CLINICAL SYNDROMES 319 



myopia and, when more marked, in arteriovenous aneurisms, cellulitis 

 and tumors of the orbit as well as in -patients with atheroma and dilata- 

 tion of the arteries and in chronic cyanosis of the head. Mueller has 

 also reported its occurrence in some cases of lead poisoning as resulting 

 from a toxic vasomotor condition. 



Dalrymple s Sign, Widening of the lid slits or palpebral fissure 

 was first described by Dalrymple in 1849, according to his friend W. W. 

 Cooper, though we could not find the original reference. It may be notice- 

 able when the eyes are at rest but is best seen when the patient suddenly 

 fixes his eyes on an object held before him;- then the upper lid is dis- 

 tinctly retracted with a resulting exposure of the sclera above and below 

 the cornea. This sign is quite independent of the protrusion of the eye- 

 balls, but when present with slight protrusion, it may exaggerate the 

 degree of the latter. By some writers the term is reserved for the sudden 

 widening of the lid slit on fixation of the eyes and would not include the 

 widening when the eyes are at rest. It is not peculiar to exophthalmic 

 goiter but occurs in maniacal conditions, hysteria, orbital tumor, tabes 

 dorsalis, tetanus and pregnancy; in certain cases of myocardial disease it 

 is sometimes noted with a peculiar staring of the eyes resembling the 

 Stellwag sign. 



A true Dalrymple sign, though wrongly called Stellwag' s sign by 

 Murray, was present in 47 of his first 76 cases (or 61.5 per cent), and in 

 70 of his second 125 cases (or 56 per cent). 



Stellwag' s Sign. Though Stellwag' s name has been wrongly asso- 

 ciated with widening of the lid slits by even such masters as the late 

 Sir William Osier, the sign should imply the rarity and incompleteness 

 of involuntary winking, which Stellwag states in his excellent paper of 

 1869 has nowhere been previously described, but which he considers 

 to be among the most constant and even the most characteristic signs of 

 exophthalmic goiter. It must be admitted that Stellwag also discusses in 

 this same article the widening of the lid slits amongst the ocular phe- 

 nomena of Graves' disease, but so has nearly every writer since 1849. 



While normally involuntary winking occurs from three to ten times 

 per minute, in Graves' disease it occurs much less frequently, sometimes 

 only once in several minutes. Furthermore, in this disease each act of 

 winking is not as complete as in health. The sign is said by Barker to 

 occur in from thirty to fifty per cent of the cases. 



Von Graefe's Sign. Barker defines this sign as "a disturbance of 

 the associated movement of the upper lid with the eyeball on looking 

 downward, so that the lid does not follow the eyeball down as normally, 

 but is held back owing to an abnormal tonus in the levator muscle." It was 

 described by von Graefe (&) in 1864 as "a loss of coordination between 

 the lid movement and the raising and lowering of the plane of direction." 

 It is a very frequent sign, especially if carefully looked for, even in 



