Hemiparaplegia; with Report of a Case Com- 
pletely Recovered After One Year's 
Duration. 
Read before the Section of Neurology and Medical Jurisprudence, at the 
Forty-fourth Annual Meeting of the American Medical 
Association. 
BY L. HARRISON METTLER, A.M., M.D. 
CHICAGO. 
REPRINTED FROM 
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 
' SEPTEMBER 29, i893. / , , ) /) 
CHICAGO: 
PUBLISHED AT THE OFFICE OF THE ASSOCIATION 
1893. HEMIPARAPLEGIA; WITH REPORT OF A CASE 
COMPLETELY RECOVERED AFTER ONE 
YEAR'S DURATION. 
In certain lesions of the spinal cord, the prospects 
of recovery are so much more hopeful from surgical 
interference than from medical treatment, that an 
exact diagnosis is of paramount importance. Hence 
every ray of light, however feeble it may be, that 
illuminates the question of spinal cord localization, 
should be most carefully cherished. Our knowledge 
of the motor centers of the cord is already sufficiently 
exact to guide the surgeon in his operations, but the 
precise limitations of the sensory areas are matters 
still of much uncertainty. A great deal has been 
accomplished towards increasing our information in 
this respect by Oppenheim, Westphal, Rosenthal, 
Eulenberg, Ross, Mills, Osler, Church, and especially 
Thorburn. According to the general concensus of 
opinion to-day, the decussations of the sensory and 
motor tracts are such that a lateral focal lesion any- 
where below the cervical enlargement gives rise to a 
hemiparaplegia, with paralysis upon one side of the 
body and anaesthesia upon the other. Every instance 
of an anomalous presentation of this classical picture 
must be possessed of unique interest, hence I beg to 
present the following case, which has seemed to me 
to be worthy of special study : 
Case.-M. D., a bright, cultured girl 20 years of age and 
residing in the western part of Pennsylvania, was brought to 
me Oct. 5, 1890, by Dr. C. J. Steim. The following history was 
narrated to me by the patient herself in the presence of the 2 
doctor and her elder sister: On the morning of Dec. 25, 
1889, while walking along the street, she accidentally stepped 
upon a loose coal-hole cover and fell in such a manner that 
the left leg passed down into the coal-chute while the 
righ twas extended out over the pavement. She fell heav- 
ily with her whole weight. Unconsciousness at once re- 
sulted, and on account of the free use of narcotics by her 
medical attendants, she was not fully cognizant of her sur- 
roundings until a week after the accident. In the mean- 
while the hip joint was found to have been dislocated and 
was immediately reduced. There was a considerable hem- 
orrhage from the vagina, and in some way indistinctly 
described, she was torn. Shortly after the accident the left 
limb began to swell, became extremely painful and was 
completely paralyzed. Poultices and hot applications were 
employed. The fever continued high and with it there was 
excruciating pain at the back of the head. A week later the 
swelling of the limb entirely disappeared. Six weeks after 
the accident, the faradic current was employed locally to 
the paralyzed muscles without any improvement. In March, 
three months after the accident, the swelling of the limb 
reappeared. At this time there was no local sweating, no 
glossing of the skin, no formation of blisters or sores. This 
was the last time that the leg swelled. During the course 
of the year, the right arm enlarged somewhat and became 
cold and cyanosed. This occurred some five or six times. 
At no time were there any symptoms of a similar character 
in the left arm or right leg. There were no cincture pains, 
no eye disturbances, no dysphagia, no dyspepsia, no dysp- 
noea. The bowels remained unaffected, with the exception 
of a few small bleeding piles which appeared immediately 
after and seemed to be one of the direct results of the fall. 
The rectal sphincter was very slightly if at all affected. 
The sphincter of the bladder was much weakened. Severe 
metrorrhagia occurred some five or six times, and during 
the entire year there was a profuse leucorrhea which for 
a time contained considerable pus. Prior to the accident 
menstruation had always been painful and scanty, but now 
had become very much more so. Micturition also produced 
severe pain. The urine was never voided in normal quan- 
tity, but frequently contained a small amount of blood and 
sediment. At times violent pains shot along the spinal col- 
umn, especially in the lumbar and lower dorsal regions; 
while a continuous intense pain was felt in the occipital 
region of the head. This latter pain was almost constantly 
present, but on alternate days became so exceedingly 
unbearable that the patient was obliged to take to her bed 
and make free use of anodynes and narcotics. 
