CLINICAL SYNDROMES 307 



apparent factor in the female, it is probably significant that a considerable 

 number of males have been engine-drivers, station-masters, stock brokers 

 and persons in other occupations involving mental strain. 



Fright and Mental Anxiety. While fright has always been much 

 emphasized as an exciting cause, careful cross-examination of the patient 

 will usually reveal the fact that the disease preexisted in a mild or latent 

 form before the mental shock. Nevertheless all writers are in the habit 

 of pointing out the close resemblance between fear and exophthalmic goi- 

 ter : thus Mackenzie (&) aptly puts it : "The descriptions given by Darwin 

 and Sir Charles Bell of the condition presented by persons under the influ- 

 ence of intense fear at once suggest the symptoms of exophthalmic goiter." 

 "The heart beats rapidly and forcibly, the eyes become prominent, the 

 thyroid is swollen, the limbs tremble, the skin becomes red or very pale 

 and sweating, vomiting and diarrhea may appear. 7 ' Among the causes 

 assigned by the patient for the onset of the disease are a fall from a 

 height or into the water, an injury to the head, receipt of bad news or 

 being attacked by thieves. 



Closely related to sudden fright is prolonged mental anxiety or worry 

 especially if associated with physical exertion and loss of sleep. This is 

 notoriously true of war: thus Gowers says in his text-book that many 

 cases of exophthalmic goiter occurred in Alsace and Lorraine during the 

 Franco-German War of 1870. Many cases of so-called "neurocirculatory 

 asthenia" of soldiers have been assigned by Harlow Brooks to hyper- 

 thyroidism brought on by the two factors of mental anxiety and physical 

 exertion. Buschan probably over-emphasized the neuropathic origin of the 

 disease, though Mackenzie (c) elicited a previous history of mental shock, 

 strain or worry in one^third of his 438 cases. While it must be admitted 

 that a large proportion of the patients with exophthalmic goiter give a 

 previous history of nervousness or even of nervous prostration, we must 

 agree with Dock (6) when he states that "the neurotic subjects and fam- 

 ilies are much more likely to have gastric or sexual neuroses than exoph- 

 thalmic goiter." 



Infections. General Infections. Coryza, sinusitis, tonsillitis and 

 other acute infections, as influenza, often precede the symptoms of exoph- 

 thalmic goiter. Such was the case in 25 per cent of W. G. Thompson's 

 series of 80 cases. In Swan's (a) series of fifty the disease appeared after 

 an acute infection in 13 : the latter included typhoid, scarlet fever, influ- 

 enza, tonsillitis, diphtheria, etc. Other authors have suggested rheumatic 

 fever, measles, mumps, pertussis and malaria as of possible etiological im- 

 portance. In a small number of cases acute thyroiditis is suggested by a 

 swelling of the thyroid gland during or after the acute infection, as was 

 noted by Reinhold in a case of influenza. Again, in patients with simple 

 parenchymatous goiter, an acute infection of any region may change the 

 clinical picture to one of hyperthyroidism. It is interesting to note that 



