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a LANGE medical book

Clinical Neurology
TENTH EDITION

Roger P. Simon, MD
Professor of Medicine (Neurology) and Neurobiology
Morehouse School of Medicine
Clinical Professor of Neurology
Emory University
Atlanta, Georgia

Michael J. Aminoff, MD, DSc, FRCP

Distinguished Professor
Department of Neurology
School of Medicine
University of California
San Francisco, California

David A. Greenberg, MD, PhD

Professor Emeritus
Buck Institute for Research on Aging
Novato, California

New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto
Clinical Neurology, Tenth Edition

Copyright © 2018 by McGraw-Hill Education. All rights reserved. Printed in the United States of America. Except as
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Previous editions copyright © 1999, 1996, 1993, 1989 by Appleton & Lange.

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ISBN 978-1-259-86172-7
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ISSN 1522-6875

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To our families, as well as to our patients and students over the years.
 Contents
Preface vii

1. Neurologic History & Examination 1 11. Movement Disorders 311

2. Investigative Studies 27 12. Seizures & Syncope 344

3. Coma 46 13. Stroke 369

 
4. Confusional States 65 Appendix: Clinical Examination of
Common Isolated Peripheral
Nerve Disorders 407
5. Dementia & Amnestic Disorders 106

Index 415
6. Headache & Facial Pain 139

7. Neuro-Ophthalmic Disorders 166

8. Disorders of Equilibrium 190

9. Motor Disorders 219

10. Sensory Disorders 278

 Preface
Forty years ago, as clinical teachers at the UCSF School of Medicine, we decided that there was a need for a new teaching
text that combined the basic and clinical aspects of neurology. Following a lunch meeting, Jack Lange of Lange Medical
Publications agreed to the addition of a clinical neurology textbook to the Lange textbook series. He smiled when one of
us (RPS) offered to provide the text in two years, noting that no one had produced a textbook in that time. With two
coauthors (MJA and DAG) and after some ten years, the text of Clinical Neurology was finally completed and in 1989 the
first edition was published. With the publication of the 10th edition and translations in eight languages, our text will have
provided nearly 30 consecutive years of neurology teaching material to medical students in the United States and around
the world via the print volume (purchased or rented), e-book edition, and AccessMedicine website.
As in each new edition, we have retained and refined the core didactic material relating to the function of the nervous
system in health and disease and added new and evolving diagnostic and therapeutic material. Full-color figures illustrate
key concepts. Over the years, the book has encompassed the evolution of therapeutics in neurology, particularly for
epilepsy and headache and most recently for demyelinating disease. This edition continues to document the expansion of
diagnostic and therapeutic approaches to nervous system disease. To those who still believe that there are limited therapeutic
options in neurology, we hope that the present volume will help to convince them otherwise. Within just the last year,
advances in molecular biology and immunology have led to the approval of new drugs for the treatment of multiple sclerosis
(alemtuzumab), spinal muscular atrophy (nusinersen), amyotrophic lateral sclerosis (edaravone), and Huntington’s disease
(deutetrabenazine). These and other therapeutic advances are included in this new edition.
Over the years, many colleagues have suggested revisions, contributed figures and radiographic material, and read over
portions of the book. In this regard, we thank the members of the faculty of UCSF, the University of Pittsburgh, the Oregon
Health and Sciences University, and Emory University who helped us, as well as the current and past staff of our publisher,
McGraw-Hill, and particularly Andrew Moyer and Christie Naglieri for their assistance with this latest edition. Special
thanks are due to Martha Johnson, PhD, for her careful copy-editing of the entire 10th edition and to McGraw-Hill for
providing a new index to optimize accessibility.

