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PAIN REVIEW
This page intentionally left blank

     
PAIN REVIEW SECOND EDITION

Steven D. Waldman, MD, JD

Associate Dean
Chair and Professor
Department of Medical Humanities and Bioethics
Clinical Professor of Anesthesiology
University of Missouri-Kansas City School of Medicine
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

PAIN REVIEW, SECOND EDITION ISBN: 978-0-323448895

Copyright © 2017 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or any information storage and retrieval system, without permission in writing from
the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our
arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be
found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as
may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using
any information, methods, compounds, or experiments described herein. In using such information or methods they
should be mindful of their own safety and the safety of others, including parties for whom they have a professional
responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current
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verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the
responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to
determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability
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any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2009

Library of Congress Cataloging-in-Publication Data

Names: Waldman, Steven D., author.
Title: Pain review / Steven D. Waldman.
Description: Second edition. | Philadelphia, PA : Elsevier, [2017] | Includes
bibliographical references and index.
Identifiers: LCCN 2016036815 (print) | LCCN 2016038118 (ebook) | ISBN
9780323448895 (pbk. : alk. paper) | ISBN 9780323481656 (Online)
Subjects: | MESH: Pain Management | Musculoskeletal Diseases | Nerve Block |
Nervous System Diseases | Peripheral Nervous System
Classification: LCC RB127 (print) | LCC RB127 (ebook) | NLM WL 704.6 | DDC
616/.0472--dc23
LC record available at https://lccn.loc.gov/2016036815

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 Dedication

Every long journey begins

with a first step.
—CONFUCIUS
To my children—David Mayo, Corey, Jennifer, and Reid—all of
whom are sick of hearing me invoke the above quote . . . but who
have nevertheless steadfastly followed its
timeless wisdom in their daily lives!
Preface
Hypnopedia: the art or process of learning while asleep by means of lessons
recorded on disk or tapes
As a child, I was always fascinated by the advertisements on the back of
the comic books that my brother Howard and I avidly read. Among the
many ads for a myriad of amazing items and services was one featuring a
picture of a white-bearded Russian scientist standing next to a sleeping
woman, touting that for just $19.95 you could purchase lessons that could
teach you to Learn While You Sleep. Given that the Russians had just
launched Sputnik and had supposedly detonated a hydrogen bomb, I was
completely convinced that this was something I could not live without.
I must admit that part of my desire to buy Learn While You Sleep was that
I hated school and was always looking for an easier way to complete my
lessons.
While I was never able to con my parents into spending the $19.95 for
the Learn While You Sleep lessons, they did buy me a pair of the x-ray vision
glasses for the then princely sum of $1.99. Needless to say, they didn’t work
nearly as well as I had hoped, and I began to wonder if the other things
advertised on the back pages of my comics were as bogus. I didn’t have to
wonder too long as the full-size replica of a Sherman tank that my brother
had ordered off the back of a Superman comic turned out to be little more
than a big orange cardboard box. So much for Learn While You Sleep!
At this point, the reader might ask, ‘‘What does an old comic book ad for
Learn While You Sleep have to do with a review text for pain management?’’
vi
Well, as my brother Howard, with whom I have practiced pain manage-
ment for the past 26 years, will tell you, I am still and always looking for an
easier way to do things. When I started studying for my American Board of
Anesthesiology recertification examination in pain management, there were
no texts written to specifically help one review pain management in an
­organized and time-efficient manner, and I approached my publishers with
the concept of creating such a review text. The result of our efforts is Pain
Review.
In writing Pain Review, it was my goal to create a text that not only
contained all of the material needed to review the specialty of pain manage-
ment but also to organize that material into small, concise, easy-to-read
chapters.
I believe that by breaking up the overwhelming amount of knowledge
related to pain management into smaller and more manageable packets of
information, the task of reviewing the entire specialty becomes much less
daunting. I have also made liberal use of illustrations, as in many chapters a
picture is the best way to convey a concept or technique.
Whether you are getting ready to take your certification or recertifica-
tion examination in pain management or simply want to learn more about
the specialty, I hope that Pain Review will serve your needs and help with
your studies.
Steven D. Waldman, MD, JD
 Contents

SECTION 1 ANATOMY 33. The Brachial Plexus 79

1. Overview of the Cranial Nerves 1 34. The Musculocutaneous Nerve 82
2. The Olfactory Nerve—Cranial Nerve I 2 35. The Ulnar Nerve 83
3. The Optic Nerve—Cranial Nerve II 4 36. The Median Nerve 84
4. The Oculomotor Nerve—Cranial Nerve III 9 37. The Radial Nerve 86
5. The Trochlear Nerve—Cranial Nerve IV 12 38. Functional Anatomy of the Shoulder Joint 88
6. The Trigeminal Nerve—Cranial Nerve V 15 39. The Acromioclavicular Joint 90
7. The Abducens Nerve—Cranial Nerve VI 17 40. The Subdeltoid Bursa 91
8. The Facial Nerve—Cranial Nerve VII 19 41. The Biceps Tendon 91
9. The Vestibulocochlear Nerve—Cranial Nerve VIII 23 42. Functional Anatomy of the Rotator Cuff 93
10. The Glossopharyngeal Nerve—Cranial Nerve IX 25 43. The Supraspinatus Muscle 94
11. The Vagus Nerve—Cranial Nerve X 27 44. The Infraspinatus Muscle 94
12. The Accessory Nerve—Cranial Nerve XI 30 45. The Subscapularis Muscle 96
13. The Hypoglossal Nerve—Cranial Nerve XII 32 46. The Teres Minor Muscle 96
14. The Sphenopalatine Ganglion 34 47. The Subcoracoid Bursa 98
15. The Greater and Lesser Occipital Nerves 34 48. Functional Anatomy of the Elbow Joint 98
16. The Temporomandibular Joint 36 49. The Olecranon Bursa 100
17. The Superficial Cervical Plexus 37 50. The Radial Nerve at the Elbow 101
18. The Deep Cervical Plexus 38 51. The Cubital Tunnel 102
19. The Stellate Ganglion 39 52. The Anterior Interosseous Nerve 104
20. The Cervical Vertebrae 40 53. The Lateral Antebrachial Cutaneous Nerve 105
21. Functional Anatomy of the Cervical 54. Functional Anatomy of the Wrist 105
Intervertebral Disk 51 55. The Carpal Tunnel 107
22. The Cervical Dermatomes 53 56. The Ulnar Tunnel 108
23. The Meninges 55 57. The Carpometacarpal Joints 109
24. The Cervical Epidural Space 56 58. The Carpometacarpal Joints of the Fingers 110
25. The Cervical Facet Joints 59 59. The Metacarpophalangeal Joints 111
26. The Third Occipital Nerve 60 60. The Interphalangeal Joints 112
27. The Ligaments of the Cervical Spine 62 61. The Intercostal Nerves 113
28. Functional Anatomy of the Thoracic Vertebrae 64 62. The Thoracic Sympathetic Chain and Ganglia 114
29. The Thoracic Dermatomes 70 63. The Splanchnic Nerves 116
30. Functional Anatomy of the Lumbar Spine 71 64. The Celiac Plexus 117
31. Functional Anatomy of the Lumbar 65. The Lumbar Sympathetic Nerves and Ganglia 118
Intervertebral Disk 73
66. The Lumbar Plexus 119
32. Functional Anatomy of the Sacrum 75

vii
viii Contents

67. The Sciatic Nerve 121 109. The Relationship Between the Sympathetic and
­Parasympathetic Nervous Systems 180
68. The Femoral Nerve 122
110. Functional Anatomy of the Nociceptors 181
69. The Lateral Femoral Cutaneous Nerve 123
111. Functional Anatomy of the Thermoreceptors 182
70. The Ilioinguinal Nerve 124
112. Functional Anatomy of the Mechanoreceptors 183
71. The Iliohypogastric Nerve 126
113. Functional Anatomy of the Chemoreceptors 186
72. The Genitofemoral Nerve 127
114. Functional Anatomy of the Dorsal Root Ganglia
73. The Obturator Nerve 128 and Dorsal Horn 187
74. The Hypogastric Plexus and Nerves 129 115. The Gate Control Theory 188
75. The Ganglion of Impar 130 116. The Cerebrum 188
76. The Tibial Nerve 131 117. The Thalamus 191
77. The Common Peroneal Nerve 133 118. The Hypothalamus 193
78. Functional Anatomy of the Hip 134 119. The Mesencephalon 194
79. The Ischial Bursa 138 120. The Pons 195
80. The Gluteal Bursa 138 121. The Cerebellum 196
81. The Trochanteric Bursa 139 122. The Medulla Oblongata 197
82. Functional Anatomy of the Sacroiliac Joint 140
83. Functional Anatomy of the Knee 142 SECTION 3 PAINFUL CONDITIONS
84. The Suprapatellar Bursa 145 123. Tension-Type Headache 199
85. The Prepatellar Bursa 145 124. Migraine Headache 200
86. The Superficial Infrapatellar Bursa 146 125. Cluster Headache 203
87. The Deep Infrapatellar Bursa 147 126. Pseudotumor Cerebri 204
88. The Pes Anserine Bursa 147 127. Analgesic Rebound Headache 205
89. The Iliotibial Band Bursa 148 128. Trigeminal Neuralgia 207
90. Functional Anatomy of the Ankle and Foot 149 129. Temporal Arteritis 209
91. The Deltoid Ligament 150 130. Ocular Pain 211
92. The Anterior Talofibular Ligament 151 131. Otalgia 213
93. The Anterior Tarsal Tunnel 152 132. Pain Involving the Nose, Sinuses, and Throat 215
94. The Posterior Tarsal Tunnel 152 133. Temporomandibular Joint Dysfunction 217
95. The Achilles Tendon 153 134. Atypical Facial Pain 218
96. The Achilles Bursa 155 135. Occipital Neuralgia 219
136. Cervical Radiculopathy 220
SECTION 2 NEUROANATOMY 137. Cervical Strain 222
97. The Spinal Cord—Gross Anatomy 157 138. Cervicothoracic Interspinous Bursitis 223
98. The Spinal Cord—Cross-Sectional Anatomy 159 139. Fibromyalgia of the Cervical Musculature 224
99. Organization of the Spinal Cord 159 140. Cervical Facet Syndrome 226
100. The Spinal Nerves—Organizational and 141. Intercostal Neuralgia 227
Anatomic Considerations 161
142. Thoracic Radiculopathy 228
101. The Spinal Reflex Arc 165
143. Costosternal Syndrome 230
102. The Posterior Column Pathway 166
144. Manubriosternal Joint Syndrome 231
103. The Spinothalamic Pathway 168
145. Thoracic Vertebral Compression Fracture 232
104. The Spinocerebellar Pathway 168
146. Lumbar Radiculopathy 233
105. The Pyramidal System 170
147. Sacroiliac Joint Pain 235
106. The Extrapyramidal System 171
148. Coccydynia 236
107. The Sympathetic Division of the Autonomic
Nervous System 173 149. Reflex Sympathetic Dystrophy of the Face 238
108. The Parasympathetic Division of the Autonomic 150. Post-Dural Puncture Headache 239
­Nervous System 178 151. Glossopharyngeal Neuralgia 241
 Contents ix

