THE THYKOID GLAND AND ITS DISEASES 483 



section the epinephrin sensitiveness as a rule gradually disappears. In 

 the case of subjects suspected of having possibly hyperthyroidism but in 

 whom there is a negative epinephrin reaction operation is not advised, 

 for it has been found that these individuals are rarely if ever benefited 

 by operation. 



In brief, the author does not hold that the epinephrin chlorid test 

 is pathognomonic of hyperthyroid states. He would say, however, that 

 a negative test excludes hyperthyroidism; that in all cases of hyper- 

 thyroidism the test is positive, that there are some few conditions which 

 give a more or less typical reaction, and which are to be remembered 

 as exceptions. The latter, he thinks, can be fairly well recognized after 

 a careful history and physical examination. At any rate, he feels that 

 the test is practically always confirmatory, in many cases diagnostic and 

 in others suggestive of the diagnosis. It has led to further and more 

 careful search for causes in the small percentage of exceptions. There 

 is a remarkable parallelism between the hyper sensitiveness to epinephrin 

 and the degree of clinical hyperthyroidism present. The test has the 

 distinct advantage of being easily made. From a therapeutic standpoint 

 one can by means of the test follow the well known variations in the 

 degree of hyperthyroidism present from time to time and regulate the 

 amount of gland feeding accordingly. 



Furthermore, the test has many advantages over either the metabolic 

 rate determinations or the hyperglycemia test in that it is readily under- 

 stood, performed and interpreted. It is not subject to errors of possible 

 defective apparatus, requires no special training to carry out, is inex- 

 pensive, involves no calculations and is accompanied by a minimum of 

 inconvenience and annoyance to the patient. In the mild and latent cases 

 of hyperthyroidism it seems to be more sensitive and therefore more 

 diagnostic than the metabolic rate tests. It is not subject to the great 

 variations found in the case of the metabolic determinations under dif- 

 ferent circumstances and in the hands of various observers. It would 

 seem that in one important group, at any rate, namely in the obscure 

 adenoma and adenomatosis group of thyroid disorders (Woodbury), a 

 positive epinephrin test reveals the diagnosis whereas the metabolic rate 

 determination, being within normal limits, fails to indicate the presence 

 of a latent hyperthyroidism. The author has also seen cases of this 

 kind. On the other hand, in cases of hyperthyroidism of severer grades 

 of toxicity the epinephrin determinations run as a rule remarkably parallel 

 to the curve of increased metabolism (Woodbury). It is possible that 

 in the mild and latent hyperthyroidism of adenoma and diffuse adenomato- 

 sis we are dealing with an altered secretion, which has a stimulating 

 effect upon the sympathetic nervous system and is therefore discoverable 

 by a positive epinephrin test, whereas, failing to produce an increased 

 metabolism, it might escape recognition. 