Roger P. Simon
Michael J. Aminoff
David A. Greenberg
 Neurologic History &
Examination

History/ 1 Neurologic Examination/ 7

Age/ 1 Mental Status/ 7
Chief Complaint/ 1 Cranial Nerves/ 1O
History of Present Illness/ 2 Motor Function / 17
Past Medical History/ 3 Sensory Function/ 19
Family History/ 3 Coordination/ 20
Social History/ 3 Reflexes/ 21
Review of Systems/ 4 Stance & Gait/ 21
Summary/ 4 Neurologic Examination in Special
General Physical Examination/ 4 Settings/ 23
Vital Signs/ 4 Coma/ 23
Skin/ 5 "Screening" Neurologic Examination/ 23
Head, Eyes, Ears, & Neck/ 5
Diagnostic Formulation/ 23
Chest & Cardiovascular/ 6
Principles of Diagnosis/ 23
Abdomen/ 7
Anatomic Diagnosis: Where Is the Lesion?/ 23
Extremities & Back/ 7
Etiologic Diagnosis: What Is the Lesion?/ 24
Rectal & Pelvic/ 7
Laboratory Investigations/ 26

HISTORY from-the correct diagnosis. The goal is for the patient to

describe the nature of the problem in a word or phrase.
Taking a history from a patient with a neurologic com- Common neurologic complaints include confusion,
plaint is fundamentally the same as taking any history. dizziness, weakness, shaking, numbness, blurred vision,

• Age
Age can be a clue to the cause of a neurologic problem.
Epilepsy, multiple sclerosis, and Huntington disease usu-
ally have their onset by middle age, whereas Alzheimer
disease, Parkinson disease, brain tumors, and stroke pre-
dominantly affect older individuals.
• Chief Complaint
The chief complaint should be defined as clearly as possi-
ble, because it will guide evaluation toward-or away
and spells. Each of these terms means different things to
different people, so it is critical to clarify what the patient
is trying to convey.
A. Confusion
Confusion may be reported by the patient or by family
members. Symptoms can include memory impairment,
getting lost, difficulty understanding or producing spoken
or written language, problems with numbers, faulty judg-
ment, personality change, or combinations thereof. Symp-
toms of confusion may be difficult to characterize, so
specific examples should be sought.

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 2 CHAPTER 1

B. Dizziness (allodynia). The severity of symptoms should also be

Dizziness can mean vertigo (the illusion of movement of
oneself or the environment), imbalance (unsteadiness due
to extrapyramidal, vestibular, cerebellar, or sensory defi-
cits), or presyncope (light-headedness resulting from
cerebral hypoperfusion).
C. Weakness
Weakness is the term neurologists use to mean loss of
power from disorders affecting motor pathways in the
central or peripheral nervous system or skeletal muscle.
However, patients sometimes use this term when they
mean generalized fatigue, lethargy, or even sensory
disturbances.
D. Shaking
Shaking may represent abnormal movements such as
tremor, chorea, athetosis, myoclonus, or fasciculation (see
Chapter 11, Movement Disorders), but the patient is
unlikely to use these terms. Correct classification depends
on observing the movements in question or, if they are not
present when the history is taken, asking the patient to
ascertained. Although thresholds for seeking medical
attention vary among patients, it is often useful to ask a
patient to rank the present complaint in relation to past
problems.
B. Location of Symptoms
Patients should be encouraged to localize their symptoms
as precisely as possible because location is often critical to
neurologic diagnosis. The distribution of weakness,
decreased sensation, or pain helps point to a specific site in
the nervous system (anatomic diagnosis).
C. Time Course
It is important to determine when the problem began,
whether it came on abruptly or insidiously, and if its subse-
quent course has been characterized by improvement,
worsening, or exacerbation and remission (Figure 1-1).
For episodic disorders, such as headache or seizures, the
Severity

demonstrate them.
Stroke
E. Numbness
Numbness can refer to any of a variety of sensory distur-
bances, including hypesthesia (decreased sensitivity),
hyperesthesia (increased sensitivity), or paresthesia (“pins
and needles” sensation). Patients occasionally also use this
term to signify weakness. Alzheimer disease
Severity

Brain tumor
F. Blurred Vision
Blurred vision may represent diplopia (double vision),
ocular oscillations, reduced visual acuity, or visual field
cuts.

