AN ANALYSIS OF THE OCULAR SYMPTOMS 
OBTAINABLE 
IN EPILEPSY IN THE MALE ADULT. 
Read before the Philadelphia Neurological Society, December 27, 1886. 
BY iX 
CHARLES A. OLIVER, M.D., 
Visiting Physician and Ophthalmologist to the State Hospital for the Insane, 
Norristown, Pennsylvania; Ophthalmic and Aural Surgeon to 
St. Mary's Hospital, Philadelphia. 
[.REPRINTED FROM THE PHILADELPHIA MEDICAL TIMES 
FOR FEBRUARY 5, 1887 ] 
PHILADELPHIA: 
J. B. LIPPINCOTT COMPANY. 
1887. AN ANALYSIS OF THE OCULAR 
SYMPTOMS OBTAINABLE IN EPI- 
LEPSY IN THE MALE ADULT. 
THE clinical material for these observa- 
tions was obtained at the State Hos- 
pital for the Insane at Norristown, Penn- 
sylvania. The report embraces a study of 
all of the ophthalmic symptoms that could 
be gotten from fifty male adult epileptics, 
without reference to any past etiological 
factor or present mental condition. This 
method was pursued for several reasons, 
most prominent being— 
First. A special form of symptomatic 
disease was taken in preference to any 
mental condition, because similar mental 
states may be present in the many and bi- 
zarre forms of nerve-lesion, masking and 
hiding the true significance of the objec- 
tive symptoms peculiar to any one disease 
to such an extent as to render differentia- 
tion impossible. 
Second. A definite variety of disease 
was chosen, so as to avoid obtaining mere 
percentages of the ophthalmoscopic signs 
(which, as a rule, have been limited to an 
arbitrary designation of the tint of the 
optic disk and the size of the retinal ves- 
sels) of the total number of cases occur- 
ring in one asylum,—practically giving, if 
at all correct, a resume of the different 
varieties of optic-nerve color and retinal- 
vessel size of the gross amount of resi- 
dents of that asylum : an answer which is 
1 2 
liable to alter at any time through change 
of number of patients and character of 
mentality, or to be totally diverse from 
the results obtained by another observer 
placed in a different situation. 
Third. A large percentage of similar 
cases was taken. This was done so that 
the different mental states which are seen 
during the course of any one disease might 
be united into a theoretical average case, 
which would represent a typical example 
of the physical and physiological condi- 
tions of that disease. 
Fourth. Males were used. This is im- 
portant, for, by exclusion of the female 
subject, any errors that might arise from 
additional ocular changes dependent upon 
diseases which are peculiar to the sex are 
avoided. 
It may be interesting to note that na- 
tive American stock has been used. There 
is nothing absolutely important in this se- 
lection, because, by reason of many obvi- 
ous causes, a true American type of man 
has not as yet been established among us; 
yet it was intentionally done, so that re- 
sults obtained from subjects born on Ameri- 
can soil could be contrasted and compared 
with statistics of foreign-born population, 
in order to see whether the data would ex- 
hibit any decided peculiarity in ratios. 
OBSERVATIONS AND CONCLUSIONS. 
First. Direct vision for form, as a rule, 
normal in both emmetropia and corrected 
ametropia. 3 
Second. Accommodative action normal 
in due proportion to age and refractive 
error. 
Third. Visual fields for form and color 
reduced to one-third to one-twentieth of 
normal areas. 
Fourth. Visual fields for form and color 
regularly diminished, without any indenta- 
tions or scotomata. 
Fifth. Order of color-fields follows the 
regular physiological sequence, without 
transposition or reversion. 
Sixth. Subnormal color-perception to a 
slight extent, as evidenced by faulty selec- 
tion of delicate tints and shades contain- 
ing low percentages of green and red. 
Seventh. Pupils, as a rule, equal in size 
and alike in shape. 
Eighth. Irides freely and equally mo- 
bile to light-stimulus, accommodation, 
and convergence. 
