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NEUROLOGICAL
EXAMINATION
MADE EASY
This page intentionally left blank

     
NEUROLOGICAL
EXAMINATION
MADE EASY

GERAINT FULLER MD FRCP

Consultant Neurologist
Gloucester Royal Hospital
Gloucester, United Kingdom

SIXTH EDITION

For additional online content visit StudentConsult.com

Edinburgh London New York Oxford Philadelphia St Louis Sydney 2020

© 2019, Elsevier Limited. All rights reserved.

The right of Geraint Fuller to be identified as author of this work has been asserted
by him in accordance with the Copyright, Designs and Patents Act 1988.

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

First edition 1993

Second edition 1999
Third edition 2004
Fourth edition 2008
Fifth edition 2013
Sixth edition 2020

ISBN: 9780702076275
International ISBN: 9780702076282

Notices

Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds or
experiments described herein. Because of rapid advances in the medical sci-
ences, in particular, independent verification of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed
by Elsevier, authors, editors or contributors for any injury and/or damage to
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Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

CONTENTS

Preface vii
Acknowledgements viii
How to use this book ix
1. History and examination 1
2. Speech 11
3. Mental state and higher function 20
4. Gait 35
5. Cranial nerves: General 41
6. Cranial nerve I: Olfactory nerve 45
7. Cranial nerves: The eye 1 – pupils, acuity, fields 46
8. Cranial nerves: The eye 2 – fundi 62
9. Cranial nerves III, IV, VI: Eye movements 77
10. Cranial nerves: Nystagmus 87
11. Cranial nerves V and VII: The face 91
12. Cranial nerve VIII: Auditory nerve 99
13. Cranial nerves IX, X, XII: The mouth 103
14. Cranial nerve XI: Accessory nerve 108
15. Motor system: Introduction 110
16. Motor system: Tone 115
17. Motor system: Arms 118
18. Motor system: Legs 130
vi CONTENTS

19. Motor system: Reflexes 139

20. Motor system: What you find and what it means 148
21. Sensation: General 155
22. Sensation: What you find and what it means 168
23. Coordination 174
24. Abnormal movements 178
25. Special signs and other tests 187
26. The autonomic nervous system 196
27. The unconscious or confused patient 199
28. Summary of standard neurological examination 215
29. Passing clinical examinations 217
Bibliography for further reading and reference 230
Index 231
PREFACE

Many medical students and junior doctors think that neurological

examination is extremely complicated and difficult (and some-
times frightening!).
This is because they find it hard to remember what to do, are
not sure what they are looking for, do not know how to describe
what they find and do not know what it means.
The aim of this book is to provide a simple framework to allow
a medical student or junior doctor to perform a straightforward
neurological examination. It explains what to do, pointing out
common problems and mistakes, what you might find, and then
discusses what the findings might mean.
However, just as you cannot learn to drive by reading a book,
this book cannot replace conventional bedside teaching and clini-
cal experience, and I hope it will encourage you to see patients.
Neurological Examination Made Easy aims to provide advice on
your examination technique to ensure your clinical findings are
robust, and will help you analyse your findings to help you come
to an anatomical or syndromic diagnosis. Inevitably, when trying to
simplify the range of neurological findings and their interpretation,
not all possible situations can be anticipated. This book has been
designed to try to accommodate most common situations and
tries to warn of common pitfalls; however, despite this, there will
be some occasions where incorrect conclusions will be reached.
Neurology is still a very clinical specialty where the core clinical
skills of taking a history and of neurological examination remain
central when making a diagnosis – indeed many neurological diag-
noses are entirely dependent on the clinical assessment alone.
Developing these skills takes time but will be very rewarding for
you as the doctor and very beneficial for your patients. Neurologi-
cal Examination Made Easy will give you an excellent foundation
in learning the skills needed for neurological examination and an
introduction to the thought processes needed in their interpretation.
ACKNOWLEDGEMENTS

I would like to thank all my teachers, particularly Dr Roberto

Guiloff, who introduced me to neurology. I am grateful to the
many medical students at Charing Cross and Westminster Medi-
cal School who have acted as guinea pigs in the preparation of
the previous editions of this book and to the colleagues who have
kindly commented on the text. I am also most appreciative of
all the constructive comments made about the earlier editions of
the book by students, mainly from Bristol University, junior doc-
tors and colleagues, and particularly from those neurologists who
were involved in translating it into other languages.
In learning to be a clinical neurologist and in writing this book,
I am indebted to a wide range of textbooks and scientific papers
that are too many to mention.

This book is dedicated to Cherith.

HOW TO USE THIS BOOK

This book concentrates on how to perform the neurological part of a

physical examination. Each chapter starts with a brief background and
relevant information. This is followed by a section telling you ‘What to
do’, both in a straightforward case and in the presence of abnormalities.
The abnormalities that can be found are then described in the ‘What
you find’ section, and finally the ‘What it means’ section provides an
interpretation of the findings and suggests potential pathologies.
It is important to understand that the neurological examination can
be used as:
  
• a screening test
• an investigative tool.
  
It is used as a screening test when you examine a patient in whom you
expect to find no neurological abnormalities: for example, a patient
with a non-neurological disease or a patient with a neurological illness
not normally associated with physical abnormalities, such as migraine
or epilepsy. Neurological examination is used as an investigative tool
in patients when a neurological abnormality is found on screening,
or when an abnormality can be expected from the history. The aim of
examination is to determine whether there is an abnormality, deter-
mining its nature and extent and seeking associated abnormalities.
There is no ideal neurological examination technique. The methods
of neurological examination have evolved gradually. There are conven-
tional ways to perform an examination, a conventional order of examina-
tion and conventional ways to elicit particular signs. Most neurologists
have developed their own system for examination, a variation on the
conventional techniques. Most experienced neurologists will adjust
their examination technique depending on the nature of the patient’s
history. One such variation is presented here, which aims to provide a
skeleton for students to flesh out with their own personal variations.
In this book, each part of the examination is dealt with separately.
This is to allow description and understanding of abnormalities in
each part of the examination. However, these parts need to be consid-
ered together in evaluating a patient as a whole. Thus the findings in
total need to be synthesised.
x HOW TO USE THIS BOOK

The synthesis of the examination findings should be as described

answering the questions: where (is the lesion) or what (is the syn-
drome) and why (has it developed).

1. Anatomical (where?)
Can the findings be explained by:
  
• one lesion
• multiple lesions
• a diffuse process?
  
What level/levels of the nervous systems is/are affected (Fig. 0.1)?

Cortex

Basal ganglia

Cerebellum

Brain stem

Nerve Spinal cord

Neuro-
muscular
junction

Nerve root

Plexus

Cauda equina
Muscle

Fig. 0.1
The levels of the nervous system
 HOW TO USE THIS BOOK xi

2. Syndromal (what?)
Do the clinical findings combine to form a recognisable clinical syn-
drome: for example, parkinsonism, motor neurone disease, multiple
sclerosis?