G. Spells
Severity

Spells imply episodic and often recurrent symptoms such Multiple sclerosis
as in epilepsy or syncope (fainting).

▶ History of Present Illness

▶

The history of present illness should provide a detailed

description of the chief complaint, including the following
features.
Severity

Migraine
A. Quality and Severity of Symptoms Epilepsy
Some symptoms, such as pain, may have distinctive fea-
tures. Neuropathic pain—which results from direct injury
to nerves—may be described as especially unpleasant (dys-
Time
esthetic) and may be accompanied by increased sensitivity
to pain (hyperalgesia) or touch (hyperesthesia), or by the ▲ Figure 1-1. Temporal patterns of neurologic disease
▲

perception of a normally innocuous stimulus as painful and examples of each.

 NEUROLOGIC HISTORY & EXAMINATION
time course of individual episodes should also be
determined.
D. Precipitating, Exacerbating, and Alleviating
Factors
Some symptoms may appear to be spontaneous, but in
other cases, patients are aware of factors that precipitate or
worsen symptoms, and which they can avoid, or factors
that prevent symptoms or provide relief.
E. Associated Symptoms
Associated symptoms can assist with anatomic or etiologic
diagnosis. For example, neck pain accompanying leg weak-
ness suggests a cervical myelopathy (spinal cord disorder),
and fever in the setting of headache suggests meningitis.
▶ Past Medical History
▶
The past medical history may provide clues to the cause of
a neurologic complaint.
A. Illnesses
Preexisting illnesses that can predispose to neurologic dis-
ease include hypertension, diabetes, heart disease, cancer,
and human immunodeficiency virus (HIV) disease.
B. Operations
Open heart surgery may be complicated by stroke or a
confusional state. Entrapment neuropathies (disorders of a
peripheral nerve due to local pressure) affecting the upper
or lower extremity may occur perioperatively.
C. Obstetric History
Pregnancy can worsen epilepsy, partly due to altered
metabolism of anticonvulsant drugs, and may increase or
decrease the frequency of migraine attacks. Pregnancy is a
predisposing condition for idiopathic intracranial hyper-
tension (pseudotumor cerebri) and entrapment neuropa-
thies, especially carpal tunnel syndrome (median
neuropathy) and meralgia paresthetica (lateral femoral
cutaneous neuropathy). Traumatic neuropathies affecting
the obturator, femoral, or peroneal nerve may result from
pressure exerted by the fetal head or obstetric forceps dur-
ing delivery. Eclampsia is a life-threatening syndrome in
which generalized tonic-clonic seizures complicate the
course of pre-eclampsia (hypertension with proteinuria)
during pregnancy.
D. Medications
A wide range of medications can cause adverse neurologic
effects, including confusional states or coma, headache,
ataxia, neuromuscular disorders, neuropathy, and
seizures.
3
E. Immunizations
Vaccination can prevent neurologic diseases such as polio-
myelitis, diphtheria, tetanus, rabies, meningococcal or
Haemophilus influenzae meningitis, and Japanese encepha-
litis. Rare complications include postvaccination autoim-
mune encephalitis, myelitis, or neuritis (inflammation of
the brain, spinal cord, or peripheral nerves).
F. Diet
Deficiency of vitamin B1 (thiamin) is responsible for the
Wernicke–Korsakoff syndrome and polyneuropathy in
alcoholics. Vitamin B3 (niacin) deficiency causes pellagra,
which is characterized by dementia. Vitamin B12 (cobala-
min) deficiency usually results from malabsorption associ-
ated with pernicious anemia and produces combined
systems disease (degeneration of corticospinal tracts and
posterior columns in the spinal cord) and dementia (mega-
loblastic madness). Inadequate intake of vitamin E
(tocopherol) can also lead to spinal cord degeneration.
Hypervitaminosis A can produce intracranial hyperten-
sion (pseudotumor cerebri) with headache, visual deficits,
and seizures, whereas excessive intake of vitamin B6
(pyridoxine) is a cause of polyneuropathy. Excessive con-
sumption of fats is a risk factor for stroke. Finally, ingestion
of improperly preserved foods containing botulinum toxin
causes botulism, which presents with descending
paralysis.
G. Tobacco, Alcohol, and Other Drug Use
Tobacco use is associated with lung cancer, which may
metastasize to the central nervous system or produce para-