152. Spasmodic Torticollis 243 198. Metatarsalgia 313

153. Brachial Plexopathy 244 199. Plantar Fasciitis 314
154. Thoracic Outlet Syndrome 246 200. Complex Regional Pain Syndrome 315
155. Pancoast’s Tumor Syndrome 248 201. Rheumatoid Arthritis 317
156. Tennis Elbow 250 202. Systemic Lupus Erythematosus 320
157. Golfer’s Elbow 251 203. Scleroderma–Systemic Sclerosis 322
158. Radial Tunnel Syndrome 252 204. Polymyositis 324
159. Ulnar Nerve Entrapment at the Elbow 254 205. Polymyalgia Rheumatica 325
160. Anterior Interosseous Syndrome 256 206. Central Pain States 327
161. Olecranon Bursitis 257 207. Conversion Disorder 328
162. Carpal Tunnel Syndrome 259 208. Munchausen Syndrome 329
163. Cheiralgia Paresthetica 260 209. Thermal Injuries 330
164. de Quervain’s Tenosynovitis 261 210. Electrical Injuries 331
165. Dupuytren’s Contracture 263 211. Cancer Pain 333
166. Diabetic Truncal Neuropathy 264 212. Multiple Sclerosis 335
167. Tietze’s Syndrome 266 213. Post-Polio Syndrome 338
168. Post-Thoracotomy Pain Syndrome 267 214. Guillain-Barré Syndrome 339
169. Postmastectomy Pain 269 215. Sickle Cell Disease 341
170. Acute Herpes Zoster of the Thoracic Dermatomes 271 216. Dependence, Tolerance, and Addiction 343
171. Postherpetic Neuralgia 273 217. Placebo and Nocebo 344
172. Epidural Abscess 274
SECTION 4 DIAGNOSTIC TESTING
173. Spondylolisthesis 275
218. Radiography 347
174. Ankylosing Spondylitis 277
219. Nuclear Scintigraphy 348
175. Acute Pancreatitis 278
220. Computed Tomography 350
176. Chronic Pancreatitis 279
221. Magnetic Resonance Imaging 351
177. Ilioinguinal Neuralgia 281
222. Diskography 352
178. Iliohypogastric Neuralgia 283
223. Electromyography and Nerve Conduction Studies 353
179. Genitofemoral Neuralgia 285
224. Evoked Potential Testing 355
180. Meralgia Paresthetica 286
225. Pain Assessment Tools for Adults 358
181. Spinal Stenosis 287
226. Pain Assessment Tools for Children and the Elderly 362
182. Arachnoiditis 289
183. Orchialgia 290
SECTION 5 NERVE BLOCKS, THERAPEUTIC
184. Vulvodynia 293 ­INJECTIONS, AND ADVANCED INTERVENTIONAL
185. Proctalgia Fugax 294 PAIN MANAGEMENT TECHNIQUES
186. Osteitis Pubis 296 227. Atlanto-occipital Block Technique 367
187. Piriformis Syndrome 297 228. Atlantoaxial Block 369
188. Arthritis Pain of the Hip 299 229. Sphenopalatine Ganglion Block 370
189. Femoral Neuropathy 300 230. Greater and Lesser Occipital Nerve Block 373
190. Phantom Limb Pain 301 231. Gasserian Ganglion Block 374
191. Trochanteric Bursitis 303 232. Trigeminal Nerve Block—Coronoid Approach 376
192. Arthritis Pain of the Knee 304 233. Supraorbital Nerve Block 377
193. Baker’s Cyst of the Knee 305 234. Supratrochlear Nerve Block 379
194. Bursitis Syndromes of the Knee 306 235. Infraorbital Nerve Block 380
195. Anterior Tarsal Tunnel Syndrome 309 236. Mental Nerve Block 382
196. Posterior Tarsal Tunnel Syndrome 311 237. Temporomandibular Joint Injection 384
197. Achilles Tendinitis 312 238. Glossopharyngeal Nerve Block 385
x Contents

239. Vagus Nerve Block 387 278. Thoracic Paravertebral Block 448
240. Spinal Accessory Nerve Block 388 279. Thoracic Facet Block 449
241. Phrenic Nerve Block 389 280. Thoracic Sympathetic Block 453
242. Facial Nerve Block 391 281. Intercostal Nerve Block 454
243. Superficial Cervical Plexus Block 392 282. Radiofrequency Lesioning—Intercostal Nerves 455
244. Deep Cervical Plexus Block 393 283. Interpleural Nerve Block 456
245. Recurrent Laryngeal Nerve Block 395 284. Sternoclavicular Joint Injection 459
246. Stellate Ganglion Block 396 285. Suprascapular Nerve Block 460
247. Radiofrequency Lesioning of the Stellate 286. Costosternal Joint Injection 462
Ganglion400 287. Anterior Cutaneous Nerve Block 463
248. Cervical Facet Block 401 288. Injection Technique for Lumbar Myofascial Pain
249. Radiofrequency Lesioning of the Cervical ­Syndrome 464
Medial Branch 404 289. Splanchnic Nerve Block 465
250. Cervical Epidural Nerve Block—Translaminar 290. Celiac Plexus Block 467
­Approach 406
291. Ilioinguinal Nerve Block 474
251. Cervical Selective Nerve Root Block 410
252. Brachial Plexus Block 411 292. Iliohypogastric Nerve Block 475
293. Genitofemoral Nerve Block 476
253. Suprascapular Nerve Block 416
294. Lumbar Sympathetic Ganglion Block 477
254. Radial Nerve Block at the Elbow 417
295. Radiofrequency Lesioning—Lumbar
255. Median Nerve Block at the Elbow 418 Sympathetic Ganglion 479
256. Ulnar Nerve Block at the Elbow 419 296. Lumbar Paravertebral Block 480
257. Radial Nerve Block at the Wrist 420 297. Lumbar Facet Block 482
258. Median Nerve Block at the Wrist 421 298. Lumbar Epidural Block 486
259. Ulnar Nerve Block at the Wrist 422 299. Lumbar Subarachnoid Block 489
260. Metacarpal and Digital Nerve Block 423 300. Caudal Epidural Nerve Block 491
261. Intravenous Regional Anesthesia 425 301. Lysis of Epidural Adhesions: Racz Technique 494
262. Injection Technique for Intra-articular Injection 302. Sacral Nerve Block 497
of the Shoulder 427
303. Hypogastric Plexus Block 499
263. Injection Technique for Subdeltoid Bursitis Pain 428
304. Ganglion of Walther (Impar) Block 502
264. Injection Technique for Intra-articular Injection
of the Elbow 429 305. Pudendal Nerve Block 504
265. Injection Technique for Tennis Elbow 431 306. Sacroiliac Joint Injection 507
266. Injection Technique for Golfer’s Elbow 432 307. Intra-articular Injection of the
Hip Joint 509
267. Injection Technique for Olecranon Bursitis Pain 433
308. Injection Technique for Ischial Bursitis 510
268. Injection Technique for Cubital Bursitis Pain 434
309. Injection Technique for Gluteal Bursitis 512
269. Technique for Intra-articular Injection of the
Wrist Joint 436 310. Injection Technique for Psoas Bursitis 513
270. Technique for Intra-articular Injection of the 311. Injection Technique for Iliopectineal Bursitis 514
Inferior Radioulnar Joint 437 312. Injection Technique for Trochanteric Bursitis 515
271. Injection Technique for Carpal Tunnel Syndrome 438 313. Injection Technique for Meralgia Paresthetica 517
272. Injection Technique for Ulnar Tunnel Syndrome 439 314. Injection Technique for Piriformis Syndrome 518
273. Technique for Intra-articular Injection of the 315. Lumbar Plexus Block 520
­Carpometacarpal Joint of the Thumb 440
316. Femoral Nerve Block 526
274. Intra-articular Injection of the Carpometacarpal
Joint of the Fingers 441 317. Obturator Nerve Block 528
275. Intra-articular Injection of the 318. Sciatic Nerve Block 531
Metacarpophalangeal Joints 442 319. Tibial Nerve Block at the Knee 534
276. Intra-articular Injection of the 320. Tibial Nerve Block at the Ankle 536
Interphalangeal Joints 443
321. Saphenous Nerve Block at the Knee 537
277. Thoracic Epidural Block 444
 Contents xi

322. Common Peroneal Nerve Block at the Knee 539 SECTION 7 PHARMACOLOGY
323. Deep Peroneal Nerve Block at the Ankle 541 344. Local Anesthetics 577
324. Superficial Peroneal Nerve Block at the Ankle 542 345. Chemical Neurolytic Agents 579
325. Sural Nerve Block at the Ankle 543 346. Nonsteroidal Anti-inflammatory Drugs and the
326. Metatarsal and Digital Nerve Block at the Ankle 545 COX-2 Inhibitors 580
327. Intra-articular Injection of the Knee 546 347. Opioid Analgesics 584
328. Injection Technique for Suprapatellar Bursitis 547 348. Antidepressants 588
329. Prepatellar Bursitis 549 349. Anticonvulsants 592
330. Injection Technique for Superficial Infrapatellar 350. Skeletal Muscle Relaxants 595
­Bursitis 550
331. Injection Technique for Deep Infrapatellar SECTION 8 SPECIAL PATIENT POPULATIONS
Bursitis551 351. The Parturient and Nursing Mother 599
332. Intra-articular Injection of the Ankle Joint 553 352. The Pediatric Patient with Headaches 600
333. Intra-articular Injection of the Toe Joints 554 353. The Pediatric Patient with Pain 604
334. Lumbar Subarachnoid Neurolytic Block 555 354. Pain in the Older Adult 606
335. Lumbar Diskography 558
336. Vertebroplasty 561 SECTION 9 ETHICAL AND LEGAL ISSUES IN
PAIN ­MANAGEMENT
337. Spinal Cord Stimulation 562
355. Informed Consent and Consent to Treatment 609
338. Totally Implantable Infusion Pumps 565
356. Patient Confidentiality 610
SECTION 6 PHYSICAL AND BEHAVIORAL 357. Prescribing Controlled Substances 612
­MODALITIES 358. Prevention of Drug Diversion, Abuse, and
339. The Physiologic Effects of Therapeutic Heat 567 Dependence613
340. Therapeutic Cold 570 Review Questions and Answers 615
341. Transcutaneous Electrical Nerve Stimulation 571 Index000
342. Acupuncture 573
343. Biofeedback 574
This page intentionally left blank

     
 SECTION 1 Anatomy
1 CHAPTER

Overview of the Cranial Nerves

Abnormal cranial nerve examination should alert the clinician to the pos-
sibility of not only central nervous system disease but also significant sys- Table 1-1 The Cranial Nerves
temic illness. For this reason, a careful examination of the cranial nerves •  st—Olfactory
1
should be carried out in all patients suffering from unexplained pain. Ab- • 2nd—Optic
normalities of the cranial nerves may affect one or more of the cranial • 3rd—Oculomotor
nerves, and identification of these abnormalities may aid in the localization • 4th—Trochlear
of a central nervous system lesion or may suggest a more diffuse process • 5th—Trigeminal
such as meningitis, pseudotumor cerebri, or the presence of systemic disease • 6th—Abducens
• 7th—Facial
such as diabetes, sarcoidosis, botulism, myasthenia gravis, Guillain-Barré,
• 8th—Acoustic/auditory/vestibulocochlear
vasculitis, and others. Common causes of specific cranial nerve abnormali-
• 9th—Glossopharyngeal
ties are listed in respective chapters that discuss each of the 12 cranial • 10th—Vagus
nerves. The 12 cranial nerves are listed here in Table 1-1. The classic acros- • 11th—Spinal accessory
tic, On Old Olympia’s Towering Top A Finn And German Vault And Hop, • 12th—Hypoglossal
has been augmented by the use of a novel clockface-based paradigm to help
learners memorize the names and functions of the cranial nerves (Fig. 1-1).
This clockface paradigm will be presented in each chapter describing the
individual cranial nerves. H
To best understand cranial nerve abnormalities, it is useful to think A O
about them in the context of their anatomy. Although the anatomy of the
specific cranial nerves will be discussed in the individual chapters covering
each cranial nerve, the following schema may be applied to all of the 12 V O
cranial nerves. The efferent fibers of the cranial nerves arise deep within the
brain in localized anatomic areas called the nuclei of origin. These nerves exit
the brain and brainstem at points known as the superficial origins (Fig. 1-2).
The afferent fibers of the cranial nerves arise outside the brain and may take G O
the form of either specialized fibers that are grouped together in a sense
organ (e.g., the eye or nose) or grouped together within the trunk of the
nerve to form ganglia. The fibers enter the brain to coalesce to form the
V T
nuclei of termination. Lesions that affect the peripheral portion or trunks of
the cranial nerves are called infranuclear lesions. Lesions that affect the nuclei
of the cranial nerves are called nuclear lesions. Lesions that affect the central F T
connections of the cranial nerves are called supranuclear lesions. When
A
evaluating a patient presenting with a cranial nerve abnormality, it is also
helpful for the clinician to remember that the first two cranial nerves, the Fig. 1-1 The clockface paradigm for the twelve cranial nerves. (Modified from
olfactory and the optic, are intimately associated with the quite specialized Weiss, KL, Eldevik, OP Bieliauskas, L, et al: Cranial nerve clock: Part I. A declarative
anatomic structures of the nose and eye and are subject to myriad diseases memory paradigm. Acad Radiol 2001; 8[12]: 1215–1222.)
that may present as a cranial nerve lesion. The remaining 10 cranial nerves
are much more analogous in structure and function to the spinal nerves and
thus more subject to entrapment and/or compression from extrinsic pro-
cesses such as a tumor, an aneurysm, or an aberrant blood vessel rather than
primary disease processes.

