The musings of a physician who served the community for over six decades
367 Topics
Downtown A discussion about downtown area in Philadelphia and connections from today with its historical past.
West of Broad A collection of articles about the area west of Broad Street, Philadelphia, Pennsylvania.
Delaware (State of) Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Religious Philadelphia William Penn wanted a colony with religious freedom. A considerable number, if not the majority, of American religious denominations were founded in this city. The main misconception about religious Philadelphia is that it is Quaker-dominated. But the broader misconception is that it is not Quaker-dominated.
Particular Sights to See:Center City Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.
Philadelphia's Middle Urban Ring Philadelphia grew rapidly for seventy years after the Civil War, then gradually lost population. Skyscrapers drain population upwards, suburbs beckon outwards. The result: a ring around center city, mixed prosperous and dilapidated. Future in doubt.
Historical Motor Excursion North of Philadelphia The narrow waist of New Jersey was the upper border of William Penn's vast land holdings, and the outer edge of Quaker influence. In 1776-77, Lord Howe made this strip the main highway of his attempt to subjugate the Colonies.
Land Tour Around Delaware Bay Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Tourist Trips Around Philadelphia and the Quaker Colonies The states of Pennsylvania, Delaware, and southern New Jersey all belonged to William Penn the Quaker. He was the largest private landholder in American history. Using explicit directions, comprehensive touring of the Quaker Colonies takes seven full days. Local residents would need a couple dozen one-day trips to get up to speed.
Touring Philadelphia's Western Regions Philadelpia County had two hundred farms in 1950, but is now thickly settled in all directions. Western regions along the Schuylkill are still spread out somewhat; with many historic estates.
Up the King's High Way New Jersey has a narrow waistline, with New York harbor at one end, and Delaware Bay on the other. Traffic and history travelled the Kings Highway along this path between New York and Philadelphia.
Arch Street: from Sixth to Second When the large meeting house at Fourth and Arch was built, many Quakers moved their houses to the area. At that time, "North of Market" implied the Quaker region of town.
Up Market Street to Sixth and Walnut Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
Sixth and Walnut over to Broad and Sansom In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Montgomery and Bucks Counties The Philadelphia metropolitan region has five Pennsylvania counties, four New Jersey counties, one northern county in the state of Delaware. Here are the four Pennsylvania suburban ones.
Northern Overland Escape Path of the Philadelphia Tories 1 of 1 (16) Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
City Hall to Chestnut Hill There are lots of ways to go from City Hall to Chestnut Hill, including the train from Suburban Station, or from 11th and Market. This tour imagines your driving your car out the Ben Franklin Parkway to Kelly Drive, and then up the Wissahickon.
Philadelphia Reflections is a history of the area around Philadelphia, PA
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Philadelphia Revelations
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George R. Fisher, III, M.D.
Obituary
George R. Fisher, III, M.D.
Age: 97 of Philadelphia, formerly of Haddonfield
Dr. George Ross Fisher of Philadelphia died on March 9, 2023, surrounded by his loving family.
Born in 1925 in Erie, Pennsylvania, to two teachers, George and Margaret Fisher, he grew up in Pittsburgh, later attending The Lawrenceville School and Yale University (graduating early because of the war). He was very proud of the fact that he was the only person who ever graduated from Yale with a Bachelor of Science in English Literature. He attended Columbia University’s College of Physicians and Surgeons where he met the love of his life, fellow medical student, and future renowned Philadelphia radiologist Mary Stuart Blakely. While dating, they entertained themselves by dressing up in evening attire and crashing fancy Manhattan weddings. They married in 1950 and were each other’s true loves, mutual admirers, and life partners until Mary Stuart passed away in 2006. A Columbia faculty member wrote of him, “This young man’s personality is way off the beaten track, and cannot be evaluated by the customary methods.”
After training at the Pennsylvania Hospital in Philadelphia where he was Chief Resident in Medicine, and spending a year at the NIH, he opened a practice in Endocrinology on Spruce Street where he practiced for sixty years. He also consulted regularly for the employees of Strawbridge and Clothier as well as the Hospital for the Mentally Retarded at Stockley, Delaware. He was beloved by his patients, his guiding philosophy being the adage, “Listen to your patient – he’s telling you his diagnosis.” His patients also told him their stories which gave him an education in all things Philadelphia, the city he passionately loved and which he went on to chronicle in this online blog. Many of these blogs were adapted into a history-oriented tour book, Philadelphia Revelations: Twenty Tours of the Delaware Valley.
He was a true Renaissance Man, interested in everything and everyone, remembering everything he read or heard in complete detail, and endowed with a penetrating intellect which cut to the heart of whatever was being discussed, whether it be medicine, history, literature, economics, investments, politics, science or even lawn care for his home in Haddonfield, NJ where he and his wife raised their four children. He was an “early adopter.” Memories of his children from the 1960s include being taken to visit his colleagues working on the UNIVAC computer at Penn; the air-mail version of the London Economist on the dining room table; and his work on developing a proprietary medical office software using Fortran. His dedication to patients and to his profession extended to his many years representing Pennsylvania to the American Medical Association.
After retiring from his practice in 2003, he started his pioneering “just-in-time” Ross & Perry publishing company, which printed more than 300 new and reprint titles, ranging from Flight Manual for the SR-71 Blackbird Spy Plane (his best seller!) to Terse Verse, a collection of a hundred mostly humorous haikus. He authored four books. In 2013 at age 88, he ran as a Republican for New Jersey Assemblyman for the 6th district (he lost).
A gregarious extrovert, he loved meeting his fellow Philadelphians well into his nineties at the Shakespeare Society, the Global Interdependence Center, the College of Physicians, the Right Angle Club, the Union League, the Haddonfield 65 Club, and the Franklin Inn. He faithfully attended Quaker Meeting in Haddonfield NJ for over 60 years. Later in life he was fortunate to be joined in his life, travels, and adventures by his dear friend Dr. Janice Gordon.
He passed away peacefully, held in the Light and surrounded by his family as they sang to him and read aloud the love letters that he and his wife penned throughout their courtship. In addition to his children – George, Miriam, Margaret, and Stuart – he leaves his three children-in-law, eight grandchildren, three great-grandchildren, and his younger brother, John.
A memorial service, followed by a reception, will be held at the Friends Meeting in Haddonfield New Jersey on April 1 at one in the afternoon. Memorial contributions may be sent to Haddonfield Friends Meeting, 47 Friends Avenue, Haddonfield, NJ 08033.
By CHARLES PLATT of the New York Post February 7, 2009
Some people, usually community activists, loath Wal-Mart. Others, like the family of four struggling to make ends meet, are in love with the chain. I, meanwhile, am in awe of it.
With more than 7,000 facilities worldwide, coordinating more than 2 million employees in its fanatical mission to maintain an inventory from more than 60,000 American suppliers, it has become a system containing more components than the Space Shuttle - yet it runs as reliably as a Timex watch.
