480 EMIL GOETSCH 



are often increased tremor, apprehension, throbbing, asthenia, and in fact 

 an increase o,f any of the symptoms of which the patient may have com- 

 plained. There may be, furthermore, manifestations of symptoms latent 

 previous to the injection and characteristic of the hyperthyroidism syn- 

 drome. Vasomotor changes are common and quite characteristic. Thus, 

 an early pallor of the face, lips and fingers, due to vasoconstriction is com- 

 mon, and is followed in thirty minutes to an hour by the stage of vasodila- 

 tion with consequent flushing, sweating and warmth of the face, hands and 

 feet. The respirations at first become slower and deeper, even sighing in 

 character, and later more shallow and rapid. Yawning is common. In 

 fact, in a number of instances patients have fallen asleep during the 

 test. They complain of considerable fatigue. The symptoms described 

 have never been dangerous, and the manifestations produced by the test 

 are no more than the disease itself produces and are transient, the status 

 of the patient usually being quite normal in the course of an hour to 

 an hour and a half. 3 



In order to interpret a test as positive it is necessary to have a 

 majority of these signs and symptoms definitely brought out or increased. 

 Thus, there is at times a considerable exacerbation of the objective signs 

 and symptoms; there may be an increase of ten points in the pulse and 

 blood pressure together with a moderate increase of symptoms and signs; 

 there may be only slight changes in pulse and blood pressure and con- 

 siderable change in signs and symptoms. Any combination of this kind 

 may be regarded as positive. One must not regard a test as negative 

 because there has not resulted from the epinephrin injection an increase 

 or manifestation of all the possible signs and symptoms for, in order 

 to gain a correct interpretation, one must consider the entire clinical pic- 

 ture produced, just as in the disease itself one cannot require every 

 one of the characteristic signs and symptoms to be present in order to 

 make a diagnosis. 



In the exophthalmic goiter cases the epinephrin reaction in my ex- 

 perience lias been uniformly positive and as a rule remarkably parallel 

 in its manifestations with the severity of the symptoms. There is one 

 qualification to the latter statement, however, and that is, that in the 

 late advanced cases the reaction which one might expect to be very 

 marked is only mild as a result of the fact that the nervous system, 

 heart and other organs, having been severely damaged by the thyroid 

 intoxication, are unable to respond to the epinephrin. The test in these 

 cases is of course unnecessary for the diagnosis. 



In tho colloid o-oiter cases, without symptoms of hyperthyroidism, 



3 Very striking is the fact that patients giving marked objective evidence of dis- 

 tress, such as pallor, tremors and weeping, may deny any subjective discomfort what- 

 ever. K. G. 11. 



