoses                    No.

Precordial pain                                 486
Chronic ischemic heart disease                  301
Coronary artery disease                         301
Sickle cell crisis                              283
Hypertensive renal disease with renal failure   278
Lymphoid leukemia                               189
Atrial fibrillation                             133
Ovarian carcinoma                               133
Carotid artery stenosis                         133
Complication of renal dialysis                  125
  (paid, thrombosis, stenosis)
TABLE 4

Leading Causes of Death in in North Carolina

1987 (16)

            Cause               No.

Heart disease                 19,498
Cancer                        12,124
Stroke                         4,522
Lung disease                   1,794
Pneumonia and influenza        1,613
Diabetes mellitus              1,025
Motor vehicle accidents        1,575
Other unintentional injuries   1,518
Chronic liver disease            787
Suicide                          678

1998 (17)

Heart disease                 19,441
Cancer                        15,327
Storke                         5,434
Lung disease                   3,206
Pneumonia, influenza           2,688
Diabetes mellitus              1,963
Motor vehicle accidents        1,632
Other unintentional injuries   1,586
Suicide                          846
Septicemia                       789

Acknowledgments. We wish to thank Jeanne Goode, Department of Medical Records, North Carolina Baptist Hospital; Betty Metcalf, Department of Radiology, Wake Forest University School of Medicine; and Christine Sheppard, Emeritus House, Wake Forest University School of Medicine for their assistance in the preparation of this manuscript.

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(15.) North Carolina Center for Health Statistics: Leading Causes of Death: North Carolina Vital Statistics, Vol. 2. Raleigh, NC, North Carolina Department of Health and Human Services, Division of Public Health, 2000

(16.) Atkinson D: Leading Causes of Mortality. Raleigh, NC, North Carolina Department of Health and Human Services, Division of Public Health, Vol 2, 1987

(17.) Jones-Vessey K, Buescher P, Gizlice Z, et al: Leading Causes of Death in North Carolina. Vital Statistics, Vol. 2 1998. Raleigh, NC, North Carolina Department of Health and Human Services, Division of Public Health, 1999

From the Departments of Internal Medicine, Public Health Sciences, Surgical Sciences and the Coy C. Carpenter Library, wake Forest University Baptist Medical Center, Winston-Salem, North Carolina.

Reprint requests to M. Robert Cooper, MD, Section on Hematology and Oncology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157.