Three weeks before the patient was brought to me, a 
brilliant stroke of lightning flashed close beside the room 3 
wherein she was seated. She experienced a most peculiar 
sensation or "kind of rush" up the spine into the head. 
She fell, became unconscious for a time and continued to 
be delirious for several days after. For a long while she said 
she could feel a kind of repetition of the shock about every 
third or fourth day. Usually the sensation died out in ten 
or twelve hours. When I saw her she was still subject to 
intense constricting headaches. These seemed to strike 
from the back of the head forward to the temples, were 
always worse in wet weather, and as a rule lasted about 
twelve hours. Sometimes the face became puffed and pale, 
while the eyes would be directed inwards. Two weeks after 
the accident the patient first noticed for herself that her 
left leg was completely paralyzed and anaesthetic. No im- 
provement had occurred in this respect during the course 
of the year. So much for the history of the case. 
Upon examination I found the eyesight and hear- 
ing both good. The grasp of the hands was normal 
and the same in both.' In the right leg the patella 
reflex, ankle clonus, muscular movements and sensa- 
tion were all normal. In the left leg they were all 
completely abolished. The line of beginning anaes- 
thesia corresponded quite sharply with that of Pou- 
part's ligament in front, the crest of the left ilium 
and a line drawn transversely across the left half of 
the back on a level with the crest of the ilium or fourth 
lumbar spine. Above this line there was consider- 
able hyperesthesia. The limb was well developed, 
warm to the touch in its upper part, and exhibited 
the natural color of health. Both the cutaneous and 
muscular sense were entirely wanting. The deep in- 
sertion of a needle into the tissues, the strongest 
electric currents as well as simple contact with the 
skin, were absolutely unperceived. So thoroughly 
did I test for sensation that the possibility of simu- 
lation was completely eliminated. A similar ex- 
amination of the opposite leg and of the two 
arms revealed nothing abnormal in regard to mo- 
tion cr sensation. Severe pressure along the course 
of the left crural and sciatic nerves gave no indi- 
cation of pain. There was no atrophy, as actual 
measurement showed both limbs to be of the same size. 
With the use of faradaism, a mild primary current pro- 4 
duced slow but decided muscular contractions, while 
the secondary current gave rise to more marked mus- 
cular movements. The galvanic current produced the 
usual normal responses. I could detect no indication 
of the reaction of degeneration. The electrical exam- 
ination was not, however, as complete as I would like 
to have made it, as the patient was suffering from 
considerable pain in the spine and I did not care to 
distress her further. The distal circulation was slow, 
and as a result the leg and foot were cold and cyanotic. 
The whole spinal column was so exceedingly sensitive 
to the touch that its examination was not so satisfac- 
tory as could have been desired. In the region of the 
lower lumbar vertebrae it was unusually tender, so 
that the patient winced and screamed with the pain 
each time I gently pressed the lumbar spines. Be- 
tween the third and fourth lumbar vertebrae I could 
distinguish on the left side a small, hard nodule 
about the size of a pea which was especially painful. 
The distress and general nervous excitement of the 
patient prevented my determination at that time of 
the nature of this swelling. In the vicinity of the 
sacrum and coccyx the pain upon pressure was quite 
unbearable. 
As a result of this somewhat incomplete examina- 
tion, I diagnosticated the case as one of incipient 
meningo-myelitis, with the meningitis as the more 
pronounced feature and the maximum intensity of the 
disease focalized on the left side of the lumbar cord. 
I imagined that at the time of the accident there 
had been a hemorrhage within the spinal column, 
either in the lumbar region or elsewhere, and that 
some of the blood had gravitated and formed an irri- 
tative clot which in conjunction with the attending 
inflammatory process was compressing and constrict- 
ing certain nerve roots from the left side of the cord. 
With this conception of the case, I recommended a 
vigorous daily counter irritation of the entire spine, 
the administration of mercury (blue mass guarded 
by opium) to the point of ptyalism, the use of the 5 
mild faradaic current to the paralyzed muscles, 
and the employment of cod liver oil by local inunc- 
tion. The treatment was commenced Oct. 5, 1890. 