1
2 Section 1 Anatomy

Olfactory nerve

Optic chiasm

Oculomotor nerve
Trochlear nerve
Intermediary nerve
of Wrisberg Trigeminal nerve
(nervus intermedius) Abducent nerve

Glossopharyngeal Facial nerve

nerve
Vagus nerve Vestibulocochlear
Accessory nerve nerve

Hypoglossal nerve

Spinal nerve

Fig. 1-2 The superficial origin of the cranial nerves. (From Barral JP, Croibier A: Anatomical organization of cranial nerves.
In: Barral JP, Croibier A (eds): Manual Therapy for the Cranial Nerves, Edinburgh, Churchill Livingstone, 2009, pp. 15-18.)

Suggested Readings
Fisch A: Clinical examination of the cranial nerves. In Tubbs RS, Rizk E, Shoja MM, et al
(eds): Nerves and Nerve Injuries, San Diego, Academic Press, 2015, pp 195–225.
Weiss K, Eldevik OP, Bieliauskas L, et al: Cranial nerve clock: Part I. A declarative
memory paradigm, Academic Radiology 8:1215–1222, 2001.

2 CHAPTER

The Olfactory Nerve—Cranial Nerve I

The first cranial nerve is known as the olfactory nerve and is denoted by the
Roman numeral I. It is composed of special afferent nerve fibers that are
responsible for our sense of smell (Fig. 2-1). The olfactory nerve and associ-
ated structures include the chemoreceptors known as the olfactory receptor
cells, which are located in the epithelium covering the roof, septum, and
superior conchae of the nasal cavity (Fig. 2-2). Inhaled substances dissolve
in the moist atmosphere of the nasal cavity and stimulate its chemorecep-
tors. If a firing threshold is reached, these chemoreceptors initiate action
potentials that fire in proportion to the intensity of the stimulus. These
stimuli are transmitted via fibers of the olfactory nerve that traverse the
cribriform plate to impinge on the olfactory bulb, which contains the cell
bodies of the secondary sensory neurons that make up the olfactory tract.
The olfactory tract projects into the cerebral cortex to areas known as
the lateral, intermediate, and medial olfactory areas. The lateral olfactory area
is most important to humans’ sense of smell, with the intermediate area less
so. The medial olfactory area, via its interconnections with the limbic sys-
tem, serves to help mediate humans’ emotional response to smell. Collec-
tively, the olfactory receptor cells, epithelium, and bulb tracts and areas are
known as the rhinencephalon (Fig. 2-3).
All three olfactory areas interact with a number of autonomic centers via
a network of interconnected fibers. The medial forebrain bundle carries in-
formation from all three olfactory areas to the hypothalamus, while the stria
terminalis carries olfactory information from the amygdala to the preoptic
region of the cerebral cortex. The stria medullaris carries olfactory informa-
tion to the habenular nucleus, which along with the hypothalamus inter-
faces with a number of cranial nerves to mediate humans’ visceral responses
associated with smell. Examples of such visceral responses include the dor-
sal motor nuclei of the vagus nerve (10th cranial nerve), which can ­modulate
 Chapter 2 The Olfactory Nerve—Cranial Nerve I 3

nausea and vomiting and changes in gastrointestinal motility, as well as the

H superior and inferior salivatory nuclei, which modulate salivation.
A I. Olfactory
V O
G O
V T
I
Abnormalities of the olfactory nerve may result in a condition known as
anosmia, or the inability to smell. A simple approach to the testing of smell
is outlined in Table 2-1. Anosmia can be permanent or temporary like that
occurring with bad allergies or colds. It may be congenital or acquired; the
most common causes of anosmia are listed in Table 2-2. Although anosmia
might seem at first glance to be of little consequence, the lack of smell is
associated with significant morbidity and mortality because of impairment
of the extremely important warning function that olfaction plays in activi-
ties of daily living. The ingestion of spoiled foods, the inability to smell toxic
gases such as the mercaptan in natural gas, or the inability to smell the
smoke of a house fire are just a few examples of how the inability to smell
can harm.

F T
A

I. Olfactory nerve
• Sensory
• Smell

Fig. 2-1 Olfactory nerve I.

Bowman's
Schwann cell gland
Connective
tissue

Basal cell

Olfactory
receptor cell

Sustentacular
cell
Dendrite

Olfactory vesicle

Olfactory cilia Microvilli

Duct of Bowman's gland
Fig. 2-2 The anatomy of the olfactory epithelium. (From Gartner LP, Hiatt, JL: Color Textbook of Histology. Phila-
delphia, Saunders, 2007.)
4 Section 1 Anatomy

Nerve fibers within the olfactory bulb

Olfactory
bulb Olfactory
Olfactory tract
stem cell
Cribriform plate

Olfactory Columnar
ensheathing epithelial cell
glia

Olfactory
Olfactory receptor cell
epithelium
Cilia
Respiratory Olfactory
Mucous layer mucosa mucosa

Fig. 2-3 The olfactory bulb, tract, and areas. (Reprinted with permission from Thuret S, Moon LDF, Gage FH:
Therapeutic interventions after spinal cord injury. Nat Rev Neurosci 2006; 7:628-643.)

Table 2-1 How to Test Function of the Olfactory Nerve Table 2-2 Causes of Anosmia
1.  scertain that the nasal passages are open.
A •  ongenital
C
2. Have the patient close his or her eyes. • Upper respiratory tract infections
3. Occlude one nostril. • Nasal sprays containing zinc
4. Place a vial of nonirritating test substance (e.g., fresh ground coffee or • Facial and nasal trauma
oil of lemon) near the open nostril • Prolonged exposure to tobacco smoke
Note: Avoid irritating substances such as oil of peppermint that may • Enlarged adenoids
stimulate the peripheral endings of the trigeminal nerve of the nasal • Nasal polyps
mucosa. • Paranasal sinusitis
5. Have the patient inhale forcibly. • Head trauma damaging the cribriform plate or olfactory areas of the
6. Ascertain whether the patient can perceive an odor. cerebral cortex
Note: The ability to identify what the odor is requires higher cerebral • Cerebrovascular accident
function, and it is the perception of odor or lack thereof rather • Tumors involving the
than its identification that is important. Paranasal sinuses
7. Repeat the above process with the ipsilateral nostril. Pituitary gland
Cranial vault, including gliomas, meningiomas, and neuroblastomas

Suggested Readings
Fisch A: Clinical examination of the cranial nerves. In: Tubbs RS (ed): Nerves and
Nerve Injuries, Elsevier Science, London, Volume 2, 2015, pp 195–225.
Shipley MT, Puche AC: Olfactory nerve (cranial nerve I). In: Daroff RB, Aminoff MJ
(eds): Encyclopedia of the Neurological Sciences, San Diego, Academic Press,
2014, pp 638–642.

3 CHAPTER

The Optic Nerve—Cranial Nerve II

Functional Anatomy of the Optic Nerve
The second cranial nerve is known as the optic nerve and is denoted by the
Roman numeral II. Its special afferent sensory fibers carry visual informa-
tion from the retina to the cerebral cortex for processing and interpretation
(Fig. 3-1). In order to best understand abnormalities of vision, it is helpful
for the clinician to think about these abnormalities in the context of the
functional anatomy of the optic nerve. Light enters the eye in the form of
photons, which pass through the cornea, aqueous humor, pupil, lens, and
vitreous humor to reach the retina (Fig. 3-1). Special photoreceptor cells
known as the rods and cones, which are located in the deep layers of the
retina, begin the conversion of the photons into electrical signals. As these
photoreceptor cells are stimulated, they become hyperpolarized and pro-
duce either depolarization (stimulation) or hyperpolarization (inhibition)
of the bipolar cells, which are the primary sensory neurons of the visual
pathway.
 Chapter 3 The Optic Nerve—Cranial Nerve II 5

The bipolar cells synapse with and either stimulate or inhibit the gan-
glion cells that are the secondary sensory neurons of the visual pathway. The
axons of the ganglion cells converge at the optic disk near the center of the
retina. These axons then exit the posterior aspect of the eye as the optic
nerve (cranial nerve II) (Fig. 3-2). Exiting the orbit via the optic canal, the
optic nerve enters the middle cranial fossa to join the ipsilateral optic nerve
to form the optic chiasm. Fibers from each optic nerve cross the midline to
exit the chiasm together as the opposite optic tract (Fig. 3-3).
The optic tracts containing fibers from both optic nerves travel posteri-
orly, passing around the cerebral peduncles of the midbrain. Most of the
fibers of the optic tracts synapse with the tertiary sensory neurons of the
lateral geniculate nucleus within their contralateral thalamus (see Fig. 3-3).
A few optic tract fibers travel to the pretectal region of the midbrain and
provide necessary information for the pupillary light reflex. Via the optic
radiations, the tertiary sensory neurons of the lateral geniculate nuclei
project to the primary visual cortex, which is located in the occipital lobe
(Fig. 3-4).

H
The Visual Field Pathways
A O The entire area that is seen by the eye when it is focused on a central point
is called the visual field of that eye. It must be remembered that the photons
entering the cornea converge and pass through the narrow pupil, with the
V II. Optic entire visual field being projected on the retina in a reversed and upside
down orientation (see Fig. 3-3). This means that the upper half of the retina
is stimulated with photons from the lower half of the visual field and the
II lower half of the retina is stimulated with photons from the upper half of
G O the visual field. Furthermore, the right half of the retina receives stimuli
from the left visual field, and the left half of the retina receives stimuli from
the right half of the visual field.
V T Given the consistent way that the ganglion cells from the retina group
together to form the optic nerve and carry information to the primary visual
cortex, the clinician may find it useful to divide the visual field of each eye
F T into four quadrants: (1) the nasal hemiretina, which lies medial to the fovea;
A (2) the temporal hemiretina, which lies lateral to the fovea; (3) the superior
hemiretina, which lies superior to the fovea; and (4) the inferior hemiretina,
which lies inferior to the fovea (see Fig. 3-3). The axons of the ganglion cells
II. Optic nerve of the nasal hemiretina decussate at the optic chiasm and travel on to
• Sensory
­project onto the contralateral lateral geniculate nucleus and midbrain. The
• Vision
axons of the ganglion cells of the temporal hemiretina remain ipsilateral
Fig. 3-1 The second cranial nerve is known as the optic nerve and is denoted through their course and project onto the ipsilateral lateral geniculate nu-
by the Roman numeral II. cleus and midbrain (see Fig. 3-4). The axons of the ganglion cells of the

Conjunctiva Lateral rectus

Ora serrata Sclera

Schlemm's
Choroid
canal

Anterior
chamber Retina

Lens Fovea centralis

Cornea Central retinal

artery
Posterior
chamber Central retinal
vein
Iris
Optic nerve

Ciliary body
Medial rectus

Fig. 3-2 The path of light though the eye. (From Aaron M, Solley WA, Broocker G: Chapter 1 - General Eye Ex-
amination. In: Palay DA, Krachmer JH [eds]: Primary Care Ophthalmology, ed 2. Philadelphia, Mosby, 2005, pp 1-23.)
6 Section 1 Anatomy

Fig. 3-3 The visual pathway. (From Remington LA: Chapter 13 - Visual Pathway. In: Remington LA (ed): Clinical
Anatomy and Physiology of the Visual System, ed 3. St. Louis, Butterworth-Heinemann, 2012, pp 233-252.)

Retina Optic nerve superior hemiretina carrying images from the inferior visual field project via
the parietal lobe portion of the optic radiations to the portion of the pri-
Lateral mary visual cortex located above the calcarine fissure (see Figs. 3-4 and 3-5).
geniculate The axons of the ganglion cells of the inferior hemiretina carrying images
Optic chiasm
nucleus from the superior visual field project via the temporal lobe portion of the
optic radiations to the portion of the primary visual cortex located below
the calcarine fissure (see Figs. 3-4 and 3-5). Axons of the ganglion cells from
the center of the retina or fovea project onto the tip of the occipital pole.
Armed with the above knowledge of the functional anatomy of the visual
Visual
pathway and the optic nerve, based on the patient’s symptoms and visual
cortex
abnormalities, the clinician can reliably predict what portion of the visual
pathway is affected.