3. Aetiological (why?)
Once you have come to an anatomical or syndromal synthesis, con-
sider what pathological processes could have caused this:
  
• genetic
• congenital
• infectious
• inflammatory
• neoplastic
• degenerative
• traumatic
• metabolic and toxic
• paroxysmal (including migraine and epilepsy)
• endocrine
• vascular?
  
The interpretation of the neurological history and the synthesis of
the neurological examination require experience and background
knowledge. This book will not be able to provide these. However,
using this book you should be able to describe, using appropriate
terms, most of the common neurological abnormalities, and you will
begin to be able to synthesise and interpret them.
Throughout the book, the patient and examiner are presumed to be
male, to avoid the awkward use of he/she.
Cranial nerves will be referred to by their name, or by their number
in roman numerals.

GLOSSARY OF NEUROLOGICAL TERMS

Neurological terms have evolved and some terms may be used in dif-
ferent ways by different neurologists.
Here are some terms used to describe pathologies at different levels
of the nervous system.
-opathy: suffix indicating abnormality at the level of the nervous sys-
tem indicated in the prefix; see encephalopathy below. Cf. -itis.
-itis: suffix indicating inflammation of the level of the nervous system
indicated in the prefix; see myelitis below.
Encephalopathy: abnormality of the brain. May be refined by adjec-
tives such as focal or diffuse, or metabolic or toxic.
Encephalitis: inflammation of the brain. May be refined by adjec-
tives such as focal or diffuse. May be combined with other terms to
indicate associated disease, e.g. meningo-encephalitis = meningitis and
encephalitis.
xii HOW TO USE THIS BOOK

Meningitis: inflammation of the meninges.

Myelopathy: abnormality of the spinal cord. Refined by terms indi-
cating aetiology, e.g. radiation, compressive.
Myelitis: inflammation of the spinal cord.
Radiculopathy: abnormality of a nerve root.
Plexopathy: abnormality of nerve plexus (brachial or lumbar).
Peripheral neuropathy: abnormality of peripheral nerves. Usually
refined using adjectives such as diffuse/multifocal, sensory/sensorimo-
tor/motor and acute/chronic.
Polyradiculopathy: abnormality of many nerve roots. Usually
reserved for proximal nerve damage and to contrast this with length-
dependent nerve damage.
Polyneuropathy: similar term to peripheral neuropathy, but may be
used to contrast with polyradiculopathy.
Mononeuropathy: abnormality of a single nerve.
Myopathy: abnormality of muscle.
Myositis: inflammatory disorder of muscle.
Functional: when the neurological problem is not due to struc-
tural pathology; examples range from non-organically determined
weakness (often diagnosed as functional neurological disorders) to
more specific psychiatric syndromes such as hysterical conversion
disorder.
 1
HISTORY AND EXAMINATION

HISTORY
The history is the most important part of the neurological evaluation.
Just as detectives gain most information about the identity of a crimi-
nal from witnesses rather than from the examination of the scene of
the crime, neurologists learn most about the likely pathology from
the history rather than from the examination.
The general approach to the history is common to all complaints.
Which parts of the history prove to be most important will obviously
vary according to the particular complaint. An outline for approach-
ing the history is given below. The history is usually presented in
a conventional way (see below) so that doctors, being informed of
or reading the history, know what they going to be told about next.
Everyone develops their own way of taking a history and doctors
often adapt the way they do it depending on the clinical problem
facing them. This section is organised according to the usual way in
which a history is presented—recognising that, sometimes, elements
of the history can be obtained in a different order.
Many neurologists would regard history taking, rather than neuro-
logical examination, as their special skill (though you obviously need
both). This indicates the importance attached to history taking within
neurology, and reflects that it is an active process, requiring listening,
thinking and reflective questioning rather than simply passive note
taking. There is now evidence that it is not just what the patient says,
but the way he says it that can be diagnostically useful (for example,
in the diagnosis of non-epileptic attack disorder).

The neurological history

• Age, sex, handedness, occupation
• History of present complaint
• Neurological screening questions
• Past medical history
• Drug history
• Family history
• Social history.
2 NEUROLOGICAL EXAMINATION MADE EASY

Basic background information

Establish some basic background information initially—the age, sex,
handedness and occupation (or previous occupation) of the patient.
Handedness is important. The left hemisphere of the brain con-
tains language in almost all right-handed individuals, and in 70% of
patients who are left-handed or ambidextrous.

Present complaint
Start with an open question such as ‘Tell me all about it from the very
beginning’ or ‘What has been happening?’ Try to let patients tell their
story in their own words without (or with minimal) interruption. The
patient may need to be encouraged to start from the beginning. Often
patients want to tell you what is happening now. You will find this easier
to understand if you know what events led up to the current situation.
Whilst listening to their story, try to determine (Fig. 1.1):
  
• The nature of the complaint. Make sure you have understood what
the patient is describing. For example, dizziness may mean vertigo
(the true sensation of spinning) or lightheadedness or a swimming
sensation in the head. When a patient says his vision is blurred,
he may mean it is double. A patient with weakness but no altered
sensation may refer to his limb as numb.

TIP It is better to get an exact description for specific

events, particularly the first, last and most severe events,
rather than an abstracted summary of a typical event.

  
• The time course. This tells you about the tempo of the pathology
(Table 1.1 and Fig. 1.2).
– The onset: How did it come on? Suddenly, over a few seconds,
a few minutes, hours, days, weeks or months?
– Progression: Is it continuous or intermittent? Has it improved,
stabilised or progressed (gradually or in a stepwise fashion)?
When describing the progression, use a functional gauge where
possible: for example, the ability to run, walk, using one stick,
walking with a frame or walker.
– The pattern: If intermittent, what was its duration and what
was its frequency?

TIP It can be useful to summarise the history, thinking

about how you would describe the time course, as the
terms used can point towards the relevant underly-
ing pathological process. For example, sudden onset or
acute suggests vascular; subacute suggests inflammation,
infection or neoplasia; progressive suggests neoplasia or
degenerative; stepwise or stuttering suggests vascular or
inflammation; relapsing–remitting suggests inflammation.
 HISTORY AND EXAMINATION 3

Interpretation of patient's
symptoms

Time course of symptoms

Generate hypothesis and Test hypothesis

differential diagnosis

Ask about associated features

Neurological screening history Ask about risk factors

Impact of neurological problem on life, home, work and family

Conventional background history

Past medical history; drug history; social history; family history

Synthesise differential diagnosis and hypotheses to test during

examination

Fig. 1.1
Flow chart: the present complaint

TIP Remember: when a patient cannot report all events

himself or cannot give a history adequately for another
reason such as a speech problem, it is essential to get the
history from others if at all possible, such as relatives,
friends or even passers-by.
If you cannot see them in person—call them on the
telephone!