About a month later, Nov. 7, or nearly eleven months 
after the accident and onset of the paralysis, the pa- 
tient arose from her chair and walked with as much 
ease apparently as she would have done in perfect 
health. She stated that a few days prior to my last 
visit she suddenly felt a kind'of tingling and burn- 
ing sensation, as though the leg had been "asleep," 
and were recovering, and that this was immediately 
followed by a complete restoration of its movement 
and sensation. Hypersesthesia, I found, had replaced 
the anaesthesia and though it tired the patient 
quickly to use the limb its power of motion seemed 
to have been completely regained. The tingling sen- 
sation was noticed at the same time with a similar 
sensation up and down the entire length of the spi- 
nal cord. I found the tenderness of th'e vertebrae 
almost entirely gone so that the patient could stand 
quite vigorous blows upon the back, except in the 
lumbar region where it was still somewhat sensitive. 
From this time on she ate and slept better and the 
bleeding of the hemorrhoids ceased. On Nov. 4, Dr. 
Steim wrote me as follows: "Patient is steadily im- 
proving and is quite as strong as ever she was." On 
April 28, 1892, I received this note from the Doctor. 
"I am glad to inform you that Mrs. S. (she had be- 
come married by this time) has never had a single 
symptom of the old trouble since you saw her. In 
fact her health generally since then has been almost 
perfect." Again during the summer of last year the 
Doctor wrote me : "The recovery has been perfect and 
the patient has been as strong, if not indeed stronger 
than ever before in her life, with the exception of 
typhoid pneumonia over a year ago." 
The unilateral distribution of the anaesthesia and 
paralysis in this case indicates, of course, a unilat- 
eral lesion. The presence of the motor and sensory 
paralysis upon the same side would suggest a lesion 6 
outside of the cord proper. The absence of any 
girdle pain, of pronounced alteration of the sphincter 
functions, and of atrophy of the muscles establishes 
the non-involvement of the gray matter of the cord. 
The upper border of the anaesthetic area limits the 
upper border of the lesion to the level of the first 
lumbar segment. The tenderness of the spine, the 
fever and other constitutional symptoms resulted of 
course from the meningitis, which was probably a 
mere extension of the inflammatory process from the 
lumbar region upwards. The traumatic origin of 
the paralysis is extremely indicative of a focal hem- 
orrhage and the presence of an irritative clot would 
be an all-sufficient reason for the inflammation of the 
membranes. The hemorrhage was probably sub- 
arachnoid. The transitory symptoms which arose dur- 
ing the course of the year in conjunction with the 
upper regions of the cord may have been due to a 
number of smaller hemorrhages of which the blood 
may have gravitated and so produced a large irritative 
clot along the line of the lumbar segments and in the 
meshes of the cauda equina. The chief difficulty in 
this explanation, however, is the completeness of the 
anaesthesia from the very beginning of the paralysis; 
for such a sudden and complete anaesthesia usually 
follows a lesion in the substance of the cord itself or 
complete severance of the nerve roots. When nerve 
roots are compressed by hemorrhagic clots or menin- 
geal adhesions it is more customary for the anaes- 
thesia and paralysis to be preceded by pain, hyper- 
aesthesia, paraesthesia and spasm. Furthermore, with 
anaesthesia dependent upon destruction of the pos- 
terior nerve roots, there is generally very decided 
atrophy of the corresponding muscles, especially if 
the lesion involve the root ganglion or that part of 
the root external to the ganglion. 
It must be admitted that there are certain features 
about this case strongly suggestive of hysterical 
hemiparaplegia. They are for instance the sex and 
age of the patient, the location of the paralysis (hys- 7 
terical paralysis being most frequent in the left leg) 
the absence of any considerable atrophy, the appar- 
ent preservation of the rectal with but slight involve- 
ment of the genito-urinary functions, the association 
of the paralysis and anaesthesia in the same area and 
the peculiar distribution of the anaesthesia which 
corresponded so closely with Charcot's well-known 
limitations of anaesthesia in hysterical paraplegia. 
Against the hysterical hypothesis, however, 1 place 
the traumatic origin of the motor and sensory paraly- 
sis, the absence of all other hysterical symptoms dur- 
ing this or any previous period of the patient's life, 
the prolonged duration of the paralysis and anaes- 
thesia without the slightest modification, the absence 
of the hysterical temperament, the completeness of 
the anaesthesia and the perfect insensibility of the 
nerves to the strongest electric currents, the hyper- 
aesthetic zone just above the level of the anaesthetic 
area and the complete restoration without the slight- 
est subsequent reappearance of any of the old symp- 
toms. Furthermore, the upper limit of the anaesthe- 
sia posteriorly corresponded with a horizontal line 
drawn across the back on a level with the fourth 
lumbar vertebra, and not with the line of hysterical 
paraplegia which Charcot says, "follows the insertion 
of the muscle of the buttocks exclusive of a V-shaped 
area over the sacrum." 