neoplastic neurologic syndromes. Alcohol abuse can pro-
duce withdrawal seizures, polyneuropathy, and nutritional
disorders of the nervous system. Intravenous drug use may
suggest HIV disease, infection, or vasculitis.
▶ Family History
▶
This should include past or current diseases in the spouse
and first- (parents, siblings, children) and second- (grand-
parents, grandchildren) degree relatives. Several neuro-
logic diseases exhibit Mendelian inheritance, such as
Huntington disease (autosomal dominant), Wilson disease
(autosomal recessive), and Duchenne muscular dystrophy
(X-linked recessive) (Figure 1-2).
▶ Social History
▶
Information about the patient’s education and occupation
helps determine whether cognitive performance is appro-
priate to the patient’s background. The sexual history may
indicate risk for sexually transmitted diseases that affect
the nervous system, such as syphilis or HIV disease. The
travel history can document exposure to infections
endemic to particular geographic areas.
 4 CHAPTER 1
Autosomal dominant
Autosomal recessive
X-linked recessive
▲ Figure 1-2. Simple Mendelian patterns of inheri-
▲
tance. Squares represent males, circles females, and
filled symbols affected individuals.
▶ Review of Systems
▶
Non-neurologic complaints elicited in the review of sys-
tems may point to a systemic cause of a neurologic
problem as described below:
1. General—Weight loss may suggest an underlying neo-
plasm and fever indicate an infection.
2. Immune—Acquired immune deficiency syndrome
(AIDS) may lead to dementia, myelopathy, neuropa-
thy, myopathy, or infections (eg, toxoplasmosis) or
tumors (eg, lymphoma) affecting the nervous system.
3. Hematologic—Polycythemia and thrombocytosis
may predispose to ischemic stroke, whereas thrombo-
cytopenia and coagulopathy are associated with intra-
cranial hemorrhage.
4. Endocrine—Diabetes increases the risk for stroke and
polyneuropathy. Hypothyroidism may lead to coma,
dementia, or ataxia.
5. Skin—Characteristic skin lesions are seen in certain
disorders that affect the nervous system, such as neu-
rofibromatosis and postherpetic neuralgia.
6. Eyes, ears, nose, and throat—Neck stiffness is a
common feature of meningitis and subarachnoid
hemorrhage.
7. Cardiovascular—Ischemic or valvular heart disease
and hypertension are major risk factors for stroke.
8. Respiratory—Cough, hemoptysis, or night sweats
may be manifestations of tuberculosis or lung neo-
plasm, which can disseminate to the nervous system.
9. Gastrointestinal—Hematemesis, jaundice, and diar-
rhea may suggest hepatic encephalopathy as the cause
of a confusional state.
10. Genitourinary—Urinary retention, incontinence, and
impotence may be manifestations of peripheral neu-
ropathy or myelopathy.
11. Musculoskeletal—Muscle pain and tenderness
accompany the myopathy of polymyositis.
12. Psychiatric—Psychosis, depression, and mania may
be manifestations of several neurologic diseases.
▶ Summary
▶
Upon completion of the history, the examiner should
have a clear understanding of the chief complaint, includ-
ing its location and time course, and familiarity with ele-
ments of the past medical history, family and social
history, and review of systems that may be related to the
complaint. This information should help to guide the
general physical and neurologic examinations, which
should focus on areas suggested by the history. For exam-
ple, in an elderly patient who presents with the sudden
onset of hemiparesis and hemisensory loss, which is likely
to be due to stroke, the general physical examination
should stress the cardiovascular system, because a variety
of cardiovascular disorders predispose to stroke. On the
other hand, if a patient complains of pain and numbness
in the hand, much of the examination should be devoted
to evaluating sensation, strength, and reflexes in the
affected upper extremity.
GENERAL PHYSICAL EXAMINATION
In a patient with a neurologic complaint, the general
physical examination should focus on looking for sys-
temic abnormalities often associated with neurologic
problems.
▶ Vital Signs
▶
A. Blood Pressure
Elevated blood pressure may indicate chronic hyperten-
sion, which is a risk factor for stroke and is also seen
acutely in the setting of hypertensive encephalopathy,
 NEUROLOGIC HISTORY & EXAMINATION 5

