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EPIGRAMS
E NEWS FROM THE MICHIGAN STATE MEDICAL SOCIETY
January 12, 1972, Volume 71, Number 1 Michigan State Medical Society Save this Issue for Reference
MSMS Testifies before National Democratic Council
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JAN 2 8 1872
MSMS Lists Michigan Medical Meeds; Describes Steps toward Solutions
I appreciate the invitation extended to the Michigan State Medical Society to appear today before the Democratic Policy Council of the Democratic National Committee. I am Doctor Brooker L. Masters, a family physician at Fremont, Michigan, a rural community of 3,400 in western Michigan. I appear here in my capacity as chair- man of the board of directors (Council) of the Michigan State Medical Society, the professional association of 8,101 doctors of medicine in Michi- gan.
With me today is Doctor Donald N. Sweeny, Jr., a surgeon in group practice here in Detroit. Doctor Sweeny is a member of our board of directors; and long has been active in the Wayne County Medical Society. Should you have any questions today or in the future, we are available to provide the views of both the rural and urban doctor of medicine.
We are pleased that you have invited providers of health care so that you can obtain first-hand the views and suggestions of the doctors, nurses, dentists.
We accepted because it is our strong contention that the political parties, candidates, and the elected representatives have not generally sought views of the physicians in practice. Those doctors who actually see patients every day can accurately evaluate the problems and suggest possible work- able solutions.
Our Michigan State Medical Society member- ship spans the whole spectrum of medical doctors —from the medical school professor to the medi- cal researcher to the salaried physician to the fee- for-service solo practitioner. But it is only through the Michigan State Medical Society that the pri- vate practitioner has a voice in Michigan.
* * #
As the prime providers of medical care in Michigan, doctors are deeply concerned about the health and medical needs of the people in Michi- gan. We have 40 active committees which study
various medical concerns and we are activists in attacking these problems.
Our presentation today is developed in accord- ance with the request made in your invitational letter. Your letter said— “These hearings will give
EDITOR’S NOTE:
Here is the complete testimony offered by the Michigan State Medical Society before the national Democratic Policy Council in Detroit, Jan. 12. The Democratic Policy Council invited MSMS to discuss Michigan medical needs. Brooker L. Masters, MD, Chairman, MSMS Council, who presented the testimony, explains that the statement was developed to establish MSMS as a leader in working on Michigan health needs, and to report steps being taken by MSMS to help solve these problems.
The testimony was based on resolutions adopted by the MSMS House of Delegates in recent years. The statement. Doctor Masters adds, also pointed out several weak- nesses in current governmental health care programs without implying that any new revolutionary approach is needed. The state- ment also stressed the need to continue the pluralistic approach to the practice of medi- cine.
Members of the MSMS Council over- whelmingly indicated to Doctor Masters that this Democratic Party invitation should be accepted. The Party plans four such hear- ings across the nation, the first being the one in Detroit.
The AMA will testify before the Demo- cratic Platform Committee on national issues and advised MSMS to make its presentation deal with Michigan needs and projects.
the Democratic Party an opportunity to develop proposals which respond appropriately to the needs of the country.”
We have studied the 1968 platform of the National Democratic Party. We share your con- cerns about medical research, the physician short- age, maternal and perinatal health care, drug edu- cation, and others.
Your 1968 platform also called for “new co- ordinated approaches through a partnership of government and private enterprise.” Again, the Michigan State Medical Society is at work to bring about stronger cooperative programs between the private practice of medicine and government.
Doctors agree with your 1968 health statement that— and I quote— “The best of modern medical care should be made available to every American.”
* * *
We will discuss some of the specific needs that the Michigan State Medical Society has identified and urge that your Democratic Policy Council consider our approaches toward solutions.
These needs have been officially recognized by the Medical Society House of Delegates, which supervises ongoing study and action to solve these problems. Our House of Delegates is a truly rep resentative body, consisting of one delegate elected in each county medical society to represent each 50 physicians.
Time forces me to select what 1 feel are six major medical needs facing doctors and everyone in Michigan.
Need #1:
Michigan medical schools should be enlarged
Michigan issues an average of 650 permanent licenses each year to doctors of medicine. In order to better meet our own needs in Michigan, our Medical Society was a prime proponent of the new medical school at Michigan State University. We have worked for many years to convince the State legislature to increase appropriations to ex- pand the medical school enrollments at the Uni- versity of Michigan and Wayne State University— and now also at Michigan State University. We are pleased that the number of medical students in Michigan has increased from 1,342 in 1966 to 1,710 in 1971. This is an increase of 368 in just five years.
Last June there were 343 young men and women graduated from Michigan medical schools. This figure will soon surpass 400; but still leaves us considerably short. In addition to the 650 doc- tors who receive permanent licenses in Michigan each year, there are 200 graduates of foreign medi-
“MSMS has worked many years to convince the legislature to increase appropriations to the medical schools ”
cal schools who receive temporary Michigan li- censes.
We feel that every qualified applicant for medi- cal schools in Michigan and the nation should be admitted. Medical school officials report that at present only 60 per cent of the qualified stu- dents can be accepted.
I believe many Michigan doctors will utilize the newly-emerging physician assistants to help pro- vide more care for more people. In 1965 the Mich- igan State Medical Society was the first such society in the nation to support this new kind of medical personnel. HEW reports that the developing phy- sician assistant program at Western Michigan University is the only one in the nation with the endorsement of a state medical society.
# * #
Need #2:
Michigan needs more family physicians
Michigan residents— and I am sure those in other states too— need and want more family physicians. Doctors do too. During the ’60s, more and more doctors chose to specialize and fewer went into general practice. The Michigan State Medical Society has had active committees since 1967 work- ing to help turn this situation around.
Dedicated GPs are spearheading real progress here— Future Family Physician Clubs have been established at all three schools, and five Michigan hospitals now are offering family practice residen- cies. The three medical schools have altered their curricula to give more attention to family and community medicine.
MSMS has urged the legislature and the medical schools to create Departments of Family Practice, and we are cooperating now in a special Michigan Legislative Study Committee to study the complex problem.
We are encouraged, too, with the reports in Michigan that a much higher percentage of medi- cal students is deciding today to enter general practice as a meaningful way to treat the whole person.
# * #
Need #3:
Distribution of physicians must be improved
There are areas in Michigan where there are shortages of physicians and other health personnel. We are deeply concerned about such shortages in some rural areas, in some small communities, and the inner city of Detroit.
Many rural areas lack educational facilities as well as the chance for professional relationships and cultural activities for the doctor and his fam- ily. The center city has become a depressing place to work or live and the threats to safety of the person and property are real. For example, five doctors of medicine have been murdered in the inner city of Detroit in the past two years.
We are opposed to coercion or mandatory as- signment to practice in any specified area, because we believe the doctor should have freedom to choose his own place to practice.
“Medicare and Medicaid programs should cover home health care service and more preventive medicine ”
MSMS committees are active to solve these problems and we see some improvements. Each situation requires different solutions. We can point to examples of group practice arrangements, community health centers, satellite clinics, mobile screening programs, and others as innovative answers.
Here in Detroit, for example, a new medical center was erected in 1971 by a group of Black private physicians led by Doctor Lionel Swan to provide them the opportunity to practice in one building with savings in personnel, laboratory facilities, business operations and other oppor- tunities.
The Michigan Medical Society is the major supporter of the Michigan Health Council which operates an effective program to assist Michigan communities to obtain more physicians. Since 1953 the Health Council has helped to place 1,100 physicians in our state.
* # #
Need # 4 :
There must be more preventive medicine
Because the level of education in Michigan and the nation has never been higher than it is today we find a new acceptance by the people of pre- ventive medicine. Doctors are trained to practice and preach preventive medicine and we are pleased to see the climate improving.
The Michigan State Medical Society has adopted resolutions endorsing multiphasic health screening, and supporting the use of computers. MSMS regu- larly sponsors public seminars on cancer, arthritis, smoking and alcoholism, often with the support of local newspapers. MSMS every day distributes edu- cational materials about drug abuse, about venereal disease, and other health problems to school chil- dren.
Our Medical Society was active in urging the Michigan legislature in 1969 to pass a law which now assures comprehensive health education from kindergarten through high school.
I will make further comments about preventive medicine under Need #5.
* * *
Need #5:
There must be improvements in current governmental health programs
In the original Medicare and Medicaid legisla- tion, home health care services such as visiting nurses were covered . . . but last year this part of the program was severely curtailed. MSMS adopted a resolution pointing out that such cur-
tailment denies health care to a large segment of our chronically-ill aging population. Home health services by visiting nurses under the direction of physicians are traditional, are effective, and are the most economical of all health services.
The present guidelines for Medicare and Medi- caid must be changed to permit doctors to practice preventive medicine with these patients. Today, physical examinations, immunizations, Pap smears for cancer, and other preventive medical pro- cedures are not covered.
Speaking about Medicaid, the doctors of Michi- gan have worked diligently to make the state program operate effectively and efficiently. We have conferred many times with state Medicaid officials.
On March 2, 1971, MSMS presented 12 sugges- tions to improve the state Medicaid program to provide better health care for the medically indi- gent. At that time, we advocated greater emphasis on preventive programs, health maintenance, and ambulatory care. A copy of the 12 recommenda- tions is attached to the statement given members of your policy council.
# * *
Need #6:
The pluralistic system must continue
The Michigan State Medical Society has an official position recognizing that “there are cur- rently many acceptable methods of practicing medicine.” Michigan physicians “feel that multiple options for the delivery of medical care should remain open to physicians.”
Our nation is great because we do have plural- istic systems of education, agriculture and others. It is appropriate because no single approach will work across our large nation where population densities vary, where cultural values differ, and so1 many conditions are unique.
In Michigan today we have solo medical prac- tices, group practices, professional corporations, clinics, hospitals with salaried staffs, hospitals with fee-for-service staffs, and other forms of practice. We believe that each in its own way is contrib- uting to the effective practice of medicine in Mich- igan. These variations permit the doctor to select the best structure to provide care for his patients.
Any insistence that medicine be practiced the same in the inner city of Detroit as in my rural community in Western Michigah would be unwise.
* # #
Let me recap the six major Michigan medical needs we have identified for you as requested in your invitational letter:
“MSMS feels that multiple options for the delivery of medical care should be open to physicians.”
TO MSMS MEMBERS:
As you read this testimony, I especially call your attention to the discussion of the six Michigan medical needs and to the copy which describes our MSMS work to relieve and solve these problems.
If you feel that too little has been done to correct these problems, MSMS members can take the following actions : ( 1 ) work harder through appropriate component so- ciety committees to develop positive pro- grams, ( 2 ) urge component society delegates to the MSMS House of Delegates to intro- duce resolutions with workable plans to attack the issues, and (3) encourage and assist MSMS committees to deal effectively with problems in their sphere of expertise.
This review of Michigan needs and our efforts also will challenge the MSMS Com- mittee on Planning and Priorities to step up its work.
Any reactions to the testimony or sugges- tions to improve MSMS efforts to solve medical needs in our state will sincerely be welcomed. Just mail them to me at MSMS, 120 West Saginaw, East Lansing 48823.
Brooker L. Masters, MD Chairman, MSMS Council
1. Michigan medical schools should be enlarged.
2. Michigan needs more family physicians.
3. The distribution of physicians must be im- proved.
4. There must be more preventive medicine.
5. There must be improvements in current governmental health programs.
6. The pluralistic system must continue.
In discussing each of these Michigan needs, we have described briefly only a few of the many posi- tive programs of the Michigan State Medical So- ciety. Our component county medical societies, too, have action programs, as do the Michigan medical specialty organizations.
“ The medical profession accepts its vital role in this evolution toward further improvements ”
We continually work with and have offered our services to the Michigan legislature, the medical schools, the Michigan Consumer Council, and con- cerned lay groups.
Our testimony has focused on Michigan medical needs because we are certain the American Med- ical Association will be invited to discuss national issues later before the Democratic Party platform committees.
# # #
Through our illustrations today we hopefully have convinced you that the Michigan State Med- ical Society is a responsible organization of dedi- cated professional people. We think the individual physicians of Michigan provide good quality care for the people of Michigan.
We share the same concerns that consumers have. New ideas must be considered jointly so that practitioners in medicine can share in new experimental programs.
The medical profession accepts its vital role in this fast-moving evolution toward further improve- ments. We are dedicated to making available med- ical care for everybody. We are deeply concerned about the costs of medical care. We are insistent through our many review committees that high professional standards of quality be maintained.
No country has developed, in the opinion of physicians, a better combination of these three fac- tors—general access, reasonable cost, and high qual- ity.
There HAS been real progress in Michigan and our nation.
The Michigan State Medical Society is dedicated to working for further improvements. Toward this end Michigan’s doctors are prepared to work with any responsible political force such as this Council.
Thank you again for inviting us. If we can be of further help, please call on us.
Jan. 12, 1972, Vol. 71, No. 1
Second Class Postage Paid at East Lansing, Mich, and at additional mailing offices.
MICHIGAN STATE MEDICAL SOCIETY
Published three times each month and four times in December and January, 38 issues, by the Michigan State Medical Society as its official journal. Second class postage paid at East Lansing, Mich, and at additional mailing offices. Yearly subscription rate, $9.00. Printed in USA. All communications should be addressed to the Publications Committee, Michigan State Medical Society, 120 West Saginaw Street, East Lansing, Michigan 48823. © 1972 Michigan State Medical Society. Phone: Area Code 517, 337-1351.
UNIVERSITY OF CAL LIBRARY SCH OF MED THIRD £ PARNASSUS AVE SAN FRANCISCO CAL 94122
EDITOR: HERBERT A. AUER
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OFFICIAL JOURNAL OF THE MICHIGAN STATE MEDICAL SOCIETY • VOLUME 71, NUMBER 2 . JANUARY, 1972
MOTHER AND CHILD by Gari Melchers. Courtesy of the Art Institute of Chicago
See page 38 for complete program
of 1972 Michigan Conference on Maternal and Perinatal Health
IF MORE MEN CRIED
References: 1. Silen, W.: “Peptic Ulcer,” in Wintrobe, M. M., ct al. (eds.) : Harrison’s Principles of Internal Medicine, ed. 6, New York, McGraw-Hill Book Company, 1970, p. 1444. 2. Wolf, S., and Goodell, H. (eds.): Harold G. Wolff’s Stress and Disease, ed. 2, Springfield, 111., Charles C Thomas, 1968, pp. 68-69. 3. Ibid., p. 257. 4. Schottstaedt, W. W.: Psychophysiologic Approach in Medical Practice, Chicago, 111., The Year Book Publishers, Inc., 1960, p. 163. 5. Alvarez, W. C.: The Neuroses, Philadelphia, Pa., W. B. Saunders Company, 1951, p. 384.
Hypersecretion— an atavistic response.
Stewart Wolf, who, with Harold G. Wolff, studied the personalities of duodenal ulcer patients, wonders if masculine competitive- ness is related to “an atavistic urge to devour an adversary.” It is striking, he reports, that an accentuation of gastric acid secretion and motility can be “induced in ulcer patients by discussions that arouse feelings of inade- quacy, frustration and resentment.”2
By chance? A lean, hungry lot. Was the link between emotions and gastric hyper- acidity acquired through mutation to serve a purpose? During man’s jungle period of evolution, the investigator points out, a male dealt with a foe by killing and devouring it. “It may be more than coincidence,” he con- cludes, that peptic ulcer patients appear to be “a lean, hungry, competitive lot.”3
At least seventy-five out of one hundred adults with duodenal ulcers are men.1 Why? It may be signifi- cant that duodenal ulcer patients tend to crave recognition and are “especially vulnerable to threats to their manly assertive independence.”2
Big boys don’t cry. If more men cried, maybe fewer would wind up with duodenal ulcers. But men will be men— the sum total of their genes and what they are taught. Schottstaedt observes that when a mother admonishes her son who has hurt himself that big boys don’t cry, she is teaching him stoicism.4 Crying is the negation of everything society thinks of as manly. A boy starts defending his manhood at an early age.
Take away stress, you can take away symptoms.
There is no question that stress plays a role in the etiology of duodenal ulcer. Alvarez5 observes that many a man with an ulcer loses his symptoms the day he shuts up the office and starts out on a vacation. The problem is, the type of man likely to have an ulcer is the type least likely to take long vacations or take it easy at work.
The rest cure vs. the two-way action of Librax. For most patients, the rest cure is as unrealistic as it is desirable. Still, the stress factor must be dealt with. And here is where the dual action of adjunctive Librax can help. Librax is the only drug that com-
mes the antianxiety ition of Librium hlordiazepoxide HC1) ith the dependable ntisecretory/ ntispasmodic Aion of •uarzan® (clidinium Br).
Protects man from his own hungry per- onality. The action of Librium reduces nxiety — helps protect the vulnerable patient [’om the psychological overreaction to stress fiat clutches his stomach. At the same time, le action of Quarzan helps quiet the hyper- ctive gut, decreasing hypermotility and ypersecretion.
An inner healing environment with 1 r 2 capsules, 3 or 4 times daily. Of course, lere’s more to the treatment of duodenal leer than a prescription for Librax. The pa- ient — with your guidance — will have to ad- ust to a different pattern of living if treat- lent is to succeed. During this adjustment eriod, 1 or 2 capsules of Librax 3 or 4 times aily can help establish a desirable environ- nent for healing.
Librax: It can’t change man’s nature. But it can usually make it easier for men to :ope with the discomfort of stress— both )sychic and gastric — that can precipitate ind exacerbate duodenal ulcer.
Abrax : Rx #60 1 cap. a.c. and 2 h.s.
Before prescribing, please consult complete product information, a summary of which follows:
Indications: Indicated as adjunctive therapy to control emotional and somatic factors in gastrointestinal disorders.
Contraindications: Patients with glaucoma; prostatic hypertrophy and benign bladder neck obstruction; known hypersensitivity to chlordiazepoxide hydrochloride and/or clidinium bromide.
Warnings: Caution patients about possible combined effects with alcohol and other CNS depressants. As with all CNS-acting drugs, caution patients against hazardous occupations requiring complete mental alertness (e.g., operating machinery, driving). Though physical and psychological dependence have rarely been reported on recommended doses, use caution in administering Librium (chlordiazepoxide hydrochloride) to known addiction-prone individuals or those who might increase dosage; withdrawal symptoms (including convulsions), following discontinuation of the drug and similar to those seen with barbiturates, have been reported. Use of any drug in pregnancy, lactation, or in women of childbearing age requires that its potential benefits be weighed against its possible hazards. As with all anticholinergic drugs, an inhibiting effect on lactation may occur.
Precautions: In elderly and debilitated, limit dosage to smallest effective amount to preclude development of ataxia, over- sedation or confusion (not more than two capsules per day initially; increase gradually as needed and tolerated). Though generally not recommended, if combination therapy with other psychotropics seems indicated, carefully consider individual pharmacologic effects, particularly in use of potentiating drugs such as MAO inhibitors and phenothiazines. Observe usual precautions in presence of impaired renal or hepatic function. Paradoxical reactions (e.g., excitement, stimulation and acute rage) have been reported in psychiatric patients. Employ usual precautions in treatment of anxiety states with evidence of impending depression; suicidal tendencies may be present and protective measures necessary. Variable effects on blood coagulation have been reported very rarely in patients receiving the drug and oral anticoagulants; causal relationship has not been established clinically.
Adverse Reactions: No side effects or manifestations not seen with either compound alone have been reported with Librax. When chlordiazepoxide hydrochloride is used alone, drowsi- ness, ataxia and confusion may occur, especially 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 syncope has been reported. Also encountered are isolated instances of skin eruptions, edema, minor menstrual irregularities, nausea and constipation, extrapyramidal symptoms, increased and decreased libido— all infrequent and generally controlled with dosage reduction; changes in EEG patterns (low-voltage fast activity) may appear during and after treatment; blood dyscra- sias (including agranulocytosis), jaundice and hepatic dys- function have been reported occasionally with chlordiazepoxide hydrochloride, making periodic blood counts and liver function tests advisable during protracted therapy. Adverse effects reported with Librax are typical of anticholinergic agents, i.e., dryness of mouth, blurring of vision, urinary hesitancy and constipation. Constipation has occurred most often when Librax therapy is combined with other spasmolytics and/or low residue diets.
in the treatment of duodenal ulcer « i adjunctive
Librax
Each capsule contains 5 mg chlordiazepoxide HC1 and 2.5 mg clidinium Br.
Roche Laboratories
Division of Hoffmann-La Roche Inc.
Nutley, N.J. 07110
Our leaders
I
i
MSMS Officers
PRESIDENT
PRESIDENT-ELECT
SECRETARY
TREASURER
ASS T SECRETARY ASST TREASURER
SPEAKER
VICE SPEAKER PAST PRESIDENT
DIRECTOR
GENERAL COUNSEL LEGAL COUNSEL ECONOMIC CONSULTANT SCIENTIFIC EDITOR
MSMS Council
CHAIRMAN
VICE CHAIRMAN
AMA DELEGATION CHAIRMAN
Sidney Adler, MD Detroit
John J. Coury, MD Port Huron
Kenneth H. Johnson, MD Lansing
John R. Ylvisaker, MD Pontiac
Ross V. Taylor, MD Jackson
Ernest P. Griffin, MD Flint
Vernon V. Bass, MD Saginaw
Janies D. Fryfogle, MD Detroit
Harold H. Hiscock, MD Flint
Warren F. Tryloff East Lansing
Lester P. Dodd Detroit
A. Stewart Kerr Detroit
Clyde T. Hardwick, PhD Houghton
John W. Moses, MD Detroit
Brooker L. Masters, MD Fremont
Robert M. Leitch, MD Battle Creek
Donald N. Sweeny, Jr., MD Detroit
COUNCILOR
First District Councilors: (Wayne County)
Edward J. Tallant, MD, Detroit Ralph R. Cooper, MD, Detroit Frank G. Bicknell, MD, Detroit Brock E. Brush, MD, Detroit Louis R. Zako, MD, Allen Park Second District Councilor: Ross V. Taylor, MD, Jackson Counties: Clinton, Eaton, Hillsdale, Ingham, Jackson Third District Councilor: Robert M. Leitch, MD, Battle Creek Counties: Branch, Calhoun, St. Joseph Fourth District Councilor: W. Kaye Locklin, MD, Kalamazoo Counties: Allegan, Berrien, Cass, Kalamazoo, Van Buren Fifth District Councilor: Noyes L. Avery, MD, Grand Rapids Counties: Barry, Ionia-Montcalm, Kent, Ottawa Sixth District Councilor: Ernest P. Griffin, Jr., MD, Flint Counties: Genesee, Shiawasse^
Seventh District Councilor: James H. Tisdel, MD, Port Huron Counties: Huron, Sanilac, Lapeer, St. Clair Eighth District Councilor: William A. DeYoung, MD, Saginaw Counties: Gratiot-Isabella-Clare, Midland, Saginaw, Tuscola Ninth District Councilor: Adam C. McClay, MD, Traverse City
Counties: Grand Traverse-Leelanau-Benzie, Manistee, Northern Michigan (Antrim, Charlevoix, Cheboygan and Emmet combined), Wexford-Missaukee Tenth District Councilor: Robert C. Prophater, MD, Bay City
Counties: Alpena-Alcona-Presque Isle, Bay-Arenac-Iosco, North Central Counties, (Otsego, Mont- morency, Crawford, Oscoda, Roscommon, Ogemaw, Gladwin and Kalkaska, combined)
Eleventh District Councilor: Brooker L. Masters, MD, Fremont
Counties: Mason, Mecosta-Osceola-Lake, Muskegon, Newaygo, Oceana Twelfth District Councilor: Raymond Hockstad, MD, Escanaba
Counties: Chippewa-Mackinac, Delta-Schoolcraft, Luce, Marquette-Alger Thirteenth District Councilor: Donald T. Anderson, MD, Wakefield
Counties: Dickinson-Iron, Gogebic, Houghton-Baraga-Keweenaw, Menominee, Ontonagon Fourteenth District Councilor: Donato F. Sarapo, MD, Adrian Counties: Lenawee, Livingston, Monroe, Washtenaw Fifteenth District Councilor: Sydney Scher, MD, Mount Clemens Counties: Macomb, Oakland
2 MICHIGAN MEDICINE JANUARY 1972
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ANGRY?
Doctor, are you upset over the recent freeze on medical fees or any in a series of political moves to control the medical profession? What are you going to do?
Ask yourself, how would George Meany or Leonard Woodcock respond to similar pressures? Almost every working man in Michigan “voluntarily” contributes $1 a week, $52 a year, for political action.
Can you afford to do less?
Within the past few days you have received your billing statement for county, state and AMA dues. Attached to the statement is a separate billing for MDPAC, the Michigan Doctors Political Action Committee, which is voluntary and not deductible. In view of the fee freeze, you have only three options on the MDPAC contribution:
1. You can delete the MDPAC portion com- pletely and continue to complain about government control of health care.
2. You can make the minimal contribution of $25 to MDPAC. If every physician in Michigan contributed $25, the voice of medicine would be able to speak out to the tune of more than $200,000.
3. Or if you are really angry and want to start playing the game by the same rules as those who are consistent winners, cross out the $25 and make your contribution for $100. $100 makes you a sustaining member of MDPAC.
Think about what a freeze on medical fees means to you. Think about what kind of precedent it sets for the future. Think about it — and decide what you’re going to do about it.
MDPAC
Michigan Doctors Political Action Committee
P.O. Box 769 East Lansing, Ml 48823
MICHIGAN MEDICINE JANUARY 1972 3
Coqteqts
SCIENTIFIC ARTICLES
15 Hypovolemic Shock, William R. Olsen, MD 27 Complications of Splenectomy, Robert D. Allaben, MD; William S. Carpenter, MD; Paul J. Connolly, MD; Angelos A. Kambouris, MD
33 Are Congenital Viral Infections Possible in Successive Pregnancies? Thad H. Joos, MD
(£ Michigan (fMediciqe
SPECIAL ARTICLE
48 The status of Michigan’s Medicaid Program; Stuart Paterson
NEW FEATURES
32 Clinical notes
54 County Society in the Spotlight
75 Sound Off
New Maternal Health Desk Reference Card on "The High Risk Fetus,” page 69
OTHER FEATURES
2 Our leaders 7 Small doses 10 Your opinion please 26 Perinatal tips 36 MSMS in action 38 Zip Code 48823 58 Michigan Mediscene 60 In memoriam
71 New members
72 Classified
Publication of Michigan Medicine is under the direction of the Publication Committee, Michigan State Medical So- ciety. The scientific editor is responsible for the scientific content. The managing editor is responsible for the pro- duction, correspondence and contents of the journal. He and the executive editor share final responsibility of the entire publication.
Neither the editors nor the state medical society will accept responsibility for statements made or opinions ex- pressed by any contributor in any article or feature pub- lished in the pages of the journal. In editorials, the views expressed are those of the writer and not necessarily offi- cial positions of the society.
SCIENTIFIC EDITOR
John W. Moses, MD
EXECUTIVE EDITOR
Herbert A. Auer
MANAGING EDITOR
Judith Marr
PUBLICATION COMMITTEE
Robert M. Leitch, MD Battle Creek Chairman
Donato F. Sarapo, MD Adrian
Edward J. Tallant, MD Detroit
Devoted to the interests of the medical profession and public health in Michigan.
INFORMATION FOR CONTRIBUTORS
1. Address scientific manuscripts to the Publication Com- mittee, Michigan State Medical Society, 120 West Saginaw Street, East Lansing, Michigan 48823. Submit original, double- spaced typewritten copy and two carbon copies or photo copies on letter size (8V2 x H inch) paper. On page one, include title, authors, degrees, academic titles, and any institutional or other credits.
2. Authors are responsible for all statements, methods, and conclusions. These may or may not be in harmony with the views of the Editorial Staff. It is hoped that authors may have as wide a latitude as space available and general policy will permit. The Publication Committee expressly reserves the right to alter or reject any manuscript, or any contribution, whether solicited or not.
3. Illustrations should be submitted in the form of glossy prints or original sketches from which reproductions will be made by Michigan Medicine.
4. Articles should ordinarily be less than four printed pages in length (3000 words).
5. References should conform to Cumulative Index Medicus, including, in order: Author, title, journal, volume number, page, and year. Book references should include editors, edition, publisher, and place of publication, as well.
6. The editors welcome, and will consider for publication, letters containing information of interest to Michigan physi- cians, or presenting constructive comment on current contro- versial issues. News items and notes are welcome.
7. It is understood that material is submitted for exclusive publication in Michigan Medicine.
MICHIGAN MEDICINE is the official organ of the Michigan State Medical Society, published under the direction of the Publication Committee. Published Semi-Monthly, Trimonthly in January and December; 26 issues, by the Michigan State Medical Society as its official journal. Second class postage paid at East Lansing, Mich, and at additional mailing offices. Yearly subscription rate, $9.00; single copies, 80 cents. Addi- tional postage: Canada, $1.00 per year; Pan-American Union, $2.50 per year; Foreign, $2.50 per year. Printed in USA. All communications relative to manuscripts, advertising, news, exchanges, etc., should be addressed to Judith Marr, Mich- igan State Medical Society, 120 West Saginaw Street, East Lansing, Michigan 48823. Phone Area Code 517, 337-1351. © 1972 Michigan State Medical Society.
4 MICHIGAN MEDICINE JANUARY 1972
phenformin HCi
■Hi
DBI® phenformin HCI tablets of 25 mg.
DBI-TD® phenformin HCI capsules of 50 and 100 mg.
Indications: Stable adult diabetes mellitus; sulfonylurea failures, primary and second- ary; adjunct to insulin therapy of unstable diabetes mellitus.
Contraindications: Diabetes mellitus that can be regulated by diet alone; juvenile diabetes mellitus that is uncomplicated and well regulated on insulin; acute complica- tions of diabetes mellitus (metabolic acido- sis, coma, infection, gangrene); during or immediately after surgery where insulin is indispensable; severe hepatic disease; renal disease with uremia; cardiovascular collapse (shock); after disease states associated with hypoglycemia.
Warnings: Use during pregnancy is to be avoided.
Precautions: 1. Starvation Ketosis: This must be differentiated from “insulin lack” ketosis and is characterized by ketonuria
which, in spite of relatively normal blood and urine sugar, may result from excessive phenformin therapy, excessive insulin reduc- tion, or insufficient carbohydrate intake. Adjust insulin dosage, lower phenformin dosage, or supply carbohydrates to alleviate this state. Do not give insulin without first checking blood and urine sugar.
2. Lactic Acidosis: This drug is not recom- mended in the presence of azotemia or in any clinical situation that predisposes to sustained hypotension that could lead to lactic acidosis. To differentiate lactic acido- sis from ketoacidosis, periodic determina- tions of ketones in the blood and urine should be made in diabetics previously sta- bilized on phenformin, or phenformin and insulin, who have become unstable. If elec- trolyte imbalance is suspected, periodic determinations should also be made of elec- trolytes, pH, and the lactate-pyruvate ratio. The drug should be withdrawn and insu- lin, when required, and other corrective measures instituted immediately upon the appearance of any metabolic acidosis.
3. Hypoglycemia: Although hypoglycemic reactions are rare when phenformin is used alone, every precaution should be observed during the dosage adjustment period particu- larly when insulin or a sulfonylurea has been given in combination with phenformin. Adverse Reactions: Principally gastrointes- tinal; unpleasant metallic taste, continuing to anorexia, nausea and, less frequently, vomiting and diarrhea. Reduce dosage at first sign of these symptoms. In case of vom- iting, the drug should be immediately withdrawn. Although rare, urticaria has been reported, as have gastrointestinal symptoms such as anorexia, nausea and vomiting fol- lowing excessive alcohol intake.
(B) 98-146- 103-C
For complete details, including dosage, please see full prescribing information.
GEIGY Pharmaceuticals Division of CIBA-GEIGY Corporation Ardsley, New York 10502 Distributors
DBI- 8345-9
/Burroughs Wellcome Co.
Research Triangle Park North Carolina 27709
A gratifying announcement about Empirin Compound with Codeine
You may now specify up to five refills within six months when you prescribe Empirin Compound with Codeine (unless restricted by state law).
It is significant in this era of increased regulation, that Empirin Compound with Co- deine has been placed in a less restrictive category. You may now wish to consider Empirin with Codeine even more frequently for its predictable analgesia in acute or protracted pain of moderate to severe intensity.
Empirin Compound with Codeine No. 3 contains codeine phosphate* (32.4 mg.) gr. V2. No. 4 contains codeine phosphate* (64.8 mg.) gr. 1. *( Warning— may be habit-forming.) Each tablet also contains: aspirin gr. 3V2, phenacetin gr. 2V2, caffeine gr. V2.
,
SEDATE EFFECTIVELY
'
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With QUI-A-ZONE — you can sedate ef- fectively. A balanced combination of short, intermediate, and long-acting barbiturates (totaling 100 mg.) in a rapidly disintegrat- ing tablet — sedation is provided within a few minutes . . . followed by sound restful sleep . . . usually without morning hangover. The four barbiturates in QUI-A-ZONE have dual channels of elimination (renal and hepatic) to lessen metabolic burden, decrease barbitu- rate retention, and minimize depression.
QUI-A-ZONE
Each rapidly-disintegrating tablet contains 25 mg. secobar- bital, 25 mg. pentobarbital, 25 mg. butabarbital, and 25 mg. phenobarbital. Bottles of 100.
Usual Adult Dose: 1 to 2 tablets before retiring. PRECAUTION: Should not be administered to patients sen- sitive to barbiturates, or in cases of known previous addic- tion. Warning: May be habit forming.
SEND FOR SAMPLES.
WALKER, CORP & CO., INC. Syracuse, New York 13201
small doses
Charles L. Votaw, MD, Ann Arbor,
is new assistant dean for curriculum in the Uni- versity of Michigan Medical School, effective Dec. 1. He will be responsible for administrative support to the development, implementation and evaluation of the undergraduate medical school curriculum.
Harold Roehm, MD, Bloomfield Hills,
is the recipient of a special plaque from St. Jo- seph Mercy Hospital acknowledging his contri- bution to the growth of its pediatric department, which he founded in 1927. Doctor Roehm has retired after 48 years in practice.
Memorial contributions
in the name of the late P. F. Stoller, MD, St. Johns, will be used to refurnish and provide new equipment for the pediatric department of the Clinton Memorial Hospital. The department also is being renamed for Doctor Stoller, who served as school physician for the children of the com- munity before his death Aug. 28.
Harry J. Burkholder, MD, Alpena,
has completed 50 years of service as a surgeon in his northern Michigan community. He was honored at an open house in the Alpena Civic Auditorium recently, and at halftime during an Alpena High School football game and by his office staff and medical colleagues at the Alpena Hospital. He was graduated in 1916 from Johns Hopkins Medical School and received a 50-year award in 1966 from MSMS.
James L. Conklin, MD, Ann Arbor,
is new associate dean for student affairs at the Michigan State University College of Human Medicine. He has been associate professor of anatomy in the University of Michigan Medical School. At MSU, Doctor Conklin will be responsi- ble for student admissions, counseling and fi- nancial assistance programs in the medical school. He succeeds Daniel F. Cowan, MD, who will return to full-time teaching and research.
David Charles Nolan, MD, Detroit,
is new director of the Detroit Health Depart- ment’s epidemiology division and is therefore responsible for reports and investigations of communicable diseases. He has been associated with the Wayne State University School of Med- icine as an assistant professor of medicine.
Muskegon County is seeking
a new health department director since the resig- nation Nov. 12 of Paul R. Engle, MD, who is planning to relocate in California. Doctor Engle has held the position since 1969.
MICHIGAN MEDICINE JANUARY 1972 7
In acute gonorrhea
(urethritis, cervicitis, proctitis when due to susceptible strains of N. qonorrhoeae)
it
Sterile Trobicin®
(spectinomycin dihydrochloride pentahydrate)— For Intramuscu- lar injections, 2 gm vials containing 5 ml when reconstituted with diluent. 4 gm vials containing 10 ml when reconstituted with diluent.
An aminocyclitol antibiotic active in vitro against most strains of Neisseria gonorrhoeae (MIC 7.5 to 20 mcg/ml). Definitive in vitro studies have shown no cross resistance of N. gonorrhoeae be- tween Trobicin and penicillin.
Warnings: Antibiotics used to treat gonorrhea may mask cj delay the symptoms of incubating syphilis. Patients should b 1,^ carefully examined and monthly serological follow-up for (j<::
Indications: Acute gonorrheal urethritis and proctitis in the male and acute gonorrheal cervicitis and proctitis in the female when due to susceptible strains of N. gonorrhoeae.
Contraindications: Contraindicated in patients previously found hypersensitive to Trobicin. Not indicated for the treatment
of Syphilis. ®1972 The Upjohn Company
least 3 months should be instituted if the diagnosis of syphilis suspected.
Safety for use in infants, children and pregnant women has nc been established.
Precautions: The usual precautions should be observed wil atopic individuals. Clinical effectiveness should be monitored t detect evidence of development of resistance of N. gonorrhoea
Adverse reactions: The following reactions were observe during the single-dose clinical trials: soreness at the injection sit urticaria, dizziness, nausea, chills, fever and insomnia.
During multiple-dose subchronic tolerance studies in norm* human volunteers, the following were noted: a decrease in heme
W
8 MICHIGAN MEDICINE JANUARY 1972
Irobkin
sterile spectinomycin dihydrochloride penta hydrate, Upjohn
single-dose intramuscular treatn a r 1
igh cure rate:* 96% of 571 males, 95% of 294 females
)osages, sites of infection, and criteria for diagnosis and cure are defined below.)**
.ssurance of a single-dose, physician-controlled treatment schedule
o allergic reactions occurred in patients with an alleged history of penicillin sensitivity fhen treated with Trobicin, although penicillin antibody studies were not performed
active against most strains of Neisseria gonorrhoeae in vitro (M I C 7.5-20 mcg/ml)
, single two-gram injection produces peak serum concentrations averaging about 50 mcg/ml in one hour (average serum concentrations of 15 mcg/ml present 8 hours after dosing)
ote: Antibiotics used in high doses for short periods of time to treat gonorrhea may mask or delay the 'mptoms of incubating syphilis. Since the treatment of syphilis demands prolonged therapy with any ■fective antibiotic, and since Trobicin is not indicated in the treatment of syphilis, patients being treated for Dnorrhea should be closely observed clinically. Monthly serological follow-up for at least 3 months should 3 instituted if the diagnosis of syphilis is suspected. Trobicin is contraindicated in patients previously found /persensitive to it.
*pta compiled from reports of 14 investigators. **Diagnosis was confirmed by cultural identification of N. gonorrhoeae on Thayer- artin media in all patients. Criteria for cure: negative culture after at least 2 days post-treatment in males and at least 7 days post-
' satment in females. Any positive culture obtained post-treatment was considered evidence of treatment failure even though the llow-up period might have been less than the periods cited above under “criteria for cure" except when the investigator determined at reinfection through additional sexual contacts was likely. Such cases were judged to be reinfections rather than relapses or ilures. These cases were regarded as non-evaluatable and were not included. JA72 1IM8-6
pbin, hematocrit and creatinine clearance; elevation of alka- le phosphatase, BUN and SGPT. In single and multiple-dose Eidies in normal volunteers, a reduction in urine output was i ted. Extensive renal function studies demonstrated no con- sent changes indicative of renal toxicity.
I>sage and administration: Keep at 25°C and use within ' hours after reconstitution with diluent.
i a/e — single 2 gram dose (5 ml) intramuscularly. Patients with unorrheal proctitis and patients being re-treated after failure ' previous antibiotic therapy should receive 4 grams (10 ml). In ! ^ographic areas where antibiotic resistance is known to be pre- sent, initial treatment with 4 grams (10 ml) intramuscularly is eferred.
-male — single 4 gram dose (10 ml) intramuscularly.
satic Water for Injection with Benzyl Alcohol 0.9% w/v. Recon- stitution yields 5 and 10 ml respectively with a concentration of spectinomycin dihydrochloride pentahydrate equivalent to 400 mg spectinomycin per ml. For intramuscular use only. Susceptibility Powder — lor testing in vitro susceptibility of N. gonorrhoeae.
Human pharmacology: Rapidly absorbed after intramuscular injection. A two-gram injection produces peak serum concentra- tions averaging about 100 mcg/ml at one hour with 15 mcg/ml at 8 hours. A four-gram injection produces peak serum concen- trations averaging 160 mcg/ml at two hours with 31 mcg/ml at 8 hours.
For additional product information, see your Upjohn representa- tive or consult the package insert. med-b-i-s (lwb)
Jw supplied: Vials, 2 and 4 grams — with ampoule of Bacterio-
Upjohn
The Upjohn Company, Kalamazoo, Michigan 49001
MICHIGAN MEDICINE JANUARY 1972 9
cYour> opiqiori please
MSMS asked the question:
What would you suggest be done to slow down the emigration of medical graduates from Michigan? (The recent MSMS House of Delegates authorized the speaker to appoint an Ad Hoc com- mittee to investigate the reasons why so many Michigan medical school grad- uates go to other states for internships and residencies , and to submit recom- mendations back to the 1972 House to help counteract this movement.)
These doctors replied :
Donald N. Fitch, MD Escanaba
I think the answer obviously touches many fields inasmuch as the reasons a physician picks to settle in a certain area are practically as diverse as the number of doctors themselves. Thus I think we need to look at each level of the problem and see what can be done at that particular level.
First of all, it depends somewhat on where the medical students are taken from, as to where they are most likely to return. Certainly this does not hold true in every instance or maybe not even in most instances, but it is a fact that many students do return to a similar environment from which they came. Consequently, we need to be sure we are getting enough students from the rural areas and from the minority and ghetto areas.
As far as attracting students to particular prac- tice areas, I think the senior externship program is probably the best means of accomplishing this. We have had some experience with this, and I am sure the results are going to prove this out within a few years. Although we don’t necessarily expect any or all of the students to come back to this area we feel we have interested them in our type of prac- tice and to some extent in our area. I think much more could be done to encourage the senior stu- dents to take externships outstate where they will be exposed to the various practice situations to which we hope to attract them later. Certainly this is not always as convenient but those who do make the effort, are very pleased with the results. Un- questionably more encouragement could be given by the faculties and counselors in this regard.
The internships and residencies certainly are a major factor in a doctor’s decision on where to practice. Many students prefer to take their training in the area in which they hope to locate.
Doctor Fitch Doctor Stilwill
In this regard, there are several problems. First of all, the internships themselves lately have become of much less importance than the residency pro- gram inasmuch as the full rotating internship is al- most a thing of the past. Consequently many stu- dents are looking very carefully at the particular department in which they hope to specialize and the internship as well is chosen with this in mind. Thus we need to look carefully to see if our de- partments are giving the leadership that the stu- dents are looking for and are presenting as attrac- tive programs to the students. In this regard also, Michigan is far behind in developing family prac- tice residencies as compared with several other states which are very definitely attracting students from our state. I think strong departments in family practice should be organized with some if not most representation in the departments being actual pre- vious practitioners Of that type of medicine. In ad- dition the medical schools themselves need to put more emphasis in that specialty.
A further factor relates to the fact that many of the out-state training programs in regard to intern- ship and residency are probably not nearly as well advertised as they might be. The students barely know that they exist and certainly are not strongly attracted to them unless they have some special knowledge of the situations. In the same light, however, I might state that there are also particular internships, in which a strong effort is made to the student but it is quickly found out once the intern- ship is begun that what was stated and what ac- tually exists are two entirely different things. I think that this can only discourage a doctor from decid- ing to settle in that area and certainly this situa- tion is a very negative factor.
Finally, I think we have to propagandize to coun- teract the mythological attraction of other areas of the country. When it boils right down to it, I think Michigan has more to offer than a lot of these states and yet bepause we aren’t as well adver- tised, the grass always seems much greener there.
(Continued on Page 12)
10 MICHIGAN MEDICINE JANUARY 1972
NOW!
PRICE CUT
FOR EVEN GREATER PATIENT ECONOMY..
Vfersaper
WASiUM^ETACILLIN THE AMPCmiN DERIVATIVE
BRISTOL LABORATORIES
BRISTOL Division of Bristol-Myers Company Syracuse, New York 13201
MICHIGAN MEDICINE JANUARY 1972 11
YOUR OPINION PLEASE/Continued
But actually in talking to some of the emigrants to these areas I don’t think they’re really that satis- fied with their choice. If we could retain their in- terest in Michigan before they go away, I think we would have a much greater chance of keeping these doctors.
