Three Cases of Brown-Sequard 
Paralysis, with Remarks on 
the Sensory Tract in the 
Human Spinal Cord. 
BY 
PEARCE BAILEY, M.D., 
Assistant in Neurology, Vanderbilt Clinic ; Assistant in Pathol- 
ogy, College of Physicians and Surgeons, New York ; 
Attending Physician, Almshouse and Work- 
house Hospitals. 
REPRINTED FROM THE 
■Neto York iFHe&ical Journal 
for March 9, 1895. R‘printed from the New York Medical Journal 
for March 9, 1895. 
THREE CASES OF 
BROWY-SEQUARD PARALYSIS, 
WITH REMARKS ON 
THE SENSORY TRACT IN THE HUMAN SPINAL CORD * 
By PEARCE BAILEY, M. D., 
ASSISTANT IN NEUROLOGY, VANDERBILT CLINIC ; 
ASSISTANT IN PATHOLOGY, COLLEGE OP PHYSICIANS AND SURGEONS, NEW YORK ; 
ATTENDING PHYSICIAN, ALMSHOUSE AND WORKHOUSE HOSPITALS. 
Of the three cases here detailed, one, which I am able 
to report through the courtesy of Dr. Fisher, I have seen 
constantly in the neurological division of the Almshouse 
Hospital on Blackwell’s Island. The two others have been 
at the Vanderbilt Clinic in the course of the past two 
years. Dr. Starr has kindly permitted me to look them up 
and examine them: 
Case I. Right.—Diminution of tactile sensibility; analge- 
sia; thermo-ansesthesia; all reflexes present; no clonus; no 
loss of muscular sense. 
Left.—Stab wound of neck; myosis; cilio-spiral reflex ab- 
sent; paralysis, with contractures, of arm and leg; wrist, el- 
bow, and knee jerks exaggerated; clonus; cremaster reflex 
diminished; abdominal reflex absent; no loss of muscular 
sense. 
* Read before the New York Neurological Society, January 8, 1895. 
Copyright, 1895, by D. Appleton and Company 2 
THREE CASES OK 
The patient, a Norwegian, aged forty-seven years, first 
found his way into the Almshouse Hospital last October for a 
malarial fever, which yielded quickly to quinine. His nervous 
condition being recognized, he was transferred to the Hospital 
for Incurables. I wish to take this opportunity to thank Dr. 
Witmer, the house neurologist, for his efficient assistance in the 
report of the case. The history which he tells is as follows: 
That soon after his arrival in this country, twelve years ago, he 
was stabbed in the back of the neck close to the skull on the 
left side. His history, both personal and that of his antece- 
dents, previous to this time is of no medical interest. He was 
unconscious for three hours after receipt of this injury, and was 
removed to Chambers Street Hospital. On regaining con- 
sciousness he found himself hemiplegic on the left side. The 
fact that he was hemi-ansesthetic on the right side was not 
noticed until some time later. His head hung limp upon his 
right shoulder, and for five weeks he was in bed with his head 
in supports. At the end of that time the power began to re- 
turn to the leg, and still later to the arm. Complete return of 
muscular strength has not occurred in either, and, though the 
leg is better than the arm, both are stiff. Sensations in these 
limbs were normal. On the right side tactile sensibility was but 
slightly affected, while sensation for pain and temperature was 
so much impaired that ordinary cuts, bruises, etc., caused no 
pain unless very severe. He could hold a piece of ice in his right 
hand indefinitely, and could not distinguish between hot and 
cold water. A bedsore developed over the right buttock, and 
there was a temporary paralysis of the bowels. All the im- 
provement which occurred was complete in eight months. 
Since then his condition has been what it is at present. He 
has been subject to ulcerations on the right leg, and had incon- 
tinence of urine for one year after the injury. After that time 
the urine passed involuntarily if the patient were on his left 
side; now, if asleep on his left side, it passes involuntarily. He 
is a man of medium frame and fairly well nourished. On the 
right leg are numerous scars, results of local suppuration which 
has occurred since the injury. Examination of the vegetative 
organs is negative; mentality is unimpaired, and he is a man of BROWN-SEQUARD PARALYSIS. 
3 
fair intelligence. On the left side of the upper part of the neck, 
in front of the anterior border of the trapezius and about an 
inch from the median line, is a scar which is the result of a 
punctured wound. On palpation over this scar the finger 
comes upon the posterior arches of the atlas and axis. There 
is no pain on pressure in this region. The head is deviated to 
the right to a slight degree. All the cranial nerves are intact. 
