Blueprints Neurology (Blueprints

Series) Fifth Edition

Visit to download the full and correct content document:
https://ebookmass.com/product/blueprints-neurology-blueprints-series-fifth-edition/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Blueprints Psychiatry 6th Edition, (Ebook PDF)

https://ebookmass.com/product/blueprints-psychiatry-6th-edition-
ebook-pdf/

Parkinson Disease (Contemporary Neurology Series) Roger

L. Albin

https://ebookmass.com/product/parkinson-disease-contemporary-
neurology-series-roger-l-albin/

Parkinson Disease (Contemporary Neurology Series) Roger

L. Albin

https://ebookmass.com/product/parkinson-disease-contemporary-
neurology-series-roger-l-albin-2/

Gifts, Glamping, & Glocks (A Camper & Criminals Cozy

Mystery Series Book 29) Tonya Kappes

https://ebookmass.com/product/gifts-glamping-glocks-a-camper-
criminals-cozy-mystery-series-book-29-tonya-kappes/
Autoimmune Neurology 1st Edition Sean J. Pittock And
Angela Vincent (Eds.)

https://ebookmass.com/product/autoimmune-neurology-1st-edition-
sean-j-pittock-and-angela-vincent-eds/

Neurologic Complications of Critical Illness

(CONTEMPORARY NEUROLOGY SERIES) [Team-IRA] 4th Edition
Eelco F.M. Wijdicks

https://ebookmass.com/product/neurologic-complications-of-
critical-illness-contemporary-neurology-series-team-ira-4th-
edition-eelco-f-m-wijdicks/

Kaufman’s Clinical Neurology for Psychiatrists (Major

Problems in Neurology)

https://ebookmass.com/product/kaufmans-clinical-neurology-for-
psychiatrists-major-problems-in-neurology/

On Call Neurology 4th Edition Stephen A. Mayer

https://ebookmass.com/product/on-call-neurology-4th-edition-
stephen-a-mayer/

PharmCards Fifth Edition

https://ebookmass.com/product/pharmcards-fifth-edition/
 Contents

Preface
Acknowledgments
Abbreviations

PART I BASICS OF NEUROLOGY

1 The Neurologic Examination

2 Neurologic Investigations

PART II COMMON NEUROLOGIC SYMPTOMS

3 The Approach to Coma and Altered Consciousness

4 Neuro-Ophthalmology

5 The Approach to Weakness

6 The Sensory System

7 Dizziness, Vertigo, and Syncope

8 Ataxia and Gait Disorders

9 Urinary and Sexual Dysfunction

10 Headache and Facial Pain

PART III NEUROLOGIC DISORDERS

 11 Aphasia and Other Disorders of Higher Cortical Function

12 Dementia

13 Sleep Disorders

14 Vascular Disease

15 Seizures

16 Movement Disorders

17 Head Trauma

18 Systemic Conditions with Neurologic Manifestations

19 Central Nervous System Tumors

20 Demyelinating Diseases of the Central Nervous System

21 Infections of the Nervous System

22 Disorders of the Spinal Cord

23 Radiculopathy, Plexopathy, and Peripheral Neuropathy

24 Disorders of the Neuromuscular Junction and Skeletal Muscle

25 Pediatric Neurology

Questions
Answers
Appendix: Evidence-Based Resources
Index
 Preface

B lueprints Neurology was first published more than 15 years ago as one of
a series of books designed to help medical students prepare for USMLE
Steps 2 and 3. As the study and practice of Medicine and Neurology and
professional board examinations have evolved over the years, so too has
Blueprints Neurology changed to assist students to learn Neurology in
multiple evaluation and examination settings.
Examination preparation remains at the core of the series. To that end, the
authors review the subject matter of the examination before each edition. The
authors and editors work together to organize the most important, current,
and factually correct material into a complete but concise review guide. Our
goal remains integrating the depth of factual knowledge with the breadth of
practice information in order to optimize both understanding and retention.
We have been pleased to hear from our readers that the book is utilized by
many medical students during their clinical rotations, as well as in
preparation for shelf and board examinations. Residents in Internal Medicine,
Emergency Medicine, and Family Practice, as well as nurse practitioners and
physicians’ associates have found Blueprints helpful during the Neurology
portion of their training. We believe the book’s applications have broadened
with each edition due to the quality of our authors’ experience and their
dedication to highlighting and clarifying a targeted range of basic but
important topics that should be mastered.
Virtually all chapters are authored by experts in the content area, including
neurologists from both academic medicine and busy private practice groups.
They have incorporated suggestions received from medical students, faculty,
clinicians, and program directors with regard to content and organization.
Each chapter covers a single subject area for review; most can be read in
under an hour. “Key Points,” highlighted throughout, facilitate quick review
of the key concepts tested most frequently. Most chapters have Vignettes
with characteristic clinical presentations to test one’s review of the chapter.
The 100 Questions at the end of the book are also written in the “Clinical
Vignette” style used in USMLE and Board examinations, as recommended
by student reviewers of the Blueprints series.
This fifth edition of Blueprints Neurology is the most thoroughly updated
edition to date, with several new authors (generally closer in stage of
education to the students for whom the book is written). It includes important
updates on areas such as Multiple Sclerosis, Stroke, Epilepsy, Movement
disorders and their genetic bases, Sleep disorders such as narcolepsy and
cataplexy, and new drug and other treatments for each. Each chapter includes
the most recent information and practice principles available and accepted at
the time of publication.
We hope that readers of Blueprints Neurology will come to see the wonder
of the human nervous system, how important it is to individuals in health and
when it fails, and how the study and practice of Neurology is more helpful to
patients than ever before.