Clinical Evaluation of the Optic Nerve and

Fig. 3-4 Visual field pathways. The visual pathway begins with the retinas in
both eyes and depart from the eyes through the optic nerves. All information from
the left of the visual field travels through the optic chiasm and continues to the
right lateral geniculate nucleus (LGN). The converse occurs for information from
the right side of the visual field. This necessitates that information from both eyes
crosses at the optic chiasm. From the LGNs, visual information proceeds to the
visual cortex of the respective cerebral hemisphere. (From Escobar A: Qualia as the
fundamental nature of visual awareness. J Theor Biol 2011; 279[1]:172-176.)
Visual Pathway
Evaluation of optic nerve function also by necessity includes evaluation of
retinal function. The clinician examines each of the patient’s eyes individu-
ally and begins the examination with an assessment of visual acuity. Distant
vision is tested using a standard Snellen test chart, and near vision is tested
by having the patient read the smallest type possible from a Jaeger reading
test card placed 14 inches from the eye being tested. Color blindness, which
 Chapter 3 The Optic Nerve—Cranial Nerve II 7

RGC Axonal Length

Lateral
geniculate
93 nucleus
mm
Optic Superior Visual
chiasm colliculus cortex

Optic
nerve Cortical
Optic
cells
tract

Retina

Fig. 3-5 The optic tract and radiations to and from the visual cortex. (From Yücel Y, Gupta N: Glaucoma of the
brain: a disease model for the study of transsynaptic neural degeneration. In: Nucci C, Cerulli L, Osborne NN,
Bagetta G [eds]: Progress in Brain Research, San Diego, Elsevier, 2008, Volume 173, pp 465-478.)

Fig. 3-7 Confrontation method of visual field testing. (From Aaron M, Solley WA,
Broocker G: Chapter 1 - General Eye Examination. In: Palay DA, Krachmer JH [eds]:
Primary Care Ophthalmology, ed 2. Philadelphia, Mosby, 2005, pp 1-23.)

Fig. 3-6 Ishihara color blindness test showing (left to right) plate nos. 4 and 6
(1st row) and plate nos. 10 and 16 (2nd row) (From Kumar A, Choudhury R:
Chapter 5 - Unusual visual phenomena and colour blindness. In: Kumar A,
Choudhury R [eds]: Principles of Colour and Appearance Measurement, Wood-
head Publishing, Cambridge 2014, pp 185-208.)
occurs in approximately 3% to 4% of males and 0.3% of women, can be
tested by having the patient read isochromatic plates such as the Ishihara
plates, with an inability to read the embedded numbers in the presence of
normal visual acuity highly suggestive of color blindness (Fig. 3-6).
The next step in evaluation of the optic nerve and associated structures of
the visual pathway is examination of the visual fields. Although there is intra-
patient variation in visual fields due to the patient’s facial characteristics and
shape of the globe and orbit, the following general observations can be made.
In health, a person is able to see laterally approximately 90 to 100 degrees
and medially approximately 60 degrees. The patient can see upward approxi-
mately 50 to 60 degrees and downward 60 to 70 degrees with the eye fixed
in the midline. The easiest test for evaluation for significant visual field loss is
the confrontation test. The confrontation test is performed with the clinician
using his or her own visual fields as a control. To perform the confrontation
test for visual fields, the examiner and patient both cover opposite eyes, and
with the examiner standing approximately 3 feet in front of the patient, the
examiner slowly brings his or her finger into each quadrant of the visual field.
The patient is instructed to inform the examiner the second the examiner’s
finger is seen, with the examiner comparing his or her own response with that
of the patient’s (Fig. 3-7). While beyond the scope of this review, the clinician
should be aware that specific patterns of visual field loss are associated with
specific clinical abnormalities of the optic nerve and visual pathways, such as
homonymous hemianopia, which is often associated with occipital lobe neo-
plasms or stroke; bitemporal hemianopia, which is often associated with pi-
tuitary adenomas; and so on (Fig. 3-8).
Fundoscopic examination of the retina and the optic disk is an essential
part of the evaluation of the optic nerve. The optic disk, which is located just
medial and slightly above the center of the fundus, should appear oval in
shape and pale pink in color. The margin of the optic disk should be clearly
defined with the margins slightly elevated (Fig. 3-9). A pale or poorly
8 Section 1 Anatomy

Aneurysmal
Intima

Fragmented internal
elastic lamina
Adventitia

Normal
Endothelial cells
Intima

Internal
elastic lamina
Media
Adventitia

Fig. 3-8 Specific patterns of visual field loss are associated with specific clinical abnormalities of the optic nerve
and visual pathways, such as homonymous hemianopia, which is often associated with occipital lobe neoplasms or
stroke; bitemporal hemianopia, which is often associated with pituitary adenomas and aneurysms. (From Grant GA,
Ellenbogen RG: Chapter 2 - Clinical Evaluation of the Nervous System. In: Principles of Neurological Surgery, ed 3.
Philadelphia, Saunders, 2012, pp 37-52.)

Fig. 3-9 The normal optic disk. (From Fingeret M, Medeiros FA, Susanna R Jr,
Weinreb RN: Five rules to evaluate the optic disk and retinal nerve fiber layer for
glaucoma. Optometry 2005; 76[11]:661-668.)

defined optic disk is highly suggestive of pathology of the optic nerve, as is

a swollen head of the optic nerve, which is called papilledema. Papilledema
is pathognomonic for increased intracranial pressure (Fig. 3-10). It should
be noted that optic neuritis associated with multiple sclerosis may resemble
papilledema and confuse the diagnosis.
Abnormalities of the retinal vessels seen on fundoscopic examination
may also provide the clinician with useful diagnostic information. Occlu-
sion of the central retinal artery can result in sudden visual loss and is as-
sociated with a pale, edematous optic disk and thin arteries, which can only
be followed outward a short distance from the disk. Atherosclerosis can be
identified by noting a silver wire appearance of the retinal arteries. Systemic
hypertension can result in arterial narrowing and cotton wool patches that Fig. 3-10 Florid papilledema. (From Rogers DL: A review of pediatric idiopathic
appear stuck onto the retina. Common abnormalities of the optic nerve and intracranial hypertension. Pediatr Clin North Am 2014; 61[3]:579-590.)
visual pathways are listed in Table 3-1.
 Chapter 4 The Oculomotor Nerve—Cranial Nerve III 9

Table 3-1 Common Diseases That Result in Visual Impairment

Suggested Readings
Fingeret M, Medeiros FA, Susanna Jr R, Weinreb RN: Five rules to evaluate the
Systemic Diseases optic disk and retinal nerve fiber layer for glaucoma, Optometry - Journal of
the American Optometric Association 76(11):661–668, 2005 Nov.
•  iabetes mellitus
D
Fisch A: Clinical examination of the cranial nerves. In: Tubbs RS, et al (eds):
• Hypertension
Nerves and Nerve Injuries, San Diego, Academic Press, 2015,pp 195–225.
• Vitamin A deficiency
Sadun AA, Wang MY: Optic nerve (cranial nerve II). In: Aminoff M (ed): Encyclo-
• Vitamin B12 deficiency
pedia of the Neurological Sciences, ed 2. San Diego, Academic Press, 2014,
• Lead poisoning
pp 672–674.
• Migraine with aura
Waldman SD: Migraine headache. In: Waldman SD (ed): Atlas of Common Pain
• Graves’ disease
Syndromes, ed 3. Philadelphia, Saunders, 2015.
• Sarcoidosis
• Collagen vascular diseases
• Atherosclerosis and stroke
• Sickle cell disease
• Multiple sclerosis
• Refsum’s disease
• Tay-Sachs disease
Infection
•  IV-associated infections including cytomegalovirus
H
• Trachoma
• Bacterial infections including gonococcal infections
• Parasitic infections including onchocerciasis
• Spirochete infections including syphilis
• Viral infections
• Leprosy
Eye Diseases
•  acular degeneration
M
• Glaucoma
• Cataracts
• Retinitis pigmentosa
• Rod and cone dystrophy
• Best disease, also known as vitelliform macular dystrophy
Trauma
•  urns
B
• Projectile injuries
• Side effects of medications
• Bungee cord and rubber band injuries
• Fish hook injuries
• Fireworks injuries
• Sports injuries
• Complications of eye surgery
Neoplasms
•  ptic gliomas
O
• Melanoma
• Pituitary adenoma

4 CHAPTER

The Oculomotor Nerve—Cranial Nerve III

The oculomotor nerve is the third cranial nerve and is denoted by the
Roman numeral III. It is made up of both general somatic efferent and
general visceral efferent fibers, which serve two distinct functions. The
general somatic efferent fibers of the oculomotor nerve provide motor in-
nervation to four of the six extraocular muscles: (1) the ipsilateral inferior
rectus muscle, (2) the ipsilateral inferior oblique muscle, (3) the ipsilateral
medial rectus muscle, and (4) the contralateral superior rectus muscle
(Fig. 4-1). The superior oblique muscles are innervated by the trochlear
nerve (cranial nerve IV), and the lateral rectus muscles are innervated by
the abducens nerve (cranial nerve VI) (see Chapters 5 and 7). The actions
of the six extraocular muscles are summarized in Table 4-1. The general
somatic efferent fibers of the oculomotor nerve also provide motor in-
10 Section 1 Anatomy

Superior rectus muscle (3rd nerve) Levator palpebrae muscle (3rd nerve)
Inferior oblique muscle (3rd nerve) Superior oblique muscle (4th nerve)
Inferior rectus muscle (3rd nerve) Lateral rectus muscle (6th nerve)
Medial rectus muscle (3rd nerve)
Fig. 4-1 The extraocular muscles. (From Wojno TH: Orbital Disease. In: Palay DA, Krachmer JH [eds], Primary Care
Ophthalmology, ed 2. Philadelphia, Mosby, 2005, pp 275-292.)

Table 4-1 Actions of the Extraocular Muscles

Muscle Innervation Primary Action Secondary Action Tertiary Action
Superior rectus CN III Elevation Intorsion Adduction
Medial rectus CN III Adduction … …
Inferior rectus CN III Depression Extorsion Adduction
Inferior oblique CN III Extorsion Elevation Abduction
Superior oblique CN IV Intorsion Depression Abduction
Lateral rectus CN VI Abduction … …
CN, cranial nerve.

nervation to levator palpebrae superioris muscles bilaterally, which elevate
the upper eyelids (Fig. 4-2).
The general somatic efferent fibers of the oculomotor nerve that provide
motor innervation to four of the six extraocular muscles originate from the
oculomotor nucleus located near the midline just ventral to the cerebral
aqueduct in the rostral midbrain at the level of the superior colliculus. The
oculomotor nucleus is bordered medially by the Edinger-Westphal nucleus
(see later). Efferent general somatic fibers exit the oculomotor nucleus and
pass ventrally in the tegmentum of the midbrain, passing through the red
nucleus and medial portion of the cerebral peduncle to emerge in the inter-
peduncular fossa at the junction of the midbrain and pons.
Exiting the brainstem, the oculomotor nerve (cranial nerve III) passes
between the posterior cerebral and superior cerebellar arteries and then
passes through the dura mater to enter the cavernous sinus. The nerve runs
along the lateral wall of the cavernous sinus just superior to the trochlear
nerve (cranial nerve IV) and enters the orbit via the superior orbital fissure
(Fig. 4-3). After entering the orbit, the oculomotor nerve passes through the
tendinous ring of the extraocular muscles and then divides into the superior
and inferior divisions. The superior division travels superiorly just lateral to
the optic nerve to innervate both the superior rectus and levator palpebrae
superioris muscles. The inferior division of oculomotor nerve divides into
three branches to innervate the medial rectus, inferior rectus, and inferior
oblique muscles (see Fig. 4-2).
The general visceral efferent motor fibers of the oculomotor nerve mediate
the eye’s accommodation and pupillary light reflexes by providing parasympa-
thetic innervation of the constrictor pupillae and ciliary muscles of the eye (see
Fig. 4-2). After entering the orbit, preganglionic parasympathetic fibers leave the
inferior division of the oculomotor nerve to synapse in the ciliary ganglion,
which lies deep to the superior rectus muscle near the tendinous ring of the
extraocular muscles (see Fig. 4-2). Postganglionic fibers exit the ciliary ganglion
via the short ciliary nerves, which enter the posterior aspect of the globe at a
point near the spot where the optic nerve exits the eye. Traveling anteriorly
 Chapter 4 The Oculomotor Nerve—Cranial Nerve III 11

Ciliary ganglion

Caudal branch of the

oculomotor nerve

Cephalic branch of the

oculomotor nerve
Optic nerve
Maxillary nerve

Mandibular nerve

Oculomotor nerve

Ophthalmic nerve
Fig. 4-2 The oculomotor nerve. (From Jean-Pierre Barral: Manual Therapy for the Cranial Nerves. Edinburgh,
Churchill Livingstone, 2009; Fig. 12-1.)