Ninth. Extra-ocular motion intact in all 
directions. The presence of insufficiency 
of the interni in the majority of cases is 
readily explained by association with ex- 
isting H -f- Ah, and probably has no rela- 
tion to the epileptic condition. 
Tenth. Optic disk superficially over- 
capillary, with a decided grayness in its 
deeper layers, showing a low grade of in- 
cipient optic-nerve degeneration. 
Eleventh. Scleral ring rather more 
sharply cut and broader, especially to the 
temporal side of the disk, than in the 
healthy eye ; this being probably due to a 
slight shrinkage of lowered nerve-tissue. 4 
Twelfth. Fibre-layer of retina increased 
in thickness, as evidenced by dense and 
coarse massings of striation extending in 
all directions from the disk, these being 
more particularly marked in the superior 
and inferior portions of the eye-ground, 
even hiding the edges of the disk itself in 
many instances. 
Thirteenth. Retinal vessels large in size 
and carrying rather dark-colored blood, 
this being more pronounced than usual 
with the veins. 
Fourteenth. Retinal veins exceedingly 
tortuous, and in a few instances pulsating. 
Fifteenth. Retinal arteries frequently 
wavy and sometimes tortuous, especially 
the temporal and macular twigs. 
Sixteenth. Retinal lymph-channels vis- 
ible in the majority of cases, particularly 
seen along the larger vascular distribu- 
tions and at the vessel-entrance as glisten- 
ing and yellowish-white opacities. 
Seventeenth. No other visible changes of 
any significance throughout the eye-ground 
except a granular condition of the choroid 
in the macular region. 
In addition, it may be mentioned that, 
as far as practicable, nearly all of the deep 
and superficial reflexes were obtained 
throughout the body. These, as a rule, 
were above normal, and presented some 
curious anomalies, which will be reserved 
for a later publication. 
As was to be expected among this class 
of patients, many of the subjective signs 
were negative; but, withal, sufficient data 5 
have been produced to warrant proper 
conclusions in this direction. The results 
obtained from the study made of the vis- 
ible ocular changes are of special value, 
and may be cited as of sufficient impor- 
ance to be useful in diagnosis. 
Thanks are due to Drs. Charles A. 
Woodnutt and Henry Sykes, assistant res- 
ident-physicians, for good work and care- 
fulness displayed throughout these re- 
searches. 
Dr. Louis J. Lautenbach : The subject 
which has been discussed bv Dr. Oliver has 
been for the past three or four years worked 
upon by myself, both among male and female 
subjects, and among those not insane as well 
as among the insane. The cases have been 
both from hospital and private practice. 
Within the past week I have seen three pa- 
tients with the ordinary epileptic symptoms. 
One of these had the typical eye-ground 
which Dr. Oliver mentions. This was a case 
of idiopathic epilepsy. In another case, sup- 
posed to be one of syphilitic epilepsy, the 
eye-ground was different. In the third case 
there was still another picture, and in this 
instance the convulsions were due to the 
presence of a brain-tumor. 
It is an interesting as well as instructive 
fact that there is a close resemblance between 
the eye-ground in a case of imbecility and that 
in a case of epilepsy : so far as I know, there is 
no essential point in which they differ. 
There is one point which Dr. Oliver has 
not mentioned that I have noted, and that is 
that in perhaps one-third of the cases exam- 
ined, and especially in those seen in insane 
hospitals, the macular region presents a red 
DISCUSSION. 6 
granular appearance, and, in addition thereto, 
the macula itself was of a dull red color, I 
have not observed the darkness of the color 
of the blood to which reference has been 
made. 
Gowers states, as the result of the exami- 
nation of a thousand cases of epilepsy, that 
there is only one condition that appears to be 
somewhat frequent in these cases, and that 
is that the arteries and veins appear to be 
about equal in size. It is strange that a care- 
ful observer like Gowers has not noted the 
thickening of the fibrous tissue of the retina 
which has been described by Dr. Oliver, and 
which is usually the first thing that is ob- 
served upon examining the fundus. In ex- 
amining these cases I was struck with the 
frequency of high grades of hypermetropia, 
the proportion being greater than is observed 
among healthy individuals. 