Frank W. Drislane, MD
Aimee K. Boegle, MD, PhD
Alexandra Hovaguimian, MD
Courtney McIlduff, MD, MMSc
Andrew W. Tarulli, MD
Louis R. Caplan, MD
 Acknowledgments

W e thank our patients for the opportunity of working with them and
learning Neurology; our colleagues and teachers (and particularly,
upon his retirement, Michael Ronthal, MBBCh) at Beth Israel Deaconess
Medical Center Neurology department for teaching us more fascinating
concepts about the nervous system; and our families for tolerating the many
hours spent writing and revising this book.
 Abbreviations

A(β) amyloid-beta
ABP abductor pollicis brevis
Abs antibodies
AβPP amyloid–beta protein precursor
ACA anterior cerebral artery
ACE angiotensin-converting enzyme
AChR acetylcholine receptor
AD Alzheimer disease
ADEM acute disseminated encephalomyelitis
ADHD attention deficit–hyperactivity disorder
ADM abductor digiti minimi
AICA anteroinferior cerebellar artery
AIDP acute inflammatory demyelinating polyradiculoneuropathy
AIDS acquired immunodeficiency syndrome
AION anterior ischemic optic neuropathy
ALS amyotrophic lateral sclerosis
ANA antinuclear antibody
APP amyloid precursor protein
APS antiphospholipid syndrome
ASD anti-seizure drug
AVM arteriovenous malformation
AZT zidovudine
BMD Becker muscular dystrophy
BPPV benign positional paroxysmal vertigo
CBC complete blood count
GMP cyclic guanosine monophosphate
CIDP chronic inflammatory demyelinating polyradiculoneuropathy
CJD Creutzfeldt-Jakob disease
CK creatine kinase
CMAP compound muscle action potential
CMT Charcot-Marie-Tooth disease
CN cranial nerve
CNS central nervous system
COMT catechol O-methyl transferase
CP cerebral palsy
CPAP continuous positive airway pressure
CSF cerebrospinal fluid
CT computed tomography
DH detrusor hyperreflexia
DI detrusor instability
DLB dementia with Lewy bodies
DM dermatomyositis
DMD Duchenne muscular dystrophy
DSD detrusor sphincter dyssynergia
DTRs deep tendon reflexes
DWI diffusion-weighted imaging
EA episodic ataxia
ED erectile dysfunction
EEG electroencephalogram
EMG electromyography
ER emergency room
ESR erythrocyte sedimentation rate
ET essential tremor
EWN Edinger-Westphal nuclei
FDI first dorsal interosseus
FEV1 forced expiratory volume in 1 second
FLAIR fluid-attenuated inversion recovery
FTA fluorescent treponemal antibody
FTD frontotemporal dementia
FVC forced vital capacity
GAD glutamic acid decarboxylase
GBS Guillain-Barré syndrome
GCS Glasgow Coma Scale
GTC generalized tonic–clonic
HD Huntington’s disease
HIV human immunodeficiency virus
HNPP hereditary neuropathy with liability to pressure palsies
HS Horner’s syndrome
HSAN hereditary sensory and autonomic neuropathy
HSV herpes simplex virus
IBM inclusion body myositis
ICA internal cerebral artery
ICP intracranial pressure
ICU intensive care unit
IIH idiopathic intracranial hypertension
INO internuclear ophthalmoplegia
INR international normalized ratio
IVIg intravenous immunoglobulin
LEMS Lambert-Eaton myasthenic syndrome
LGN lateral geniculate nucleus
LMN lower motor neuron
LND light-near dissociation
LP lumbar puncture
MAG myelin-associated glycoprotein
MCA middle cerebral artery
MELAS mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke
MERRF myoclonic epilepsy with ragged red fibers
MFS Miller Fisher syndrome
MG myasthenia gravis
MLF medial longitudinal fasciculus
MMN multifocal motor neuropathy
MND motor neuron disease
MRA magnetic resonance angiography
MRC Medical Research Council
MRI magnetic resonance imaging
MRV magnetic resonance venography
MS multiple sclerosis
MSA multiple system atrophy
MSLT multiple sleep latency test
MuSK muscle-specific kinase
NCS nerve conduction studies
NCV nerve conduction velocity
NFTs neurofibrillary tangles
NIF negative inspiratory force
NMDA N-methyl-D-aspartate
NMJ neuromuscular junction
NMS neuroleptic malignant syndrome
NSAIDs nonsteroidal anti-inflammatory drug
OCD obsessive-compulsive disorder
ON optic neuritis
PANDAS pediatric autoimmune neurologic disorders associated with streptococcal
infection
PAS periodic acid–Schiff
PCA posterior cerebral arteries
PCD paraneoplastic cerebellar degeneration
PCNSL primary central nervous system lymphoma
PCR polymerase chain reaction
PD Parkinson’s disease
PDC paroxysmal (nonkinesigenic) dystonic choreoathetosis
PEO progressive external ophthalmoplegia
PET positron emission tomography
PICA posteroinferior cerebellar artery
PKC paroxysmal kinesigenic choreoathetosis
PM polymyositis
PML progressive multifocal leukoencephalopathy
PN peripheral neuropathy
PNS peripheral nervous system
POTS postural orthostatic tachycardia syndrome
PP periodic paralysis
PPD purified protein derivative
PPRF paramedian pontine reticular formation
PS1 presenilin 1
PS2 presenilin 2
PSP progressive supranuclear palsy
PT prothrombin time
PTT partial thromboplastin time
PVR postvoid residual
QSART quantitative sudomotor axon reflex test
RAPD relative afferent pupillary defect
REM rapid eye movement
RF radiofrequency
riMLF rostral interstitial nucleus of the MLF
RPR rapid plasma reagin
rt-PA recombinant tissue-type plasminogen activator
SAH subarachnoid hemorrhage
SCA spinocerebellar ataxia
SCA superior cerebellar artery
SE status epilepticus
SLE systemic lupus erythematosus
SMA spinal muscular atrophy
SNAP sensory nerve action potential
SPECT single-photon emission computed tomography
SSRI selective serotonin reuptake inhibitor
STT spinothalamic tract
TB tuberculosis
TCD transcranial Doppler
TE time to echo
TIA transient ischemic attack
TORCH toxoplasmosis, other agents, rubella, cytomegalovirus, herpes simplex
TR time to repetition
TSC tuberous sclerosis complex
UMN upper motor neuron
VA visual acuity
VDRL Venereal Disease Research Laboratory
VOR vestibulo-ocular reflex
VP venous pulsation
VPL ventroposterolateral
WD Wilson’s disease
 PART I BASICS OF NEUROLOGY
1 The Neurologic Examination

