Adrenal atrophy and (often) reduction of pituitary reserve appear to be a frequent, but not invariable, accompaniment of continuous treatment with exogenous corticosteroids. Maintenance therapy with corticotropin seems less likely to be associated with adrenal-pituitary unresponsiveness. The exact dose and duration of corticosteroid therapy productive of adrenal atrophy and reduction of pituitary reserve are unknown, and the time required for either gland to recover from a hyporesponsive state is also not known; therefore, it appears prudent to administer supplementary hydrocortisone if a patient has received 25 mg. cortisone or its equivalent for more than seven days (or an unknown amount) during the year before surgery. Empirical regimens used at two large surgical clinics are summarized; both provide about 300 mg. of cortisone in the 24 hour period before and during which major surgery is performed. Somewhat less is provided during minor procedures; in addition, an intravenous corticosteroid preparation is always kept in readiness. Despite the uncertainties of the physiologic mechanisms depressing the stress-adaptive ability of these patients, practical management through a hazardous period is quite simple, provided a few principles are kept firmly in mind.
