The “Kimmelstiel-Wilson Lesion”

normal vasomotor responses, venular dilatation and parteriolar constriction seen in the bulbar conjunctival I vessels of diabetics are exaggerated in the pregnant diaSbetic. Similar changes in uterine, placental and pelvic vessels are inferred. Although poorly judged timing and errors in dates may turn intra-uterine into neonatal deaths, early timed deliveries have lowered viable mortality rates. Pelvic deliveries are admittedly desirable, but failure of progress after induction, late diagnosis of disproportion, and breech presentation indicate the need for cesarean section. Such programs eliminate intrapartum deaths completely. In part because of prematurity, in part because of cesarean sections, but mostVy because oi diabetes, pu\monary hyaline membranes are the most important cause of morbidity and mortality in the neonatal period. The early time of appearance of symptoms and signs suggests a prenatal influence; the demonstration that the protein is fibrin suggests an intravascular origin. The 3 per cent mortality due to congenital anomalies can perhaps be lowered by avoiding such causes of anoxia as acidosis and hypoglycemia. Prevention of those due to chronic vascular insufficiency will depend upon the preservation of better vascular states prior to pregnancy onset. Much confusion exists today because of exaggerated claims. These are largely two: one that good treatment of diabetes alone guarantees fetal survival; or, two, that female sex hormones guarantee salvage in spite of poor control of diabetes, late timing of delivery and omission of a diuretic program. Constant supervision and dietary control in revealed prediabetes has given a fetal salvage higher than that of the general population. The combination of chemical control of diabetes with diet and insulin, the use of diuretics, the use of female sex hormones, early timing of the delivery and immediate care of the newborn infant has resulted in nondiabetic salvage in Class B patients (adult at onset, short-term without vascular lesions). As maternal vascular lesions progress, fetal salvage decreases until in cases with the severest grade, nephropathy (Class F), fetal salvage occurs in only half the patients. PRISCILLA WHITE, M.D., Boston