Also determine:
  
• Precipitating or relieving factors. Remember that a spontaneously re-
ported symptom is much more significant than one obtained on di-
rect questioning. For example, patients rarely volunteer that their
headaches get worse on coughing or sneezing, and when they do
so without prompting it suggests raised intracranial pressure. In
contrast, many patients with tension-type headaches and migraine
4 NEUROLOGICAL EXAMINATION MADE EASY

Table 1.1
Some illustrations of how time course indicates pathology

Time course Pathological process

A 50-year-old man with complete visual loss in his right eye
Came on suddenly and lasted 1 Vascular: impaired blood flow to the
minute retina; ‘amaurosis fugax’
Came on over 10 minutes and Migrainous
lasted 20 minutes
Came on over 4 days and then Inflammatory; inflammation in the optic
improved over 6 weeks nerve; ‘optic neuritis’
Progressed over 3 months Optic nerve compression; possibly from
a meningioma
A 65-year-old woman with left-sided face, arm and leg weakness
Came on suddenly and lasted 10 Vascular:
minutes • transient ischaemic attack
Came on over 10 minutes and Vascular:
persists several days later • stroke
Came on over 4 weeks Consider subdural tumour
Came on over 4 months Likely to be tumour
Has been there since childhood Congenital

will say their headaches get worse with coughing or sneezing if

directly asked about them.
• Previous treatments and investigations. Prior treatments may have
helped or have produced adverse effects. This information may
help in planning future treatments.
• The current neurological state. What can the patient do now? De-
termine current abilities in relation to normal everyday activities.
Clearly, the relevance of this will differ depending on the problem
(headaches will interfere with work but not walking). Consider
asking about their work; mobility (can he walk normally or what
is the level of impairment?); ability to eat, wash and go to the
toilet.
• Hypothesis generation and testing. Whilst listening, think about
what might be causing the patient’s problems. This may sug-
gest associated problems or precipitating factors that would be
worth exploring. For example, if a patient’s history makes you
wonder whether he has Parkinson’s disease, ask about his hand-
writing—something you would probably not talk about with
most patients.
• Screening for other neurological symptoms. Determine whether the
patient has had any headaches, fits, faints, blackouts, episodes of
numbness, tingling or weakness, any sphincter disturbance (uri-
nary or faecal incontinence, urinary retention and constipation) or
visual symptoms including double vision, blurred vision or loss of
sight. This is unlikely to provide any surprises if hypothesis testing
has been successful.
 Onset Vascular Epileptic Migrainous Inflammatory Infective Neoplastic Degenerative Genetic Congenital

Seconds

Minutes

Hours

Days

*
Weeks

Months

HISTORY AND EXAMINATION

Years

Fig. 1.2
The tempo of different pathological processes. The onset of metabolic and endocrinological problems relates to the rate of onset of the
metabolic or endocrine problem. *Late vascular problems from chronic subdural haematoma

5
6 NEUROLOGICAL EXAMINATION MADE EASY

COMMON MISTAKES
• Patients frequently want to tell you about the doctors they
have seen before and what these doctors have done and said,
rather than describing what has been happening to them
personally. This is usually misleading and must be regarded
with caution. If this information would be useful to you, it
is better obtained directly from the doctors concerned. Most
patients can be redirected to give their history rather than the
history of their medical contacts.
• You interrupt the story with a list of questions. If uninter-
rupted, patients usually only talk for 1–2 minutes before
stopping. Listen first, and then clarify what you do not un-
derstand later.
• The history just does not seem to make sense. This tends to
happen in patients with speech, memory or concentration
difficulties and in those with non-organic disease. Think of
aphasia, depression, dementia and hysteria.

TIP It is often useful to summarise the essential points of

the history to the patient—to make sure that you have under-
stood them correctly. This is called ‘chunking and checking’.

Conventional history
Past medical history
This is important to help understand the aetiology or discover con-
ditions associated with neurological conditions. For example, a his-
tory of hypertension is important in patients with stroke; a history
of diabetes in patients with peripheral neuropathy; and a history of
previous cancer surgery in patients with focal cerebral abnormalities
suggesting possible metastases.
It is always useful to consider the basis for any diagnosis given
by the patient. For example, a patient with a past medical history
that starts with ‘known epilepsy’ may not in fact have epilepsy; once
the diagnosis is accepted, it is rarely questioned and patients may be
treated inappropriately.

Drug history
It is essential to check what prescribed drugs and over-the-counter
medicines are being taken. This can act as a reminder of the condi-
tions the patient may have forgotten (hypertension and asthma).
Drugs can also cause neurological problems—it is often worth check-
ing their adverse effects.
N.B. Many women do not think of the oral contraceptive as a drug
and need to be asked about it specifically.
 HISTORY AND EXAMINATION 7

Family history
Many neurological problems have a genetic basis, so a detailed fam-
ily history is often very important in making the diagnosis. Even if no
one in the family is identified with a potentially relevant neurological
problem, information about the family is helpful. For example, think
about what a ‘negative’ family history means in:
  
• a patient with no siblings whose parents, both only children, died
at a young age from an unrelated problem (for example, trauma);
• a patient with seven living older siblings and living parents (each
of whom has four younger living siblings).
  
The former might well have a familial problem though the family
history is uninformative; the latter would be very unlikely to have an
inherited problem.
In some circumstances, patients can be reluctant to tell you about
certain inherited problems: for example, Huntington’s disease. On
other occasions, other family members can be very mildly affected;
for example, in hereditary neuropathies, some family members will
simply have high arched feet rather than an overt neuropathy, so
this needs to be actively sought if it is likely to be relevant.

Social history
Neurological patients frequently have significant disability. For these
patients, the environment in which they normally live, their financial
circumstances, their family and carers in the community are all very
important to their current and future care.

Toxin exposure
It is important to establish any exposure to toxins, including in this
category both tobacco and alcohol, as well as industrial neurotoxins.

Systemic inquiry
Systemic inquiry may reveal clues that general medical disease
may be presenting with neurological manifestations. For example, a
patient with atherosclerosis may have angina and intermittent clau-
dication as well as symptoms of cerebrovascular disease.

Patient’s perception of illness

Ask patients what they think is wrong with them. This is useful when
you discuss the diagnosis with them. If they turn out to be right, you
know they have already thought about the possibility. If they have
something else, it is also helpful to explain why they do not have
what they suggested and probably are particularly concerned about.
For example, if they have a migraine but are concerned that they
have a brain tumour, it is helpful to discuss this differential diagnosis
specifically.
8 NEUROLOGICAL EXAMINATION MADE EASY

Anything else?
Always include an open question towards the end of the history—
’Is there anything else you wanted to tell me about?’—to make
sure patients have had the chance to tell you everything they
wanted to.

Synthesis of history and differential diagnosis

It is useful to summarise the history before moving on to the exami-
nation—in your own mind at least—and try to come to a differential
diagnosis. The type of differential diagnosis will vary according to
the patient—some examples:
  
• In a patient with a history of wrist drop, your main question may
be whether this is a radial nerve palsy, C7 radiculopathy or some-
thing else.
• In a patient with right-sided slowness, you might wonder whether
what they have is a movement disorder, such as Parkinson’s dis-
ease, or an upper motor neurone weakness.
  
If you think about the differential at this stage, you can then be sure
to use the examination to try to come to a diagnosis.
So, think about the differential diagnosis generated from the his-
tory. Think what might be found on examination in these circum-
stances and ensure you focus on these possibilities during your
examination.
In summary, think about the history.