The author working at Wal Mart
Sheltered by rabble-rousers who forced Wal-Mart's CEO to admit it; wasn't worth the effort's to try to open in Queens or anywhere else in the city, New Yorkers may not fully realize the unique, irreplaceable status of the World's Largest Retailer in rural and suburban America. Merchandise from Wal-Mart has become as ubiquitous as the water supply. Yet still, the company is rebuked and reviled by anyone claiming a social conscience and is lambasted by legislators as if its bad behavior places it somewhere between investment bankers and the Taliban.
Considering this is a company that is helping families ride out the economic downturn, which is providing jobs and stimulus while Congress bickers, which had sales growth of 2% this last quarter while other companies struggled, you have to wonder why. At least, I wondered why. And in that spirit of curiosity, I applied for an entry-level position at my local Wal-Mart.
*
Getting hired turned out to be a challenge. The personnel manager told me she had received more than 100 applications during that month alone, chasing just a handful of jobs. Thus the mystery deepened. If Wal-Mart was such an exploiter of the working poor, why were the working poor so eager to be exploited? And after they were hired, why did they seem so happy to be there? Anytime I shopped at the store, blue-clad Walmartians encouraged me to " Have a nice day" with the sincerity of the pope issuing a benediction.
I found my first clue in the application screening process. A diabolically ingenious quiz probed for my slightest hesitation or uncertainty regarding four big no-nos of retailing: theft, insubordination, poor timekeeping, and substance abuse. (The quiz also tried to make sure that I wasn't accident-prone.) After I cleared that hurdle, I was called in for an interview. At the Flagstaff, Ariz., store where I applied, this took place in a vinyl-floored, gray-walled, windowless room, tucked away at the back of the store and crowded with people sitting on cheap folding chairs at cheap folding tables. Some of these people were talking on phones, some were doing job interviews, some were typing on computer terminals, and some seemed to be eating lunch.
I sat at a table that was covered in the untrimmed fabric under a protective layer of sticky transparent vinyl, as a couch cover. I'd have seen better-looking decor at firehouse bingo evenings. Was Wal-Mart going out of its way to emphasize its commitment to cost-cutting? I guessed that the utilitarian ethic was so deeply embedded, it was just taken for granted.
A friendly lady in her 50s, wearing the Wal-Mart Smile, sat opposite me and started asking questions from a printed form. Meanwhile, another job applicant was going through his interview right behind me. Privacy, apparently, was as unaffordable here as tasteful decor.
" Are you easy to work with?" the lady asked. Since I couldn't imagine anyone being dumb enough to say " No," I concluded that the content of my answer must be irrelevant, and the way I answered must be the real issue. To judge from my interviewer's sunny demeanor, enthusiasm, and sincerity were key. Fortunately, I had no problem reflecting her positivism, because I was becoming so fascinated with the Wal-Mart phenomenon, I really did want to work there.
I managed to satisfy her expectations, and then went through two additional interviews, followed by a drug test, before I received formal approval. It may have been one of the most intense hiring processes I've been through; hardly the schedule of a company that didn't care who is hired, or employees who didn't care about getting a job.
A week later, I found myself in an elite group of 10 successful applicants convening for two (paid) days of training in the same claustrophobic, windowless room. As we introduced ourselves, I discovered that more than half had already worked at other Wal-Marts. Having relocated to this area, they were eager for more of the same.
Why? Gradually the answer became clear. Imagine that you are young and relatively unskilled, lacking academic qualifications. Which would you prefer: standing behind the register at a local gas station, or doing the same thing in the most aggressively successful retailer in the world, where ruthless expansion is a way of life, creating a constant demand for people to fill low-level managerial positions? A future at Wal-Mart may sound a less-than-stellar prospect, but it's a whole lot better than no future at all.
In addition, despite its huge size, the corporation turned out to have an eerie resemblance to a Silicon Valley startup. There was the same gung-ho spirit, same lack of dogma, same lax dress code, same informality - and the same interest in owning a piece of the company. All of my coworkers accepted the offer to buy Wal-Mart stock by setting aside $2 of every paycheck.
They were less enthused about health benefits, which offered minimal coverage during our first six months. The full corporate plan would kick in after that but seemed to require significant employee contributions. Still, my fellow trainees assured me that health plans at other retail chains were even worse, and since the federal government had raised the limits for Medicaid eligibility, that was an option for people with children. (In the time since my experience at Wal-Mart, the company has improved its health plans significantly.) The assistant manager who served as our trainer was still in her 20s, highly motivated, friendly, smart, and perceptive. Naturally, she overflowed with Wal-Mart positivism. In fact, she projected the feel-good sincerity of a Baptist running a bake sale.
Still, she wasn't afraid to tackle the topic of termination. During our initial six months on the job, we would be on probation on a " three strikes" basis. One major screw-up would trigger a session of " verbal coaching." (Since positivism is endemic in Wal-Mart, words such as "discipline" are seldom used. The goal is self-improvement.) A second offense would trigger some written coaching. On the third offense, the employee would be sent home to think long and hard about what happened and would have to come back the next day with a good argument for not being fired. In effect, Wal-Mart would say, " You seem to be a hopeless case. Now tell us why we' re the wrong." We were given only a handful of outright prohibitions. No swearing in the store, for instance - not even the word " damn," because some people might be offended. No funny-colored hair or blatant skin piercings, because some people might be offended. In fact, almost all the rules devolved to the sacred principle of never, ever offending a customer - or " guest," in Wal-Mart terminology.
The reason was clearly articulated. On average, anyone walking into Wal-Mart is likely to spend more than $200,000 at the store during the rest of his life. Therefore, any clueless employee who alienates that customer will cost the store around a quarter-million dollars. " If we don't remember that our customers are in charge," our trainer warned us, " we turn into Kmart." She made that sound like devolving into some lesser being - a toad, maybe, or an ameba.
And so we came to the Wal-Mart Pledge. Solemnly, each of us raised one hand and intoned: "If a customer comes within 10 feet of me, I'm going to look him in the eye, smile and greet him." Having pledged ourselves, we encountered the aspect of Wal-Mart employment that impressed me most: The Telxon, pronounced "Telzon," a hand-held bar-code scanner with a wireless connection to the store's computer. When pointed at any product, the Telxon would reveal astonishing amounts of information: the quantity that should be on the shelf, the availability from the nearest warehouse, the retail price, and (most amazing of all) the markup.
All of us were given access to this information, because - in theory, at least - anyone in the store could order a couple of extra pallets of anything, and could discount it heavily as a Volume Producing Item (known as a VPI), competing with other departments to rack up the most profitable sales each month. Floor clerks even had portable equipment to print their own price stickers. This was how Wal-Mart detected demand and responded to it: by distributing decision-making power to the grass-roots level. It was as simple yet as radical as that.
We received an inspirational talk on this subject, from an employee who reacted after the store test-marketed tents that could protect cars for people who didn't have enough garage space. They sold out quickly, and several customers came in asking for more. Clearly this was a singular, exceptional case of word-of-mouth, so he ordered literally a truckload of tent-garages, "Which I shouldn't have done really without asking someone," he said with a shrug, "because I hadn't been working at the store for long." But the item was a huge success. His VPI was the biggest in-store history - and that kind of thing doesn't go unnoticed in Arkansas.