A big factor, especially nowadays, is that a doc- tor’s wife is probably one of the major deter- minants in where they settle and how happy they are going to be there. I think we have to pay a particular attention to this aspect and see what can be done to keep these girls content as well as attracting them to certain areas in our state.
In summary then, I think there are many avenues we might attack in improving the situation and from the above comments I think there are definite areas in which the Michigan State Medical Society could actively participate to improve situations which would help this problem area.
George E. Stilwill, MD Lansing
I have thought about this a lot, both before and after the meeting of the House of Delegates. I wish I had the answers. I sincerely believe that I don’t have the answers, and most likely nobody who has been in practice more than five years has, either.
I think we’re going to have to go to those in- volved.
I think the Speaker’s Committee should survey the graduates of the last five years at Wayne State University and at the University of Michigan and ask them their opinions and specifically, their rea- sons for staying in Michigan or leaving the state.
I know residents go where the desirable resi- dencies are available, and most frequently when they know the area, they generally stay fairly close to where they took their residency. I cannot, how- ever, back any of this with any facts. It would seem to me that would be the major job of the Speaker’s Committee — to gather facts, gather opin- ions of those who have been graduates and resi- dents and have started practices in the last five years.
I personally am looking forward to the results of the deliberations of the Speaker’s Committee on immigration of medical students.
(Doctor Stilwill was the sponsor of the resolution to appoint an investigative ad hoc committee, ap- proved by the MSMS House.)
Doctor Swisher
Scott N. Swisher, MD East Lansing
Physicians are virtually unanimous in believing that successful therapy hinges on a correct diag- nosis. We, and the people of Michigan whom we serve, must be equally careful to insist first on an accurate diagnosis of the causes of the loss of young physicians from Michigan before we try to deal with the problem. I, for one, would be more impressed by factual data bearing upon the prob- lem than by opinions about the situation, including my own opinion!
Recognizing that efforts have been made and may well be expanded to gather these necessary facts, one might still consider an hypothesis. I have been impressed with the number of young people who, after 10 to 12 years of education in one geographic area, are looking for a change of location for the sake of change. With already ex- tensive family commitments, many of these physi- cians will make only one geographic move, com- monly in search of a climate they at least think will be more agreeable. They never return. Would it not be wise to structure our undergraduate ed- ucation, medical school experience and residency training deliberately to encourage some movement of students between geographic areas of the coun- try with both rural and urban experiences? The fact is that Michigan is an excellent place to live and to practice medicine. If this can become known by both our own students after they have seen other areas and by other students who have had an opportunity to see this State, we may find ourselves in the position of receiving as many graduates as we lose.
The modernization of our licensure laws is an im- portant step in promoting this exchange. Since the residency years seem to be crucial in determining a physician’s location for practice, we should also look to ways to strengthen these programs and to extend their influence throughout the State.
12 MICHIGAN MEDICINE JANUARY 1972
r
v.
The Michigan Heart Association
1972 Heart Days and Scientific Sessions
April 13, 14 & 15, 1972 • Cobo Hall, Detroit
r
Friday, April 14
ATHEROSCLEROSIS AND ITS COMPLICATIONS
ATHEROSCLEROTIC CORONARY DISEASES AND SUDDEN DEATH
Wilson-Meyers Memorial Lecture
Charles K. Friedberg, M.D., Editor of “Circulation,” author of the definitive text on CVD, Mt. Sinai School of Medi- cine, New York.
ATHEROSCLEROSIS — LONGITUDINAL OBSERVATIONS FROM FRAMINGHAM
William B. Kannel, M.D., Medical Director, Framingham Heart Disease and Epidemiology Study, N.H.L.I., Fram- ingham, Mass.
ATHEROSCLEROSIS: WHY AND HOW —
A PATHOLOGIST’S VIEW
Gardner C. McMillan, M.D., Ph.D., Chief, Atherosclerotic Disease Branch, N.H.L.I., N.I.H., Bethesda, Md.
ATHEROSCLEROSIS AND HYPERTENSION Ray W. Gifford, Jr., M.D., Head, Dept, of Hypertension and Nephrology, Cleveland Clinic.
DIETARY TREATMENT OF HYPERLIPIDEMIA & ATHEROSCLEROSIS William E. Connor, M.D., Director, Clinical Research Cen- ter, University of Iowa College of Medicine.
PANEL - PRIMARY AND SECONDARY PREVENTION OF ATHEROSCLEROSIS
Saturday, April 15
CORONARY ARTERY DISEASE
THE SURGEON'S ROLE IN THE TREATMENT OF CORONARY ARTERY DISEASE
Norman E. Shumway, M.D., Ph.D., Chief, Cardiovascular Surgery Division, Stanford U. School of Medicine.
A RADIOLOGIST LOOKS AT CORONARY ARTERY DISEASE Herbert L. Abrams, M.D., Chairman, Department of Radi- ology, Harvard Medical School.
THE ENIGMA OF ANGINA IN PATIENTS WITH NORMAL CORONARY ARTERIOGRAMS Bernard L. Segal, M.D., Director, Post-Graduate Educa- tion, Division of Cardiology, Hahnemann Medical Col- lege, Philadelphia.
PANEL -CORONARY ARTERIOGRAPHY - WHY, WHEN AND FOR WHOM?
Thursday, April 13
STROKE - MOBILIZING THE COMMUNITY FOR THE VICTIM
DIMENSIONS OF STROKE IN THE COMMUNITY Charles Wylie, M.D., Ph.D., Professor of Public Health Administration, School of Public Health, U. of M.
DEVELOPMENT OF STROKE ACUTE CARE UNITS John Gilroy, M.D., Director, Department of Neurology, Wayne State University School of Medicine.
V.
PANEL - PLANNING FOR THE DISCHARGE OF THE PATIENT
Four Concurrent Afternoon Workshops
vj Cardiovascular Nursing Sessions, all day Friday, April ^For technicians and nurses, a day long ECG Seminar, 14, will feature a faculty from Sinai Hospital of Detroit; Thursday, April 13.
keynote speaker will be Adrian Kantrowitz, M.D., Director K For those interested in emergency techniques, a CPR of Surgery. session Thursday afternoon.
AAGP credit hours have been applied for Headquarters hotel is the Pontchartrain; make reservations early.
Gerald M. Breneman, M.D., President, MHA Donald C. Overy, M.D., Chairman, Heart Days; President-Elect, MHA Irwin J. Schatz, M.D., Chairman, Scientific Sessions Abraham Brickner, A.C.S.W., Executive Director, MHA
Affiliate: American Heart Association Member: Michigan United Fund
For information, contact HEART DAYS, 1972,
P.O. BOX LV-160 SOUTHFIELD, MICHIGAN 48076
MICHIGAN MEDICINE JANUARY 1972 13
Nowina i 200 -ml. I
breakable
Plastic
Bottle
Same price as 150-ml. size*
®
■
phenoxymethyl
penicillin
Additional information available to the profession on request.
Eli Lilly arid Company Indianapolis, Indiana 46206
*Based on Lilly selling price to wholesalers.
14 MICHIGAN MEDICINE JANUARY 1972
Scientific papers
, ^.,^^-.^.^3
Hypovolemic
shock
By William R. Olsen, MD Ann Arbor
Although shock from low blood volume is a common disease familiar to most physicians, recent technological advances have allowed us to study shock more thoroughly and to understand it bet- ter. Hopefully, this increased understanding of the pathophysiology and treatment will be reflected in an increased survival of hypovolemic patients.
Although shock may be caused by a variety of conditions, the resultant circulatory derangements are similar. By definition, the common denom- inator is inadequate blood flow in the peripheral capillary bed.1-4 For one reason or another, capil- lary perfusion is not sufficient to maintain normal cellular function. If shock persists cells will die and, with sufficient cellular death, the shock be- comes irreversible, i.e., there are not enough viable cells to sustain life of the individual. Hypotension, per se, is not shock. Shock can exist with normal or elevated blood pressure, especially if the pa- tient is receiving vasopressors, and in some cir- cumstances capillary perfusion may be quite ade- quate despite a low arterial blood pressure.
Causes of Hypovolemia
The more common causes of hypovolemia need no elaboration. External hemorrhage from wounds, gastrointestinal hemorrhage, hemoperitoneum from lacerations of the spleen, etc. are usually apparent to the clinician. Bleeding into injured soft tissue following blunt trauma or retroperitoneal hemor- rhage from a ruptured aortic aneurysm may be less obvious but severe. In some instances, the clin- ical signs of hypovolemia may be the first indica- tion of hemorrhage and are the tip-off to search for the source.
External fluid losses from granulating wounds, diarrhea, etc., although usually obvious may be underestimated unless specifically measured.
Doctor Olsen is associate professor of surgery, Section of General Surgery, The University of Michigan, Ann Arbor.
Tissues injured by infection, bums, or blunt trauma become edematous over a period of hours after the injury. The resultant depletion of plasma volume may be sufficient to cause shock and death. Acute ileofemoral thrombophlebitis may cause massive edema with extravasation of many liters of fluid from the circulating blood volume and the interstitial fluid space in other parts of the body. The initial management of patients with acute bowel obstruction usually requires liberal fluid administration to replace the fluid trapped in the distended bowel and not available for tissue perfusion. This fluid reaccumulates very rapidly after operative evacuation with a resultant in- creased intravenous fluid need in the early post- operative period. A similar rapid reaccumulation of ascitic fluid after paracentesis may cause signif- icant hypovolemia and shock, necessitating IV fluid replacement.
It is important to emphasize that head injuries do not produce shock except terminally. Although many patients with severe head injuries are in shock, the shock is almost always from loss of cir- culating blood volume from hemorrhage else- where.5 Frequently, the signs and symptoms of the injury causing the hemorrhage may be ob- scured by the unconsciousness caused by the head injury. Beware of the patient with a head injury and shock— he is bleeding somewhere.
Pathophysiology of Hypovolemic Shock
Since a deficiency of nutritive capillary blood flow is accepted as the defect in hypovolemic shock, the physician must understand the micro- circulatory flow changes produced by hemorrhage and the ability of therapeutic modalities to cor- rect flow deficits if he is to evaluate methods of treatment.
Hemorrhage is followed by a variety of com- pensatory mechanisms, some more vestigial than useful. As blood volume is reduced, venous return to the heart is reduced with an associated de- crease in ventricular diastolic filling and a de- creased cardiac output. Baroreceptors in the aortic arch, carotid sinus and perhaps elsewhere, respond and trigger the release of epinephrine from the adrenal gland and norepinephrine from the sym- pathetic postganglionic nerve endings. These catecholamines stimulate adrenergic receptors throughout the body resulting in constriction of arterioles and veins (alpha adrenergic response) and tachycardia (beta adrenergic response) . The alpha adrenergic receptors of the venous system are probably more sensitive to minimal catechola- mine stimulation than those of arterioles.6 There- fore, early hypovolemia is followed by selective venoconstriction. The venous (capacitance) sys- tem normally contains about 70% of the circulat- ing blood volume but can expand or contract
MICHIGAN MEDICINE JANUARY 1972 15
HYPOVOLEMIC SHOCK/ Continued
rapidly to accommodate larger or smaller volumes without altering the internal pressure appreciably. The arterial (resistance) system cannot change capacity to accommodate volume changes. Arterial volume changes are therefore reflected by changes in arterial blood pressure. The selective veno- constriction which accompanies early hypovolemia causes a shift of blood to the arterial portion of the circulation7 allowing the patient to maintain a fairly normal cardiac output, arterial blood pres- sure and nutritive capillary flow despite the loss of 10 to 20% of the blood volume.
If the hemorrhage is limited or occurs slowly, plasma volume may be expanded or maintained by the inflow and protein from the interstitial space with resultant anemia.8910 If the hemor- rhage is rapid this compensatory mechanism oc- curs too slowly to be of benefit.
As hemorrhage approaches 30 to 40% of the blood volume, the venoconstrictor compensatory mechanism is no longer adequate, the return of blood to the heart is reduced, cardiac output falls, catecholamine release is accentuated, arteriolar con- striction predominates, and capillary flow is dimin- ished. The resultant increase in peripheral resist- ance further diminishes the outflow of the arterial system but is insufficient to allow the maintenance of arterial volume. The arterial blood pressure falls, decreasing the nutritive capillary flow even more. At this point, clinical shock has reached dangerous proportions. If untreated, capillary sludging, thrombosis and cellular death will follow with eventual death of the patient.
Blood vessels in different vascular beds11 and in different parts of the same organ12 react differently to the same degree of hemorrhage. Thus, a blood volume loss sufficient to produce ischemia in one organ may not produce ischemia in another. This may allow selective perfusion of some vital organs, perhaps the central nervous system, in early shock and allow temporary maintenance of life. Other structures, for example the distal renal tubule, become ischemic in early shock and, if sufficiently damaged, may not function well enough to sustain life in the late post-shock period. It is necessary to understand the capillary flow changes produced by hemorrhage on specific tissues to understand the effects of hypovolemia and to be logical in its treatment.
Attempts to study the flow changes in shock have been hindered by the lack of methods of measuring capillary flow. Many investigators have attempted to estimate capillary flow by measuring large vessel flow, usually by operative methods in anesthetized dogs. Dogs are not good animals for the study of clinical shock since they develop splanchnic congestion following hemorrhage, a re- sponse not seen in humans.13 Furthermore, meth- ods which measure large vessel flow fail to differ-
Blood Volume (%)
Figure 1. Blood pressure response to graded hypovolemia.19 Note the difference between the anesthetized and nonanesthetized state.
entiate nutritive capillary flow from flow through arteriovenous pathways. Frequently these methods have failed to consider the significant hemo- dynamic variables introduced by anesthesia,14-20 operative manipulation17*18-20'21 and the frequently resultant mild hypothermia14-22 and hypovolemia, making their validity questionable. Radioactive methods can determine nutritive capillary flow without the variables introduced by anesthesia or operative manipulation.12-19-23-26 Although much work remains to be done in this field, correlation of the results of studies measuring capillary flow in animals with clinical studies27-28 allows us to for- mulate opinions regarding human responses to hemorrhage.
Figure 1 illustrates the blood pressure responses to graded arterial hemorrhage in the anesthetized and nonanesthetized pig,19 an animal which does not develop splanchnic congestion after hemor- rhage. These pressure curves are similar to those seen in humans after hemorrhage. When corre- lated with data regarding capillary perfusion fol- lowing hemorrhage,12-19 several generalizations can be made.
A mild (10 to 20%) hemorrhage produces little change in aortic blood pressure and no significant change in capillary flow to tissues other than the stomach. The venous, cardiac and arteriolar com- pensatory mechanisms seem to be sufficient to maintain a fairly normal microcirculation.
The protective compensatory mechanisms are no longer adequate after a 40% hemorrhage. The arterial blood pressure falls, peripheral vasocon- striction is accentuated and significant decreases occur in capillary blood flow to the renal cortex, stomach, skin, and skeletal muscles. Interestingly,
16 MICHIGAN MEDICINE JANUARY 1972
adrenal blood flow is increased after hemorrhage. The difference in the degree of ischemia of various tissues is thought to represent local differences in reactivity to the adrenergic stimulation of hemor- rhage, with varying degrees of local arteriolar con- striction.
It is of particular interest that, while studies on anesthetized animals have shown the detri- mental effect of hypotension on coronary artery flow,16'19'29-32 this does not occur in the non- anesthetized state.12
The effect of hemorrhage on the anesthetized animal and human is considerably different than that observed in the nonanesthetized state. Anes- thesia has a profound effect on the local distribu- tion of nutritive capillary blood flow after hemor- rhage.19 A 20% hemorrhage under anesthesia will cause hypotension and ischemia of the stomach, skin and skeletal muscle in the presence of sodium pentobarbital. A 40% hemorrhage in the presence of anesthesia will cause a decrease in capillary flow to the myocardium, stomach, small intestine and skin. As in the nonanesthetized state, an in- crease in adrenal blood flow is observed. In the anesthetized state, the arterial blood pressure falls as low after a 20% hemorrhage as it does after a 40% hemorrhage in the nonanesthetized state and becomes a more sensitive indicator of the amount of hypovolemia.
The differences in responses of the anesthetized and nonanesthetized state are emphasized for two reasons. First, to caution the clinician against un- due reliance upon experimental data derived from anesthetized animals, usually dogs, when evaluat- ing and treating shock in nonanesthetized humans. Second, to emphasize the dangers of anesthetizing a patient in hypovolemic shock. Although a pa- tient may be deceptively well compensated and have a reasonable arterial blood pressure following a 20% hemorrhage, anesthesia will convert him to a poorly compensated state, interfering with local capillary blood flow and causing the arterial blood pressure to drop to an unacceptable level. Since this mechanism may be responsible for some of the cardiac arrests that are seen, with the institu- tion of general anesthesia in hypovolemic patients, it is important, when feasible, to assure that the blood volume has been restored preoperatively.
The compensatory mechanisms and local capil- lary flow changes of cardiogenic shock are similar to those of shock from hypovolemia. A deficiency of nutritive capillary flow is the basic pathophysi- ologic defect in both types of shock. A low arterial blood pressure results from a decrease in cardiac output due to deficient ventricular contractile force. A compensatory adrenergic response, clin- ically indistinguishable from that of hypovolemia, occurs with an increase in peripheral vascular tone and a further decrease in capillary flow. Whereas
the patient with hypovolemic shock usually has a decreased central venous pressure, the patient with cardiogenic shock cannot propel his adequate blood volume through the heart, resulting in an overloading of the capacitance vessels and increase in the central venous pressure. It is extremely im- portant to differentiate cardiogenic shock from hypovolemic shock or to detect a cardiogenic ele- ment to hypovolemic shock. Whereas rapid fluid administration is essential to the correction of shock in the patient with hypovolemia, it may be the coup-de-grace to the patient with cardiogenic shock.
Recent evidence indicates that acidosis is usually the result rather than the cause of the failing cir- culation in human shock and indicates that clin- ical acidosis is rarely a potentiating factor in shock.33-15
Initial Management of the Patient in Shock
The patient in shock offers a unique clinical challenge. There are few areas in medicine in which prompt and resourceful treatment is more liberally rewarded or where delays and mistakes can lead to such tragedy. Proper care of these pa- tients demands mature judgment, prompt action and a conditioned awareness of priorities of treat- ment.
Physician Attitude. One of the most important factors in survival of the hypovolemic patient is the degree of urgency with which the physician evaluates and treats his shock. A sense of compul- sive urgency or an urgent sense of compulsion is mandatory if one is to treat shock successfully. Patients don't live in shock. The natural course of the disease is that of progressive deterioration and death unless the cause is reversed by adequate treatment. A direct relationship between the dura- tion and severity of shock and survival exists. If treated promptly and adequately, most patients will recover from a 40 - 60% hemorrhage without sequelae. If therapy is delayed, the same patient will die from a lesser hemorrhage, especially if he is aged or has associated problems. Treatment of these patients cannot wait. The cause of the shock and any contributing factors must be rapidly as- sessed and treatment must be initiated and sus- tained until the casual factors are controlled. A physician who is not willing to exercise the degree of dedication necessary to provide this type of care should not assume responsibility for acutely ill patients.
Monitoring. Since shock is a dynamic condition which is either improving or worsening, it is im- portant that the circulatory system be monitored during evaluation and treatment. The cardiac out- put, peripheral vascular tone, capillary flow (tissue perfusion) and blood volume are of special in-
MICHIGAN MEDICINE JANUARY 1972 17
HYPOVOLEMIC SHOCK/Continued
terest. Although numerical values can be derived using elaborate electronic equipment, adequate approximations of these values can be obtained and most patients can be successfully treated using only the equipment available on any nursing sta- tion provided the physician understands the dis- ease.
The best way to follow the severity of shock and to determine the adequacy of treatment is to ex- amine the patient repeatedly. The clinical signs and symptoms of shock appear sequentially and disappear in the reverse order with adequate treat- ment. The first sign of hypovolemia will usually be oliguria. Signs and symptoms of more severe oligemia proceed from poor peripheral venous fill to pallor, tachycardia, diaphoresis, agitation, thirst, hypotension, dyspnea, confusion, cyanosis, coma and death.
A good approximation of the adequacy of the myocardium can be made from the strength of the pulse and the arterial pressure. Although a normal myocardium will not be able to maintain a strong pulse in the presence of severe hypovolemia, a strong pulse and normal blood pressure indicates that the myocardium is functioning adequately, that the cardiac output is sufficient and excludes the diagnosis of cardiogenic shock.
The status of the peripheral vascular tone is best determined by examining the patient’s skin and mucous membranes. Coldness and pallor of the skin indicate vasoconstriction from an alpha adren- ergic sympathetic response. Accompanying signs are piloerection and iris dilatation, also alpha- adrenergic responses and sweating, a cholinergic sympathetic response. Cyanosis indicates more de- ficient perfusion and capillary stasis. The change of color of the ocular conjunctivae may be more noticeable than skin color change, especially in pigmented patients.
The urinary output is a very sensitive indicator of the adequacy of the blood volume and should be followed closely. An indwelling urinary cath- eter should be inserted and the urinary output recorded every 15 minutes. In adults with normal renal function, a urinary output of about 50 ml. per hour is an indication of adequate renal per- fusion and can be assumed to indicate adequate perfusion to other tissues as well. Small deficits in blood volume are followed promptly by oliguria before other clinical signs appear. A urinary out- put of less than 30 ml. per hour is a cause for concern since it may indicate renal ischemia and is usually an indication to alter treatment to im- prove renal perfusion. Vasopressors and diuretics falsely elevate urine output and deprive the physi- cian of this valuable guide to the treatment of hypovolemia.
There are various means of measuring blood
Figure 2. Technique of percutaneous subclavian venapuncture (see text).
volume numerically, usually by the use of radio- isotopes. These methods are cumbersome, expen- sive, time consuming and the determinations are subject to the errors inherent in the use of com- plex equipment and the problems of availability of trained personnel. Since patients being actively treated for shock usually have had significant fluid losses and replacement between the time the blood volume determination is made and the values are available for interpretation, numerical blood vol- ume results usually are obsolete before they can be used and are rarely of clinical value.
Central venous pressure monitoring is a simple and reliable means of determining the adequacy of the blood volume and has been extremely valuable in the management of volume replace- ment in a variety of clinical situations. The re- sults are immediately available and the determina- tion can be repeated frequently. More important- ly, this monitoring device determines that aspect of blood volume which is most important to the physician, i.e., the relationship of the effective cir- culating blood volume to the adequacy of the myocardium. Knowing this relationship allows the clinician to distinguish cardiogenic shock from hypovolemia, and to determine whether or not the patient can tolerate more fluid. We really do not need to know the numerical blood volume. We only need to know if the patient can tolerate more fluid or if more fluid will be apt to put him into congestive failure and pulmonary edema. Central venous pressure monitoring will allow this determination. Radioisotopic blood volume deter- minations will not.
Technique of Central Venous Pressure Monitor- ing. Patients with manifest or imminent shock regardless of the cause should have a catheter placed in an intrathoracic vein and the central venous pressure monitored. We usually accomplish this by percutaneous subclavian venipuncture36-39
18 MICHIGAN MEDICINE JANUARY 1972
although percutaneous internal carotid venipunc- ture seems completely satisfactory.40-41
With the patient recumbent, the skin of the upper chest and base of the neck is carefully pre- pared and draped. The patient is placed in the Trendelenburg position (one of the few uses of this position) to distend the subclavian veins. A finger is placed in the suprasternal notch and a large needle, usually attached to a syringe, is passed horizontally just below the clavicle, aiming for the tip of the finger over the sternum (Figure 2). The direction of the needle is usually perpen- dicular to the long axis of the patient but occa- sionally is aimed slightly more cephalad. When the vein is entered, blood is withdrawn for neces- sary laboratory determinations. A catheter is threaded through the needle into an intrathoracic vein. Peripheral venous pressure is misleading and of no value in determining shock therapy.37 Care must be taken to prevent air embolism during re- moval of the syringe and passage of the catheter. Radiopaque catheters are preferred so the position of the catheter can be determined on subsequent X-rays. If radiopaque catheters are not available the position of the catheter can be checked by filling the catheter with a small amount of radi- opaque contrast material and obtaining a chest X-ray. It is important to position the tip of the catheter in the superior vena cava two to three cms. above the heart. If the catheter rests in the heart, arrhythmias may result or cardiac contrac- tion may cause an erosion of the myocardium by the catheter tip with pericardial tamponade and death.42-44 The catheter is connected to tubing containing an electrolyte solution and attached to a manometer via a three-way stop cock.
Passage of the catheter through peripheral cut- downs or venipunctures is more time consuming and, if the catheter is to remain in place for some time, is associated with a higher rate of sup- purative thrombophlebitis. The cephalic and ex- ternal jugular veins enter the subclavian vein at angles which frequently will not allow passage of the catheter. Therefore, these veins should not be used for central venous catheterization if other veins are available. Because of the excessively high rate of deep thrombophlebitis and its sequelae associated with intravenous infusions in the legs, leg veins are not satisfactory routes for central venous pressure monitoring.
Sepsis is one of the most common complications of indwelling intravenous catheters.45-47 It is essen- tial that these catheters be passed under aseptic conditions and that the skin around the catheter be kept sterile. Frequent skin cleansing, the appli- cation of antibacterial ointment, and frequent sterile dressing changes are important.
Serious complications of subclavian venipunc- ture such as pneumothorax, hemothorax, hydro-
thorax, brachial plexus injury and subclavian ar- tery puncture, although very infrequent, are the result of performing the catheterization improp- erly, usually from introducing the needle with too great a posterior angulation.37-48
Special care should be taken to prevent shearing ofF the intravenous catheter with resultant catheter embolization.49 This usually occurs while attempt- ing to position a catheter inserted through a needle while the needle is still in the vein. The catheter is withdrawn with the needle still in place (a maneuver which should never be done!) and the catheter is transected by the needle point. The incidence of breakage and embolization of cath- eters after their insertion can be reduced by sutur- ing the catheter to the skin or using a catheter with a flange for receiving the intravenous tubing attached as an integral part of the catheter.
The possible complications of central venous catheterization and subclavian venipuncture should not discourage the appropriate use of these valuable techniques. They are listed here to em- phasize the need for caution and proper technique in carrying out this extremely useful diagnostic procedure. There are very few worthwhile means of diagnosis and treatment which do not carry a risk if used improperly. With such forewarning, we believe that any physician can easily and re- peatedly catheterize central veins with few prob- lems.
Consistency in positioning the manometer is of prime importance. A mark should be made with a pen or marking pencil at the midaxillary line and this mark used repeatedly as the zero reference point for determining the venous pressure. The head of the bed is lowered until flat and respira- tors, which cause a flasely high reading, should be momentarily disconnected. The manometer is filled to the top with an electrolyte solution, all bubbles are run out of the system, the stop cock is turned and the fluid allowed to find its level. If the catheter has been inserted recently, the fluid will fluctuate with respirations, assuring that the tip is in an intrathoracic vein. After a few days, a thrombus and fibrin sleeve forms around the cath- eter and may interfere with this fluctuation but does not interfere with the continued use of the catheter for fluid administration or venous pres- sure measurements.
Naturally, the value of the central venous pres- sure monitoring is dependent upon proper inter- pretation of the reading. One must remain aware that the central venous pressure is of value only in indicating whether or not the patient’s heart and pulmonary circulation aie capable of handling the fluid volume already in the vascular system. It will not indicate whether the patient’s blood vol- ume is higher or lower than normal. If the mid- axillary line is used as the zero reference point,
MICHIGAN MEDICINE JANUARY 1972 19
HYPOVOLEMIC SHOCK/Continued
the normovolemic patient will have a central ve- nous pressure of three to eight cms. of water. If the central venous pressure is normal or low, fluid can be administered safely but should be adminis- tered only if other signs indicate the need. One should not use a seemingly low central venous pressure per se as in indication for fluid adminis- tion. If the central venous pressure is high, one of three situations prevails; (1) too much fluid has been administered, (2) the myocardium is failing or (3) there is pulmonary interstitial edema. In any case, the patient will not tolerate more fluid.
Treatment of Shock
Fluid Therapy. In shock from hypovolemia, nor- mal capillary perfusion can be restored most ef- fectively by rapid blood volume expansion. Re- placement fluid should approximate the type and amount of fluid lost. Whole blood loss is best treated by whole blood replacement in equal amounts. Unfortunately, it takes 45-60 minutes to obtain crossmatched whole blood. Since patients frequently will not tolerate such delays without irreparable sequelae, emergency resuscitation must be started with other methods of blood volume expansion.
The shock position (Figure 3) with the trunk and head elevated five degrees and the legs el- evated 30 degrees will allow more rapid return of venous blood from the extremities which, in effect, constitutes an internal transfusion of several hun- dred milliliters. The Trendelenburg position (head down, legs up, hips straight) accomplishes the same thing but impairs cerebral perfusion, in- terferes with respiration and should not be used.
Since position alone, although helpful, is not sufficient to restore normal capillary perfusion, emergency resuscitation areas must be kept stocked with satisfactory blood substitutes for use until whole blood can be obtained. These substitutes must be safe and effective and should be relatively stable, easy to store and inexpensive.
The use of the dextrans as emergency blood substitutes has been the subject of intensive labora- tory and clinical investigation recently summarized by Atik.50 Six percent Dextran 70 (clinical Dex- tran; average molecular weight 70,000) , by virtue of its colloid (oncotic) osmotic effect, is capable of expanding the blood volume for over five hours. Low molecular weight dextran (Dextran 40, Rheo- macrodex) has an average molecular weight of 40,000. It contains more molecules than Dextran 70, thus is more osmotically active. However, the small molecular fractions pass through semiper- meable membranes rapidly and the fluid expand- ing properties are more transient than those of Dextran 70. Dextran 40 has the added advantage of reducing the viscosity of whole blood when it
Figure 3. The shock position speeds venous re- turn from the legs thereby improving cardiac output during the resuscitative period of shock therapy. The Trendelenburg Position accom- plishes the same thing but, because it impairs respiration and cerebral perfusion, should not be used.
is abnormally high, as in clinical shock, which im- proves tissue perfusion.
The dextrans must be used with caution. Severe allergic reactions have occurred. Although they are relatively safe if administered in the recommended dose of 10-15 ml. /Kg body weight, higher concen- trations will interfere with the clotting mechanism and cause abnormal bleeding. This volume restric- tion severely limits the usefulness of the dextrans in hypovolemic shock.
Hydroxyethyl starch seems to possess properties appropriate for an emergency plasma substitute. It remains in the intravascular space longer than the dextrans, interferes less with coagulation, is stable in solution and is eliminated from the body with- out significant tissue storage reactions.51 Although allergic reactions have been reported they are in- frequent.52 Widespread clinical use of this ma- terial as a plasma expander must await more clin- ical experience.
Ringer’s lactate solution is free of the disadvan- tages of the above solutions and is our choice for rapid volume replacement in hypovolemic patients when blood is needed but not available. This solu- tion is readily available, is stable indefinitely, needs no refrigeration, is pyrogen free, causes no allergic reactions, does not interfere with the clot- ting mechanism, is inexpensive and, most impor- tantly, is effective.8-53-55 Rapid infusion will restore circulating blood volume and capillary perfusion
20 MICHIGAN MEDICINE JANUARY 1972
and will decrease the eventual blood require- ment.56 Because Ringer’s lactate contains no pro- tein, there is a potential risk that dilutional hypo- albuminermia will occur after rapid infusion fol- lowed by a rapid exit of the solution from the vascular space with resultant interstitial edema. However, serum albumin is not significantly low- ered following mild hemorrhage and rapidly re- turns to normal after massive hemorrhage treated with protein-free electrolyte solutions.8-57 This indi- cates that albumin enters the vascular space after hemorrhage, thereby maintaining plasma oncotic pressure. Clinical studies have shown that, if care is taken to prevent iatrogenic fluid overload, peri- pheral and pulmonary interstitial edema do not occur when hemorrhage is treated by protein-free electrolyte solutions.8
Since the serum electrolyte concentration is not significantly altered by acute hemorrhage, the fluid used for early resuscitation should have an electro- lyte concentration similar to plasma. Lactated Ringer’s solution meets this criterion.
Some surgeons have been concerned that the hepatic threshold for metabolizing lactate may be overcome by large volume infusions of lactate con- taining solutions, causing lactic acidemia and ren- dering the blood lactate levels useless. Clinical studies now show that this does not occur.53
Because of the logistical delays in obtaining whole blood when patients are admitted in shock from hemorrhage, most of our patients receive 2,000 to 4,000 ml. of Ringer’s lactate before typed specific or cross-matched whole blood is available. This allows us to resuscitate the patient and re- duces the amount of whole blood administered, thereby reducing the risk of transfusion reactions and hepatitis. The resultant post-therapy anemia usually requires no treatment.
Although blood plasma would seem to be an ideal solution for the emergency correction of hypovolemia because of its protein content, the risk of hepatitis and problems of storage preclude its use. Furthermore, patients receiving protein containing solution do not have significantly high- er total protein or albumin levels after treatment than patients receiving electrolyte solutions with- out protein.58
The type of fluid used in the treatment of shock from plasma loss depends upon the previous con- dition of the patient and the relative concentra- tions of serum electrolytes. However, several gen- eralizations can be made. Hypovolemia from re- peated vomiting often causes hypochloremic alka- losis with resultant hypokalemia. Replacement fluids should be high in chloride, e.g., normal sa- line, with added potassium chloride. Most other types of lost or extravasated fluids have an electro- lyte concentration similar to plasma. If so, lactated
Ringer’s solution is usually the replacement fluid of choice. If there are high protein losses such as with granulating wounds, peritonitis, pancreatitis, soft tissue trauma, etc., albumin may be added to the replacement fluid.
If there is a combination of blood and fluid lost as with significant soft tissue injuries after auto- mobile accidents, both Ringer’s lactate and whole blood will be needed. It must be remembered that the fluid sequestered in injured or inflamed tis- sues is released into the venous capillaries as the tissue heals. Several days later this reabsorption of fluid may equal or exceed the patient’s daily fluid requirement and may cause hypervolemia. This reabsorption should be anticipated and fluid ther- apy altered accordingly.
The amount of fluid necessary to restore a nor- mal hemodynamic state equals the loss and usually is impossible to measure accurately. Adequate re- placement can be determined only by the clinical response of the patient.
The first indication that the patient will need fluid therapy may be an appreciation of the se- verity of the patient’s disease. A badly injured pa- tient or a patient with severe peritonitis is going to require fluid. The alert physician will anticipate these requirements and begin fluid therapy promptly, often before the clinical signs of shock appear. The more proficient a physician is in the treatment of shock, the less shock he will see. His patients will endure less hypovolemia for shorter periods of time and will reap the benefit in de- creased morbidity and mortality.
With adequate therapy, the signs and symptoms of shock abate in the reverse order in which they appear. Since most patients will maintain a nor- mal arterial blood pressure with a one liter blood volume deficit, a normal arterial blood pressure cannot be used as the end point of transfusion therapy; such a patient may still be in shock. The hematocrit is rarely of value in the initial treat- ment of shock since the blood loss usually occurs much more rapidly than the body’s ability to re- place the blood volume with extracellular fluid. Other means of judging the adequacy of fluid re- placement are, therefore, necessary.
After estimating the relative proportions of crystaloid and colloid solutions needed, fluid should be administered rapidly while observing the patient, monitoring the urinary output and central venous pressure and auscultating the chest repeatedly until one of three things happens.
1. The signs and symptoms of shock disappear and the urinary output returns to normal. This is the usual and hoped for goal and indicates satisfactory re-establishment of a normal blood volume.
MICHIGAN MEDICINE JANUARY 1972 21
HYPOVOLEMIC SHOCK/Continued
2. The central venous pressure rises to greater than 10 cm. of water indicating imminent fluid overload. If this occurs prior to the dis- appearance of the signs and symptoms of shock, it implies that the shock is at least partially of cardiogenic origin and that fluid replacement must be stopped while efforts are made to improve cardiac output by in- creasing the strength of ventricular contrac- tion. This may require intravenous Isuprel (a potent Beta stimulator which must be ad- ministered cautiously to prevent excessive tachycardia) or intravenous digitalis (espe- cially useful in patients with pre-existing cardiac disease or in patients with a pulse greater than 120 per minute) .
3. Rarely, pulmonary edema occurs, signifying an excessive accumulation of fluid in the pulmonary interstitial space, perhaps, from pulmonary contusions or congestive atelecta- sis but frequently compounded by excessive fluid administration. This usually, but not always, will be accompanied by an increased central venous pressure. A stethoscope is in- dispensable in shock therapy.
Central venous pressure monitoring is most useful in preventing over transfusion during the rapid administration of fluid to patients who will tolerate fluid excesses poorly. As long as the cen- tral venous pressure is not elevated and the chest is clear, fluid can be administered as rapidly as desired without fear of fluid overload. When the central venous pressure rises, the blood volume is approaching the maximum that can be tolerated by the heart and the rate of administration must be decreased. This is the only role of central ve- nous pressure monitoring. The currently popular practices of using a low central venous pressure reading as an indication for fluid therapy or in- sisting upon raising the central venous pressure above normal (indicating borderline congestive failure) before slowing the rate of fluid adminis- tration should be avoided. The central venous pressure monitoring device is not like a fuel gauge; it will not indicate when a patient is a quarter full or three-quarters full! It will only tell the physician when the patient is too full and warn him against further fluid administration.
Vasopressors. Although vasopressors have been used extensively in the treatment of hypovolemic shock, convincing evidence of their clinical efficacy is lacking. Studies of anesthetized animals have shown the detrimental effect of hypotension on coronary artery16-19-29-32 and renal artery30-59-61 flow, and the salutary effects of the artificial eleva- tion of arterial blood pressure by vasopressors in this setting.11-29-31-32-60-62 Our results from the use of metaraminol in the anesthetized pig in hemor- rhagic shock support these findings.24
Unfortunately, some authors have assumed that vasopressors have a similar effect in nonanesthe- tized humans and have advocated vasopressors in the treatment of clinical shock. This assumption fails to consider the variables introduced by anes- thesia, the reports of the detrimental effects of vasopressors,63-70 the role of catecholamines in pre- venting re-expansion of the blood volume after hemorrhage67 and the evidence indicating that plasma catecholamine levels are already elevated in shock. 9-71-72 Our studies indicate that a 40% hemorrhage does not adversely affect myocardial perfusion12 and that therapeutic amounts of me- taraminol after hemorrhage decreases myocardial perfusion and renal capillary blood flow in the nonanesthetized animal.24 We are not aware of any data which demonstrate that vasopressors im- prove capillary perfusion in nonanesthetized hu- mans.
The ischemic insult of acute hypovolemia with profound hypotension frequently has its most se- rious and lasting effects on the central nervous system. Vasopressors may have an important role in maintaining cerebral perfusion following acute, massive hemorrhage in those few moments before blood volume replacement can be begun. Similar- ly, vasopressors may help overcome the loss of peripheral vascular tone which accompanies acute cardiac arrest, thereby shortening the period of profound hypotension. Although logical, these popular hypotheses are not substantiated. We must know the effect of graded hypotension and vaso- pressors on cerebral perfusion before the useful- ness of vasopressors in profound hypotension is accepted. In practice, we do not use vasopressors except in the first few minutes after cardiac arrest and in the anesthetized patient in profound hypo- volemic shock before blood volume can be re- placed.
Alkalinizing and Buffering Solutions. The cel- lular anoxia of hypovolemic shock invariably in- terferes with aerobic metabolism and causes some degree of metabolic acidosis. The fear that this acidosis will interfere with cardiovascular function and, therefore, needs specific treatment seems to be unjustified. Collins and co-workers have sum- marized the published data on the role of acidosis in shock and have confirmed it in their clinical studies.34 Most patients whose hypovolemic shock responds to fluid therapy will rapidly reverse the metabolic acidosis without specific therapy and re- gardless of the magnitude of the acidosis. Further- more, most patients will have no difficulty from the infused acid load of stored blood.
Patients who demonstrate persistent metabolic acidosis and lactic acidemia after treatment usual- ly have continued hemorrhage and shock or have such extensive ischemic damage that survival is unlikely. Administration of alkali to such patients
22 MICHIGAN MEDICINE JANUARY 1972
is usually without effect even when the acidosis is reversed.
Metabolic defenses against acidosis are less effi- cient during hypothermia, in the newborn and in patients with impaired liver function or with pre- existing myocardial disease. The normal defense mechanisms may be overwhelmed by sustained transfusion therapy exceeding one unit of banked blood every four to six minutes. Under any cir- cumstances, however, it is unlikely that clinical acidosis significantly affects cardiovascular function or that patients responding favorably to transfu- sion therapy will require pharmacologic manipula- tion of their acid-base balance.33-35 Routine admin- istration of alkalinizing solutions during rapid or sustained blood transfusions may cause hypocal- cemia, ventilatory depression, increased urinary potassium losses and decreased oxygen transport.34 If alkalinizing or buffering solutions are consid- ered in patients who are not responding well to transfusion therapy, their use should be based on objective measurements of the acid-base status and should be accompanied by the cautious adminis- tration of calcium.
Operative Therapy. Occasionally, it becomes evi- dent that the patient is losing blood as rapidly as it is being administered and that re-establishment of normal circulatory dynamics by rapid fluid ad- ministration is not going to be successful. If so, immediate operation is necessary to obtain hemo- stasis. Once the bleeding organ is exposed, hemo- stasis should be accomplished as expeditiously as possible, usually by simple suture or tamponade until the blood volume can be restored and de- finitive surgical correction carried out with the patient normovolemic.
Summary
Most patients with hypovolemic shock are best treated by adequate fluid replacement. The patho- physiology of shock is discussed. Methods of bed- side patient monitoring to determine the adequacy of fluid replacement are emphasized.
References
1. Baue, A. E.: Recent Developments in the Study and Treatment of Shock: Collective Review, Surg. Gynec. Obstet. 127:849-878 (Oct) 1968.
2. Clauss, R.H., and Ray, J. F.: Pharmacologic Assist- ance to the Failing Circulation: Collective Review, Surg. Gynec. Obstet. 126:611-631 (March) 1968.
3. Hamit, H. F.: Current Trends of Therapy and Re- search in Shock: Collective Review, Surg. Gynec. Obstet. 120:835-854 (April) 1965.
4. Mills, L.C., and Moyer, J.H.: “Shock and Hypo- tension: Pathogenesis and Treatment,” The
Twelfth Hahnemann Symposium, New York: Grune & Stratton, 1965.
5. Wilson, C.B., Vidrine, A., and Rives, J.D.: Un- recognized Abdominal Trauma in Patients with Head Injuries, Ann. Surg. 161:608-613, 1965.
6. Mellander, S.: Comparative Studies on the Adren- ergic Neurohormonal Control of Resistance and Capacitance Blood Vessels in the Cat, Acta Physiol. Scand. 50 (suppl 176): 1-85, 1960.
7. Dow, R.W., and Fry, W.J.: Venous Compensatory Mechanisms in Acute Hypovolemia, Surg. Gynec. Obstet. 125:511-515 (Sept) 1967.
8. Cloutier, C.T., Lowery, B.D., and Carey, L.C.: The Effect of Hemodilutional Resuscitation on Serum Protein Levels in Humans in Hemorrhagic Shock, J. Trauma 9:514-521 (June) 1969.
9. Moore, F.D.: Annual Discourse: The Effects of Hemorrhage on Body Composition, New Eng. J. Med. 273:567-677 (Sept 9) 1965.
10. Skillman, J.J., Awwad, H.K., and Moore, F.D.: Plasma Protein Kinetics in the Early Transcapillary Refill after Hemorrhage in Man, Surg. Gynec. Obstet. 125:983-996 (Nov) 1967.
11. Catchpole, B.N., Hackel, D.B., and Simeone, F.A.: Coronary and Peripheral Blood Flow in Experi- mental Hemorrhagic Hypotension Treated With L-Nor-Epinephrine, Ann. Surg. 142:372-381 (Sept) 1955.
12. Simon, M.A., and Olsen, W.R.: Capillary Flow in Hemorrhagic Shock. I: Hemorrhage in the Non- anesthetized Pig, Arch. Surg. 99:631-633 (Nov) 1969.
13. Cohn, H.E., and Ballinger, W.F.: “Research Meth- ods in Surgery” Ballinger, W.F., ed: Boston, Massa- chusetts: Little Brown 8c Company, 1964, pg. 202.
14. Beconsfield, P., and Messent, D.: Blood Flow After General Anesthesia in Sympathectomized Limbs, Anesthesiology 16:428-433 (May) 1955.
15. Greisheimer, E.M.: “The Circulatory Effects of Anesdiesia,” Handbook of Physiology, Washington, D.C.: American Physiologic Society, 1965, vol 3, sec 2, pp 2477-2510.