The care of patients in all specialties has been enhanced by the use of an
increasingly sophisticated array of biomarkers, genetic tests, and imaging
modalities. Yet even in the setting of these critical advancements, the
physical examination remains of utmost importance in Neurology. We glean
valuable information from listening to the manner in which concerns are
expressed, observing how patients walk into the clinic or lie in a hospital bed,
and performing maneuvers designed to interrogate the functional integrity of
nervous system components. Ultimately, the examination is a tool we use to
pinpoint the nature and origin of abnormalities. The resultant picture can
narrow the list of possible diagnoses and guide further investigation.

PRINCIPLES
1. It is useful to conduct a complete examination at least once for every
Neurology patient. The neurologic examination may be unique in its
length, but it is worthwhile to complete a thorough assessment at least
once with each Neurology patient for several reasons. First, that
examination provides a baseline assessment of neurologic status—which
can be particularly valuable in the hospital, where examinations can
evolve in important and sometimes unforeseen ways. Second, a full
examination may uncover unexpected abnormalities. One might be
tempted to skip a full mental status examination for a patient who can
exchange pleasantries normally—only to be surprised when the patient
identifies the year as 1962. Because neurologic problems can present with
discrete deficits, formal testing in each domain is sensible. Third,
abnormalities on basic tests can point out the need for more in-depth,
specialized evaluations. For example, the emergence of diplopia on testing
extraocular movements might prompt a search for fatigable eyelid
 weakness that can raise concern for myasthenia gravis. In this way, the
neurologic examination becomes tailored for each individual patient.
Fourth, the examination allows one to directly confirm or refute
hypotheses about contributory problems suggested by the history. Foot
drop is more likely to result from a lumbosacral radiculopathy if
accompanied by back pain; a positive straight leg raise test can help
corroborate this explanation. Finally, the examination can show a pattern
of abnormalities that provides a clue as to where in the nervous system the
problem lies.
2. The goal is to localize the problem. The nervous system is extensive.
Broadly, we can characterize elements as central or peripheral. The central
nervous system includes the brain and spinal cord. The peripheral nervous
system (PNS) incorporates nerve roots, plexi, peripheral nerves,
neuromuscular junctions, and muscles. Dysfunction originating from each
of these locations can translate into distinctive examination findings
(Table 1-1); recognizing characteristic patterns is often the key to
localizing a deficit. Using this approach, the exam can help determine
whether left hand weakness stems from carpal tunnel syndrome, a brachial
plexus injury, cervical radiculopathy, or a middle cerebral artery stroke.
These distinctions are important because the diagnostic steps, prognoses,
and therapies differ for each of these conditions.
3. Findings should be interpreted in the context of the history. In
performing a comprehensive neurologic examination, it is not uncommon
to detect incidental abnormalities. Particularly at the start of one’s career,
it can be difficult to discern whether certain abnormalities are important.
One should assign greater weight to findings related to the presenting
symptoms or a patient’s medical history. For instance, abnormal sensation
in a football-shaped region over the anterolateral thigh may be a key
finding in an obese person who developed burning in this area after
wearing tight-fitting pants, but an unimportant (or untrustworthy)
discovery in an individual who presents with an acute change in mental
status.