He was invited to corporate HQ as a guest at a management conference. " It was totally different from what I expected," he told us. " I thought it would be these fatcats talking about money, but no one even mentioned money. All they cared about was finding new ways to satisfy customers. I met everyone including the chairman of the company."
*
After my two days of instruction I returned for the first real day of work. Inevitably, it was anticlimactic. The essence of life on the sales floor should be obvious to anyone: It is extremely boring.
I had chosen the pet department, which sells goldfish, cat food, dog food, and accessories. As I patrolled the aisles, repositioning misplaced items and filling gaps in the shelves, I realized that Wal-Mart "guests" really are like guests. They are visitors who move things around and create a mess before they go home. Cleaning up after them was not very different from doing housework.
My amiable, laid-back department supervisor had been doing this kind of thing for 15 years. When I asked him why he took a moment to process the question. He had to think back to other employers he'd worked for in the distant past. None of them, he said, had treated him so well.
What exactly did he mean by that?
His answer lay in the structure of the store. " It's deceptive, because Wal-Mart isn't divided into separate stores like a mall," he said. " But really, that's how it works. Each section is separate. This is - my pet store! No one comes here and tells me how to run it. I could go for weeks without a supervisor asking any questions." Here was the unseen, unreported side of the corporate behemoth. Big as it was, it was smart enough to give employees a feeling of autonomy.
During my few subsequent days as a Walmartian, everyone at every level was friendly and decent toward me. No one had the slightest clue that I might write about my experiences; no one even knew that I had a former career as a journalist. Still, they behaved like poster children for enlightened capitalism.
My supervisor reminded me unfailingly to take my mandatory two (paid) quarter-hour breaks during every eight hours of working time. I was cautioned never to abbreviate my lunch hour. Most of all I was encouraged to educate myself using instructional videos on computer terminals at the back of the store.
These videos served Wal-Mart's self-interest by teaching skills ranging from customer service to the art of lifting heavy boxes without hurting your back. I was paid to view them and was rewarded with an increased hourly rate when I finished the course.
My starting wage was so low (around $7 per hour), a modest increment still didn't leave me with enough to live on comfortably, but when I looked at the alternatives, many of them were worse. Coworkers assured me that the nearest Target paid its hourly full-timers less than Wal-Mart, while fast-food franchises were at the bottom of everyone's list.
I found myself reaching an inescapable conclusion. Low wages are not a Wal-Mart problem. They are an industry-wide problem, afflicting all unskilled entry-level jobs, and the reason should be obvious.
In our free-enterprise system, employees are valued largely in terms of what they can do. This is why teenagers fresh out of high school often go to vocational training institutes to become auto mechanics or electricians. They understand a basic principle that seems to elude social commentators, politicians and union organizers. If you want better pay, you need to learn skills that are in demand.
The blunt tools of legislation or union power can force a corporation to pay higher wages, but if employees don't create an equal amount of additional value, there's no net gain. All other factors remaining equal, the store will have to charge higher prices for its merchandise, and its competitive position will suffer.
This is Economics 101, but no one wants to believe it, because it tells us that a legislative or unionized quick-fix is not going to work in the long term. If you want people to be wealthier, they have to create additional wealth.
To my mind, the real scandal is not that a large corporation doesn't pay people more. The scandal is that so many people have so little economic value. Despite (or because of) a free public school system, millions of teenagers enter the workforce without marketable skills. So why would anyone expect them to be well paid?
In fact, the deal at Wal-Mart is better than at many other employers. The company states that its regular full-time hourly associates in the US average $10.86 per hour, while the mean hourly wage for retail sales associates in department stores generally is $8.67. The federal minimum wage is $6.55 per hour. Also, every Wal-Mart employee gets a 10% store discount, while an additional 4% of wages go into profit-sharing and 401(k) plans.
*
As for the horror stories: Let's take a couple of random examples. Unpaid overtime? Maybe it happened at some stores in the past, but an instructional video warned me that if anyone in management ever encouraged such a heinous transgression, I should report him to his superiors immediately. Illegal aliens? That particular news story really referred to a cleaning company retained by Wal-Mart. The cleaning company hired the illegals.
You have to wonder, then, why the store has such a terrible reputation, and I have to tell you that so far as I can determine, trade unions have done most of the mudslinging. Web sites that serve as a source for negative stories are often affiliated with unions. Walmartwatch.com, for instance, is partnered with the Service Employees International Union; Wakeupwalmart.com is entirely owned by United Food and Commercial Workers International Union. For years, now, they' ve campaigned against Wal-Mart, for reasons that may have more to do with money than compassion for the working poor. If more than one million Wal-Mart employees in the United States could be induced to join a union, by my calculation they'd be compelled to pay more than half-billion dollars each year in dues.
Anti-growth activists are the other primary source of anti-Wal-Mart sentiment. In the town where I worked, I was told that activists even opposed a new Barnes & Noble because it was " too big." If they' re offended by a large bookstore, you can imagine how they feel about a discount retailer.
The argument, of course, is that smaller enterprises cannot compete. My outlook on this is hardcore: I think that many of the "mom-and-pop" stores so beloved by activists don't deserve to remain in business.
When I first ventured from New York City to the American heartland, I did my best to patronize quaint little places on Main Street and quickly discovered the penalties for doing so. At a small appliance store, I wasn't allowed to buy a microwave oven on display. I had to place an order and wait a couple of weeks for delivery. At a stationery store where I tried to buy a file cabinet, I found the same problem. Think back, if you are old enough to do so, and you may recall that this is how small-town retailing used to function in the 1960s.
As a customer, I don't see why I should protect a business from the harsh realities of commerce if it can't maintain a good inventory at a competitive price. And as an employee, I see no advantage in working at a small place where I am subject to the quixotic moods of a sole proprietor, and can never appeal to his superior, because there isn' tone.
By the same logic, I see no reason for legislators to protect Safeway supermarkets with ploys such as zoning restrictions, which just happen to allow a supermarket-sized building while outlawing a Wal-Mart SuperCenter that's a few thousand square feet bigger.
Based on my experience (admittedly, only at one location) I reached a conclusion which is utterly opposed to almost everything ever written about Wal-Mart. I came to regard it as one of the all-time enlightened American employers, right up there with IBM in the 1960s. Wal-Mart is not the enemy. It's the best friend we could ask for.
Charles Platt is a former senior writer for Wired magazine.
Obamacare is actually the product of two laws, which is an interesting commentary on Congressional procedure, but merely a distraction from a comprehension of the health care reform. For completeness it is briefly summarized here.
Over the years, the ability of the Senate to filibuster important issues was hampered by potentially applying the filibuster to every vote taken. In particular, the Budget Act contained a vast number of changes to individual dollar authorizations, many of them surfacing at the last moment, after the final compromises had been made and everyone wanted to go home. So it was decided to make an exception for budget changes, but it called on Senator Byrd of West Virginia to devise language which would prevent tricky things for sliding through in the rush toward adjournment.