16. Hackle, D.B., and Goodale, W.T.; Effects of Hem- orrhagic Shock on the Heart and Circulation of Intact Dogs, Circulation 11:628-634 (April) 1955.
17. Heilbrunn, A., and Allbritten, F.F.: Cardiac Out- put During and Following Surgical Operations, Ann. Surg. 152:197-210 (Aug) 1960.
18. Nash, C.B., Davis, F., Woodbury, R.A.: Cardio- vascular Effects of Anesthetic Doses of Pentobarbi- tal Sodium, Amer. J. Physiol. 185:107-112 (April) 1965.
19. Olsen, W.R., and Simon, M.A.: Capillary Flow in Hemorrhagic Shock. II: Hemorrhage in the Anes- thetized Pig, Arch. Surg. 99:634-636 (Nov) 1969.
20. Price, H.L.: General Anesthesia and Circulatory Homeostasis Physiol. Rev. 40:187-218 (April) 1960.
21. Barclay, A.E., and Bentley, F.H.: The Vasculariza- tion of the Human Stomach: A Preliminary Note on the Shunting Effect of Trauma, Gastroenterol- ogy 12:177-183 (Feb) 1949.
22. Suzuki, M., and Penn, I.: A Reappraisal of the Microcirculation During General Hypothermia, Surgery 58:1049-1060 (Dec) 1965.
23. Olsen, W.R.: A New Research Technique to De-
MICHIGAN MEDICINE JANUARY 1972 23
HYPOVOLEMIC SHOCK/Continued
termine Changes in Blood Capillary Flow, Arch. Surg. 99:637-640 (Nov) 1969.
24. Olsen, W.R.: Capillary Flow in Hemorrhagic
Shock. Ill: Metaraminol and Capillary Flow in the Nonanesthetized and Anesthetized Pig, Arch. Surg. 99:637-640 (Nov) 1969.
25. Sapirstein, L.A.: Fractionation of the Cardiac Out- put of Rats With Isotopic Potassium, Circ. Res. 4:689-692 (Nov) 1956.
26. Sapirstein, L.A.: Regional Blood Flow by Fraction Distribution of Indicators, Amer. J. Physiol. 193: 161-168 (April) 1958.
27. Beecher, H.K., et al: The Internal State of the Severely Wounded Man on Entry to the Most For- ward Hospital, Surgery 22:672-711 (Oct) 1947.
28. Shenkin, H.A., et al: On the Diagnosis of Hem- orrhage in Man: A Study of Volunteers Bled Large Amounts, Amer. J. Med. Sci. 208: 421-436 (Oct) 1944.
29. Corday, E., et al: Effect of Systemic Blood Pressure and Vasopressor Drugs on Coronary Blood Flow and the Electrocardiogram, Amer. J. Cardiol. 3:626- 637 (May) 1959.
30. Sapirstein, L.A., Sapirstein, E.H., and Bredemeyer, A.: Effect of Hemorrhage on the Cardiac Output and its Distribution in the Rat, Circ. Res. 8: 135- MS (Jan) 1960.
31. Sarnoff, S. J., et al: Insufficient Coronary Flow and Myocardial Failure as a Complicating Factor in Late Hemorrhagic Shock, Amer. J. Physiol. 176: 439-444 (March) 1954.
32. Vowles, K.D.J., Couves, C.M., and Howard, J.M.: Coronary and Peripheral Blood Flow Following Hemorrhagic Shock, Transfusion, and Norepine- phrine, Circulation 16:946 (Oct) 1957.
33. Clowes, G.H.A., et al: Effects of Acidosis on Car- diovascular Function in Surgical Patients, Ann. Surg., 154:524-555 (Oct) 1961.
34. Collins, J.A., et al: Acid-Base Status of Seriously
Wounded Combat Casualties: II: Resuscitation
with Stored Blood, Ann. Surg. 173:6-18 (Jan) 1971.
35. Feins, N.R., and DelGuercio, L.R.M.: Increased Cardiovascular Function in Clinical Metabolic Aci- dosis, Surg. Forum 17:39-40, 1966.
36. Dudrick, S.J., Wilmore, D.W., Vars, H.M., and Rhodes, J.E.: Can Intravenous Feeding as the Sole Means of Nutrition Support Growth in A Child and Return Weight Loss in an Adult? An Affirma- tive Answer, Ann. Surg. 169:974-984 (June) 1969.
37. Longerbeam, J.K., Vannix, R., Wagner, W., and Joergenson, E.: Central Venous Pressure Monitor- ing: A Useful Guide to Fluid Therapy During Shock and other Forms of Cardiovascular Stress, Amer. J. Surg. 110:220-230 (Aug) 1965.
38. Mogil, R.A., Delaurentis, D.A., and Rosemond, G.P.: The Infraclavicular Venipuncture: Value in Various Clinical Situations Including Central Ve- nous Pressure Monitoring, Arch. Surg. 95:320-324 (Aug) 1967.
39. Wilson, J.N., Grow, J.B., Demong, C.V., Prevedel, A.E., and Owens, J.C.: Central Venous Pressure in Optimal Blood Volume Maintenance, Arch. Sugr. 85:563-578 (Oct) 1962.
40. Daily, P.O., Griepp, R.B., and Shumwhy, N.E.: Percutaneous Internal Jugular Vein Cannulation, Arch. Surg. 101:534-536 (Oct) 1970.
41. Mostert, J.W., Kenny, G.M., and Murphy, G.P.: Safe Placement of Central Venous Catheter Into Internal Tugular Veins, Arch. Surg. 101:431-432 (Sept) 1970.
42. Geis, P.W., et al: Extrapericardial (Mediastinal) Cardiac Tamponade, Arch. Surg. 100:305-306 (March) 1970.
43. Lawton, R.L., Rossi, N.P., and Funk, D.C.: Intra- cardiac Perforation, Arch. Surg. 98:213-216 (Feb)
1969.
44. Thomas, C.S., Carter, J.W., and Lowder, S.C.: Pericardial Tamponade from Central Venous Cath- eters, Arch. Surg. 98:217-218 (Feb) 1969.
45. Collins, R.N., et al: Risk of Local and Systemic Infection with Polyethylene Intravenous Catheters. A Prospective Study of 213 Catheterizations, New Eng. J. Med. 279:340-343 (Aug 15) 1968.
46. Glover, J.L., O’Byrne, S.A., and Jolly, L.: Infusion Catheter Sepsis: An Increasing Threat, Ann. Surg. 173:148-151 (Jan) 1971.
47. Smit, H., and Freedman, L.R.: Prolonged Venous Catheterization as a Cause of Sepsis, New Eng. J. Med. 276:1229-1233 (June 1) 1967.
48. Smith, B.E., et al: Complications of Subclavian Vein Catheterization, Arch. Surg. 90:228-229 (Feb)
1965.
49. Doering, R. B., Stemmer, E.A., and Connolly, J.E.: Complications of Indwelling Venous Catheters with Particular Reference to Catheter Embolus, Amer. J. Surg. 114:259-266 (Aug) 1967.
50. Atik, M.: Dextran 40 and Dextran 70: A Review, Arch. Surg. 94:664-672 (May) 1967.
51. Thompson, W.L., et al: Intravascular Persistence, Tissue Storage, and Excretion of Hydroxyethyl Starch, Surg. Gynec. Obstet. 131:985-972 (Nov)
1970.
52. Metcalf, W., et al: A Clinical Physiologic Study of Hydroxyethyl Starch, Surg. Gynec. Obstet. 131:255- 267 (Aug) 1970.
53. Carey, L.C., Lowery, B.D., and Cloutier, C.T.: Hemorrhagic Shock, Curr. Probl. Surg., pp. 31-33 (Jan) 1971.
54. Dillon, J., et al: The Bioassay of Treatment of Hemorrhagic Shock, Arch. Surg. 93:537-555 (Oct)
1966.
55. Dillon, J., et al: The Treatment of Hemorrhagic Shock, Surg. Gynec. Obstet. 122:967-978 (May) 1966.
56. Rush, B.F., et al: Limitation of Blood Replacement with Electrolyte Solutions. A Controlled Clinical Study, Arch. Surg. 98:49-52 (Jan) 1969.
57. Moore, F.D., et al: Hemorrhage in Normal Man: I. Distribution and Dispersal of Saline Infusion Following Acute Blood Loss: Clinical Kinetics of Blood Volume Support, Ann. Surg. 163:485-504 (April) 1966.
58. Carey, L.C., Lowery, D.B., and Cloutier, C.T.: Hemorrhagic Shock, Curr. Probl. Surg., pp. 36-37 (Jan) 1971.
59. Dow, R., and Fry, W.J.: Hemorrhagic Shock;
24 MICHIGAN MEDICINE JANUARY 1972
a
MICHIGAN DEPARTMENT OF PUBLIC HEALTH
Monthly Surveillance Report
Cases of Certain Diseases Reported To the Michigan Department of Public Health
For the Four-Week Period Ending November 26, 1971
1971
1970
1971
1970
Total
This
Same
Total
Total
Cases
4-Week
4-Week
To Above
Same
for
Period
Period
Date
Date
1970
Rubella
85
104
2,854
2,883
3,012
Congenital Rubella Syndrome
0
0
1
0
2
Measles
96
34
2,523
1,798
1,834
Whooping Cough
9
7
132
187
195
Diphtheria
—
—
—
—
—
Mumps
Scarlet Fever &
375
937
10,124
6,394
7,825
Strep Sore Throat
826
958
9,941
10,265
11,863
Tetanus
1
2
3
8
8
Poliomyelitis (paralytic)
0
0
0
1
2
Hepatitis
Salmonellosis
381
331
4,388
4,153
4,594
(other than S. typhi)
64
51
634
596
665
Typhoid Fever (S. typhi)
0
0
7
12
14
Shigellosis
32
20
229
194
225
Aseptic Meningitis
17
21
208
284
296
Encephalitis
7
8
100
142
155
Meningococcic Meningitis
2
4
59
65
69
H. Influenza Meningitis
8
12
75
51
61
Tuberculosis
136
143
1,706
1,786
2,006
Syphilis
459
309
4,134
3,458
3,900
Gonorrhea
2,035
1,397
19,949
18,506
20,676
Information can be supplied by the local health department on the local incidence of disease.
Maurice Reizen, M.D., Director Michigan Department of Public Health
Changes in Renal Blood Flow and Vascular Re- sistance, Arch. Surg. 94:190-194 (Feb) 1967.
60. Mills, L.C., and Moyer, J.H.: The Effects of Var- ious Catecholamines on Specific Vascular Hemo- dynamics in Hypotensive and Normotensive Sub- jects, Amer. J. Cardiol. 5:652-659 (May) 1960.
61. Mills, L.C., Moyer, J.H., and Handley, C.A.: Ef- fects of Various Sympathicomimetic Drugs on Ren- al Hemodynamics in Normotensive and Hypoten- sive Dogs, Amer. J. Physiol. 198:1279-1283 (June) 1960.
62. West, J.W., Guzman, S.V., and Bellet, S.: Com- parative Cardiac Effects of Various Sympathomim- etic Amines, Circulation 16:950 (Nov) 1957.
63. Close, A S., et al: The Effect of Norepinephrine on Survival in Experimental Acute Hemorrhagic Hypotension, Surg. Forum 8:22-26 (Oct) 1957.
64. Drucker, W.R., Kingsbury, B., and Graham, L.: Metabolic Effect of Vasopressors in Hemorrhagic Shock, Surg. Forum 13:16-18 (Oct) 1962.
65. Finnerty, F.A., Jr., Buchholz, J.H., and Guillaudeu, R.L.: The Blood Volumes and Plasma Protein During Levarterenol-Induced Hypertension, /. Clin. Invest. 37:425-429 (March) 1958.
66. Jackson, A.J., and Webb, W.R.: Effects of Nor- epinephrine of Differential Blood Flow in Graded Hemorrhage, Surg. Forum 13:14-15 (Oct) 1962.
67. Lister, J., et al: Transcapillary Refilling after Hemorrhage in Normal Man: Basal Rates and Volumes; Effect of Norepinephrine, Ann. Surg. 158:698-712 (Oct) 1963.
68. Longerbeam, J.K., Lillehei, R.C., and Scott, W.R.: The Nature of Irreversible Shock: A Hemodynamic Study, Surg. Forum 13:1-3 (Oct) 1962.
69. Morris, R.E., Jr., Graff, T.D., and Robinson, P.: Metabolic Effects of Vasopressor Agents, Bull. N.Y. Acad. Med. 42:1007-1022 (Nov) 1966.
70. Schmutzer, K. J., Raschke, E., and Maloney, J.V., Jr.: Intravenous L-Norepinephrine as a Cause of Reduced Plasma Volume, Surgery 50:452-457 (Sept) 1961.
71. Rosenberg, J.C., et al: Studies on Hemorrhagic and Endotoxin Shock in Relation to Vasomotor Changes and Endogenous Circulating Epinephrine, Norepinephrine and Serotonin, Ann. Surg. 154: 611-628 (Oct) 1961.
72. Walker, W.F., et al: Adrenal Medullary Secretion in Hemorrhagic Shock, Amer. J. Physiol. 197:773- 780 (Oct) 1959.
MICHIGAN MEDICINE JANUARY 1972 25
cPeriqatal ^Tips
By Paul M. Zavell, MD Detroit
The following case from the files of the Wayne County Medical Society Perinatal Mortality Com- mittee is presented as an aid in continuing educa- tion.
Maternal
This was the first pregnancy for a 23 year old, white O T mother. Her pregnancy had been un- eventful and she had received regular prenatal care. At term she went into labor and delivered a 5 lb. 8 oz. female infant in eleven hours. The mother had a negative VDRL.
Fetal
At birth this infant was in a depressed state with a cord around the neck. Initial resuscitation
Doctor Zavell is chairman, Neo-Natal and Hos- pital Care Committee, Michigan Chapter, A.A.P.; and chairman, Perinatal Mortality Study Com- mittee, Wayne County Medical Society.
efforts were not successful (though vigorous) so that it was necessary to intubate her and later use a Bennett respirator. The heart rate varied from 100-120 per minute.
When first seen by the pediatric staff (30 min- utes later) the infant was cyanotic and still not breathing spontaneously. Breath sounds were heard poorly on the left side and none were noted on the right. Thinking this might be res- piratory distress, sodium bicarbonate 8cc as a di- rect push followed by 50% glucose water were in- stilled via the umbilical vein. No improvement was noted. A chest film revealed a massive right- sided tension pneumothorax which was immedi- ately relieved by direct needle aspiration so that respirations immediately improved. Shortly there- after a catheter was inserted into the right chest. The infant’s color became excellent and she now breathed normally. The endotracheal tube was re- moved shortly thereafter without difficulty.
On the second day of life she weighed 5 lbs. 4 ozs. and was generally doing well. Only minimal amounts of air were recovered following thorac- otomy drainage so that it was possible to remove the tube successfully 48 hours later. The infant’s course was completely uneventful thereafter and she was discharged home on the fifth day.
Perinatal Committee Comments
1. This case nicely stresses the truth of the statement that not all babies having respiratory distress have the true respiratory distress syndrome. That is, respiratory distress may be due to CNS, cardiac, respiratory, hematologic, or other prob- lems and not due primarily or only to “hyaline membrane disease.”
2. Whenever an infant is having respiratory dis- tress symptoms, a chest X-ray should be done to rule out possibilities other than respiratory distress symptoms (such as a pneumothorax here) .
3. Not all pneumothoracies need treatment but tension pneumothorax does (indeed, treatment is life-saving here) .
26 MICHIGAN MEDICINE JANUARY 1972
SPLENECTOMY
COMPLICA TIONS OF
By Robert D. Allaben, MD William S. Carpenter, MD Paul J. Connolly, MD Angelos A. Kambouris, MD Detroit
The incidence of complications following sple- nectomy has been variably reported from 30% to 90%. The frequency has been related to the indi- cations for the procedure, to coexisting diseases or to specific technical factors. 1-2-3'4^ Although sple- nectomy is a relatively common operation, there are only sporadic reports relative to the associated morbidity and mortality and little information about the reasons for its performance.
In order to evaluate the incidence and type of such complications, the authors reviewed their personal experience with 50 consecutive splenec- tomies performed from 1964 to 1969.
Materials
The records of 50 consecutive patients who un- derwent splenectomy by the authors in three pri- vate hospitals in Detroit were thoroughly analyzed. Emphasis was placed on the type of underlying disease, the intraoperative and postoperative course and the type and seriousness of the com- plications.
There were 30 female and 20 male patients. Their ages varied from eight to 84 years with a median of 53.5 years. Forty-seven patients were Caucasian and three were Negroes. Indications were divided into four categories (Table I).
As a primary procedure, splenectomy was per- formed through a left subcostal incision. Fre- quently a drain was left in the splenic bed and removed between the second and seventh post- operative day. Gastric decompression by nasogas- tric suction was employed selectively; early ambu- lation and bronchopulmonary care were instituted immediately after operation. Frequent platelet counts were obtained and anticoagulation was instituted when platelets exceeded one million/ cu.mm.
The authors are associated with Harper Hos- pital, Mt. Carmel Mercy Hospital and Sinai Hos- pital, all in Detroit.
Table I Indications for Splenectomy
Group
Indication
No.
Pts.
%
1.
Hematologic
22
44%
2.
Incidental to Major Operations
13
26%
3.
Iatrogenic Trauma
11
22%
4.
External Trauma
4
8%
Total
50
100%
Complications were classified as follows:
a. Pulmonary such as atelectasis, pneumonitis, pleural effusion or empyema.
b. Subphrenic abscess and collection at the area of the splenic bed.
c. Miscellaneous including peritonitis, bleeding and thrombotic episodes.
Results
1. Hematologic Disorders:
Twenty-two patients underwent splenectomy for hematologic diseases (Table II). The largest spleens removed weighed 1907 gms. (for lymphoma) and 1930 gms. (for hypersplenism) .
Complete hematologic evaluation and oftentimes prolonged specific treatment, including steroids and immunosuppressive drugs, had preceded op- eration in all instances. Four patients had plate- lets of less than 30,000/cu.mm, and in two the platelet level was below 10,000/cu.mm. Although no platelets were administered preoperatively, none of these patients exhibited abnormal bleed- ing during or following the procedure. Likewise post-splenectomy thrombocytosis of 500,000 to 750,000/cu.mm, developed in eight patients (36%), but no clinical thrombotic episodes were observed. Fifteen patients had been on long-term steroid therapy; appropriate dose adjustment prevented episodes of adrenal insufficiency and all wounds healed primarily. Accessory spleens were found in six patients (27%) . In one instance three acces- sory spleens were removed 30 years following sple- nectomy for acquired hemolytic anemia. The splenic bed was chained in eight patients (36%). No complications related to the drain were en- countered.
As indicated in Table II, atelectasis in two pa- tients and pneumonitis in one were the only com- plications in this group. All but three patients
MICHIGAN MEDICINE JANUARY 1972 27
SPLENECTOMY /Continued
Table II Complications of Splenectomy for Hematologic Disease
No. Complications
Primary Disease
Pts.
A
B
c
Deaths
Idiopathic Thrombocytopenic Purpura
6
0
0
0
0
Hypersplenism
5
2
0
0
0
Felty's Syndrome
4
0
0
0
1
Acquired Hemolytic Anemia
4
0
0
0
1
Leukemia-Lymphoma
2
1
0
0
0
Gaucher's Disease
1
0
0
0
0
Total
22
3(14%)
0
0
2(9%)
A. Bronchopulmonary
B. Subphrenic
C. Miscellaneous
Table III Complications of Splenectomy Incidental to Major Operations
Primary Operations
No.
Pts.
A
Complications
B
C
Esophagogastrectomy
8
6
1
0
Pancreatectomy
3
2
0
1
Colectomy
1
0
0
0
Splenorenal Shunt
1
0
0
0
Deaths
3
1
0
1
Total 13 8(62%)
5(38%)
A.
B.
C.
Bronchopulmonary
Subphrenic
Miscellaneous
(,
I.
were discharged by the fifteenth postoperative day. One patient remained longer because of an eye infection associated with Felty’s syndrome. Two patients died in the hospital from septic processes not related to the splenectomy; one on the forty- ninth postoperative day from sepsis incident to immunosuppression for treatment of hemolytic anemia, the other on the sixty-eighth postoperative day from sepsis secondary to extensive decubitus ulcers associated with Felty’s syndrome.
2. Splenectomy Incidental to Major Operations:
In 13 patients the spleen was removed as a normal part of another definite procedure (Table III). In eight instances the spleen was removed in the course of resective procedures for gastric or esophageal carcinoma. In three it accompanied distal pancreactomy. Subtotal colectomy for carci- noma attached to the splenic capsule and spleno- renal shunt were indications for splenectomy in the remaining two patients. Penrose drains were placed in the left upper quadrant in 1 1 instances. Severe bronchopulmonary complications devel- oped in eight patients (62%) and subphrenic ab- scess due to an anastomotic leak occurred in one instance. Asymptomatic thrombocytosis of 650,000/ cu.mm, was encountered only once. There were five hospital deaths in this group, all related to the extent of the operation and/or the underlying disease; none could be directly attributed to sple- nectomy (Table IV).
3. Iatrogenic Trauma:
Splenectomy was performed in 11 patients for accidental injury in the course of operations in the
upper abdomen (Table V). Five injuries occurred in the course of subtotal or total gastrectomy, three in the course of vagotomy, two while repairing esophageal hiatus hernias and the last during left colectomy for carcinoma. Four patients (36%) in this group developed serious bronchopulmonary complications; three of them expired, while the fourth recovered after closed thoracotomy drainage for tension hydropneumothorax. Subphrenic ab- scess as part of upper abdominal sepsis was en- countered in two patients. A duodenal fistula was considered the source in one, but no obvious source could be found in the other patient. This second patient, a cirrhotic with upper gastrointesti- nal hemorrhage -developed subphrenic abscess which progressed to diffuse peritonitis associated with ascites and died 30 days following vagotomy and hemigastrectomy.
Ileus of short duration was recorded in six of the seven patients who had an uncomplicated re- covery and in three of the four who expired.
Focal pancreatitis of no clinical significance was found at autopsy in two patients (cases 9 and 11). One (case 9) died of acute pulmonary edema four days after attempted vagotomy for bleeding peptic ulcer. The other patient (case 11) died 42 days after total gastrectomy for recurrent hemorrhagic gastritis and after multiple septic and cardiopul- monary complications.
The splenic bed was drained in eight patients in this group. No complications were directly re- lated to the drain. Underlying diseases of serious nature (cases 8,11) and serious technical problems (cases 6,10) accounted for the complications and
I
l*
IB
1
4
(i
til
[«
tii
28 MICHIGAN MEDICINE JANUARY 1972
Table IV Fatal Complications in Group 2
Age/Sex Primary Procedure Fatal/Complication Day of Death Post op.
52, M Proximal Gastrectomy Leak, Empyema 9
84, F Proximal Gastrectomy Myocardial Infarction
Pulmonary edema 6
57, F Esophagogastrectomy
and Colon Interposition Leak, Empyema 12
53, M Splenorenal Shunt Liver failure 15
60, M 95% Pancreatectomy Myocardial Infarction 3
Table V Complications and Deaths in Patients with Accidental Splenic Injury
Age Complications
No.
Sex
1° Disease
Procedure
Incision
Injury
Drain
A
B
C
Outcome
Comments
1.
83, M
Ca. Stomach
Gastrectomy
Midline
Splenic
Tear
+
0
0
Ileus
Recovered
2.
62, F
Gastric Polyps
11
”
It
-
0
0
’’
>f
3.
65, F
Leiomyoma,
Excision,
71
”
+
0
0
11
11
Stomach
Pyloroplasty
4.
69, M
Bleeding
Gastritis
Gastrotomy
Transverse
11
+
0
0
11
5.
66, F
Cholelithiasis
Cholecystectomy
Right
11
+
0
0
0
"
Hiatus hernia
Hernia repair
subcostal
6.
69, F
Recurrent
Hernia repair
Midline
Tear of
+
Hydro-
11
Closed Chest
hiatus hernia
Suture of
esophagus
pneumo-
0
Ileus
Drainage
Esophagus
thorax
7.
72, F
Ca, Left Colon
Left Colectomy
Lt. Para-
Splenic
+
0
0
”
11
Median
Pedicle
Tear
8.
59, F
U.G.I. Bleeding
Vagotomy
Midline
Splenic
—
0 Abscess
Peritonitis
Expired
30th p.o. day
Cirrhosis
Hemigastrectomy
Tear
Ascites
9.
63, M
Bleeding
Attempted
”
11
+
Pneumo-
0
Ileus
”
4th p.o. day
Peptic Ulcer
Vagotomy
nitis
Tail Pancre-
Effusion
atitis at
Pulm. edema
Autopsy
10.
76, M
U.G.I. Bleeding
V+P Suture
1}
Splenic
—
Effusion
0
Ileus
11
16th p.o. day
on ACTH
Esophagus
Esophageal
Tear
A-C block
11.
75, M
Bleeding
Total
11
Splenic
+
Broncho-
0
Duod.
11
42nd p.o. day
Gastritis
Gastrectomy
Tear
pneumonia
Fistula
had V+P
Congestive
Abscess
2 wks. preop.
Failure
Wound
Autopsy:
Dehiscence
Focal
Pancreatitis
probably the fatal outcome. Although no death could be directly attributed to the splenectomy, there is little doubt that the additional procedure prolonged the operating time, increased the opera- tive and postoperative stress, and added to the postoperative morbidity.
4. External Trauma:
Of the four patients in this category (Table VI) two sustained fractures of the left rib cage in auto- mobile accidents; another was injured falling off a a stepladder and the last received a direct blow with a baseball bat. Splenectomy was performed through a left subcostal incision in three, through a midline incision in the other. The splenic bed was drained in three instances and no related com- plications developed. Mild transient ileus was re- corded in all patients. One patient with multiple rib fractures developed a transient left pleural ef- fusion and thrombocytosis of over 1 million/ cu.mm. She was treated with anticoagulants and
discharged the twenty-sixth postoperative day. Asymptomatic thrombocytosis of 610,000/cu.mm, was observed in the other patient with rib fracture but no anticoagulants were used; he was dis- charged on the eighth postoperative day.
Discussion
A. Complications:
Very few complications developed following splenectomy for hematologic diseases. All three pulmonary complications were minor, in spite of pre-existing illness of long standing, of significant hematologic deviations and of prolonged use of steroids. Splenectomy for isolated splenic trauma was also associated with minimal morbidity. The only complication occurred in one patient with fractured ribs and was probably related to the associated injury.
All subphrenic abscesses occurred in instances where the gastrointestinal tract had been entered.
MICHIGAN MEDICINE JANUARY 1972 29
SPLENECTOMY/Continued
Table VI Complications of Splenectomy for External Trauma
Complications Day of
Age/Sex Injury Drai
62, F Auto Accident, +
Rib Fractures
36, M Auto accident +
Rib Fracture
23, M Fall -
12, M Direct Injury +
None of eight patients in group I (hematologic) and of three patients in group IV (trauma) where clean splenectomies were drained, developed wound infection or subphrenic abscess. This tends to refute the contention that drains lead to wound or subphrenic spaced infection.5 We are currently using drains only selectively and remove them by , the fourth postoperative day unless a pancreatic
injury is suspected or recognized, when drainage may be necessary for longer periods. We agree with Daoud, et al.,7 that patients have equal chance for infection whether drains are used or not and that special circumstances dictate the use of drtins.
The high incidence of complications and deaths in group II (incidental) reflects the seriousness and the extent of the primary operations and is not related to the splenectomy. Six of the eight bronchopulmonary complications and three of the four deaths occurred after extensive thoroabdom- inal resective procedures where the spleen was part of the intended surgical specimen. Only one of 11 patients writh left upper quadrant drains developed subphrenic abscess and this was due to an anasto- motic leak. This again supports our impression that special circumstances dictate the use of drains.
The incidence of splenectomy for accidental splenic injury in the course of abdominal opera- tions is variously quoted from 3% to 40%. J, 2,3,6, - Accidental injury occurs most frequently in the course of upper abdominal operations and is more likely to occur when such operations are of an ur- gent or emergency nature. Inadequate exposure, lack of adequate skilled assistance and the sense of need for rapid completion of an emergency pro- cedure contribute to the higher incidence of splenic injury when compared to that accompany- ing elective upper abdominal operations. Five of
Table VII
Causes of Death
Group
No. Deaths
Cause of Death
1.
2/22
Systemic Sepsis
2
2.
5/13
Mycardial Infarction
2
Bronchopulmonary Sepsis
2
Liver Failure
1
3.
4/11
Pulmonary Edema
1
Bronchopulmonary Sepsis
2
Peritonitis
1
4.
0/4
Total
n
A
B
C
Discharge
Comments
Effusion
0
+
26th
Platelets
over l,000,000mm3 Anticoag. Rx.
0
0
+
8th
Platelets3 610,000mm no Rx
0
0
0
7th
0
0
0
8th
our 1 1 patients who had splenectomy for iatro- genic injury, were operated for upper gastro- intestinal bleeding under urgent or emergency conditions. Olsen and Beaudoin3 attributed most accidental splenic injuries to misdirected traction of the stomach or colon during upper abdominal procedures, causing avulsions at the splenic hilum. This would explain the splenic rupture in two of their patients following exploration through the inguinal hernial sac at the time of herniorrhaphy. Placing a pack cephalad to the spleen as advocated by Baker,1 directing gastric or colonic traction to- ward the patient’s left foot and avoidance of deep retractors in the left upper quadrant have been effective in reducing splenic injuries in our hands.
The contribution of the iatrogenic splenic in- jury to morbidity or mortality is difficult to assess. Olsen and Beaudoin3 reported 20 complications and four deaths in a group of 121 splenectomies for iatrogenic injury. Bostrom and Page0 observed 50% complications and 19% deaths in 16 patients who required splenectomy for accidental injury. Although we could not directly link the complica- tions and death of any of our patients in group III (accidental) to the splenectomy there is little doubt that the additional procedure prolonged the operative time and the surgical stress, contributed to a change in blood coagnlation status and in- directly influenced the clinical course in an ad- verse manner.
Post-splenectomy thrombocytosis is frequently recorded and occasionally accounts for deaths from thromboembolic phenomena.8 In our patients thrombocytosis reached its maximum between the 5th and 7th postoperative day. One of our patients developed thrombocytosis with platelets in excess of one million and was treated with anticoagulants for three weeks. In nine more patients the platelet levels reached 500,000 to 750,000/cu.mm, and then reverted to normal with no treatment. In contrast to others8 we believe that anticoagulant treatment should be instituted if platelets exceed one mil- lion/cu.mm.
Accessory spleens were found in six patients undergoing splenectomy for hematologic disease and only once in the incidental group. This find- ing has been commented upon by Olsen and Beau- doin.9 Recurrence of the original hematologic dis-
30 MICHIGAN MEDICINE JANUARY 1972
order after splenectomy should alert one to such a possibility.
B. Deaths:
There were 11 deaths in the entire series (22%). When broken down by group, however, it is ob- vious that the majority of deaths were due to fac- tors not related to splenectomy (Table VII).
Both deaths in group I were due to septic proc- esses. In one the septic process was obviously ag- gravated by immunosuppression. Whether splenec- tomy as such had a detrimental systemic effect on the patient's defense mechanisms as alluded to by Hodam2 would be difficult to ascertain. The deaths in group II (incidental) have no relation to the removal of the spleen as indicated in Table IV. Of the four deaths in group III (iatrogenic) one was attributed to acute pulmonary edema, confirmed by autopsy on the 4th postoperative day. Two more were directly related to severe bronchopul- monary complications; left pleural effusion with alveolocapillary block following vagotomy and pyloroplasty and sepsis after total gastrectomy for recurrent bleeding gastritis, two weeks follow- ing vagotomy and pyloroplasty. This latter patient also had extensive upper abdominal sepsis from duodenal fistula, wound infection with dehiscence and prolonged ileus. He had been successfully resuscitated by open cardiac massage eight years previously, with residual serious cardiopulmonary damage. At autopsy it was noted that the abdom- inal sepsis had cleared, but bronchopulmonary sepsis and chronic congestive failure persisted and were considered responsible for his demise. The fourth patient developed peritonitis, liver failure with ascites and died BO days after vagotomy and hemisgastrectomy. No drain had been left in the abdomen. The gastrointestinal anastomosis most likely accounted for the peritoneal sepsis, while the pre-existing cirrhosis and ascites curtailed her chances for recovery.
Summary and Conclusions
Experience with 50 patients who underwent sple- nectomies for various indications is summarized. Eleven patients (22%) died as a result of the un- derlying disease or of complications developing from the primary operations. Severe bronchopul- monary cardiac complications accounted for seven deaths, sepsis for three, and liver failure for one. No death could be directly attributed to the sple- nectomy.
The overall complication rate was 40% with a preponderance of bronchopulmonary complica- tions in 32%. This high incidence of bronchopul- monary complications is attributed to extensive upper abdominal or thoraco-abdominal operations in patients of the older age group and does not seem to be directly related to the splenectomy.
There were no complications associated with the use of drains when adjacent organs were left in- tact.
Preoperative thrombocytopenia of significant de- gree was not associated with hemorrhagic prob- lems. Postoperative thrombocytosis occurred in 20% of the patients, but remained asymptomatic and was treated with anticoagulants in only one patient.
Most of the splenic injuries in the iatrogenic group occurred in patients undergoing emergency procedures or in those with improper technical exposure. Improvement of these technical factors should be associated with a lower incidence of in- jury and decrease in the associated morbidity.
References
]. Rich, N.M., Lindner, H.H., and Mathewson, C., Jr.: Splenectomy incidental to Iatrogenic Trauma. Am. J. Surg. 110: 209-215, 1965
2. Hodam, R.P.: The risk of Splenectomy. A review of 310 cases. Am. J. Surg. 119: 709-713, 1970
3. Olsen, W.R., and Beaudoin, D.E.: Surgical Injury to the Spleen. Surg. Gynec. Obstet. 131: 57-62, 1970
4. Olsen, W.R.: Emergency Splenectomy. Surg. Gynec. Obstet. 123: 351-353, 1966
5. Olsen, W.R., and Beaudoin, D.E.: Wound drainage after Splenectomy. Indications and Complications. Am. J. Surg. 117: 615-620, 1969
6. Bostrom, P.D., and Page, H.G.: Splenectomy. An eleven year Review. Arch. Surg. 98: 167-170, 1969
7. Daoud, F.S., Fischer, D.C., and Hafner, C.D.: Com- plications following Splenectomy with special em- phasis on drainage. Arch. Surg. 92: 32-34, 1966
8. Devlin, H. Brendan, Evans, D.S., and Birkhead, J.S.: Elective Splenectomy for primary Hematologic and Splenic Disease. Surg. Gynec. Obstet. 131: 273- 276, 1970
9. Olsen, W.R., and Beaudoin, D.E.: Increased inci- dence of Accessory Spleens in Hematologic Disease. Arch. Surg. 98: 762-763, 1969
MARMP
offers new booklet on four neoplasms
A new 21-page booklet on the diagnosis and management of four neoplasms — malignant lym- phoma, including Hodgkin’s disease; carcinoma of the cervix, carcinoma of the uterus and carci- noma of the breast — is available to physicians from the Michigan Association of Regional Medical Pro- grams.
The MARMP Professional Advisory Council on Cancer, chaired by Harold Bowman, MD, Grand Rapids, has developed the free booklet, which may be obtained by writing the MARMP Central Office, Suite 200, 1111 Michigan Ave., East Lansing, 48823.
MICHIGAN MEDICINE JANUARY 1972 31
CftutoaJP note*
Hematoma
of the nasal septum
By Oliver B. McGillicuddy, MD Lansing
It is more important to examine the septum of the nose of an injured child or teenager than to X-Ray the nasal bones. X-Rays may not reveal a nasal bone and septal dislocation but should be taken for possible legal action. Palpation of the nasal arch and careful inspection is more apt to reveal deformity.
On careful inspection of the interior of the nose, it is not uncommon to find the septum dis- lodged from its midline base and it becomes a matter of judgment as to whether or not it can or needs to be corrected.
It becomes an emergency if a hematoma of the septum is discovered. Fortunately, this complica- tion is rare and probably most general practition- ers and many pediatricians have never encoun- tered it. Unfortunately, rhinologists often see these cases too late to save the septal cartilage.
The hematoma develops after severe trauma to the nose. The septal cartilage is fractured. A blood vessel in the perichondrium is lacerated and bleed- ing occurs under the perichondrium.
As the bleeding continues, the perichondrium is lifted off the septal cartilage on both sides.
Cartilage without its perichondrial blood sup- ply softens like “butter on a hot stove.”
If diagnosed early, and this means within forty- eight hours, the treatment is simple. The septum is incised, blood is aspirated from the interior of the septum and both nostrils are firmly packed, press- ing the perichondrium and mucous membrane against the septal cartilage. The packs are left in place for three or four days.
If diagnosed late, the treatment is the same but the end result is a disaster. The septal cartilage will have become jelly and the septal support to the lower two thirds of the dorsum of the nose will be lost.
Doctor McGillicuddy is a Lansing otolaryngolo- gist and is past chairman of the MSMS Council and past MSMS president.
32 MICHIGAN MEDICINE JANUARY 1972
The inevitable result will be an ugly saddle deformity of the nose. This saddle deformity can be corrected later, after scar tissue contraction has ceased, by a bone implant under the dorsum skin and a strut of bone in the columella. If the child is young, the implants may have to be replaced when or if the nose has reached its full growth. The nose may remain infantile.
The long period of waiting, often six months or more, before corrective surgery can be started, is a very emotionally traumatic experience for the child.
The patient with a hematoma of the septum complains of increasing nasal obstruction and headache. The parents, sometimes unaware of the injury, think the child has a severe cold or has developed a nasal allergy. There is no epistaxis. Home and drug store remedies are frequently ad- ministered. When the child finally sees a doctor it is apt to be too late to save the septal cartilage.
On examination of the interior of the nose, the doctor, if he as aware of the possibility of a hema- toma, may see both nostrils blocked by a red swelling. If late, the swollen tissue will actually protrude from the anterior nares. If early, he will note a thickening of part or all of the septum.
The most common mistake is to diagnose this swollen tissue as nasal polyps or a severe allergic swelling or to temporize and think it a swelling due to the injury and to wait for it to subside.
This complication may occur in adults but is much more common in children.
On discovery, a dislocated septum can often be corrected without too much deformity even a week after injury. The neglected hematoma of the septum is a childhood tragedy.
U-M research of early abortions supported by new grant
Two research projects aimed at developing drugs to produce early abortions either by pill or injec- tion are included in a new $1,089,428 federal grant to The University of Michigan Center for Popula- tion Planning. The Center is a unit of the School of Public Health.
One study will involve implanting a transducer into the uterus of 15 female volunteers. The other will seek an antibody which will cause rejection of the early fetus allowing repeated abortions with minimal effect on the patient.
The two projects are among seven scientific in- vestigations to be funded for three years for $572,- 036 by the U.S. Agency for International Develop- ment (AID). They are directed by Samuel J. Behr- man, MD, professof of obstetrics and gynecology.
Are congenital virus infections possible in successive pregnancies?
By Thad H. Joos, MD Detroit
That maternal infection with a viral agent dur- ing early pregnancy, can lead to multiple congen- ital defects in the offspring has been well docu- mented.1’2-3'4 This report is presented not to en- large an already adequate fund of information, but to pose the following question. Can the prod- ucts of two successive pregnancies be victims of congenital virus infections?
Case Reports: Mr. and Mrs. M. were both nor- mal Caucasians of the ordinary child-producing age. There was a paternal great grandfather who at age of 80, developed cataracts and Mrs. M. had infectious hepatitis in 1960 with complete recov- ery.
Mrs. M's first pregnancy ended in a miscarriage at six weeks in 1961. The cause was unknown. The second pregnancy produced a full-term, nor- mal female on February 3, 1965.
Pregnancy number three began in December, 1964. A respiratory infection occurred during the first six weeks and was treated with aspirin and an antihistamine preparation. At two months some minor vaginal bleeding occurred, which promptly stopped. Vitamins and iron were taken during the pregnancy.
A. M. was born at term on August 29, 1965. The weight was 3750 grams. At three weeks of age, bilateral cataracts along with icterus were noted. A urinary test for galactose was negative. The icterus gradually faded.
On examination by the author on November 15, 1965, the cataracts were observed, but in addi- tion, a cardiac murmur was heard and the frontal bossae were prominent. Head circumference was 42.3 cm. Neither the spleen nor liver were palpa- ble.
The cataract OD was removed on December 10, 1965 and on December 19, 1965 the child was ad- mitted to the Children’s Hospital of Michigan for further evaluation. Pertinent findings were: (1)
small IV septal defect; (2) very large bilateral porencephalic cysts; (3) rubella antibody titers using the indirect fluorescent antibody technique5 were positive in the mother between 1:64 and 1:128, and in the baby positive 1:4. The baby’s
Doctor Joos is an adjunct instructor in pedi- atrics at Wayne State University College of Med- icine.
titer most likely would have been higher had not the serum become contaminated with mold; (4) cultures from the nasopharynx of both baby and mother grown on rabbit cornea cells were negative for rubella virus.6 The child’s head size continued to rapidly increase and her motor development lagged. She was placed in custodial care at 10 months of age.
The fourth pregnancy began in November of
1966, or about 15 months after the birth of A. M. Vaginal bleeding occurred at 2 and S1/2 months. The latter being controlled by one month of bed rest. No respiratory infections were present, and as in previous pregnancies, vitamins and iron were taken, J.M. was born near term on August 16,
1967, weighing 2500 grams. The placenta was nor- mal. The neonatal course was normal except for slight icterus. No hepto or splenomegally was pres- ent. At two months of age a cataract was found OD and at three months OS. Their descriptions were: “advanced lens opacities in the right, the left eyes, a central white opacity surrounded by small granular opacities.”7 To date, no other anatomic abnomalies have been found. Urine for galactose was negative as were two nasopharangeal cultures from the mother and baby for rubella virus. These were obtained in December, 1967, and February, 1968. Rubella antibody titers done in December of 1967 on the mother’s serum showed a positive titer as in 1965. Those done on the baby’s serum were equivocal for the presence of rubella antibody.
Cataract removal was performed in November, 1967, and the report is as follows. “Suction extrac- tion was done on the right. The iris pigment tend- ed to adhere to the anterior capsule indicating separation of posterior synechia. Again the lens material, as with the sibling two years ago, was quite tenacious. A central plaque was present, which was dislodged nasally. The presence of the adhesions between the iris and lens suggest an in- flammatory etiology such as the rubella virus.’’8 A contact lens was employed in the operated eye and some vision has been maintained. Her growth and development have been normal considering the visual handicap.
In November of 1967 the fifth pregnancy began, and ended fortunately with the delivering of a normal female infant weighing 3600 grams. As of December 1, 1968, no abnormalities have been found in this child.
The placenta was normal, nasopharangeal cul- tures for rubella virus were negative from mother
MICHIGAN MEDICINE JANUARY 1972 33
CONGENITAL VIRUS INFECTIONS/Continued
and baby. Quantitative immunoglobulins on cord blood showed IGG 1000 mgm%, IGM trace, IGA absent. Rubella antibodies were absent in the same blood specimen. Lack of facilities precluded some of these studies on the earlier babies.
Discussion: Coffey and Jessop9 in a hospital survey reported that an influenza-like upper res- piratory infection was obtained five times as often from mothers of abnormal babies (18.4 per cent) as from controls (3.6 per cent) . In an excellent review article by Wright,1 however, it is stated that while a number of maternal viral diseases have been etiologically incriminated in congenital defects only two, rubella and cytomegalovirus, have definitely been proven to be associated with defects. All babies in the series of Weller and Hanshaw10 with cytomegalic inclusion disease had heptosplenomegally. Jaundice and neurological sequelae were frequent, but not ocular lesions.
Even with the absence of clinical rubella in Mrs. M. during her third pregnancy, the offspring fits the rubella syndrome, with eye, heart, and nervous system abnormalities. Conception occurred in 1964, a rubella epidemic year. Karmody,11 Butler, et al,12 Schiff, et al,13 and Weller, et al,14 report that fre- quently a clinical case of rubella is diagnosed only in retrospect after finding the stigmata in the child and rubella antibodies in the sera of the mother and child.
The antihistamine chlorcyclizine has been re- ported to cause major anomalies in the fetus,15 but there was no use of this particular antihista- mine by Mrs. M. in either pregnancy.