TABLE 1-1. Localizing Patterns of Sensorimotor Abnormalities

Location of Lesion Characteristic Distribution
Brain Right or left hemi-body (face, arm, and leg)
Brainstem Crossed face and limbs (e.g., right face, left limbs)
 Spinal cord At a sensory level on one or both sides of the posterior torso (at or
above the site of the lesion)
Nerve root Along an individual nerve root (i.e., a dermatome if a sensory change,
or a myotome if weakness)
Plexus Patchy in affected upper or lower extremity
Peripheral nerves Distal, symmetric sensorimotor changes
(polyneuropathy)
Neuromuscular junction Fatigable weakness
Muscle Proximal, symmetric weakness

KEY POINTS
● A complete neurologic examination is important to identify and characterize patterns of
abnormalities.
● The goal of the examination is to localize lesions in the nervous system.
● Findings should always be interpreted in the context of the clinical history.

ELEMENTS OF THE EXAMINATION

The details of the neurologic examination (Table 1-2) should be tailored to fit
the patient’s presenting symptoms and identified abnormalities on a basic
exam.

MENTAL STATUS
The mental status exam is performed to identify cognitive deficits related to
specific regions in the brain. The first step is to assess level of consciousness,
which can range from awake and alert to unarousable even with noxious
stimulation. Rather than using medical terms such as stuporous or obtunded
in the latter setting, it is more helpful to describe what external stimuli are
required to arouse a patient or maintain wakefulness. The level of
consciousness frames further testing of cognitive function. Attention is
tested, typically by asking patients to recite spans of numbers, months, or
words such as “world,” forward and backward. A specific form of inattention
is referred to as neglect. Patients with dense neglect may fail to describe
items on one side of a picture or of their surroundings or fail to bisect a line
properly. Subtle neglect may manifest as extinction to double simultaneous
stimulation; in this scenario, a patient can sense a single visual or sensory
stimulus on either side of the body but reports it on the nonneglected side
alone when bilateral stimuli are presented. In some cases, it is not possible to
perform formal tests of attention because patients become focused on one
detail or task and keep repeating it (“perseveration”). Deficits in attention are
important to recognize because they can compromise the ability to complete
other tasks in the mental status examination. Orientation is tested by asking
a patient to identify his or her name and location as well as the day, date,
month, year, and current situation.
Memory is assessed by asking patients to repeat several words
immediately and again after intervals (e.g., 30 seconds and 3 minutes). The
examiner should make note of whether the patient is aware of current events.
Language is assessed in several ways: by listening to the fluency and
prosody of spontaneous speech, identifying word substitutions (i.e.,
paraphasic errors), and assessing the ability to repeat phrases, read, write, and
name common and uncommon objects. Furthermore, the examiner can ask
the patient to name as many words as possible starting with the letter “F,”
“A,” or “S” in 1 minute, paying attention not only to the number of words
generated but also to the manner in which they are named. For example, does
the patient recognize whether she or he repeated words? Were words
volunteered in identifiable categories? In addition to insight into language
function, these details provide insight into how well patients can plan and
organize information (i.e., frontal lobe executive function). To assess verbal
comprehension, check to see if patients can follow spoken midline,
appendicular, and cross-body commands.