GENERAL EXAMINATION
General examination may yield important clues as to the diagnosis
of neurological disease. Examination may find systemic disease with
neurological complications (Fig. 1.3 and Table 1.2).
A full general examination is therefore important in assessing
a patient with neurological disease. The features that need to be
particularly looked for in an unconscious patient are dealt with in
Chapter 27.
 HISTORY AND EXAMINATION 9

Rash
Temporal artery (Dermatomyositis)
(temporal arteritis)

Thyroid disease
(myopathy; neuropathy)

Carotid bruits Heart sounds

(TIA, stroke) (stroke)

BP
(stroke)

Heart rhythm
(→syncope)

Chest examination
(lung cancer;
bronchiectasis)

Nail folds
(vasculitis; SBE)
Clubbing Liver
(cerebral metastases) (metastases)

Fig. 1.3
General examination of neurological relevance. (BP = blood pressure;
SBE = subacute bacterial endocarditis; TIA = transient ischaemic attack)
10 NEUROLOGICAL EXAMINATION MADE EASY

Table 1.2
Examination findings in systemic disease with neurological complications

Neurological
Disease Sign condition
Degenerative diseases
Atherosclerosis Carotid bruit Stroke
Valvular heart disease Murmur Stroke
Inflammatory disease
Rheumatoid arthritis Arthritis and rheumatoid Neuropathies
nodules Cervical cord compres-
sion
Endocrine disease
Hypothyroidism Abnormal facies, skin, Cerebellar syndrome
hair Myopathy
Diabetes Retinal changes Neuropathy
Injection marks
Neoplasia
Lung cancer Pleural effusion Cerebral metastases
Breast cancer Breast mass Cerebral metastases
Dermatological disease
Dermatomyositis Heliotrope rash Dermatomyositis
 2
SPEECH

BACKGROUND
Abnormalities of speech need to be considered first, as these may inter-
fere with your history taking and subsequent ability to assess other
aspects of higher function and perform the rest of the examination.
Abnormalities of speech can reflect abnormalities anywhere along
the following chain.

PROCESS ABNORMALITY
Hearing Deafness
Understanding
Aphasia
Thought and word finding
Voice production Dysphonia
Articulation Dysarthria

Problems with deafness are dealt with in Chapter 12.

1. Aphasia
In this book, the term aphasia will be used to refer to all disorders of
understanding, thought and word finding. Dysphasia is a term used
by some to indicate a disorder of speech, reserving aphasia to mean
absence of speech.
Aphasia has been classified in a number of ways and each new clas-
sification has brought some new terminology. There are therefore a
number of terms that refer to broadly similar problems:  
• Broca’s aphasia = expressive aphasia = motor aphasia
• Wernicke’s aphasia = receptive aphasia = sensory aphasia
• nominal aphasia = anomic aphasia
  
12 NEUROLOGICAL EXAMINATION MADE EASY

Concept area

4 5

Wernicke’s Broca’s
area area
1 3 2

Hearing Voice production

& articulation

Fig. 2.1
Simple model of speech understanding and output

Most of these systems have evolved from a simple model of apha-

sia (Fig. 2.1). In this model, sounds are recognised as language in
Wernicke’s area, which is then connected to a ‘concept area’ where
the meaning of the words is understood. The ‘concept area’ is con-
nected to Broca’s area, where speech output is generated. Wernicke’s
area is also connected directly to Broca’s area by the arcuate fascicu-
lus. These areas are in the dominant hemisphere and are described
later. The left hemisphere is dominant in right-handed patients and
some left-handed patients, and the right hemisphere is dominant in
some left-handed patients.
The following patterns of aphasia can be recognised and are associ-
ated with lesions at the sites as numbered on the figure:  
1. Wernicke’s aphasia—poor comprehension; fluent but often mean-
ingless (as it cannot be internally checked) speech; no repetition
2. Broca’s aphasia—preserved comprehension; non-fluent speech;
no repetition
3. Conductive aphasia—loss of repetition with preserved compre-
hension and output
4. Transcortical sensory aphasia—as in (1) but with preserved rep-
etition
5. Transcortical motor aphasia—as in (2) but with preserved repeti-
tion  
Reading and writing are further aspects of language. These can
also be included in models such as the one above. Not surprisingly,
the models become quite complicated!
 SPEECH 13

2. Dysphonia
This is a disturbance of voice production and may reflect either
local vocal cord pathology (such as laryngitis), an abnormality of
the nerve supply via the vagus, or occasionally a psychological
disturbance.

3. Dysarthria
Voice production requires coordination of breathing, vocal cords, lar-
ynx, palate, tongue and lips. Dysarthria can therefore reflect difficul-
ties at different levels.
Lesions of (a) upper motor neurone type, (b) the extrapyramidal
system (such as Parkinson’s disease) and (c) cerebellum, all disturb
the integration of processes of speech production and tend to disturb
the rhythm of speech.
Lesions of one or several of the cranial nerves tend to produce
characteristic distortion of certain parts of speech, but the rhythm is
normal.

1. APHASIA

WHAT TO DO
Speech abnormalities may hinder or prevent taking a history from
the patient. If so, take the history from relatives or friends.  
Establish if the patient is right- or left-handed.
Discover the patient’s first language.

Assess understanding
Ask the patient a simple question:  
• What is your name and address?
• What is/was your job? Explain exactly what you do.
• Where do you come from?
  
If he does not appear to understand:
  
• Repeat louder.
Test understanding
• Ask questions with yes/no answers:
– e.g. ‘Is this a pen?’ (showing something else, then a pen).
• Give a simple command:
– e.g. ‘Open your mouth’ or ‘With your right hand touch your
nose.’
14 NEUROLOGICAL EXAMINATION MADE EASY

• If successful, try more complicated commands:

– e.g. ‘With your right hand touch your nose and then your left ear.’
• Define how much is understood.

TIP Remember: if patients are weak, they may not be able

to perform simple tasks.

Assess spontaneous speech

If the patient does appear to understand but is unable to speak:  
• Ask if he has difficulty in finding the right words. This often brings a
nod and a smile, indicating pleasure that you understand his problem.
• If the problem is less severe, he may be able to tell you his name
and address slowly.

Ask further questions

Enquire, for example, about the patient’s job or how the problem started.  
• Is speech fluent?
• Does he use words correctly?
• Does he use the wrong word (paraphasia) or is it meaningless jar-
gon (sometimes called jargon aphasia)?

Assess word-finding ability and naming

• Ask the patient to name all the animals he can think of (normal =
18–22 in 1 minute).
• Ask him to give all the words he can think of beginning with a par-
ticular letter, usually ‘f’ or ‘s’ (abnormal = less than 12 in 1 minute
for each letter).
• These are tests of word finding. The test can be quantified by count-
ing the number of objects within a standard time.
• Ask him to name familiar objects that are to hand, e.g. a watch, watch
strap, buckle, shirt, tie, buttons. Start with easily named objects and
later ask about less frequently used objects that will be more difficult.

Assess repetition
• Ask the patient to repeat a simple phrase, e.g. ‘The sun is shining’,
and then increasingly complicated phrases.

Assess severity of impairment of speech

• Is the aphasia socially incapacitating?

