THE THYROID GLAND AND ITS DISEASES 



and face, increased size of the pupils, throbbing of the carotids and 

 precordium, tremor, changes in temperature of the hands and feet, per- 

 spiration and any other characteristic signs or symptoms. The presence 

 or absence of these signs is noted previous to the epinephrin injection 

 for purposes of comparison with the manifestations following the in- 

 jection. A hypodermic syringe armed with a fine needle which, when 

 inserted, causes little discomfort is then used to inject deep subcutane- 

 ously 0.5 c.c. (7.5 minims) of the commercial 1-1000 solution of adrenalin 

 chlorid (Parke, Davis & Co.) into the deltoid region. 2 The solution of 

 epinephrin chlorid should be as fresh as possible. If the latter has been 

 allowed to become dark-red or brown by action of the oxygen of the air 

 it should be discarded, as this means that the drug has lost considerable 

 of its potency due to oxidation. Failure to observe this precaution has 

 been responsible for mistakes in the interpretation of the test. Readings 

 of the pulse, blood pressure and respirations and any changes in the sub- 

 jective and objective manifestations are then noted every two and a half 

 minutes for ten minutes, then every five minutes up to one hour, and 

 then every ten minutes for half an hour longer. At the end of one and 

 one-half hours sometimes earlier the reaction has usually entirely 

 passed off. The oft-repeated, early readings are made in order not to 

 miss certain reactions on the part of the pulse and blood pressure that 

 may come on in less than five minutes after the injection. Prompt 

 responses are particularly prone to occur in cases of active hyperthy- 

 roidism. 



In a positive reaction there is usually an early rise in systolic and 

 a fall in diastolic blood pressures, in other words, a marked increase 

 in pulse pressure. In a very mild reaction the fall in diastolic pressure 

 alone may occur. In a definitely positive test the rise in blood pressure 

 may be all the way from ten to as much as fifty or more millimeters of 

 mercury. In -the course of thirty to thirty-five minutes there is a mod- 

 erate fall of the pulse and blood pressure, then the characteristic sec- 

 ondary slight rise and finally a second fall to the normal in about one 

 and one-half hours. Together with these changes one sees an exag- 

 geration of the clinical picture of Graves' disease or other forms of 

 hyperthyroidism, especially the nervous manifestations. The symptoms 

 of which the patient has complained are usually increased and often 

 symptoms which are latent at the time of examination but which have 

 previously been present are characteristically brought out. Thus, for 

 example, in numerous instances there occur extrasystoles. The patients 

 themselves are aware of these and recall having had them on previous occa,- 

 sions, doubtless, at times of clinical exacerbation of their disease. There 



2 A positive reaction is more convincing if the patient has given a negative re- 

 sponse to an injection of isotonic salt solution administered under the same conditions 

 as the epinephrin. K. G. H. 