The result was the Byrd Rule, which defined permissible material for such special allowance. It did two things: it defined a permissible item for inclusion in budget reconciliation as one which was financial but did not change the total budget. The second thing it did was hedge this exception around with controls by the majority leader, right up to the ability of the majority leader to replace the Speaker and anyone else he felt was getting around the rule. The rules surrounding this matter were incorporated into the Congressional Budget Act of 1974, including a provision that there would only be one Budget Reconciliation Act per year. The volume of such technical amendments grew to be so great that there were multiple Reconciliation Acts, automatically incorporated into one big one by a special automatic amendment from the Rules Committee. That explains why the technical amendments to the Affordable Care Act are only part of the Health Care and Education Reconciliation Act of 2010, which was never intended to become law.
Many parts of the Affordable Care Act were thought to be suitable for this exclusion, particularly since the complete ACA did not fit completely within the requirements for filibuster protection. Pages of these technical amendments were added to a Reconciliation Bill mostly designed for the student loan program. Most readers will not find these numerous provisions contribute much to an understanding of what the Act actually does, or what it means. But you never know, for sure.
The President signed the Affordable Care Act on March 23, 2010. He signed the Health Care and Education Reconciliation Act a week later. When the Supreme Court handed down the NFIB v. Sibelius decision, further rearrangement of the indexing and wording became necessary to make the whole thing coherently unified as Chapter 48 of Subchapter D of the Internal Revenue Code of 1986. The whole episode is reminiscent of the epitaph of Leonidas, at Thermopylae.
Go tell the Spartans, passerby, That here, obedient to their laws, we lie.
Just to clarify the jargon, life insurance companies are of two types: one-year term of risk ("term insurance"), and whole-life term of risk ("whole-life insurance"). In this chapter, we use whole-life insurance as a model for the idea we have for health insurance, but there are many significant differences.
The premium is lower for term insurance because you buy it one-year-at a time, it expires if you don't renew it, but the premium may go up in subsequent years, and the insurance company makes most of its profit when people don't renew it. Most health insurance is run on a one-year term basis, rather inappropriately, because it protects against risk rather than to reimburse claim losses. As a matter of fact, a well-run term insurance company might never pay a claim, although it does happen. So in the long run, term is more expensive for healthcare than whole-life. In a whole-life policy, by contrast, the premium is level each year until you die. Because the subscriber of whole-life has contracted to pay the premium for many years, the insurance company is comfortable with making long-term investments, which pay them more for the float than short-term. Furthermore, the insuring company can enjoy long-term compound interest, which is eventually what makes whole-life coverage cheaper than term, assuming you are even allowed to keep renewing it.
In whole-life coverage, a whole lot of wheels are invisibly turning as premiums are paid yearly, your lifetime gets shorter but your life expectancy increases, new investments replace old ones. To ensure a margin of safety, premiums are higher than actuaries say is actually necessary, and yearly discounts are often (but not promised to be) paid back, or reinvested at more compound interest. Underneath all of this turmoil, the risk of your dying is gradually increasing, and a few people actually do die and collect benefits, terminating the policy. Life insurance is generally a state-regulated activity, and state taxes vary. There are special taxes for certain types of insurance, and there is a distinction between estate tax and inheritance tax. All of this and more are all taken care of for you by the company and is particularly suitable for children and infirm elderly. Just sign on the dotted line, pay the premiums, and wait to die. Simple.
As a matter of fact, the whole-life approach is more suitable for paying the constant nibbles of health insurance than it is for the single lifetime benefit of paying for a coffin, but the two businesses took different paths, long ago. If you simply wanted to set aside enough money for a funeral, you could buy an index fund, put the certificate into a lock-box, and direct your heirs to use it when the time comes.
Although passive index-fund investing has made it possible for an individual to manage it all by himself, it's a nuisance and management gets particularly awkward for children and old folks. But that's not primarily why we began looking at other models; we're looking for somewhat higher returns than are currently offered. And that, in turn, is spurred by the realization that protracted retirement costs are just part of the costs of not getting sick. If you treat prolonged retirement as an inherent cost of health insurance, it's almost five times larger than the direct healthcare costs. Social Security was supposed to take care of it, but it simply cannot cope with such rapid increases. Are you supposed to starve to death? You can't keep working forever, your insurance doesn't cover it, and our whole economy was once based on the idea of dying at "three score and ten." But now the average person lives to be 84, soon to be 90, and we haven't even cured cancer yet. Making retirement cost an entitlement without funding it put the whole economy into a predicament with no ready answer, as soon as we started curing diseases.
So the Health Savings (and Retirement) Account was devised to be a Christmas Savings Fund for this need, but even HSA can't produce money out of thin air. So we now turn to professional investors, professional accountants, and others with sharp pencils, for help. Life insurance makes payments year by year for the final moment when you have to pay for your funeral. It was expanded to help support your widow. It's big and well spoken, housed in impressive big buildings. Maybe it can help by adding investment experience, computers, actuaries, and business degrees. Just a little extra efficiency would pay for a lot of extra administrative help; even half a percent extra for 90 years would make a big difference. And the sums involved are significant. Lifetime healthcare costs are estimated to average $300,000 per person. To add a generous retirement, would make it well over a million dollars -- per client. And please hurry up. Inflation is constantly making things worse.
As a matter of fact, judged from the outside, life insurance doesn't seem to be as frugal as it might be. Its marketing costs are high, and its investments are certainly conservative. Its executives are certainly well compensated. There would appear to be room for efficiencies. If health insurance adopted a whole-life approach for its revenue, it is not claiming too much to conjecture it would add 1% extra return to pay for retirement claims losses.
Invest the Withholding Tax and Pre-pay Medicare? Borrowing to pay for Medicare, except temporarily, has very little to be said for it. On the other hand, the choice between pre-paying for it and paying at the time of service is a closer argument. Pre-payment can sometimes be arranged to reduce the price out of recognition of the interest foregone, but usually, the seller gets the better of such a deal. In this section, we propose to arrange the payment stream to give the buyer the interest, but Medicare finances are so strained, it doesn't make a heavy impact. About a quarter of Medicare cost is paid from premiums from current beneficiaries. If that were collected in advance over a period of forty years like the payroll deduction, the combined interest payments would considerably reduce the eventual total cost. Unfortunately, young people are now so suspicious the money will be diverted to other purposes, it is a political question whether they would permit the withholding to be increased in amount. Furthermore, the other half of Medicare is essentially borrowed, so interest payments each way would about cancel each other without affecting the principal cost.
