478 EMIL GOETSCH 



hyper thy roidism are brought out. Normal subjects do not react to this 

 dose (Peakyly and others, Wearn and Sturgis) and therefore reactions 

 from very mild to very marked must be considered respectively mild, 

 moderate and marked positive responses. The exceptions stated by 

 some as occurring in "effort syndrome" and even in so-called normal in- 

 dividuals, and in neurasthenics often do not give a typical, positive epi- 

 nephrin response. The typical response is characteristically sustained and 

 occurs in two phases, a primary major reaction followed by a secondary 

 minor reaction. In one and one-half hours the reaction disappears, leav- 

 ing the patient practically normal. Again, the response to the drug is 

 parallel to the degree of toxicity clinically recognizable, in a way similar 

 to tho parallelism described for the metabolism determinations in the 

 higher degrees of toxicity. After operation followed by subsidence of 

 liyperthyroid symptoms there is a fairly prompt subsidence of the sympa- 

 thetic hypersensitiveness to epinephrin. 



The test is carried out as follows: The patient should preferably be 

 put at rest in bed at least a day previously. If this is impossible, re- 

 clining for half an hour to an hour may be sufficient to obtain quiet and 

 composure. The more composed the patient is at the time the test is 

 carried out, the better, for under such conditions the re-action stands out 

 more sharply by contrast. Having become acquainted with the attending 

 physician who is to make the test, the patient is assured that the examina- 

 tion is in no way painful or dangerous. It cannot be emphasized too 

 strongly that these precautions be observed in patients suffering with 

 hyperthyroidism or similar conditions, for failure to do so has in many 

 instances been responsible for the failure to obtain a sharp contrast re- 

 action after the administration of the epinephrin. If one allows the 

 patient to bo disturbed by outside factors there is already a psychic 

 reaction which, as is well known, is accompanied by increased pulse 

 rate and blood pressure and by the exhibition of positive subjective and 

 objective siiins and symptoms which are characteristic of the epinephrin 

 response. I nder such conditions, it cannot be expected that a small dose 

 ot opinephriii should thereupon further increase the signs and symptoms as 

 to he sharply positive. We must have a true norm on the part of the 

 patient before the test is carried out. 



r \ wo or three readings of the blood pressure, systolic and diastolic, 

 pulse rate and respiration are taken at five-minute intervals. These 

 readings should be fairly constant. If they are not, time should be al- 

 lowed for the patient to become calm. A note is then made in regard 

 to the presence or absence of the subjective or objective status. This in- 

 cludes the subjective nervous manifestations, throbbing of the precordium, 

 abdominal aorta or peripheral largo arteries, heat and cold sensations, 

 asthenia, and the objective sinus, such as pallor or flushing of the hands 



