Panel Discussion

MODERATOR SPRAGUE: Those of you who were here this morning are familiar with the forms and faces of our panelists this afternoon. I am moderator or chairman, and Mr. Dewey Barrett recently said that the position of a chairman is that of a minor official at the bull fight who opened and closed the gates to let the bull in and out. Well, at least like the Portuguese bull fighter we will let the bull live rather than kill him at the end. I have a great many questions here. I tried to be selective at lunch time. We are going to start with a question to Dr. Metcalfe. "Do you consider toxemia or pre-eclampsia as a cardiovascular emergency? What is the current management of the acute hypertensive episodes accompanying these conditions?" DR. JAMES METCALFE: I do consider preeclampsia as a cardiovascular emergency, at least historically. In the series collected before 1950, about 10 per cent of the maternal mortality in pre-eclampsia was due to pulmonary edema, and a great amount of theoretical work was done without much experimental work trying to explain whether or not this was a myocardial toxemia, as was suggested by Dexter and White among others, or whether this could all be explained by the effect of hypertension. Fortunately from the standpoint of the population and unfortunately from my own experience, pre-eclampsia has disappeared from our population. I have never seen pulmonary edema in a patient of the Boston Lying-In Hospital or its affiliated service. I have seen pulmonary edema in patients sent to the hospital who have had an atrocious sodium intake. I believe that the decline in toxemia of pregnancy is due to a realization of the role of sodium in its production and to prophylaxis by sodium restriction. Once pulmonary edema occurs in these circumstances, I assume it would be managed as pulmonary edema in general with more attention to diuresis because these people have a demonstrable large water content although not a large blood volume. As for the acute hypertensive emergency itself, I would gather that, as in other forms of acute hypertension and hypertensive crises, any of the high potency agents will get you over the acute phase; diuresis and eventually delivery will eradicate the disease. MODERATOR SPRAGUE: Dr. Gasul, at what age do you discontinue streptococcus prophylaxis in children with rheumatic fever? At what age would you not start the streptococcus prophylaxis program when rheumatic disease is first diagnosed in adults? You may