CLINICAL SYNDKOMES 347 



frequently noted. Some patients have a morbid exaltation with a capacity 

 for great mental labor. This mental condition is aptly described by the 

 term "chorea of ideas." In many cases these early symptoms are diag- 

 nosed as either neurasthenia or psychasthenia, and the underlying hyper- 

 thyroidism is overlooked. It is a good rule to consider in every case of 

 neurasthenia or mild psychosis the possibility of an underlying hyper- 

 thyroidism. 



Kaymond and Serieux state that the psychic symptoms are not an 

 integral part of the disease but develop because of some hereditary 

 psychopathic taint, which is stimulated by the same cause as has pro- 

 duced the exophthalmic goiter. They point out that any form of mental 

 disease can occur either preceding the onset of the Graves' disease syn- 

 drome, during its course or even after its apparent cure. We are more in 

 agreement with Parhon, Mateesco and Tupa, who consider that the psychic 

 functions are influenced and regulated in a large measure by the activity 

 of the thyroid gland. We would, therefore, suggest that the mental excite- 

 ment and unrest at least, possibly even the actual psychosis, may be 

 due directly to the hyperthyroidism. 



In any event Murray noted the development of a true insanity in three 

 patients in his series of 180 cases. Again Kappenburg reports that eleven 

 of the fifty-six cases of "parenchymatous goiter" seen in the general hos- 

 pital at Utrecht showed either manic-depressive insanity or melancholia. 

 Martin and Shenk (quoted by Murray (&)) collected from the literature 

 forty-four cases of definite exophthalmic goiter complicated by mental dis- 

 ease which was classified as mania in sixteen, melancholia in ten, delusions 

 of persecution in ten and various other psychopathies in the remaining 

 eight. Woodburn believes that only a relatively small proportion of hyper- 

 thyroid cases actually become insane. He concludes from a study of four 

 hundred and sixty such cases that there is no distinct thyrotoxic psychosis 

 but that certain well defined neurotic and psychic symptoms may arise in 

 well marked thyrotoxic cases. In the exophthalmic goiter patient the symp- 

 toms are of the overcerebration and overstimulation type dependent upon 

 (a) cerebral hyperemia, (b) the thyrotoxicosis per se and (c) a toxicity 

 from the increased waste products of metabolism. 



In conclusion we would insist that while recovery from such a psychosis 

 is possible, the prognosis is very grave. 



Sensory Symptoms, General, Barker emphasizes the rarity of phe- 

 nomena referable to the peripheral neurones (both sensory and motor) of 

 the cerebrospinal nervous system ; this in marked contrast to the manifold 

 symptoms due to disturbances of the sympathetic and parasympathetic 

 systems. Among the sensory phenomena, subjective symptoms are common 

 and these are not confined to the ordinary sensibility for the special senses 

 are also involved; tnus subjective luminous phenomena and subjective 

 auditory symptoms have been described. There are also paresthesise in 



