CLINICAL SYNDROMES 323 



lateral; finally, after one side of the thyroid was removed, the ex- 

 ophthalmos disappeared on that side. These observations were of course 

 very ^ suggestive and are usually quoted by those who regard the protrusio 

 lulU, Dalrymple's, Stellwag's, von Graefe's and Moebius' signs as the re- 

 sult of stimulation of the sympathetic fibers. It is true that Wilbrand 

 and Saenger mention four other possibilities for von Graefe's sign, 

 namely central irritation, action of the orbital vessels upon the levator 

 palpebrarum, insufficiency of the orbicularis muscle and increase of the 

 forces that cause elevation all purely hypothetical possibilities, 



Minor Ocular Signs. In addition to the above described six or seven 

 ocular signs there are several of less importance. 



Gifford's Sign. Gifford in 1906 described, as an early sign, difficulty 

 in everting the upper eyelid, on account of its retraction and rigidity. 

 He also described swelling of the eyelids, sometimes of the upper alone 

 and sometimes of the lower as well. It is not a true edema, as it can 

 be dissipated by causing contraction of the orbicularis by faradic stimu- 

 lation. Sometimes, however, there is a solid edema of the eyelids which 

 remains for a long period, even after many of the other symptoms have 

 disappeared, and probably caused by a subsequent hypothyroidism an- 

 other point in favor of the dysthyroidism theory. Suker has confirmed the 

 first mentioned sign of Gifford. 



The Glistening Eye and Epiphora. Those due to the vagatonic symp- 

 tom of increased lacrimation are not infrequent. The increased flow of 

 tears is due to a stimulation of the autonomic fibers of the seventh 

 cranial nerve. 



Loewi's Sign. Loewi's sign, or epinephrin mydriasis, is due to a 

 heightened tonus of the dilator pupillse muscles. The test consists in the 

 instillation of a few drops of a 1 to 1000 epinephrin solution into the 

 conjunctiva! sac; this is followed by a dilation of the pupil. The sign 

 is also occasionally positive in diabetes mellitus. This phenomenon, to- 

 gether with the dry eyes from lessened lacrimation, are sympathi- 

 cotonic phenomena, Sometimes idceration of the cornea results from 

 the diminished secretion and the lessened sensitiveness of the cornea, 

 according to von Graefe and Jessop, even in patients not severely ill. It 

 is more frequent in the male than in the female, probably from increased 

 exposure. This ulceration may go on to actual sloughing of the cornea, 

 perforation, panophthalmitis and destruction of the eye. In Mackenzie's 

 case the perforation occurred quite painlessly and the eye was lost before 

 the patient made any complaint about it. C. ID. Mayo has observed two 

 patients totally blind from this cause and several patients blind in one 

 eye. 



Anisocoria. Anisocoria or inequality of the pupils is due to a dis- 

 turbance of balance between the sympathetic and vagal autonomic nerve 

 supply of the pupillary muscles on one side. It occurred in only two 



