360 C. P. HOWAED 



with enlarged thyroids, of whom only 3.8 per cent had symptoms of neuro- 

 circulatory asthenia the second those without enlarged thyroids, of whom 

 3.9 per cent had neurocirculatory signs. From this they concluded that the 

 thyroid had no demonstrable etiological relationship with the neurocircu- 

 latory asthenia of soldiers. Further, Tompkins and his associates and 

 Boas, hy the determination of the basal metabolism and the response to 

 ephinephrin, conclusively demonstrated that hyperthyroidism was not an 

 underlying feature of the clinical syndrome known as neurocirculatory 

 asthenia or the disturbed heart action of soldiers. Incidentally we might 

 add the tremor is coarser and the heart has not such a tendency to en- 

 largement in this group as in hyperthyroidism. In spite of this Harlow 

 Brooks' s contention was supported in 1919 by Pende (&)., who wrote: a The 

 war, in my opinion, showed clearly the importance of the constitutional 

 hormonic anomalies." He speaks first of the emotive-commotive psycho- 

 neuroses of the soldier and next of the cardiovascular syndrome often 

 referred to under the appropriate caption of the "irritable heart of the 

 soldier." Pende noted two forms of dysharmonism in the war, one pre- 

 eminently hyperthyroid and the other preeminently hypoadrenal. The 

 contrast between the neurasthenia of civil life and exophthalmic goiter has 

 been graphically drawn by Plummer (d). 



In exophthalmic goiter there is usually an increased appetite; in neu- 

 rasthenia, anorexia. The fluctuation of the symptoms in Graves' disease 

 is marked bv a periodicitv of weeks or months and not by hours or days as 



*/ IT / i/ / 



in neurasthenia. 



The short, quick, nervous step, the bright and prominent eyeballs, the 

 mental alertness and physical restlessness of the sufferer from hyperthyroid- 

 ism form a striking contrast to the ordinary picture of a pure neurasthenia. 

 In both types of patients some sweating of the body surface and warm moist 

 hands may occur, and indeed a subjective sensation of heat more often 

 with (though at times without) a history of hyperhidrosis is the most char- 

 acteristic symptom of the vasomotor group, but it should not be confused 

 with the transitory hot flashes and cold sweats of neurasthenia. 



Palpable thrills and audible bruits over the thyroid gland are present 

 in eighty per cent of patients with Graves' disease, while they are practi- 

 cally never found in the uncomplicated neurasthenia. 



Finally, hyperthyroidism results in an increased metabolism which 

 nature attempts to compensate for by demanding more food, more water 

 and more air. 



Pulmonary Tuberculosis. The differential diagnosis of mild thyroid 

 toxemia and incipient pulmonary tuberculosis is by no means an easy task. 

 -I (minings points out that "certain cases of mild toxemia with cough 

 and chronic pyrexia bear so close a resemblance to incipient pulmonary 

 tuberculosis that a differential diagnosis may require a very close analysis 