The case for rubella-caused cataracts is indeed less impressive for the fourth child, J. M., with only a questionable antibody titer in the serum and negative cultures from the nasopharynx. Clin- ically and pathologically the cataract fits into the type, seen with congenital rubella. Gregg16 de- scribes the rubella cataract as follows . . . “In the undilated condition of the pupil the opacities filled the entire area. After dilation, the opacities appeared densely white— sometimes quite pearly in the central area with a small, apparently clear zone between this and the pupillary border of the iris.” Zimmerman17 further supports the above by stating that histologically, “The most marked al- terations are always observed centrally, accounting for the dense nuclear cataract observed clinically.”
Hereditary cataracts are pathologically different and, typically occur as a dominant trait or reces- sive factor, but sex linked inheritance has been reported.18 It seems, therefore, that more than one remote member of the family would have had cataracts had heredity been involved.
One would like to believe that two such de- formed babies were chance happenings and not etiologically related. Circumstantial evidence, how-
ever, makes the physician observer wonder if such were the case.
Summary: The problem of viral infections ante natal in the mother is briefly discussed. A family is presented that may well represent such infec- tions in two successive pregnancies.
References
1. Wright, H. T.: Congenital Anomalies and Viral Infections in Infants. Calif. Med., 105, 345, 1966
2. Nora, J. J., Nora, A. H„ Sommerville, R. J., Hill, R. M., and McNamara, D. G.: Maternal Exposure to Potential Teratogens. JAMA, 202, 1065, 1967
3. Katz, R. G., White, L. R., and Sever, J. L.: Ma- ternal and Congenital Rubella. Clin. Ped., 7, 323, 1968
4. Whitty, R. J.: Foetal Infections, With Special Ref- erence to Rubella. J. of Irish Med. Assoc., 60, 86
1967
5. Brown, G. C., Maassab, H. F., Veronelli, J. A., and Francis, T., Jr.: Rubella Antibodies in Human Serum: Detection by the Indirect Fluorescent Anti- body Technique. Science, 145, 943, 1964
6. Phillips, C. A., Melnick, J. L., and Burkhardt, M.: Isolation, Propagation and Neutralization of Rubel- la Virus in Cultures of Rabbit Cornea (SIRC) Cells. Proc. Soc. Exp. Biology ir Med. 122, 783, 1966
7. Personal communication with Paul L. Cusick, MD
8. Ibid. #7
9. Coffey, V. P., and Jessop, W. J. E.: Congenital Ab- normalities, Irish J. Med. Sci. p 30, 1955
10. Weller, T. H., and Hanshaw, J. B.: Virologic and Clinical Observations on Cytomegalic Inclusion Disease. New Eng. J. Med. 266, 1233, 1962
11. Karmody, C. S.: Sub-clinical Maternal Rubella and Congenital Disease. New Eng. J. Med. 278, 809,
1968
12. Butler, N. R., Dudgeon, J. A., Hayes, K., Peckham, C. S., and Wybar, K.: Persistence of Rubella Anti- body With and Without Embryopathy. A Follow- up Study of Children Exposed to Maternal Rubel- la. Brit. Med. J. 2, 1027, 1965
13. Schiff, G. M., Sutherland, J. M„ Light, I. J., and Bloom, J. E.: Studies on Congenital Rubella. Pre- liminary Results on the Frequency and Significance of Presence of Rubella and the Effect of Gamma- globulin in Preventing Congenital Rubella. Am. J. Dis. Child. 110, 441, 1965
14. Weller, T. H., Alford, C. A., and Neva, F. A.: Retrospective Diagnosis by Serologic Means of Con- genitally Acquired Rubella Infections. New Eng. J. Med. 270, 1039, 1964
15. Sheldon, J. M., Lovell, R. G., and Mathews, K. P.: A Manual of Clinical Allergy, ed. 2. Philadelphia, Pa.: W. B. Saunders, p 142, 1967
16. Gregg, N. M.: Congenital Cataracts Secondary to German Measles. Trans. Ophth. Soc. of Australia. 3, 35, 1941
17. Zimmerman, L. E.: Histopathologic Basis for Oc- ular Manifestations of Congenital Rubella Syn- drome: Am. J. of Ophth. 65, 839, 1968
18. Dept, of Ophth., Hosp. for Sick Children, Toronto. The Eye in Childhood. Chicago, Illinois: Year Book Med. Publishers, pp 414-415, 1967
34 MICHIGAN MEDICINE JANUARY 1972
It's got the same headroom and legroom as the Rolls-Royce Silver Shadow.
And the same kind of steering system as the Ferrari racing car.
a division of Volkswagen
The Audi IOOLS.
A test drive in the Audi never fails to sur- prise people.
You see, the Audi gives you the comfort of a luxury car without sacrificing the handling of a sports car.
Aside from the Rolls and Ferrari, the Audi has something in common with a lot of other great cars.
It's got front-wheel drive like the Cadillac Eldorado, an interior incredibly similar to the Mercedes-Benz 280SE and as much trunk space as the Lincoln Continental.
But the similarities to these expensive cars go only so far.
They stop, in fact, at the price sticker.
^ood Imports, Inc. Prestige Porsche Audi, Inc.
1415 Gratiot Ave., Detroit 2955 S. Division Ave., Grand Rapids
Tom Sullivan Porsche Audi Co.
499 S. Hunter Blvd., Birmingham
Camp’s Cars, Inc.
00 S. Saginaw Rd., Midland
Williams Porsche Audi
2924 E. Grand River Ave., Lansing
Traverse Motors, Inc.
1301 Garfield Ave., Traverse City
£MSmS ill actiori
Better obstetrical services to Michigan 's residents goal of MSMS committee
An MSMS subcommittee is now beginning work on its plan to involve county medical societies, lo- cal hospitals and planning groups in effective plan- ning for obstetric and newborn services at the community level.
Through its efforts in 1972, the MSMS Subcom- mittee on Better Utilization of Obstetrical Beds hopes to eliminate and/or consolidate poorly-uti- lized obstetrical services, obtain needed obstetrical beds and services, plan regional centers for the care of high risk mothers and infants where such care is not now available.
The subcommittee, a wing of the MSMS Maternal and Perinatal Health Committee, won approval of its plans and some financial support from The MSMS Council at The Council’s November meeting.
“We are convinced that it is exceedingly impor- tant for a professional nongovernmental organiza- tion to provide the initiative and leadership in this
SEVENTEENTH ANNUAL
^ MEDICLINICS
^ POSTGRADUATE MEDICAL £n,- > REFRESHER COURSE
r/T March 6-16, 1972
FORT LAUDERDALE, FLORIDA
Headquarters:
Galt Ocean Mile Hotel
Sponsored by Florida Academy of General Practice and the Broward a ° General Hospital. Accepted for 32 hours of credit by the American Academy of General Practice.
&5T
Registration information:
MEDICLINICS
itSlT 832 Central Medical Building Saint Paul, Minnesota 55104 Registration Fee: $100.00
Pre-Registration Hotel Room Guaranteed
effort,” says Richard T. Mellis, MD, Kalamazoo, chairman of the maternal and perinatal health com- mittee.
Seven subcommittee meetings are planned, three at MSMS headquarters and four in communities around the state to be devoted to actual involve- ment in local planning efforts.
The committee includes representatives of the Department of Public Health, the Michigan Hos- pital Association and the Michigan Association of Osteopathic Physicians and Surgeons.
Doctor, are you stumped when young peo- ple ask you what colleges and universities offer courses in dietetics, medical technology, medical librarianships? Would you like a handy reference to describe various medical careers, as well as your own?
Then write MSMS headquarters, Box 950, East Lansing, Mich. 48823, for the AMA Horizons Unlimited career handbook.
Scientific Sessions
presents a Seminar with a distinguished faculty
Ala Moana Hotel — Honolulu, Hawaii
FEBRUARY 21, 22, 23, 1972
• Electrocardiography: Model for Normal and In- traventricular Conduction Defects. Heart Block and the Hemiblocks ; Indications for Pacing
Peter C. Block, M.D., Cardiac Unit,
Mass. General Hospital
• Diagnosis, Treatment, Prevention of Specific Viral Diseases in Man
Thomas C. Merigan, M.D., Chief Div. Infectious Diseases,
Stanford Univ. Medical Center
• Cancer Immunology Applied to Early Diagnosis of Tumor Growth. Detection CEA in Patient's Blood
Phil Gold, M.D., Ph.D., F.R.C.P. (C). Montreal General Hospital Div.
Clinical Immunology & Allergy Registration Limited
Program Director, Dr. Robert L. Pekarsky
Enclosed is my registration fee of $175.00 (Check payable to Scientific Sessions,
217 Alexander St., Rochester, N.Y. 14607)
,| | Want assistance with airline reservations ,[ | Information on group tours Q Will make reservations with Ala Moana Hotel for Special Scientific Sessions Rate
DR —
ADDRESS
36 MICHIGAN MEDICINE JANUARY 1972
CAMPBELL’S SOUPS IN DIABETIC DIETS*
RECOMMENDATIONS FOR PLACING CAMPBELL'S SOUPS* INTO EXCHANGE LISTS
* These recommendations are based on a one cup portion when prepared according to directions on the label. If milk is used in the preparation, use part of your daily requirement.
Exchange Substitution for 1 Bread and V2 Fat
Tomato
Tomato, Bisque of Tomato Rice, Old Fashioned
Exchange Substitution (or T Meat and f/2 Bread
Hot Dog Bean Split Pea with Ham
Exchange Substitution for Vi Bread and V2 Fat
Asparagus, Cream of
Exchange Substitution for VS Meat and '/2 Bread
Chicken Gumbo Chicken Noodle
Campbell's Soups are appetizing and enjoyable and, because of the many varieties available, offer your dia- betic patients the opportunity to plan and enjoy more interesting and appealing meals.
*To obtain copies of “Recommendations for Placing Campbell’s Soups Into Exchange Lists,” suitable for distribution to patients, write to Campbell Soup Company, Dept. 500, Campbell Place, Camden, NJ. 08101.
here s a soup for almost every patient and diet .for every meal and, it’s made by
I
I
i
I
When diarrhea wrings the wedding belle..
It’s all very well to counsel patience in diarrhea patients. There are times when relief of symptoms can’t come too soon.
X-ray studies1 in 16 normal subjects showed just how promptly the active ingredient in Lomotil does its work.
Lomotil retarded gastrointestinal motility particularly during the first three hours after administration.
It continued its moderating action on the bowel for at least three hours more.
Physicians prescribe Lomotil more often than any other drug when the urgency for the control of diarrhea is most distressing.
7. Demeulenaere, L.: Action du R 1132 sur le transit gastro-intestinai, Acta gastroent.
Belg. 21:674-680 (Sept. -Oct.) 1958.
Lomotil
Warnings: Lomotil should be used with caution in patients taking barbiturates and, it not contraindicated, in patients with cirrhosis, advanced liver disease or impaired liver function.
TABLETS/LIQUID
Each tablet and each 5 cc. of liquid contain Diphenoxylate hydrochloride . . .2.5 mg (Warning: may be habit-forming) Atropine sulfate 0.025 mg
Precautions: Lomotil is classified as a Schedule V substance by Federal Law with theoretically possible addictive potential at high dosage; this is not ordinarily a clinical problem. Use Lomotil with con- siderable caution in patients receiving ad- dicting drugs. Recommended dosages
Saves the Day
should hot 88 exceeded, and medication should be kept out of reach of children. Sips of accidental overdosage may In* elude severe respiratory depression, flush- ing, lethargy or coma, hypotonic reflexes, nystagmus, pinpoint pupils, tachycardia; continuous observation is necessary, lie subtherapeutie amount of atropine sulfate is added to discourage deliberate over- dosage.
Adverse Reactions: Side effects re- ported with Lomotil therapy include nau- sea. sedation, dizziness, vomiting,
pruritus, restlessness, abdominal discom- fort. headache, angioneurotic edema, giant urticaria, lethargy, anorexia, numb- ness of the extremities, atropine effects, swelling of tire gums, euphoria, depression and malaise.
Overdosage: Tie medication should hi kept out of reach of children since ae* cidental overdosage may cause severe, even fatal, respiratory depression. Dosage: lie recommended average ini- tial daily dosages, given in divided doses until diarrhea is controlled, are as follows:
Children:
3-6 mo. ... % tsp.* t.i.d. {3 mg.)
6-12 mo.. . % tsp. q.i.d. (4 mg.)
t-2 yr % tsp. S times daily (5 mg.)
2-5 yr I tsp. t.i.d. (6 mg.)
5-8 yr.... .1 tsp. q.i.d. (8 mg.)
8-12 yr.. . . 1 tsp. 5 times daily (10 mg.)
Adults: 2 tsp, 5 times daily (20 mg.)
or 2 tablets q.i.d.
* Based on 4 cc. per teaspoonful.
Use of Lomotil is not recommended in infants less than 3 months of age,
Maintenance dosage may be as low as one- fourth the initial dally dosage.
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epanilTen-ta
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Vhen girth gets out of control, TEPANIL can provide sound upport for the weight control program you recommend. EPANIL reduces the appetite — patients enjoy food but eat 3ss. Weight loss is significant— gradual — yet there is a rela- ively low incidence of CNS stimulation.
ontraindications: Concurrently with MAO inhibitors, in patients hypersensitive to >is drug; in emotionally unstable patients susceptible to drug abuse.
/arning: Although generally safer than the amphetamines, use with great caution in otients with severe hypertension or severe cardiovascular disease. Do not use dur- ig first trimester of pregnancy unless potential benefits outweigh potential risks, dverse Reactions: Rarely severe enough to require discontinuation of therapy, un- leasant symptoms with diethylpropion hydrochloride have been reported to occur i relatively low incidence. As is characteristic of sympathomimetic agents, it may ccasionally cause CNS effects such as insomnia, nervousness, dizziness, anxiety, nd jitteriness. In contrast, CNS depression has been reported. In a few epileptics n increase in convulsive episodes has been reported. Sympathomimetic cardio- bscu/ar effects reported include ones such as tachycardia, precordial pain,
arrhythmia, palpitation, and increased blood pressure. One published report described T-wave changes in the ECG of a healthy young male after ingestion of diethylpropion hydrochloride; this was an isolated experience, which has not been reported by others. Allergic phenomena reported include such conditions as rash, urticaria, ecchymosis, and erythema. Gastrointestinal effects such as diarrhea, constipation, nausea, vomiting, and abdominal discomfort have been reported. Specific reports on the hematopoietic system include two each of bone marrow depression, agranulocytosis, and leukopenia. A variety of miscellaneous adverse reactions have been reported by physicians. These include complaints such as dry mouth, headache, dyspnea, menstrual upset, hair loss, muscle pain, decreased libido, dysuria, and polyuria.
Convenience of two dosage forms: TEPANIL Ten-tab tablets: One 75 mg. tablet doily, swallowed whole, in midmorning (10 a.m.); TEPANIL: One 25 mg. tablet three times daily, one hour before meals. If desired, on additional tablet may be given in midevening to overcome night hunger. Use in children under 12 years of age is not recommended. 1-3325 ( 2876 )
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HIS SPACE CONTRIBUTED BY TH E PUBLISHES AS A PUBLIC SERVICE
With the steady improvement in the therapy of cancer, and consequent increase in the number of 5-year survivals, our programs reflect increasing concern with the future of the cancer patient— with the quality of his survival.
High priority is being given to the rehabilitation of cancer patients— those having had mastectomies, colostomies, laryngec- tomies, amputations, and other drastic treatments for cancer.
Our “Reach to Recovery” program is a dramatic example. This program helps the physician meet many special needs of the postmastectomy patient on the road to total recovery. Patients receive psychological reassurance and practical help from women who have had the same surgery.
The laryngectomee also receives the benefit of our rehabilitation program. Supported
by the Society, the International Associa- tion of Laryngectomees, through its local IAL clubs, provides such services as individual and group speech therapy, psychological counseling, visits to new patients, safety training, public education and social activities.
Our rehabilitation programs not only give heart and help to patients but provide the physician with vital aids necessary to improve the quality of survival.
American Cancer Society^
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. . .in the presence of spasm or hypermotility, gas distension and discomfort, KINESED provides more complete relief :
O belladonna alkaloids— for the hyperactive bowel □ simethicone— for accompanying distension and pain due to gas D phenobarbital— for associated anxiety and tension
Composition: Each chewable, fruit-flavored, scored tab- let contains: 16 mg. phenobarbital (warning: may be habit-forming); 0.1 mg. hyoscyamine sulfate; 0.02 mg. atropine sulfate; 0.007 mg. scopolamine hydrobromide; 40 mg. simethicone.
Contraindications: Hypersensitivity to barbiturates or belladonna alkaloids, glaucoma, advanced renal or he- patic disease.
Precautions: Administer with caution to patients with incipient glaucoma, bladder neck obstruction or uri-
nary bladder atony. Prolonged use of barbiturates may be habit-forming.
Side effects: Blurred vision, dry mouth, dysuria, and other atropine-like side effects may occur at high doses, but are only rarely noted at recommended dosages. Dosage: Adults: One or two tablets three or four times daily. Dosage can be adjusted depending on diagnosis and severity of symptoms. Children 2 to 12 years: One half or one tablet three or four times daily. Tablets may be chewed or swallowed with liquids.
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(from the Greek kinetikos, to move,
and the Latin sedatus, to calm)
KINESED*
antispasmodic/sedative/antiflatulent
Spring peeper (tree frog, Hyla crucifer): this small amphibian can expand its throat membrane with air until it is twice the size of its head.
MICHIGAN MEDICINE JANUARY 1972 47
Here is definitive summary
of current status of Michigan Medicaid program
The Medicare and Medicaid programs were passed by Congress as joint additions to the So- cial Security Act in 1965. By adding two new titles to this basic legislation, Title 18 (Medicare) and Title 19 (Medicaid), the Congress authorized a mechanism to finance certain health services for the elderly through the Social Security Administra- tion on the one hand, and provided Federal match- ing money to states which wished to provide health care to its “categorically needy” or “medically in- digent” on the other. Michigan’s decision to par- ticipate in the Medicaid program was expressed in Public Act 321 of 1966.
Implementation of the Michigan program began on Oct. 1, 1966. Since funds were not available to cover the estimated cost of full services for the full year, the Legislature provided that services should be initiated on a phased-in basis as follows:
Oct. 1, 1966
1. Inpatient and outpatient hospital services.
2. Nursing home services and care in approved county medical care facilities.
3. Physician’s services in the hospital.
4. Home nursing services.
This article is for Michigan physicians who would like to know more about the Michigan Medical Assistance Program (Medicaid) and:
(1) The basis for the state’s decision to as- sume fiscal agent duties for Medicaid and the implications of this decision for physicians;
(2) problems associated with the “eligibility process”;
(3) the lack of formalized publicized Medicaid policies and procedures;
(4) peer review and the Michigan State Med- ical Society, and
(5) the present methodology used to deter- mine physician reimbursement.
The information comes from the text of a talk made at the recent joint meeting of the MSMS committees on governmental medical care pro- grams and legal affairs. The speaker was Stuart Paterson, deputy director, Medical and Manage- ment Information Systems, Michigan Department of Social Services whose insight and observations so impressed the committee members that they wished to have all MSMS members share in the in- formation.
Jan. 1, 1967
1. Physician’s services in his office, client’s home, or elsewhere.
2. Prescribed drugs.
April 1, 1967
1. Dental services.
2. Eyeglasses and other prosthetic devices.
3. Ambulance and other services.
By Jan. 1, however, it was already clear that fis- cal requirements had been seriously underesti- mated and Governor Romney therefore ordered that the provision of physician office services and pre- scribed drugs be suspended for the “medically needy” and that dental and eyeglasses services be suspended for all recipients. As we all know, the basic structure of benefits provided under Medicaid has remained constant since that time.
It is worth noting that Michigan was not alone in its plight. Many other states were caught in a cost bind as well, and the Federal Government relying on an estimate of $800 million in Federal funds was probably the most surprised of all when the first eight states to initiate Medicaid submitted combined cost estimates equal to that amount. To be sure, some suspected something to this effect when the legislation was passed, but it appears that no one fully appreciated the monetary implica- tion of Title 19.
I trust the obvious attention to Medicaid’s fiscal impact does not suggest that I do not appreciate its other effects as well — on the provider, the recip- ient and the health facility. But I do think the most graphic illustration of what we have been faced with lies in a brief look at dollars expended. In its initial year, the Medicaid budget for Michigan was $81.3 million. By Fiscal 1969 it had grown to $188.7 million; last year $270.0 million was spent; and our 71-72 budget bill now stands at $326.0 million. This represents an increase of 400% in five years.
Seldom, if ever, has so large an undertaking been implemented in so short a time.
By the fall of 1968, the implications of this fact were clear to the Department of Social Services, the Executive Office and the Legislature. Some overt action was required to recapture control of Medicaid. Two critical problems, largely attributable to the fact that early implementation has precluded a thorough pre-planning, were crippling our ability to deal effectively with the program.
The first was a lack of information. For example, the average number and cost of prescriptions ob- tained by recipients per month would have per- mitted a better estimate of funds necessary to sup- port the provision of drugs. As it is, the Department
48 MICHIGAN MEDICINE JANUARY 1972
has found it necessary to request supplemental ap- propriations for this purpose.
The second general problem was a lack of man- agement control. An example of this is that no mechanism exists to ensure that the recipient in- formation supplied Blue Cross and Blue Shield by the State is completely accurate or that they prop- erly update their eligibility files.
Consequently, the Department requested, the Governor recommended and the Legislature appro- priated funds for a Title XIX Systems Development Project in the Social Services 1969-70 budget. The project was to “develop a system for the adminis- tration of the Medicaid program, to create effective utilization and fiscal controls and supporting sys- tems including claims processing, financial audit, medical surveillance, information reports, program planning and evaluation and the selection of a fis- cal agent or agents.”
Shortly after passage of the bill, a request for proposals to aid the Department in defining the re- quirements of Medicaid was sent to major consult- ing firms. A contract was signed with Touche Ross & Co. in November, 1969. The result of this effort was the “Michigan Medicaid Systems Design Re- quirements” published in April, 1970. It represents the basis for what we now call the “new system.”
In June another request for proposal was issued for aid in the implementation of the requirements. Touche Ross & Co. was again the successful bid-
The speaker, Stuart Paterson, center, is intro- duced by Kenneth H. Johnson, MD, left, chair- man of the MSMS Legal Affairs Committee. At right is Robert E. Rice, MD, Greenville, chairman of the MSMS Committee on Governmental Med- ical Care Programs. The two committees met jointly to hear Mr. Paterson.
der and in August a contract was signed with them for assistance in implementing four of the eight Medicaid subsystems: recipient eligibility; provider enrollment; invoice processing; and performance, surveillance and utilization review. The remaining four: government reporting; cost settlement and auditing; Medicare premium processing; and in-
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MICHIGAN MEDICINE JANUARY 1972 49
“At no time was the ability or integrity of either individuals of Blue Cross and Blue Shield or the organizations as a whole, questioned in any way ” (in the decision for state take-over of Medicaid).
STATUS OF MEDICAID/ Continued
quiry and advisory services would be carried out by the State.
Two other items of major importance were like- wise to be our sole responsibility — organization
planning and fiscal agent selection.
★ * *
This then brings us to the first item of attention, the selection of a fiscal intermediary for the new system. The design requirements spelled out, in detail, those functions to be carried out by a fiscal agent. In order to ensure that these duties would be performed for the least cost consistent with a high standard of performance, it was decided to permit all interested parties to bid on the work. A letter requesting an indication of interest and qual- ifications was sent to eighteen outside organiza- tions on October 1, 1970. Positive indication was received from seven. On December 15, 1970, a re- quest for proposal was issued and on February 1, 1971, responses were received from four: Blue Cross, Blue Shield, Nationwide and Prudential. The state had also determined the cost and feasibility of becoming its own fiscal agent during this time.
A fiscal agent review committee composed of two Senators, two Representatives and two mem- bers of the Executive Office was established to re- view all proposals. In May, after extensive analysis, it was decided that further discussion and negotia- tion should be carried out with Blue Cross and Blue Shield. This occurred during June and July. By early August revised proposals had been sub- mitted and examined.
A meeting of the review committee was then convened at which time it was determined that the fiscal agent functions of the new Medicaid system should be administered by the state itself.
It is my observation that the bases for this deci- sion were two. First, the proposals of the Blues represented an annual cost of some $1.0 million over that of the state. Second, the decision was consistent with sound management principles: The integration of similar responsibilities into one or- ganization thus reducing communications problems; The elimination of duplication of effort.
I think it important to emphasize that at no time was the ability or integrity of either individuals of Blue Cross and Blue Shield, or the organizations as a whole, questioned in any way.
Let me take just a minute to outline the major components of the cost differential. Quite under- standably there has been some questioning of gov- ernment’s ability to do anything for less money than those outside.
I’m sure you know that the Department must create and maintain a computer file of eligible re- cipients. In order for anyone else to process claims, they must have a copy of this file and an- nual cost of this duplication approaches $150,000. Other areas of major cost differentials were in pro- vider enrollment and invoice processing. The rea- sons for differences here are not so clear, but they amount to some $550,000 annually.
Turning to the specifics of the transfer, we ex- pect to begin on April 1, 1972, and complete the process by the following April. The exact schedule is now a matter of discussion, but will be an- nounced as soon as possible. Generally, we will make the transition on a provider type by provider type basis.
Let me now turn to four features which we are confident will be welcomed by providers:
1. Any claims which are not subject to special review, such as individual consideration, will be processed and paid within 30 days;
2. A remittance advice will accompany each payment. It will detail all claims received and note their status. Where payment is other than billed, an explanation will be provided;
3. Providers will be able to place their own identification or file numbers on the invoice and receive them back on payments to ease bookkeeping; and,
4. A mechanism for positive determination of eligibility will be available.
* * *
We have just identified the second major item of concern — recipient eligibility.
As most of you are painfully aware, this repre- sents the greatest single obstacle to the efficient operation of Medicaid. Why? Most simply put, be- cause eligibility informatidn is not always accurate nor is it always timely. Without boring you with de- tails, suffice it to say that it takes from 9-13 weeks
50 MICHIGAN MEDICINE JANUARY 1972
to move information from the county to the state to the Blues. Hence the inordinate non-eligible re- jection rate.
The solution of this problem is underway and represents one of the most massive management efforts ever undertaken by the Department of So- cial Services. When fully implemented the Client Information System will:
1. Ensure that eligibility files are accurate and timely.
2. Issue M.A. identification cards only after the file to be used in invoice processing is prop- erly updated.
3. Provide state-wide information to all author- ized inquirers.
4. Maintain positive control over all data con- tained within the system.
5. Control the processing of applications for assistance and services.
6. Provide reports which will assist the Depart- ment in case load management at the county office.
This will all be accomplished through the use of an “on-line” telecommunications network. In lay- man’s language this means that changes will be made directly into the computer rather than by mailing paper to the state office where it is man- ually put into batches, keypunched, verified and then entered into the computer. This latter process now accounts for a good portion of the 9-13 weeks mentioned earlier.
Because of the scope and complexity of the Client Information System, it is being implemented in phases. Complete state-wide operation is sched- uled for the first quarter of 1973. At this time, we do have the capability to inquire against the files — which are still updated by paper. In early 1972 the first county will begin “on-line” update. Others will follow as rapidly as possible and following “on- line” update, “on-line” registration will occur.
The important thing to you, however, is that as more and more counties go “on-line” the state’s files will become more timely and more accurate. When fully operational, virtually instantaneous file changes will occur whenever counties determine an action is indicated.
M.A. identification cards will be issued the eve- ning of the day in which the file is changed and since this file will also serve as recipient eligibility verification for invoice processing, accuracy is as- sured in that function as well.
At some time in the future, we fully intend to make this telecommunications network available to providers. I assure you that we will keep the So- ciety advised of our progress in this area.
Next, I would like to touch on what we are doing to close what we recognize to be our communica- tions gap. It certainly is no secret that a clearly written, easily used provider manual for the Mich- igan Medicaid Program does not exist today. One of the primary responsibilities of a newly created Provider and Recipient Services unit will be the
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development and maintenance of such a document. It will contain information on recipient eligibility, provider enrollment, how to prepare invoices, etc., and will be geared to the specific needs and con- cerns of the various provider types. Obviously, these must be available prior to the transfer of fiscal agent duties to the state. Since this transfer will occur on a provider by provider basis, how- ever, a proper sequencing will permit us to meet this obligation.
We also are planning “billing seminars” which will be held around the state to ensure that the people who prepare claims for you fully understand what is expected of them.
gates. We have also recently obtained a copy of the Society’s research bulletin which reports “Trends in Overhead Costs of Medical Practice.” It suggests that costs as a percent of revenues do not vary significantly across the state.
We anticipate arriving at a decision on physician reimbursement methodology prior to the implemen- tation of the new invoice processing system for physicians. Since this will occur no earlier than next fall, sufficient lead time still exists to permit a thorough review of alternatives. Dr. Leland Hall, Deputy Director for Research and Program Anal- ysis, whom I think is familiar to some of you, will provide needed expertise in this analysis.
In short, we recognize that we must give this area explicit attention and are taking steps to do so.
* ★ *
The next subject is no less complex than at least two already discussed.
When Representative Raymond Kehres mailed a questionnaire to Michigan’s physicians last May some 39% of those responding indicated that they didn’t understand the current method of reimburse- ment for services rendered under Medicaid. I can’t say I blame them. Most briefly put, Medicaid, like Blue Shield itself, pays the lesser of: 1. the charge; 2. the physician’s usual and customary fee for that procedure; or 3. the prevailing rate for that pro- cedure in his area. That is the mechanism. I am quick to recognize one other factor of major im- portance.
Pursuant to H.E.W. Policy Regulation 40-4, effec- tive July 1, 1969, reimbursement for physicians is frozen at amounts paid as of January 1, 1969. While Medicare has since relaxed this somewhat, the Medicaid program has not. We are cognizant of the inequities inherent in this policy — the rela- tive freedom of the brand new physician to set his usual and customary rate as he enters practice, while those in practice in 1969 are held to their then usual and customary amounts. Our concerns have been made known to Washington, but to date we have no indication that this regulation is to be modified or removed.
In this regard it is important to note another por- tion of 40-4 which can be summarized as follows:
Any change in reimbursement methodology can- not be made in a way which circumvents the es- sence of the 1969 freeze.
All this is by way of saying that if it is deter- mined to use a relative value schedule in Medicaid, the conversion amount would have have to be in conformity with current regulation. I might add here, that at the request of the Michigan State Medical Society we will use the Current Procedural Terminology designations and have provided capa- bility to carry the appended relative value into the payment system. Whether or not a relative value schedule is to be adopted is a matter under cur- rent examination and notes the passage of Resolu- tion 6 at your last meeting of the House of Dele-
52 MICHIGAN MEDICINE JANUARY 1972
The fifth and final topic is that of peer review.
Ever increasing public attention is being focused on the “high cost of health care” and one of the mechanisms held forth as a means to lessen the increase is peer review. You are all familiar with utilization review committees, for example. In re- cent years, some state medical societies have cre- ated medical foundations to provide a means for peer review in its broadest sense. I understand that a similar move is contemplated here. We welcome such a development.
Until such time as this occurs, however, we are working directly with the Society in the develop- ment of a peer review process for Medicaid. A committee of four physicians has been appointed by The Council to work with the Department of Public Health with which we have a contract to carry out this function. We are most pleased and encouraged by its progress.
Let me emphasize our firm belief that only through the help and cooperation of physicians can any measure of real improvement be achieved in the delivery of health services to Michigan’s citizens.
As I have indicated, we are making a major ef- fort to improve the administration and operation of Medicaid. Until this is accomplished, primary atten- tion is necessarily given to the many day-to-day crises brought on by the inability of a quickly de- veloped system to deal with a massive program.
We have high hopes that this stage of develop- ment will soon be behind us and that we can to- gether move on to address ourselves to the more significant problems in health care.
“We are making a major effort to im- prove the administra- tion and operation of Medicaid
Established 1924
MERCYWOOD HOSPITAL
4038 Jackson Road
o.
Conducted by Sisters of Mercy Ann Arbor, Michigan Telephone — 313 663-8571
Mercywood Hospital is a private neuropsychiatric hospital licensed by the Michigan Department of Mental Health. Mercywood specializes in intensive, multi-disciplinary treatment for emotional and mental disorders.
Accredited by the Joint Commission on Accreditation of Hospitals and the National League of Nursing. A full Blue Cross participating hospital.
Certified for: Medicare and M.A.A. programs
Robert J. Bahra, M.D.
Dean P. Carron, M.D. Francis M. Daignault, M.D. Gordon C. Dieterich, M.D. James R. Driver, M.D.
(Active & Associate)
Robert L. Fransway, M.D. Stuart M. Gould, Jr., M.D. Sydney Joseph, M.D. Hubert Miller, M.D.
Jacob J. Miller, M.D. Rudolf E. Nobel, M.D.
Gerard M. Schmit, M.D. Joseph J. Tiziani, M.D. Prehlad S. Vachher, M.D. Richard D. Watkins, M.D. Robert M. Zimmerman, M.D.
The treatment of
impotence
\ due to androgenic deficiency in the American male.
The concept of chemotherapy plus the JNk Physician s psychological support is confirmed Kjf J| as effective therapy.
( NE'N A
CU*«cM-
l STUO^f j
The Treatment of Impotenpe with Methyltestosterone Thyroid (100 patients — Double Blind Study) T. Jakobovits
Fertility and Sterility, January 1970 Official Journal of the American Fertility Society
Android
(thyroid-androgen) tablets
Choice of 4 strengths:
Android Android-HP
Android-x Android-Plus
Each yellow tablet contains: Methyl Testosterone ..2.5 mg. Thyroid Ext. (1/6 gr.) . .10 mg.
Glutamic Acid 50 mg.
Thiamine HCL 10 mg.
Dose: 1 tablet 3 times daily. Available:
Bottles of 100, 500, 1000.
HIGH POTENCY
Each red tablet contains: Methyl Testosterone ..5.0 mg. Thyroid Eit. (Vi gr.) ... 30 mg.
Glutamic Acid 50 mg.
Thiamine HCL .... 1 ... 10 mg. Dose: 1 tablet 3 times daily. Available:
Bottles of 100, 500. 1000.
EXTRA HIGH POTENCY
Each orange tablet contains: Methyl Testosterone .12.5 mg.
Thyroid Eit. (1 gr.) 64 mg.
Glutamic Acid 50 mg.
Thiamine HCL 10 mg.
Dose: 1 or 2 tablets daily. Available:
Bottles of 60, 500.
WITH HIGH POTENCY B-C0MPLEX AND VITAMIN C
Each white tablet contains: Methyl Testosterone ..2. 5 mg. Thyroid Eit. ('/« gr.) ... 15 mg. Ascorbic Acid (Vit. C) .250 mg.
Thiamine HCL 25 mg.
Glutamic Acid 100 mg.
Pyridoxine HCL 5 mg.
Niacinamide 75 mg.
Calcium Pantothenate .10 mg.
Vitamin B-12 2.5 meg.
Riboflavin 5 mg.
Dose: 2 tablets daily. Available: Bottles of 60, 500.
Double-Blind Study and Type of Patient:
100 patients suffering from impotence. Of the patients receiving the active medication (Android) a favourable response was seen in 78%. This compares with 40% on placebo. Although psychotherapy is indi- cated in patients suffering from functional impotence the concomitant role of chemo- therapy (Android) cannot be disputed.
Contraindications: Android is contraindicated in patients with prostatic carcinoma, severe cardiorenal disease and severe persistent hypercalcemia, coronary heart disease and hyperthyroidism. Occasional cases of jaundice with plugging biliary canaliculi have occurred with average doses of Methyl Testos- terone. Thyroid is not to be used in heart disease and hypertension.
Warnings: Large dosages may cause anorexia, nausea, vomiting abdominal pain, diarrhea, headache, dizziness, lethargy, paresthesia, skin eruptions, loss of libido in males, dysuria, edema, congestive heart failure and mammary carcinoma in males.
Precautions: If hypothyroidism is accompanied by adrenal insufficiency the latter must be corrected prior to and during thyroid administration.
Adverse Reactions: Since Androgens, in general, tend to promote retention of sodium and water, patients receiving Methyl Testosterone, in particular elderly patients, should be observed for edema. Hypercalcemia may occur, particularly in immobilized patients: use of Testosterone should be discontinued as soon as hypercalcemia is detected.
thyroid compound. West Med 5:67, 1964 3. Titeff, A. S. Methyltestosterone-thyroid in treating impotence Gen Prac 25:6, 1962 4. Heilman, L., Bradlow, H. L., Zumoff. B., Fukushima, D. K.,and Gallagher, T F Thyroid-androgen interrelations and the hypocholesteremic effect of androsterone J Clin Endocr 19:936 1959. 5. Farris, E. J., and Colton, S. W. Effects of L-thyroxine and liothyronine on spermatogenesis J Urol 79:863, 1958. 6. Osol, A., and Farrar. G. E. United States Dispensatory (ed, 25). Lippincott, Phi delphia. 1955, p. 1432. 7. Wershub, L. P. Sexual Impotence in the Male. Thomas, Springfield III., 1959, pp. 79-99.
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MICHIGAN MEDICINE JANUARY 1972 53
New Feature: County Spotlight
Kent County leads the nation in emergency care
By Jeanne Smith Assistant
MSMS Communications
Early this year, one of the potentially most effec- tive emergency medical care programs in the coun- try will be operative in the Grand Rapids area as the latest achievement of the Kent County Medical Society’s emergency services committee.
The dedicated physicians who have worked in this program since it began seven years ago with first aid classes for policemen and firemen talk about the program in terms of the accident victims it has aided, the acutely ill individuals it has helped.
But the public relations value of the program, which recently caused the Grand Rapids Press to comment editorially, “There are few communities that can boast anything similar to it,” cannot be overlooked.
The latest achievement in the Kent County pro- gram involves installation of a separate radio sys- tem linking police emergency vehicles and private
(See related editorial, page 76)
ambulances to emergency rooms of Grand Rapids hospitals and special training of police and ambu- lance attendants in electrocardiography, the same training given nurses working in intensive care units in hospitals.
With equipment already installed in emergency vehicles and ambulances, emergency personnel will be able to relay electrocardiograms to be printed out in emergency rooms.
The specially trained police and ambulance at- tendants will be permitted to proceed with defibril- lation and other emergency treatment for patients under direct instructions from physicians given by radio from emergency rooms.
Financing of the $40,000 program has been ar- ranged by the Kent County Medical Society under a grant from the federal government, with the aid of matching local funds obtained by the society.
It is the first such program in Michigan and is believed to be one of only two now being under- taken in the United States.
The new aid for heart patients becomes the latest step in the program that began under im- petus from C. Mark Vasu, MD, chairman of the
(Photo courtesy of Grand Rapids Press)
C. Mark Vasu, MD, chairman of the Kent County Medical Society emergency services committee, explains use of defibrillator to Grand Rapids policement.
Kent County emergency services committee. Start- ing with first aid courses, the next step was the establishment of the “Crash Squad” of volunteer physicians who devote weekends to duty with po- lice emergency vehicles, not only providing med- ical care but also giving in-service training to po- lice personnel.
Doctor Vasu, along with other key members of his committee, Lee R. Pool, MD, John R. Wilson, MD, and Fred A. Doornbos, MD, have police radios in their cars and frequently respond to off-time emergency calls as well as taking their regular turns of duty on the list of 20 MD “Crash Squad” volunteers.
Specialized training for police assigned to the emergency vehicles has produced skilled person- nel devoted to their work. Special arm patches have been provided for them by the county med- ical society.
“We have seen this develop as an important community relations program for police,” said Doc- tor Pool. “The E Units have become well known and, particularly in the inner city, help alleviate fear of police.”
As of January 1, only police who have com- pleted specialized training are assigned to emer- gency units, eliminating the one-time system of ro- tating emergency vehicle service for police as for other types of duty.
Grand Rapids firemen regularly complete courses in cardiopulmonary resuscitation in a KCMS-Mich- igan Heart Association program.
According to Doctor Vasu, Grand Rapids’ ambu- lance ordinance, adopted in 1968 with the urging
54 MICHIGAN MEDICINE JANUARY 1972
f the county medical society, has been vital in im- lementing the work of the emergency services ommittee.
He called the Grand Rapids code “the strongest mbulance ordinance of its type in the United tates,” adding, “It is strong because it requires /vo men in an ambulance instead of one man as is pecified in the state ordinance and it provides ad- itional training which can be matched no where Ise.”
Each of the physicians involved in the Kent ounty program has his own special reasons for is interest, but Doctor Vasu summarized the gen- ral motivation for participation:
“The Grand Rapids and Kent County area has ttracted attention nationwide to some of the more nique aspects of our program. When we carefully nalyze these aspects, we find that it boils down ) one simple fact, that the physician has willingly nd graciously allowed himself to be involved in ommunity affairs.”
■lints for county societies onsidering this idea:
contributed to the success of the seven-year- old emergency care program in Grand Rapids.
In addition to providing an important com- munity service, the program has had strong public relations value for physicians as well as for police in Grand Rapids.
According to the committee, the medical community must take the lead in establishing such a program. Here are some of the in- gredients:
1. A group of physicians who are moti- vated to see improvements in the emergency care given accident victims.
2. Rapport and cooperation with police and fire departments.
3. A strong ambulance ordinance, as writ- ten into law in Grand Rapids, insuring that the patient is getting attention from qualified personnel. Kent County physicians note that pressure from the medical profession is im- portant in achieving effective ordinances cov- ering operation of ambulances.
4. A group such as the KCMS emergency services committee to explore and propose programs.
Intense interest and activity by members of the Kent County Medical Society’s emergency services committee, along with the backing and cooperation of the entire society, have
SOME PHYSICIANS KNOW what to do with their patients who are alcoholics or problem drinkers.
SOME PHYSICIANS WISH they knew what to do with them.
Have you thought of the Alcoholism Services of the Battle Creek Sanitarium Hospital? Since 1965 we have maintained an enviable record in the rehabilitation of the alcoholic or problem drinker.
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5. Backing of the local medical society in seeking cooperation of involved community agencies, seeking outside financing if neces- sary and implementing programs.
“My secret ?
For heartburn I always use ‘Dicarbosil’.”
Dicarbosil.
ANTACID
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In the coronary ischemic patient on cerebral or peripheral vasodilator therapy
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• conflicts have not been reported with diuretics, corticosteroids, antihypertensives or miotics.
• complications in the treatment of diabetes hypertension, peptic ulcer, glaucoma or liver disease have not been reported.
In fact, there are no known contraindica- tions in recommended oral doses other than it should not be given in the presence of frank arterial bleeding or immediately postpartum.
Although not all clinicians agree on the value of vasodilators in vascular disease, several investigators'''1 have reported favorably on the effects of isoxsuprine. Effects have been dem- onstrated both by objective measurement and observation of clinical improvement. 1,3 Indications: Cerebrovascular insufficiency, arteriosclerosis obliterans, diabetic vascular diseases, thromboangiitis obliterans (Buerger’s disease), Raynaud’s disease, postphlebitic conditions, acroparesthesia, frostbite syndrome and ulcers of the extremities (arterio- sclerotic, diabetic, thrombotic). Composition: VasodTlan tablets, isoxsuprine HC1 10 mg. and 20 mg. Dosage: Oral — 10 to 20 mg. t.i.d. or q.i.d. Contraindications and Cautions: There are no known contraindications to recommended oral dosage. Do not give imme- diately postpartum or in the presence of arterial bleeding. Side Effects: Occasional pal- pitation and dizziness can usually be controlled by dosage reduction. Complete details available in product brochure from Mead Johnson Laboratories. References : (1) Clarkson, I. S., and LePere, D. M. : Angiology 77:190-192 (June) 1960. (2) Horton, G. E., and Johnson, P. C., Jr. : Angiology 75:70-74 (Feb.) 1964. (3) Dhry- miotis, A. D., and Whittier, J. R. : Curr. Ther. Res: 7:124-128 (April) 1962. (4) Whittier, J. R. : Angiology 75 :82-87 (Feb.) 1964.
© 1971 MEAD JOHNSON a COMPANY • EVANSVILLE, INDIANA 47721 U.S.A.
