INTRAVENOUS INJECTIONS OF PEPTONE AS AN AID TO VACCINE TREATMENT
Authors: H. W. Crowe
Journal: BMJ (1923)

rT AR?Rins and a rapid pulse, and sweat freely.Such cases I have described as the " vascular group," and as a rule they show only a moderate reaction and rapid improvement after operation.The second group I have designated the " nervous type."Here the patient is more comamoinly between the ages of 40 and 45; the thyroid is smaller atnd more nodular, the pulse is less rapid, though often more irregular, and the nervous symptoms are much more prominent.These patients show considerably more reaction and make a slow post-operative recovery.Even when these two groups have been recognized and separated, a careful study of the immediate post-operative results will show a very considerable variation in the reaction, and it is to one cause of this variation that I wish to direct attention in this communication.It has long been realized that the thyroid secretion has a very marked effect on the heat regulation.All cases of myxoedema feel the cold very severely, while those of hyperthyroidism are in a like degree affected by the heat, so that they are much more comfortable during the cold weather.In my own cases the post-operative distress in hot weather has been much accentuated, and special precautions, such as the use of electric fans, of ice, and of cold sponging, have long been used.In spite of all such precautions it has been my steadily increasing opinion that the mortality during the hot periods has been abnormally high.A care- ful analysis of my cases front this point of view shows very clearly that such is the case.In my own series there have been two deaths, occurring respectively in the months of January and December.Both of these were in patients with advanced degrees of the disease and were dependent upon secondary cardiac changes.All the others occurred during the hot months of June, July, and August, and all were what may be described as unexpected deaths in that they occurred in patients who by no means showed a pre- operative hyperthyroidism in excess of the others and in whom all the usual precautions had been taken.They also all showed extreme post-operative reaction passing on to acute hyperthyroidism and death.In the accompanying chart I have plotted out the percentage mortality among the total cases operated upon in the individual months of the year, and it is seen that whereas in February, March, April, May, September, October, and November there is no mortality, in the three months of June, July, and August it is in the region of 20 per cent.The effect upon the curve in January and December of the two deaths mentioned above is also shown. J0Chart showing the percentage mortality among cascs of exophtialmic goitre operated upon ill the individual months of the year.These figures have been collected over a period of ten years, and hence are of considerable value, for it is unlikely that any accidental factor should give so marked an altera- tion in the mortality which occurs for these three months.Molreover, a mortality of 20 per cent.which is present when the cases operated upon in June, July, and Augu:st are considered alone, is one that is much too high and must in fact be considered as an unjustifiable risk.These figures have made it manifest to me-and I publish them in the hope that they will warn others-that no operation on a case of exophthalmic goitre should be undertaken in extremzely hot wveather, for uInder such conditions the risk inl spite of all precautions is too great and* can be easily countered by awaiting more suitable conditions.For-Guaate1y from this aspect the English climnate is so variable that seldom would it be necessary to postpone operation for more than two or three weeks.