Further tests
Test reading and writing
• Check there is no visual impairment and that usual reading glasses
are used.
 SPEECH 15

• Ask the patient to:

– read a sentence
– obey a written command, e.g. ‘Close your eyes’
– write a sentence (check there is no motor disability to prevent this)
• Impaired reading = dyslexia. Impaired writing = dysgraphia.

TIP If there are difficulties, check the patient is normally

able to read and write.

WHAT YOU FIND

See Figure 2.2.

Fig. 2.2
Flow chart: aphasia
16 NEUROLOGICAL EXAMINATION MADE EASY

Before continuing your examination, describe your findings:

for example, ‘This man has a socially incapacitating non-fluent
global aphasia which is predominantly expressive, with para-
phasia and impaired repetition. There is associated dyslexia and
dysgraphia’.

WHAT IT MEANS
• Aphasia: lesion in the dominant (usually left) hemisphere.
• Global aphasia: lesion in the dominant hemisphere affecting both
Wernicke’s and Broca’s areas (Fig. 2.3).
• Wernicke’s aphasia: lesion in Wernicke’s area (supramarginal gyrus
of the parietal lobe and upper part of the temporal lobe). May be
associated with field defect.
• Broca’s aphasia: lesion in Broca’s area (inferior frontal gyrus). May
be associated with a hemiplegia.
• Conductive aphasia: lesion in arcuate fasciculus.
• Transcortical sensory aphasia: lesion in the posterior parieto-occipital
region.
• Transcortical motor aphasia: incomplete lesion in Broca’s area.
• Nominal aphasia: lesion in the angular gyrus.  
Common causes are given on page 34 under Focal Deficits.