182971
LABOR ATO RIBS
£Micliigaii medisceqe
Jan. 5 — Council of Medical Specialty Societies, 2 p.m., MSMS Headquarters, contact: Glenn E. Moore, MD, 323 W. Second St., Flint, 48503 Jan. 7-9 — Michigan Allergy Society Family Winter Weekend, Shanty Creek Lodge, contact: Rudolph E. Wilhelm, MD, Michigan Allergy Society, 751 S. Military Rd., Dearborn, 48124 Jan. 19 — Conference on Changing Patterns of Care for Children and Youth, Michigan Nurses Asso- ciation, 9:30 a.m., MNA Headquarters, contact: Mrs. Susan Gerds, conference secretary, MNA, 120 Spartan Ave., East Lansing, 48823 Jan. 21 — Michigan Association for Regional Med- ical Programs, board meeting, 2 p.m., MSMS Headquarters, contact: Miss Gaetane LaRocque, acting coordinator, MARMP, 1111 Michigan, East Lansing, 48823
Jan. 24-28 — Family Practice Review with the Mich- igan Academy of Family Physicians, Towsley Center, University Medical Center, Ann Arbor, contact: Neal A. Vanselow, MD, acting chairman, Department of Postgraduate Medicine, Towsley Center, Ann Arbor, 48104
Jan. 25 — Woman’s Auxiliary to MSMS, executive committee meeting, MSMS Headquarters, con- tact: Mrs. Charles Schoff, 5209 Sunset Drive, Mid- land, 48640
Jan. 29-30 — Educational seminar and board meet- ing, Michigan State Medical Assistants Society, Holiday Inn, Battle Creek, contact: Patricia Voke, 196 S. Woodrow Ave., Battle Creek 49015 Feb. 9— Michigan Committee on Trauma, American College of Surgeons, 6:30 p.m., MSMS Head- quarters, contact: Thomas C. Blair, MD, 1322 E. Michigan Ave., Lansing, 48912 March 20-21 — Spring Session, MSMS House of Delegates, Detroit Hilton Hotel, contact: Richard Campau, MSMS Headquarters March 26 — Board meeting, Michigan State Medical Assistants Society, 11 a.m., MSMS Headquarters, contact: Mrs. Betty L. Boers, president, MSMAS, 1116 Sheridan, Kalamazoo, 49001 March 29 — Muskegon Trauma Day, Holiday Inn, Muskegon, contact: Guida Anessa, MD, 205 Med- ical Center, Muskegon
March 29-30 — Annual Michigan Conference on Ma- ternal and Perinatal Health, Olds Plaza Hotel, Lansing, contact: Joseph L. Sheets, MD, 2909 E. Grand River, Lansing, or Helen Schulte, MSMS Headquarters
April 3 — Annual Beaumont Lecture — Wayne County Medical Society, Detroit, contact: William Blod- gett, MD, Wayne County Medical Society, 1010 Antietam, Detroit, 48207
April 13-15 — Michigan Heart Association Heart Days, Cobo Hall, Detroit, contact: Harold Arnow, publicity director, MHA, 13100 Puritan, Detroit, 48227
April 19 — Woman’s Auxiliary to MSMS, Legislative Day, Olds Plaza, Lansing, contact: Mrs. R. J. Westerhoff, WAMSMS legislative chairman, 2458 Maplewood, SE, Grand Rapids, 49506 April 19-20 — Woman's Auxiliary to MSMS, spring conference, Hospitality Inn, Lansing, contact: Mrs. Charles Schoff, 5209 Sunset Drive, Midland, 48640
April 27-30 — Annual Convention, Michigan State Medical Assistants Society, Holiday Inn, Cross- town Parkway, Kalamazoo, contact: Mrs. Betty Boers, 1116 Sheridan, Kalamazoo, 49001 April 30-May 5 — American Nurses Association Bi- ennial Convention, Cobo Hall, Detroit, contact: Miss Virginia Stone, executive director, Detroit District, Michigan Nurses Association, 316 Fisher Building, Detroit, 48202
May 18-19 — Annual Gull Lake meeting, MSMS Com- mittee on Maternal and Perinatal Health, Kellogg Biological Station, Gull Lake, contact: Helen Schulte, MSMS Headquarters May 22-23 — Michigan chapter meeting and scien- tific session of the American College of Emer- gency Physicians, Shanty Creek, Bellaire, con- tact: Gaius Clark, MD, 865 Pebblebrook Lane, East Lansing, 48823
June 2-3 — Gaylord Trauma Day, Hidden Valley Ot- sego Ski Club, Gaylord, contact: Benjamin Henig, MD, Keyport Clinic, 308 Michigan Ave., Grayling, 49738
June 5-7 — Initial Management of the Acutely III and Injured Patient, Ann Arbor, contact: Charles F. Frey, MD, Department of Surgery, University of Michigan Medical Center, Ann Arbor, 48104
MSMS bureau has new member file
The MSMS Bureau of Economic Information has developed, with the help of the AMA, a new com- puter system that will have vital information on each member physician. The system will be up- dated on a yearly basis, through the use of the AMA’s master files, and will facilitate specific mail- ings.
Some of the information maintained on each member will be his year and place of graduation, his specialty and his board achievements. Qualified associations may obtain such information from the Bureau.
For further information, contact John H. Anthony, chief of the bureau, at MSMS headquarters.
What better forum for your ideas is there than Michigan Medicine, which monthly reaches over 8,000 physicians? Instead of let- ting your flashes of insight, gripes and full- blown theories end with the hospital staff meeting or colleagues gathered over coffee, develop them, put them on paper and mail them to Michigan Medicine.
Maybe you can move mountains.
58 MICHIGAN MEDICINE JANUARY 1972
For my patients who need a laxative, I recommend EVAC-U-GEN . . . because it relieves constipation gently . . . particularly important in cardiac and post surgical patients
FVA(M I-CFM very^pa£a table
JLj V £ ^ economical
A highly-flavored and palatable tablet of yellow phenolphthalein, bismuth subcarbonate, bismuth subgallate in special base. Chewable. Bottles of 35 and 100. Adult Dose: Chew 1 or 2 tablets night or morning. Children (up to age 10): 1/2 tablet. A citrus drink taken with tablet will stimulate action.
PRECAUTION: Do not use when symptoms of appendicitis are present and discontinue use if skin rash appears. Dependence on laxatives can result from continued use.
WALKER, CORP & CO., INC. Syracuse, New York 13201
MICHIGAN MEDICINE JANUARY 1972 59
^Itl memoriam
J. Kenner Bell, MD Highland Park
Detroit-area gastroenterologist for 40 years, J. Kenner Bell, MD, died Nov. 25 at the age of 73.
Doctor Bell was former doctor for the Highland Park Police Department, and medical director of the Shrine Circus and the Moslem Shrine in De- troit.
Doctor Bell was graduated from the University of Toronto School of Medicine and was affiliated with Hutzel and Receiving hospitals of Detroit and Highland Park General Hospital, where he was a past chief of staff. He had been a member of the council of the Detroit Gastroenterological Society.
A. W. Byrnes, MD Battle Creek
A. W. Byrnes, MD, former director of the Battle Creek VA Hospital from 1963 to 1967, died Nov. 3 at the age of 61.
Doctor Byrnes, a native of Traer, Iowa, had also served as chief of the neuropsychiatric service at
VA facilities in Dayton, Ohio; as chief of physical medicine and rehabilitation service at the Downey, III., and Danville, III., VA hospitals; as chief of staff at the St. Cloud, Minn., VA hospital and as director of the Knoxville, Iowa, VA hospital.
Doctor Byrnes also had held medical positions with the Army and was a retired lieutenant colonel. He was a graduate of the Iowa University School of Medicine.
Willard Chipman, MD Detroit
Willard Chipman, MD, former chief of staff at Mt. Carmel Mercy Hospital, died Nov. 30 at the age of 74.
Doctor Chipman was a graduate of Harvard Med- ical School and had practiced medicine for 50 years. He was a member of the American College of Surgeons, the International College of Surgeons and the Society of Abdominal Surgeons.
William T. Krebs, MD Grosse Pointe Farms
William Thomas Krebs, MD, a Detroit-area gen- eralist, died Dec. 2 at the age of 63. He had served as medical director for the Hudson Motor Par Co. from 1937-1946.
Doctor Krebs was graduated from University of Michigan Medical School and was affiliated with
ypecia
tized St
PROFESSIONAL LIABILITY INSURANCE
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60 MICHIGAN MEDICINE JANUARY 1972
Cottage and Evangelical Deaconess hospitals in Detroit. He was a charter member of the Michigan Industrial Hygienic Society and also was a mem- ber of the American Association of Industrial Hy- gienists.
Herbert K. Kent, MD Lansing
Retired Lansing physician Herbert K. Kent, MD, died Nov. 4 at the age of 77.
Doctor Kent was a life member of the Ingham County Medical Society and had been on the senior staffs at Sparrow and Ingham Medical hos- pitals in Lansing.
An enterologist, Doctor Kent was a graduate of Loyola University.
John J. Long, Sr., MD Southfield
John Joseph Long, MD, Southfield generalist, died Nov. 8 at the age of 66.
Doctor Long was a staff member of Mt. Carmel Mercy Hospital, and had been a member of the Wayne County Medical Society Council. He was graduated from Detroit College of Medicine and was a member of the American Academy of Fam- ily Physicians.
Daniel Landron, MD Jackson
Daniel Landron, MD, Jackson generalist, died Nov. 26 at the age of 63. He was affiliated with W. A. Foote and Mercy hospitals in Jackson. Doc- tor Landron was a native of Puerto Rico. He was graduated from Temple University School of Med- icine.
Doctor Landron was vice president of the Jack- son County Doctor’s Emergency Service which he helped found. He was a member of the American Academy of Family Physicians.
Harold C. Mitchell, MD Grand Rapids
Harold C. Mitchell, MD, retired Grand Rapids physician, died Nov. 6 at the age of 70.
Doctor Mitchell had served as chief medical of- ficer at the Michigan Veterans Facility in Grand Rapids, as chief medical officer at,Coldwater Train- ing School for Children and chief officer at Ionia Reformatory. He also had been in private practice in Grand Rapids and Bay City.
Doctor Mitchell was a graduate of the University of Toronto Medical School and was a past presi- dent of the Mecosta-Osceola-Lake and Branch county medical societies.
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MICHIGAN MEDICINE JANUARY 1972 61
IN MEMOR I AM /Continued
Bradley M. Patten, PhD Ann Arbor
Bradley M. Patten, PhD, professor and chairman emeritus of the University of Michigan Medical School’s anatomy department, died Nov. 8 at the age of 82. Doctor Patten was a member of the Washtenaw County Medical Society.
An internationally recognized researcher in his field, Doctor Patten authored textbooks used world- wide. He is credited with laying the cornerstone of modern embryological teaching and with being one of the top scientists in his field for his pioneering work in time-lapse cinematography for the study of early developmental changes in heart and blood vessels.
Doctor Patten was U-M anatomy department chairman from 1936 to 1958 when he retired.
E. C. Raabe, MD Morenci
Elmer Charles Raabe, MD, Morenci generalist, was struck and killed by a truck Nov. 11. He was 75.
Doctor Raabe had practiced medicine in Morenci since 1925 and was affiliated with Morenci Area Hospital, where he was chief of staff this year, and Bixby Hospital in Adrian. He was a graduate of Ohio State University School of Medicine.
Doctor Raabe was a past president of the Len- awee County Medical Society.
David Standiford, MD Bay City
David Standiford, Bay City obstetrician-gynecolo- gist, died Oct. 27 after a long illness. He was 47.
Doctor Standiford was a graduate of the Univer- sity of Michigan Medical School and was affiliated with Mercy and General hospitals in Bay .City. He was certified with the American Board of Obstetrics and Gynecology and was a member of the Interna- tional Society for the Advancement of Humanistic Studies in Gynecology.
Max 0. Wolfe, MD Detroit
Retired Detroit Psychoanalyst Max O. Wolfe, MD, died Nov. 25 at the age of 74.
Doctor Wolfe was a graduate of Marquette Uni- versity School of Medicine and had practiced in Detroit until retiring seven months ago. He was a former director of the Haven Sanitarium in Roch- ester, past Michigan president of the Cornelian Corner and past treasurer of the Detroit Psycho- analytic Society.
PFIZERPEN VK
(POTASSIUM PHENOXYMETHYL PENICILLIN)
ACTIONS: Microbiology: Phenoxymethyl penicillin
exerts high in vitro activity against staphylococci (ex- cept penicillinase-producing strains), streptococci (groups A, C, G, H, L, and M) and pneumococci. Other organisms sensitive to phenoxymethyl penicillin are Corynebocterium diphtheriae. Bacillus anthracis, Clos- tridia, Actinomyces bovis, Streptobocillus moniliformis. Listeria monocytogenes, Leptospira, and Neisseria go n- orrhoeae Treponema pallidum is extremely sensitive. Pharmacology: Phenoxymethyl penicillin is more re- sistant to inactivation by gastric acid than penicillin G. It may be given with meals and average blood levels are two to five times higher than the levels following the same dose of oral penicillin G Once absorbed, phenoxymethyl penicillin is about 80% bound to serum protein. Tissue levels are highest in the kidneys, with lesser amounts in the liver, skin, and intestines and small amounts in all other body tissues and cerebro- spinal fluid. Only about 25% of the dose given is absorbed. In neonates, young infants, and individuals with impaired kidney function, excretion is considerably delayed.
INDICATIONS: Phenoxymethyl penicillin is indicated in the treatment of mild to moderately severe infections caused by penicillin G-sensitive microorganisms that are sensitive to the low serum levels common to this
articular dosage form Therapy should be guided by
acteriological studies (including sensitivity tests) and by clinical response. Culture and sensitivity testing are especially important in suspected staphylococcal infec- tions because increased resistance has been reported. Phenoxymethyl penicillin is not active against penicil- linase-producing bacteria
Note: Severe pneumonia, empyema, bacteremia, peri- carditis, meningitis, and arthritis should not be treated with phenoxymethyl penicillin during the acute stage.
Indicated surgical procedures should be performed.
Medical conditions in which oral penicillin therapy is indicated as prophylaxis: For the prevention of recur- rence following rheumatic fever and/or chorea. To pre- vent bacterial endocarditis in patients with congenital and/or rheumatic heart lesions who are to undergo dental procedures or minor upper respiratory tract sur- gery or instrumentation.
Note Oral penicillin should not be used as adjunctive prophylaxis for genitourinary instrumentation or sur- gery, lower intestinal tract surgery, sigmoidoscopy and childbirth.
CONTRAINDICATION: A previous hypersensitivity reac- tion to any penicillin.
WARNINGS: Serious and occasionally fatal hypersen- sitivity (anaphylactoid) reactions have been reported in patients on penicillin therapy. While more frequent fol- lowing parenteral therapy, anaphylaxis has occurred in patients on oral penicillins. These reactions are more apt to occur in individuals with a history of sensitivity to multiple allergens.
Some individuals with a history of penicillin hyper- sensitivity reactions have experienced severe hypersen- sitivity reactions from a cephalosporin. Before therapy with a penicillin, careful inquiry should be made con- cerning previous hypersensitivity reactions to penicillins, cephalosporins, and other allergens. If an allergic reac- tion occurs, the drug should be discontinued and the patient treated with the usual agents, e.g., pressor amines, antihistamines and corticosteroids. PRECAUTIONS: Penicillin should be used with caution in individuals with histories of significant allergies and/or asthma.
The oral route of administration should not be relied on in patients with severe illness, or with nausea, vomiting, gastric dilatation, cardiospasm, or intestinal hypermotility.
Occasional patients will not absorb therapeutic amounts of orally administered penicillin.
In streptococcal infections, therapy must be sufficient to eliminate the organism (10 days minimum); other- wise the sequelae of streptococcal disease may occur. Cultures should be taken following completion of treat- ment to determine whether streptococci have been eradicated.
Prolonged use of antibiotics may promote the over- growth of nonsusceptible organisms, including fungi. Should superinfection occur, appropriate measures should be taken
ADVERSE REACTIONS: While the incidence of reactions to oral penicillins is much less than with parenteral therapy, it should be remembered that all degrees of hypersensitivity, including fatal anaphylaxis, have been reported with oral penicillin.
The most common reactions to oral penicillin are nausea, vomiting, epigastric distress, diarrhea, and black hairy tongue The hypersensitivity reactions re- ported are skin eruptions (maculopapular to exfoliative dermatitis), urticaria and other serum sickness reactions, laryngeal edema, and anaphylaxis. Fever and eosino- philic may frequently be tne only reaction observed. Hemolytic anemia, leucopenia, thrombocytopenia, neu- ropathy, and nephropathy are infrequent reactions and ore usually associated with high doses of parenteral penicillin.
HOW SUPPLIED: Pfizerpen VK (potassium phenoxy- methyl penicillin) for Oral Solution Each 5 ml. of recon- stituted solution contains potassium phenoxymethyl penicillin equivalent to 125 mg (200,000 units) or 250 mg. (400,000 units) of phenoxymethyl penicillin.
1 25 mg. bottles of 1 00 ml. and 1 50 ml.
250 mg. bottles of 1 00 ml. and 150 ml.
Pfizerpen VK (potassium phenoxymethyl penicillin) Tablets. Each tablet contains potassium phenoxymethyl penicillin equivalent to 250 mg (400,000 units) or 500 mg. (800,000 units) of phenoxymethyl penicillin.
250 mg. bottles of 100.
500 mg. bottles of 100.
More detailed professional information available on request.
LABORATORIES DIVISION
PFIZER INC . NEW YORK. N Y 10017
62 MICHIGAN MEDICINE JANUARY 1972
8S3wkS8S&^ SHE?:
Now there are two ways to cut the cost of brand-name penicillin therapy.
Pfizerpen VK now joins Pfizerpen G (potas- sium penicillin G) for true economy in brand-name penicillin therapy.
When you write penicillin VK, it's for acid stability, solubility and rapid absorption. But when you write Pfizerpen VK, you add economy. Pfizerpen VK, more economical than the two leading brand-name peni- cillin VK products. G or VK. Just make sure it's Pfizerpen.
Tablets and Powder for Syrup
, PFIZERPEN VK 4
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Name
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City/State/Zip
Who are they? Why are they rejected by the medical profession? What exactly is the cult of chiropractic?
Learn the answers to these questions and many more from a startling new book by renowned medical jour- nalist and public affairs specialist, Ralph Lee Smith.
AT YOUR OWN RISK: The Case Against Chiropractic is a probing study of chiropractors and their methods of A treatment. It follows the history of chiropractic from its conception by an Iowa grocer in 1895 to present day practices.
Travel with Mr. Smith as both patient and visitor to many of the nation’s chiropractic schools and clinics. And learn why he recommends that chiropractic be the subject of immediate legislative review.
Available from the AMA through special arrangements with the publisher. Send your order to the AMA, 535 North Dearborn Street, Chicago, Illinois 60610.
I enclose $- The Case Against Chiropractic.
copy(s) of At Your Own Risk:
All Other Countries
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INTRODUCING
Alelhol-50
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Meltrol-50 (phenformin HCI)
50 mg. timed-disintegration capsules
also Meltrol-100™
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FROM THE NEW
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When you select this familiar antibiotic for IV infusion you have available a broad dosage range that hospitalized patients may need.
Intravenous Lincocin (lincomycin hydrochloride, Upjohn), with its 1.2 to 8 grams/day dosage range, covers many serious and even life-threatening infections. Lincocin is effective in infections due to susceptible strains of streptococci, pneumococci, and staphylococci. Lincocin IV therefore can be as useful in your hospitalized patients as its IM use has proved to be in your office patients. As with all antibiotics, in vitro susceptibility studies should be performed.
In life-threatening situations as much as 8 grams/ day has been administered intravenously to adults.
1.2 to 8 grams/ day IV dosage
Most hospitalized patients with uncomplicated pneumonias respond satisfactorily to 1 .2 to 1 .8 grams/ day of Lincocin IV. These doses may have to be increased for more serious infections.
In usual IV doses, Lincocin (lincomycin hydrochloride, Upjohn) should be diluted in 250 ml or more of normal saline solution or 5% glucose in water. But when 4 grams or more per day is given, Lincocin should be diluted in not less than 500 ml of either solution, and the rate of administration should not exceed 1 00 ml/hour. Too rapid intravenous administration of doses ceeding 4 grams may result in tension or, in rare instances, cardiopulmonary arrest.
Effective gram-positive antibiotic:
Lincocin IV is effective in respiratory tract, skin and soft-tissue, and bone
nfections caused by susceptible strains >f pneumococci, streptococci, and taphylococci, including penicillin- esistant strains. Staphylococcal strains esistant to Lincocin (lincomycin lydrochloride, Upjohn) have been ecovered. Before initiating therapy, ulture and susceptibility studies should >e performed. Lincocin has proved aluable in treating patients hyper- ensitive to penicillin or cephalosporins, ince Lincocin does not share ntigenicity with these compounds, lowever, hypersensitivity reactions [ave been reported, some of these in •atients known to be sensitive to ienicillin.
administered concomitantly with other antimicrobial agents when indicated. However, Lincocin should not be used with erythromycin, as in vitro antagonism has been reported.
Sterile Solution (300 mg per ml)
(lincomycin hydrochloride, Upjohn)
For further prescribing information, please see following page.
Veil tolerated at infusion site: Lincocin itra venous infusions have not iroduced local irritation or phlebitis, (hen given as recommended. Lincocin » usually well tolerated in patients who re hypersensitive to other drugs. Nevertheless, Lincocin should be used autiously in patients with asthma or ignificant allergies.
n patients with impaired renal function tie recommended dose of Lincocin hould be reduced to 25—30% of tie dose for patients with normal idney function. Its safety in regnant patients and in infants iss than one month of age has ot been established.
jncocin may be used with other ntimicrobial agents: Since Lincocin > stable over a wide pH range, it is uitable for incorporation in itra venous infusions; it also may be
5 1972 The Upjohn Company
(lincomycin hydrochloride, Upjohn)
Up to 8 grams per day by IV infusion for hospitalized patients with life-threatening infections. Lincocin is effective in infections due to susceptible strains of streptococci, pneumococci, and staphylococci. As with all antibiotics, in vitro susceptibility studies should be performed.
Each Lincomycin
preparation hydrochloride
contains: monohydrate
equivalent to lincomycin base
250 mg Pediatric Capsule 250 mg
500 mg Capsule 500 mg
‘"Sterile Solution per 1 ml 300 mg
Syrup per 5 ml 250 mg
'■'Contains also: Benzyl Alcohol 9 mg; and, Water for Injection — q.s.
Lincocin (lincomycin hydrochloride) is in- dicated in infections due to susceptible strains of staphylococci, pneumococci, and strepto- cocci. In vitro susceptibility studies should be performed. Cross resistance has not been demonstrated with penicillin, ampicillin, cephalosporins, chloramphenicol or the tet- racyclines. Some cross resistance with eryth- romycin has been reported. Studies indicate that Lincocin does not share antigenicity with penicillin compounds.
CONTRAINDICATIONS: History of prior hypersensitivity to lincomycin or clindamy- cin. Not indicated in the treatment of viral or minor bacterial infections.
WARNINGS: CASES OF SEVERE AND PERSISTENT DIARRHEA HAVE BEEN REPORTED AND HAVE AT TIMES NECESSIT ! 77 D DISCONTINUANCE OF THE DR l (E 1 HIS DIARRHEA HAS BEEN OCCASIONALLY ASSOCIATED WITH BLOOD AND MUCUS IN THE STOOLS AND HAS AT TIMES RE- SULTED IN CUTE COLITIS. THIS SIDE EFFECT l LY HAS BEEN
ASSOCIATED WITH INF ORAL DOS- AGE FORM BUT LY HAS
BEEN REPORTED FOLLOWING PA- RENTERAL THERAPY . A careful inquiry should be made concerning previous sensi- tivities to drugs or other allergens. Safety for use in pregnancy has not been estab- lished and Lincocin (lincomycin hydrochlo- ride) is not indicated in the newborn. Reduce dose 25 to 30% in patients with severe im- pairment of renal function.
PRECAUTIONS: Like any drug, Lincocin should be used with caution in patients having a history of asthma or significant allergies. Overgrowth of nonsusceptible or- ganisms, particularly yeasts, may occur and require appropriate measures. Patients with pre-existing monilial infections requiring Lincocin therapy should be given concomi- tant antimoniHal treatment. During pro- longed Lincocin therapy, periodic liver function studies and blood counts should be performed. Not recommended (inadequate data) in patients with pre-existing liver dis- ease unless special clinical circumstances in- dicate. Continue treatment of /3-hemolytic streptococci infections for 10 days to diminish likelihood of rheumatic fever or glomerulonephritis.
ADVERSE REACTIONS: Gastrointestinal —Glossitis, stomatitis, nausea, vomiting. Per- sistent diarrhea, enterocolitis, and pruritus ani. Hemopoietic— Neutropenia, leukopenia, agranulocytosis, and thrombocytopenic pur- pura have been reported. Hypersensitivity reactions— Hypersensitivity reactions such as angioneurotic edema, serum sickness, and anaphylaxis have been reported, sometimes in patients sensitive to penicillin. If allergic reaction occurs, discontinue drug. Have epinephrine, corticosteroids, and antihista-
mines available for emergency treatment Skin and mucous membranes— Skin rashes: urticaria, vaginitis, and rare instances of ex foliative and vesiculobullous dermatitis havi been reported. Liver— Although no direct re lationship to liver dysfunction is established jaundice and abnormal liver function test: (particularly serum transaminase) have beer observed in a few instances. Cardiovasculai —Instances of hypotension following paren teral administration have been reported particularly after too rapid IV administra tion. Rare instances of cardiopulmonary ar rest have been reported after too rapid IV administration. If 4.0 grams or more admin istered IV, dilute in 500 ml of fluid anc administer no faster than 100 ml per hour Special senses— Tinnitus and vertigo have been reported occasionally. Local reaction : —Excellent local tolerance demonstrated tc intramuscularly administered Lincocir (lincomycin hydrochloride). Reports of pair following injection have been infrequent Intravenous administration of Lincocin ir 250 to 500 ml of 5% glucose in distillec water or normal saline has produced nc local irritation or phlebitis.
HOW SUPPLIED: 250 mg and 500 m, f Capsules— bottles of 24 and 100. Sterile Soltetion, 300 mg per ml— 2 and 10 ml vial: and 2 ml syringe. Syrup, 250 mg per 5 rn —60 ml and pint bottles.
For additional product information, consult the package insert or see your Upjohn representative.
MED B-6-S (K.ZL-7) JA71-1631
The Upjohn Company Kalamazoo, Michigan 49001
Dpjohn
MATERNAL HEALTH DESK REFERENCE CARD NO. 14
(Sponsored and Prepared by the Committee on Maternal and Perinatal Health, Michigan State Medical Society)
THE HIGH RISK FETUS
Recent advances in our knowledge of placental circulation and fetal physi- ology have made it possible to correlate certain clinical situations in the mother with their high perinatal mortality and morbidity rates. It is important that physicians learn to recognize these high risk situations early and provide the special care and precautions necessary to prevent fetal and neonatal loss. In many patients the increased risk is due to the impaired feto-placental circula- tion prior to the onset of labor. In normal labor, the placental circulation al- most stops for the duration of the uterine contraction, but promptly returns to normal between contractions and produces no fetal distress. In abnormal situa- tions, when the placental circulation is already marginal before the onset of labor, oxygenation may be severely limited once contractions become frequent.
We can anticipate increased fetal risk in the following conditions:
1. Diabetes mellitus
2. Chronic hypertension
3. Acute toxemia
4. Post-maturity
5. Erythroblastosic fetalis
6. Exhaustion, dehydration and acidosis of prolonged labor
7. Anemia
8. Maternal sepsis (amnionitis, Septicemia, pyclonephrisis, pneumonia)
9. Drug addiction
Early and careful care of these patients should be undertaken in hospitals staffed and equipped to deal with all obstetrical contingencies as well as the critically ill newborn.
Some laboratory help in evaluating the well-being of the feto placental unit prior to the onset of labor is available. Serial measurements of urinary estriol excretion that remain above baseline levels have correlated well with the favor- able condition of the fetus. Hopefully, the future will bring better, more specific placental function tests.
When a trial of labor is elected in these patients, recognition of fetal dis- tress requires careful observation of the fetal heart rate by frequent auscultation or fetal monitoring equipment. (See subsequent “fetal distress” card.)
Treatment of fetal distress arising in labor includes: I) changing the pa- tient’s position from supine to lateral to eliminate any compression of abdom- inal and pelvic vessels, 2) oxygen given to the mother by mask at 6 liters/min., 3) intravenous hydration and glucose administration to correct maternal and fetal acidosis. If these simple measures fail to reverse the abnormal fetal brady- cardia, immediate steps should be taken to deliver the infant vaginally or by Cesarean section.
Welcome to £MSMS
Members of the Michigan State Medical Society join in welcoming the following new members into a progressive state medical organization. MSMS is dedicated to promoting the science and art of medicine, the protection of the public health, and the betterment of the medical profession. Each new member is encouraged to join with other MSMS members at both the local and the state levels in achieving these goals.
Manuel A. Airala, MD, 1554 E. Michigan, Albion 49224
Sabah H. Atchu, MD, 21240 Virginia, Southfield 48075
John J. Back, MD, 21701 W. 11 Mile Rd., South- field 48076
Barry F. Bates, MD, Dept, of Radiology, St. Joseph Mercy Hospital, Ann Arbor 48104 Billy B. Baumann, MD, 2021 Klingensmith #7, Pontiac 48053
Ferdinand M. Bumagat, MD, Metropolitan Hospital, Detroit 48206
Vicente T. Castillo, MD, 3901 Beaubein, Detroit
48201
Luis A. Chavez, MD, 690 Mullett St., Detroit 48226 Yoon Ha Cho, MD, 1400 Chrysler Expwy., Detroit 48207
Ralph R. Cook, MD, W-5641 University Hosp., Ann Arbor 48104
Douglas E. Cox, MD, 2355 Monroe, Dearborn 48124 Ben Droblas, MD, 8233 W. Chicago, Detroit 48204 Milagros T. Ebreo, MD, 31772 Allerton Dr., Birm- ingham 48009
Daniel C. English, MD, Dept, of Surgery, MSU Col- lege of Human Med., East Lansing 48823 Abdul Fayyad, MD, 1322 E. Michigan #318, Lan- sing 48912
Julian Go., Jr„ MD, 27537 Parkview, Warren 48092 Alfred C. Hanscom, MD, 197 N. Washington, Battle Creek 49017
Karl R. Herwig, MD, Dept, of Urology, Univ. Medical Center, Ann Arbor 48104
Eugene Ho, MD, Wyandotte General Hosp., Wyan- dotte 48192
Paul Hollister, MD, Dept, of Medicine, Mich. State Univ., East Lansing 48823
Elizabeth A. Hutchinson, MD, 2909 E. Grand River #208, Lansing 48912
Arturo D. Imperial, MD, 770 Fisher Building, Detroit
48202
Milo L. Johnson, MD, Sparrow Hospital, Radiology Dept., Lansing 48902
Samba Jung, MD, 5571 Parkview Dr. C-1 #304, Clarkston 48016
Andrea C. Jungwirth, MD, Physical Medicine, Uni- versity Hosp., Ann Arbor 48104 E. Patrick Juras, MD, 2036 Stone Hollow Ct., Bloomfield Hills 48013
Adrian Kantrowitz, MD, Sinai Hospital, Detroit 48235
G. Howard Kent, MD, 8300 Mack Ave., Detroit 48207
John R. Kirkpatrick, MD, Wayne State University, Detroit 48201
Fatella L. Lessani, MD, St. Mary’s Hospital, Livonia 48154
Frederick S. Lim, MD, 806 W. Sixth Ave., Flint 48503
K. Z. Masud, MD, 2355 Williamson, Saginaw 48601
Charles A. Main, Jr., MD, 2143 Brenthaven Dr., Bloomfield Hills 48013
James E. McCourt, MD, 915 Almira St., Saginaw 48602
Lawrence Mendelsohn, MD, 10601 W. Seven Mile Rd., Detroit 48221
Dwijendra K. Misra, MD, 828 Fisher Bldg., Detroit 48202
Sunghee Nam, MD, Kirwood Hospital, Detroit 48238
Ahmed N. M. Nasr, MD, 1352 McIntyre, Ann Arbor 48105
Baha Onder, MD, 23023 Orchard Lake Rd., Farm- ington 48024
Mohammad Riahi, MD, 456 Cherry St., S.E., Grand Rapids 49506
Waldomar M. Roeser, MD, 1660 Arlington, Ann Arbor 48104
Robert R. Ross, Jr., MD, 540 E. Canfield, Detroit 48201
David R. Rovner, Dept, of Medicine, MSU College of Human Medicine, East Lansing 48823
Benedicto A. Ruiz, MD, 3001 Miller Rd., Ford Motor Co., Dearborn 48124
Charles R. Schmitter, Jr., MD, 2825 Sequoia Park- way, Ann Arbor 48103
Ramesh C. Shah, MD, Hurley Hospital, Radiology Dept., Flint 48502
Joseph T. Stroyls, MD, 3800 Woodward Ave., De- troit 48201
E. M. Tendero, MD, 1151 Taylor, Detroit 48202
Richard A. Wetzel, MD, Dept, of Nuclear Medicine, Wm. Beaumont Hospital, Royal Oak 48072
Robert M. Zimmerman, MD, 555 E. Williams, Ann Arbor 48108
Glenn A. Zimmermann, MD, 100 Michigan St., N.E., Grand Rapids 49503
DRUG ABUSE AND ALCOHOLISM CONTROL PROGRAM DIRECTOR
$25,000 — $30,000
Sought by major public employer.
Detail resume' requested.
Box 1, 120 W. Saginaw East Lansing, Ml 48823
MICHIGAN MEDICINE JANUARY 1972 71
Classified Advertising
$5.00 per insertion of 50 words or less, with an additional 10 cents per word in excess of 50.
Are you tired of the smog, traffic congestion, sociolog- ical problems, crime and other irritations which have become part of today’s urban living? Well then DIS- COVER WATERTOWN, WISCONSIN. Exchange all the big city unpleasantries for the peaceful en- vironment and easy going pace of a residential city. Watertown, a progressive community is ideally lo- cated equidistant between Milwaukee and Madison in Southeastern Wisconsin’s lake district. 1 he com- munity has a trade (and medical practice) area serv- ing 40-50,000 people. Many new schools, parks, trees and recreational opportunities. A stable economy. Our new Community Health Care Center with its beautiful 110-bed general hospital, connecting ('but separate) 24-unit Medical-Dental Office Building (choice of suites still avilable), and connecting 130- bed Nursing Home, was completed in the Spring of 1971. WE URGENTLY NEED another Internist, an Otolaryngologist, an Ophthalmologist, Obstetrician- Gynecologist, and Family Practitioners to join exist- ing medical staff. An immediate successful practice assured. Excellent rapport with the University of Wisconsin Medical School at Madison, and the Med- ical College of Wisconsin (formerly Marquette Uni- versity School of Medicine) at Milwaukee. Medical Staff leading and supporting recruitment effort. Write or call Dr. Paul Glunz, Watertown Memorial Hos- pital, Watertown, Wise. 53094. Telephone (404) 261-4210.
PSYCHIATRIC RESIDENCIES— Excellent, approved psychiatric training; both demanding and clinically rich with a stimulating, well-balanced program. Af- filiated with Michigan State University’s College of Human Medicine. The setting is a culturally satisfy- ing community; the serene, scenic Grand Traverse Bay area. Three-year plan: $12,215 to $13,885; five- year plan: $13,927 to $26,121. Contact Dr. Paul E. Kauffman, Director of Psychiatric Training, Room 165, Traverse City State Hospital, Traverse City, Michigan 49684. Phone: (616) 947-5550. An equal
opportunity employer.
CIVIL SERVICE: Prison Physician $30,735. Formal vacation and sick leave plan plus other fringe bene- fits in excess of $4,700 annually, under state civil service. Regular hours. Must possess a license to practice medicine or osteopathic medicine and sur- gery in Michigan and have five (5) years of ex- perience. Send resume to Richard Crable, Chief, Recruitment Section, Michigan Dept, of Civil Service, Lansing, Michigan 48913. An equal opportunity employer.
PSYCHIATRISTS— Ann Arbor Area: Board eligible or board certified to join staff of newly established 50- bed forensic center. Active inpatient and outpatient diagnostic program with court experience. Excellent
paramedical staff with opportunity for varied treat- ment of patients in milieu program, teaching, and research in all areas of forensic psychiatry. Private practice allowed. Salary: $23,531 to $30,735; liberal fringe benefits. Write: Lynn W. Blunt, M.D., Clin- ical Director, Center for Forensic Psychiatry, Box 2060, Ann Arbor, Michigan 48106. (313) 429-2531.
ANN ARBOR-YPSLANTI AREA: 3 year approved, university affiliated, psychiatric residency at mental health center offering comprehensive services to SE Michigan; teaching faculty and supervisors include University of Michigan faculty, private psychiatrists and analysts as well as hospital staff; resident’s time divided approximately equally between didactic sem- inars (including supervision) and clinical experience; first year ADM and intensive treatment units; second and third year assigned community psychiatry and/or OPC and/or Children’s Unit; additional experience in psychosomatic medicine, University Mental Hy- giene Clinic and neurology. 3 years: $12,215 to $13,- 893; 5 years: $13,927 to $18,708 (4th and 5th year salaries negotiable) . All Michigan Civil Service ben- efits. Contact: W. Bogard, M.D., Ypsilanti State Hos- pital, Ypsilanti, Michigan 48197. An Equal Oppor- tunity Employer.
PSYCHIATRIC RESIDENCY. Three years fully ap- proved program in a large university affiliated gen- eral hospital. We provide closely supervised training in dynamic psychiatry, child psychiatry, medicolegal experience, and basic neurology. Salary to $15,000 plus benefits. For further details and consideration submit your resume to Dr. Robert Schopbach, Di- rector of Psychiatric Training, Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, Michigan 48202.
INTERNIST AND GENERAL PRACTITIONER ur- gently needed. Practice in community of Charlevoix, population 4,000. Modern, fully accredited hospital, 47 beds, CCU-ICU started. Serves population of 16,- 000. Office available, rent free until established. Nine member Medical Staff actively assisting in recruit- ment. Ideal area for really living without big city problems. Beyond compare for recreation year around. Two junior colleges close by. Excellent schools. Reply to: Administrator, Charlevoix Hos-
pital, Charlevoix, Michigan 49720.
GP’s, Internists, Pediatricians— The Family Health Cen- ter, Inc. is about to begin providing health services to an underserved area of Kalamazoo. Advantages of joining staff include: a chance to develop an exciting medical program; income of $25,000-$40,000/ year plus fringe; a sophisticated medical community; and two fine general hospitals. Contact John Vogt, 418 W. Kalamazoo Ave., Kalamazoo, Michigan 49006. (616) 342-0204 #18 collect. An equal opportunity
employer.
72 MICHIGAN MEDICINE JANUARY 1972
CITY PHYSICIAN: for employment exam center and public health consultation. Attractive to physician who wants activity limited to a standard work week. Contact D. L. Sherman, Personnel Director, City Hall, Dearborn, Michigan 48126 (313) LU 4-1200.
FOR SALE: Medical Equipment suitable for use by internist of F.M.D.: X-Ray, Diathermy, examining tables, treatment tables, instrument and supply cab- inets, surgical instruments, cautery, centrifuge, office furniture, steel hies and many other items. Will sell at appraised value. Reply Box #10, 120 West Sag- inaw St., East Lansing, Mi 48823.
CHILD PSYCHIATRY RESIDENCIES OFFERED: MICHIGAN— ANN ARBOR, YPSILANTI: “Where it’s at.” New Child Psychiatry Residencies offered in an innovative, established clinical program. Commu- nity Child Psychiatry, Day Treatment, Out-Patient and Residential Treatment offer opportunities for a variety of treatment techniques. Crisis intervention (“life-space” interview) ; behavioral therapy pharma- cotherapy, individual, group and family treatment methods; dynamic, social and developmental psychiatry taught. Learning by independent study, seminars, su- pervised experiences. Multi-disciplinary staff including: six child psychiatrists, pediatrician, pediatric neurolo- gist, psychologists, social workers, special education teachers, speech therapists, occupational therapist, rec- reational therapists, etc. Program affiliated with the University of Michigan and a variety of clinical set- tings including: community mental health centers, guidance clinics, etc. Salaries negotiable. Contact: Elissa P. Benedek, M.D., York Woods Center, Box A, Ypsilanti, Michigan 48197. Phone: (313) 434-3666. An Equal Opportunity Employer.
FOR LEASE: In the Prairie Professional Building, lo- cated in the City of Grandville, Michigan. With the construction of phase 3 nearly complete, we have choice suites available. Will be developed to your exact requirements. Suitable for medical, dental or related professions. Also, lower level suite available at reduced rates. Lease rentals include heat, electric, air conditioning, snow removal, paved parking, built- in vacuum system, music, attractive landscaping. This location is convenient and desirable. Reply to Prairie St. Realty Corp., 2700 28th St., S.W., Grand Rapids, Michigan or phone (616) 538-9000 days or evenings (616) 457-9645.
OPPORTUNITY for Internist or Family Physician to take over thirty year old practice in splendid loca- tion. Hospital privileges assured. Less than ten min- utes drive to three local hospitals. Excellent hospital and office facilities in city of 125,000 population. Will introduce. Retiring. Reply Box #9, 120 W. Saginaw St., East Lansing, Mi 48823.
GENERAL PRACTITIONERS - Community of Mt. Pleasant, Michigan desirous of securing 4 general practitioners. Good hospital privileges available. 125 bed, fully accredited. Excellent consultants available in community. Mixed M.D., D.O. Staff. Active staff of 28 physicians. Community of 22,000. Site of Cen- tral Michigan University. 14,500 students. Four season area. Metropolitan areas within 50 miles. Service area of 75,000. Five G.P.’s in active practice. Community will assist actively in helping you get established. Call collect R. E. Pieratt, Adm. (517) 773-7941 or Frank Johnson, M.D., Chairman Recruitment Com- mittee, area (517) 772-4846.
PROFESSIONAL PERSONNEL RECRUITMENT
FOR
HOSPITALS CLOIICS UNIVERSITIES
Administrators, Physicians,
Dept. Heads
PHYSICIANS— ALL SPECIALTIES
At no financial obligation, send us your resume if you would like a fine full-time position with one of our Clients:
HOSPITALS: Full-time Chiefs of Services, Di- rectors of Medical Education (General and Specialty).
MULTI-SPECIALTY CLINICS: General Practice and all Specialties.
SINGLE-SPECIALTY GROUPS. General Practice and all Specialties.
MEDICAL SCHOOLS: Teaching and Research appointments — all Disciplines.
DRUG FIRMS: Basic Science and Clinical Trials Research
INDUSTRIAL FIRMS: Employee Health Care. COLLEGES and UNIVERSITIES: Student Health Care.
In addition to our service to Client organizations, we assist physicians in considering relative merits of a va- riety of fine opportunities. No financial obligation at any time to the candidate. Appointments can be made as much as a year or more in advance. Send complete resume plus your professional objectives and geographic preferences in confidence to Arthur A. Lepinot.
INDEX TO ADVERTISERS
American Cancer Society . .
Arch Laboratories
Battle Creek Sanatorium . .
Bristol Laboratories
Brown Pharmaceuticals . . . Burroughs-Wellcome & Co.
Campbell Soup Co
Chicago Medical Society . .
Classified Advertising
Employment Opportunity . . Geigy Pharmaceuticals . . . Hospital Planning, Inc. . . Import Motors Limited, Inc.
Lilly, Eli and Co
MD PAC
Mead-Johnson
Medical Protective Co. . . . Medicenter of America . .
Medidinics
Mercywood Hospital
Merrell National
Michigan Heart Association
Pfizer Laboratories
Poythress, Wm. P. & Co. . Professional Management .
Roche Laboratories
Scientific Sessions
Searle, G. D. & Co
Stratton, Ben P. Agency . . Stuart Pharmaceuticals . . . .
Upjohn
U. S. V. Pharmaceutical . .
Walker Corp. & Co
Wallace
Willingway
45
55
55
11
53
6
39
49
72, 73
71
5
73
35
14
3
56, 57
60
Cover III
36
53
43, 44
13
62, 63
42
61
1, Cover II, Cover IV
36
40, 41
74
46, 47
... 8, 9, 66, 67, 68
65
7, 59
51
37
We hope you will visit our new main office when you are in the Lansing area. It was designed to provide for efficient service and for our growing staff.
0
il
bps
BEN P. STRATTON AGENCY, INC.