They would, however, probably be sufficient to keep the debt from continuing to rise at 7% a year, and that's a major advance. The withholding tax and the Medicare premiums would remain the same, the benefits would be unchanged. So what's in it for the average voter? Most accountants would say it was still a desirable change toward a more stable system, but many politicians would say it runs a risk without any political benefit at the next election. Everybody is correct; it isn't enough but it is something. It solves a definable portion of the problem, of bringing future deficit increases to a stand-still. Things are so bad I'm afraid that's all you can buy for $3.5 billion a year. We must find some way to supplement it, but it's a start. We have five other suggestions:
Devise Some Way to Escrow Long-term Funding. New revenue ordinarily arrives as cash and is invested in short-term loans until it is decided what to do with it. With thirty-day loans, or even overnight loans, you just have to wait for a little, in order to restore cash status. But money market funds show us what can potentially happen. If customers get into a sudden panic, they want their money back immediately. If it's already invested in thirty-year mortgages, the money market fund may go bankrupt unless someone "bails them out". Which is to say, loans them more money to supply some cash -- even though they have ample funds frozen in long term investments. The creditors have their own creditors to consider. If no one will help out, the creditors may shut them down and you get the beginning of a liquidity crash.
Because of this remote but very real possibility, the longer the loan, the higher its interest rate, because the liquidity risk gets extended. That's bad if you are a borrower, but please if you are a lender. Therefore, if the Medicare wage-tax receipts flowed into a frozen single-purpose investment account, creditors would be more assured money would be unrequested before the stated time, and its rate of return could rise with this new attractiveness. Just how much extra income would be provided is a little uncertain, because very few loans are currently for longer than thirty years. However, about forty-five years are potentially available between age 21 and 65, and educated guesses could be made. A one-or-two percent rise in income might change many calculations, not just this one alone.
Find Ways to Extend the Years at Compound Interest. Since retirement is conventional at age 65, a fund for retirement will immediately start to dwindle until the date of death. But many people continue to work or have other retirement funding sources. If they do not need the surplus immediately, they should be permitted to leave it in the escrow fund, to prolong its term. This could be either fixed-term extensions or demand deposits, at the election of the depositor, and its election would make these funds preferable to retain, compared with Social Security, for example.
The open-endedness of retirement is always going to be a problem. If we speak in averages, they suggest half of the population will be dead, mid-way to the average. Any unexpended surplus after their deaths will be a source of contention, and there will be a struggle for it between heirs and longer-term survivors. If the compounding of unused income could continue longer, for even five years after death, the extra revenue would be considerable.
Continue to Earn Interest after the Death of the Depositor, as in a Trust Fund Long ago, perpetuity was defined as one lifetime, plus 21 years. Adding another two decades would add two more doublings, and still not run afoul of inheritance traditions. In effect, it would increase the multiplier from 512 to one -- to 2048 to one, increasing the number of newborns who could afford $100, considerably, by making it only $25.
Because of the de minimus initial deposits, it would be a small matter to devote a small portion of the deposit to a backward-funding for childbirth costs. My Libertarian friends would be shocked to hear the proposal, but this small diversion would settle a myriad of cases before the Matrimonial courts about paternity, divorce, single parenthood, and even same-sex marriage. Indeed, the financial incentive might be so great it would affect behavior, and need to be debated on that level separately.
But all of the foregoing is small-time, based on the mistaken notion the system is basically sound. Let's look, without pretense, for seriously larger amounts of money:
Contingency Fund. Any projection a century in advance risks making gross mistakes in its planning. No matter how confident the predicting party may seem, it is only prudent to have a contingency fund, when the multiplier of compound interest is so great. For example, most people can expect to be of Medicare age when they die, but not everyone will do so. But mostly a contingency will need to cover the considerable risk of simple miscalculation, without creating a temptation to divert it. The size of the contribution is scarcely a handicap. That is, a contingency fund of $2000 can be envisioned from the gift of $1 to a newborn. Since you know with absolute certainty that every newborn will die someday, a contingency fund of a million dollars per person is possible with a grant of $500 to everyone born in poverty, so long as:
you don't spend any of it for 111 years, providing you can get an average 7% return, and providing the government doesn't devise other uses for your money in the meantime.
Incidentally, increasing public resistance to inflation is one of the hidden virtues of this proposal. Most people would laugh at such a long-term projection. For a single individual, yes, for an extended family, not so much. The trick is to get started with small amounts, which don't attract much attention until they demonstrate some power.
Instead of fanciful extrapolations, it is possible to say almost every working person could summon up $200 per child, and the government could summon up $200 for those who can't. This is what is needed to provide supplements which would accomplish reasonable goals for lifetime healthcare, plus a somewhat more modest description of a comfortable retirement supplement to Social Security. And for those who are unable to support themselves for handicap reasons, the government might summon up the cost for indigents. In the long run, that would be a bargain investment. Since every child has two parents, it leaves a 100% cushion for under-estimates when we extend this idea to children. The problem is not arithmetic, it is public acceptance of the whole idea of individual long-term contingency funds, plus a way to store such a fund for centuries at a time, protecting it from pilfering by its custodians.
First and Last Years of Life Re-Insurance By far the best proposal for refinancing Medicare, however, is to anticipate the way science is going to re-design costs. In the long, long, run, there will be very little medical cost left, except for the first and last years of life. We have no idea how long it will take, but that's the direction it is going.
So, phase in a restructuring of funding for both children and elderly first, and then add in the rest of a lifespan, step by step. The rest of the lifespan will eventually shrink as a cost center, while the beginning and end would not. Be sure to do all this in such a way that maximizes investment income at compound interest. This might be a project under construction for decades, but its first step would be to begin funding for the Last Four Years of Life, which happens to be an early step in the proposal for refinancing Medicare. Since the reader may be unprepared for the topic, it is considered in a free-standing way, in the next section.
Management of the Early and the Mild Late Toxemias of Pregnancy
By Stuart B. Blakely, M.D.
Read at Syracuse, N.Y.
April 3, 1941
Profound anatomies and physiological changes in pregnancy. A dividing line between what is normal and abnormal is impossible to fix. When the pregnant women present evidence of perverted body function we usually say that she is "toxic" a highly indefinite term. In spite of a vast amount of research, "toxemia of pregnancy" still remains largely a hypothetical concept. While it may be justifiable to assume the presence in the women's body of some toxin or toxins (it is almost impossible to postulate only one), such pressure in the blood has never been demonstrated. The source and method of action are unknown. Any tissue may be involved, but especially the hepatic, renal, nervous and reticuloendothelial. There is a growing belief that endocrine disturbances and vitamin and mineral deficiencies play an important role. One writer says that vitamin deficiency may simulate toxemia. it may well be true that vitamin deficiency is the toxemia. But the ultimate cause eludes reaches. In general, we can only say that the symptoms of the toxicities of pregnancy are due to altered or abnormal maternal function, induced directly or indirectly by the products of conception.
As far as I know Dr. De Lee is the only textbook writer who has specifically considered what he calls the minor toxemias of pregnancy. He allows two pages to the subject. The symptoms are very varied and often obscure and may stem from any material tissues or organ. A few may be of great significance, but most of them are not serious, and many may be considered as, and are minor discomforts of pregnancy. Some may be really toxic, many are metabolic or endocrine in origin, a number simply mechanical. The possibilities and possible combinations are almost endless. I shall not try to define or unscramble or classify them but discuss some of the more common. I shall not stick too closely to my text. I hope that you will pardon the frequent use of the first person singular.