Frontal lobe Parietal lobe

Arcuate fasciculus

Broca’s area

Wernicke’s area

Occipital lobe

Temporal lobe

Fig. 2.3
Diagram of the brain showing the location of Broca’s and Wernicke’s areas
Another random document with
no related content on Scribd:
Úrsula, desposada y virgen pura,
mostraba su figura, en una pieza 1485
pintada su cabeza. Allí se vía
que los ojos volvía ya espirando;
y estábate mirando aquel tirano[186]
que con acerba mano llevó a hecho
de tierno en tierno pecho tu compaña. 1490
Por la fiera Alemaña de aquí parte
el Duque, a aquella parte enderezado
donde el cristiano estado estaba en dubio.[187]
En fin al gran Danubio se encomienda;
por él suelta la rienda a su navío,[188] 1495
que con poco desvío de la tierra,
entre una y otra sierra el agua hiende.
El remo, que deciende en fuerza suma,
mueve la blanca espuma como argento.
El veloz movimiento parecía 1500
que pintado se vía ante los ojos.
Con amorosos ojos adelante
Carlo, César triunfante, le abrazaba
cuando desembarcaba en Ratisbona.[189]
Allí por la corona del imperio 1505
estaba el magisterio de la tierra
convocado a la guerra que esperaban.
Todos ellos estaban enclavando
los ojos en Fernando, y en el punto
que así le vieron junto, se prometen 1510
de cuanto allí acometen la vitoria.
Con falsa y vana gloria y arrogancia,
con bárbara jatancia allí se vía
a los fines de Hungría el campo puesto
de aquel que fue molesto en tanto grado 1515
al húngaro cuitado y afligido;[190]
las armas y el vestido a su costumbre,
era la muchedumbre tan estraña,
que apenas la campaña la abrazaba,
ni a dar pasto bastaba, ni agua el río. 1520
 César con celo pío y con valiente
ánimo aquella gente despreciaba;
la suya convocaba, y en un punto
vieras un campo junto de naciones
diversas y razones, mas de un celo.[191] 1525
No ocupaban el suelo en tanto grado
con número sobrado y infinito
como el campo maldito; mas mostraban
virtud, con que sobraban su contrario,[192]
ánimo voluntario, industria y maña; 1530
con generosa saña y viva fuerza
Fernando los esfuerza y los recoge,
y a sueldo suyo coge muchos dellos.
De un arte usaba entre ellos admirable;
con el disciplinable alemán fiero 1535
a su manera y fuero conversaba;
a todos se aplicaba de manera,
que el flamenco dijera que nacido
en Flandes había sido, y el osado
español y sobrado, imaginando[193] 1540
ser suyo don Fernando y de su suelo,
demanda sin recelo la batalla.
Quien más cerca se halla del gran hombre
piensa que crece el nombre por su mano.
El cauto italiano nota y mira,[194] 1545
los ojos nunca tira del guerrero,[195]
y aquel valor primero de su gente[196]
junto en este y presente considera.
En él ve la manera misma y maña
del que pasó en España sin tardanza, 1550
siendo solo esperanza de su tierra,
y acabó aquella guerra peligrosa
con mano poderosa y con estrago
de la fiera Cartago y de su muro,
y del terrible y duro su caudillo, 1555
cuyo agudo cuchillo a las gargantas
Italia tuvo tantas veces puesto.[197]
 Mostrábase tras esto allí esculpida
la envidia carcomida, así molesta;[198]
contra Fernando puesta frente a frente, 1560
la desvalida gente convocaba,
y contra aquel la armaba, y con sus artes
busca por todas partes daño y mengua.
Él con su mansa lengua y largas manos
los tumultos livianos asentando, 1565
poco a poco iba alzando tanto el vuelo,
que la envidia en el cielo lo miraba;
y como no bastaba a la conquista,
vencida ya su vista de tal lumbre,
forzaba su costumbre, y parecía 1570
que perdón le pedía, en tierra echada.
Él, después de pisada, descansado
quedaba y aliviado de este enojo;
y lleno del despojo desta fiera,
hallaba en la ribera del gran río, 1575
de noche, al puro frío del sereno,
a César, que en su seno está pensoso,
del suceso dudoso desta guerra;
que, aunque de sí destierra la tristeza,
del caso la grandeza trae consigo 1580
el pensamiento amigo del remedio.[199]
Entrambos buscan medio convenible
para que aquel terrible furor loco
les empeciese poco, y recibiese
tal estrago, que fuese destrozado. 1585
Después de haber hablado, ya cansados,
en la hierba acostados se dormían;
el gran Danubio oían ir sonando,
casi como aprobando aquel consejo.
En esto el claro viejo río se vía 1590
que del agua salía muy callado,
de sauces coronado y de un vestido
de las ovas tejido mal cubierto,
y en aquel sueño incierto les mostraba
todo cuanto tocaba al gran negocio. 1595
Y parecía que el ocio sin provecho
les sacaba del pecho; porque luego,
como si en vivo fuego se quemara
alguna cosa cara, se levantan
del gran sueño y se espantan, alegrando 1600
el ánimo y alzando la esperanza.
El río sin tardanza parecía
que el agua disponía al gran viaje;
allanaba el pasaje y la corriente,
para que fácilmente aquella armada[200] 1605
que había de ser guiada por su mano,
en el remar liviano y dulce viese
cuánto el Danubio fuese favorable.
Con presteza admirable vieras junto
un ejército a punto denodado; 1610
y después de embarcado, el remo lento,
el duro movimiento de los brazos,
los pocos embarazos de las ondas
llevaban por las hondas aguas presta
el armada, molesta al gran tirano.[201] 1615
El artificio humano no hiciera
pintura que esprimiera vivamente,
el armada, la gente, el curso, el agua;
apenas en la fragua, donde sudan
los cíclopes y mudan fatigados[202] 1620
los brazos, ya cansados del martillo,
pudiera así esprimillo el gran maestro.
Quien viera el curso diestro por la clara
corriente, bien jurara a aquellas horas[203]
que las agudas proras dividían 1625
el agua y la hendían con sonido,
y el rastro iba seguido. Luego vieras
al viento las banderas tremolando,
las ondas imitando en el moverse.
Pudiera también verse casi viva 1630
la otra gente esquiva y descreída,
que, de ensoberbecida y arrogante,
pensaban que delante no hallaran
hombres que se pararan, a su furia.
Los nuestros, tal injuria no sufriendo, 1635
remos iban metiendo con tal gana,
que iba de espuma cana el agua llena.
El temor enajena al otro bando;
el sentido, volando de uno en uno,
entrábase importuno por la puerta 1640
de la opinión incierta, y siendo dentro,
en el íntimo centro allá del pecho
les dejaba deshecho un hielo frío,
el cual, como un gran río en flujos gruesos,
por médulas y huesos discurría. 1645
Todo el campo se vía conturbado
y con arrebatado movimiento;
solo del salvamento platicaban.[204]
Luego se levantaban con desorden,
confusos y sin orden caminando, 1650
atrás iban dejando con recelo,
tendida por el suelo, su riqueza.
Las tiendas do pereza y do fornicio,
con todo bruto vicio obrar solían,
sin ellas se partían. Así armadas, 1655
eran desamparadas de sus dueños.
A grandes y pequeños juntamente
era el temor presente por testigo,
y el áspero enemigo a las espaldas,
que les iba las faldas ya mordiendo. 1660
César estar teniendo allí se vía
a Fernando, que ardía sin tardanza
por colorar su lanza en turca sangre.
Con animosa hambre y con denuedo
forcejea con quien quedo estar le manda. 1665
Como lebrel de Irlanda generoso
que el jabalí cerdoso y fiero mira,
rebátese, sospira, fuerza y riñe,
y apenas le constriñe el atadura,
que el dueño con cordura más aprieta;[205] 1670
así estaba perfeta y bien labrada
la imagen figurada de Fernando,
que quien allí mirándola estuviera,
que era desta manera bien juzgara.
Resplandeciente y clara de su gloria 1675
pintada la vitoria se mostraba;
a César abrazaba, y no parando,
los brazos a Fernando echaba al cuello.
Él mostraba de aquello sentimiento,
por ser el vencimiento tan holgado. 1680
Estaba figurado un carro estraño
con el despojo y daño de la gente
bárbara, y juntamente allí pintados
cautivos amarrados a las ruedas,
con hábitos y sedas variadas; 1685
lanzas rotas, celadas y banderas,
armaduras ligeras de los brazos,
escudos en pedazos divididos,
vieras allí cogidos en trofeo,
con que el común deseo y voluntades 1690
de tierras y ciudades se alegraba.
Tras esto blanqueaba falda y seno
con velas al Tirreno de la armada
sublime y ensalzada y gloriosa.
Con la prora espumosa las galeras, 1695
como nadantes fieras, el mar cortan,
hasta que en fin aportan con corona
de lauro a Barcelona, do cumplidos[206]
los votos ofrecidos y deseos,
y los grandes trofeos ya repuestos, 1700
con movimientos prestos de allí luego,
en amoroso fuego todo ardiendo,
el Duque iba corriendo, y no paraba.
Cataluña pasaba, atrás la deja;
ya de Aragón se aleja, y en Castilla, 1705
sin bajar de la silla, los pies pone.
El corazón dispone a la alegría
que vecina tenía, y reserena
su rostro, y enajena de sus ojos
muerte, daños, enojos, sangre y guerra. 1710
Con solo amor se encierra sin respeto,
y el amoroso afeto y celo ardiente
figurado y presente está en la cara;
y la consorte cara, presurosa,
de un tal placer dudosa, aunque lo vía, 1715
el cuello le ceñía en nudo estrecho,[207]
de aquellos brazos hecho delicados;
de lágrimas preñados relumbraban
los ojos que sobraban al sol claro.
Con su Fernando caro y señor pío 1720
la tierra, el campo, el río, el monte, el llano,
alegres a una mano estaban todos,
mas con diversos modos lo decían.
Los muros parecían de otra altura;
el campo en hermosura de otras flores 1725
pintaba mil colores disconformes;
estaba el mismo Tormes figurado,
en torno rodeado de sus ninfas,
vertiendo claras linfas con instancia,
en mayor abundancia que solía; 1730
del monte se veía el verde seno
de ciervos todo lleno, corzos, gamos,
que de los tiernos ramos van rumiando;
el llano está mostrando su verdura,
tendiendo su llanura así espaciosa, 1735
que a la vida curiosa nada empece,
ni deja en qué tropiece el ojo vago.
Bañados en un lago, no de olvido,
mas de un embebecido gozo, estaban
cuantos consideraban la presencia 1740
deste, cuya ecelencia el mundo canta,
cuyo valor quebranta al turco fiero.
 Aquesto vio Severo por sus ojos,
y no fueron antojos ni ficiones;
si oyeras sus razones, yo te digo 1745
que como a buen testigo lo creyeras.
Contaba muy de veras que, mirando
atento y contemplando las pinturas,
hallaba en las figuras tal destreza,
que con mayor viveza no pudieran 1750
estar si ser les dieran vivo y puro.
Lo que dellas escuro allí hallaba,
y el ojo no bastaba a recogello,
el río le daba dello gran noticia.
—Este de la milicia —dijo el río— 1755
la cumbre y señorío tendrá solo
del uno al otro polo, y porque espantes
a todos cuantos cantes los famosos
hechos tan gloriosos, tan ilustres,[208]
sabe que en cinco lustres de sus años[209] 1760
hará tantos engaños a la muerte,
que con ánimo fuerte habrá pasado
por cuanto aquí pintado della has visto.
Ya todo lo has previsto, vamos fuera,
dejarte he en la ribera do estar sueles. 1765
—Quiero que me reveles tú primero,
—le replicó Severo—, qué es aquello,
que de mirar en ello se me ofusca
la vista; así corusca y resplandece,[210]
y tan claro parece allí en la urna, 1770
como en hora noturna la cometa.
—Amigo, no se meta —dijo el viejo—
ninguno, le aconsejo, en este suelo
en saber más que el cielo le otorgare;
y si no te mostrare lo que pides, 1775
tú mismo me lo impides, porque en tanto
que el mortal velo y manto el alma cubren,
mil cosas se te encubren, que no bastan
tus ojos, que contrastan, a mirallas.
No pude yo pintallas con menores 1780
luces y resplandores, porque sabe,
y aquesto en ti bien cabe, que esto todo
que en ecesivo modo resplandece
tanto, que no parece ni se muestra,
es lo que aquella diestra mano osada 1785
y virtud sublimada de Fernando
acabarán entrando más los días.
Lo cual, con lo que vías comparado,
es como con nublado muy escuro
el sol ardiente, puro, relumbrante. 1790
Tu vista no es bastante a tanta lumbre,
hasta que la costumbre de miralla
tu ver al contemplalla no confunda.
Como en cárcel profunda el encerrado,
que, súbito sacado, le atormenta 1795
el sol que se presenta a sus tinieblas;
así tú, que las nieblas y hondura,
metido en estrechura, contemplabas
que era cuanto mirabas otra gente,
viendo tan diferente suerte de hombre, 1800
no es mucho que te asombre luz tamaña;
pero vete, que baña el sol hermoso
su carro presuroso ya en las ondas,
y antes que me respondas será puesto.—
Diciendo así, con gesto muy humano 1805
tomole por la mano. ¡Oh admirable
caso, y, cierto, espantable! Que en saliendo,
se fueron estriñendo de una parte
y de otra de tal arte aquellas ondas,
que las aguas, que hondas ser solían, 1810
el suelo descubrían, y dejaban
seca por do pasaban la carrera,
hasta que en la ribera se hallaron;
y como se pararon en un alto,
el viejo de allí un salto dio con brío, 1815
y levantó del río espuma al cielo,
y comovió del suelo negra arena.
Severo, ya de ajena ciencia instruto,
fuese a coger el fruto sin tardanza
de futura esperanza; y escribiendo, 1820
las cosas fue esprimiendo muy conformes
a las que había de Tormes aprendido;
y aunque de mi sentido él bien juzgase
que no las alcanzase, no por eso
este largo proceso sin pereza 1825
dejó, por su nobleza, de mostrarme.
Yo no podía hartarme allí leyendo,
y tú de estarme oyendo estás cansado.
 SALICIO