▲ Figure 1-3. Test for orthostatic hypotension. Systolic and diastolic blood pressure and heart rate are measured
▲

with the patent recumbent (left) and then each minute after standing for 5 min (right). A decrease in systolic blood
pressure of ≥20 mm Hg or in diastolic blood pressure of ≥10 mm Hg indicates orthostatic hypotension. When auto-
nomic function is normal, as in hypovolemia, there is a compensatory increase in heart rate, whereas lack of such an
increase suggests autonomic failure.

ischemic stroke, or intracerebral or subarachnoid hemor- D. Temperature

rhage. Blood pressure that drops by ≥20 mm Hg (systolic)
or ≥10 mm Hg (diastolic) when a patient switches from
recumbent to upright signifies orthostatic hypotension
(Figure 1-3). If the drop in blood pressure is accompanied
by a compensatory increase in pulse rate, sympathetic
autonomic reflexes are intact, and the likely cause is hypo-
volemia. However, the absence of a compensatory response
is consistent with central (eg, multisystem atrophy) or
Fever (hyperthermia) occurs with infection of the menin-
ges (meningitis), brain (encephalitis), or spinal cord
(myelitis). Hypothermia can be seen in ethanol or sedative
drug intoxication, hypoglycemia, hepatic encephalopathy,
Wernicke encephalopathy, and hypothyroidism.
▶ Skin
▶

peripheral (eg, polyneuropathy) disorders of sympathetic
function or an effect of sympatholytic (eg, antihyperten-
sive) drugs.
B. Pulse
A rapid or irregular pulse—especially the irregularly
irregular pulse of atrial fibrillation—may point to a car-
diac arrhythmia as the cause of stroke or syncope.
C. Respiratory Rate
The respiratory rate may provide a clue to the cause of a
metabolic disturbance associated with coma or a confu-
sional state. Rapid respiration (tachypnea) can be seen in
Jaundice (icterus) suggests liver disease as the cause of a
confusional state or movement disorder. Coarse dry skin,
dry brittle hair, and subcutaneous edema are characteristic
of hypothyroidism. Petechiae are seen in meningococcal
meningitis, and petechiae or ecchymoses may suggest a
coagulopathy as the cause of subdural, intracerebral, or
paraspinal hemorrhage. Bacterial endocarditis, a cause of
stroke, can produce a variety of cutaneous lesions, includ-
ing splinter (subungual) hemorrhages, Osler nodes (pain-
ful swellings on the distal fingers), and Janeway lesions
(painless hemorrhages on the palms and soles). Hot dry
skin accompanies anticholinergic drug intoxication.
▶ Head, Eyes, Ears, & Neck
▶