There is slight hypermetropia, and the left pupil is somewhat 
smaller than the right. There is also a slight internal squint of 
the right eye, dating from childhood. While there is general 
weakness of the arm and leg on the left side, this is most 
marked in the muscles of the shoulder and in all the extensors. 
The finer movements of the left hand are impaired. The 
movements of the spinal column are natural. The left finger 
joints are stiff, owing to the tense condition of the flexor mus 
cles. There is also stiffness of the joints in the left leg, depend- 
ent on a like cause. The left trapezius is more tense than its 
fellow. The muscles around the left shoulder joint are smaller 
than those on the right, but this difference is not too marked 
to be accounted for by a disuse atrophy. The circumference 
of the middle of the left arm is less than that of the right by 
an inch and a half. Between the left and right thigh the 
difference is an inch. These differences in size agree almost 
exactly with those of several cerebral hemiplegias of about ten 
years’ duration which I have recently examined. The chest 
expansion is two inches and the diaphragm acts normally. As 
regards motion in the right hand, the patient says there is no 
actual loss of power, but it is not so strong as it was before the 
injury. The dynamometer shows a difference of nearly a half 
on the two sides—right, 65; left, 35. In walking, the patient 
makes a mowing movement with his left leg in characteristic 
hemiplegic style. There are slight fibrillary twitchings of the 
muscles of both shoulders, running down into the arms. These 
also are more marked on the left. All muscles respond readily 
to mild faradaic currents. The right knee jerk is active and the 
left considerably exaggerated, and a clonus may be easi y elicit- 
ed on the left side. While the superficial reflexes on the right 
side are preserved, on the left the cremasteric reflex is dimii>- THREE CASES OF 
4 
ished and the abdominal could not be obtained. The left wrist 
and elbow jerks are active and are obtainable on the right. The 
right pupil dilates slightly on irritation in the supraclavicular 
fossa; on the left not at all. There are no sensory changes 
Case] I.—Below the line AM, diminished tactile sensibility; below the line 
B M, analgesia ; below the line C M, thermo-anaesthesia. 
whatever on the left. The muscular sense, as determined by 
distinguishing similar objects of different weights by assuming 
certain muscular positions at command and by telling in what 
position the muscles are, is everywhere intact. The following BROWN-SEQUARD PARALYSIS. 
5 
description, amplified by the charts, applies only to the right 
side, including right side of genital organs. The sense of touch 
and pressure is impaired below a line drawn horizontally from 
the lower border of the thyreoid cartilage in front to the fifth 
cervical spine behind. The impairment of tactile sensibility is 
so slightly marked that it gives but few subjective symptoms, 
and in fact the patient’s first knowledge of sensory involvement 
was his inability to distinguish between hot and cold water. 
The localization of touch is everywhere good. The loss of 
temperature sense extends below a curved line drawn from the 
third rib up over the shoulder, which descends again on the 
back to the third dorsal spine. This loss is well marked, and 
has become but little less since the injury. Analgesia, which 
is fairly complete, has still another distribution. It is present 
below a line which, beginning at the inner border of the clavi- 
cle, runs parallel with this bone for a third of its length, and 
then dips down for one or two inches and then ascends again 
over the shoulder and continues to the sixth cervical spine. 
The change in these anaesthetic areas, although present at the 
limits given, becomes most marked about an inch and a half 
below the superior boundary. There is not now, nor has there 
ever been, any hyperaesthesia. The absence of all atrophy, 
other than a disuse atrophy, indicates that the anterior horn is 
but little, if at all, involved. The absence of inco-ordination 
and presence of muscular sense would seem to indicate that the 
posterior median columns were intacr. The motor change— 
viz., hemiplegia with contractures, increase of deep reflexes, 
and diminution of superficial reflexes—points clearly to a de- 
scending degeneration in the pyramidal tract. In fact, the 
motor symptoms are identical with those that might be fur- 
nished by a cerebral hemiplegia, even to the extent that the leg 
recovered more completely than the arm. 