There is another point of some interest, 
and that is that in long-standing epilepsy, 
where the attacks have been very frequent or 
severe, it frequently happens that the nerve 
presents very marked signs of degeneration, 
the atrophy being decidedly advanced, the 
direct form of vision being well preserved. 
Dr. Francis X. Dercum : The use of the 
ophthalmoscope in epilepsy for diagnostic 
purposes I regard as of comparatively slight 
value, for the diagnosis is usually made with 
ease from the history. The chief value is 
the light which it throws upon the pathology. 
Other things being equal, there is a certain 
correspondence between the condition of nu- 
trition in the retina and the nutrition of the 
cerebral tissues. There is a certain amount 
of agreement between the ophthalmoscopic 
appearances and the microscopic appear- 
ances of the brain-tissue. In one case of 
epilepsy in which Dr. Oliver examined the 7 
eye-ground, the patient subsequently died, 
and section of the brain showed changes 
similar to those found in the eye. There 
was a similar tortuosity of the vessels, a simi- 
lar infiltration of the sheath of the vessels, 
and a general increase in the neuroglia. 
Dr. Charles A. Oliver: I am not now 
prepared to give any data in reference to the 
similarity of the eye-grounds of the imbecile 
and the epileptic, although I am pursuing in- 
vestigations among the imbeciles at the Nor- 
ristown Hospital for the Insane. Also, as I 
ha\ e before noted, I have carefully avoided 
any endeavor to make any differential diag- 
nosis as to the causation of the convulsions. 
Inequality of pupil independent of local ad- 
hesion can be readily understood when dif- 
ferences of vision and accommodative action 
dependent upon refractive error, etc., which 
are so often seen in the two eyes of the same 
subject, are considered. These were care- 
fully studied and purposely excluded, merely 
giving the pupillary reactions, sizes, and 
shapes, as a rule, although in a number of 
instances, especially where there was unequal 
contraction of the visual fields, I found some 
curious errors in the innervation arcs of the 
irides. In reference to the occurrence of 
high degrees of hypermetropia (varying from 
four to five dioptrics), I must say that I have 
not found this to be the case, at least in those 
subjects that were at my disposal. The fact 
that the amount of grayness of the disk in 
some instances seems to bear no absolute re- 
lation to the amount of nerve-degeneration 
—as was curiously shown in a series of ob- 
servations made some years ago upon young, 
seemingly healthy males, in which I found 
that those nerves which were apparently ex- 
tremely gray had excellent quantitative color- 
perception, while some of the nerves which 8 
appeared of good healthy tint had not as 
good (none of these cases making a single 
mistake in Holmgren’s loose-wool selection, 
and all having perfect acuity for form)—is cu- 
rious, yet it must be admitted that the amount 
of vision and color-perception seen with de- 
generation of nerve-tissue is dependent upon 
the squeezing or atrophy to which the nerve 
is subjected. Those of Gowers’s observations 
which were made during or immediately after 
a convulsive attack were extremely difficult 
to manage, although limited to cases in which 
the seizure began locally. His assertion that 
during the intervals of the fits there are no 
abnormal ophthalmoscopic appearances can, 
I think, hardly be borne out. Amongst my 
conclusions, I have most distinctly pointed 
out the granular condition of the choroid in 
the macular region, and lay great stress upon 
the dirty red-gray degeneration of the optic 
nerve. In framing the conclusions which I 
have presented, I have grouped all the symp- 
toms, both subjective and objective, into an 
average case, hoping thereby to obtain a some- 
what typical picture. 
The peculiarities of the eye-ground seen 
in the cases I have studied—those of long- 
standing attacks of frequent occurrence—are 
most probably explained by the presumption 
that every convulsive discharge leaves an ad- 
ditional pathological condition, by which the 
objective appearances of a low and chronic 
form of retinitis and perivasculitis, associated 
with dirty red-gray degeneration of the optic 
nerve, are at last as the visible 
living results of a similar process which has 
been taking place within the intracranial sub- 
stance, and which may be readily seen post 
mortem by careful microscopic examination. 
Adjourned. 
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