Espantado me tienes
con tan estraño cuento, 1830
y al son de tu hablar embebecido;
acá dentro me siento,
oyendo tantos bienes
y el valor deste príncipe escogido,
bullir con el sentido 1835
y arder con el deseo,
por contemplar presente
a aquel que, estando ausente,
por tu divina relación ya veo.
¡Quién viese la escritura, 1840
ya que no puede verse la pintura!
Por firme y verdadero,
después que te he escuchado,
tengo que ha de sanar Albanio cierto;
que, según me has contado, 1845
bastará a tu Severo
a dar salud a un vivo y vida a un muerto;
que a quien fue descubierto
un tamaño secreto,
razón es que se crea 1850
que, cualquiera que sea,
alcanzará con su saber perfeto,
y a las enfermedades
aplicará contrarias calidades.

NEMOROSO

Pues ¿en qué te resumes, di, Salicio, 1855

acerca deste enfermo compañero?

SALICIO

En que hagamos el debido oficio.

 Luego de aquí partamos, y primero
que haga curso el mal y se envejesca,
así le presentemos a Severo. 1860

NEMOROSO

Yo soy contento, y antes que amanesca

y que del sol el claro rayo ardiente
sobre las altas cumbres se paresca,
el compañero mísero y doliente
llevemos luego donde cierto entiendo 1865
que será guarecido fácilmente.

SALICIO

Recoge tu ganado, que cayendo

ya de los altos montes las mayores
sombras, con ligereza van corriendo.
Mira en torno, y verás por los alcores 1870
salir el humo de las caserías
de aquestos comarcanos labradores.[211]
Recoge tus ovejas y las mías,
y vete ya con ellas poco a poco
por aquel mismo valle que solías. 1875
Yo solo me avendré con nuestro loco,
que pues él hasta aquí no se ha movido,
la braveza y furor debe ser poco.

NEMOROSO

Si llegas antes, no te estés dormido;

apareja la cena, que sospecho 1880
que aún fuego Galafrón no habrá encendido.

SALICIO

Yo lo haré, que al hato iré derecho,

si no me lleva a despeñar consigo
de algún barranco Albanio a mi despecho.
Adiós, hermano.

NEMOROSO

Adiós, Salicio amigo. 1885

 ÉGLOGA III

Aquella voluntad honesta y pura,[212]

