Motor involvement constitutes the most marked and important manifesta tion of average cases, and when present may range all the way from the slightest degree of weakness up to complete flac cidity. While any of the voluntary mus cles may stiffer, certain prevalent types can be made out. Monoplegias and more limited paralyses, running as such from the start, occur in some of the rare cases of hmmorrhage corticoid of the internal capsule. When this is in the occipital, frontal, or temporal lobes, there may be no definite paralysis unless the focus becomes so large that the transmitted pressure affects the motor neurons. But, as the great majority occur in the basal ganglia or pons, the hemiplegic type is by far the most common. Of this there are two distinct forms: the one of sim ple hemiplegia, where all the affected parts are on one side (arm, leg, and face, all or in part), and the other of crossed hemiplegia, where an arm-and-leg pa ralysis on one side is associated with some involvement of the cranial motor tracts on the other side. This latter form is typical of localization in the pons, be cause of the fact that the cranial tracts have already decussated, while the first form is that dne to the common site in the basal ganglia. In the very rare cases of bleeding in a cerebral erns, there may be a. special form of crossed paralysis: involvement of the arm and leg on the side opposite the lesion and oculomotor paralysis on the same side, due to the intimate relationship of this nerve with the crus..
There is some basis for the view that lesions of the thalamus may present a special characteristic. This consists of loss of emotional or pantomimic move ments, while the volitional motions are still preserved. This applies specially to the cranial distribution. If, on the con trary, the cranial paralysis is due to lesions more anterior at the same level or higher up there may be a preserva tion of the so-called mimic, with a loss of voluntary, movement. In practice, htemorrhages of this region are usually so massive that both grades of motion are equally lost.
It is possible that something of the kind also holds for the extremities, since we sometimes see cases of hemiplegia where, in sleep, the patient is able to lift a hand to the head. Here inay also be classed the so-called inethemipleg-ic movements; these are such as occur in a paralyzed part in association with vol untary movements in the corresponding well part.
In ordinary hemipIegia we find the arm and leg motionless or nearly so, a little motion possibly remaining in the fingers or toes. The arm lies helpless by the side or across the chest. The pa tient, if requested to move it, reaches over with the other hand. The leg stays in almost any position in which it is placed. In the complete form it is im possible for the patient to turn in bed or to rise at all from the recumbent position. In coma the paralysis 'nay be
presumed from the drawn face, expi ratory puffing of one cheek, and the heavier, passive drop of the affected arm when lifted and let go.
As a rule, the leg improves faster than the arm, perhaps, as claimed, because the arm-tract is apt to be more involved than the leg, or, perbaps, because the leg-movements (as in walking) are more automatic in character. It is consid cred an unfavorable omen when, on the 'contrary, the arm improves faster than the leg. The hypoglossal and facial tracts are more apt to escape direct im plication, and the upper facial quite reg ularly escapes (a point of distinction from like hysterical paralysis).
Sensory loss is also a common though less frequent and lasting accompaniment than motor. In many cases it is so transient that in a few days little trace of it remains. Its occurrence d.epends on interference with the sensory nen ons. Their most exposed point is at the carrefour sensitif (posterior border of the internal capsule), where the sensory tracts are inore closely grouped than elsewhere in their course. This point is also about opposite the commoner sites of hiemorrliage, though a little to one side, which harmonizes with the fact that permanent loss of sensation is the exception. The most-marked feat ures of this type are loss of common sensation in the opposite half of the body and homonymous hemianopsia (blind ness of opposite half of visual field of each eye). Hearing may also be inter fered with and sometimes taste and smell, the latter two only on the opposite side. In hminorrhages involving either the hearing-centre in the first temporal gyre, the visual centre in the cuneus, the other sensory centres, or the paths connecting these with parts below, there will be a correspondingly-limited loss of sensation. In pons lesions the special senses escape, unless occasionally those of hearing or equilibrium. At the same time the tracts for general sensation to the other side of the body may suffer. In cases where there is more lasting amestliesia it involves deep parts and mucous membranes as well as the sur face.
Pupillary changes have but little value here for purposes of localization. They do, however, serve one important and usually overlooked purpose: the presence of anisocoria (in equality of the pupils) is valuable ob jective evidence of the existence of some real lesion, and has a bearing on differ ential diagnosis. Of course, this pre supposes the existence of corroborative symptoms and the recent acquisition of the inequality. The possibility of latent anisocoria should be excluded by deter mining whether the condition persists on full illumination of the two eyes; if, on so testing, the pupils become equal, the inequality can be put down as prob ably an affair of long-standing or spinal i n origin.