Trochlear nerve [IV] Abducens nerve [VI]

Internal carotid artery

Oculomotor nerve [iii]

Pituitary gland Dura mater

Diaphragma sellae

Sphenoidal (paranasal) sinus

Cavernous (venous) sinus

Ophthalmic division of trigeminal nerve [V1]

Maxillary division of trigeminal nerve [V2]

Fig. 4-3 Exiting the brainstem, the oculomotor nerve (cranial nerve III) passes between the posterior cerebral and
superior cerebellar arteries and then passes through the dura mater to enter the cavernous sinus. The nerve runs
along the lateral wall of the cavernous sinus just superior to the trochlear nerve (cranial nerve IV) and enters the
orbit via the superior orbital fissure. (Reprinted from Drake R, Vogl W, Mitchell A: Gray’s Anatomy for Students, ed
2. London, Churchill Livingstone, 2010; with permission.)
12 Section 1 Anatomy
A occupying lesions such as tumor, abscess, or aneurysm. Increased intracra-
B vessel disease due to diabetes or vasculitis associated with temporal arteritis
C eyelids (Fig. 4-4). Compromise of the visceral fibers of the oculomotor
D (eds): Encyclopedia of the Neurological Sciences, ed 2. 2014, pp 633–635.
Fig. 4-4 A, B, C, D In almost all disorders of the oculomotor nerve, symptoms
will take the form of either a palsy of the extraocular muscles presenting as
diplopia, strabismus, or an inability to look upward or downward or by a ptosis
of the eyelids. (From Prasad S, Volpe NJ: Paralytic strabismus: third, fourth, and
sixth nerve palsy. Neurol Clin 2010; 28[3] pp 803-833.)
5 CHAPTER
The Trochlear Nerve—Cranial Nerve IV
The trochlear nerve (cranial nerve IV) is composed of somatic general effer-
ent motor fibers and is denoted by the Roman numeral IV. It innervates the
superior oblique extraocular muscle of the contralateral orbit (Fig. 5-1).
Contraction of the superior oblique extraocular muscle intorts (rotates in-
ward), depresses, and abducts the globe. As outlined in Chapter 4, the
­superior oblique extraocular muscles work in concert with the five other
extraocular muscles to allow the eye to perform its essential functions of
tracking and fixation on objects.
The fibers of the trochlear nerve originate from the trochlear nucleus,
which is just ventral to the cerebral aqueduct in the tegmentum of the mid-
brain at the level of the inferior colliculus. As the trochlear nerve leaves the
trochlear nucleus, it travels dorsally, wrapping itself around the cerebral aque-
duct to then decussate in the superior medullary velum. The decussated fibers
between the choroid and the sclera, these postganglionic fibers innervate the
ciliary muscles, which alter the shape of the lens, as well as the constrictor
muscle of the iris, which constricts the aperture of the iris (see Fig. 4-2).
Disorders of the oculomotor nerve can be caused by central lesions that
affect the oculomotor or Edinger-Westphal nuclei such as stroke or space-
nial pressure due to subdural hematoma, sagittal sinus thrombosis, or ab-
scess can compromise the nuclei and/or the efferent fibers of the oculomotor
nerve as they exit the brainstem and travel toward the orbit, with resultant
abnormal nerve function. Traction on the oculomotor nerve due to loss of
cerebrospinal fluid has also been implicated in cranial nerve III palsy. Small
may cause ischemia and even infarction of the oculomotor nerve with resul-
tant pathologic symptoms.
In almost all disorders of the oculomotor nerve, symptoms will take the
form of either a palsy of the extraocular muscles presenting as diplopia,
strabismus, or an inability to look upward or downward or by a ptosis of the
nerve can result in anisocoria, the loss of the direct or consensual light re-
flex, and/or the loss of accommodation. Examples of these abnormalities
include the Argyll Robertson pupil most frequently associated with syphi-
lis, Adie’s pupil, and the Marcus Gunn pupil.
Suggested Readings
Brazis PW: Isolated palsies of cranial nerves III, IV, and VI, Seminars in Neurology,
29 (2009), pp 14–28.
Prasad S, Volpe NJ: Paralytic strabismus: third, fourth, and sixth nerve palsy,
Neurologic Clinics Volume 28(3):803–833, 2010 August.
Rucker JC, Rudich DS: Oculomotor nerve (cranial nerve III). In: Daroff RD, Aminoff MJ
Waldman SD: Post-dural puncture headache. In: Waldman SD (ed): Atlas of Un-
common Pain Syndromes, ed 3. Philadelphia, Saunders, 2015.
of the trochlear nerve then exit the dorsal surface of the brainstem just below
the contralateral inferior colliculus, where they then curve around the brain-
stem, leaving the subarachnoid space along with the oculomotor nerve (cra-
nial nerve III) between the superior cerebellar and posterior cerebral arteries
(Fig. 5-2). The trochlear nerve then enters the cavernous sinus and runs an-
teriorly along the lateral wall of the sinus with the oculomotor (cranial nerve
III), trigeminal (cranial nerve V), and abducens (cranial nerve VI) nerves.
Exiting the cavernous sinus, the trochlear nerve enters the orbit via the
superior orbital fissure. Unlike the oculomotor nerve, the trochlear nerve
does not pass through the tendinous ring of the extraocular muscles but
passes just above the ring (Fig. 5-3). The trochlear nerve then crosses medi-
ally along the roof of the orbit above the levator palpebrae and superior
rectus muscles to innervate the superior oblique muscle (see Fig. 5-2).
 Chapter 5 The Trochlear Nerve—Cranial Nerve IV 13

H
A O

V O

IV
G O

V IV. Trochlear

F T
A

IV. Trochlear nerve

• Motor
• Eye movement
• Superior oblique (S.O.) muscle

Fig. 5-1 The trochlear nerve (cranial nerve IV) is composed of somatic general efferent motor fibers and is de-
noted by the Roman numeral IV. It innervates the superior oblique extraocular muscle of the contralateral orbit.

Fig. 5-2 The relationship of the trochlear nerve and the superior oblique extraocular muscle. (From Smoker WRK,
Reede DL: Denervation atrophy of motor cranial nerves. Neuroimaging Clinics of North America 2008 May;
18[2]:387-411.)
14 Section 1 Anatomy
V3
OA V2
V1
III
ON IV
Fig. 5-3 The course of the trochlear nerve. (From Iaconetta G, Notaris MD
Galino AP: Chapter 21 - Anatomy of the Trochlear Nerve. In: Tubbs RS, Rizk E,
Shoja MM, et al [eds]. Nerves and Nerve Injuries. San Diego, Academic Press,
2015, pp 311-317.)
Superioris rectus m.
Superior oblique m.
Trochlear nerve
Fig. 5-4 The relationship of the terminal trochlear nerve to the orbit and ten-
dinous ring of the extraocular muscles.
Disorders of the trochlear nerve can be caused by central lesions that
affect the trochlear nucleus such as stroke or space-occupying lesions such
as tumor, abscess, or aneurysm. Increased intracranial pressure due to sub-
dural hematoma, sagittal sinus thrombosis, or abscess can compromise the
nucleus and/or the efferent fibers of the trochlear nerve as they exit the
brainstem and travel toward the orbit, with resultant abnormal nerve func-
tion. Traction on the trochlear nerve due to loss of cerebrospinal fluid has
also been implicated in cranial nerve IV palsy. Small vessel disease due to
diabetes or vasculitis associated with temporal arteritis may cause ischemia
and even infarction of the trochlear nerve, with resultant pathologic
symptoms.
In almost all disorders of the trochlear nerve, symptoms will take the
form of a palsy of the superior oblique muscle, most commonly presenting
as the inability to look inward and downward (Fig. 5-5). Often, the patient
will complain of the difficulty in walking down stairs because of the inabil-
ity to depress the affected eye or eyes. On physical examination, the clinician
Fig. 5-5 Clinical examination: right fourth nerve palsy in a 65-year-old man
with a 6-month history of vertical image separation. Note reduced downward
and inward gaze of the right eye. (From Smoker WRK, Reede DL: Denervation
atrophy of motor cranial nerves. Neuroimag Clin N Am 2008 May; 18[2]:
387-411.)
C
Fig. 5-6 A 7-year-old girl with bilateral congenital fourth nerve palsy. Brain
MRI was normal. (A) Normal alignment in primary gaze. (B) Left hypertropia in
right gaze, with left inferior oblique overaction. (C) Right hypertropia in left gaze,
with right inferior oblique overaction. (From Prasad S, Volpe NJ: Paralytic strabis-
mus: third, fourth, and sixth nerve palsy. Neurol Clin 2010 Aug; 28[3]:803-833.)
may note extorsion (outward rotation) of the affected eye because of the
unopposed action of the inferior oblique muscle (Fig. 5-6). In an effort to
compensate, the patient may deviate his or her face forward and downward
with the chin rotated toward the affected side in order to look downward.
Suggested Readings
Brazis PW: Isolated palsies of cranial nerves III, IV, and VI, Seminars in Neurology
29:14-28, 2009.
Iaconetta G, Notaris M: Galino, AP: Anatomy of the trochlear nerve. In: Tubbs RS,
Rizk E, Shoja MM, Loukas M, Barbaro N (eds): Nerves and Nerve Injuries, San
Diego, Academic Press, 2015, pp 311–317.
Prasad S, Volpe NJ: Paralytic strabismus: third, fourth, and sixth nerve palsy,
Neurologic Clinics 28:803–833, 2010 August.
Rucker JC, Rudich DS: Trochlear nerve (cranial nerve IV). In: Daroff RB, Aminoff MJ
(eds): Encyclopedia of the Neurological Sciences, ed 2. 2014, pp 534–535.
Waldman SD: Post-dural puncture headache. In: Waldman SD (ed): Atlas of Un-
common Pain Syndromes, ed 3. Philadelphia, Saunders, 2015.
 Chapter 6 The Trigeminal Nerve—Cranial Nerve V 15

6 CHAPTER

The Trigeminal Nerve—Cranial Nerve V

The trigeminal nerve is the fifth cranial nerve and is denoted by the Roman joins the mandibular division as it exits the cranial cavity via the foramen
numeral V. The trigeminal nerve has three divisions and provides sensory ovale.
innervation for the forehead and eye (ophthalmic V1), cheek (maxillary V2), Three major branches emerge from the trigeminal ganglion (Fig. 6-3).
and lower face and jaw (mandibular V3), as well as motor innervation for Each branch innervates a different dermatome. Each branch exits the cra-
the muscles of mastication (Fig. 6-1). The fibers of the trigeminal nerve nium through a different site. The first division (V1; ophthalmic nerve) exits
arise in the trigeminal nerve nucleus, which is the largest of the cranial nerve the cranium through the superior orbital fissure, entering the orbit to in-
nuclei. Extending from the midbrain to the upper cervical spinal cord, the nervate the globe and skin in the area above the eye and forehead.
trigeminal nerve nucleus is divided into three parts: (1) the mesencephalic The second division, V2, maxillary nerve, exits through a round hole, the
trigeminal nucleus, which receives proprioceptive and mechanoreceptor fi- foramen rotundum, into a space posterior to the orbit, the pterygopalatine
bers from the mandible and teeth; (2) the main trigeminal nucleus, which fossa. It then reenters a canal running inferior to the orbit, the infraorbital
receives the majority of the touch and position fibers; and (3) the spinal canal, and exits through a small hole, the infraorbital foramen, to innervate
trigeminal nucleus, which receives pain and temperature fibers. the skin below the eye and above the mouth. The third division, V3, man-
The sensory fibers of the trigeminal nerve exit the brainstem at the level dibular nerve, exits the cranium through an oval hole, the foramen ovale.
of the mid-pons with a smaller motor root emerging from the mid-pons at Sensory fibers of the third division either travel directly to their target tis-
the same level. These roots pass in a forward and lateral direction in the sues or reenter the mental canal to innervate the teeth, with the terminal
posterior cranial fossa across the border of the petrous bone. They then branches of this division exiting anteriorly via the mental foramen to pro-
enter a recess called Meckel’s cave, which is formed by an invagination of the vide sensory cutaneous innervation to the skin overlying the mandible.
surrounding dura mater into the middle cranial fossa. The dural pouch that
lies just behind the ganglion is called the trigeminal cistern and contains ce-
rebrospinal fluid.
The gasserian ganglion is canoe shaped, with the three sensory divisions: V1
(1) the ophthalmic division (V1), which exits the cranium via the superior Supratrochlear
orbital fissure; (2) the maxillary division (V2), which exits the cranium via Infratrochlear
the foramen rotundum into the pterygopalatine fossa where it travels ante- Supraorbital
riorly to enter the infraorbital canal to exit through the infraorbital foramen; External nasal
and the mandibular division (V3), which exits the cranium via the foramen V1 Lacrimal
ovale anterior convex aspect of the ganglion (Fig. 6-2). A small motor root
V2
Zygomaticotemporal
Zygomaticofacial
H Infraorbital
A O V2
V3
Auriculotemporal
V O Buccal
V1
Mental
V3
G O
V2