TABLE 1-2. Commonly Performed Elements of the Neurologic

Examination
Mental Status
Attention Serial backward tasks (months of the year, digit span)
Language Fluency of speech, repetition, comprehension of commands, naming
objects, reading, writing
Memory Recall of words after 5 minutes
Visuospatial function Clock drawing; complex figure copying
Neglect Line bisection, double simultaneous stimulation
Frontal lobe function Generation of word lists; performance of learned motor sequence; test of
inhibition
Cranial Nerves
 II Visual acuity, fields, pupils, funduscopic exam
III, IV, VI Extraocular movements
V, VII Facial sensation and movement
IX, X, XII Palate and tongue movement
Motor
Bulk Inspection for atrophy
Tone Evaluation for rigidity, spasticity
Power Observational tests (pronator drift, rising from chair, walking on heels and
toes), direct confrontation strength testing
Reflexes
Muscle stretch reflexes Assessment at sites including biceps, brachioradialis, triceps, knee, ankle
Babinski sign Stroking lateral sole of foot
Sensory
Pinprick and Mapping of pinprick, cold sensation
temperature
Vibration and joint Timing appreciation of tuning fork stimulus at joints, assessing perception
position sense of location of limbs in space
Romberg sign Unsteady, when standing with feet together, then closing eyes
Coordination
Accuracy of targeting Finger-to-nose, heel-to-shin tests
Rhythm of movements Rapid alternating movements, rhythmic finger or heel tapping
Gait
Stance Evaluation of narrow or wide base
Stride and arm swing Assessment for shuffling, decreased arm swing
Ataxia Evaluation of ability to tandem walk

Calculation ability can be tested by asking patients to perform simple

arithmetic (e.g., the number of quarters in $1.50). One can check for apraxia
by asking patients to pantomime a learned motor task—optimally one that
requires use of both hands, for example, cutting a loaf of bread. Visuospatial
function and nonverbal learning can be tested in a variety of ways. Patients
can be asked to draw numbers in a circle to form a clock; alternatively, they
can be asked to copy a complex figure drawn by the examiner (Fig. 1-1).
FIGURE 1-1. Example of a complex figure to be copied by the patient as test of visuospatial
function.

Other tests of frontal lobe function include learning and then repeating a
simple motor sequence of hand postures (i.e., the Luria manual sequencing
task). Another test of appropriate inhibition, the go/no go test, comprises
tapping the table when only one letter (e.g., “B”) is said aloud in a string of
letters. Perseveration is also considered a frontal deficit. If cognitive
impairment emerges as a concern, the examiner should consider looking for
the presence of primitive reflexes, which are signs of “frontal release” or
disinhibition. Examples include the palmo-mental, snout, and rooting
reflexes; of note, the examiner should be careful not to overinterpret these
reflexes, because they can occur in normal subjects with age or may not be
relevant to the presenting problem.

KEY POINTS
● The mental status exam should begin with assessment of level of consciousness and attention
because these can affect the interpretation of subsequent tests.
● Memory, language, calculation, praxis, visuospatial, and frontal lobe function are other key
elements of the mental status exam that can suggest focal brain lesions.

CRANIAL NERVES
One way to test cranial nerves is to start at eye level and move down the face
in approximate numerical order (Table 1-3).
Olfaction (I) is rarely tested. When patients report alterations in the ability
to smell, each nostril should be tested separately. A non-noxious stimulus,
such as coffee or vanilla, can be used.
Optic nerve (II) function is assessed in several ways. Visual acuity is
investigated with a near card. Visual fields are tested by having the patient
cover one eye and focus on the examiner’s nose; they are then asked to signal
when they can appreciate a small red object enter the field of view from each
of four quadrants when the object is held halfway between the patient’s eye
and the examiner’s (the limits of the patient’s visual fields should correspond
to those of the examiner’s). Direct visualization of the optic nerve can be
achieved by fundoscopy. The afferent limb of the pupillary light reflex is also
mediated by the optic nerve; the efferent limb is subtended by CN III.
Extraocular movements (III, IV, and VI) are tested in three main ways: by
having the patient pursue a moving target (e.g., an examiner’s finger drawing
of the letter “H” in front of the face; i.e., pursuit); by directing the patient’s
gaze to various stationary targets or directions (saccades); and by having the
patient fixate on an object while the head is turned passively (vestibulo-
ocular movements). The presence of nystagmus should be noted.
Muscles of mastication (V) are tested by assessing the strength of jaw
opening and palpating the contraction of the masseter when the jaw is
clenched. Facial sensation can be tested to all modalities over the forehead
(V1), cheek (V2), and jaw (V3) regions. The afferent limb of the corneal
reflex is mediated by CN V; the efferent limb is controlled by CN VII.
Muscles of facial expression (VII) are tested by having patients raise the
eyebrows, squeeze the eyes shut, puff the cheeks, or show the teeth. Though
uncommonly tested, taste over the anterior two-thirds of the tongue is
mediated by this nerve and can be evaluated with sugar or another
nonnoxious stimulus.
Hearing (VIII) may be evaluated in each ear simply by whispering or
rubbing fingers; more detailed assessment of hearing loss may be
accomplished with the Weber and Rinne tuning fork (512 Hz) tests.
Vestibular function can be tested in many ways, including evaluation of eye
fixation while the patient’s head is turned rapidly or by observation for a
gradual rotation of gait direction while the patient is walking in place with the
eyes closed.
 TABLE 1-3. The Cranial Nerves
Nerve Name Exit through the Function
Skull
I Olfactory Cribriform plate Olfaction (test using nonnoxious
substance)
II Optic Optic canal Vision (acuity, fields, color), afferent
limb of pupillary reflex
III Oculomotor Superior orbital fissure Superior rectus, inferior rectus, medial
rectus, inferior oblique, levator
palpebrae, efferent limb of pupillary
reflex
IV Trochlear Superior orbital fissure Superior oblique of contralateral eye
V Trigeminal Superior orbital fissure Muscles of mastication, tensor
(V1), foramen tympani, tensor veli palatini, facial
rotundum (V2), sensation, afferent limb of corneal
foramen ovale (V3) reflex
VI Abducens Superior orbital fissure Lateral rectus
VII Facial Internal auditory Muscles of facial expression, stapedius,
meatus taste on anterior two-thirds of tongue,
efferent limb of corneal reflex
VIII Vestibulocochlear Internal auditory Hearing, vestibular function
meatus
IX Glossopharyngeal Jugular foramen Movement of palate, sensation over
palate and pharynx, taste over posterior
one-third of tongue, afferent limb of
gag reflex
X Vagus Jugular foramen Movement of palate; sensation over
pharynx, larynx, and epiglottis; efferent
limb of gag reflex; parasympathetic
function of viscera
XI Accessory Jugular foramen Sternocleidomastoid and trapezius
movement
XII Hypoglossal Hypoglossal foramen Tongue movement