hepatic encephalopathy, pulmonary disorders, sepsis, or

salicylate intoxication; depressed respiration is observed
with pulmonary disorders and sedative drug intoxication.
Tachypnea may also occur in neuromuscular disease
affecting the diaphragm. Abnormal respiratory patterns
may be observed in coma: Cheyne-Stokes breathing (alter-
nating deep breaths, or hyperpnea, and apnea) can occur in
metabolic disorders or with hemispheric lesions, whereas
apneustic, cluster, or ataxic breathing (see Chapter 3,
Coma) implies a brainstem disorder.
A. Head
Examination of the head may reveal signs of trauma, such
as scalp lacerations or contusions. Basal skull fracture may
produce postauricular hematoma (Battle sign), periorbital
hematoma (raccoon eyes), hemotympanum, or cerebro-
spinal fluid (CSF) otorrhea or rhinorrhea (Figure 1-4).
Percussion of the skull over a subdural hematoma may
cause pain. A bruit heard over the skull is associated with
arteriovenous malformations.
 6 CHAPTER 1
A noid hemorrhage. Restricted lateral movement (flexion or
B
▲ Figure 1-4. Signs of head trauma include periorbital
▲
(raccoon eyes, A) or postauricular (Battle sign, B) hema-
toma, each of which suggests basal skull fracture. (Used
with permission from Kevin J Knoop (A) and Frank Birinyi
(B); from Knoop K, Stack L, Storrow A, Thurman RJ. Atlas of
Emergency Medicine. 4th ed. New York, NY: McGraw-Hill; 2016).
B. Eyes
Icteric sclerae are seen in liver disease. Pigmented (Kayser–
Fleischer) corneal rings—best seen by slit-lamp
examination—are produced by copper deposits in Wilson
disease. Retinal hemorrhages (Roth spots) may occur in
bacterial endocarditis, which may cause stroke. Exophthal-
mos is observed with hyperthyroidism, orbital or retro-
orbital masses, and cavernous sinus thrombosis.
C. Ears
Otoscopic examination shows bulging, opacity, and ery-
thema of the tympanic membrane in otitis media, which
may spread to produce bacterial meningitis.
D. Neck
Meningeal signs (Figure 1-5), such as neck stiffness on
passive flexion or thigh flexion upon flexion of the neck
(Brudzinski sign), are seen in meningitis and subarach-
rotation) of the neck may accompany cervical spondylosis.
Auscultation of the neck may reveal a carotid bruit, which
may be a risk factor for stroke.
▶ Chest & Cardiovascular
▶
Signs of respiratory muscle weakness—such as intercostal
muscle retraction and the use of accessory muscles—may
A Kernig sign
Involuntary hip and
knee flexion
B Brudzinski sign
▲ Figure 1-5. Signs of meningeal irritation. Kernig
▲
sign (A) is resistance to passive extension at the knee
with the hip flexed. Brudzinski sign (B) is flexion at the
hip and knee in response to passive flexion of the neck.
(Used with permission from LeBlond RF, DeGowin RL,
Brown DD. DeGowin’s Diagnostic Examination. 9th ed.
New York, NY: McGraw-Hill; 2009.)
 NEUROLOGIC HISTORY & EXAMINATION
occur in neuromuscular disorders. Heart murmurs may be
associated with valvular heart disease and infective endo-
carditis, which predispose to stroke.
▶ Abdomen
▶ ▶ Rectal & Pelvic
Abdominal examination may suggest liver disease and is
always important in patients with the new onset of back
pain, because intra-abdominal processes such as pancre-
atic carcinoma or aortic aneurysm may present with pain
that radiates to the back.
▶ Extremities & Back
▶
Resistance to passive extension of the knee with the hip
flexed (Kernig sign) (Figure 1-5) is seen in meningitis.
Raising the extended leg with the patient supine (straight
leg raising, or Lasègue sign) stretches the L4-S2 roots and
sciatic nerve, whereas raising the extended leg with the
patient prone (reverse straight leg raising) stretches the
L2-L4 roots and femoral nerve and may reproduce radicu-
lar pain with lesions affecting these structures (Figure 1-6).
▲ Figure 1-6. Signs of lumbosacral nerve root irrita-
▲
tion. The straight leg raising or Lasègue sign (top) is
pain in an L4-S2 root or sciatic nerve distribution in
response to raising the extended leg with the patient
supine. The reverse straight leg raising sign (bottom) is
pain in an L2-L4 root or femoral nerve distribution in
response to raising the extended leg with the patient
prone. (Used with permission from LeBlond RF, DeGowin
RL, Brown DD. DeGowin’s Diagnostic Examination. 9th ed.
New York, NY: McGraw-Hill, 2009.)
7
Localized pain with percussion of the spine may be a sign of
vertebral or epidural infection. Auscultation of the spine
may reveal a bruit due to spinal vascular malformation.
▶
Rectal examination can provide evidence of gastrointesti-
nal bleeding, which is a common precipitant of hepatic
encephalopathy. Rectal or pelvic examination may disclose
a mass lesion responsible for pain referred to the back.
NEUROLOGIC EXAMINATION
The neurologic examination should be tailored to the
patient’s specific complaint. All parts of the examination—
mental status, cranial nerves, motor function, sensory func-
tion, coordination, reflexes, and stance and gait—should be
covered, but the points of emphasis will differ. The history
should have raised questions that the examination can now
address. For example, if the complaint is weakness, the
examiner seeks to determine its distribution and severity
and whether it is accompanied by deficits in other areas,
such as sensation and reflexes. The goal is to obtain the
information necessary to generate an anatomic diagnosis.
▶ Mental Status
▶
The mental status examination addresses two key ques-
tions: (1) Is level of consciousness (wakefulness or alert-