In the American Journal of the Medical Sciences for 
July, 1892 Starr reports a case (No. 5) possessing 
many points of similarity with our own. Briefly 
stated, the patient was a woman, 28 years of age, who 
was well until May, 1889, when after a day of fatigue 
she was suddenly seized with severe pain in the sacral 
region and in the back of both thighs, with retention 
of urine and feces and with a sensation of numbness 
over the lower sacral region, perineum and vagina. 
The urine and feces were moved with much difficulty. 
The sphincter ani contracted on the finger. The 
knee-jerks were exaggerated. The plantar and gluteal 
reflexes were normal, and there was no tendency to 8 
bedsores, no tenderness of the back, no girdle sensa- 
tion nor anaesthesia of the legs. When examined 
again in Feb. 1890, there was beginning muscular 
weakness in the left leg and a diminished response 
to faradaism, without atrophy. There was still some 
pain in the back and in the left leg constantly but 
more especially in the left ilio-inguinal region. 
There was still no girdle sensation, spinal tenderness 
or bedsore. The area of total anaesthesia had in- 
creased. There was slight impairment of the tactile 
sensation on the outer side of the leg below the knee 
and on the back of the thigh from the anaesthetic 
area downwards. The case was not so far advanced 
as ours, but in the association of its symptoms closely 
resembled it. The diagnosis of Starr was that of a 
hemorrhage into the conus medullaris and lower sa- 
cral segments of the cord. He suggested that this 
hemorrhage had lighted up a chronic meningo-mye- 
litis and as this advanced slowly upwards, if had in- 
creased the symptoms. 
Starr and Lloyd's case (No. 11) in the same paper, 
was one of compression of the cauda equina produc- 
ing a localized paralysis and limited anaesthesia in 
the right leg. There was a fracture of the lumbar ver- 
tebrae, followed immediately by a paralysis and indefi- 
nite area of anesthesia in the right leg. A year later 
there was marked deformity at the third lumbar ver- 
tebra, paralysis with atrophy, reaction of degeneration 
of most of the muscles of the right leg, anesthesia 
down the back and outer side of the same limb. In 
view of the diagnosis of compression of the cauda 
equina at the third lumbar level, Dr. Lloyd ope- 
rated and removed the second and third lumbar 
spines and lamine with ultimate recovery of the 
patient. The point of significance in this case is the 
association of the anesthesia and paralysis, which is 
explained here by the limitation of the lesion to the 
cauda since the spinal cord proper terminates at 
the first lumbar vertebra. The absence of the 
sphincter symptoms would exclude involvement of 9 
the corresponding nerve centers, which Starr finds 
from two of his cases to be located in the "lower 
two segments of the cord," a fact which has been 
confirmed by autopsies in the cases of Kirchkoff, 
Westphal, Oppenheim and Herter, and in the cases 
of Rosenthal, Bernhardt, Eulenberg, Mills and 
Huber. It is always difficult, except in fracture 
cases, to differentiate lesions of the cauda from 
those of the cord; and Starr takes the position that 
it is "questionable whether, except in cases of frac- 
ture below the first lumbar vertebra with displace- 
ment of the vertebrae any sharp line of distinction 
between cord and cauda lesions should be 
attempted." It is to be hoped, however, that some 
day our knowledge may permit us to make such a 
differentiation. 
In connection with the case I have reported, the 
question arises as to the possibility of there being a 
unilateral paralysis and anaesthesia in the same 
limb, as a result of a single unilateral lesion of the 
cord. In other words, Is there such a thing as a 
true hemiparaplegia produced by a focal lesion in 
which the paralysis and anaesthesia are not crossed? 
The textbooks almost universally answer this ques- 
tion in the negative. Ranney1 says : "The muscles 
below the seat of the lesion are paralyzed on the 
side of the body corresponding to the exciting cause 
and the skin is sometimes rendered hyperaesthetic; 
while the integument of the side opposite the lesion 
is deprived of sensibility." In his "Lectures on the 
Nervous System," he furthermore most emphatically 
states that "should symptoms of anaesthesia appear 
upon the side where the motor paralysis is present, 
you may regard it as conclusive evidence that the 
exciting lesion is progressing and the opposite lat- 
eral half of the cord is being involved to a greater 
or less extent." Seguin'2 writes that "hemiparaplegia 
i Applied Anatomy of the Nervous System. Appleton & Co., N. Y. 
