The deep reflexes are always increased. Ankle elonus as well as the Babinsky reflex and Oppenheim's leg reflex are not infrequent. In older cases and in cases in which the herniplegic phenomena have been less pronounced, a unilateral increase of the deep reflexes is sometimes the only visible sign of cerebral infantile palsy. Diminution or absence of the reflexes is extremely rare and occurs only in exceptional cases that have never been explained. The skin reflexes in these conditions are often diminished.
It is not rare for individual cranial nerves to be involved in cerebral hemiplegia. The tongue may deviate toward the sound side (on account of paralysis of the muscles on the other side of the tongue), indicating involvement of the hypoglossus. Strabismus is quite frequent. Nystag mus, hemianopsia, a tendency to a forced position of the eyes and atrophy of the optic nerve are observed.
Sensory disturbances are rare and, when present, mostly confined to the hands. The disturbance of stereognosis which occasionally occurs is perhaps partly referable to the lack of digital dexterity which prevents the child from feeling objects properly.
Motor aphasia as ft sequel of a left-sided cortical lesion is conceiva ble and is in fact sometimes observed. It is to be remembered, however, that we are dealing with cerebral processes engaged in recovery, and accordingly there is a general interference with the function of speech rather than pronounced aphasia; much the same condition, in fact, as we observe in adults after lesions accompanied by aphasia. It is a note worthy fact that in ft child the power of speech may be restored even after complete destruction of the centre of speech in the left side, sug gesting the possibility of a vicarious function in the right cerebral hemi sphere. In addition to this kind of speech disturbance, due to a focal lesion, children with cerebral infantile palsy quite often exhibit other minor abnormalities of speech which depend in a great measure on feeble mindedness or idiocy and are sometimes the expression of bulbar disturbances such as will be discussed later.
Atrophy of individual groups of muscles does not occur in cerebral hemiplegia. On the other hand, interference with the growth of the paralyzed side is not infrequent, particularly when the palsies are ac quired in early childhood or are congenital. The face may he narrow,
producing the impression of a hemiatrophia faciel; both the arm and leg may be smaller in all their dimensions, the muscles as well as the bones taking part in the atrophy (this can be demonstrated with the X-rays). The electric irritability of the nerves and muscles in all such cases, however, is normal or increased, and in doubtful cases this symp tom can be utilized to distinguish positively between a cerebral and a spinal palsy.
Muscular hypertrophy occurs when the spasticity is very great and particularly in the case of posthemiplegic motor disturbances, which will be discussed separately. It is to be explained as a hypertrophy' due to overwork.
Among rare and unimportant symptoms should be mentioned diminution in the size of the breast, the testicle; anomalies in the growth of the hair, the formation of the fingers, eyes, etc., on one side of the body. Epilepsy and idiocy, which are common in cerebral infantile palsy, will be discussed later.
A peculiar phenomenon of infantile henaiplegia is seen in the post heiniplegic motor disturbances, which are of frequent occurrence. The mildest form is the tremor which occurs during active movements, particularly at the height of tbe intended movement (intention tremor); in its severest form the phenomenon consists in permanent tremor, chorea, athetosis. These motor disturbances make their appearance either soon after the beginning of the disease or later, following an existing spastic paralysis. The facial muscles sometimes take part in the involuntary' movements. In this variety of the disease the paralysis is not marked, but the patients are greatly disturbed by the movements of the arms and fingers which come on with every intentional act. In posthemiplegic chorea the movements are of a jerky, rotating and ex tending character, and persist practically without interruption except during sleep. In athetosis the characteristic movements consist in spreading, extending and flexing the fingers, and render the child fre quently incapable of holding an object in its hands, writing, or doing any kind of manual work. The feet may also take part in these motor disturbances.