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arm, and leg of the opposite side (see Fig 3-2) The lesion in such cases may in some patients be localized by the presence of a third nerve palsy (Weber syndrome) or other segmental abnormality on the same side as the lesion (opposite the hemiplegia) With low pontine lesions, an ipsilateral abducens or facial palsy is combined with a contralateral weakness or paralysis of the arm and leg (Millard-Gubler syndrome) Lesions in the medulla affect the tongue and sometimes the pharynx and larynx on one side and the arm and leg on the other These crossed paralyses, so characteristic of brainstem lesions, are described further in Chap 34 Even lower in the medulla, a unilateral infarct in the pyramid causes a accid paralysis followed by slight spasticity of the contralateral arm and leg, with sparing of the face and tongue Some motor function may be retained, as in the case described by Ropper and colleagues; interestingly, in this case and in others previously reported, there was considerable recovery of voluntary power even though the pyramid was almost completely destroyed Rarely, an ipsilateral hemiplegia may be caused by a lesion in the lateral column of the cervical spinal cord In this location, however, the pathologic process more often induces bilateral signs, with resulting quadriparesis or quadriplegia A homolateral paralysis that spares the face, if combined with a loss of vibratory and position sense on the same side and a contralateral loss of pain and temperature, signi es disease of one side of the spinal cord (BrownSequard syndrome, as discussed in Chap 44) As indicated above, muscle atrophy that follows upper motor neuron lesions never reaches the proportions seen in diseases of the lower motor neuron The atrophy in the former cases is due to disuse When the motor cortex and adjacent parts of the parietal lobe are damaged in infancy or childhood, normal development of the muscles as well as the skeletal system in the affected limbs is retarded The limbs and even the trunk are smaller on one side than on the other This does not happen if the paralysis occurs after puberty, by which time the greater part of skeletal growth has been attained In hemiplegia due to spinal cord lesions, muscles at the level of the lesion may atrophy as a result of damage to anterior horn cells or ventral roots In the causation of hemiplegia, ischemic and hemorrhagic vascular diseases of the cerebrum and brainstem exceed all others in frequency Trauma (brain contusion, epidural and subdural hemorrhage) ranks second Other important causes, less acute in onset, are, in order of frequency, brain tumor, brain abscess, demyelinative diseases, and the vascular complications of meningitis and encephalitis Most of these diseases can be recognized by their mode of evolution and characteristic clinical and laboratory ndings, which are presented in the chapters on neurologic diseases Alternating transitory hemiparesis may be due to a special type of migraine (see discussion in Chap 10) From time to time, hysteria is found to be the cause of a hemiplegia, as discussed further on.

Probably the best way to think of NET is as a big control system with two key elements First is the NET framework class library This library has thousands of classes organized into namespaces This large set of classes was designed to provide all the class support for virtually any application a developer would want to create This library is a repository of reusable types for object-oriented development For example, SystemWebUI Namespace allows you to create several different ASPNET server controls and user interfaces A namespace can be understood as an organizing concept for classes Each namespace contains a collection of classes, most of which you do not need for any single application

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The act of swallowing, like breathing, continues periodically through waking and sleep, largely without conscious will or awareness Swallowing occurs at a natural frequency of about once per

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minute while an individual is idle; it is suppressed during concentration and emotional excitement The fundamental role of swallowing is to move food from the mouth to the esophagus and thereby to begin the process of digestion, but it also serves to empty the oral cavity of saliva and prevent its entry into the respiratory tract Since the oropharynx is a shared conduit for breathing and swallowing, obligatory re exes exist to assure that breathing is held in abeyance during swallowing Because of this relationship and the frequency with which dysphagia and aspiration complicate neurologic disease, the neural mechanisms that underlie swallowing are of considerable importance to the neurologist and are described here The reader is also referred to other parts of this book for a discussion of derangements of swallowing consequent upon diseases of the lower cranial nerves (Chap 47), of muscle (Chap 48), and of the neuromuscular junction (Chap 53) Anatomic and Physiologic Considerations A highly coordinated sequence of muscle contractions is required to move a bolus of food smoothly and safely through the oropharynx This programmed activity may be elicited voluntarily or by re ex movements that are triggered by sensory impulses from the posterior pharynx Swallowing normally begins as the tongue, innervated by cranial nerve XII, sweeps food to the posterior oral cavity, and brings the bolus into contact with the posterior wall of the oropharynx As the food passes the pillars of the fauces, tactile sensation, carried through nerves IX and X, re exly triggers (1) the contraction of levator and tensor veli palatini muscles, which close the nasopharynx and prevent nasal regurgitation, followed by (2) the upward and forward movement of the arytenoid cartilages toward the epiglottis (observed as an upward displacement of the hyoid and thyroid cartilages), which closes the airway With these movements the epiglottis guides the food into the valleculae and into channels formed by the epiglottic folds and the pharyngeal walls The airway is closed by sequential contractions of the arytenoid-epiglottic folds, and below them, the false cords, and then the true vocal cords, which seal the trachea All of these muscular contractions are effected largely by cranial nerve X (vagus) The palatopharyngeal muscles pull the pharynx up over the bolus and the stylopharyngeal muscles draw the sides of the pharynx outward (nerve IX) At the same time, the upward movement of the larynx opens the cricopharyngeal sphincter A wave of peristalsis then begins in the pharynx, pushing the bolus through the sphincter into the esophagus These muscles relax as soon as the bolus reaches the esophagus The entire swallowing ensemble can be elicited by stimulation of the superior laryngeal nerve (this route is used in experimental studies) Re ex swallowing requires only medullary functioning and is known to occur in the vegetative and locked-in states as well as in normal and anencephalic neonates The integrated sequence of muscle activity for swallowing is organized in a region of brainstem that roughly comprises a swallowing center, located in the region of the NTS, close to the respiratory centers This juxtaposition ostensibly allows the re ned coordination of swallowing with the cycle of breathing Besides a programmed period of apnea, there is a slight forced exhalation after each swallow that further prevents aspiration The studies of Jean, Kessler and others (cited by Blessing), using microinjections of excitatory neurotransmitters, have localized the swallowing center in animals more precisely to a region adjacent to the termination of the superior laryngeal nerve.

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