MSMS Insurance Administrators Serving the Michigan State Medical Society Since 1954
BRANCH OFFICE
19400 West Ten Mile Road Southfield, Michigan 48075 (313) 357-5083
MAIN OFFICE
5848 Executive Drive Lansing, Michigan 48910 (517) 393-7660
74 MICHIGAN MEDICINE JANUARY 1972
G§ouijd Off
Why does Michigan need a foundation?
By Brooker L. Masters, MD Chairman, MSMS Council
There are at least 12 proposals before Congress at the present time which deal with the provision and financing of health care. Although it seems certain that not one of these bills will become law this year, and possibly not next year, it is inevitable that Congress will, sooner or later, vote on a meas- ure for national health insurance — probably one that includes specific features of several different bills already introduced.
The one thing that most all of these bills have in common is the demand for cost and quality control of health care services through peer review.
True “peer” review requires that the work of physi- cians be reviewed by other physicians, not by bu- reaucratically-appointed representatives of labor, business, government, or the public, who have no qualifications for this task. MSMS has an operating peer review program and is, in fact, ahead of some of its sister state organizations in this area. In real- ity, however, Michigan has only scratched the sur- face in this relatively new concept.
Local and regional peer review committees must do more than merely exist. Their members must be trained in the methods of operation. Hospital util- ization review must be encouraged and stimulated to reach its peak of effectiveness. It must be con- vincingly demonstrated to the physicians of Mich- igan that peer review is not a punitive mechanism, but rather an educational program which will en- courage physicians who have not “kept up,” to take the necessary remedial steps.
There are strong indications from Washington that medical associations themselves would not be authorized to perform this review function, but that a separate organization (foundation) sponsored by a state association could be awarded contracts to carry out this responsibility.
With this issue of MICHIGAN MEDICINE, MSMS members will find greater emphasis on the view- points of Michigan physicians. On these pages we begin a new, four page, monthly section in which the state’s doctors may “sound off.”
The demand for experimentation in alternate sys- tems of health care delivery is present and growing stronger every day. The physicians in Michigan need to keep abreast of these developments, ad- vise and consult with those who promote them, and make very sure that their voice is heard so that they may maintain some control over their own destiny. We must guard against those organiza- tional patterns which suggest non-medical control over medical services.
* * *
These things an individual physician cannot do for himself. Nor can his medical association legally be- come involved in many of these areas without plac- ing its tax exempt status in jeopardy. A foundation can do these things for him.
Many health insurance policies sold in this State, in many instances, offer substandard coverage. Physicians should be interested in seeing that this situation is corrected. A foundation could develop minimum standards of coverage for health insur- ance and use its influence and good offices to see that substandard policies are upgraded or removed from the market.
Some foundations are designed to contract with government and insurance carriers to administer programs, including the processing of claims and writing checks. Others have (entered) contracts to set up prepaid group health organizations. These are not our purposes, but the beauty of the founda- tion concept is that it can be set up to accomplish whatever purpose its members direct.
* ★ *
The purpose envisioned for our Foundation is to contract with health insurers and governmental agencies to perform effective peer review by (1) establishing guidelines that insure quality medical care at a reasonable cost and (2) reviewing cases based upon exception reporting that fall outside established norms. The actual peer review work will be done by local and area review committees.
MICHIGAN MEDICINE JANUARY 1972 75
SOUND OFF/Continued
The Foundation should, however, have freedom of action and purpose to allow it, within all legal bounds, to engage in such activities as may be necessary to maintain our position of leadership in health matters in Michigan in keeping with devel- opments in the legislative, social or medical fields.
The Bylaws for the proposed MSMS Foundation have been carefully drawn to insure that the con- trol of its activities remain with physicians:
1. Members of the Michigan State Medical So- ciety and the Michigan Association of Osteo- pathic Physicians and Surgeons are auto- matically participating members of the Foun- dation. There is no coercion because a par- ticipating member may resign his membership in the Foundation at any time.
2. There are 18 administrative members who control the activities of the Foundation. Twelve are provided by MSMS and six are provided by the MAOPS.
3. The twelve M.D. administrative members are composed of MSMS officers plus the Chair- man and Vice-Chairman of The Council and six members elected at large by the MSMS membership.
4. The eighteen administrative members elect the Foundation nine member Board of Trus- tees. Six trustees must be participating mem- bers from MSMS and three from MAOPS.
5. Any trustee may be removed from office by the affirmative vote of two-thirds of the ad- ministrative members or two-thirds vote of the trustees.
6. Officers of the Foundation are elected by and serve at the pleasure of the Board of Trus- tees.
7. A majority of participating members may re- scind any prior policy decision of the officers or trustees.
8. Twenty or more participating members may petition the corporation to amend its Bylaws and these petitions must be considered and voted upon by the administrative members.
9. The corporation at any time may be dissolved by a two-thirds vote of the participating mem- bers at a meeting of 49% of the total mem- bership.
The Foundation approach is medicine’s best hope of shaping a future that will afford freedom to de- liver quality health services and provide consumer safeguards. Several state medical societies with large physician population, including Illinois and Pennsylvania, have already established their state foundations. We must act now before it is too late.
Press kudos
for Kent physicians
It was no remarkable coincidence that on the front page of last Monday’s Press there appeared two stories, almost side by side recounting the ef- forts of local doctors aiding the police in two res- cue attempts. Less than a week before the twin incidents, the Patrolman’s Wives Club singled out 20 Grand Rapids physicians for special commenda- tion for similar activities.
The letters that went to the 20 doctors cited them for “making the Grand Rapids police emer- gency units and first-aid training the best in the country.” They then went on to express the hope of not only the policemen’s wives but of the Police Department and the public generally that the doc- tors would continue their close association with the policemen “to fulfill the never-ending need for the best emergency first-aid training and services.”
In the two most recent cases of doctor-police cooperation, one of the most active members of the police emergency unit program, Dr. Lee Pool, hurried to the scene of a shooting on Franklin St., SW, in answer to a police call. His efforts to restart the heart of a man who had been shot three times failed, but Pool gave it his best. Not many hours later, Dr. John Wilson, another active member of the unit, proved more successful when, answering a police call, he hastened to Bridge St. bridge, where, at some peril to his own life, he helped the police to prevent a woman from leaping into the river.
Drs. Pool and Wilson are among the 20 or so local physicians who regularly ride with the police emergency vehicles on weekends and often on other nights, who have two-way police radios in their cars and even offices and who almost auto- matically respond to any police pleas for their services. They are not paid for their efforts.
The doctor emergency service was conceived by Dr. C. Mark Vasu, who, of course, deserves a large measure of the credit for its success. But never has it been more true than in this instance that it takes many willing hands to make such a program work. And this program requires not only willing but ex- traordinary skilled hands that are not in abundant supply in any community. The Patrolman’s Wives Club says this program is the best of its kind in the country. We don’t think there is any doubt on that score. In fact, there are few communities that can boast anything similar to it.
Grand Rapids Press, October 28, 1971 (Editorial, reprinted by permission)
76 MICHIGAN MEDICINE JANUARY 1972
Hello, Doctor Coye; Thank you.
Doctor Evans
By Edward J. Tallant, MD
MSMS Publication Committee Chairman
Michigan’s medical doctors extend a warm, wel- coming handshake to the new dean of the Wayne State University School of Medicine, Robert D. Coye, MD.
At the same time, we are quick to congratulate and praise those men who have led the WSU med- ical school during the two years since the resigna- tion of former dean Ernest D. Gardner, MD, in March, 1970.
Tommy N. Evans, MD, acting dean, has ably commanded the day-to-day work of the medical school, and presided over such high points as the construction of the new Scott Hall of Basic Med- ical Sciences, the ground-breaking and early con- struction of the C. S. Mott Center for Human Growth and Development and a 50 percent in- crease in the number of entering freshmen medical students at WSU.
For his work as WSU acting dean, Doctor Evans was awarded a 1971 MSMS Certificate of Com- mendation.
We offer our support and cooperation to you, Dean Coye, as you begin your work in a challeng- ing time when medical schools are being called upon to produce more and better physicians to meet the rising demand for medical care across the nation.
In 1971, the WSU entering freshman class num- bered 208 students, placing it among the top 10 in size among the medical schools in the country. If finances are made available soon to acquire addi- tional faculty, the WSU entering medical class could rise to 256 by 1973, placing it among the top two or three in the nation.
We are pleased with your qualifications as for- mer assistant and then associate dean of the Uni- versity of Wisconsin Medical School.
Doctor Coye comes to Michigan with high qual- ifications. From 1966-70 he served as associate dean of the University of Wisconsin Medical School. From 1960 until 1966 he was assistant dean. He has been a full professor of pathology at Wis- consin since 1968.
Certified in pathological anatomy in 1958, Doctor Coye is a member of the American Society of Ex- perimental Pathology and the American Association of Pathologists and Bacteriologists.
He and his wife, Janet, have two daughters, Carol, 19, and Joel, 23, and a son, Peter, 21.
When Doctor Coye accepted his new position, he said he was impressed with the basic science, clin- ical and research facilities at the medical school.
“The WSU School of Medicine and the develop- ing Detroit Medical Center are contributing much to the teaching, research, and health care needs of Detroit, the State of Michigan and the nation at large,” he said. “I know they will continue to play a major role in helping to solve many of the health care problems confronting us today.”
We look forward to working with you to solve these problems, Dean Coye.
Doctor McGrath
We do not belong to the organization; it belongs to us
By William B. McGrath, MD Phoenix, Ariz.
The following article is reprinted with permis- sion, from the September issue of Arizona Med- icine.
The structure of an organization is the sum of the individuals who comprise it. The function of an organization is to lessen individuality in the pursuit of cooperation and efficiency. It is true of any so- ciety: the stronger the organization, the weaker its members. This is a looming dilemma which con-
MICHIGAN MEDICINE JANUARY 1972 77
SOUND OFF/Continued
fronts every one of us, in any trade or profession and in government.
A man cannot make a living without belonging (sic) to some organization, thereby relinquishing some of his independence. Count, for illustration, the number of associations which a licensed physi- cian has to join — ingratiating himself, submitting his qualifications, taking examinations, requesting “privileges,” attending mandatory meetings, paying dues and special assessments, accepting the by- laws and a hundred restrictive rules and regula- tions; dreading that at any time his fitness and therefore his very livelihood will be brought into question by self-appointed peers or anonymous committees.
He will be graded and stamped and certified like beef in a packing house. Above him in the vertical pecking order will be the courtesy staff, the honor- ary staff, the consulting staff, the visiting staff, the active staff, the teaching staff, and finally the “chiefs” of services, the real in-group, employed by the hospital.
There is no grading without degrading. Subordi- nation of the individual is perhaps even worse in the military and in industry and commerce. An em- ployee had better contribute a specified amount to a “voluntary” charity drive. The board arrogates the right to require a teacher to take a loyalty oath. An executive must be willing (a contradiction in terms) to undergo psychological testing, and his whole personal life will come under evaluative in- vestigation. Everyone rises at the entrance of the judge in his medieval robes, and we address him as “your honor,” but he must “run” for office.
Organization for the sake of efficiency is wit- lessly dragging mankind back to feudalism: people become serfs and vassals, paying homage and fees and service for the “privilege” of working.
Impotent and oppressed, the individual cannot resist the emasculating power of organization. He has to join and submit. Repressing the instinctive (stallion) goal of self-determination and free enter- prise, he will ignore his serfdom or rationalize. So he will forgive us, sweetly, and protest that an ef- fective team must have pyramidal organization, must have’ leadership and followers, a hierarchical system.
We have no real proof that this is so since any other approach has never had sufficient trial. In either case our technologies are advancing so overwhelmingly that we could afford to sacrifice a little efficiency in the interest of individual integ- rity. We had better! Machismo is not measured by status or proven on the golf course.
Organized medicine at any level ought not lead or follow the subservient inclinations of the masses. The hackneyed phrase, “delivery of health serv- ices,” suggests that medicine is a commodity — perhaps to be sold or traded for coupons in a chain of supermarkets? It is the same old episte- mological error: Medicine is not a service; it is a positive function.
And the function of organized medicine is to preserve and enrich the health of society. When organization itself begins to undermine the health of society, then it is our duty to attack organiza- tion.
Any illness of society can hardly be different from the illness of an individual. Our country seems to be organically sound. We can defend ourselves against invasion; the drinking water is pure and our sewage systems are better than average; we have more than our share of food and housing.
But no one would dispute that collectively as well as individually we are nervous.
Now in any functional disorder, in any case of nervousness, what does the psychiatrist look for? Invariably he will find a basic loss of self-esteem. All the symptoms and all the defense mechanisms seem to derive from the losing of self-esteem.
It is up to the professions to set the restorative example. Our own societies and associations should be as loosely knit as possible, freely co- operative, never intimidating or coercive. The phy- sician’s connection with the hospital, for example, could well do without most of the ranking and regulating. The fact of being on a staff (just yes or no) should presume the individual’s good judgment and he should be quite free to work according to his abilities.
In almost every issue and at every opportunity the educated person should stand and vote against more administration, more management, more regi- mentation. He should vigorously oppose anything that smacks of rigidity or grading or group coer- cion.
The lifeblood of mental health is self-esteem. When we are mindful of this, then both profession- ally and privately each of us will always discourage any kind of subordination. We will not invite or permit any human being to enter a master-servant relationship which would allow him to be obse- quious, subservient.
It is not just a play on words to insist that the individual does not belong to the organization or work for it. He works for himself and the organiza- tion belongs to him. He must never be treated or view himself as a member, in the sense of an arm or leg. He is a whole man. In or out of the organ- ization a man can work for himself in whatever job, using his own skills and resources. He must get back the feeling that he is tilling his own small plot of land. When he cooperates with his fellows it is because they are his fellows, and they and he are scornful of status or rank. Such a subtle change of attitude will help to restore the self- esteem of the individual and of the society to which he belongs — no; which belongs to him!
Doctor McGrath is a member of the Publish- ing Committee and Editorial Board of the Ari- zona Medical Association, Inc.
78 MICHIGAN MEDICINE JANUARY 1972
I EPIGRAMS
ATE NEWS FROM THE MICHIGAN STATE MEDICAL SOCIETY
«•». o/iiv
■At.
J- If ?'■ f: - p f ,0,0 A
-outrt LIBRARY
Ft'B 1 0 IS72
January 28, 1972, Volume 71, Number 3 Michigan State Medical Society Reading Time: 2 Mins. 45 Seconds
FFORTS ARE UNDERWAY to tell Governor Milliken and the State Legislature bout the MSMS Council's "extreme displeasure" over the Governor's budget lessage proposal to discount all Medicaid payments to physicians by 3% f paid in 30 days. The matter was discussed by The Council Jan. 26 and four-step action program to protest the proposed cut was approved.
The entire MSMS membership will be sent a special mailing with per- inent data and with suggestions for individual action. Watch for the tailing.
The Governor alleges this discounting proposal can reduce state costs y $2 million and federal costs by a further $2 million. If approved by he Legislature, the cut would become effective with the next fiscal year, uly 1, 1972.
MEMBERS OF THE MSMS House of Delegates will receive Draft #7 of the pro- posed bylaws for a MSMS-sponsored foundation early in February for study before the spring meeting of the House. The MSMS Committee on Utilization Review and Health Insurance Problems developed Draft //7 after reactions from various delegates and component societies to Draft #6. The MSMS Council on Jan. 26 received Draft #7 and voted to "present it to the House of Delegates for approval."
XPLANATION OF PRICE COMMISSION 2.5% CEILING:
The government has published fee-freeze regulations ordered by the rice Commission under Phase II of the President's new economic policies nd the MSMS Bureau of Economic Information provides these interpretations:
1. Physicians are held to fees in effect on Nov. 14, 1971. Any in- :reases in fees up to a maximum of 2.5% must be justified on the basis of illowable cost (overhead) increases. Such ‘increases are permissible only ,f they don't increase the doctor's profit margin (the difference between he practice's gross income and net income) and only to the extent they Lre not offset by increased productivity.
2. Requests for exceptions to the guidelines may be directed to:
District Director
Economic Stabilization Program of the IRS 2011 Park Avenue Building Detroit, Michigan 48226
3. Incorporated physicians' salaries (including benefits) cannot be .ncreased more than 5.5%. Exempt from the 5.5% ceiling are automatic or ilanned "longevity" increases in salaries for physicians in medical cor- >orations, provided this salary plan existed before Nov. 14, 1971. But,
:he corporation is restricted to the 2.5% fee guidelines.
4. The individual's request must state the reason for the request, md indicate to the Commission that a serious hardship or gross inequity -S in effect with the guidelines.
The AMA has protested the fee-freeze regulations as being "discriminatory >y singling out providers of health care. The AMA declares that the guidelines 'violate the principles of equal treatment and fair play."
COMPONENT SOCIETY SECRETARIES are being invited to a special workshop at MSMS on March 1. A similar workshop for presidents-elect of the county societies on Dec. 9 was rated very informative.
MSMS COUNCIL on Jan. 26 received a comprehensive report from Chairman Brooker L. Masters, MD, about his testimony before the national Democratic Policy Council’s Subcommittee on Health in Detroit, Jan. 12. (A copy of the testimony was sent to all MSMS members as Vol. 71, Issue //I of Mi chigan Medicine.) Doctor Masters reported that "there was a parade of providers and consumers at the hearing who argued for pluralism, new ideas, flex- ibility, medical education, more physicians and better distribution of doctors." One Democratic congressman who testified supported the Kennedy- Griffiths bill. Doctor Masters told The Council that "the only comments I have received from fellow doctors since the hearing have been favorable."
I
MSMS WILL PRESENT A STATEMENT at a "Hearing on Malpractice Insurance Prob- lems" being called at the request of MSMS by the State Insurance Commission: in Lansing, Feb. 28. The hearing will bring together medical, legal and insurance interests to express views. MSMS Councilor Frank Bicknell, MD, Detroit, and Fredrick Weissman, MD, Detroit, chairman of the MSMS Committee on Professional Insurance, will represent MSMS. Insurance Commissioner Vai Hooser says the hearing "could also establish a sound foundation for evalu- ating future changes in the area of malpractice insurance."
THE REPORT OF the Phase II membership opinion survey is being completed now by the Alexander Grant Company and will be submitted to the MSMS Council and House of Delegates. The Council will refer the report to appropriate committees to evaluate the conclusions and recommendations. Ten members of the MSMS Council met with survey directors Jan. 25 to discuss the findings and preliminary draft of the report.
-
PARTICIPATION IS NOW being sought for the 1972 Student American Medical Association-Medical Education and Community Orientation summer project which again will place medical students in community hospitals for 10-week periods. The program is designed to provide students with valuable learning experiences and introduce them to medical practice in Michigan communities.! For additional information about the SAMA-MECO program, contact the MSMS Education Liaison Committee.
A NINE-MEMBER board to review requests by hospitals and other health care institutions to exceed the 6% price limit established by the Price Commission has been appointed by the Governor. He selected members of the present State Comprehensive Health Planning Council as the review group.
THE MICHIGAN DEPARTMENT of Social Services recently contracted with the Model Neighborhood Comprehensive Health Program, Inc. (Detroit) to provide comprehensive, preventive medical and health services to 10,000 Group I Medicaid beneficiaries. The program commences on March 1 as a demonstra- tion project. Details will be in the Mar. issue of Michigan Medicine.
Jan. 28, 1972 Vol. 71, No. 3
MICHIGAN STATE MEDICAL SOCIETY
Published three times each month and four times in December and January, 38 issues, by the Michigan State Medical Society as its official journal. Second class postage paid at East Lansing, Mich, and at ad- ditional mailing offices. Yearly subscription rate, $9.00. Printed in USA. All communications should be addressed to the Publications Committee, Michigan State Medical Society, 120 West Saginaw Street, East Lansing, Michigan 48823. © 1972 Michigan State Medical Society. Phone: Area Code 517, 337-1351.
Second Class Postage Paid at East Lansing, Mich, and at additional mailing offices.
UNIVERSITY OF CAL LIBRARY SCH OF MED THIRD 8 PARNASSUS AVE SAN FRANCISCO CAL 94122
EDITOR: HERBERT A. AUER
(fMichigari £Mediciqe
OFFICIAL JOURNAL OF THE MICHIGAN STATE MEDICAL SOCIETY . VOLUME 71, NUMBER 4 . JANUARY, 1972
oster of MSMS members by component societies
Officers of the Michigan State Medical Society
PRESIDENT
Sidney Adler, MD
Detroit
PRESIDENT-ELECT
John J. Coury, MD
Port Huron
SECRETARY
Kenneth H. Johnson, MD
Lansing
TREASURER
John R. Ylvisaker, MD
Pontiac
SPEAKER
Vernon V. Bass, MD
Saginaw
VICE SPEAKER
James I). Fryfogle, MD
Detroit
PAST PRESIDENT
Harold H. Hiscock, MD
Flint
Officers and Members of The Council
CHAIRMAN
Brooker L. Masters, MD
Fremont
VICE CHAIRMAN
Robert M. Leitch, MD
Battle Creek
SECRETARY
Kenneth H. Johnson, MD
Lansing
TREASURER
John R. Ylvisaker, MD
Detroit
Frank B. Bicknell, MD
1st
Detroit
Brock E. Brush, MD
1st
Detroit
Ralph R. Cooper, MD
1st
Detroit
Edward J. Tallant, MD
1st
Detroit
Louis R. Zako, MD
1st
Allen Park
Ross V. Taylor, MD
2nd
Jackson
Robert M. Leitch, MD
3rd
Battle Creek
W. Kaye Lock 1 in, MD
4th
Kalamazoo
Noyes L. Avery, MD
5 tit
Grand Rapids
Ernest P. Griffin, Jr., MD
6th
Flint
James H. Tisdel, MD
7th
Port Huron
William A. DeYoung, MD
8th
Saginaw
Adam C. McClay, MD
9th
Traverse City
Robert C. Prophater, MD
1 Oth
Bay City
Brooker L. Masters, MD
11th
Fremont
Raymond Hockstad, MD
12th
Escanaba
Donald T. Anderson, MD
13th
Kingsford
Donato F. Sarapo, MD
14th
Adrian
Sydney Seller, MD
15th
Mt. Clemens
Executive Staff
Tryloff, Warren F., Director
Ambrose, Bruce W., Manager, Department of Government Relations
Auer, Herbert A., Manager, Department of Communications and Professional Information
Campau, Richard M., Manager, Department of Operations and Economics
Administrative Staff
Anthony, John H. — Chief, Bureau of Economic Information Berry, Margaret J. — Secretary, Accounting and Membership
Brewbaker, Mary K. — Committee and Exhibits Coordinator, Division of Scientific Affairs Davis, Vada L. — Administrative Assistant to Director
Decker, Sherry L. — Secretary, Department of Communications and Professional Information Evey, Lenora M. — Secretary, Department of Government Relations
Hall, Sherry L. — Special Assistant, Legislative Liaison, Department of Government Relations Hoover, Maynard J. — Reproduction Operator, Department of Operations and Economics Irish, Mary V. — Secretary to Manager, Department of Operations and Economics
Marr, Judith E. — Managing Editor, Michigan Medicine, Communications and Professional Information May, Lois — Receptionist
Mehler, Herbert — Chief, Research and Analysis, Governmental Medical Care Programs Roney, Robert J. — Controller, Accounting and Membership Schulte, Helen A. — Chief, Division of Scientific Affairs
Smith, Jeanne — Assistant, Department of Communications and Professional Information VanDeventer, Jacqueline — Coordinator of Women’s Activities Zaletskis, Maija — Secretary, Division of Scientific Affairs
Advisory Staff
Lester P. Dodd — General Counsel
Clyde T. Hardwick, PhD — Economic Consultant
A. Stewart Kerr — Legal Counsel
John W. Moses, MD — Scientific Editor, Michigan Medicine
MICHIGAN STATE MEDICAL SOCIETY DIRECTORY
CONTENTS
This Directory lists the membership of each component medical society and therefore the tptal membership of the Michigan State Medical Society.
Page
Alcona County ( Alpena-Alcona-Presque Isle) 6
Alger County (Marquette-Alger) 35
Allegan County 6
Alpena County (Alpena-Alcona-Presque Isle) 6
Antrim (Northern Michigan) 39
Arenac ( Bay-Arenac-Iosco ) 7
Lake County ( Mecosta-Osceola-Lake )
Lapeer County
Leelanau County (Grand Traverse-Leelanau-
Benzie )
Lenawee County
Livingston County
Luce County
Page . 36 . 31
, . 16 . 32 . 32 . 33
Baraga County ( Houghton-Baraga-Keweenaw ) 17
Barry County 6
Bay County (Bay-Arenac-Iosco) 7
Benzie County (Grand Traverse-Leelanau-Benzie ) ... 16
Berrien County 8
Branch County 9
Calhoun County 9
Cass County 11
Charlevoix County (Northern Michigan) 39
Cheboygan County ( Northern Michigan ) 39
Chippewa County (Chmpewa-Mackinac) 11
Clare County ( Gratiot-Isabella-CIare ) 16
Clinton County 11
Crawford (North Central Counties) 36
Delta County ( Delta-Schoolcraft ) 11
Dickinson County (Dickinson-Iron) 11
Mackinac County ( Chippewa-Mackinac ) 11
Macomb County 33
Manistee County 35
Marquette County (Marquette-Alger) 35
Mason County 36
Mecosta County (Mecosta-Osceola-Lake) 36
Menominee County 36
Midland County 36
Missaukee County ( Wexford-Missaukee ) 58
Monroe County 37
Montcalm County ( Ionia-Montcalm ) 21
Montmorency (North Central Counties) 36
Muskegon County 38
Newaygo County 39
North Central 39
Northern Michigan Counties ( Antrim-
Charlevoix-Cheboygan-Emmet) 40
Eaton County 12
Emmet County (Northern Michigan) 39
Genesee County 12
Gladwin (North Central Counties) 36
Gogebic County 16
Grand Traverse County (Grand Traverse-
Leelanau-Benzie) 16
Gratiot County ( Gratiot-Isabella-CIare ) 17
Oakland County 40
Oceana County 48
Ogemaw (North Central Counties) 36
Ontonagon County 49
Osceola County (Mecosta-Osceola-Lake) 36
Oscoda (North Central Counties) 36
Otsego (North Central Counties) 36
Ottawa County 49
Presque Isle County (Alpena-Alcona-Presque Isle) ... 6
Hillsdale County 17
Houghton County (Houghton-Baraga-Keweenaw) .... 17 Huron County IS
Ingham County 18
Ionia County ( Ionia-Montcalm ) 22
Iosco County (Bay-Arenac-Iosco) 7
Iron County (Dickinson-Iron) 11
Isabella County (Gratiot-Isabella-CIare) 16
Jackson County 22
Kalamazoo County (Kalamazoo Academy of
Medicine ) 23
Kalkaska (North Central Counties) 36
Kent County 26
Keweenaw County (Houghton-Baraga-Keweenaw) .... 17
Roscommon (North Central Counties) 36
Saginaw County 49
St. Clair County 51
St. Joseph County 52
Sanilac County 53
Schoolcraft County ( Delta-Schoolcraft ) 11
Shiawassee County 53
Tuscola County 53
Van Buren County 53
Washtenaw County 54
Wayne County 59
Wexford County (Wexford-Missaukee) 90
Published four times a month in December and January, three times all other months, 38 issues, by the Michigan State Medical Society as its official journal. Second class postage paid at East Lansing, Mich., and at additional mailing offices. Yearly subscription rate, $9.00; single copies, 80 cents. Additional postage: Canada, $1.00 per year. Printed in USA. All communications relative to manuscripts, advertising, news, exchanges, etc., should be addressed to Judith Marr, Managing Editor, Michigan State Medical Society, 120 West Saginaw Street, East Lansing, Michigan 48823. Phone Area Code 517, 337-1351. © 1972 Michigan State Medical Society. Directory artwork of MSMS Headquarters by Maripat Kreski, junior art student at Eastern Michigan University.
JANUARY, 1972/Michigan Medicine 3
Guide to Help Locate Cities withir
This guide matches up the counties for Michigan communities
Ada (Kent)
Addison (Lenawee)
Adrian (Lenawee)
Albion (Calhoun)
Algonac (St. Clair)
Allegan (Allegan)
Allendale (Ottawa)
Allen Park (Wayne)
Alma (Gratiot)
Almont (Lapeer)
Alpena (Alpena)
Ann Arbor (Washtenaw) Augusta (Kalamazoo)
Bad Axe (Huron)
Baldwin (Lake)
Bangor (Van Buren)
Baraga (Baraga)
Bark River (Delta)
Battle Creek (Calhoun)
Bay City (Bay)
Bay View (Emmet)
Bear Lake (Manistee) Belding (Ionia)
Bellaire (Antrim)
Belleville (Wayne)
Benton Harbor (Berrien) Berkley (Oakland)
Berrien Center (Berrien) Berrien Springs (Berrien) Bessemer (Gogebic)
Beulah (Benzie)
Big Rapids (Mecosta)
Birch Run (Saginaw) Birmingham (Oakland) Blanchard (Isabella) Blissfield (Lenawee) Bloomfield Hills (Oakland) Bloomingdale (Van Buren) Boyne City (Charlevoix) Branch (Mason) Breckenridge (Gratiot) Bridgeport (Saginaw) Bridgman (Berrien) Brighton (Livingston) Bronson (Branch)
Brooklyn (Jackson)
Brown City (Sanilac) Buchanan (Berrien)
Byron Center (Kent)
Cadillac (Wexford) Caledonia (Kent)
Calumet (Houghton) Camden (Hillsdale)
Capac (St. Clair)
Carleton (Monroe)
Caro (Tuscola)
Caseville (Huron)
Cass City (Tuscola) Cassopolis (Cass)
Cedar Springs (Kent) Center Line (Macomb) Centreville (St. Joseph) Champion (Marquette) Charlevoix (Charlevoix) Charlotte (Eaton)
Chassell (Houghton) Cheboygan (Cheboygan) Chelsea (Washtenaw) Chesaning (Saginaw)
Clare (Clare)
Clarkston (Oakland)
Clawson (Oakland)
Clinton (Lenawee)
Clio (Genesee)
Coldwater (Branch)
Coleman (Midland)
Coloma (Berrien)
Colon (St. Joseph) Columbiaville (Lapeer) Concord (Jackson)
Constantine (St. Joseph) Coopersville (Ottawa)
Corunna (Shiawassee)
Croswell (Sanilac)
Crystal Falls (Iron)
Custer (Mason)
Daggett (Menominee)
Davison (Genesee)
Dearborn (Wayne)
Dearborn Heights (Wayne) Decatur (Van Buren) Deckerville (Sanilac)
Deerfield (Lenawee)
Delton (Barry)
Detroit (Wayne)
Dewitt (Clinton)
Dexter (Washtenaw)
Douglas (Allegan)
Dowagiac (Cass)
Drayton Plains (Oakland) Drummond Island (Chippewa) Dundee (Monroe)
Durand (Shiawassee)
Eagle Harbor (Keweenaw)
East Detroit (Macomb)'
East Jordan (Charlevoix)
East Lansing (Ingham)
East Tawas (Iosco)
Eaton Rapids (Eaton)
Ecorse (Wayne)
Edmore (Montcalm) Edwardsburg (Cass)
Elk Rapids (Antrim)
Elkton (Huron)
Eloise (Wayne)
Elsie (Clinton)
Engadine (Mackinac)
Escanaba (Delta)
Essexville (Bay)
Evart (Osceola)
Fairgrove (Tuscola) Farmington (Oakland)
Farwell (Clare)
Fennville (Allegan)
Fenton (Genesee)
Fenwick (Montcalm)
Ferndale (Oakland)
Flat Rock (Wayne)
Flint (Genesee)
Flushing (Genesee)
Fowlerville (Livingston) Frandor (Ingham) Frankenmuth (Saginaw) Frankfort (Benzie)
Franklin (Oakland)
Fraser (Macomb)
Freeland (Saginaw)
Fremont (Newaygo)
Galesburg (Kalamazoo) Garden City (Wayne)
Gaylord (Otsego)
4 JANUARY, 1972/Michigan Medicine
i the Counties
containing doctors.
Gladstone (Delta)
Gladwin (Gladwin)
Glen Arbor (Leelanau)
Gobles (Van Buren)
Goodrich (Genesee)
Grand Beach (Berrien)
Grand Blanc (Genesee)
Grand Haven (Ottawa)
Grand Ledge (Eaton)
Grand Marais (Alger)
Grand Rapids (Kent)
Grandville (Kent)
Grant (Newaygo)
Grayling (Crawford)
Greenville (Montcalm)
Grosse lie (Wayne)
Gwinn (Marquette)
Hamburg (Livingston)
Hamilton (Allegan)
Hamtramck (Wayne)
Hancock (Houghton)
Hanover ( Jackson)
Harbert (Berrien)
Harbor Beach (Huron)
Harbor Springs (Emmet)
Harper Woods (Wayne)
Harrison (Clare)
Harrisville (Alcona)
Harsens Island (St. Clair)
Hart (Oceana)
Hartford (Van Buren)
Haslett (Ingham)
Hastings (Barry)
Hazel Park (Oakland)
Hemlock (Saginaw)
Hessel (Mackinac)
Hickory Corners (Barry) Highland (Oakland)
Highland Park (Wayne)
Hillsdale (Hillsdale)
Holland (Ottawa)
Holly (Oakland)
Holt (Ingham)
Homer (Calhoun)
Horton (Jackson)
Houghton (Houghton)
Howell (Livingston)
Hudson (Lenawee)
Hudsonville (Ottawa) Huntington Woods (Oakland)
Imlay City (Lapeer)
Indian River (Cheboygan) Inkster (Wayne)
Ionia (Ionia)
Iron Mountain (Dickinson)
Iron River (Iron)
Ironwood (Gogebic)
Ishpeming (Marquette)
Ithaca (Gratiot)
Jackson (Jackson)
Jamestown (Ottawa)
Jonesville (Hillsdale)
Kalamazoo (Kalamazoo) Kalkaska (Kalkaska)
Keego Harbor (Oakland)
Kent City (Kent)
Kinde (Huron)
Kingsford (Dickinson)
Lake City (Missaukee)
Lakeland (Livingston)
Lake Odessa (Ionia)
Lake Orion (Oakland)
Lakeview (Montcalm) Lambertville (Monroe)
LAnse (Baraga)
Lansing (Ingham)
Lapeer (Lapeer)
La Salle (Monroe)
Lathrup Village (Oakland) Laurium (Houghton)
Lawrence (Van Buren)
Lawton (Van Buren)
Leonidas (St. Joseph)
Leslie (Ingham)
Lincoln Park (Wayne)
Linden (Genesee)
Litchfield (Hillsdale)
Livonia (Wayne)
Lowell (Kent)
Ludington (Mason)
Luther (Lake)
Luzerne (Oscoda)
Mackinaw Island (Mackinac) Madison Heights (Oakland) Manchester (Washtenaw) Manistee (Manistee)
Manistiquc (Schoolcraft) Manitou Beach (Lenawee) Marcellus (Cass)
Marine City (St. Clair)
Marion (Osceola)
Marlette (Sanilac)
Marquette (Marquette)
Marshall (Calhoun)
Martin (Allegan)
Marysville (St. Clair)
Mason (Ingham)
Mecosta (Mecosta)
Melvindale (Wayne)
Memphis (St. Clair)
Menominee (Menominee) Merrill (Saginaw)
Metamora (Lapeer)
Michigan Center (Jackson) Middleville (Barry)
Midland (Midland)
Milan (Washtenaw)
Milford (Oakland)
Millington (Tuscola)
Mio (Oscoda)
Monroe (Monroe)
Montague (Muskegon) Montrose (Genesee)
Morenci (Lenawee)
Mount Clemens (Macomb) Mount Morris (Genesee)
Mount Pleasant (Isabella)
Muir (Ionia)
Mullet Lake (Cheboygan) Munising (Alger)
Muskegon (Muskegon) Muskegon Heights (Muskegon)
Nashville (Barry)
Negaunee (Marquette) Newaygo (Newaygo)
Newberry (Luce)
New Buffalo (Berrien)
New Era (Oceana)
New Port (Monroe)
Niles (Berrien)
North Branch (Lapeer)
North Muskegon (Muskegon)
North port (Leelanau)
Northville (Wayne)
Norway (Dickinson)
Oak Park (Oakland)
Okemos (Ingham)
Olivet (Eaton)
Onaway (Presque Isle)
Onsted (Lenawee)
Ontonagon (Ontonagon)
Orchard Lake (Oakland)
Oscoda (Iosco)
Ossineke (Alpena)
Otisville (Genesee)
Otsego (Allegan)
Ovid (Clinton)
Owosso (Shiawassee)
Oxford (Oakland)
Parchment (Kalamazoo)
Parma (Jackson)
Paw Paw (Van Buren)
Pentwater (Oceana)
Petoskey ("Emmet)
Pigeon (Huron)
Pinckney (Livingston)
Pinconning (Bay)
Plainwell (Allegan)
Pleasant Lake (Jackson)
Pleasant Ridge (Oakland)
Plymouth (Wayne)
Pontiac (Oakland)
Portaee (Kalamazoo)
Port Huron (St. Clair)
Portland (Ionia)
Potterville (Eaton)
Prudenville ("Roscommon)
Pullman (Allegan)
Quincy (Branch)
Reading (Hillsdale)
Reed City (Osceola)
Reese (Tuscola)
Remus (Mecosta)
Richland ("Kalamazoo)
Richmond (Macomb)
River Rouge (Wayne)
Riverview (Wayne)
Rives Junction ("Jackson)
Rochester (Oakland)
Rockford ("Kent)
Rockwood (Wayne)
Rogers City (Presque Isle)
Romeo (Macomb)
Romulus (Wayne)
Roscommon (Roscommon)
Rosebush (Isabella)
Roseville (Macomb)
Royal Oak (Oakland)
Saginaw (Saginaw)
Sagola (Dickinson)
Saline (Washtenaw)
Sandusky (Sanilac)
Sanford (Midland)
Saranac (Ionia)
Saugatuck (Allegan)
Sault Sainte Marie (Chippewa)
Sawyer (Berrien)
Schoolcraft (Kalamazoo)
Scottville (Mason)
Sebewaing (Huron)
JANUARY,
Shelby (Oceana)
Sidney (Montcalm)
Southfield (Oakland)
Southgate (Wayne)
South Haven (Van Buren)
South Lyon (Oakland)
Sparta (Kent)
Spring Lake (Ottawa)
Stambaugh (Iron)
Standish (Arenac)
Stanton (Montcalm)
St. Charles (Saginaw)
St. Clair (St. Clair)
St. Clair Shores (Macomb) Stephenson (Menominee)
Sterling Heights (Macomb)
St. Ignace (Mackinac)
St. James (Charlevoix)
St. Johns (Clinton)
St. Joseph ("Berrien)
St. Louis (Gratiot)
Stockbridge (Ingham)
Sturgis (St. Joseph)
Sunfield (Eaton)
Suttons Bay (Leelanau)
Swartz Creek (Genesee)
Tawas City (Iosco)
Taylor (Wayne)
Tecumseh (Lenawee) Temperance (Monroe)
Three Rivers (St. Joseph) Traverse City (Grand Traverse) Trenton (Wayne)
Troy (Oakland)
Trufant (Montcalm)
Ubly (Huron)
Union City (Branch)
Union Lake (Oakland)
Utica (Macomb)
Vandalia (Cass)
Vassar (Tuscola)
Vicksbure (Kalamazoo)
Vulcan (Dickinson)
Wakefield (Gogebic)
Walkerville (Oceana)
Walled Lake (Oakland)
Warren (Macomb")
Waterford (Oakland)
Watervliet (Berrien)
Wayland ("Allegan)
Wayne (Wayne)
Weidman ("Isabella)
Wellston (Manistee)
West Branch (Ogemaw) Westland (Wayne)
Westphalia ("Clinton)
White Cloud (Newaygo) Whitehall (Muskegon)
White Pigeon (St. Joseph)
White Pine (Ontonagon) Whitmore Lake (Washtenaw) Williamston (Ingham)
Wixom (Oakland)
Wyandotte (Wayne)
Wyoming (Kent)
Yale (St. Clair)
Ypsilanti (Washtenaw)
Zeeland (Ottawa)
1972/Michigan Medicine 5
Directory, Listed by Component Medical Societies
Special memberships are indicated as follows: “L” for Life Member; “M” for Military Members; “N” for Non-Resident Members; “R” for Retired Members; “A” for Associate Members; “O” for Osteopathic Associate Members; all others are Active Members.
