78 ENDOCRINE GLANDS 



3. EXOPHTHALMOS completes the picture. The eye- 

 balls protrude, and the lids are wide open, giving an ex- 

 pression of fright. In most cases it is symmetrical, but 

 sometimes starts in one eye before becoming noticeable 

 in the other. Very rarely it stays unilateral, coinciding 

 with a thyroid hypertrophy on the same or opposite side. 



The protrusion of the eyes may become so prominent 

 that the insertion of the anterio ocular muscles is visible, 

 and interferes with the closure of the eyelids and exposes 

 the cornea to infection. 



Emotions, fatigue, menstruation, increase exophthalmos 

 just as they do the goitre. 



As a rule the patients do not have any visual dis- 

 turbances, except a certain difficulty in fixing objects or 

 reading small print. 



The pupils are equal, usually with a slight mydriasis 

 and react quickly to light and accommodation. Paralysis 

 of any of the extrinsic muscles is exceptional. 



Next to ophthalmia we have a number of signs indicating 

 an absence of coordination between the movements of the 

 eyelids and those of the eyeball. They are as follows: 



1. Von Graefes Sign. The movements of the lids lag 

 behind those of the eyeball. When the patient looks 

 downwards the superior eyelids do not follow it completely 

 and the eyeball stays abnormally open. 



2. Boston's Sign. The eyelids follow by jerks the 

 ocular movements. 



3. Stellwag's Sign. When the lids try to close, the 

 pupil hides under the superior lid instead of the latter 

 coming down. 



4- Jqffroy's Sign. The frontal muscle does not 

 move when the patient looks upwards (due to lack of 

 synergy between the movements of the frontal muscle and 

 the levator palpebrarum) . Other signs not as common: 



