A Case of Hemiplegic Epilepsy, 
probably Diabetic, sim- 
ulating Cerebral 
Abscess. 
BT 
ROBERT ABBE, M. D. 
REPRINTED from 
®ttc Nete ¥orb Jf&rtrtcal Journal 
for August 9, 1890. Reprinted from the New York Medical Journal 
for August 9, 1890. 
A CASE OF HEMIPLEGIC EPILEPSY, 
PROBABLY DIABETIC, SIMULATING CEREBRAL ABSCESS.* 
EGBERT ABBE, M. D. 
The case the history of which I am about to narrate 
presents features of much interest to the physician as well 
as the surgeon, and bears directly on diagnosis in cerebral 
surgical disease. 
The patient was an active man of forty-four years and in 
exceptionally good health until attacked by the grippe on last 
Christmas, His influenza was of a severe type—general pains, 
prostration, sore throat, cough. The sore throat seems to have 
been the worst, and swallowing was difficult. Two or three 
days later severe pain began in the left ear, and suppurative 
otitis media was established. The discharge diminished but 
never ceased. He was unable to resume work, lost flesh and 
strength. There were no cerebral symptoms, and he was able 
to be about. A few days after the onset of his trouble—that 
is, about January 1st—he observed a marked increase in the fre- 
quency and quantity of urination, but no examination of it was 
then made. 
In February he noticed a growing difficulty in giving ex- 
pression to certain words. This and the patient’s general con- 
dition seemed a little worse on alternate days. He had one or 
* Read before the New York Surgical Society, April 23, 1890. 2 
A CASE OF HEMIPLEGIC EPILEPSY. 
two headaches weekly, mostly left-sided, with tendency to ver- 
tigo. Became rather somnolent. 
On March 4th he became dizzy, his legs gave way, and 
he fell while walking in the street. A sensation “like a shock 
of wind,” as he expressed it, seemed to start in the right foot 
and spread very rapidly over the right leg, arm, and side. The 
paresis seemed to come on gradually, as he felt less and less 
able to walk, and finally dropped, not unconscious but unable 
to walk. 
March 9, 1890.—Admitted to St, Luke’s Hospital, under Dr. 
George L. Peabody’s care. Examination showed that the pa- 
tient had a mitral murmur; no paralyses; no deviation of 
tongue; no anaesthesia. Pupils reacted to light. Knee-jerk 
absent. The other reflexes were present, the plantar rather ex- 
aggerated. There was a purulent discharge from the left ear, 
with perforation of the drum. His skin was dry, tongue coated 
with brown fur, but moist. Pulse, 80; temperature, normal. 
The patient was somnolent. About an hour after admission he 
began to have convulsive movements of the right side, begin- 
ning in the foot, was given a hypnotic, and slept. The next 
morning he was able to walk with a limp. After breakfast 
another convulsion of the right leg, lasting half an hour. There 
was some paresis of the leg and hypertesthesia of the right side, 
passing away quickly. Also a slight transient aphasia. His 
chief complaint was of general weakness and the discharge from 
the ear. 
The urine was acid. Specific gravity, D 042. Sugar, thirty- 
two grains to the ounce. No albumin. No casts. The ear was 
frequently syringed with boric-acid solution, and he was given 
bichloride of mercury, gr. t. i. d., with diabetic diet. During 
the following week his urine increased in quantity from forty 
to eighty-six ounces, and the sugar diminished to twenty six 
grains. There were several times each day attacks of numbness 
of the right arm and leg, with considerable loss of power. The 
patient could stand but not walk. He could not grasp with his 
right hand. There were no optic symptoms. During the at- 
tacks there was hesitation in speaking and difficulty in pro- 
nouncing some words. The mind was dull, but there was no A CASE OF HEMIPLEGIC EPILEPSY. 
3 
loss of memory. The attacks lasted from a few seconds to five 
or ten minutes and went off as suddenly as they came on. 
There was a vague history of early syphilis, and he was given 
eight doses daily of iodide of potassium, forty grains each. 
On March 14th convulsive movements of the right arm and 
hand were noticed, and to a much less degree of the right leg 
and foot. These lasted only a few seconds and were followed 
by a stupid condition. Aphasia followed each attack. 
17th.—At least two attacks daily were associated with con- 
vulsive movements of the right hand and arm. Mouth open 
widely; eyes closed. On coming out of one attack he was 
unconscious that it had happened. Examined by Dr. M. A. 
Stan- with Dr. Peabody, no retinal changes were present. 
20th.—Up to this date he had been having three or more 
marked epileptic seizures daily, beginning with numbness of the 
right leg and arm, andsucceded by severe spasmodic convulsions 
limited to these members. It now extended to the same side of 
the face. His temperature also rose to 101°, having previously 
been normal, or nearly so. Evidence of mastoid inflammation 
also developed rapidly, and in twenty-four hours a well-marked 
suppurative mastoiditis was found, and he was transferred to 
my care for surgical relief. 
His urine still showed no albumin or casts, but sugar, 
twenty-four grains to the ounce. During the succeeding 
twenty-four hours six similar epileptic seizures occurred, wholly 
limited to the right side. He was seen by Dr. Dana, who noted 
also some anaesthesia, as well as diminished muscular power of 
the right side. It was thought possible there might be an ex- 
tension of suppuration by perforation from the mastoid, causing 
pressure upon the portions of the brain indicated by the parts 
involved in the seizures—namely, the centers for the leg, arm 
and face, and for speech. Preparation was made to operate 
upon the mastoid, and, if indicated, to trephine also over the as 
cending frontal convolution. 