ALLEGAN
WILLIAM H SCHOCK MD 315 MAPLE ST SAUGATUCK MICH
*9*53
JAMES GREENWOOD MD 115 N FIRST ST ALPENA MI
*9707
A PETER BRACHMAN JR 222 TROWBRIDGE ST ALLEGAN MICH
MD
*9010
ELWIN W TOPP MD 353 NAOMI ST PLAINWELL MICHIGAN
*9080
ALI GUNER MD 115 N FIRST AVE ALPENA MI
*9707
WALTER E CHASE MO 223 W BRIDGE PLAINWELL MICHIGAN
*9080
ORHAN A TUGRUL MD *25 CUTLER ST ALLEGAN MI
*9010
EDWARD A HIER MO 125 N SECONO AVE ALPENA MICH
*9707
JAMES I CLARK MD ROUTE 1 BOX 25D FENNVILLE MICH
*9*08
WILLARD R VAUGHAN MD PLAINWELL MI
L
*9080
WM F JACKSON MD RFD 1 HURON SHORE DR ROGERS CITY MI
*9779
HARLAND C DANGLE MD 3650 LARCHMONT DR ANN ARBOR MI
*8105
BERTHA C WISEMAN MD R R ** BOX 1*3 ALLEGAN MICH
*9010
W F KUTSCHE MD 208 LAKE ST OSCODA MICH
*8753
G B GODDARD MD 218 E ORLEANS OTSEGO MICH
*9078
C R YANG MD *12 WATER ST ALLEGAN MI
*9010
W K LEHMANN MD ALPENA GEN HOSP ALPENA MI
*9707
JAMES D HAYS MD DOUGLAS MICHIGAN
*9*06
ALPENA
J M LEOPARO MD 312 E CHISHOLM ALPENA MICH
*9707
ELWIN B JOHNSON MD ROUTE 1 PULLMAN MI
L
*9*50
PETER ALIFERIS MO ALPENA GENERAL HOSP ALPENA MICHIGAN
*9707
C L MCOOUGALL MD 601 W CHISHOLM ST ALPENA MI
*9707
MARIETTA J KAYLOR MD 500 LINN ST ALLEGAN MI
*9010
SURINDAR S BEDI MD FINCH CLINIC ONAWAY MI
*9765
WM E NESBITT MD 123 N 2NO AVE ALPENA MICH
*9707
VAN 0 KEELER MD 30* DIX ST OTSEGO MI
*9078
JOHN W BUNTING MD P 0 BOX 5*2 ALPENA MI
R
*9707
F C 0 DELL JR MD 615 W CHISHOLM ST ALPENA MICH
*9707
LAWRENCE LAGATUTTA MD
H J BURKHOLDER MD
L
BRUCE R OHMART MD
560 LINN ST ALLEGAN MI
*9010
122 N SECOND AVE ALPENA MICH
*9707
108 SO FIRST ST ALPENA MI
*9707
JAMES E MAHAN MD
L
STUART L COHN MD
ELBERT S PARMENTER MD L
*02 TROWBRIDGE ST ALLEGAN MICH
*9010
1253 W WASHINGTON ALPENA MICH
*9707
*13 E FIRST ST DIXON ILLINOIS
61021
KENNETH C MILLER MD SAUGATUCK MI
*9*53
AENEAS CONSTANTINE MD HARRISVILLE MI *87*0
ROBT C RIES MD 573 N BRADLEY HWY ROGERS CITY MI
*9779
R L PLAGENHOFF MD 30* OIX ST OTSEGO MI
*9078
THOMAS J COOK MD 312 E CHISHOLM ST ALPENA Ml
*9707
JOHN L RIKER MD 601 N SECONO ALPENA MICHIGAN
*9707
JANIS PONE MD MARTIN MICH
*9070
CHARLES T EGLI MD 312 E CHISHOLM ST ALPENA MI
*9707
PAUL A SCHOLTENS MD ALPENA GEN HOSP ALPENA MI
*9707
MICHAEL SYED OUADIR P 0 BOX 326 FENNVILLE MI
MD
*9*08
DONALD E FINCH MD ONAWAY MI
*9765
JAMES E SPENS MD 123 N SECOND AVE ALPENA MICH
*9707
GLADWIN E RAMSEYER MD 125 E BRIDGE
PLAINWELL MICH *9080
RICHARD FOLEY MD ROGERS CITY MICH
*9779
HENRY B STIBIT2 MO 1065 US 23 NORTH ALPENA MI
*9707
HARRY E SCHNE ITER MD *25 CUTLER ST ALLEGAN MICH
*9010
WILLIAM L FOX MD 601 W CHISHOLM ST ALPENA MI
*9707
DANA A TOMPKINS MD POSEN MICH
*9776
DARWIN E WAGONER MD 5007 N CEDAR LAKE RD
OSCODA MICHIGAN *8753
T M WATKINS MD
312 E CHISHOLM ST
ALPENA MICHIGAN *9707
T W WIENC2EWSKI MD 919 N 2ND AVE
ALPENA MICH *9707
CARLOS S WILLIS MD 113 STATE AVE
ALPENA Ml *9707
RICHARD F WILLIS MD
312 E CHISHOLM
ALPENA MI *9707
CHAS S WILSON MD L
730 STATE AVE
ALPENA MICH *9707
BARRY
JAMES E ATKINSON MD
523 E CHARLES ST
HASTINGS MI *9058
WM D BAXTER MD
1005 W GREEN ST
HASTINGS MI *9058
LARRY BLAIR MD 1005 W GREEN
HASTINGS MI *9058
JACK A BROWN MD 535 FRANCIS
HASTINGS MI *9058
DOUGLAS H CASTLEMAN MD
607 N BROADWAY
HASTINGS MICHIGAN *9058
RAYMOND G FINNIE MD A
535 E FRANCIS
HASTINGS MICH *9058
ALEXANDER B GWINN MD L
860 OAK ST P0 BOX 307 BALDWIN MI *930*
JOS 0 HEASLIP MD R
100 BLUFF VIEW DR
BELL E A I R BLUFFS FL 335*0
R J HUEBNER MD
1005 W GREEN ST
HASTINGS MI *9058
STEWART L0FDAHL MD R
R 1 BOX 172
ST CHARLES IL 6017*
WESLEY G LOGAN MD
1005 W GREEN ST
HASTINGS MICHIGAN *9058
6 JANUARY, 1972/Michigan Medicine
49058
49073
49058
49058
48849
R
48706
48706
L
48706
48706
48706
R
85201
48706
45206
I
48706
10
48706
48730
L
48706
48650
48706
48732
48706
48706
Bay County
RAYMOND R COOK MD 1115 FIFTH STREET BAY CITY MICHIGAN 48706
STANLEY A COSENS MD 101 W JOHN ST
BAY CITY MICH 48706
ROBT R CRISSEY MD
1405 CENTER AVE
BAY CITY MICH 48706
ROBT H CRISWELL MD L
3419 PORTAGE BLVD #43 FT WAYNE INDIANA 46804
NICHOLAS CSONKA MD
1308 COLUMBUS AVE
BAY CITY MICHIGAN 48706
MICHAEL J DARDAS MO
1413 CENTER AVE
BAY CITY MICHIGAN 48706
JAMES H DAVIS MD 1308 COLUMBUS
BAY CITY MICHIGAN 48706
MALCOLM K DOLBEE MD BOX 518
STANDI SH MICHIGAN 48658
JAMES L FENTON MD
701 N GRANT ST
BAY CITY MI 48706
ROBERT FERGUSON MD 101 W JOHN ST
BAY CITY MICHIGAN 48706
HANS FISCHER MD
ST AN DI SH MICHIGAN 48658
MARTIN D JAFFE MD
2110 1 6TH STREET
BAY CITY MICHIGAN 48706
RICHARD L JANKOWSKA MD
303 DAVIDSON BLDG
BAY CITY MI 48706
OTTO F JENS MD L
ROUTE #1
WHITTEMORE MI 48770
ORLEN J JOHNSON MD L
105 PARKWOOD
BAY CITY MI 48706
M CULVER JONES MD 900 N JACKSON
BAY CITY MICH 48706
TYRE K JONES I I I MD 1639 CARLA CT
ESSEXVILLE MI 48732
LARRY STANLEY KELLY MD
TAWAS CITY MICHIGAN 48763
SABINA KESSLER FRUX MD L
504 W MIDLAND ST
BAY CITY MI 48706
HOWARD T KNOBLOCH MD
1102 COLUMBUS
BAY CITY MICH 48706
MARTA SZEGO KOLTAY MD
3439 HIGHLAND WOODS
BAY CITY MI 48706
OSCAR P KOLTAY MD
3439 HIGHLAND WOODS
BAY CITY MI 48706
ALLEN B MOORE MD
1106 S MADISON ST
BAY CITY MI 48706
NEAL R MOORE MD
2138 FIFTH STREET
BAY CITY MICH 48706
DWIGHT J HOSIER MD 101 W JOHN ST
BAY CITY MICH 48706
SEZAI OLGAC MD 101 W JOHN ST
BAY CITY MI 48706
NORMAN P PAYEA MD
1198 COURT DRIVE
EAST TAWAS MI 48730
STANLEY M PEARSON MD 101 W JOHN ST
BAY CITY MICH 48706
B L PEDERSON MO 2108 16TH ST
BAY CITY MI 48706
WALTER E PELCZAR MD
1308 COLUMBUS AVE
BAY CITY MICH 40706
ROBT C PROPHATER MD
202 BOEHRINGER CT
BAY CITY MICHIGAN 48706
ALAN A RE I 0 INGE R MD M
4307 ELMWOOD
ROYAL OAK MI 48073
E H RODDA MD 101 W JOHN ST
BAY CITY MICH 48706
WM M POLL I S MD 101 W JOHN
BAY CITY MICH 48706
WM G GAMBLE JR MD L
2010 5TH AVE
BAY CITY MICH 48706
JOHN T GENECZKO MD
1308 COLUMBUS AVE
BAY CITY MICH 48706
JOHN W GRIGG MD
515 MULHOLLAND ST
BAY CITY MICHIGAN 48706
MONO GUERAMY MD 1411 CENTER AVE BAY CITY MI 48706
ROBERT C HAFFORD MD
101 W JOHN ST
BAY CITY MICH 48706
GAYLAND L HAGELSHAW MD 101 W JOHN ST
BAY CITY MICH 48706
HAROLD H HEUSER MD 916 WASHINGTON AVE BAY CITY MICH 48706
S AML F HOROWITZ MD
1415 CENTER AVE
BAY CITY MICH 48706
WALTER L HOWLAND MD
2110 E 16TH ST
BAY CITY MI 48706
MAURICE E HUNT MD 5000 MAPLE ST
FAIRGROVE MI 48733
J E JACQUES MD
TAWAS CITY MICHIGAN 48763
LASZLO KOVACSI MD 820 N JOHNSON
BAY CITY MICHIGAN 48706
EUGENE J KULINSKI MD 2110 1 6TH ST
BAY CITY MICHIGAN 48706
LESLIE A LAMBERT MD R
ROUTE #2
EAST TAWAS MICHIGAN 48730
JOHN L LANGIN MD
100 15TH ST
BAY CITY MICH 48706
JOHN A LEY MD
101 W JOHN ST
BAY CITY MI 48706
G B LOAN M D ESSEXVILLE MDCL BLDG ESSEXVILLE MI 48732
JOSEPH LOREE MD 2110 16TH ST
BAY CITY MICHIGAN 48706
JOHN C MAYNE M 0 2108 16TH ST
BAY CITY MICH 48706
HARRY B MC GEE MD 101 W JOHN
BAY CITY MICHIGAN 48706
PETER L MC GEE M 0 2110 16TH ST
BAY CITY MICH 48706
LEO B MC SHERRY JR MD
1308 COLUMBUS AVE
BAY CITY MICH 48706
ARLYN MOELLER MD
700 BORTON AVE
ESSEXVILLE MICHIGAN 48732
CHARLES S ROGERS MD 101 W JOHN ST
BAY CITY MICHIGAN 48706
PAUL W ROWE MD MERCY HOSPITAL BAY CITY MICHIGAN 48706
WM J SCHMELZER MD 602 MERCER ST PO 746
PINCONNING MICHIGAN 48650
HAROLO C SHAFER MD 101 W JOHN ST
BAY CITY MICH 48706
HUBERT L SHIELDS MD 101 W JOHN ST
BAY CITY MICH 48706
L I V I US N STROIA MD 101 W JOHN ST
BAY CITY MICH 48706
R L SUTTON JR MD
116 W STATE ST
EAST TAWAS MICH 48730
Z I A E TAHERI MD
1411 CENTER AVENUE
BAY CITY MICHIGAN 48706
NASIT TANAL MD 101 W JOHN ST
BAY CITY MI 48706
CLYDE S TARTER MD R
ROUTE 5
ALPENA MI 49707
BERHAN I TOSUNER MD
1106 S MADISON
BAY CITY MI 48706
GAYLORD TREADWAY MD 900 N JACKSON
BAY CITY MICH 48706
JANUARY, 1972/Michigan Medicine 7
LISTED BY COMPONENT MEDICAL SOCIETIES
Bay County
HARRY F VAIL MO 564 W HAMPTON RO ESSEXVILLE MI
48732
JOHN R BRUNI M 0 1 SOUTH FIFTH ST NILES MICH
49120
MARSHALL J FEELEY MO 2516 NILES AVE ST JOSEPH MICH
49085
P VANASUPA MO 101 W JOHN ST BAY CITY MICHIGAN
48706
FRANK H BUNKER MD 7770 RIVERVIEW OR #108 BENTON HARBOR MI 49022
MORRIS E FRIEOMAN MD 115 N BARTON ST NEW BUFFALO MI
49117
JOHN H WAY MO 101 W JOHN ST BAY CITY MI
48706
HALE W CADIEUX MO 645 RIVERVIEW DR BENTON HARBOR MICH
49022
JAMES 0 GALLES MD PAW PAW ISLAND COLOMA MI
49038
THOS G WILSON MO 210 PHILADELPHIA CT PALM HARBOR FL
R
33563
OONALD C CAMP MD 8 N ST JOSEPH AVE NILES MICH
49120
SAMUEL H GOULD MO 1850 COLFAX AVE BENTON HARBOR MICH
49022
JOHN WINBURNE MD 101 W JOHN ST BAY CITY MI
48706
JOHN H CARTER MO 687 E EMPIRE AVENUE BENTON HARBOR MICH
49022
BARBARA G GREEN MO 2600 MORTON STREET ST JOSEPH MICH
49085
HARRIS L WOOOBURNE MD
1420 CENTER ST
BAY CITY MICH 48706
HAROLD J CAWTHORNE MO R
R 4 BOX 201
COLOMA MI 49038
ROBT L GREEN MD 2600 MORTON STREET ST JOSEPH MICH
49085
THOMAS B WRIGHT MO 101 W JOHN ST 8AY CITY MICH
48706
WM A CHICKERING MO 2016 LAKE V I EW ST JOSEPH MI
49085
JAMES H GROVE MD 102 NO 4TH ST NILES MI
49120
ALOIS L ZILIAK JR MD 3447 HIGHLANO WOODS BAY CITY MICH
48706
S G C1LELLA M 0 PAWATING HOSPITAL NILES MICH
49120
HAROLD M GRUNOSET MO 61 N ST JOSEPH AVE NILES MICHIGAN
49120
BERRIEN
JOS CONWAY MD 358 N MAIN WATERVLIET MI
49098
RALPH 0 GUSTIN MO PO BUX 159 BERRIEN SPRINGS MI
49103
OEAN R ASSELIN MO 2817 S STATE ST ST JOSEPH MICHIGAN
49085
ROBT C CONYBEARE MD 7770 RIVERVIEW DR BENTON HARBOR MICH
49022
HERALO A HABENICHT MD ANDREWS UN I V MED CTR BERRIEN SPRINGS MI 49103
ROBERT L ATKINSON MO 777-0 RIVERVIEW OR BENTON HARBOR MI
49022
WELDON COOKE MO BERRIEN GENERAL HOSP BERRIEN CENTER MICH
49102
ARTHUR S HAIGHT MO 645 RIVERVIEW DR BENTON HARBOR MI
49022
RUDOLFO 8 8AC0L0R MD 687 E EMPIRE AVE BENTON HARBORN HI
49022
WM L COOPER MO ROUTE 4 BOX 78 COLOMA MI
49038
0 KENT HASSAN MD 802 E FRONT ST BUCHANAN MICH
49107
JOHN H BAILEY MO 2150 SAMUEL AVE BENTON HARBOR MICH
49022
RUSSELL T COSTELLO MO
645 RIVERVIEW DR
BENTON HARBOR MI 49022
EDWARD C HAUPT MO 7770 RIVERVIEW DR BENTON HARBOR MICH
49022
GERALD N BEAL MO 2817 S STATE ST ST JOSEPH MICH
49085
WALTER S DAILEY MD 122 GRANT ST NILES MICHIGAN
49120
FRED C HENDERSON MO 703 E MAIN NILES MICH
49120
WM H BENNER MD 960 AGARO ST LAB BENTON HARBOR MI
49022
ARCHIE J DALGLEISH MO 373 N MAIN ST
WATERVLIET MICH 49098
NOEL J HERSHEY MO PO BOX 222 NILES MICH
49120
HECTOR BENSIMON MD 777-0 RIVERVIEW OR BENTON HARBOR MI
49022
JOHN E DOOLITTLE MD 9 S ST JOSEPH AVENUE NILES MICHIGAN
49120
DAVID W HILLS MO 2821 STATE ST ST JOSEPH MICHIGAN
49085
I AM P BHISITKUL MO 1903 OAK ST NILES MI
49120
HAZEL 0 EIOSON M 0 413 N BLUFF BERRIEN SPRINGS MI
L
49103
FRANK W HOWARD MO 756 PIPESTONE BENTON HAR80R MICH
49022
DIXON L BIERI MO 645 RIVERVIEW OR BENTON HARBOR MICH
49022
RICHARD M ELGHAMMER 1850 COLFAX AVE BENTON HARBOR MICH
MO
49022
DEAN HUONUTT MO 807 MYRTLE ST ST JOSEPH MI
49085
AUGUST F BLIESMER MO 505 PLEASANT ST ST JOSEPH MICH
49085
CLAYTON S EMERY MO 1329 LAKE BLVD ST JOSEPH MI
L
49085
HAROLD 0 HUFF MD 126-1/2 E MAIN ST NILES MICH
R
49120
WILLIAM C BOCK MO 645 RIVERVIEW DR BENTON HARBOP MI
49022
WM K EMERY MD 1020 NILES AVE ST JOSEPH MICH
49085
EDWIN R IRGENS MD
11 PEOPLES ST BK BLDG
ST JOSEPH MICH 49085
CHARLES E BOONSTRA MO MERCY HOSPITAL LAB BENTON HARBOR MI 49022
MICHAEL FABER MO 756 PIPESTONE ST BENTON HARBOR MICH
49022
WADI J JIBRAIL MD 2912 S STATE ST ST JOSEPH MI
49085
JOHN W BRINK MD 807 MYRTLE ST ST JOSEPH MI
49085
ROLANDO M FAJARDO MD 429 PAW PAW
COLOMA MI
49038
WM H JOHNSTON MD 715 MARKET ST ST JOSEPH MICH
49085
JACK BRONFENBRENNER 687 E EMPIRE AVE BENTON HARBOR MICH
MO
49022
GROVER R FATTIC JR MD
61 N ST JOSEPH AVE
NILES MICHIGAN 49120
HARVEY I KELSALL MD 1600 NILES AVE ST JOSEPH MICH
49085
W J KENFIELD MO P 0 BOX 6
ST JOSEPH MI 49085
F ALAN KENNEDY MO 315 FIDELITY BLDG BENTON HARBOR MICH 49022
ORHAN KILIC MO
8 N ST JOSEPH ST
NILES MI 49120
FRANK A KING JR MO 858 PIPESTONE
BENTON HARBOR MICH 49022
HENRY J KLOS MO
777-0 RIVERVIEW OR
BENTON HARBOR MI 49022
R08T L LANDGRAF MO PO BOX 222
NILES MICH 49120
K ROBERT LANG MO ANDREWS UN I V MED CTR BERRIEN SPRINGS MI 49103
DAVID W LEARNED MO
645 RIVERVIEW DR
BENTON HARBOR MICH 49022
BYUNG HOON LEE MO
925 PIPESTONE ST
BENTON HARBOR MI 49022
HA I SOON LEE MO
711 BEECHWOOD DRIVE
NILES MICHIGAN 49120
JOHN B LEVA MO 1122 SALEM AVE BENTON HARBOR MICH 49022
FREDK H LINDENFELD MO 8 N ST JOSEPH AVE
NILES MICH 49120
RICHARO E LININGER MO 2712 HIGHLAND CT ST JOSEPH MICH 49085
FRANK LINN MD 2522 NILES
ST JOSEPH MICH 49085
AQUILES G LIRA MO PAWATING HOSP
NILES MI 49120
GENE E MAOOOCK MO MERCY HOSP X-RAY DEPT BENTON HARBOR MI 49022
J T MC LELLANO MD MERCY HOSP X RAY DEPT BENTON HARBOR MICH 49022
STANLEY M MESIROW MO
777D RIVERVIEW OR
BENTON HARBOR MICH 49022
T SCOTT MOORE MO
24 NO ST JOSEPH
NILES MICH 49120
CHAN NAMTZE MD 302 BROADWAY
NILES MICHIGAN 49120
JOHN J 0 TOOLE MD 133 E NAPIER
BENTON HARBOR MICH 49022
CHAS J OZERAN MO 127 E NAPIER
BENTON HARBOR MICH 49022
WM J PAOELFORD MD
206 WHIPPLE BLVD
SOUTH LYON MI 48178
8 JANUARY, 1972/Michigan Medicine
49085
49120
49022
49022
49106
49085
49022
49085
49085
49022
49102
49085
49022
49022
49120
ID
49102
49085
49022
i
49117
49117
49107
49085
49102
MEMBERS
Calhoun County
H 0 WESTERVELT MD L
539 PEARL ST
BENTON HARBOR MI 49022
DEAN WILLSON MD
777D RIVERVIEW DR
BENTON HARBOR MICH 49022
CLINTON W WILSON MD
925 PIPESTONE ST
BENTON HARBOR MICH 49022
WARREN A WISE MD
777D RIVERVIEW DR
BENTON HARBOR MI 49022
BRANCH
NAPIER S ALDRICH MD
162 MARSHALL ST
COLDWATER MICH 49036
CHARLES R BACON MD 300 E CHICAGO ST COLDWATER MICH 49036
JAMES E BAILEY JR MD 300 E CHICAGO ST COLDWATER MICH 49036
JAMES R BAKER MD ROUTE 7 BOX 239B COLDWATER MI 49036
VANGALA P REODY MD 292 E CHICAGO ST COLDWATER MI 49036
FREDERICK C REIGLE MD
LITCHFIELD MICHIGAN 49252
JOHN J RICK MD
61 E CHICAGO ST
COLDWATER MICHIGAN 49036
H K SCHILLINGER MD 300 BERKLEY
DEARBORN MI 48124
CARL A SHURTZ MD 56 BISHOP AVE
COLDWATER MI 49036
MALCOLM D STEIDER MD ROUTE 7 BOX 248 COLDWATER MI 49036
WILLIAM K STEWART MD 403 ANN ST
UNION CITY MICHIGAN 49094
JAMES A THOMAS MD L
1200 NO SHORE OR #108 ST PETERSBURG FL 33701
F P VALDERRAMA MD 235 E CHICAGO
COLDWATER MI 49036
ROY H BAR I BEAU MD L
1003 CAPITAL AVE SW BATTLE CREEK MI 49015
GEORGE H BARTELS MD 151 NORTH AVE
BATTLE CREEK MI 49017
JOHN BERGHORST MD A
89 S LAVISTA BLVD
BATTLE CREEK MI 49015
PHILIP P BONIFER JR MD 131 E COLUMBIA #213 BATTLE CREEK MI 49015
PHILIP P BONIFER MD 231 NORTH AVE
BATTLE CREEK MICH 49017
ROBT W BROWN MD
231 NORTH AVENUE
BATTLE CREEK MICH 49017
MARTIN F BUELL MD A
V A HOSPITAL
FT CUSTER MICHIGAN 49016
ALICE F CAMPBELL MO
103 E MULBERRY ST
ALBION MICH 49224
RICHARD J CAMPBELL MD R BOX 158 CAPE HAZE PLACIDA FL 33946
DEAN T CULVER MD 173 E CHICAGO ST COLDWATER MICH
49036
NATHANIEL J WALTON MD BOX 148
COLDWATER MICHIGAN 49036
MARCELO CANLAS MD LEILA HOSPITAL 9 EMMETT ST
ROBT J FRASER MD 52 FAIRFIELD DR COLDWATER MICH 49036
ORMOND 0 GEIB MO L
133 WALNUT BLVD ROCHESTER MI 48063
JACK GIFT MO 274 E CHICAGO ST COLDWATER MI 49036
HENRY C GOMLEY MD
108 E CHICAGO ST
BRONSON MICH 49028
JOHN C HEFFELFINGER MD 292 E CHICAGO AVE COLOWATER MICH 49036
RONALD H HOEKSEMA MD 292 E CHICAGO ST COLDWATER MICH 49036
ROBT M LEITCH MD
719 CAPITAL AVE SW
BATTLE CREEK MI 49015
RALPH W LENZ MD 235 E CHICAGO
COLDWATER MI 49036
HAROLD J MEIER MD L
87 W PEARL ST
COLDWATER MI 49036
HENRY R MOO I MD 292 E CHICAGO ST COLDWATER MICH 49036
HARVEY L MOSS MD 47 CARLYLE
COLDWATER MICHIGAN 49036
CHI EH-CHENG WU MD 235 E CHICAGO ST COLDWATER MI 49036
CALHOUN
MANUEL A AIRALA MD
1554 E MICHIGAN
ALBION MI 49224
MARTA S AIRALA MD 1554 E MICHIGAN AVE ALBION MI 49224
ARNOLD A ALBRIGHT MD R 1 BOX 300
BATTLE CREEK MI 49017
R H ALLEN M D 191 COLLEGE
BATTLE CREEK MICH 49017
NORMAN H AMOS MD R
ROUTE 1 BOX 450
AUGUSTA MI 49012
NORMAN 0 AMOS MD 710 NORTH AVENUE BATTLE CREEK MI 49017
HAROLD E ANDERSON MD
131 E COLUMBIA AVE
BATTLE CREEK MI 49015
VICTOR AZUELA MD 124 LAKEVIEW AVE BATTLE CREEK MI 49015
JAMES E BAKER MD A
VA HOSPITAL
BATTLE CREEK MI 49016
BATTLE CREEK MI 49016
M J CAPRON JR MD 806 SECURITY BK BLDG BATTLE CREEK MICH 49014
L HAROLD CAVINESS MD
185 N WASHINGTON
BATTLE CREEK MICH 49017
PAULINO CHAN MD 105 N JEFFERSON ST MARSHALL MI 49068
EOWARD M CHANDLER MD 411 MICH NAT BK BLDG BATTLE CREEK MICH 49014
CHARLES CHEN MD 167 COLLEGE
BATTLE CREEK MI 49017
WM R CHYNOWETH MD L
207 POST BLDG
BATTLE CREEK MICH 49017
JACK E COAKES MD A
716 GORHAM ST
MARSHALL MI 49068
GRAHAM F COLQUHOUN MD
188 COLLEGE ST
BATTLE CREEK MICH 49017
WILLIAM B COMA I MD 710 NORTH AVE
BATTLE CREEK MI 49017
RALPH A CRAM MD
500 S IONIA ST
ALBION MICH 49224
ROBT K CURRY MD
WM E NETTLEMAN MD 87 W PEARL ST
COLDWATER MICHIGAN 49036
KENNETH L OLMSTED MD 675 MONROE
COLDWATER MICHIGAN 49036
RICHARD L BAKKEN MD
200 COLLEGE ST
BATTLE CREEK MICH 49017
STUART P BARDEN MD LEILA HOSP
BATTLE CREEK MICH 49014
HOMER MI 49245
HAROLD L DALY JR MD
500 S IONIA ST
ALBION MICHIGAN 49224
MARY V DALY MD 201 RIVER ST
ALBION MI 49224
JANUARY, 1972/Michigan Medicine 9
Calhoun County
LISTED BY COMPONENT MEDICAL SOCIETIES
MIRIAM S DALY MO
500 S IONIA ST
ALBION MICH *9224
PAUL J DIAMANTE MD
710 NORTH AVENUE
BATTLE CREEK MICH 49017
M EKREM DIMBILOGLU MD
10 1 B NORTH AVE
BATTLE CREEK MI 49017
LIONEL E DORFMAN MD
1018 NORTH AVE
BATTLE CREEK MI 49017
ROBERT EDWARDS MD A
CHIEF OF STAFF VA HOSPITAL
BATTLE CREEK MI 49016
STEPHEN FAIRBANKS MD R
WELLSTON MI 49689
F V FEATHERSTONE MD A
400 NORTH AVE
BATTLE CREEK MI 49017
PATRICK S FERAZZI M D
1018 NORTH AVE
BATTLE CREEK MICH 49017
FELIPE B FIGURACION MD 133 PLEASANT VIEW DR BATTLE CREEK MI 49017
DUWARD L FINCH MD R
719 CAPITAL AVE S W BATTLE CREEK MICH 49015
ROBT E FISHER MD 1501 W MICHIGAN AVE BATTLE CREEK MICH 49017
ROBT H FRASER MO L
1112 SECURITY BK BLDG BATTLE CREEK MI 49014
WM G FRITSCHEL MD 109 W ERIE ST
ALBION MI 49224
L D FUNK MD L
133 W BURR OAK
ATHENS MICHIGAN 49011
A M GIDDINGS MD L
BATTLE CREEK SAN
BATTLE CREEK MI 49017
E PAUL GIESER JR MO 188 COLLEGE
BATTLE CREEK MICH 49017
JOHN G GIRARDOT MD 713 CAPITAL AVE SW BATTLE CREEK MICH 49015
PHILIP R GLOTFELTY MD
123 S JEFFERSON
MARSHALL MICHIGAN 49068
FRANKLIN L GRAUBNER MD BOGAR THEATER BLDG MARSHALL MICH 49068
J ALAN GRAY MD
309 MICH NATL BK BLDG
BATTLE CREEK MICH 49014
HAROLD E GREEN MD P 0 BOX 1518
BATTLE CREEK MI 49016
JACK C GRIFFITH MD 616 MICH NAT BNK BLDG BATTLE CREEK MICH 49014
MEHMET E HALAC MD 231 NORTH AVE
BATTLE CREEK MI 49017
ALFRED HAMADY MD
1018 NORTH AVE
BATTLE CREEK MICH 49017
ALFRED C HANSCOM MD
197 N WASHINGTON
BATTLE CREEK MI 49017
HARVEY C HANSEN MD 231 NORTH AVE
BATTLE CREEK MICH 49017
DONALD M HARRIS MD
517 E ROOSEVELT
BATTLE CREEK MI 49017
PHILIP M HENDERSON MD 109 W ERIE
ALBION MICH 49224
J D HENRIKSEN MD A
119 ST PETERS ALBANS HERTS ENGLAND
MARJORIE J HICKMAN MD A
216 NORTH AVE
BATTLE CREEK MI 49017
C C HIGGINS MD 710 NORTH AVE
BATTLE CREEK MI 49017
GABRIEL 0 HOLLIS MD
124 LAKEVIEW AVE
BATTLE CREEK MI 49015
LEONARD R HOWARD MD 1506 SECURITY TOWER BATTLE CREEK MI 49014
ARCHIE E HUMPHREY MD
122 N MADISON ST
MARSHALL MI 49068
ARTHUR A HUMPHREY MD P 0 BOX 1518
BATTLE CREEK MICH 49016
HERBERT E HUMPHREY MD 122 N MAO I SON ST MARSHALL MICHIGAN 49068
JOHN HUNTINGTON MD 710 NORTH AVE
BATTLE CREEK MICH 49017
ALI ISMAILOGLU MD
242 PARKSHORE DR
BATTLE CREEK MI 49017
DWIGHT JACOBSON MD 411 MICH NATL BANK BATTLE CREEK MI 49014
JAMES R JEFFREY MO L
62 ANN AVE
BATTLE CREEK MI 49017
MELVIN JOHNSON JR MD
710 NORTH AVENUE
BATTLE CREEK MI 49017
AUBREY H JONES MD A
513 W MICHIGAN AVE MARSHALL MI 49068
TYRE K JONES MD L
118 W GREEN
MARSHALL MICH 49068
GEO T KELLEHER MD 235 NORTH AVE
BATTLE CREEK MICH 49017
JAMES D KIESS MD 710 NORTH AVE
BATTLE CREEK MI 49017
MATTHEW R KINDE MD A
400 NORTH AVE
BATTLE CREEK MI 49016
PAUL C KINGSLEY MD 191 COLLEGE
BATTLE CREEK MICH 49017
EDWARD J KLOPP MD
173 COLLEGE ST
BATTLE CREEK MICH 49017
GORDON W LAKKE MD 151 NORTH AVE
BATTLE CREEK Ml 49017
FRANCIS L LAM MD 408 CAPITAL AVE S W BATTLE CREEK MICH 49015
VANCE B LANCASTER MD 710 NORTH AVE
BATTLE CREEK MI 49017
FRANK LANUTI MD 216 NORTH AVE
BATTLE CREEK MI 49017
JOS LEVY JR MD 231 NORTH AVE
BATTLE CREEK MICH 49017
WALTER B LONG MD
HOMER MICH 49245
KENNETH H LOWE MD R
141 PLEASANTVI EW
BATTLE CREEK MICH 49017
STANLEY T LOWE MD R
12 HIAWATHA DR
BATTLE CREEK MI 49015
CAE LUND MO L
226 DOGWOOD TRAIL
BATTLE CREEK MI 49017
JAMES J MAURER MO 616 MICH NATL BK BLOG BATTLE CREEK MICH 49014
ALFRED G MC CUAIG MD
719 CAPITAL ST S W
BATTLE CREEK MICH 49015
JOHN W MCGEE MD 105 IRWIN AVE
ALBION MICHIGAN 49224
FREDK J MELGES MD 1506 SECURITY TOWER BATTLE CREEK MICH 49014
HUGH K MOIR MD A
2731 W MICHIGAN
BATTLE CREEK MI 49017
DONALD B MORRISON MD R
719 CAPITAL ST S W BATTLE CREEK MICH 49015
H F MULLENME I S TER MD
614 N E CAPITAL
BATTLE CREEK MICH 49017
CASMIR MURILLO MD
21136 WAUBASCON RD
BATTLE CREEK MI 49017
JULES L NETREBA MO 112 W MANSION
MARSHALL MI 49068
ANNE F NORGAN MD 131 E COLUMBIA #207 BATTLE CREEK MI 49015
SUSAN J PATRICK MD
181 LAKEWAY DRIVE
BATTLE CREEK Ml 49017
ALBERT J PATT MO 154 WEST ST
BATTLE CREEK MI 49017
DONALD J PEARSON MD 255 NORTH AVE
BATTLE CREEK MICH 49017
CLARENCE T PIER MD A
P 0 BOX 1536
HOLMES BEACH FL 33509
LAWRENCE D PIPE MD
LEILA HOSPITAL
BATTLE CREEK MI 49014
C E POWELL MD 632 NORTH AVE
BATTLE CREEK MI 49017
OONNA POWELL MD A
V A HOSPITAL
FT CUSTER MI 49016
JOHN R POWER MD 154 WEST ST
BATTLE CREEK MICH 49017
ALVIN J RATZLAFF MD
197 N WASHINGTON
BATTLE CREEK MI 49017
F H REGUALOS JR MD 1331 W MICHIGAN AVE BATTLE CREEK MI 49017
WILMA C W RORICH MD R
164 N DIVISION ST
BATTLE CREEK MI 49017
RUSSELL C ROWAN MD
500 S IONIA ST
ALBION MICHIGAN 49224
CLARK W ROYER MD R
10624 TROPICANA CIR
SUN CITY ARIZ 85351
CHAS J RYAN MD LEILA HOSP
BATTLE CREEK MICH 49014
FREDERICK J SAWCHUK MD
191 COLLEGE ST
BATTLE CREEK MI 49017
CHARLES L SEIFERT MD 632 NORTH AVE
BATTLE CREEK MI 49017
PEDRO A SEVIDAL JR MD
1018 NORTH AVE
BATTLE CREEK MI 49017
H M SHELLENBERGER MD R
131 W HANOVER
MARSHALL MI 49068
A CLARK SIBILSKY MD A
281 HONEY LANE
BATTLE CREEK MI 49015
ROBT S SIMPSON MD
700 CAPITAL AVE SW
BATTLE CREEK MICH 49015
GEO W SLAGLE MD L
203 CAPITAL AVE NE BATTLE CREEK MI 49017
RUSSELL T SMITH MD
7864 T DR NORTH
BATTLE CREEK MI 49017
COLL IS M SPENCER MO 308 1/2 S SUPERIOR ST ALBION MICH 49224
WENDALL H STAOLE MD R
607 JENNINGS LANOING GOUGAC LAKE
BATTLE CREEK MI 49014
PETER J STEPHENS MD
175 COLLEGE ST
BATTLE CREEK MI 49017
C D STEPHENSON M D 154 WEST ST
BATTLE CREEK MICH 49017
RICHARD A STIEFEL MD L
260 WAHWAHTAYSEE WAY BATTLE CREEK MICH 49015
10 JANUARY, 1972/Michigan Medicine
DIRECTORY OF MSMS MEMBERS
Dickinson County
FRANK J STROHMENGER MD
500 S IONIA ST
ALBION MICHIGAN 49224
CLIFFORD B TAYLOR MD
500 S IONIA ST
ALBION MI 49224
MYRON A TAZELAAR MD
219 N MADISON ST
MARSHALL MICH 49068
HARRY VANDER KAMP MD A
V A HOSPITAL
BATTLE CREEK MICH 49016
A GLENN VAN NOORD DDS A 131 E COLUMBIA AVE 210 BATTLE CREEK MI 49015
LLOYD E VERITY MD R
212 HOURGLASS WAY SARASOTA FL 33581
GUNNAR VETNE MD
725 CAPITAL SW
BATTLE CREEK MICH 49015
CHAS S WALKER MD L
709 W VAN BUREN ST
BATTLE CREEK MICH 49017
JOHN F WALTERS MD 163 NORTH AVE
BATTLE CREEK MICH 49017
WM D WALTERS MD P 0 80X 1518
BATTLE CREEK MICH 49016
KEITH S WEMMER MD 1472 W MICHIGAN AVE BATTLE CREEK MICH 49017
SHERWOOD B WINSLOW MD
710 NORTH AVE
BATTLE CREEK MICH 49017
S A YANNITELLI MD 710 NORTH AVE
BATTLE CREEK MI 49017
JOHN R YOUNG MD
719 CAPITAL AVE SW
BATTLE CREEK MICH 49015
MALCOLM C YOUNG MD P 0 BOX 1518
BATTLE CREEK MI 49016
R B ZAPLITNY MD
1018 NORTH AVE
BATTLE CREEK MI 49017
SOPHIA ZAPLITNY MD A
1018 NORTH AVE
BATTLE CREEK MI 49017
BERTRAM ZHEUTLIN MD 50 ADAMS ST
BATTLE CREEK MI 49015
GEO A ZINDLER MD
1201 SECURITY BNK BLDG
BATTLE CREEK MICH 49014
CASS
URIAH M ADAMS MD
MARCELLUS MI 49067
RUDOLPH I CLARY MD R
204 JAMAICA WAY
PUNTA GORDA FL 33950
JUSTO DEVARONA MD 420 W HIGH ST
DOWAGIAC MI 49047
HENRY V GUZZO MD 515 MAIN ST SUITE 1
DOWAGIAC MI 49047
JOHN K HICKMAN MD R
P 0 BOX 226
DOWAGIAC MICH 49047
KENNETH C PIERCE MD 417 W HIGH ST
DOWAGIAC MICHIGAN 49047
LOWELL D SMITH MD 109 SCHOOL ST
CASSOPOL I S MI 49031
AARON K WARREN MD 109 SCHOOL ST
CASSOPOL I S MICHIGAN 49031
MOHAMMED ZAMAN MD
515 MAIN ST #3
DOWAGIAC MI 49047
CHIPPEWA
HUGH R ALLOTT MD 816 ASHMUN ST
SAULT STE MARIE MICH 49783
H MILTON BLAIR MD
300 COURT ST
SAULT STE MARIE MICH 49783
CLAIRE H CLAUSEN MD L
1110 LUCERNE AVE
CAPE CORAL FL 33904
WM J COULTER MD
DRUMMOND ISLAND MI 49726
DONALD 0 FINLAYSON MD
301 E SPRUCE ST
SAULT STE MARIE MI 49783
MARIE A HAGELE MD 126 PARK PL
SAULT STE MARIE MI 49783
HERBERT E HAMEL MD
220 BURDETTE ST
ST IGNACE MI 49781
ROBERT D HEILMAN MD
WAR MEMORIAL HOSP
SAULT STE MARIE MI 49783
DONNELL C HOWE JR MD 300 COURT ST
SAULT STE MARIE MICH 49783
THOS B MACK I E MD
300 COURT ST
SAULT STE MARIE MICH 49783
WM F MERTAUGH MD
104 W SPRUCE ST
SAULT STE MARIE MICH 49783
BEN J T MONTGOMERY MD L
P 0 BOX 39
SAULT STE MARIE MI 49783
EARL S RH1ND MD
SAULT POLYCLINIC
SAULT STE MARIE MICH 49783
DALE SCOTT MD 816 ASHMUN ST
SAULT STE MARIE MICH 49783
THOMAS SLOUGH MD
301 E SPRUCE ST
SAULT STE MARIE MI 49783
CHAS F THOMPSON MO L
DRUMMOND ISLAND MI 49726
TONY J TRAPASSO MD 816 ASHMUN
SAULT STE MARIE MICH 49783
ANTON G VENIER MD 816 ASHMUN ST
SAULT STE MARIE MI 49783
ERLING S WEDDING MD 203 HUDSON DR
SAULT STE MARIE MI 49783
CLINTON
GEO W BENNETT MD 203 W MAIN ST
ELSIE MI 48831
BRUNO C COOK MD
WESTPHALIA MI 48894
JAMES M GROST MD PARK AVENUE
ST JOHNS MI 48879
SHERWOOD R RUSSELL MO
210 E WALKER ST
ST JOHNS MI 48879
VICTOR L SHELINE MD
MEDICAL CENTER
ITHACA MICH 48847
EARL M SLAGH MD
ELSIE MI 48831
WESLEY F STEPHENSON MD
510 £ WALKER ST
ST JOHNS MICH 48879
DELTA
FRANCIS C ANDERSON MD 218 S 10TH ST
ESCANABA MICH 49829
THEODORE L BASH MD
BARK RIVER MICHIGAN 49807
ROLAND E BERRY MD
ST FRANCIS HOSP
ESCANABA MI 49829
MARY CRETENS MD DIR DELTA-MENOM HLTH DEPT DELTA COUNTY BLDG
ESCANABA MI 49829
JAMES R DEHLIN MD 8 S 11TH ST
GLADSTONE MI 49837
DONALD N FITCH MD DOCTORS PARK
ESCANABA MI 49829
JAMES H FYVIE MD
202 S CEDAR ST
MANISTIQUE MI 49854
E JAMES GORDON MD DEER PARK
ESCANABA MI 49829
LOUIS P GROOS MD
1015 S 1ST AVE
ESCANABA MICH 49829
RAYMOND L HOCKSTAD MD DOCTORS PARK
ESCANABA MI 49829
OTTO S HULT MD 1005 DELTA AVE GLADSTONE MICH 49837
JOHN LE MIRE MD DOCTORS PARK
ESCANABA MI 49829
WM A LE MIRE III MD DOCTORS PARK
ESCANABA MI 49829
WILLIAM A LE MIRT MD DOCTORS PARK
ESCANABA MICH 49829
GEO MAN I AC I MD 8 SOUTH 11TH ST GLADSTONE MICH 49837
THOS A MC INERNEY MD 1221 LUDINGTON ST ESCANABA MICH 49829
CARL J OLSON MD 8 S 11TH ST
GLADSTONE MICH 49837
HOWARD J PARKHURST MD H
1551 DOUSMAN ST
GREEN BAY W I SC 54303
A LESLIE ROSE MD DOCTORS PARK
ESCANABA Ml 49829
ROBT E RYDE MD 1221 LUDINGTON ESCANABA MICH 49829
LAWRENCE SELL JR MD MANISTIQUE CLINIC MANISTIQUE MI 49854
NIKOLAUS J THE I SEN MD 1400 16TH AVENUE S ESCANABA MI 49829
DUANE L WATERS MD
200 S CEDAR ST
MANISTIQUE MICH 49854
MERLE E WEHNER MD 131 RIVER ST
MANISTIQUE MICH 49854
DICKINSON
EARL R ADDISON MD
412 SUPERIOR AVE
CRYSTAL FALLS MICH 49920
WM H ALEXANDER MD L
411 EAST C ST
IRON MOUNTAIN MI 49801
DONALD T ANDERSON MD
408 HAMILTON AVE
K 1 NGSFORD MICH 49801
ROBERT ANDERSON MD DICKINSON MEM CO HOSP IRON MOUNTAIN MI 49801
GEORGE H BOYCE JR MD A
VA HOSPITAL
IRON MOUNTAIN MI 49801
ROBERT CALDERWOOD DDS A
1ST NATL BANK BLDG
IRON MOUNTAIN MI 49801
RALPH E CARLSON MD 500 STEPHENSON AVE IRON MOUNTAIN MICH 49801
R D CECCONI M D COMMERCIAL BANK BLDG IRON MOUNTAIN MICH 49801
JOYCE GENDZWELL MD
805 VULCAN STREET
IRON MOUNTAIN MICH 49801
WM R GLADSTONE JR MD 804 MAIN ST
NORWAY MI 49870
WILLARD N HAYES MD 720 N MAIN ST
NORWAY MICH 49870
JANUARY, 1972/Michigan Medicine 11
49801
L
49935
49801
49801
49801
49801
10
49935
A
49801
ID
49801
49801
49920
49801