ness) normal or abnormal? (2) If the level of consciousness
permits more detailed examination, is cognitive function
normal, and if not, what is the nature and extent of the
abnormality?
A. Level of Consciousness
Consciousness is awareness of the internal and external
world, and the level of consciousness is described in terms
of the patient’s apparent state of wakefulness and response
to stimuli. A patient with a normal level of consciousness
is awake (or can be easily awakened), alert (responds
appropriately to visual or verbal cues), and oriented
(knows who and where he or she is and the approximate
date and time).
Abnormal (depressed) consciousness represents a con-
tinuum ranging from mild sleepiness to unarousable unre-
sponsiveness (coma, see Chapter 3, Coma). Depressed
consciousness short of coma is sometimes referred to as a
confusional state, delirium, or stupor, but should be char-
acterized more precisely in terms of the stimulus–response
patterns observed. Progressively more severe impairment
of consciousness requires stimuli of increasing intensity to
elicit increasingly primitive (nonpurposeful or reflexive)
responses (Figure 1-7).
B. Cognitive Function
Cognitive function involves many spheres of activity, some
thought to be localized and others dispersed throughout
 8 CHAPTER 1
Coherent
Purposeful
Response
Semi-
purposeful
Reflexive
or none
Verbal Tactile
or visual
Stimulus
▲ Figure 1-7. Assessment of level of consciousness in relation to the patient’s response to stimulation. A normally
▲
conscious patient responds coherently to visual or verbal stimulation, whereas a patient with impaired conscious-
ness requires increasingly intense stimulation and exhibits increasingly primitive responses.
the cerebral hemispheres. The strategy in examining cog-
nitive function is to assess a range of specific functions
and, if abnormalities are found, to evaluate whether these
can be attributed to a specific brain region or require more
widespread involvement of the brain. For example, discrete
disorders of language (aphasia) and memory (amnesia)
can often be assigned to a circumscribed area of the brain,
whereas more global deterioration of cognitive function, as
seen in dementia, implies diffuse or multifocal disease.
1. Bifrontal or diffuse functions—Attention is the abil-
ity to focus on a particular sensory stimulus to the
exclusion of others; concentration is sustained atten-
tion. Attention can be tested by asking the patient to
immediately repeat a series of digits (a normal person
can repeat five to seven digits correctly), and concentra-
tion can be tested by having the patient count backward
from 100 by 7s. Abstract thought processes like insight
and judgment can be assessed by asking the patient to
list similarities and differences between objects (eg, an
apple and an orange), interpret proverbs (overly con-
crete interpretations suggest impaired abstraction abil-
ity), or describe what he or she would do in a
hypothetical situation requiring judgment (eg, finding
an addressed envelope on the street). Fund of knowl-
edge can be tested by asking for information that a
normal person of the patient’s age and cultural back-
ground would possess (eg, the name of the President,
sports stars, or other celebrities, or major events in the
news). This is not intended to test intelligence, but to
determine whether the patient has been incorporating
new information in the recent past. Affect is the exter-
nal expression of internal mood and may be manifested
by talkativeness or lack thereof, facial expression, and
posture. Conversation with the patient may reveal
Normal consciousness
Depressed consciousness
Coma
Painful
abnormalities of thought content, such as delusions or
hallucinations, which are usually associated with psy-
chiatric disease, but can also exist in confusional states
(eg, alcohol withdrawal).
2. Memory—Memory is the ability to register, store, and
retrieve information and can be impaired by either dif-
fuse cortical or bilateral temporal lobe disease. Memory
is assessed by testing immediate recall, recent memory,
and remote memory, which correspond roughly to
registration, storage, and retrieval. Tests of immediate
recall are similar to tests of attention (see earlier discus-
sion) and include having the patient immediately repeat
a list of numbers or objects. To test recent memory, the
patient can be asked to repeat a list of items 3 to 5 min-
utes later. Remote memory is tested by asking the patient
about facts he or she can be expected to have learned in
past years, such as personal or family data or major his-
toric events. Confusional states typically impair imme-
diate recall, whereas memory disorders (amnesia) are
characteristically associated with predominant involve-
ment of recent memory, with remote memory preserved
until late stages. Personal and emotionally charged
memories tend to be preferentially spared, whereas the
opposite may be true in psychogenic amnesia. Inability
of an awake and alert patient to remember his or her
own name strongly suggests a psychiatric disorder.
3. Language—The key elements of language are compre-
hension, repetition, fluency, naming, reading, and writ-
ing, and all should be tested when a language disorder
(aphasia) is suspected. There are a variety of aphasia
syndromes, each characterized by a particular pattern of
language impairment (Table 1-1) and often correlating
with a specific site of pathology (Figure 1-8). Expres-
sive (also called nonfluent, motor, or Broca) aphasia
 NEUROLOGIC HISTORY & EXAMINATION 9

