IDIOPATHIC EPILEPSY.—In idiopathic epilepsy—that is, in those cases where no gross changes in the brain can be demonstrated by autopsy—the eye symptoms are numerous and interesting. Wecker287 tells us that at the commencement of the spasm there is contraction of the pupils. Usually, soon after the tonic spasm sets in or coincident with it, we have marked dilatation of the pupil and an abolition of the eye-reflexes, this being shown by the want of contraction of the orbicularis or of the pupil when the conjunctiva is touched. Reynolds, Echeverria, Clouston, and Hammond have called attention to a development of hippus (an alternate contraction and dilatation of the pupil) at the end of the convulsive paroxysms; but this is exceptional. The last author considers a state of alternate contraction and dilatation of the pupils, or a contraction of one pupil with dilatation of its fellow, to be characteristic of the convulsive stage. When the convulsions are unilateral the head and eyes are often turned toward the convulsed side. Although ophthalmoscopic examination is favored by dilatation of the pupil, yet the convulsions make it so difficult that we have quite conflicting accounts of the state of the disc and retina during the paroxysm. Six cases have been accurately examined by Albutt during the convulsion, in three of which there was congestion of the disc, and pallor in the remainder. Jackson also reports cases of pallor during the convulsion. More lately, Schreiber288 has examined three cases in which he found pallor in the convulsive stage, this being very marked in one case, where the convulsion was violent. Gowers, on the other hand, maintains that in convulsions which commence locally without initial pallor of the face he was unable to perceive any alteration of the calibre of an artery which he kept continuously in view during the convulsion. The same author tells us that during the stage of cyanosis the veins of the retina become distended and dark, and that once in the status epilepticus he has seen a congestion of the discs with oedema, which subsequently disappeared. He does not consider that there is any abnormal appearance of the discs in the intervals between the attacks, while both Albutt and Bouchut hold that they are congested. In several of the chronic cases which the writer has had an opportunity of examining there has been a low grade of atrophy of the discs with concentric limitation of the field of vision. That this, at least, is common in advanced cases is well shown by the observations of Michel,289 who in 1867 published careful examination of the eye-ground, acuity, and field of vision of 58 epileptics. In 15 of these cases there were no visible changes; in 10, hyperæmia; in 1, hyperæmia with oedema; 1 of hyperæmia passing into atrophy; 10 of unilateral atrophy (9 of the right nerve and 1 of the left); 13 cases of atrophy of both optic nerves; the remaining cases showing changes in the eye-ground which were probably attributable to other causes. Auræ which affect the special senses have been recorded, and have been usually described as flashes of light or balls of fire. Maisonneuve (quoted by Robin) gives an instance where the auræ consisted in convulsions of the eyelids. Gowers gives 119 cases of auræ which affected the special senses, 84 of these being of the sense of sight. He divides the latter into five classes: I. Sensation in the eyeball; II. Diplopia; III. Apparent increase or diminution in the size of objects; IV. Loss of eyesight; V. Distinct visual sensations, consisting sometimes of flashes of light, colored spectra, and rarely some more specialized sensation, such as an apparition. The only one of these cases in which there was an autopsy appears to have been one of symptomatic rather than idiopathic character, as there was found a tumor of the occipital lobe which had extended as far forward as the angular gyrus.
287 G. u. S., Bd. iv. p. 565.
288 Ueber Voränderungen des Augenhintergrundes, etc., 1878 (S. 42).
289 Inaug. Diss., von Dr. Julius Michel, Würzburg, 1867.
HYSTERO-EPILEPSY.—The remarkable co-ordinated convulsions which are associated with hemianæsthesia, and which have been so minutely described by Charcot as characteristic of this disease, are constantly accompanied by subjective or objective disorders of the visual apparatus. Visions of animals, such as rats, vipers, crows, cats, etc., frequently precede the convulsive seizure, followed by a transient loss of sight; a return of the illusions (sometimes pleasant and gay, at others erotic in their nature, or again sad or terror-striking) coming on in a later stage. It is said that processions of animals are often seen, which usually come and go on the hemianæsthetic side as the attack passes off and the patient becomes quiet. The objective symptoms have been carefully studied by Landolt in Charcot's wards. They were found by him to consist in a diminution of the acuity of vision and a concentric limitation of the field for form and color. All these symptoms are bilateral, and much more marked on the anæsthetic side, they occurring before any ophthalmoscopic changes are visible. These are followed later by alterations in the eye-ground, which consist at first of slight congestion and oedema of the discs, followed by partial atrophy. The difference in the affection of the two eyes was so marked that Charcot at first described it as a crossed amblyopia, but he admits that the lesion is bilateral, as above described.290
290 Leçons sur les Localisations dans les Mal. du Cerveau, vol. i. p. 119 (foot-note), Paris, 1876.
EXOPHTHALMIC GOITRE.
GRAVE'S DISEASE; BASEDOW'S DISEASE.—The most prominent characteristics of this affection are an irritability of the heart with increased frequency of the pulse, and enlargement of the thyroid gland and a swelling of the tissues of the orbit, which cause the eyeballs to become prominent. The size of the goitre and the amount of protrusion of the eyeball vary very much in different cases. Frequently there is a symptom to which Graefe was the first to call attention—namely, a disturbance of the usual consensual movements of the eyeball and upper eyelid. When the patient looks downward below the horizontal line, the lid no longer accompanies the eyeball in its motion, but halts in its course. This derangement in the action of the lid is supposed to depend upon some defect in the innervation of the orbicularis, as it is not present in cases of equal prominence of the eyeball from other causes. The amount of secretion from the tear-glands and from the conjunctival surface is also at times much diminished. Owing to the prominence of the eyes and the relaxation of the orbicularis, the fissure of the lids is wider open than usual, and the eye has a peculiar stare. At times, when the prominence of the eyes is very great, the lids fail to cover the balls during sleep, and the cornea becomes inflamed and ulcerated from exposure to air and dust. The disease rarely develops till after puberty, and is more frequent in females than in males: in the former it often develops after childbirth. It is so frequently accompanied by disease of the reproductive organs that Foerster, in his paper on the "Relation of Eye Diseases to General Disease,"291 places it in the section devoted to eye symptoms from diseases of the sexual organs. Ophthalmoscopic examination usually shows a slight thickening of the fibre-layer of the retina in and around the disc, with dilatation and tortuosity of the veins—a state of affairs which may often be fairly attributed to venous stasis caused by the swelling tissues. In addition to these symptoms there is sometimes, as Becker has pointed out, a dilatation of the arteries, which may almost equal the veins in calibre. At times there is an arterial pulse. As found by autopsies, the anatomical changes are usually enlargement and dilatation of the heart, hypertrophy and various degenerative changes in the thyroid glands, and a state of hyperæmia at times associated with hypertrophy of the fat tissue of both orbits.
291 Graefe und Saemisch, vol. vii. p. 97.