V T
V3

F V. Trigeminal V1, Ophthalmic nerve

A V2, Maxillary nerve
Fig. 6-1 The trigeminal nerve is the fifth cranial nerve and is denoted by the
V3, Mandibular nerve
Roman numeral V. The trigeminal nerve has three divisions and provides sensory
innervation for the forehead and eye (ophthalmic V1), cheek (maxillary V2), and Fig. 6-2 The sensory divisions and peripheral branches of the trigeminal nerve.
lower face and jaw (mandibular V3), as well as motor innervation for the muscles (From Waldman SD: Atlas of Interventional Pain Management, ed 4. Philadelphia,
of mastication. Saunders, 2015; Fig. 16-1.)
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without the consent of the principals. Ah Sam resigned himself to
matrimony. The office was reached, the door opened and out in the darkness
bolted the bride, for she knew not what these preparations meant, or
whether she had fallen among friends or enemies. After a lively chase we
cornered and caught her; and having thus at last brought this refractory
couple together we placed them in position, and the Justice commenced the
ceremony by asking Hi Sing if she took that man for her lawful wedded
husband, which interrogatory being Chaldaic to her, she replied only by an
unmeaning and unspeculative stare. Spoke, who seemed destined to be the
soul and mainspring of this whole affair, now threw light on the Mongolian
intellect by bringing into play his stock of Chinese English, and translating
to her the language of the Justice thus: “You like ’um he, pretty good?”
Upon which her face brightened, and she nodded assent. Then turning to the
groom, he called in a tone fierce and threatening, “You like ’um she?” and
Ah Sam—who was now only a passive object in the hands of Spoke, forced
and galvanized into matrimony—dared not do otherwise than give in his
adhesion, upon which the Justice pronounced them man and wife;
whereupon two Virginians present with their violins (all Virginians fiddle
and shoot well) struck up the “Arkansas Traveller;” and the audience—
which was now large, every bar-room in Jamestown having emptied itself
to witness our Chinese wedding—inspired by one common impulse, arose
and marched seven times about the couple. Ah Sam was now informed that
he was married “American fashion,” and that he was free to depart with his
wedded encumbrance. But Ah Sam, whose intoxication had broken out in
full acquiescence with these proceedings, now insisted on making a
midnight tour of all the saloons in camp, and treating everybody to the
deathly whiskey vended by them, to which the crowd—who never objected
to the driving of this sort of nails in their own coffins—assented, and the
result of it was (Ah Sam spending his money very freely) that when
daylight peeped over the eastern hills the Bella Union saloon was still in
full blast; and while the Justice of the Peace was winning Spoke’s thirty
hard-earned dollars in one corner, and the two Virginians still kept the
“Arkansas Traveller” going on their violins in another, Stephen Scott
(afterward elected to Congress) was weeping profusely over the bar, and on
being interrogated as to the cause of his sadness by General Wyatt, ex-
member of the State Senate, Scott replied that he could never hear played
the air of “Home, Sweet Home” without shedding tears.
 Ah Sam departed with his bride in the morning, and never were a man’s
prospects brighter for a happy honeymoon until the succeeding night, when
he was waylaid by a band of disguised white men in the temporary service
and pay of old Ching Loo; and he and Hi Sing were forced so far apart that
they never saw each other again.
Ah Sam returned to the attorney, apparently deeming that some help
might be obtained in that quarter; but Spoke intimated that he could no
longer assist him, since it was every man’s special and particular mission to
keep his own wife after being married; although he added, for Ah Sam’s
comfort, that this was not such an easy matter for the Americans
themselves, especially in California.
Upon this Ah Sam apparently determined to be satisfied with his brief
and turbulent career in matrimony; and betaking himself again to Swett’s
Bar cooked in such a villainous fashion and desperate vigor, finding thereby
a balm for an aching heart, that in a twelvemonth several stalwart miners
gave up their ghosts through indigestion, and the little graveyard on the red
hill thereby lost forever its distinctive character of affording a final resting
place only to those who had died violent deaths.
 CHAPTER XXI.

ON A JURY.

Year after year, and term after term, the great case of Table Mountain
Tunnel vs. New York Tunnel, used to be called in the Court held at Sonora,
Tuolumne County. The opposing claims were on opposite sides of the great
mountain wall, which here described a semicircle. When these two claims
were taken up, it was supposed the pay streak followed the Mountain’s
course; but it had here taken a freak to shoot straight across a flat formed by
the curve. Into this ground, at first deemed worthless, both parties were
tunnelling. The farther they tunnelled, the richer grew the pay streak. Every
foot was worth a fortune. Both claimed it. The law was called upon to settle
the difficulty. The law was glad, for it had then many children in the county
who needed fees. Our lawyers ran their tunnels into both of these rich
claims, nor did they stop boring until they had exhausted the cream of that
pay streak. Year after year, Table Mountain vs. New York Tunnel Company
was tried, judgment rendered first for one side and then for the other, then
appealed to the Supreme Court, sent back, and tried over, until, at last, it
had become so encumbered with legal barnacles, parasites, and cobwebs,
that none other than the lawyers knew or pretended to know aught of the
rights of the matter. Meantime, the two rival companies kept hard at work,
day and night. Every ounce over the necessary expense of working their
claims and feeding and clothing their bodies, went to maintain lawyers. The
case became one of the institutions of the county. It outlived several judges
and attorneys. It grew plethoric with affidavits and other documentary
evidence. Men died, and with their last breath left some word still further to
confuse the great Table Mountain vs. New York Tunnel case. The county
town throve during this yearly trial. Each side brought a small army of
witnesses, who could swear and fill up any and every gap in their respective
chains of evidence. It involved the history, also, of all the mining laws made
since “ ’49.” Eventually, jurors competent to try this case became very
scarce. Nearly every one had “sat on it,” or had read or heard or formed an
opinion concerning it, or said they had. The Sheriff and his deputies
ransacked the hills and gulches of Tuolumne for new Table Mountain vs.
New York Tunnel jurors. At last, buried in an out-of-the-way gulch, they
found me. I was presented with a paper commanding my appearance at the
county town, with various pains and penalties affixed, in case of refusal. I
obeyed. I had never before formed the twelfth of a jury. In my own
estimation, I rated only as the twenty-fourth. We were sworn in: sworn to
try the case to the best of our ability; it was ridiculous that I should swear to
this, for internally I owned I had no ability at all as a juror. We were put in
twelve arm-chairs. The great case was called. The lawyers, as usual, on
either side, opened by declaring their intentions to prove themselves all
right and their opponents all wrong. I did not know which was the plaintiff,
which the defendant. Twenty-four witnesses on one side swore to
something, to anything, to everything; thirty-six on the other swore it all
down again. They thus swore against each other for two days and a half.
The Court was noted for being an eternal sitter. He sat fourteen hours per
day. The trial lasted five days. Opposing counsel, rival claimants, even
witnesses, all had maps, long, brilliant, parti-colored maps of their claims,
which they unrolled and held before us and swung defiantly at each other.
The sixty witnesses testified from 1849 up to 1864. After days of such
testimony, as to ancient boundary lines and ancient mining laws, the
lawyers on either side, still more to mystify the case, caucused the matter
over and concluded to throw out about half of such testimony as being
irrelevant. But they could not throw it out of our memories. The “summing
up” lasted two days more. By this time, I was a mere idiot in the matter. I
had, at the start, endeavored to keep some track of the evidence, but they
managed to snatch every clue away as fast as one got hold of it. We were
“charged” by the judge and sent to the jury room. I felt like both a fool and
a criminal. I knew I had not the shadow of an opinion or a conclusion in the
matter. However, I found myself not alone. We were out all night. There
was a stormy time between the three or four jurymen who knew or
pretended to know something of the matter. The rest of us watched the
controversy, and, of course, sided with the majority. And, at last, a verdict
was agreed upon. It has made so little impression on my mind that I forget
now whom it favored. It did not matter. Both claims were then paying well,
and this was a sure indication that the case would go to the Supreme Court.
It did. This was in 1860. I think it made these yearly trips up to 1867. Then
some of the more obstinate and combative members of either claim died,
and the remainder concluded to keep some of the gold they were digging
instead of paying it out to fee lawyers. The Table Mountain vs. New York
Tunnel case stopped. All the lawyers, save two or three, emigrated to San
Francisco or went to Congress. I gained but one thing from my experience
in the matter—an opinion. It may or may not be right. It is that juries in
most cases are humbugs.
 CHAPTER XXII.

SOME CULINARY REMINISCENCES.

I lived once with an unbalanced cook. Culinarily he was not self-poised.