This case makes an interesting contribution to the 
localization of sensation of the cervical segments. In- 
jury of the entire cord above the fifth cervical segment 
is immediately fatal. Gowers’s * case (with autopsy), in 
* Gowers. Clin. Soc. Tram., xi, p. 24, 6 
THREE CASES OF 
which a pistol bullet lodged between the atlas and 
axis and contused the right anterior half of the third 
cervical segment, is the highest lesion of the spinal cord 
reported in which examination of the various resulting 
symptoms had been made ante mortem. But in his case, 
while there followed a right spinal hemiplegia, the result- 
ing left sided sensory symptoms were incomplete. In the 
absence of recognizable injury to the anterior horn in my 
case there is some difficulty in determining the exact seg- 
ment implicated. The knife blade entered, however, pretty 
surely in the immediate region of the atlas and axis ; these 
vertebrae surround the second, third, and fourth cervical 
segments. From the fact that in lesions of the fifth 
cervical segment, hypera3sthesia extends over the top of 
the shoulder and in the region of the supraclavicular nerves, 
Starr * infers that this area represents the sensory distribu- 
tion of the fourth cervical segment. The anaesthesia of 
this case corresponds very closely to these limits, and so 
furnishes additional evidence for the correctness of Starr’s 
inference. Certain peculiar symptoms in Gowers’s case led 
him to think that the sensory fibers have a different ar- 
rangement in the cervical cord than in segments lower 
down. In his case there were nowhere observed any 
diminution of tactile sensibility or any impairment of mus- 
cular sense. The sense of pain was diminished, but only 
below the left nipple. From this Gowers concludes : f “It 
is to be assumed, therefore, that the sensory path from 
middle and upper cervical nerves only crosses at the highest 
point of cord, above level of (present) injury.” Turner, \ 
from his experiments on monkeys, was led to believe that 
the course of tactile sensation for the arms passed up both 
* Starr. Brain, 1894. 
•f Gowers. Diseases of the Nervous System, 1892. 
% Turner. Brain, 1891. BROWX-SEQUA RD PARALYSIS. 
7 
sides of the cord, while the fibers for pain and temperature 
sense decussated entirely on entrance. In support of this 
view he adduces some of Brown-Sequard’s cases of injury to 
the cervical cord, where there was a bilateral anaesthesia, 
and one of Hoffman’s cases, where there was loss of tactile 
sensation on the paralyzed side as well as on the side with 
the analgesia and thermo-anaesthesia. Now the different 
experiments on the sensory tract of animals are contradic- 
tory, and Brown-Sequard’s cases appear to me hardly con- 
clusive, while Hoffman’s case was evidently (and so ex- 
plained by himself) one where the posterior columns of both 
sides were involved. In the case which I have just de- 
scribed, where the lesion is certainly as high as the fourth 
cervical segment, the resulting hemiamesthesia has the 
characteristics of a clinical hemisection of the cord at 
lower levels—viz., intact sensation of the paralyzed side, 
diminution of tactile sensibility, with loss of pain and 
temperature sense on the opposite side. So the evidence 
that the fibers for tactile sensibility for the arms and clavic- 
ular regions have a different arrangement than those for 
lower areas appears insufficient. 
Case II. Right Side.—Diminution of tactile sensibility; 
analgesia ; thermo-ansesthesia ; deep reflexes present; superfi- 
cial reflexes active ; no loss of muscular sense. 
LeftSide.—Stab wound of the neck; myosis; loss of cilio- 
spinal reflex ; paralysis, with contractures of arm and leg; loss 
of superficial reflexes; exaggeration of deep reflexes; no loss 
of muscular sense. 
The second case, a patient of Dr. Morrell, of Yonkers, whom 
he has very kindly allowed me to examine, is very similar to the 
one just described. This man was stabbed in August, 1892, in the 
left side of the neck, well up. He recovered quickly from the 
traumatism, and shortly afterward commenced to regain power 
in the left side, which had been paralyzed. The leg recovered 
more than the arm. He now presents a left spinal spast 8 
THREE CASES OF 
hemiplegia, with loss of superficial reflexes on paralyzed side, 
but with activity of these reflexes on the other side. There is 
left myosis and loss of left cilio-spinal reflex. There is no loss 
of muscular sense on either side, and no sensory symptoms have 
ever been observed on the left side. On the right side there 
Case II.- Upper limits of anaesthesia indistinct. 
is diminution of sense of pain and temperature. This analge- 
sia and thermo-anaesthesia is marked in the leg and abdomen— 
much less so on the arm and trunk. There is also some diminu- 
tion of tactile sensibility. Owing to the slight impairment on BROWN-SEQUARD PARALYSIS. 
9 
the upper extremity of these three forms of sensibility, it is im- 
possible to define exactly the superior limit of involvement. 
