482 EMIL GOETSCH 



there is increased tolerance to epinephrin, the injection test has served 

 as a guide yi the amount of thyroid gland administered, for it has been 

 found that by using the standard dose of 0.5 cubic centimeter of 

 epinephrin subcutaneously the gland therapy can with safety and ben- 

 efit be increased to the point at which there appears a slight reaction. 

 The amount of gland feeding indicated and at the same* time compat- 

 ible with safety can thus be determined as the proper dosage in a given 

 case. 



The epinephrin test has proved to be of the greatest value in the 

 differential diagnosis of many conditions simulating hyperthyroidism, of 

 which incipient tuberculosis is possibly the most important (Nicholson 

 and Goetsch). It has been found, fortunately for the differentiation, 

 that tuberculosis uncomplicated with hyperthyroidism gives a negative 

 reaction to the test. This fact has afforded means for distinguishing 

 early tuberculosis from hyperthyroidism, two conditions which clinically 

 simulate each other so closely that mistakes in diagnosis are frequently 

 made. Other conditions simulating hyperthyroidism and incipient tuber- 

 culosis, which might be mentioned, are psychasthenia, psychoneurosis, hys- 

 teria, neurasthenia, dementia prnecox, melancholia, alcoholism, tabagism, 

 acromegaly, arteriosclerosis, and several other diseases. Cases of this 

 kind give essentially negative results with the test. 



The importance of recognizing these conditions and separating from 

 thorn the eases of true hyperthyroidism for which surgical relief can be 

 offered need hardly be mentioned. In a few cases such as those men- 

 tioned some acceleration of the pulse and slight lise of blood pressure 

 were observed but in all cases there was a complete absence of the sub- 

 jective and objective symptoms so important in the interpretation of a 

 positive test. Again, in these allied conditions there might be a slight 

 transient reaction, whereas, in hyperthyroidism cases the reaction char- 

 acteristically lasts from an hour to an hour and a half. 



The test has been of value, furthermore, in estimating the degree of 

 toxicity present in early exophthalmic goiter. A markedly positive reac- 

 tion is often a better criterion than clinical judgment in helping to 

 decide as to whether an exophthalmic goiter patient can safely undergo 

 operation. The surgeon is thus warned in instances of this kind by a 

 strikingly sharp preoperative epinephrin reaction, in which case the 

 patient is advised to take a period of bed rest. If this has been done, a 

 preliminary Miration of the thyroid arteries is performed. In cases in 

 which there is a moderately sharp preoperative reaction, a thorough re- 

 section of the gland is indicated in order to gain a prompt improve- 

 ment. It, in a year or more in the case of a single lobectomy in ex- 

 ophthalmic goiter, the, symptoms have n<;t improved to the desired degree 

 and the epinephrin reaction is still definitely positive a second operation 

 for removal of the remaining lobe is advised. After the second re- 



