320 C. P. HOWAKD 



cases without other symptoms or signs of hyper thy roidism, though it is 

 well to warn the inexperienced clinician against laying too much stress on 

 this sign in the absence of other symptoms of the disease. It is generally 

 bilateral but a unilateral manifestation has been reported by Hitschmann, 

 Friedenburg, Long and Pringle. As far as the incidence of the sign is 

 concerned this varies greatly: no doubt pari passu with the care with 

 which the sign has been looked for. Thus Hill Griffith reports it positive 

 in 13 per cent, West in 14 per cent, Paessler in 17.6 per cent, Murray in 

 34 to 40 per cent, Dock in 50 per cent, and Lewin (quoted by Wilbrand 

 and Saenger) in 55.5 per cent. As has been already stated it is sometimes 

 present in healthy persons but has also been noted in Thomsen's disease. 



Moebius' Sign. Moebius (a.) first, noted that when a patient with 

 Graves' disease is looking straight before him at the examiner's finger, he 

 is unable to converge the eyes as the finger is gradually moved nearer, 

 and one or other eye will soon deviate outward, leaving only one eye look- 

 ing at the finger. The patient, however, denies the sensation of diplopia. 

 The best method of inducing this sign is by directing the patient to fix his 

 eyes on the ceiling and then quickly on the examiner's finger. Many cases 

 of hyperthyroidism reveal this insufficiency of convergence, but it must 

 not be forgotten that one also meets with it in myopia of more than ten 

 diopters and in neurasthenic conditions other than hyperthyroidism. 



Joffroy's Sign. In 1893 Joffroy described in four cases the follow- 

 ing sign (we quote his own words) : u lf one asks some one who is looking 

 down to look quickly upwards to the ceiling, holding the head immov- 

 able, one notices that at the same time as the ocular globe executes a move- 

 ment upwards, the eyebrows are elevated and the forehead is wrinkled: 

 it is a synergic movement produced in the normal and absent in this 

 patient whose eyebrows and forehead remain absolutely immobile, even . 

 when she makes a considerable effort to look up." The patient that he 

 was demonstrating was, needless to say, one of his four cases of exoph- 

 thalmic goiter. "One must not conclude that there is a true paralysis of 

 the frontal muscle but rather a dissociation of the reflex movement of 

 the muscles of the forehead and eyebrows." This sign is not noted by 

 Mackenzie in his article in Allbutt and Eolleston's System, nor by Dock 

 in Osier and McCrae's System. It is a relatively frequent ocular sign, 

 though we have no figures as to its exact incidence. 



tinker's Sign. Suker states in his article, 191Y, that "after ex- 

 treme lateral rotation of the eyes either to the right or to the left, with 

 the head fixed and with fixation on an object at this point maintained for a 

 second or two, on attempting to follow the fixation point as it is rapidly 

 swung into the median line, one of the eyes (it may be either) fails to 

 follow the other in a complementary manner into proper convergence and 

 fixation for this point when it is brought into the median plane. Either 

 the right or the left eye makes a sudden rotation into the fixation with 