1888, page 638. 
2 Pepper's System of Medicine, Vol. v, page 44. 10 
is a rare variety in which one lower extremity is 
paralyzed while the other is anaesthetic." 
Mills3 says that "motor paralysis occurs in the 
leg of the same side and anaesthesia in the trunk and 
leg of the opposite side." So authority after author- 
ity might be quoted, all stating the same truth. 
They insist upon the crossed nature of the symp- 
toms. The sensory fibers, after passing through the 
posterior nerve roots, enter the gray matter of the 
posterior cornua and at once cross to the opposite 
side of the cord through the posterior commissure 
and then continue their course upward to the cere- 
bral cortex. In the upper part of the cord the fibers 
decussate almost immediately after they enter the 
posterior cornua but farther down the cord wre find 
them running for a short distance more or less ver- 
tically in the side of the cord and in company with 
the corresponding nerve roots before they pass to 
the opposite side. In other words, the decussations 
are relatively higher than the corresponding nerve 
roots the farther we proceed down the cord. In the 
words of Gowers,4 "The decussation of the sensory 
tract is not immediate but occurs somewhat above 
the entrance of the nerves." This, I believe, is of 
some importance in the diagnosis of our case; for 
as Gowers again remarks, "A lesion in one side of the 
lumbar enlargement often affects sensation on the 
same side as motion because it damages the sensory 
path before it has crossed." In our case I can not 
think the anaesthesia was due merely to compression 
of the nerve roots by the meningeal trouble, because 
it came on so early and suddenly and was not pre- 
ceded by the usual hyperaesthesia and initiative 
signs of local meningitis. In fact, the whole set of 
meningeal symptoms seems to have been of later 
development. Nor can I think that the posterior 
nerve roots supplying the anaesthetic area were them- 
3 Spinal Localization in its Practical Relations. Detroit. 1889. 
* Diseases of the Nervous System. P. Blakiston, Son & Co., Philadel- 
phia, 1888, page 166. 11 
selves torn or injured in such a way as to be alone 
responsible for the loss of sensibility, because the 
anaesthesia lasted too long to be so quickly recov- 
ered from. Torn nerve roots are not usually restored 
in a few weeks' time by mere external counter irrita- 
tion and the administration of mercury. I assume, 
therefore, that the sensory tracts must have been 
injured somewhere near the periphery of the cord, 
and that this must have been before the tracts which 
transmit tactile impressions were separated from 
those which carry the sensations of pain and tem- 
perature since all forms of sensibility were abolished 
from the anaesthetic area. 
According to the most recently constructed tables 
of segmental spinal localizations, the lesions could 
not have extended higher than the first lumbar seg- 
ment. The paralysis and anaesthesia stopped quite 
abruptly at Poupart's ligament anteriorly and the 
upper part of the buttock posteriorly. There were 
no girdle pains whatever, either of the body or of the 
limb to enable me to determine the level of the 
lesion more accurately. If the original trouble were 
a subarachnoid hemorrhage, as I fancy it must have 
been, the blood may have gravitated to the lower 
part of the spinal column and involved the fibers of 
the cauda without doing any special damage to that 
structure beyond compressing it. A clot may readily 
have formed on the left side of the cord opposite the 
lumbo-sacral region, there exerted a pressure suffi- 
ciently deleterious to prevent the transmission of 
the motor and sensory impulses in the correspond- 
ing tracts as they passed along near the circumfer- 
ence of the cord, and also to have lighted up a menin- 
gitis which gradually extended along the whole 
column and even implicated to a slight' degree the 
membranes covering the brain especially in the 
occipital region. Such an explanation is the most 
reasonable to my mind and harmonizes most satis- 
factorily some of the discordant symptoms of the 
case. If such be the correct explanation, the case 12 
indicates that we may have a hemiparaplegia, espe- 
cially from a lesion in the lower part of the cord, in 
which the anaesthesia and paralysis appear upon the 
same side of the body. Further investigations are 
needed, however, upon this point, though I feel sure 
that the textbooks are somewhat too dogmatic in 
asserting that in all cases hemiparaplegia is a par- 
alysis of one-half of the lower part of the body with 
anaesthesia of the opposite half. 
Columbus Memorial Building.