However, the impairment for all three begins at about a line 
drawn from a point in the middle of the sternum, two inches 
above the nipple, which ascends over the shoulder and then 
descending slightly continues to the vertebra. This area of 
sensory loss corresponds to the distribution of the fifth cervical 
segment. 
Case III. Right Side.—Paresis, with slight contractures of 
leg; no loss of muscular sense; cremasteric reflex present; ab- 
dominal reflex absent; knee jerk exaggerated ; clonus. 
Left Side.—No loss of touch ; analgesia; thermo-anaesthesia; 
no loss of muscular sense; cremasteric reflex present; abdomi- 
nal reflex present; knee jerk absent. 
This case is that of a man whom I saw about a year ago in 
Professor Starr’s department at the Vanderbilt Clinic. He 
presents the symptoms of a right-sided lesion in the lower dor- 
sal and upper lumbar cord. His own history or that of his 
antecedents throws no light on the aetiology. He is thirty- 
seven years of age, a machinist, married, and a resident of 
Newark. He is a man of temperate habits and more than ordi- 
nary intelligence. He denies syphilis, and no evidences of it 
are to be found. The disease commenced about a year and nine 
months ago and has been slowly progressive. He is a man of 
robust frame, well nourished, and symptoms of disease of his 
vegetative organs are not obtainable. He is more irritable than 
formerly. The only evidences of nervous disease are found in 
the lower part of the abdomen, and in the legs. The motor dis- 
turbances consist in weakness with some stiffness of the right leg. 
His gait, as observed in the right leg. is paretic rather than spas- 
tic. There are no hypertrophy or atrophy, no fibrillary twitch- 
ings, no inco-ordination, no pains or hyperaesthesia. On the left 
side, below a line drawn almost horizontally from the umbilicus 
to the vertebral spine behind, exists a well-marked analgesia, 
and below a line about an inch inferior to this one there is well- 
marked thermo-anaesthesia. On neither side is there any im- 
pairment of sensation for contact or localization of touch, and 
muscular sense is everywhere normal. (Muscular sense was 10 
THREE CASES OF 
tested by simply having the patient determine with closed eyes 
the position of the limb.) The cremasteric reflexes are present 
on both sides, and while the left abdominal reflex is present the 
Case III—Below the line A M, analgesia ; below the line B M, thermo-anaes- 
thesia. 
right is gone. The left knee jerk is gone while the right is 
active, and there is a slight clonus on the right side. There is 
some loss of bladder control and some lessening of sexual 
power. The bowels are somewhat constipated. The case ap- 
pears to me as one of right unilateral gliosis of the lower dorsal 
and upper lumbar region. BROWX-SEQUARD PARALYSIS. 
11 
These three cases of unilateral lesion of the spinal cord 
agree in most respects with the cases, about seventy-five in 
number, which have been reported since Brown-Sequard’s 
first description. The motor disturbance has generally 
been one indicative of degeneration in the pyramidal tract 
—viz., paralysis, with spastic rigidity, but no marked 
atrophy. In some cases the anterior horn escapes injury ; 
but from the now established fact that most muscles have 
a cellular representation in more than one segment, and as 
only a small portion of any one segment would be injured 
by a knife blade, it is fair to suppose, at least in cases resulting 
from stab wounds, that even if the anterior horn is involved, 
the functions of the destroyed cells are assumed by the 
uninjured cells of the affected segment, together with the 
cells of the other segments which are together devoted to 
any one muscle or muscle group, and so prevent recogniz- 
able symptoms of cell death in the anterior horn. There is 
on the side of the lesion an increased excitability of the deep 
reflexes while the superficial reflexes are diminished or lost. 
In both of my cervical cases, in common with most re- 
ported cervical cases, there is myosis on the injured side, 
and in neither is a cilio-spinal reflex obtainable on the af- 
fected side. Hyperesthesia and pain on the paralyzed side, 
a common and puzzling symptom, was present in but one of 
these three. The fact that fibers for touch, pain, and tem- 
perature decussate at slightly different levels is illustrated 
in the accompanying charts. Kobner * observed that tac- 
tile sensibility was involved higher than that for either pain 
or temperature. In my cases this difference is notable, the 
order of involvement being, from above downward, touch, 
pain, and temperature. In a case of spondylitis involving- 
half of the cord, Rosenthal f found thermo-anaesthesia two 
* Kobner. Deutsch. Arch, fur klin. Med., 1877, p. 19. 
f Rosenthal. Wien. rned. Presse, 1887. 12 
THREE CASES OF 
spaces higher than analgesia. His patient finally recovering, 
the restoration of sensation, in point of time, was touch, 
pain, and temperature. 