He lacked judgment. He was always taking too large cooking contracts. He
was for a time my partner. He was a lover of good living and willing to
work hard for it over a cook stove. He would for a single Sunday’s dinner
plan more dishes than his mind could eventually grasp or his hands handle.
And when he had exhausted the whole of the limited gastronomical
repertoire within our reach he would be suddenly inspired with a
troublesome propensity to add hash to the programme. In cooking, as I have
said, he lost his balance. His imagination pictured more possibilities than
his body had strength to carry out. So busied in getting up a varied meal, he
would in a few minutes’ leisure attempt to shave himself or sew on shirt or
pantaloon buttons. This put too many irons in the fire. A man who attempts
to shave while a pot is boiling over or a roast requiring careful watching is
in the oven, will neither shave nor cook well. He will be apt to leave lather
where it is not desirable, as he sometimes did. Trousers-buttons are not
good in soup. I do not like to see a wet shaving brush near a roast ready to
go into the oven. The æsthetic taste repudiates these hints at combination.
Then sometimes, in the very crisis of a meal, he became flurried. He rushed
about in haste overmuch, with a big spoon in one hand and a giant fork in
the other, looking for missing stove-covers and pot-lids, seldom found until
the next day, and then in strange places. Nothing is well done which is done
in a hurry, especially cooking. Some argue that men and women put their
magnetic and sympathetic influences in the food they prepare. If a man
kneading bread be in a bad temper he puts bad temper in the bread, and that
bad temper goes into the person who eats it. Or if he be dyspeptic he kneads
dyspepsia in his dough. It is awful to think what we may be eating. I think
the unbalanced cook puts flurries in his stews, for I felt sometimes as if
trying to digest a whirlwind after eating this man’s dinners. He ruled the
house. I was his assistant. I was his victim. I was the slave of the spit, and
the peon of the frying-pan. When his energies culminated and settled on
hash, when already the stove-top was full of dishes in preparation, I was
selected as the proper person to chop the necessary ingredients. We had
neither chopping-knife nor tray. The mining stores then did not contain such
luxuries. This to him made no difference. He was a man who rose superior
to obstacles, circumstances, and chopping trays. He said that hash could be
chopped with a hatchet on a flat board. He planned; I executed. He
theorized and invented; I put his inventions in practice. But never
successfully could I chop a mass of beef and boiled potatoes with a hatchet
on a flat board. The ingredients during the operation would expand and fall
over the edge of the board. Or the finer particles would violently fly off at
each cut of the hatchet, and lodge on the beds or other unseemly places.
I do not favor a dinner of many courses, especially if it falls to my lot to
prepare these courses. Few cooks enjoy their own dinners. For two reasons:
First—They eat them in anticipation. This nullifies the flavor of the reality.
Second—The labor of preparation fatigues the body and takes the keen
edge from the appetite. You are heated, flushed, exhausted, and the nerves
in a twitter. The expected relish palls and proves a myth. Ladies who cook
will corroborate my testimony on this point. It is a great, merciful and
useful vent for a woman that a man can come forward able and willing to
sympathize with her in regard to this and other trials of domestic life.
Having kept my own house for years I know whereof I speak. Two hours’
work about a hot stove exhausts more than four hours’ work out of doors.
Americans in Europe are shocked or pretend to be at sight of women doing
men’s work in the fields. They are much better off than the American
woman, five-sixths of whose life is spent in the kitchen. The outdoor
woman shows some blood through the tan on her cheeks. The American
kitchen housewife is sallow and bleached out. I have in Vienna seen women
mixing mortar and carrying bricks to the sixth story of an unfinished house,
and laying bricks, too. These women were bare-legged to the knee, and
their arms and legs were muscular. They mixed their mortar with an energy
suggestive of fearful consequences to an ordinary man of sedentary
occupations. They could with ease have taken such a man and mixed him
with their mortar. Coarse, were they? Yes, of course they were. But if I am
to choose between a coarse woman, physically speaking, and one hot-
housed and enervated to that extent that she cannot walk half a mile in the
open air, but requires to be hauled, I choose the coarse-grained fibre.
 I once lived near a literary cook. It was to him by a sort of natural
heritage that fell the keeping of the Hawkins Bar Library, purchased by the
“boys” way back in the A.D. eighteen hundred and fifties. The library
occupied two sides of a very small cabin, and the man who kept it lived on
or near the other two sides. There, during nights and rainy days, he read and
ate. His table, a mere flap or shelf projecting from the wall, was two-thirds
covered with books and papers, and the other third with a never-cleared-off
array of table furniture, to wit: A tin plate, knife, fork, tin cup, yeast-powder
can, pepper-box, ditto full of sugar, ditto full of salt, a butter-plate, a bottle
of vinegar and another of molasses, and may be, on occasions, one of
whiskey. On every book and paper were more or less of the imprint of
greasy fingers, or streaks of molasses. The plate, owing to the almost entire
absence of the cleansing process, was even imbedded in a brownish,
unctuous deposit, the congealed oleaginous overflow of months of meals.
There he devoured beef and lard, bacon and beans and encyclopedias,
Humboldt’s “Cosmos” and dried apples, novels and physical nourishment at
one and the same time. He went long since where the weary cease from
troubling, and the wicked, let us hope, are at rest. Years ago, passing
through the deserted Bar, I peeped in at Morgan’s cabin. A young oak
almost barred the door, part of the roof was gone, the books and shelves had
vanished; naught remained but the old miner’s stove and a few battered
cooking utensils. I had some thought at the time of camping for the night on
the Bar, but this desolate cabin and its associations of former days
contrasted with the loneliness and solitude of the present proved too much
for me. I feared the possible ghost of the dead librarian, and left for a
populated camp. Poor fellow! While living, dyspepsia and he were in close
embrace. A long course of combined reading and eating ruined his
digestion. One thing at a time; what a man does he wants to do with all his
might.
Eggs in the early days were great luxuries. Eggs then filled the place of
oysters. A dish of ham and eggs was one of the brilliant anticipations of the
miner resident in some lonesome gulch when footing it to the nearest large
camp. A few enterprising and luxurious miners kept hens and raised
chickens. The coons, coyotes, and foxes were inclined to “raise” those
chickens too. There was one character on Hawkins Bar whose coop was
large and well stocked. Eggs were regularly on his breakfast-table, and he
was the envy of many. Generous in disposition, oft he made holiday
presents of eggs to his friends. Such a gift was equivalent to that of a turkey
in older communities. One foe to this gentleman’s peace and the security of
his chickens alone existed. That foe was whiskey. For whenever elevated
and cheered by the cup which does inebriate, he would in the excess of his
royal nature call his friends about him, even after midnight, and slay and eat
his tenderest chickens. Almost so certain as Kip got on a spree there came a
feast and consequent midnight depletion of his chicken-coop—a depletion
that was mourned over in vain when soberer and wiser counsels prevailed.
The pioneer beefsteaks of California were in most cases cut from bulls
which had fought bull-fights all the way up from Mexico. Firm in fibre as
they were, they were generally made firmer still by being fried in lard. The
meat was brought to the table in a dish covered with the dripping in which it
had hardened. To a certain extent the ferocity and combativeness of human
nature peculiar to the days of “ ’49” were owing to obstacles thrown in the
way of easy digestion by bull beef fried to leather in lard. Bad bread and
bull beef did it. The powers of the human system were taxed to the
uttermost to assimilate these articles. The assimilation of the raw material
into bone, blood, nerve, muscle, sinew and brain was necessarily imperfect.
Bad whiskey was then called upon for relief. This completed the ruin. Of
course men would murder each other with such warring elements inside of
them.
The ideas of our pioneer cooks and housekeepers regarding quantities,
kinds, and qualities of provisions necessary to be procured for longer or
shorter periods, were at first vague. There was an Argonaut who resided at
Truetts’ Bar, and, in the fall of 1850, warned by the dollar a pound for flour
experience of the past winter, he resolved to lay in a few months’
provisions. He was a lucky miner. Were there now existing on that bar any
pioneers who lived there in ’49, they would tell you how he kept a barrel of
whiskey in his tent on free tap. Such men are scarce and win name and
fame. Said he to the Bar trader when the November clouds began to signal
the coming rains, “I want to lay in three months’ provisions.” “Well, make
out your order,” said the storekeeper. This troubled G——. At length he
gave it verbally thus: “I guess I’ll have two sacks of flour, a side of bacon,
ten pounds of sugar, two pounds of coffee, a pound of tea, and—and—a
barrel of whiskey.”
My own experience taught me some things unconsidered before. Once,
while housekeeping, I bought an entire sack of rice. I had no idea then of
the elastic and durable properties of rice. A sack looked small. The rice
surprised me by its elasticity when put on to boil. Rice swells amazingly.
My first pot swelled up, forced off the lid and oozed over. Then I shoveled
rice by the big spoonful into everything empty which I could find in the
cabin. Still it swelled and oozed. Even the washbasin was full of half-boiled
rice. Still it kept on. I saw then that I had put in too much—far too much.
The next time I tried half the quantity. That swelled, boiled up, boiled over
and also oozed. I never saw such a remarkable grain. The third time I put
far less to cook. Even then it arose and filled the pot. The seeds looked
minute and harmless enough before being soaked. At last I became
disgusted with rice. I looked at the sack. There was the merest excavation
made in it by the quantity taken out. This alarmed me. With my gradually
decreasing appetite for rice, I reflected and calculated that it would take
seven years on that Bar ere I could eat all the rice in that sack. I saw it in
imagination all boiled at once and filling the entire cabin. This determined
my resolution. I shouldered the sack, carried it back to the store and said:
“See here! I want you to exchange this cereal for something that won’t
swell so in the cooking. I want to exchange it for something which I can eat
up in a reasonable length of time.”
The storekeeper was a kind and obliging man. He took it back. But the
reputation, the sting of buying an entire sack of rice remained. The “boys”
had “spotted” the transaction. The merchant had told them of it. I was
reminded of that sack of rice years afterward.
 CHAPTER XXIII.

THE COPPER FEVER.

In 1862-63 a copper fever raged in California. A rich vein had been

found in Stanislaus County. A “city” sprung up around it and was called
Copperopolis. The city came and went inside of ten years. When first I
visited Copperopolis, it contained 3,000 people. When I last saw the place,
one hundred would cover its entire population.
But the copper fever raged in the beginning. Gold was temporarily
thrown in the shade. Miners became speedily learned in surface copper
indications. The talk far and wide was of copper “carbonates,” oxides,
“sulphurets,” “gosson.” Great was the demand for scientific works on
copper. From many a miner’s cabin was heard the clink of mortar and pestle
pounding copper rock, preparatory to testing it. The pulverized rock placed
in a solution of diluted nitric acid, a knife blade plunged therein and coming
out coated with a precipitation of copper was exhibited triumphantly as a
prognosticator of coming fortune from the newly found lead. The fever flew
from one remote camp to another. A green verdigris stain on the rocks
would set the neighborhood copper crazy. On the strength of that one
“surface indication” claims would be staked out for miles, companies
formed, shafts in flinty rock sunk and cities planned. Nitric acid came in
great demand. It was upset. It yellowed our fingers, and burned holes in our
clothes. But we loved it for what it might prove to us. A swarm of men
learned in copper soon came from San Francisco. They told all about it,
where the leads should commence, in what direction they should run, how
they should “dip,” what would be the character of the ore, and what it
would yield. We, common miners, bowed to their superior knowledge. We
worshipped them. We followed them. We watched their faces as they
surveyed the ground wherein had been found a bit of sulphuret or a green
stained ledge, to get at the secret of their superior right under ground. It
took many months, even years for the knowledge slowly to filter through
our brains that of these men nine-tenths had no practical knowledge of
copper or any other mining. The normal calling of one of the most learned
of them all, I found out afterward to be that of a music teacher. Old S——,
the local geologist of Sonora, who had that peculiar universal genius for
tinkering at anything and everything from a broken wheelbarrow to a clock
and whose shop was a museum of stones, bones and minerals collected
from the vicinity, “classified,” and named, some correctly and some
possibly otherwise, took immediately on himself the mantle of a copper
prophet, and saw the whole land resting on a basis of rich copper ore. He
advised in season and out of season, in his shop and in the street, that all
men, and especially young men, betake themselves to copper mining. It
was, he said, a sure thing. It needed only pluck, patience, and perseverance.
“Sink,” he said, “sink for copper. Sink shafts wherever indications are
found. Sink deep. Don’t be discouraged if the vein does not appear at
twenty, thirty, sixty or an hundred feet.”
And they did sink. For several years they sunk shafts all over our county
and in many another counties. In remote gulches and cañons they sunk and
blasted and lived on pork and beans week in and week out and remained all
day underground, till the darkness bleached their faces. They sunk and sunk
and saw seldom the faces of others of their kind, and no womankind at all.
They lived coarsely, dressed coarsely, and no matter what they might have
been, felt coarsely and in accordance, acted coarsely. They sunk time and
money and years and even health and strength, and in nineteen cases out of
twenty found nothing but barren rock or rock bearing just enough mineral
not to pay.
I took the copper fever with the rest. In a few weeks I became an
“expert” in copper. I found two veins on my former gold claim at Swett’s
Bar. I found veins everywhere. I really did imagine that I knew a great deal
about copper-mining, and being an honest enthusiast was all the more
dangerous. The banks of the Tuolumne became at last too limited as my
field for copper exploration and discovery. I left for the more thickly
populated portion of the county, where there being more people, there was
liable to be more copper, and where the Halsey Claim was located. The
“Halsey” was having its day then as the King claim of the county. It had
really produced a few sacks of ore, which was more than any other
Tuolumne copper claim had done, and on the strength of this, its value was
for a few months pushed far up into high and airy realms of finance.
I told some of my acquaintances in Sonora that I could find the
“continuation” of the Halsey lead. They “staked” me with a few dollars, in
consideration of which I was to make them shareholders in whatever I
might find. Then I went forth into the chapparal to “prospect.” The Halsey
claim lay about a mile east of Table Mountain near Montezuma, a mining
camp then far in its decline. Table Mountain is one of the geological
curiosities, if not wonders of Tuolumne and California. As a well-defined
wall it is forty miles long. Through Tuolumne it is a veritable wall, from
250 to 600 feet in height, flat as a floor on the top. That top has an average
width of 300 yards. The “table” is composed of what we miners call “lava.”
It is a honey-combed, metallic-looking rock, which on being struck with a
sledge emits a sulphurous smell. The sides to the ungeological eye seem of
a different kind of rock. But parts of the sides are not of rock at all—they
are of gravel. On the eastern slope you may see from the old Sonora stage
road two parallel lines, perhaps 200 feet apart, running along the mountain
side. Mile after mile do these marks run, as level and exact as if laid there
by the surveyor. Climb up to them and you find these lines enlarged to a
sort of shelf or wave-washed and indented bank of hard cement, like gravel.
You may crawl under and sit in the shade of an overhanging roof of gravel,
apparently in some former age scooped out by the action of waves. Not
only on the Table Mountain sides do you find these lines, but where Table
Mountain merges into the plains about Knight’s Ferry will you see these
same water marks running around the many low conical hills.
A geological supposition. That’s what water seems to have done outside
of Table Mountain. Were I a geologist I should say that here had been a lake
—maybe a great lake—which at some other time had suddenly from the
first mark been drained down to the level of the second, and from that had
drained off altogether. Perhaps there was a rise in the Sierra Nevada, and
everything rising with it, the lake went up too suddenly on one side and so
the waters went down on the other. Inside of Table Mountain there is an old
river bed, smoothly washed by the currents of perhaps as many if not more
centuries than any river now on earth has seen, and this forms a layer or
core of gold-bearing gravel. In some places it has paid richly: in more
places it has not paid at all.
I said to myself: “This Halsey lead, like all the leads of this section, runs
northeast and southwest.” (N. B.—Three years afterward we found there
were no leads at all in that section.) “The Halsey lead must run under Table
Mountain and come out somewhere on the other side.” So I took the
bearings of the Halsey lead, or what I then supposed were the bearings, for
there wasn’t any lead anyway, with a compass. I aimed my compass at a
point on the ledge of the flat summit of Table Mountain. I hit it. Then I
climbed up over the two water shelves or banks to that point. This was on
the honey-combed lava crags. From these crags one could see afar north
and south. South, over Tuolumne into Mariposa the eye following the great
white quartz outcrop of the Mother or Mariposa lead. North was Bear
Mountain, the Stanislaus River and Stanislaus County. This view always
reminded me of the place where one very great and very bad historical
personage of the past as well as the present showed another still greater and
much better Being all the kingdoms of the earth. For the earth wasn’t all
laid out, pre-empted and fenced in those days, and its kingdoms were small.
Then I ran my lines over the flat top of Table Mountain, southeast and
northwest. So they said ran all the copper leads, commencing at
Copperopolis. So then we believed, while tossing with the copper fever.
Certainly they ran somewhere, and ran fast too, for we never caught any
paying copper vein in Tuolumne County, at least any that paid—except to
sell.
I aimed my compass down the other side of the mountain. There, when
the perpendicular lava rock stopped pitching straight up and down,
sometimes fifty, sometimes two hundred feet, was a dense growth of
chaparral—the kind of chaparral we called “chemisal.” I got into the
chemisal. Here the compass was of no more use than would be a certificate
of Copperhead copper stock to pay a board bill. It was a furry, prickly,
blinding, bewildering, blundering, irritating growth, which sent a pang
through a man’s heart and a pricker into his skin at every step. At last,
crawling down it on all-fours, for I could not walk, dirty, dusty, thirsty, and
perspiring, I lit on a rock, an outcrop of ledge. It was gray and moss grown.
It hid and guarded faithfully the treasure it concealed. Like Moses, I struck
the rock with my little hatchet. The broken piece revealed underneath a
rotten, sandy-like, spongy formation of crumbling, bluish, greenish hue. It
was copper! I had struck it! I rained down more blows! Red oxides, green
carbonates, gray and blue sulphurets! I had found the Copperhead lead! I
was rich. I got upon that rock and danced! Not a graceful, but an
enthusiastic pas seul. I deemed my fortune made. I was at last out of the
wilderness! But I wasn’t.
 CHAPTER XXIV.

