THE THYEOID GLAND AND ITS DISEASES 481 



the reaction is negative; in fact, in many instances of this kind a dose 

 of 1 c.c. or larger is necessary to produce any symptoms resembling 

 those seen in cases of hyperthyroidism. If, however, a colloid goiter 

 is functionally overactive and then accompanied by symptoms of hyper- 

 thyroidism, the reaction is mildly or moderately positive. 



In the adenoma cases, in which the adenoma or adenomata were 

 found to be active by histologic examination and in which there were 

 clinical symptoms of hyperthyroidism, the reaction was found to be 

 positive and in proportion to the severity of the symptoms. In cases 

 in which the adenomata had become degenerated and had lost their activ- 

 ity and were then naturally unassoeiated with clinical symptoms the 

 reaction was nearly or entirely negative. In some cases in which there 

 was a latent or quiescent period with absence 1 of symptoms as a result 

 of degeneration in an adenoma formerly active the symptoms could again 

 be elicited by an injection of epineplhrin. This was doubtless due 

 to a certain degree of hypersensitiveness of the sympathetic nervous sys- 

 tem which persisted for some time after the activity of the adenoma had 

 disappeared. 



In cases of adenomata of doubtful activity, operation is now being 

 advised by the author, on the basis of a positive epinephrin test in the 

 absence -of which the diagnosis often remains entirely obscure. At opera- 

 tion adenomata too small to be seen or palpated on physical examination 

 are often found and upon their removal striking benefits result. Ac- 

 cordingly, the test has led directly to a clearer conception of an ob- 

 scure group of cases, which are dependent for their symptomatology 

 upon a very definite pathological change in the thyroid gland. The 

 author (d) (1920) has designated this condition "Diffuse Adenomatosis." 

 The pathological condition is microscopic in character and recognized by 

 a hyperplasia of the interstitial or "fetal" cells or tissue without accom- 

 panying hypertrophy or hyperplasia of the alveolar parenchyma. The 

 symptomatology, much as in the adenoma cases, is a characteristic one, 

 though, as a rule, unassociated with positive eye signs or microscopic 

 changes in the gland. The symptoms are asthenia, nervousness, lability 

 of the pulse but without definite constant tachycardia, emotional instabil- 

 ity with mental symptoms, oftentimes loss of weight, vasomotor instability 

 and a variable tremor. Without a positive epinephrin response and with 

 a metabolic rate within normal limits, a point to be mentioned again, 

 one would hardly feel that he was dealing with hyperthyroidism, and 

 hence would hesitate to advise operation. By some, in fact, operation 

 is felt to be contra-indicated because of the absence of increased me- 

 tabolism. In such cases, however, the author has had striking success 

 following thyroid resection. 



In conditions of hypothyroidism, myxedema and cretinism, in which 



