318 C. P. HOWAKD 



must be admitted a few have another etiology. Let us now consider 

 each in detail. 



Protrusio Bulborwn. Though protrusion of the eyeballs was noted 

 by Parry (a) (&) as early as 1815 in one of his eight cases, the credit of 

 emphasizing its importance as a diagnostic sign is due to Basedow (1840). 

 To quote the latter 's description : the eyes "were so pushed forward that 

 one saw three lines wide of sclerotic below and above the cornea: the 

 eyelids were widely separated and could not be shut with the greatest 

 effort and the patient slept with wide open eyes." Further on Basedow 

 describes them as like "crab's-eyes" or "Glotzaugen." 



The protrusion is best seen by examining the profile of the patient, and 

 is occasionally so great that the eyelids cannot voluntarily be closed, nor 

 do they meet during sleep. It may be so slight as to be hardly perceptible 

 even to the trained observer. Various attempts have been made to de- 

 termine the degree of protrusion. Neumann, quoted by Murray, has esti- 

 mated that the diameter of the globe is actually increased by one-tenth. 

 It may or may not be accompanied by Dalrymple's sign or widening of 

 the lid slits. It is usually bilateral but may be unilateral or at least more 

 marked on one side than on the other, which is true of one-seventh of the 

 cases, according to AVilbrand and Saenger. Unilateral exophthalmos, 

 however, is relatively rare, as Falta (b) was able to collect only 109 cases 

 from the literature and to add one himself. If there be a difference 

 between the two sides, the protrusion is usually more marked on the side 

 corresponding to the more enlarged lobe of the thyroid. Dock (&), however, 

 states that in some cases there is goiter on one side and exophthalmos on 

 the other. In any event protrusio bulborum is by no means a constant 

 sign and, according to Barker, does not occur in more than 33 per cent 

 of the cases of Graves' disease. Other authors give a much higher inci- 

 dence (W. G. Thompson in 64 per cent of 80 cases, Wilbrand and Saenger 

 in 61) per cent of 39 cases, Murray (e) in 70 per cent of his second series 

 of 170 cases, and 72 per cent on his first series of 114 cases). The dis- 

 parity is due no doubt to a confusion of the term "exophthalmos" with 

 ocular phenomena other than pure "protrusio bulborum." 



The protrusion is usually a late manifestation of the disease but it 

 may have existed for years in some members of a hyperthyroid family, 

 before the complete clinical syndrome is manifest. Again it may develop 

 very suddenly in the very acute cases of hyperthyroidism. At first the 

 eyeball can be pushed back by gentle pressure, but later on the eyeball is 

 fixed in its protruded position by the fat tissue in the orbit. Barker 

 insists that "protrusion of the eyeball" should be distinguished from a 

 mere widen ing of the lid slits (Dalrymple's sign). The term "exophthal- 

 mos" has been applied loosely to one or the other, but he believes should 

 be more correctly restricted to the actual ^protrusion of the eyeballs. It 

 is of course not peculiar to Graves' disease; it occurs in high degrees of 