Gastro-intestinal
HEARTBURN- one of the most common, and to me, obscure and difficult to relieve. It has certainly never been demonstrated that it occurs exclusively or predominantly in those patients with increased gastric acidity. It is usually a rather late symptom if at all sever, and while possibly toxic is better considered as being in some way related to altered gastric motility. Reverse peristalsis has been offered. A better suggestion is that it is due to a relaxation of the cardio (all smooth muscle tubes relax and dilate in pregnancy) plus increased intraabdominal pressure which results in a regurgitation of acid gastric juice into the lower esophagus. Many remedies have been used, usually some combination of "antacids", such as sodium bicarbonate, magnesia, bismuth, other carbonates, often with the addition of aromatic. In my experience, milk of magnesia makes them worse. Many patients find relief in "tums". I have no experience with colloidal preparations, and little success with fresh cream, dilute HCL or finely chewed nuts. Occasionally the drinking of sparkling water benefits. Some are helped by the reduction of total food intake, especially if eating too much and of fats. Sleeping with the head elevated on a pillow or with the head of the bed raised often is of help. A few patients find relief in auto lavage. Most obstetricians have their own favorite prescription or method for the treatment of heartburn, thus proving the non-existence of any specific for the condition.
SORE TONGUE- glossitis in my own experience the exhibition of large doses of vitamin B complex with dilute HCl and iron has helped these cases quite definitely.
GINGIVITES- local treatment by a really good dentist is of great value, as the instruction of the patent in careful and persistent oral hygiene and the use of astringent mouthwashes. Attention should be directed toward the general health and the prescribing of iron and whatever "tonics" may be indicated. While vitamins A, B, and C have been suggested for this condition, I feel that I have had the best results with large doses of C a quart or more of orange juice a day.
PTYALISM- probably best considered and treated as one of the rarer complications of early nausea and vomiting of pregnancy. I have never thought that I have ever been able to do much for this annoying condition by any drug.
EARLY NAUSEA AND VOMITING- while this symptom group probably has a toxic basis and possibly an endocrine factor, I firmly believe that the psychic element is predominant. These patients suffer from a conflict of desires and/or fears that causes them to reject the pregnancy; occasionally their nausea and vomiting is a punishment of self or husband. why do I think so?
Its greatly lessened incidence in recent years due to a more sane and enlightened attitude toward pregnancy. An induced abortion for this condition is a rarity nowadays.
The weakening of the influence of old ideas how often do the young pregnant women say that she does not see how she can be pregnant when she is not "sick".
Cures by cervical treatments attempted or faked abortion and by all sorts of therapy, basically psychic.
The results of the modern treatment which is practically psychotherapy plus sedation and glucose. It is quite impossible to maintain the toxic theory in the face of the rapid and often dramatic and spectacular results so often obtained.
What do I do with early nausea and vomiting of pregnancy? I never mention the possibility to my patients. If they say that they are so troubled or I discover it by roundabout inquiry, the casual statement is made that it occurs in not over half of pregnant patients, it doesn't last very long and few women are much bothered with it anymore. If they do not want to eat, all right, but insist that they should have daily the equivalent of one good meal which is sufficient to maintain their health. Assure them that their baby is not in need of line or any particular food at this time. They can have ANYTHING they want I emphasize that often naming some crazy and impossible food combinations. If they have no particular choice, I suggest that they eat largely sugars and starches, mentioning several. It is better to eat a half dozen or more times a day if they wish they may "piece" all day long. I tell them to take their food dry, without soups and milk, etc., to drink little or nothing with their food. Often the taking of something before rising help, and one else's cooking. I have always felt that the insistence on diet lists for these patients, while possibly of merit, is largely psychotherapy. They are so busy keeping track of their diet, that they forget their troubles. These will usually get well anyway, for patients rarely come to the doctor earlier than six weeks and in another six weeks they are pretty well over their vomiting. Of the interne and his recommendations for afterpains. I often give them phenobarbital ½-1 grain 3-4 times a day. I think it helps. I also believe that the reading of a good book or booklet on prenatal care, commensurate with their intelligence, is valuable. Finally, I have a talk with them. Sometimes I tell them that they don't want their baby, which they will indignantly deny. Then I explain. I tell them that they possess an inescapable instinct for a baby which cannot be denied, but that various conflicting factors enter into the pictures, and so arise fears and anxieties. Often these will come out if a little patience and ingenuity are exercised. Get them to face whatever the situation may be, and to adopt a good or at least as good as possible philosophy toward it. If these vomiting patients cannot be controlled and made reasonable comfortable by these measures, I insist on hospitalization, under the charge of a nurse who knows how to manage them. If nausea and vomiting are not then speedily controlled, I believe that abortion should be induced. I have had very little experience with the use of adrenal cortex or other endocrine substances or of vitamin B or other vitamins in the treatment of early nausea and vomiting of pregnancy. I cannot deny their worth nor would I disparage their use. Finally, and emphatically, in spite of whatever I have said this afternoon, believe me, I have the greatest respect for nausea and vomiting of pregnancy.
Late vomiting of pregnancy suggests an infection, not infrequently a pyelitic; or latent toxemia; or a reflex or mechanical cause, like a gallbladder disturbance. The older practitioners believed and often quite rightly in the intestinal origin of illness, and often prescribed for these patients a cathartic, usually a dose of calomel. It still often works well.
Of course, in all discussion of this type, it is not to be forgotten that pregnant women are not immune to diseases and conditions that may affect the non-pregnant women.
Circulatory system
Extrasystoles occur frequently in pregnancy, are usually of no importance and the patient can be assured of their harmlessness. "Formes Frustes", or mild manifestations of hyperthyroidism, are common in pregnancy. I hope that, eventually, I can have a basal reading on every obstetric patient, for it might furnish a clue to many obscure symptoms. Besides, a lowered basal reading in early pregnancy is a factor in abortion, as well as the development of late toxemia.
Vertigo and fainting are evidence of vasomotor instability. It is said that if you see a young woman being helped out of church or the theatre, she is probably pregnant. For the fatigue, exhaustion, "no pep" symptom of early pregnancy, I suggest all the sleep and rest they can get or want, and the prescription of alcohol and strychnine, which the older doctors used to say should never be given together.
Varices are certainly not due to pressure. Some women can tell immediately when they are pregnant by their veins beginning to swell. Rest, elevation and support by adhesive, stocking or elastic bandage. Of the elastic bandages, the real rubber ones are best, though not always the most comfortable. With the injection treatment, which has staunch champions, I have had no experience. Possibly, like many of the older men, I am afraid of a radical quite so bad as often pictured. Hemorrhoids should generally be handled conservatively, except in the case of thrombosed external hemorrhoids where the complete removal of the clot under local anesthesia and strict asepsis gives great and welcome relief.