March 21st.—The patient was etherized and the mastoid well 
excavated of all suppurative tissue. A piece of loose seques- 
trum was found within the hone. The hone was so far removed 
as to undermine the dura constituting the floor of the lateral 4 
A CASE OF HEMIPLEGIC EPILEPSY. 
sinus, and still further in a space the size of the finger nail of the 
roof of the petrous portion. Into these openings the director 
was passed between hone and dura mater for an inch in different 
directions, but no intracranial pus was found. 
After this the convulsive twitchings were slight, but re- 
curred every half hour or less all the next day, lasting, how- 
ever, only a minute. Ills tongue deviated to the right. His lips 
were drawn to the right. Between attacks he seemed fairly in- 
telligent, but could not express himself. He would sometimes 
repeat words suggested correctly after vain attempts to make 
himself understood. 
It was thought best to defer further operation. 
On the second day after operation the convulsions were more 
violent though not so frequent, and his general sense was more 
blunted. 
On the third day I felt that the indications were more than 
ever for irritation of the cortex of the suspected convolution. 
The wound was in perfect condition, yet the temperature rose on 
this day to 102°, pulse varying from 72 to 100 at different hours— 
on the whole, a disproportionately slow one. The convulsions 
were wholly localized and the aphasia more complete, suggest- 
ing a left-side lesion directly related to the left-ear condition. 
On March 24th, therefore, I trephined with a one-inch tre- 
phine just in front of the lower end of the Rolandic fissure as 
mapped out for me by Dr. Dana. The dura and brain seemed 
normal but a little full. Arachnoid fluid normal. A small punct- 
ure was made in the pia and a director gently pressed into the 
presenting convolution for an inch in three directions. Neither 
suppuration nor tumor was found. The dura was therefore 
sutured with fine catgut and the wound closed. 
The operation had no appreciable effect on the condition of 
things. The convulsions were repeated every twenty minutes 
as before, and on the following day became more general, both 
sides of the body and face participating. His aphasia grew more 
complete. 
On the third day the convulsions abated in frequency ; only 
one occurred in the night and eight in the day. These were 
general though more marked on the right. He seemed to un- A CASE OF HEMIPLEGIC EPILEPSY. 
derstand everything that was said and done, but could not make 
himself understood. 
On the fifth day the convulsions came hourly, were more se- 
vere and more general. He gave evidence of exhaustion from 
this cause. His pulse became weaker. Temperature rose to 
lOfi'o0 just before death, and he died, after a few hours, of 
coma. 
The autopsy was made ten hours after death by Dr. Thacher, 
and was watched with great interest by Dr. Peabody, Dr. Starr, 
Dr. Kinnicutt, Dr. Robinson, Dr. Bangs, and others, besides my- 
self. The brain and membranes, as far as gross examination re- 
vealed, were in an absolutely normal condition. 
No trace of pus was found anywhere, even in the temporal 
bone. The arteries at the base and throughout the brain were 
scrutinized and found apparently normal. 
Many close sections were made in the region about the Ro- 
landic fissure as well as elsewhere, and a more normal appear- 
ing brain it would be difficult to find. The site of puncturing 
was exactly in the hand and face convolutions, and no harm had 
coine from the use of the director. 
(The linear scar in the brain substance is here shown.) 
Further examination of the body showed an abdominal ad- 
hesion matting together the pancreas, spleen, and transverse 
colon. The pancreas was atrophied to a fibrous relic about one 
quarter its normal bulk. No suppurative process could be de- 
tected. It was impossible to say whether this was a recent or 
long-standing lesion. 
Further consideration of the history and revelations of 
the autopsy led to the conviction that the train of reraarka* 
bly delusive symptoms resulted from the poisoning of his 
system through the diabetic poison. This suppurative mas- 
toiditis was undoubtedly the determining cause of irrita- 
tion of the left convolutions. 
Bibliography. 
A. Reference Hand-bool: of the Med. Sciences, 
(Dr. Kinnicutt, Med. Ree., New York, vol. xxiv, p. 221.) 6 
A CASE OF HEMIPLEGIC EPILEPSY. 
1; Facial hemiplegia: the patient died in syncope with sud- 
den hemiplegia of the body. 
2. Landesburg mentions a case of paralysis of the abdncens 
3. Dementia paralytica, Hamilton, JV". Y. Med. Journ., xl, 
1-5. ~ • 
Locomotor ataxia, tabes dorsalis, insanity, and hemiplegia, 
are all mentioned as occurring in conjunction with diabetes 
mellitus, - 
(Pavy, On Clinical Aspect of Glycosuria. Brit. Med. Journ.. 
1885, ii, p. 1049.) 
B. Guy's Hospital Reports, vol. xliv, 1886-1887, p. 189. 
“ Dr. Pavy states that nervous symptoms, especially spinal 
ones, are very apt to accompany diabetes. He has seen ataxia 
associated with it in a great many cases, the symptoms coming 
on either simultaneously or at different times. There may be 
pains in the limbs, a feeling of heaviness in the feet, darting or 
lightning pains, hyperesthesia, deep seated pain in the bones, 
and loss of knee-jerks.” 
Bouchard and Marie and Guignon, in an abstract in Brit. 
Med. Journ., 1887, i, p. 286, direct special attention to the loss 
of knee-jerks. 
Nervous symptoms occurred in one form or another in sev- 
enty-one out of one hundred and sixty-eight cases at Gny’s. REASONS WHY 
Physicians Should 
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