These unilateral lesions of the spinal cord prove, with a 
fair degree of certainty, that the fibers for pain and tem- 
perature undergo complete decussation immediately on en- 
tering the cord, and proceed uninterruptedly upward on the 
opposite side. The conduction of sensation of tempera- 
ture, as the early loss of this sensation in syringomyelia 
indicates, takes place probably in the gray matter. Painful 
impressions may be transmitted in this part also. Gowers* 
infers from his case that they go in the ascending lateral 
tract, but as in this case the gray matter, as well as the as- 
cending lateral tract, was involved, it can not be excluded 
as a means of conduction of this form of sensation. The 
loss of muscular sense is the most uncertain of the symp- 
toms of Brown-Sequard paralysis. It is retained in all of 
our cases, and in only a few of the reported cases has its 
loss been satisfactorily recorded. Its loss is generally be- 
lieved to occur on the paralyzed side. Ferrier f reports a 
case of syphilis in which loss of muscular sense occurred 
opposite the paralyzed side and on the same side as complete 
tactile anaesthesia and diminution of the sense of pain and 
temperature. The value of this observation appears to me 
to be invalidated by the fact that a temporary paresis as 
well had preceded the sensory loss on this side. Also the 
complete loss of touch is so extremely rare in unilateral 
lesions that it of itself would suggest a bilateral involve- 
ment. 
From this case, together with the results of experiments 
on animals, Ferrier believes that the muscular sense fibers 
undergo an immediate decussation on entering the cord. 
* Loc. cit. 
f Ferrier. Croonian Lecture, 1890. BROWN-SEQUARD PARA LYSIS. 
13 
The correctness of this view, in man at least, is hardly up- 
held by the reported cases of unilateral lesion. From the 
pathology of tabes we infer that the muscular sense, at 
least in so far as the sense of posture and co-ordination is 
concerned, is transmitted by the columns of Goll. This is 
generally believed for man, although the experiments of 
Ferrier and Bechterew * seem to prove that it is not true 
for monkeys. These results, however, do not agree with 
the earlier researches of Schiff, nor entirely with those of 
Gotch and Horsley.f Between the fibers for muscular 
sense and those for tactile sensibility there seems also 
to be a very close relation. While in unilateral lesions of 
the cord both of these sensory functions are often unim- 
paired when the muscular sense remains intact, I find but 
one casej in which the muscular sense was interfered with 
without disturbance of tactile sensibility. This also was a 
case of sclerosis, a form of growth in which the fibers of 
ordinary sensation are often left unimpaired. Also the fact 
that in uncomplicated tabes there is so frequently a loss of 
ordinary sensation in the legs lends force to the theory 
that the columns of Goll transmit some sensory impressions. 
This view is strengthened by the two following cases. 
Hoffman # reports a case in which he inferred from the 
direction of the wound that the posterior columns of both 
sides and the white matter of the left side of the cord were 
involved. The sensibility to touch was diminished in the 
left leg and there was a right-sided impairment of this sense. 
Muller || also reports a case quoted in Kobner’s article, in 
* Bechterew. Quoted by Ferrier, loc. cit. 
f Gotch and Horsley. Croonian Lecture, 1891. 
% Charcot and Gombault. Arch, de phys., 1873, p. 145. 
# Hoffman. Deutsch. Arch, fur klin. Med., 1886. 
|| Muller. Beitrdge zur path. Anat. und Phys. des Ruckenm., Leip- 
sic, 1871. 14 
THREE CASES OF BHOWN-SEQUAKD PARALYSIS. 
which a complete hemisection of the cord, together with 
division of the posterior columns of the other side, resulted 
in complete loss of touch. Edinger believes that the sen- 
sations transmitted by the columns of Goll undergo decus- 
sation in the medulla. That all the fibers for tactile sensa- 
tion do not cross in the cord, at least at levels of recorded 
injuries, the cases of Brown-Sequard paralysis would seem 
to prove; for when, in lesions of the cord, this function is 
entirely lost, there has been a bilateral involvement. 
I can find no cases in which this sense was more than 
impaired, w'here the injury was certainly limited to one 
side; and, in fact, from the want of cases of complete cere- 
bral hemiamesthesia there is no proof that a complete de- 
cussation of them occurs anywhere. The fibers which cross 
immediately on entrance are probably somewhere in the 
white matter of the lateral columns outside of the py- 
ramidal tracts. 
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