There has been a deal of discussion recently of anemia in pregnancy. The so-called physiological anemia of pregnancy is probably the result of hydremic, though may be toxic or result from the breakdown of the red cells to supply the fetus with iron. It seldom needs treatment unless the RBC drop below 3,500,000 and the hemoglobin below 70%. A pernicious type of anemia may occur, and the obstetric patient is not immune to a factor that produces secondary anemia. Hypochromic anemia is the most common form of severe anemia encountered in pregnancy, probably a manifestation of toxemia. Factors in its development seem to be the family tendency, gastric disturbance, and a diet deficient in meat and iron. It usually begins in the latter half of pregnancy with lowered HCL; RBC above 3,000,000; low Hgb, somewhat like chlorosis. The patient's complaints are usually sore tongue, brittle nails, and neuritis manifestations, as well as the symptoms referable to any anemia condition. Iron seems almost a specific but the dosage must be adequate. Dilute HCl, liver, and transfusions should be remembered. I wish that every obstetric patient could \have at least a red count and a Hgb, determination.
Nervous system
There are many toxic symptoms referable to the nervous system, such as psychic changes of pregnancy; headaches, which in all cases demand attention and are especially of importance if late, sudden, persistent and severe; pruritic; insomnia, usually late in pregnancy and which should not be dismissed lightly. Neuritis symptoms like numbness and neuralgias usually of the extremities are very common and most of them toxic. If in the sciatic region they are usually glibly ascribed to "pressure", while as a matter of fact they are rarely so caused, being either toxic or referred from the Sarco-iliac joints. Most toxic neuritis symptoms of pregnancy can be helped by iron, calcium and vitamin B complex in adequate doses. Heat often helps them, e.g. the therapeutic lamp and the wrapping of an arm in flannel at night. In this group can probably be classed the cramps in the calves, usually the right, that often waken the patients in the early morning hours. I believe that there is here often an associated circulatory element, else why in the legs? Besides the medicines mentioned above iron, calcium and vitamin B and D the following procedures often help elevation of the legs several times a day for periods of fifteen minutes or longer; elastic stockings or bandages; heat, especially at night, and cautious massage.
I would like to call your attention to a neuritis symptom complex that not infrequently occurs postpartum, apparently toxic. It is severe pain in the neck shoulder upper thorax area, or in that of the hip-thigh-pelvis. That is the upper extremity is usually ascribed to the draught from a window or door. Heat, counterirritation, aspirin and very large amounts of vitamin B seem to help them.
At this place it might not be amiss to briefly consider the daily amounts of vitamins and minerals required by the pregnant women since these have been so frequently mentioned up to now and are definitely of great importance to the pregnant women's metabolic processes, though probably in nowhere the degree usually claimed.
Vitamin requirements of the pregnant women daily probably twice as much as is required by the non-pregnant.
Vitamin A 10,000 international units
Vitamin B 800 international units
Vitamin C 100 mgs. Ascorbic acid
Vitamins D 800 international units
These figures are not to be considered final. If we can believe advertisements, three yeast tablets a day fills the bill. Mineral requirements in pregnancy.
Phosphorus usually adequate, if enough animal protein in the diet. Iron 15-20 mg. Daily
Calcium the most important; beat companied by Vitamin D. The usual daily adult calcium requirement is about o.6 mgs. The fetus deposits little calcium before the fifth month but in the latter part of pregnancy 20 30 grams, 60% of it in the last two months. In the latter part of pregnancy, pregnant women need about 1 gm. Of calcium daily.
One Quart of milk 1.5 mgs. Calcium The following medicaments contain calcium as follows;
Abbott- Bone Phosphates tablet 1.7 mgs. Calcium
Decal D. Wafer 3.5 " "
Decal D. Capsule 1.75 " "
Squibs Dicalphos. C Vicsterol wafer 3.5 " "
Calcium gluconate powder 8.9% calcium
Many writers believe that non-traumatic abruptic placentae are often one of the best examples of one type of pregnancy toxemia. Omitting all reference to its possible role in abortion and all use of progesterone, we shall confine the discussion to slight localized premature separation of the placenta in the latter part of pregnancy. Shute of Canada has studied and written much on this subject. He believes that the condition is characterized by the appearance of local areas of pain and tenderness (sometimes with rigidity) in the uterine wall, associated with sacral backache and often though not necessarily accompanied by uterine bleeding. He maintains that they are very common, and are always toxic in origins, that the toxemia is associated with (not the same as caused by) an increased estrogenic substance in the blood that causes the resistance of the serum to proteolytic ferment. He maintains that the condition can be controlled and cured by adequate doses of vitamin E which is antagonistic to the estrogenic substance. He used wheat germ oil for this purpose which must be kept under refrigeration where it retains its potency for about eight weeks. He gives 12 drams the first twenty-four hours and continues one dram a day, which had best be continued to term. Much larger doses have been given without harmful results, and the dose must be ADEQUATE. He claims that under the treatment one can observe the shrinking and disappearance of the areas described and the subsidence of the symptoms. I believe that he is, in the main, correct. Local pain and tenderness in the wall of the pregnant uterus (note that the round ligament is excluded) are due either to a fibroid or a hemorrhage.
It might be of interest to compare vitamin E products as to tocopherol (name of synthetic vitamin E) Content and approximate retail cost in Binghamton.
It is obvious that there is wheat germ oil and wheat germ oil, that vitamin E capsules are not all the same, and that tablets of tocopherol vary in strength.
A common obstetric experience is to be confronted by a patient in late (occasionally earlier) pregnancy with rising blood pressure, albuminuria, and evidence of water retention. These three are the cardinal symptoms late toxemia of pregnancy, though eye, cerebral, gastrointestinal and other disturbances may even then be present or may be added as the disease progresses. For our purposes, the first procedure is the determination of the type of toxemia, and the second, the management of the three symptoms named.
The nephropathies of late pregnancy are still unsolved. A disease of kidneys and blood vessels predisposes to toxemia. Pregnancy is a very delicate test of renal function and unmasks latent or aggravates already existing reno-vascular disease. It seems probable that pregnancy elaborates a toxin with a specific action on the kidneys and blood vessels.
Corwin and Herrick believe that there are two broad types of late toxemia of pregnancy.
Closely related to vascular renal disease, more commonly essential hypertension. It appears earlier with history or evidence of the pre-existence of these diseases. First, the blood pressure rises, and considerably later if at all, albuminuria and edema appear. HAs a good prognosis with rest, and rarely drifts into pre-eclampsia or eclampsia? Reacts to the cold pressor test, and not to intravenous Pitressin except as the normal women.