Palate elevation should be symmetric, and the voice should not be hoarse
or nasal (IX and X). Failure of the right palate to elevate implies pathology of
the right glossopharyngeal nerve. The gag reflex is also mediated by these
nerves.
Sternocleidomastoid strength is tested by having the patient turn the head
against resistance; weakness on turning to the left implies a right accessory
nerve (XI) problem. The trapezius muscle is tested by having patients shrug
the shoulders.
Tongue protrusion should be in the midline. If the tongue deviates toward
the right, the problem lies with the right hypoglossal nerve (XII).

KEY POINTS
● Cranial nerve testing is most easily performed and recorded in approximate numerical order.
● Key elements of the cranial nerve exam include assessment of vision and eye movements,
facial movement and sensation, and movements of the palate and tongue.

MOTOR EXAM
First, bulk is assessed by observing and palpating the muscles and comparing
each side to the other and the patient’s overall muscle bulk to that expected
for age.
Tone is one of the most important parts of the motor exam. In the arms,
tone is checked by moving the patient’s arm, flexing and extending at the
elbow, moving the wrist in a circular fashion, and pronating and supinating
the forearm rapidly using a handshake grip. Abnormalities of tone such as
spasticity and rigidity are discussed in subsequent chapters. Tone in the legs
can be tested well only with the patient supine. The examiner lifts the leg up
suddenly under the knee; in the presence of increased tone, the heel comes
off the bed. Increased tone can be characterized further as rigid or spastic. In
rigid limbs, the examiner can sense increased resistance throughout the
passive movements, but spasticity is speed dependent, with abnormalities
emerging with quick movements (e.g., elbow extension).
Strength is assessed by both observation and direct confrontation (Fig. 1-
2). A pronator drift may be observed in an arm held supinated and extended
in front of the body. The patient may be asked to rise from a chair without
using the arms or to walk on the heels and toes. The power of individual
muscles as assessed by direct confrontation testing is most often graded
according to the Medical Research Council (MRC) scale (Table 1-4). In some
settings, such as the intensive care unit, it is not possible to perform detailed
motor assessments. In this case, the examiner can look to see if there is
symmetry to voluntary limb movements. Another approach is to evaluate
whether the patient can withdraw meaningfully (i.e., pull the examined limb
away from a mildly noxious stimulus such as a pinch).
Another random document with
no related content on Scribd:
The Project Gutenberg eBook of Poetry for
children
 This ebook is for the use of anyone anywhere in the United
States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it away
or re-use it under the terms of the Project Gutenberg License
included with this ebook or online at www.gutenberg.org. If you
are not located in the United States, you will have to check the
laws of the country where you are located before using this
eBook.

Title: Poetry for children

Author: Charles Lamb

Mary Lamb

Author of introduction, etc.: Israel Gollancz

Illustrator: Winifred Green

Release date: June 21, 2022 [eBook #68359]

Most recently updated: October 14, 2022

Language: English

Original publication: United Kingdom: J. M. Dent & Co, 1898

Credits: Charlene Taylor, Charlie Howard, and the Online

Distributed Proofreading Team at https://www.pgdp.net
(This file was produced from images generously made
available by The Internet Archive/American Libraries.)