RISE AND FALL OF COPPERHEAD CITY.

I trudged back nine miles to Sonora, my pockets full of “specimens”

from the newly discovered claim, my head a cyclone of copper-hued air
castles. I saw the “boys.” I was mysterious. I beckoned them to retired
spots. I showed them the ores. I told them of the find. They were wild with
excitement. They were half crazed with delight. And in ten minutes some of
them went just as far into the domains of unrest and unhappiness for fear
some one might find and jump the claim ere I got back to guard it. The
Copperhead Company was organized that night. The “Enthusiast,” a man
who lived in the very top loft of copper insanity, was sent down with me to
superintend the sinking of the shaft. The secret was soon out. Shares in the
vein were eagerly coveted. I sold a few feet for $500 and deemed I had
conferred a great favor on the buyer in letting it go so cheaply. I lived up,
way up, in tens of thousands and hundreds of thousands of dollars. The
“company” in Sonora met almost every night to push things while the
Enthusiast and myself blasted and burrowed in the rock. By day they
exhausted their spare cash in horse hire, riding down to the claim in hope of
being on hand when the next blast should reveal a bed of ore, immense in
breadth and unfathomable in depth.
My Company was made up chiefly of lawyers, doctors, politicians, and
editors. They never realized how much they were indebted to me. For four
months I made them feel rich,—and if a man feels rich, what more should
he want? For a millionaire can do no more than feel rich.
Feeling certain that the Copperhead was a very rich claim, and that other
rich claims would be developed from the “extensions,” and that a bustling
town would be the result, I pre-empted a section of the land which I deemed
most valuable, on which it was intended that “Copperhead City” should be
built. This “city” I partly laid out. I think this was the third city I had laid
out in California. There is a sepulchral and post-mortem suggestion in the
term “laid out” which is peculiarly applicable to all the “cities” which I
attempted to found, and which “cities” invariably foundered. Actuated, also,
at that time, by those business principles so largely prevalent in most
Christian communities, I “claimed” the only spring of good drinking water
in the neighborhood of my “city.” My intent in this was in time to realize a
profit from the indirect sale of this water to such of the future “city’s”
population as might want water—not to sell it by the glass or gallon, of
course; but if there was to be a “city” it would need water-works. The
water-works would necessarily lie on my land. I would not be guilty of the
inhumanity of selling water to parch-tongued people, but I proposed that the
“city” should buy of me the ground out of which came the water.
But one house was ever erected in Copperhead City proper, and that had
but one room. But three men ever lived in it. Yet the city was thickly
populated. It was located in a regular jungle, so far as a jungle is ever
attained in California, and seemed the head-centre and trysting-place of all
the rattlesnakes, coons, skunks, owls, and foxes on the west side of Table
Mountain. When the winter wore off and the warm California spring wore
on and merged into the summer heat of May, and the pools made by the
winter rains dried up, I think all the rattlesnakes and copperheads for miles
around went for my pre-empted spring of pure water. The “city,” I mean the
house, was located within a few feet of the spring. Returning thither at noon
for dinner, I have started half a dozen snakes from the purlieus and suburbs
of that spring. Snakes get dry like human beings. Snakes love water.
Snakes, poor things, can’t get anything else to drink, and must fill up on
water. These were sociable snakes. When startled at our approach they
would not run away from our society. No. They preferred to remain in the
“city,” and so, in many instances they ran under the house. It is not pleasant
at night to feel that you are sleeping over a veteran rattler four feet long,
with a crown of glory on his tail in the shape of fourteen or fifteen rattles.
You won’t crawl under your house to evict such a rattlesnake, either.
Skunks inhabited our “city,” also. Skunks know their power—their peculiar
power.
The evening gloaming seems the favorite time for the skunk to go
abroad. He or she loves the twilight. There must be a vein of sentiment in
these far-smelling creatures. I have in the early evening travelled up the
only street our “city” ever laid out—a trail—and ahead of me on that trail I
have seen a skunk. I was willing he should precede me. In the matter of
rankness I was perfectly willing to fall a long way behind him. Now, if you
have studied skunks you will know that it is far safer to remain in the
skunk’s rear than to get ahead of him, because when he attacks with his
favorite aromatic means of offensive defence he projects himself forward
(as it were). I have then, in my city, had a skunk keep the trail about fifty
feet ahead of me at a pace which indicated little alarm at my presence, and,
do my best, I could not frighten the animal, nor could I get ahead of him or
her. If I ran he ran; if I walked he concurred in rapidity of pace. I dared not
approach too near the animal. I would rather break in upon the “sacred
divinity” which, they say, “doth hedge a king” than transgress the proper
bounds to be observed with reference to a skunk. Let a king do his best, and
he cannot punish an intruder as can a skunk.
The skunk is really a pretty creature. Its tail droops over its back, like the
plumes of the Knight of Navarre. It is an object which can really be admired
visually at a distance. Do not be allured by him to too near approach.
“Beware! he’s fooling thee!”
At last it dawned upon the collective mind of the Copperhead Company
that their Superintendent, the Enthusiast, was digging too much and getting
down too little. They accepted his resignation. It mattered little to him, for
by this time his mind was overwhelmed by another stupendous mining
scheme, to which the Copperhead was barely a priming. He had the happy
talent of living in these golden visions which, to him, were perfect realities.
He held the philosophy that the idea, the hope, the anticipation of a thing is
sometimes more “the thing” than the thing itself. The Enthusiast’s rich
mines lay principally in his head, but his belief in them gave him as much
pleasure as if they really existed. It was like marrying, sometimes. The
long-sought-for, longed-for, wished-for wife, or husband, turns out, as a
reality, a very different being from what he or she was deemed while in
process of being longed and sought for. The long-longed-for may have been
estimated an angel. The angel, after wedlock, may prove to have been a
myth. The reality may be a devil, or within a few shades or degrees of a
devil.
So the shaft was sunk, as they said, properly and scientifically, by the
new Superintendent. The rock got harder as we went down, the ore less, the
vein narrower, the quantity of water greater, the progress slower, the weekly
expenses first doubled and then trebled, the stock became less coveted, and
as to reputed value, reached that fatal dead level which really means that it
is on its downward descent. The shareholders’ faces became longer and
longer at their weekly Sunday afternoon meetings in the Sonora Court-
house.
The Copperhead Claim and Copperhead City subsided quietly. The
shareholders became tired of mining for coin to pay assessments out of their
own pockets. They came at last to doubt the ever-glowing hopeful assertion
of the Enthusiast that from indications he knew the “ore was forming.” The
inevitable came. Copperhead City was deserted by its human inhabitants.
The skunk, the snake, the squirrel, the woodpecker, and the buzzard came
again into full possession, and I bitterly regretted that I had not sold more at
ten dollars a foot when I found the stock a drug at ten cents.
 CHAPTER XXV.

PROSPECTING.

The failure of the Copperhead Claim and the collapse of Copperhead

City did not discourage me. The flame only burned the brighter to go forth
and unearth the veins of mineral wealth which imagination showed me
lying far and near in this land still of such recent settlement.
This was in 1863-64. The great silver leads of Nevada had but recently
been discovered. The silver excitement was at its height. People were
thinking that barely the threshold of the mineral richness of the Pacific
slope had been reached and that untold treasure underground awaited the
prospector’s exploration north, south, and east, so far as he could go.
Fired with this all-pervading thought I projected one of the grandest of
my failures. I organized the “Mulford Mining, Prospecting, and Land
Company,” whose intent was to take up and hold all the mineral veins I
found and secure all desirable locations I might come upon for farms, town
sites, and other purposes.
“Holding” a mineral vein, or whatever I might imagine to be a mineral
vein, could be done after the proper notices were put up, by performing on
such veins one day’s work a month, and such “day’s work” was supposed to
be done by turning up a few shovelfuls of dirt on the property.
My Company consisted of thirty members, who lived at varying
distances apart, within and without the county of Tuolumne. For my
services as general prospector, discoverer, and holder of all properties
accumulated (by myself) I was to receive from each member three dollars
per month.
I fixed this princely stipend myself, being then ever in fear that I should
overcharge others for services rendered.
By dint of great exertion, I succeeded in getting one-third of the
members together one hot summer afternoon in a Montezuma grocery. I
unfolded then the Company’s Constitution and By-Laws, written by myself
at great length on several sheets of foolscap pasted together. I read the
document. It provided for the Company a President, Secretary, Treasurer,
and Board of Directors. It set forth their duties and my duties as “General
Prospector.” I was particularly stringent and rigid regarding myself and my
responsibilities to the Company.
The fragment of the new Company present assented to everything, paid
in their first installment of three dollars, and bade me go forth and “strike
something rich” as quickly as possible.
I went forth at first afoot with the few dollars paid me. I subsisted in a
hap-hazard—indeed I must say beggarly fashion, stopping with mining
friends and dependent to great extent on their hospitality, while I “held” the
few claims I had already found and found others in their neighborhood.
At last I found a man who subscribed the use of a horse for the summer
in consideration of being enrolled as a shareholder. On similar terms I
gained a saddle, a shot-gun, a dog, and some provisions. This put the
“Company” on a more stable footing, for I was now no longer dependent on
house or hospitality, and could stop wherever night overtook me, and wood,
water, and grass were at hand.
My horse I think was the slowest of his kind in the Great West, and my
gun kicked so vigorously when discharged that I frequently sustained more
injury than the game aimed at.
My field of operations extended over 150 miles of country, from the foot
hills of the Sierras to their summits and beyond in the Territory of Nevada.
Land, wood, water, grass, and game, if found, were free in every direction.
The country was not fenced in, the meaning of “trespassing” on land was
unknown—in fact it was then really a free country—a term also not
altogether understood in the older States, where if you build a camp-fire in
a wood lot you run some risk from the farmer who owns it, and his bulldog.
Sometimes, I would be a week or ten days without seeing a human face.
A roof rarely covered me. I would camp one day near a mountain summit
looking over fifty or sixty miles of territory and the next at its base with a
view bounded by a wall of rock a few hundred yards distant. Sometimes I
was very lonesome and uneasy at night in these mountain solitudes. I
longed generally about sundown for some one to talk to. Anything human
would answer such purpose then. In the bright clear morning the lonesome
feeling was all gone. There was companionship then in the trees, the clouds,
the mountain peaks, far and near, yet there were times when the veriest clod