ilustre y hermosísima María,
que en mí de celebrar tu hermosura,
tu ingenio y tu valor estar solía,
a despecho y pesar de la ventura 5
que por otro camino me desvía,
está y estará en mí tanto clavada,
cuanto del cuerpo el alma acompañada.[213]
Y aun no se me figura que me toca
aqueste oficio solamente en vida; 10
mas con la lengua muerta y fría en la boca[214]
pienso mover la voz a ti debida.
Libre mi alma de su estrecha roca,
por el Estigio lago conducida,
celebrándote irá, y aquel sonido 15
hará parar las aguas del olvido.
Mas la fortuna, de mi mal no harta,
me aflige y de un trabajo en otro lleva;
ya de la patria, ya del bien me aparta,
ya mi paciencia en mil maneras prueba; 20
y lo que siento más, es que la carta,[215]
donde mi pluma en tu alabanza mueva,
poniendo en su lugar cuidados vanos,
me quita y me arrebata de las manos.
Pero, por más que en mí su fuerza pruebe, 25
no tornará mi corazón mudable;
nunca dirán jamás que me remueve
fortuna de un estudio tan loable.
Apolo y las hermanas, todas nueve,
me darán ocio y lengua con que hable 30
lo menos de lo que en tu ser cupiere,
que esto será lo más que yo pudiere.[216]
En tanto no te ofenda ni te harte
tratar del campo y soledad que amaste,
ni desdeñes aquesta inculta parte 35
de mi estilo, que en algo ya estimaste.
Entre las armas del sangriento Marte,
do apenas hay quien su furor contraste,
hurté de el tiempo aquesta breve suma,
tomando, ora la espada, ora la pluma.[217] 40
Aplica, pues, un rato los sentidos
al bajo son de mi zampoña ruda,
indina de llegar a tus oídos,
pues de ornamento y gracia va desnuda;
mas a las veces son mejor oídos 45
el puro ingenio y lengua casi muda,
testigos limpios de ánimo inocente,
que la curiosidad del elocuente.
Por aquesta razón de ti escuchado,
aunque me falten otras, ser meresco. 50
Lo que puedo te doy, y lo que he dado,
con recibillo tú yo me enriquesco.
De cuatro ninfas que del Tajo amado
salieron juntas, a cantar me ofresco,
Filódoce, Dinámene y Crimene, 55
Nise, que en hermosura par no tiene.
Cerca del Tajo en soledad amena,
de verdes sauces hay una espesura,
toda de hiedra revestida y llena,
que por el tronco va hasta el altura, 60
y así la teje arriba y encadena,
que el sol no halla paso a la verdura;
el agua baña el prado, con sonido
alegrando la vista y el oído.
Con tanta mansedumbre el cristalino 65
Tajo en aquella parte caminaba,
que pudieran los ojos el camino
determinar apenas que llevaba.
Peinando sus cabellos de oro fino,
una ninfa, del agua, do moraba, 70
la cabeza sacó, y el prado ameno
vido de flores y de sombra lleno.
Moviola el sitio umbroso, el manso viento,
el suave olor de aquel florido suelo.
Las aves en el fresco apartamiento 75
vio descansar del trabajoso vuelo.
Secaba entonces el terreno aliento
el sol subido en la mitad del cielo.
En el silencio solo se escuchaba
un susurro de abejas que sonaba. 80
Habiendo contemplado una gran pieza
atentamente aquel lugar sombrío,
somorgujó de nuevo su cabeza,[218]
y al fondo se dejó calar del río.[219]
A sus hermanas a contar empieza 85
del verde sitio el agradable frío,
y que vayan les ruega y amonesta
allí con su labor a estar la siesta.
No perdió en esto mucho tiempo el ruego,
que las tres dellas su labor tomaron, 90
y en mirando de fuera, vieron luego
el prado, hacia el cual enderezaron.
El agua clara con lacivo juego[220]
nadando dividieron y cortaron,[221]
hasta que el blanco pie tocó mojado, 95
saliendo de la arena, el verde prado.
Poniendo ya en lo enjuto las pisadas,[222]
escurrieron del agua sus cabellos,
los cuales esparciendo, cubijadas
las hermosas espaldas fueron dellos. 100
Luego sacando telas delicadas,
que en delgadeza competían con ellos,[223]
en lo más escondido se metieron,
y a su labor atentas se pusieron.
Las telas eran hechas y tejidas 105
del oro que el felice Tajo envía,
apurado, después de bien cernidas
las menudas arenas do se cría.[224]
Y de las verdes hojas reducidas
en estambre sutil, cual convenía 110
para seguir el delicado estilo
del oro ya tirado en rico hilo.
La delicada estambre era distinta
de las colores que antes le habían dado
con la fineza de la varia tinta 115
que se halla en las conchas del pescado.
Tanto artificio muestra en lo que pinta
y teje cada ninfa en su labrado,
cuanto mostraron en sus tablas antes
el celebrado Apeles y Timantes. 120
Filódoce, que así de aquellas era
llamada la mayor, con diestra mano
tenía figurada la ribera
de Estrimón, de una parte el verde llano,
y de otra el monte de aspereza fiera, 125
pisado tarde o nunca de pie humano,
donde el amor movió con tanta gracia
la dolorosa lengua del de Tracia.[225]
Estaba figurada la hermosa
Eurídice, en el blanco pie mordida[226] 130
de la pequeña sierpe ponzoñosa,[227]
entre la hierba y flores escondida;
descolorida estaba como rosa
que ha sido fuera de sazón cogida,
y el ánima, los ojos ya volviendo, 135
de su hermosa carne despidiendo.
Figurado se vía estensamente
el osado marido que bajaba
al triste reino de la escura gente,
y la mujer perdida recobraba; 140
y cómo después desto él, impaciente
por miralla de nuevo, la tornaba
a perder otra vez, y del tirano
se queja al monte solitario en vano.[228]
Dinámene no menos artificio 145
mostraba en la labor que había tejido,
pintando a Apolo en el robusto oficio
de la silvestre caza embebecido.
Mudar luego le hace el ejercicio
la vengativa mano de Cupido, 150
que hizo a Apolo consumirse en lloro
después que le enclavó con punta de oro.[229]
Dafne con el cabello suelto al viento,[230]
sin perdonar al blanco pie, corría
por áspero camino tan sin tiento, 155
que Apolo en la pintura parecía
que, porque ella templase el movimiento,
con menos ligereza la seguía.
Él va siguiendo, y ella huye como
quien siente al pecho el odioso plomo.[231] 160
Mas a la fin los brazos le crecían,
y en sendos ramos vueltos se mostraban,
y los cabellos, que vencer solían
al oro fino, en hojas se tornaban;
en torcidas raíces se estendían 165
los blancos pies, y en tierra se hincaban.
Llora el amante, y busca el ser primero,
besando y abrazando aquel madero.
Climene, llena de destreza y maña,
el oro y las colores matizando, 170
iba de hayas una gran montaña
de robles y de peñas variando.
Un puerco entre ellas, de braveza estraña,
estaba los colmillos aguzando
contra un mozo, no menos animoso, 175
con su venablo en mano, que hermoso.[232]
 Tras esto, el puerco allí se vía herido
de aquel mancebo por su mal valiente,
y el mozo en tierra estaba ya tendido,
abierto el pecho del rabioso diente; 180
con el cabello de oro desparcido
barriendo el suelo miserablemente,
las rosas blancas por allí sembradas
tornaba con su sangre coloradas.
Adonis este se mostraba que era, 185
según se muestra Venus dolorida,
que viendo la herida abierta y fiera,
estaba sobre él casi amortecida.
Boca con boca coge la postrera[233]
parte del aire que solía dar vida 190
al cuerpo, por quien ella en este suelo
aborrecido tuvo al alto cielo.
La blanca Nise no tomó a destajo
de los pasados casos la memoria,
y en la labor de su sutil trabajo 195
no quiso entretejer antigua historia;
antes mostrando de su claro Tajo
en su labor la celebrada gloria,
lo figuró en la parte donde él baña
la más felice tierra de la España.[234] 200
Pintado el caudaloso río se vía,
que, en áspera estrecheza reducido,
un monte casi al rededor teñía,
con ímpetu corriendo y con ruído;
querer cercallo todo parecía[235] 205
en su volver; mas era afán perdido;
dejábase correr, en fin, derecho,[236]
contento de lo mucho que había hecho.
Estaba puesta en la sublime cumbre
del monte, y desde allí por él sembrada, 210
aquella ilustre y clara pesadumbre,
de antiguos edificios adornada.
De allí con agradable mansedumbre
el Tajo va siguiendo su jornada,
y regando los campos y arboledas 215
con artificio de las altas ruedas.[237]
En la hermosa tela se veían
entretejidas las silvestres diosas
salir de la espesura, y que venían
todas a la ribera presurosas, 220
en el semblante tristes, y traían
cestillos blancos de purpúreas rosas,
las cuales esparciendo, derramaban
sobre una ninfa muerta que lloraban.[238]
Todas con el cabello desparcido[239] 225
lloraban una ninfa delicada,[240]
cuya vida mostraba que había sido
antes de tiempo y casi en flor cortada.[241]
Cerca del agua, en un lugar florido,
estaba entre la hierba degollada,[242] 230
cual queda el blanco cisne cuando pierde
la dulce vida entre la hierba verde.
Una de aquellas diosas, que en belleza,
al parecer, a todas ecedía,
mostrando en el semblante la tristeza 235
que del funesto y triste caso había,
apartada algún tanto, en la corteza
de un álamo unas letras escribía,
como epitafio de la ninfa bella,
que hablaban así por parte della: 240
«Elisa soy, en cuyo nombre suena
y se lamenta el monte cavernoso,
testigo del dolor y grave pena
en que por mí se aflige Nemoroso,
y llama Elisa; Elisa a boca llena 245
responde el Tajo, y lleva presuroso
al mar de Lusitania el nombre mío,[243]
donde será escuchado, yo lo fío.»
En fin, en esta tela artificiosa
toda la historia estaba figurada, 250