Has no apparent relation to vascular renal disease. Appears later with no history or evidence of such preexisting disease. Increased blood pressure is associated with, or preceded by, albuminuria and oedemic. Does not respond to rest, and drifts easily into preeclampsia and eclampsia. Does not react to the cold pressor test, but gives by .66 cc. pitressin response of 50mm. Or more for 15 minutes instead of the usual 45 or less. The idea is that this group the preeclampsia and eclampsia is the result of specific toxemia. However, the idea is growing that back of ALL pregnancies nephropathies stands renovascular disease. Preeclampsia and eclampsia are often followed by permanent essential hypertension rarely by chronic nephritis. The older the patient, the greater the parity, the higher the pressure and the longer the duration before delivery, the greater the probability of a permanent increase of the blood pressure.
The differentiation of these groups can usually be made, though some toxic cases must remain unclassified. The help of good internist in the treatment of these toxemias is very valuable.
Management of mild late toxemia of pregnancy. Very important is the appreciation of the danger inherent in the condition, not only present but potentially for the future, and of the need of thorough clinical and laboratory investigation of every case, and continuous observation. A very valuable but often neglected source of information is the eye grounds.
Management of the reno-vascular group except under most unusual circumstances I personally believe that a woman with proved chronic nephritis should not become pregnant, and if pregnant, her pregnancy should be terminated, preferably with sterilization. My own personal experience in trying to continue or prolong pregnancy in these cases has been unsatisfactory and sometimes disastrous. The mother's condition is usually worsened; the baby often dies and lengthening of its intrauterine life does not materially increase its chances for survival. I admit that there are exceptions. On the other hand, many cases of mild essential hypertension can be carried through pregnancy under a strict medical regime. Just when this should be done, is very difficult, at times, to decide. I feel that most of them are surely NOT improved by pregnancy, and I should hesitate to advise pregnancy for a woman with a blood pressure of 170 or over.
Management of preeclampsia and the three symptoms of increased blood pressure, albuminuria and edema.
Blood pressure in pregnancy. Low blood pressure in pregnancy, in my experience, is of a slight moment. With the patient reclining, it is not uncommon to have readings below 100 systolic, and many times I have not been able to definitely determine the diastolic. Normal blood pressure in pregnancy with the patient reclining is rarely over 120/80 often much lower. Surely any readings persistently over 140/90 are definitely abnormal, or any systolic rise of 40mm, or more. I have almost a rule though not quite that I induce labor in a preeclamptic patient whose systolic pressure passes 170, or diastolic 110, especially if the rise has been rapid and depending somewhat on her other symptoms. Rest and sedation are valuable in the treatment of hypertension.
Albuminuria or proteinuria. It is doubtful if albumin is ever present in the urine in normal pregnancy. The "albuminuria of pregnancy", "the kidney of pregnancy", the "low reserve kidney" probably represents a kidney with congenitally defective function, unable to stand the extra strain of pregnancy. It is characterized by an increase of blood pressure to say 150/90 in the last two months, small or very moderate amounts of albumin in the urine, normal blood chemistry, no other symptoms, disappears in the puerperium and though may recur, does not become worse in succeeding pregnancies. It is probably best to classify it as a manifestation of latent hypertension or mild preeclampsia and it represents about 35% of all late pregnancy toxemias. It has always been a puzzle to me what to do with the patient with a large amount of albumin in the urine, and nothing else demonstrably wrong. W. J. Dieckmann of the University of Chicago, who published a very good paper on the "Prevention and Treatment of Eclampsia" in the American Journal of Surgery of April 1940, says that the patient should be hospitalized and the pregnancy interrupted if the albumin is 3 plus or more than 5gms. In 24 hours. There is no specific treatment for the condition.
Weight increase and water retention in pregnancy. a woman gains, on the average, between 20-25 pounds over her usual weight during pregnancy. Rarely should she gain more? About 15 pounds of this is a fetus, placenta, amniotic fluid, and the increase in fat and water. The weight gain is roughly distributed as follows first three months, little or nothing; second trimester, one-half pound a week; In the last two weeks immediately before delivery, the normal patient often loses a pound or more, and this has been suggested as a possible indication of the imminence of labor. I insist that my patients keep their weight gain within reasonably normal limits; on many days, the topic of our conversation seems to be pounds and food and diet. I tell them that they will put less strain on their gastrointestinal and cardiovascular-renal system and that many of the minor discomforts will be less in evidence or even disappear. They feel better, look better, and do not have to struggle to lose fat afterward. Some are hard to convince that they do not have to eat for two. If a patient is definitely over weight at the beginning of pregnancy there is no reason why she should not lose some, or at least not gain, during her nine months.
Practically, an excessive gain of weight during pregnancy, not the result of hypothyroidism or too much food and drink, must be due to water retention. Some water retention is normal in pregnancy, especially late. Of, the women's smoothed face and her swollen face and hands so often complained of in the morning. It is associated with sodium retention, and the pituitary and adrenals are implicated, clinically water retention is determined by the gain of weight and edema, remembering that 8-10 pints or pounds of fluid may be stored up in the body tissues before any edema may be noted. An excessive or sudden gain of weight always suggests a disturbance of water balance, as a quarter pound in one day, two pounds in one week or over five pounds in one month. A moderate amount of edema below the knees is normal in pregnancy, but any edema higher in the body is definitely abnormal.
Abnormal water retention is an important sign of pregnancy toxicosis, and its secretion can be aided and the toxemia often relieved by the following. 1. Limitation of fluid intake. Dr. Arnold had his patients keep an intake output chart of them with the intake kept below output. 2. Limitation of sodium salts, by the avoidance of salty foods (name them) and the use of salt in cooking and at the table. The daily average salt intake is to be reduced from 10-20 mgs to three or less. In this connection is it well to remember that the use of large quantities of baking soda for heartburn may not be entirely innocuous. The rational of a skim milk diet in the treatment of preeclampsia is that it contains little sodium but is high in calcium and potassium. 3. Adequate consumption of animal protein. Though this has been disputed it does no harm even in the presence of albuminuria rather the reverse. 4. Iron for any anemia. 5. Certain saline laxatives. 6. Intravenous glucose. In eclamptic toxemia, abnormal water retention may occur before rising of blood pressure or albuminuria, and a pair of scales is an important instrument. Persistent or progressively increasing generalized edema, not greatly or permanently influenced by treatment, is an indication for the interruption of pregnancy.
This discussion of the minor toxemias of pregnancy has been sketchy, incomplete, not very scientific, and highly personal. I feel very humble in the presence of any pregnancy. Eventually, someone is going to tell us all about the toxemias of pregnancy. I fear that no one in this room will live to see it.
109 Volumes
Philadephia: America's Capital, 1774-1800 The Continental Congress met in Philadelphia from 1774 to 1788. Next, the new republic had its capital here from 1790 to 1800. Thoroughly Quaker Philadelphia was in the center of the founding twenty-five years when, and where, the enduring political institutions of America emerged.
Philadelphia: Decline and Fall (1900-2060) The world's richest industrial city in 1900, was defeated and dejected by 1950. Why? Digby Baltzell blamed it on the Quakers. Others blame the Erie Canal, and Andrew Jackson, or maybe Martin van Buren. Some say the city-county consolidation of 1858. Others blame the unions. We rather favor the decline of family business and the rise of the modern corporation in its place.
Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