*** START OF THE PROJECT GUTENBERG EBOOK POETRY

FOR CHILDREN ***
 Transcriber’s Note
Larger versions of most illustrations may be seen by right-
clicking them and selecting an option to view them separately,
or by double-tapping and/or stretching them.
Poetry for
Children
BY

Charles and
Mary Lamb
ILLUSTRATED BY
WINIFRED GREEN
With a prefatory note by
ISRAEL GOLLANCZ
PUBLISHED BY J M DENT & Co
To the
Gentle Reader
As often as I pass a little Blue-coat boy I gaze upon him lovingly: I
reverence the quaint vision of a bygone age called up by the long
blue gaberdine, the red leathern belt, the yellow stockings—a quaint
monkish figure still to be seen in crowded London streets, still adding
to their picturesqueness and ever-varying charm.
You, too, dear Reader, have yourself probably asked the
meaning of the strange sight, as you have passed one of these
English lads so strangely attired. Perhaps you have been shown the
famous old school, in the midst of the bustle of London, surrounded
by ugly warehouses, offices, and shops; and you have seen the
effigy of the Founder, “that godly and royal child, King Edward the
Sixth, the flower of the Tudor name—the young flower that was
untimely cropped as it began to fill our land with its early odours—the
boy-patron of boys—the serious and holy child who walked with
Cranmer and Ridley.”
Alas, London is no longer to be the home of these boys, and the
cloisters of the Old Grey Friars will soon moulder away, when the
merry noise of sports and revels cease to awaken them to life.
As I looked through the bars the other day watching the boys at
their games, a strange fancy came to me. I thought I saw a pale and
studious “Grecian” (as they call the head boys of the school), and
walking at his side, with glittering eyes full of wonderment, was a
younger lad—a boy with crisply curling black hair, and with ruddy
brown complexion, and in his look so much lovableness and
trustfulness, that I felt myself envying the elder lad, whose hand
rested so affectionately on the shoulder of his friend. I drew near to
listen to their talk. The thoughtful Grecian was discoursing learnedly
yet so sweetly about some deep matter of philosophy: it seemed
somewhat beyond the younger boy, but he listened quietly, rapt in
admiration. Suddenly the school-bell sounded. “Hurry on, Charles!
‘’Mid deepest meditation sounds the knell.’ That’s how your good old
Elizabethans would put it. We’ll have another talk after supper.” “I—
I’ve n—not h—h—had o—one t—t—talk y—yet, S ... T ... C,”
stammered the other in reply: a painful contrast to the sublime
eloquence that flowed from his companion.
The noise of the bell and scampering of the boys soon made me
realise that Fancy had led me back a hundred years and more, and
had given me a glimpse of the boyhood of two famous Englishmen,
who have added glory to their ancient school—Samuel Taylor
Coleridge, poet and philosopher, and Charles Lamb, essayist and
critic, the best beloved of all the good and great men whose writings
are dear to us.
Some day you will read the story of the lives of these two men,
and you will love their books,—the weird and fairy poetry of
Coleridge, recalling a dreamy youth reared amid the woodlands of
Devon—the genial and sweet essays of Lamb, so full of gentle
humour, and kindliness, and humanity, so rich in tender thoughts
concerning all his fellow-creatures in the great city where he was
born and bred, which he loved passionately. To London he had given
“his heart and his love in childhood and in boyhood,” and throughout
his life his heart was filled with “fulness of joy at the multitudinous
scenes of life in the crowded streets of ever dear London.”
Charles Lamb’s Essays are among the greatest of our treasures,
but even more beautiful than his writings is the record of his noble
life—a life of saintly self-sacrifice, cheerfully devoted to the
guardianship of a lonely sister, whose girlhood would have been
spent in loveless solitude but for her brother’s love. Mary Lamb’s
tragic story (too sad to be told here) was illumined by the light of this
brotherly love which shone forth when the world was very dark and
gloomy.
Mary Lamb had something of her brother’s gift of writing; it was
she indeed to whom you owe many of the Tales of Shakespeare you
are so fond of. They loved children, and they loved Shakespeare,
and their stories from Shakespeare have been and are still read by
boys and girls all the world over. They wrote, too, a whole collection
of Poetry for Children, and here also Mary’s share was much greater
than her brother’s. “Mine,” wrote Charles, “are but one-third in
quantity of the whole.” ... “Perhaps you will admire the number of
subjects, all of children, picked out by an old bachelor and an old
maid. Many parents would not have found so many.” This collection
of “Poetry for Children” in two small volumes, was so much liked by
the children that all the copies were soon bought up, and Charles
Lamb himself could not get a copy, when later in life he sought one
far and wide. So rare is the book now that only one or two copies are
known to exist, and even the British Museum does not possess
these precious little volumes. A small selection of the poems are now
once again offered to boys and girls: if this prove welcome, more will
follow. They are simple little poems such as children should care for,
and even grown-up people, for whom they were never intended,
cherish every word written by Mary and Charles Lamb, because they
know how much goodness and humility dwelt in their souls. If there
were any wish to be learned and to explain how they came to write
these verses, one would have to tell you something about other
writers who were then living and writing, more especially about
Lamb’s friend “S. T. C.,” who, together with an even greater poet,
William Wordsworth, had published ten years before, in 1798, a
small volume of simple English poems, which was destined to have
the greatest influence on English poetry for long years to come. In
that volume Wordsworth first printed the sweet little poem I am sure
you know, called We Are Seven, and Coleridge, “the inspired charity
boy,” as Charles Lamb called him, gave the world the magical ballad
of The Ancient Mariner. One verse from this ballad ought to be
printed on the title-page of this little book of poems by Mary and
Charles Lamb:—

