In discussing the frequency of local compression effects, Wiesmann points out that some abnormal condition of the opposite extremities was only absent in 16 out of a total of 257 cases. In 37 cases reported by Jacobson,[28] hemiplegia, of a greater or lesser extent, was present in 19 (50 per cent.). The same authority explains that ‘with regard to the onset of convulsions, if there be restlessness, spasmodic twitchings, or movements of the limbs, it is only too probable that in addition to middle meningeal hæmorrhage, contusion or laceration of the brain-substance will be found at more places than one’. In cases that have come under my observation twitchings of the muscles of the face and upper extremities were observed in 37 per cent. of cases, and paralysis in the same number. Some alteration in the condition of the muscles on the contra-lateral side was present therefore in 74 per cent. of cases. If the hæmorrhage be situated on the left side of the brain, both motor and sensory cortical speech areas may be involved, especially the former. With respect to _reflexes_, it has previously been stated that the reflexes are abolished. This is true with respect to the later stages of fully-developed compression. In the earlier state the reflexes on the contra-lateral side may be increased, the difference between the two sides affording some help in the differential diagnosis. =Pupillary changes= are variable. According to Jonathan Hutchinson, the pupil on the affected side becomes dilated, the blood extending inwards towards the cavernous sinus and exercising direct compression of the third nerve. The frequency with which a dilated pupil occurs in cases of middle meningeal hæmorrhage, and the causation thereof, are, however, matters of dispute. Phelps writes as follows: ‘Reference to cases cited show that the so-called Hutchinson pupil may be observed as well in hæmorrhages occurring in other situations than the middle fossa, and in some cases of cerebral lesion without injury at all. There is no reason to doubt that it is the result of cerebral contusion, but in what relation they stand to specific cerebral injuries is undetermined.’ Walton states that ‘doubtless various factors play an important part in producing the dilated pupil, but if disorders of any simple mechanism are to be credited with the production of the Hutchinson pupil or other pupillary changes, the only lesion worthy of the place is disturbance, irritative or paralytic, of the intracranial fibres of the cilio-spinal tract’. The late Professor von Bergmann, from 70 cases, reports as follows:-- In 39 cases both pupils were markedly dilated (56 per cent.). In 7 cases both pupils were markedly contracted (10 per cent.). In 20 cases the pupil on the same side was dilated (30 per cent.). In 4 cases the pupil on the opposite side was dilated (6 per cent.). Parsons, in answering some queries in 1903, writes:--