54121
49801
49920
49801
A
49892
48890
48813
48813
49076
A
49076
48827
►/Micl
LISTED BY COMPONENT MEDICAL SOCIETIES
FRED C GARLOCK MO
406 E JEFFERSON ST
GRAND LEDGE MICH 48837
GORDON R HARROD MD
11653 S HARTEL RO
GRAND LEDGE MI 48837
DANIEL 0 JOSEPH MD 202 S COCHRAN
CHARLOTTE MICHIGAN 48813
ROBERT L LEESER MD 202 S COCHRAN
CHARLOTTE MI 48813
ALBERT H MEINKE JR MO
800 CUMBERLAND DR
EATON RAPIDS MICH 48827
ALBERT W MYERS MO
POTTERVILLE Ml 48876
S R ROBINSON MD
11653 S HARTEL RD
GRAND LEDGE MICH 48837
LESTER G SEVENER MO 236 S MAIN ST
CHARLOTTE MICH 48813
DAVIO A BARBOUR MD
5369 BRIARCREST
FLINT MICHIGAN 48504
FLEMING A BARBOUR MD
2015 LINCOLN DR
FLINT MI 48503
FRANKLIN W BASKE MD L
923 MAXINE ST
FLINT MI 48503
JOSEPH T BATDORF MD 8483 HOLLY RO
GRAND BLANC MI 48439
LAWRENCE G BATEMAN MD 1928 LEWIS ST
FLINT MI 48506
MARTIN L BEARD MD 6606 N SAGINAW ST FLINT MI 48505
DOUGLASS R BECK MD
5445 FERNWOOD OR
FLINT MI 48504
EUGENE B BECKER MD
2849 MILLER RD
FLINT MI 48503
ROY G BRAIN MD L
460 S SAGINAW ST
FLINT MI 48502
HIRA E BRANCH MD
817 MOTT FDTN BLDG
FLINT MICHIGAN 48502
OONALD R BRASIE MD R
R 2 BOX 436
ROSCOMMON MI 48653
GUY 0 BRIGGS MD L
224 E COURT ST
FLINT MI 48503
CLARENCE A BROWN MD
2765 FLUSHING RD
FLINT MI 48504
HOWARD C BRUCKNER MD
109 FAIRMOUNT AVE
CHATHAM N J 07928
DONALD R BRYANT MD
621 MOTT FON BLDG
FLINT MICHIGAN 48502
GERALD S BUCHANAN MD 3471 GRANGE HALL RO HOLLY MICH 48442
EBER B SHERMAN MD
501 CARLISLE ST
EATON RAPIDS MI 48827
HERMAN F VAN ARK MD 410 BLAKE ST
EATON RAPIDS MI 48827
CLAYTON 0 WILL I TS MD R R XI
NASHVILLE MI 49073
GENESEE
R RODERICK ABBOTT MD
420 S BALLENGER HWY FLINT MI 48504
ALBERT C ADAMS MD
5210 LAPEER RD
FLINT MI 48503
BURNELL H ADAMS MD
609 S LYNCH ST
FLINT MI 48503
LEROI J ALEXANDER MD
915 W PASADENA
FLINT MI 48504
DONALD J ALLCORN MD
1279 COLDWATER RD
FLINT MI 48505
HARLEY H ANDERSON MD
11820 N SAGINAW
MT MORRIS MICH 48458
I TURAN BENGISU MD 1615 GENESEE TOWERS
FLINT MI 48502
JACK BENKERT MD
6384 KINGS POINTE
GRAND BLANC MICH 48439
JOHN C BENSON MD
639 MOTT FDTN BLOG
FLINT MI 48502
HARRY BERMAN MD
3309 FENTON RD
FLINT MI 48507
GERALD P BERNER MD
2765 FLUSHING RD
FLINT MICHIGAN 48504
ELI N BERNSTEIN MD
1201 FLUSHING RD
FLINT MICHIGAN 48504
J A BEST M D 3801 CLIO RD
FLINT MI 48504
GEO 0 BEYER MD
G 3337 W VIENNA
CLIO MICHIGAN 48420
GREGOIRE BOLDUC MD
325 E FIRST ST
FLINT MICHIGAN 48502
WM P BOLES MD L
714 BEACH ST
FLINT MI 48502
WM F BUCHANAN MD
238 W CAROLINE
FENTON MICH 48430
LESLIE V BURKETT MO L
618 OOUGHER T Y PL
FLINT MI 48504
DONALD R CANADA MD 1207 N BALLENGER HWY FLINT MI 48504
NORMAN A CARTER MD
1201 FLUSHING RD
FLINT MI 48504
MYRTON S CHAMBERS MD L
3402 WESTWOOD PKWY
FLINT MI 48503
EUGENE N CHARDOUL MD
202 PATERSON BLDG
FLINT MI 48502
WM D CHASE MD L
1190 RIV VALLEY DR #5 FLINT MI 48504
RONALD CHEN MD 432 N SAGINAW
FLINT MI 48502
MINOO B CHINOY MD
325 E FIRST ST
FLINT MI 48502
JOHN C CHOGICH MD
1245 DUPONT ST
FLINT MI 48504
JOHN L ANDERSON MD
2765 FLUSHING RD
FLINT MI 48504
VIRGILIO BONET MO
2765 FLUSHING RD
FLINT MI 48504
ROB T L CLARK MD
1301 FLUSHING RD
FLINT MI 48504
RICHARD A ANTELL MD 3402 SANTA CLARA CT FLINT MICHIGAN 48504
DONALD BOSKER MD
1818 LONGWAY BLVD #302
FLINT MI 48506
GERALD G COLE MD
1818 LONGWAY BLVD
FLINT MI 48501
GEO E R ANTHONY MD R
RR1 PORT LAMBTON ONTARIO CANADA
ROBERT A BOTA MD
1623 MONTCLAIR
FLINT MICHIGAN 48503
JAMES I COLLINS MD
G 1128 N DYE ROAD
FLINT MICHIGAN 48504
ROBERT M ARMBRUSTER MD 626 MOTT FDTN BLDG FLINT MI 48502
DUANE J BAILEY MD 238 W CAROLINE ST FENTON MI 48430
PETER R BOYER MD
2510 NERREOI A #103
FLINT MI 48504
ROBT M BRADLEY MD
1112 MOTT FND BLDG
FLINT MI 48502
CLIFFORD W COLWELL MD
328 S SAGINAW ST
FLINT MI 48502
DAVIO E CONGDON MD
9190 PINE BLUFF
FLUSHING MI 48433
W CLAIRE BAIRD MD
2765 FLUSHING RD
FLINT MICHIGAN 48504
JOHN L BRADY MD
302 KENSINGTON
FLINT MI 48502
MCCLELLAN 8 CONOVER MD 1209 KENSINGTON AVE FLINT MI 48503
Medicine
DIRECTORY OF MSMS MEMBERS
Genesee County
FRANK W COOK MD
MEHMET EKINCI MD
EVELYN GOLDEN MD
410 S BALLENGER
2279 GRAND BLANC RD
218 E COURT ST
FLINT MICHIGAN
48504
GRAND BLANC MI
48439
FLINT MICH
48503
JOHN L COOK MD
HARD I E B ELLIOTT MD
H MAXWELL GOLDEN MD
GENESEE BANK BLDG #208
503 S SAGINAW ST
218 E COURT ST
FLINT MI
48502
FLINT MI
48502
FLINT MI
48503
CORY E COOK INGHAM MD
RAYMOND M ENGELMAN MD
SAUL S GORNE MD
214 MEDICAL ARTS BLDG
808 N GRAND TRAVERSE
619 CLIFFORD ST
FLINT MICHIGAN
48501
FLINT MI
48503
FLINT MI
48503
LOUIS B CORIASSO MD
ALI A ESFAHANI MD
GEO H GRE I DINGER MD
9224 HAPPY HOLLOW CT
710 MOTT FDTN BLOG
ST JOSEPH HOSPITAL
GRAND BLANC MI
48439
FLINT MI
48502
FLINT MI
48502
KENNETH M COYNE MD
RALPH D ETTINGER MD
ERNEST P GRIFFIN JR
MD
325 E FIRST ST
238 W CAROLINE ST
1505 ARROW LANE
FLINT MICHIGAN
48503
FENTON MICHIGAN
48430
FLINT MI
48507
ROBERT L CROSS MD
JOHN F FAILING JR MD
JACK R GROMMONS MD
5221 WOODHAVEN DR
HURLEY HOSPITAL
721 W SIXTH AVE
FLINT MICHIGAN
48504
FLINT MICHIGAN
48502
FLINT MICHIGAN
48503
G CAMPBELL CUTLER M
D
Q C FAN MD
HAROLD F GROVER MD
L
420 S BALLENGER
2002 E COURT ST
3433 FENTON RD
FLINT MI
48504
FLINT MICH
48503
FLINT MI
48507
JOHN R DAMM MD
BEN S FARAH MD
GURDON S GUILE MD
A
8483 HOLLY RD
2765 FLUSHING RD
1621 DUPONT ST
GRAND BLANC MI
48439
FLINT MI
48504
FLINT MI
48504
ROBT C DAVIS MD
MAYNARD M FARHAT MD
EDWIN H GULLEKSON MD
G 3029 FLUSHING RD
505 W COURT ST
2765 FLUSHING RD
FLINT MI
48504
FLINT MICH
48503
FLINT MI
48504
RALPH E DAWSON MD
CYRUS FARREHI MD
C R GUMPPER MD
721 W SIXTH AVE
302 KENSINGTON
4437 MORRISH RD
FLINT HI
48503
FLINT MI
48503
SWARTZ CREEK MICH
48473
JOHN MURRAY DAY MO
HANSON G FEE MD
GEO L GUNDRY MD
L
1919 GENESEE TOWERS
108 E KEARSLEY ST
8030 GREEN VALLEY DR
FLINT MI
48502
FLINT MI
48502
GRAND BLANC MI
48439
NICHOLAS DELZINGRO MD L
JOSE A FERNANDEZ MD
ISADORE H GUTOW MD
328 N MAIN ST
2510 NERREDIA
2765 FLUSHING RD
DAVISON MI
48423
FLINT MI
48504
FLINT MI
48504
CARLTON K DETTMAN MD
JAMES W FERRIS MD
JULIUS J GUTOW MD
10512 MCKINLEY RD
1005 LEITH ST
726 CHURCH STREET
MONTROSE MICH
48457
FLINT MI
48505
FLINT MICHIGAN
48503
BERNARD DICKSTEIN MD
THEO FINKELSTEIN MD
ERWIN GUTOWITZ MD
605 NATIONAL BLDG
1415 BROADWAY BLVD
420 S BALLENGER HWY
FLINT MI
48502
FLINT MI
48506
FLINT MICHIGAN
48504
ROY D DIGGS JR MD
RICHARD 0 FLETT MD
RICHARD 0 HACKLEY MD
4250 N SAGINAW ST
1368 KRA-NUR DR
1818 R T LONGWAY BLVD
FLINT MI
48505
DAVISON MI
48423
FLINT MI
48501
SAMUEL R DISMOND MD
GRAYDON R FORRER MD
ROBT F HAGUE MD
L
1402 S SAGINAW ST
2279 E GRAND BLANC RO
2745 LAKEWOOD OR
FLINT MICHIGAN
48503
GRAND BLANC MICH
48439
FLINT MI
48507
MAX E DODDS MD
LEON FRIEDMAN MD
JOHN WM HALLITT MD
625 S GRAND TRAVERSE
2765 FLUSHING RD
102 MEDICAL ARTS BLDG
FLINT MICHIGAN
48503
FLINT MI
48504
FLINT MI
48501
JAMES F DOOLEY MD
HARVEY T FULLER MD
R
ROBT H HARPER MD
3210 S DORT HWY
2700 N HAYDEN RD
713 THOMSON ST
FLINT MI
48507
SCOTTSDALE ARIZ
85257
FLINT MI
48503
WILLIAM F DWYER MD
ALBERT J GASIS MD
BERNARD J HARRIS MD
625 S GRAND TRAVERSE
1201 FLUSHING RD
1750 LYNBROOK
FLINT MICHIGAN
48503
FLINT MI
48504
FLINT MICHIGAN
48507
RICHARD A DYKEWICZ MD
SABAH K GEORGE MD
DONALO R HARRIS MD
2744 FLUSHING RD
721 W 6TH AVE
2429 WELCH BLVD
FLINT MI
48504
FLINT MI
48503
FLINT MICHIGAN
48504
WAYNE L EATON MD
GEORGE Z GERRAS MD
FREDK V HAUSER MD
1703 CRESCENT DR
1334 N DYE ROAD
1015 MOTT FNDN BLDG
FLINT MI
48503
FLINT MICHIGAN
48504
FLINT MI
48502
ERNEST M E ICHHORN MD
JAMES J GIBBONS MD
JAMES E HAWKINS MD
2765 FLUSHING RD
101 MEDICAL ARTS BLDG
4618 ROBERTS ST
FLINT MI
48504
FLINT MI
48501
FLINT MI
48501
THOS N EICKHORST MD
RUDOLPH GOETZ MD
PHYLLIS 0 HELCHER MD
2765 FLUSHING RD
1221 CHURCH STREET
420 S BALLENGER
FLINT MI
48504
FLINT MICHIGAN
48503
FLINT MI
48504
DOUGLAS D EITZMAN MD
E MARSHALL GOLDBERG MD
ROBERT D HELFERTY MD
2765 FLUSHING RD #302
HURLEY HOSPITAL
1116 ANN ARBOR STREET
FLINT MI
48504
FLINT MI
48502
FLINT MI
48503
FREDRIC A HELHER HD 2765 FLUSHING RD »315
FLINT MI 48504
CHARLES R HENNESSY HD 917 MOTT FNDN BLDG FLINT MICH 48502
HAROLD H HISCOCK MD L
1315 MOTT FDTN BLDG FLINT MI 48502
THOMAS A HOCKMAN MD 11125 OLD BRIDGE RD GRAND BLANC MICHIGAN 48439
FRANK V HODGES MD
HURLEY HOSPITAL
FLINT MI 48502
VIRGIL R HOOPER MD 4230 TRUMBULL
FLINT MICHIGAN 48504
ROBERT J HOUSE MD 915 S GRAND TRAVERSE FLINT MICHIGAN 48503
WM C HUBBARD MD
302 PATERSON BUILDING
FLINT MICHIGAN 48502
WILFRID L HUFTON MD
2765 FLUSHING RD
FLINT MI 48504
RICHARD J HUNT MD
2025 CRESTBROOK LN
FLINT MI 48507
CLAYTON E HURD MD
205 LINCOLN ST
FENTON MICHIGAN 48430
LAWRENCE R IRISH MD
6146 SIERRA PASS
FLINT MICHIGAN 48504
ORESTES I UNG MD 2710 W COURT ST FLINT MI 48503
ROBT E JAMES MD 1860 HAMPDEN
FLINT MI 48507
WALTER H JANKE MD
710 MOTT FNDTN BLDG
FLINT MI 48502
A H JOHNSON JR MD R
429 NORTH ST SW #506 WASHINGTON D C 20024
RAYMOND E JOHNSON MD
5173 W REID RD
SWARTZ CREEK MICH 48473
ALVIN E JUDD MO 1620 N FRANKLIN FLINT MI 48506
T A I K KANG MD
432 N SAGINAW ST #707
FLINT MI 48502
PAUL H KARR MD 1818 R T LONGWAY BLVD FLINT MICHIGAN
LEWIS D KAUFMAN MD 4002 N SAGINAW ST FLINT MI
JAMES E KELLY MD 2765 FLUSHING RD FLINT MICHIGAN
DONALD M KENNETT MD 315 BELLA VISTA DR GRAND BLANC MICHIGAN 48439
C 8 KIMBROUGH MD
1402 S SAGINAW ST
FLINT MI 48503
48503
48505
48504
JANUARY, 1972/Michigan Medicine 13
Genesee County
LISTED BY COMPONENT MEDICAL SOCIETIES
0 F KLINE MD
SYONEY N LYTTLE MD
H H MENDREK MD
2765 FLUSHING RO
1207 N BALLENGER HWY
2765 FLUSHING RD
FLINT MI
48504
FLINT MI
48504
FLINT MI
48504
JAMES G KNAGGS MD
J W MAC KENZIE JR MO
ROBT M MICHELS MD
500 S GR TRAVERSE ST
4437 MORRISH RD
2702 FLUSHING RD
FLINT MI
48503
SWARTZ CREEK MICH
48473
FLINT MICHIGAN
48504
WM D KNAPP MD
ALBERT J MACKSOOD MD
RICHARD B MICHELSON MD
503 S SAGINAW ST
3169 W PIERSON RD
2014 ROBT T LONGWAY
FLINT MI
48502
FLINT MICHIGAN
48504
FLINT MI
48503
CHESTER S KOOP MD
JOHN M MACKSOOD MD
KURT W MIKAT MD
1 SAC ST
3169 W PIERSON RD
6061 ROLLING GREEN OR
FRANKFORT MI
49635
FLINT MI
48504
GRAND BLANC MI
48439
ARTHUR H KRETCHMAR MD L
JOS A MACKSOOD MD
L
LOREN E MILLER MO
481 ST ANDREWS DR
3169 W PIERSON RD
2645 CORUNNA RD
APTOS CALIF
95003
FLINT MI
48504
FLINT MI
48503
CARROLL J LA VIELLE MD
WILLIAM E MACKSOOD MD
ANTHONY J MILTICH MD
1135 N DYE RD
3169 W PIERSON RD
915 S GRAND TRAVERSE
FLINT MI
48504
FLINT MICHIGAN
48504
FLINT MI
48503
J LEONIDAS LEACH MD
L
ALBERT A MACPHAIL MD
JAN C MOELLER MD
5014 N SAGINAW ST
3302 HAWTHORNE DR
3102 WESTWOOD PKY
FLINT MI
48505
FLINT MICHIGAN
48503
FLINT MICHIGAN
48503
LESLIE L LE MIEUX MD
C H MANGEL SDORF MD
BEHROUZ MOGHTASSED MD
701 W DAYTON ST
G3393 CLIO RD
1818 R T LONGWAY BLVD
FLINT MI
48504
FLINT MICHIGAN
48504
FLINT MI
48503
MARK C LEVINE MO
JOHN T MANWARING MD
GLENN E MOORE MD
G3083 FLUSHING RD
G5432 CALKINS RD
323 W SECOND
FLINT MI
48504
FLINT MI
48504
FLINT MI
48503
BILLIE LEWIS MD
RUBEN J MARCHI SANO MD
WILLIAM H S MOORE MD
739 MOTT FON BLDG
3507 SUNSET DRIVE
1201 FLUSHING RD
FLINT MICHIGAN
48502
FLINT MI
48503
FLINT MI
48504
JOHNNY F LEWIS MD
A
PAUL J MARKUNAS MD
ALAN L MORGAN MD
1318 W GENESEE St
4002 N SAGINAW ST
3169 W PIERSON RD
FLINT MI
48504
FLINT MICH
48505
FLINT MI
48504
THOS E LEWIS MO
JAMES A MARTIN MD
PAUL MORIN MD
4071 RICHFIELD RD
812 S ADELAIDE ST
1968 MILLER RD
FLINT MICHIGAN
48506
FENTON MICH
48430
FLINT MICHIGAN
48503
VIVIAN M LEWIS MD
HELIO B F MARTINS MD
VAUGHN H MORRISSEY MD
1618 KENSINGTON
1179 N BALLENGER
101 STOCKDALE ST
FLINT MICHIGAN
48503
FLINT MI
48504
FLINT MI
48503
ROBT W LIEBER MD
BERTON J MATHIAS MO
EDWARD C MOSIER MD
6144 PEBBLESHIRE CIRC
1301 FLUSHING RD
1730 OVERHILL DR
FLINT MICHIGAN
48507
FLINT MI
48504
FLINT MI
48503
ARTHUR S LIGHTFOOT MD
J D MC ALINDON MD
WILLYS F MUELLER MD
4500 DETROIT ST
1423 OX YOKE DR
13335 PAMONA DR
FLINT MICHIGAN
48505
FLINT MICHIGAN
48504
FENTON MI
48430
FREDERICK S LIM MD
JUNIUS W MC CLELLAN MD
E GRANT MURPHY MD
806 W SIXTH AVE
BUICK MOTOR DIVISION
118 MEDICAL ARTS BLDG
FLINT MI
48503
FLINT MI
48505
FL INT MI
48504
DAVID R LIMBACH MD
EARL J MCGARVAH MO
S H NASSAR MD
900 BEGOLE ST
410 S BALLENGER HWY
8483 HOLLY RD
FLINT MI
48503
FLINT MI
48504
GRAND BLANC MI
48439
THOMAS C LINDMAN M 0
JOHN D MCGRAE JR MD
ALFRED E NEUFFER MD
2484 NOLEN DR
2433 WELCH BLVD
5384 TERRITORIAL RD
FLINT MICH
48504
FLINT MICHIGAN
48504
GRAND BLANC MI
48439
ERNESTO 0 LIS MD
ALLAN R MCGREGOR MD
WM W NICHOLLS MD
703 E COURT ST
G 3337 W VIENNA RD
806 W SIXTH AVE
FLINT MI
48503
CLIO MICHIGAN
48420
FLINT MI
48503
JACKSON E LIVESAY MD
L
THOMAS A MC LENNAN MD
DONALD A NITZ MD
503 S SAGINAW ST
913 MOTT FNDTN BLDG
1818 ROBERT T LONGWAY
FLINT MI
48502
FLINT Ml
48502
FL INT MI
48503
E R LUMAQUE MD
KENNETH W A MC LEOD MD
DAVID E OJEDA MD
6474 KINGS PTE RD
6078 WINGED FOOT DR
3169 W PIERSON RD
GRAND BLANC MI
48439
GRANO BLANC MI
48439
FL INT MI
48504
ROSIE M LUMAQUE MD
RICHARD J MC MURRAY MD
MARY RUTH OLDT MD
6474 KINGS PTE RD
2765 FLUSHING RD
602 S LYNCH ST
GRANO BLANC MI
48439
FLINT MICH
48504
FLINT MI
48503
RICHARD M LUNDEEN MD
D W MCNAUGHTON MD
ROBT S ORMOND MD
3393 CLIO
2437 PINEWOOD CT
HURLEY HOSPITAL
FLINT MICH
48504
FLUSHING MI
48433
FLINT MI
48502
JOHN A LUSK MD
DAVID MC TAGGART M D
SEYMOUR L OSHER MD
9233 W DAVISON RD
625 S GRAND TRAVERSE
315 E COURT ST
DAVISON MICHIGAN
48423
FLINT MICHIGAN
48503
FLINT MI
48503
MARJORIE OTERO MO A
307 SUNNY S l OE DR FLUSHING MI 48433
RUITSON OUYANG MO
3083 FLUSHING RD
FLINT MI 48504
HEEOONG PARK MD
3169 W PIERSON RO
FLINT MI 48504
JOON H PARK MD
1708 GENESEE TOWERS
FLINT MI 48502
BURT A PARLIAMENT MD
5126 DYEHILL COURT
FLINT MI 48504
RICHARD 0 PELHAM MD
3306 FLUSHING RD
FLINT MI 48504
ARCHIBALD C PFEIFER MD L 9798 PALMETTO CLUB DR MIAMI FL 33157
LYNN A PHELPS MD 10122 JANAROY CT GOODRICH MICH 48438
A F PHILLIPS MD X RAY DEPT HURLEY HOSP FLINT MICHIGAN 48502
WOODROW H PICKERING MD 1602 BALLENGER HWY FLINT MI
B P I ETRUSZKA MD 5210 LAPEER RD FLINT MI
WALLACE W PIKE MD 7514 MILLER RD SWARTZ CREEK MI
ALICE LEE PLATT MD 5551 TERRITORIAL RD GRAND BLANC MI
JACK E PORTNEY MD 725 STEVENS ST FLINT MI
W 0 POUGNET MD 6155 MAPLE RIDGE FLINT MI
OTTO J PRESTON MC 1315 MAXINE FLINT MI
JACK R PRICE MD 410 S BALLENGER HWY FLINT MICHIGAN
RICHARD W PRIOR M D 1266 S LE ROY FENTON MICHIGAN
JOHN QUIN JR MD 2765 FLUSHING RD FLINT MI
FOUAD RABIAH MD 1608 GENESEE TOWERS FLINT MI
HELEN RADCENKO MD 302 W PIERSON RD FLINT MI
LEONID RADCENKU MD 302 W PIERSON RD FL INT MI
OGUZ K RAMADAN MD 8483 HOLLY RD GRAND BLANC MI
D S RAO MO 2765 FLUSHING RD #301 FLINT MI 48504
48504
48503
48473
A
48439
48503
48504
48503
48504 48430
48504 48502
48505 48505 48439
14 JANUARY, 1972/Michigan Medicine
DIRECTORY OF MSMS MEMBERS
Genesee County
RICHARD L RAPPORT MD
PHILLIP G SEVEN M D
PHILIP K STEVENS MD
808 N GRAND TRAVERSE
2301 CUMMINGS
1116 MOTT FDTN BLDG
FLINT MI
48503
FLINT MICH
48503
FLINT MICH
48502
ROBERT J RATHBURN MD
GEO D SEYMOUR MD
RUDOLPH W STREAT MD
L
1706 LAUREL OAK
G7237 N SAGINAW
8100 DAVISON RD
FLINT MICH
48507
MT MORRIS MICHIGAN
48458
DAVISON MI
48423
J MOTT RAWLINGS MD
RAMESH C SHAH MD
CLAYTON K STROUP MD
8505 OLD PLANK RD
HURLEY HOSP RADIOLOGY
2002 E COURT ST
GRAND BLANC MI
48439
FLINT MI
48502
FLINT MI
48503
JOHN H REID M D
LEIGHTON 0 SHANTZ MD
L
M R SULLIVAN MD
1301 FLUSHING RD
1497 COUNTRY VIEW LANE
5352 PEPPERMILL RD
FLINT MI
48504
FLINT MI
48504
GRAND BLANC MICHIGAN
48439
GEORGE H REYE MD
JAMES P SHEEHY MD
JAMES K SUTHERLAND MD L
2279 E GRAND BLANC RD
503 S SAGINAW ST
402 E 3RD ST
GRAND BLANC MICH
48439
FLINT MI
48502
FLINT MI
48503
EDWARDO L REYES MD
DANL H SHEERAN MD
GEO 0 SUTTON MD
L
420 S BALLENGER
610 S VERNON AVE
303 W COURT ST
FLINT MI
48504
FLINT MI
48503
FLINT MI
48503
ALAN K RICE MD
FREDERICK SHERWOOD MD
GENE D TANG MD
A
2008 ROBT T LONGWAY
1207 N BALLENGER HWY
MUNSON MED CTR PATH
FLINT MICHIGAN
48503
FLINT MI
48504
TRAVERSE CITY MI
49684
GEO F RIETH MD
LEWIS E SIMONI MD
JOHN W TAUSCHER MD
1406 DAVISON ST
3210 S DORT HGWY
2016 R T LONGWAY BLVD
FLINT MI
48506
FLINT MI
48507
FLINT MICHIGAN
48503
WM J ROBERSON MD
SARJ IT SINGH MD
WALTER I THEUERLE MD
3455 LIPPINCOTT BLVD
839 MOTT FNDTN BLDG
3117 CLIO RD
FLINT MI
48507
FLINT MI
48502
FLINT MI
48504
M L ROBITAILLE MD
J BERNARD SLOAN MD
CHARLES A THOMPSON MD
2765 FLUSHING RD
3169 W PIERSON RD
1201 SAN JUAN
FLINT Ml
48504
FLINT MI
48504
FLINT MI
48504
JOHN B ROWE MD
R H SMALLEY MD
JACK W THOMPSON MD
653 SAGINAW ST
4437 MORRISH RD
2702 FLUSHING RD
FLINT MI
48502
SWARTZ CREEK MI
48473
FLINT MI
48504
WALTER Z RUNDLES MD
EUGENE C SMITH MD
PETER S THOMS MD
500 GRAND TRAVERSE ST
606 STEVENS
1368 W COLDWATER RD
FLINT MI
48503
FLINT MICHIGAN
48503
FLINT MICH
48505
RUSSELL G SANDBERG MD
HAROLD 0 SMITH MD
ELMER H TOFTELAND MD
5431 FERNWOOD DR
3769 SUNSET DR
2765 FLUSHING RD
FLINT MI
48504
FLINT MICHIGAN
48503
FLINT MI
48504
FREDK E SANOCKI MD
MAURICE J SMITH MD
RITA B TOWER MD
L
2700 W COURT ST
804 METROPOLITAN BLDG
ELMS TRAILER PARK D4
FLINT MI
48503
FLINT MI
48502
2801 S DORT HWY
SIRUN SARAFIAN MD
SIDNEY E SMITH MD
FLINT MI
48507
6820 CLIO RD
5220 PASADENA
FLINT MI
48504
FLUSHING MI
48433
ALLEN F TURCKE MD 1245 DUPONT ST
CHAS J SCAVARDA MD
BEN J F SNIDERMAN MD
FL INT MI
48504
1106 MAXINE
727 BEACH ST
FLINT MICHIGAN
48503
FLINT MI
48502
MERALD G TURNER MD G 3169 W PIERSON
RICHARD K SCHAEFER MD
A E SOUK MD
FLINT MI
48504
3248 VAN SLYKE RD
1201 FLUSHING RD
FLINT MI
48507
FLINT MICHIGAN
48504
ARTHUR L TUURI MD MOTT CHILDREN CLINIC
NELSON S SCHAFER MD
FREDRIC M SOMACH MD
FLINT MICH
48502
721 W 6TH AVE
2765 FLUSHING RD
FLINT MI
48503
FLINT MI
48504
EROL UCER MD 801 S SAGINAW
BENTON A SCHIFF MD
MORRIS L SORKIN MD
FLINT MI
48502
323 W 2ND ST
718 BEACH ST
FLINT MI
48503
FLINT MI
48502
VERNON URICH MD 3169 W PIERSON RD
ROBT W SCHMIDLIN MD
S AML S SORKIN MD
FLINT MICHIGAN
48504
3710 DAVISON RD
718 BEACH ST
FLINT MI
48506
FLINT MI
48502
DOUGLAS VANBROCKLIN MD
1300 N DORT HWY
E OSKAR SCHREIBER MD
WARREN E SOUTHALL MD
FLINT MI
48506
2765 FLUSHING ROAD
4250 N SAGINAW ST
FLINT MI
48504
FLINT MICHIGAN
48505
J D VANBROCKLIN MD 2620 FLUSHING RD
PAUL E SCHROEDER MD
HARVEY V SPARKS MD
FLINT MI
48504
1673 N CHEVROLET
2765 FLUSHING RD
FLINT MICHIGAN
48504
FLINT MI
48504
FREDK W VAN DUYNE MD 2849 MILLER RD
JOHN M SCHWARTZ MD
RALPH S STEFFE MD
FLINT MICHIGAN
48503
1300 N DORT HWY
2765 FLUSHING RD
FLINT MICHIGAN
48506
FLINT MI
48504
RAYMOND S VAN HARN MO
808 N GRAND TRAVERSE
HEINZ H SCHWARZ
FLOYD H STEINMAN MD
FLINT MICHIGAN
48503
5551 TERRITORIAL RD
503 S SAGINAW ST
GRAND BLANC MI
48439
FLINT MI
48502
S VARJAVANDI HO
3169 W PIERSON RO
FLINT MI 48504
HOWARD L VARNEY MO 1818 ROUT LONGWAY BLVD FLINT MICHIGAN 48503
ADNAN 0 VAROL MD
2279 GRAND BLANC RD
GRAND BLANC MI 48439
NICHOLAS N VELARDE MO
3083 FLUSHING RD
FLINT MI 48504
L WILLIAM VERGITH MD
2765 FLUSHING RD
FLINT MI 48504
DAVID L VER LEE MD
503 S SAGINAW ST
FLINT MI 48502
V VILLARREAL MD
1374 COUNTRYVIEW LANE
FLINT MI 48504
FRANKLIN V WADE MD 808 N GRAND TRAVERSE FLINT MICHIGAN 48503
CARVER G WALCOTT MD
201 E CAROLINA ST
FENTON MICH 48430
JAMES D WALKER MD 8483 HOLLY RD
GRAND BLANC MI 48439
DANIEL L WALTER MD 9311 ROUNO HILL CT GRAND BLANC MI 48439
RICHARD E WEBER MD
420 S BALLENGER HWY
FLINT MI 48504
ROBT M WEBER MD 3710 DAVISON RO FLINT MI 48506
WILLIAM J WEBER MD 721 W 6TH AVE FLINT MI
48503
JOHN E WENTWORTH MD
420 S BALLENGER
FLINT MI 48504
SOLOMON C WERCH MD
7320 S STATE RO
GOODRICH MI 48438
INGA W WERNESS MO L
220 EAST FOURTH ST
FLINT MI 48503
GEORGE A WEST MD
4250 N SAGINAW
FLINT MI 48505
J D WHEELER M D
118 MEDICAL ARTS BLDG
FLINT MI 48504
CARL H WHITE MD 106 RIVER ST
FENTON MICH 48430
FRANK T WHITE MD
9244 LAPEER RD
DAVISON MI 48423
ROBT H WILLARO MD 718 BEACH ST FLINT MI
A
48502
L
WM S WILLIAMS MD 12025 S SAGINAW BLDG 7 GRAND BLANC MI 48439
THOS N WILLS MD R
2760 N E 29TH
POMPANO BEACH FL 33064
JANUARY, 1972/Michigan Medicine 15
Genesee County
DALE A WILSON MO 2765 FLUSHING RD FLINT MI *850*
NAN D WOLCOTT MD R
7506 LAPEER RO
DAVISON MI *8423
MELVYN 0 WOLF MD
G3083 FLUSHING RD
FLINT MI *8503
GEO W WRIGHT JR MD 6820 CLIO RD
FLINT MI *850*
MYRON G ZEIS MO
336 W FIRST ST
FLINT MI *8502
DANIEL M ZELKO MO *071 RICHFIELD RD FLINT MICHIGAN *8506
GOGEBIC
SAML G ALBERT MD
103 SUFFOLK ST
IRONWOOD MICH *9938
DONALD L DAVIDSON MO
200 S SOPHIE ST
BESSEMER MICH *9911
JOHN R FRANCK JR MD
*01 SUNOAY LAKE
WAKEFIELD MICH *9968
BELA GALLO MD
NEWPORT CLINIC
IRONWOOD MICH *9938
MICHAEL A GERTZ MD L
109 E AURORA ST
IRONWOOD MICH *9938
ALLEN C GORRILLA MD
210 SUFFOLK ST
IRONWOOD MI *9938
REX R HARRINGTON JR MD
10* E RIDGE ST
IRONWOOD MICH *9938
M J LIEBERTHAL MD L
P 0 BOX *00
IRONWOOD MI *9938
PAUL R LIEBERTHAL MD L
BOX *00
IRONWOOD MI *9938
LESTER MEDFORD MD 306 SUNDAY LAKE ST WAKEFIELD MICH *9968
FLORIAN J SANT I N I MD
109 E AURORA ST
IRONWOOD MICH *9938
GRAND TRAVERSE
RICHARD G BARSTOW MD A
2 JASMINE ST CRESTMOOR PARK
OENVER CO 80220
JOHN R BARTONE MD 217 S MADISON
TRAVERSE CITY MI *968*
JOHN G BEALL MD 1105 E FRONT ST TRAVERSE CITY MICH *968*
HARRY M BLOUNT MO
1122 E FRONT ST
TRAVERSE CITY MI *968*
LISTED BY COMPONENT MEDICAL SOCIETIES
ELLIS S J BOLAN MD BOX 67
SUTTONS BAY MI
*9682
JEROLO R HARWOOD MO 1100 SIXTH ST TRAVERSE CITY MI
*968*
CLARK D PHELPS MD 1321 PENINSULA DR TRAVERSE CITY MI
*968*
KNEALE M BROWNSON MD 116 CASS ST TRAVERSE CITY MICH
*968*
MILDRED L HERKNER MD 1206 PENINSULA CT TRAVERSE CITY MI
A
*968*
DONALD G PIKE MD 1209 E 8TH ST TRAVERSE CITY MICH
*968*
BEN J B BUSHONG MD
R
READER J HUBBELL MD
L
FRANK H POWER MD
116 CASS ST TRAVERSE CITY MICH
*968*
317 WESTLAKE TERR PALM SPRINGS CA
92262
116 CASS ST TRAVERSE CITY MICH
*968*
THOMAS D CAMPBELL MD *03 STATE ST TRAVERSE CITY MICH
*968*
NEVIN HUENE MD 110 E FRONT ST TRAVERSE CITY MICH
*968*
DAYTON SALON MD 1030 6TH ST TRAVERSE CITY MICH
*968*
WM H CARTWRIGHT MD
R R HUSTON MD
L
EDW P SCHEIDLER JR
MD
1105 E FRONT ST TRAVERSE CITY MICH
*968*
ELK RAPIDS MI
*9629
10610 PENINSULA DR TRAVERSE CITY MI
*968*
FREDK J CHAPIN MO STATE HOSPITAL TRAVERSE CITY MI
*968*
ROBERT C JOHNSON MD 116 CASS ST TRAVERSE CITY MI
*968*
DWIGHT M SCHROEDER NORTHPORT MICHIGAN
MD
*9670
OSWALD V CLARK MD 1030 SIXTH ST TRAVERSE CITY MI
*968*
JAMES D JOHNSTON MD 1100 SIXTH ST TRAVERSE CITY MICH
*968*
CHARLES W SHIPMAN MD 20*0 INDIAN TRAIL BLVD TRAVERSE CITY MI *968*
THEOOORE N CLINE MO 999 6TH
TRAVERSE CITY MICK
*968*
ROBT L KAMP MD BEULAH MICH
*9617
L P SKENDZEL MD MUNSON HOSPITAL TRAVERSE CITY MICH
*968*
WARREN W CLINE MD 999 6TH
TRAVERSE CITY MICH
*968*
WM W KITTI MD KALKASKA MI
*96*6
M OUANE SOMMERNESS BOX C
TRAVERSE CITY MICH
MD
*968*
JOHN F COLEMAN MD 1100 SIXTH ST TRAVERSE CITY MI
*968*
JAMES A KOLBERG MD 211 S HIGH ST NORTHPORT MI
*9670
F T SORUM MD BOX C
TRAVERSE CITY MICH
*968*
ARTHUR F DUNOON MD 1100 SIXTH ST TRAVERSE CITY MI
*968*
SEIICHI KOMESU MD BOX C
TRAVERSE CITY MICH
*968*
JOHN R SPENCER MD 112* E FRONT ST TRAVERSE CITY MICH
*968*
W T EDMONOS MD CENTRAL MICH CHILDRENS CLINIC
KEITH G LIEDING MD 1333 WISTERIA DR ANN ARBOR MI
A
*810*
JOS C STEFFEY MD 116 CASS STREET TRAVERSE CITY MICH
*968*
MUNSON MED CTR TRAVERSE CITY MI
CLAUDE I ELLIS MD
*968*
LAWRENCE S LOESEL MD 2829 PRINCETON OR TRAVERSE CITY MI
*968*
G EDWARD STOKES MO 1100 SIXTH ST TRAVERSE CITY MICH
*968*
SUTTONS BAY MI
*9682
ROBT T LOSSMAN MD
FRED G SWARTZ M D
L
D W EVERETT MD
J DECKER MUNSON HOSP TRAVERSE CITY MICH
*968*
612 SIXTH ST TRAVERSE CITY MI
*968*
TRAV CITY STATE HOSP TRAVERSE CITY MI
*968*
CHARLES T LOUISELL MD
BERNARD J SWEENEY MO
JACK A FIEBING MD
P 0 BOX 581 TRAVERSE CITY MI
*968*
1100 SIXTH ST TRAVERSE CITY MICH
*968*
PO BOX 283 TRAVERSE CITY MICH
THOMAS E FINCH MD
*968*
ADAM C MC CLAY M D 217 S MADISON ST TRAVERSE CITY MICH
*968*
FREDK R THACKER MD FRONT ST FRANKFORT MICH
*9635
1122 E FRONT ST TRAVERSE CITY MI
MAX A FINTON MD
*968*
WM J MCCOOL MO 1100 SIXTH ST TRAVERSE CITY MI
*968*
LEONARO J THILL MD BOX C
TRAVERSE CITY MI
*968*
P 0 BOX 368 NORTHPORT MI
*9670
MICHAEL 0 MCMANUS MD
RICHARD L THIRLBY MD
WM A FISHBECK MD
1100 SIXTH ST TRAVERSE CITY MI
*968*
228 S MADISON TRAVERSE CITY MICH
*968*
127 S MADISON TRAVERSE CITY MICH
*968*
STANLEY L MICHAEL MD
CREIGHTON A WAGENER
MD
ROGER C FULMER MD
335 DAVIS ST TRAVERSE CITY MICH
*968*
1100 SIXTH ST TRAVERSE CITY MICH
*968*
217 S MADISON ST TRAVERSE CITY MICH
CHAS R HABERLEIN MD
*968*
JOHN G MILLIKEN MD 22* CIRCLE DR TRAVERSE CITY MICH
*968*
JACK E WE I H MD 1105 E FRONT ST TRAVERSE CITY MICH
*968*
1100 SIXTH ST TRAVERSE CITY MICH
JAMES W HALL MO
*968*
KENNETH H MUSSON MD 9680 PENINSULA OR TRAVERSE CITY MI
*968*
HARRY L WEITZ MD MUNSON HOSP TRAVERSE CITY MICH
*968*
1*31 PENINSULA DR TRAVERSE CITY MICH
*968*
ROBT E PEARSON MD
A
PAUL H WILCOX MD
THOMAS C HALL MD
611 BIRCHWOOD AVE TRAVERSE CITY MI
*968*
333 SIXTH ST TRAVERSE CITY MICH
*968*
1100 SIXTH ST TRAVERSE CITY MI
EARL E HAMILTON MD
*968*
MAURICE S PELTO MD MUNSON HOSPITAL TRAVERSE CITY MICH
*968*
PHIL IP K WILEY MD 116 CASS ST TRAVERSE CITY MICH
*968*
530 S UNION ST TRAVERSE CITY MICH
*968*
WM 0 PETERSON MO 876 E FRONT ST TRAVERSE CITY MICH
*968*
CHAS R WILLIAMS MD *16 SIXTH ST TRAVERSE CITY MICH
*968*
16 JANUARY, 1972/Michigan Medicine
DIRECTORY OF MSMS MEMBERS
Houghton County
GORDON W WILLOUGHBY MD
WM L HARRIGAN MD
R
RICHARD J REMSBERG DO
0
104 5TH ST
90TH AVE 3 SCH SEC LK
309 STATE ST
FRANKFORT MICHIGAN
49635
MECOSTA MI
49332
ALMA MI
48801
LAVERN V WOLFGR AM MD
FRANK W HEDGES MO
WM J ROTH MD
850 E FRONT ST
215 W SAGINAW
255 WARWICK DR
TRAVERSE CITY MI
49684
ST LOUIS MICHIGAN
48880
ALMA MICHIGAN
48801
ROBERT G WONACOTT MD
WM E HERSEE MO
JOHN L ROTTSCHAEFER MD
107 DEXTER ST
306 S COLLEGE
3580 NORTHLAWN PK
ELK RAPIDS MI
49629
MOUNT PLEASANT MICH
48858
ALMA MICH
48801
J K WRIGHT JR MD
A DEANE HOBBS MD
R
WILMER M RUTT MD
1105 E FRONT ST
1506 NE 11TH ST
310 WARWICK DR
TRAVERSE CITY MI
49684
WINTER HAVEN FL
33880
ALMA MI
48801
RICHARD E WUNSCH MD
FRANK 0 JOHNSON MD
A
LEWIS F SANDEL MD
207 CIRCLE DR
914 S KINNEY
245 WARWICK DR
TRAVERSE CITY MICH
49684
MT PLEASANT MICH
48858
ALMA MI
48801
JOHN HARLEY YOUNG MD
PHILIP R JOHNSON MD
JACK F SANDERS MD
CHILDRENS CLINIC
206 S COLLEGE AVE
MICH MASONIC HOME
TRAVERSE CITY MICH
49684
MOUNT PLEASANT MICH
48858
ALMA MICH
48801
IRWIN H ZIELKE MD
ROBERT B JOHNSON MD
LINCOLN B SCOTT JR MD
106 S MADISON
R 1
412 OVERLAND
TRAVERSE CITY MICH
49684
ITHACA MICHIGAN
48847
CHAPEL HILL N C
27514
LE ROY W JUHNKE MD
A A SHEPERDIGIAN MD
GRATIOT
314 S BROWN ST
421 S FANCHER
MT PLEASANT MI
48858
MT PLEASANT MI
48858
ALFRED L ALDRICH MD
JAMES D KLAUER MD
DENNIS V SMITH MD
L
COMMUNITY HOSPITAL
1435 CAMBRIDGE RD
ITHACA MICH
48847
MT PLEASANT MICHIGAN 48858
ANN ARBOR MI
48104
A ROBERT BAUER JR MD
B B KUMAR MD
D A SORIANO MD
412 E BROADWAY
MT PLEASANT STATE HOME
1115 WATSON
MT PLEASANT MICH
48858
MT PLEASANT MI
48858
MT PLEASANT MI
48858
ORHAN BAYBURA MD
MICHAEL R LINN MD
JACK STACK MD
503 E MAIN ST
GRATIOT COMM HOSPITAL
510 PROSPECT
EDMORE MI
48829
ALMA MI
48801
ALMA MICHIGAN
48801
MYRON G BECKER MD
ALEXSANDRS LUSIS MD
R
JAMES F TILDEN MD
1105 SNYDER AVE
GRATIOT COMMUNITY HOSP
EDMORE MI
48829
ANN ARBOR MI
48103
ALMA MI
48801
ANDREW V BEDO MD
STEWART C MC ARTHUR
MD L
ANDREW H VELDHUIS MD
802 GORDON
BOX 32
801 GORDON RD
MT PLEASANT MI
48858
ROSEBUSH MI
48878
MT PLEASANT MICH
48858
JOS H BERGIN MD
EDWIN G MEYER MD
RICHARD L WAGGONER MD
112 E SUPERIOR
712 MICHIGAN AVE
ALMA MICH
48801
ALMA MICHIGAN
48801
ST LOUIS MI
48880
PAUL J BRAT MD
JOHN J MINSTER MD
C HARRY WALLMAN MD
245 WARWICK OR
314 S BROWN ST
901 STATE ST
ALMA MI
48801
MT PLEASANT MI
48858
ALMA MICHIGAN
48801
E J BRENNER MO
R
DONALD F NAGLER MD
LEO R WICKERT MD
1030 NORTH DRIVE
1360 TOMAH DRIVE
1001 WATSON RD
MT