“He prayeth best, who loveth best

All things both great and small;
For the dear God who loveth us,
He made and loveth all.”
I. G.
 CONTENTS

PAGE
i. The First Tooth 11
ii. The Boy and the Skylark—A Fable 14
iii. The Rainbow 18
iv. Queen Oriana’s Dream 21
v. The Sister’s Expostulation on the Brother’s
learning Latin 23
vi. The Brother’s Reply 26
vii. On the Lord’s Prayer 29
viii. David in the Cave of Adullam 34
ix. Cleanliness 36
x. To a River in which a Child was drowned 39
 xi. The Boy and Snake 40
xii. The Beasts in the Tower 43
xiii. Time spent in Dress 47
xiv. A Ballad: noting the difference of Rich and Poor,
in the Ways of a Rich Noble’s Palace and a
Poor Workhouse 50
xv. The Broken Doll 55
xvi. Going into Breeches 57
xvii. The Three Friends 61
xviii. Memory 72
xix. Salome 74
xx. The Peach 78
xxi. The Magpie’s Nest 81
xxii. Nursing 87
xxiii. The Rook and the Sparrows 88
xxiv. Feigned Courage 91
xxv. Hester 94
xxvi. Helen 97
xxvii. The Beggar Man 100
xxviii.Breakfast 104
xxix. The Coffee Slips 107
xxx. Written in the First Leaf of a Child’s
Memorandum Book 110
xxxi. Envy 112
xxxii. Dialogue between Mother and Child 114
xxxiii. The First Sight of Green Fields 116
xxxiv. Lines suggested by a Picture of two Females by
Leonardo da Vinci 119
xxxv. Lines on the same Picture being removed to
make place for a Portrait of a Lady by Titian 121
 xxxvi. Lines on the celebrated Picture by Leonardo da 122
Vinci, called The Virgin of the Rocks
xxxvii. On the same 123
xxxviii. A Vision of Repentance 124
 THE
FIRST TOOTH

I
SISTER

Through the house what busy joy

Just because the infant boy
Has a tiny tooth to show!
I have got a double row,
All as white and all as small;
Yet no one cares for mine at all.
He can say but half a word,
Yet that single sound’s preferr’d
To all the words that I can say
In the longest summer day.
He cannot walk; yet if he put
With mimic motion out his foot,
As if he thought he were advancing,
It’s prized more than my best dancing.

BROTHER
Sister, I know you jesting are,
Yet O! of jealousy beware.
If the smallest seed should be
In your mind, of jealousy,
It will spring and it will shoot
Till it bear the baneful fruit.
I remember you, my dear,
Young as is this infant here.
There was not a tooth of those
Your pretty even ivory rows,
But as anxiously was watch’d
Till it burst its shell new-hatch’d
As if it a phoenix were,
Or some other wonder rare.
So when you began to walk—
So when you began to talk—
As now, the same encomiums pass’d
’Tis not fitting this should last
Longer than our infant days;
A child is fed with milk and praise.
 THE BOY AND THE
SKYLARK
A FABLE

II

“A wicked action fear to do,

When you are by yourself; for though
You think you can conceal it,
A little bird that’s in the air
The hidden trespass shall declare
And openly reveal it.”

Richard this saying oft had heard,

Until the sight of any bird
Would set his heart a-quaking;
He saw a host of winged spies
For ever o’er him in the skies,
Note of his actions taking.
This pious precept, while it stood
In his remembrance, kept him good
When nobody was by him;
For though no human eye was near,
Yet Richard still did wisely fear
The little bird should spy him.
But best resolves will sometimes sleep;
Poor frailty will not always keep
From that which is forbidden;
And Richard one day, left alone,
Laid hands on something not his own,
And hoped the theft was hidden.

His conscience slept a day or two,

As it is very apt to do,
When we with pain suppress it;
And though at times a slight remorse
Would raise a pang, it had not force
To make him yet confess it.

When on a day, as he abroad

Walk’d by his mother, in their road
He heard a skylark singing;
Smit with the sound, a flood of tears
Proclaim’d the superstitious fears
His inmost bosom wringing.

His mother, wondering, saw him cry,

And fondly ask’d the reason why?
Then Richard made confession,
And said, he fear’d the little bird
He singing in the air had heard
Was telling his transgression.

The words which Richard spoke below,

As sounds by nature upwards go,
Were to the skylark carried:
The airy traveller with surprise,
To hear his sayings, in the skies
On his mid-journey tarried.