ifs, ands, or buts”), but their language comprehension

Table 1-1. Aphasia Syndromes. is intact. Thus, if the patient is asked to do something
that does not require language expression (eg, “close
Type Fluency Comprehension Repetition your eyes”), he or she can do it. The patient is typically
Expressive (Broca) – + – aware of the disorder and frustrated by it. In receptive
(also called fluent, sensory, or Wernicke) aphasia, lan-
Receptive (Wernicke) + – –
guage expression is preserved, but comprehension and
Global – – – repetition are impaired. A large volume of language is
Conduction + + – produced, but it lacks meaning and may include para-
phasic errors (use of words that sound similar to the
Transcortical – + +
expressive
correct word) and neologisms (made-up words). Com-
prehension of written language is similarly poor, and
Transcortical receptive + – + repetition is defective. The patient cannot follow oral
Transcortical global – – + or written commands, but can imitate the examiner’s
Anomic (naming) + + +
action when prompted by a gesture to do so. These
patients are usually unaware of and therefore not dis-
+, preserved; −, impaired turbed by their aphasia. Global aphasia combines
See Figure 1-8 for anatomic correlates. features of expressive and receptive aphasia—patients
Modified from Waxman SG. Clinical Neuroanatomy. 26th ed. New can neither express, comprehend, nor repeat spoken
York, NY: McGraw-Hill; 2010. or written language. Other forms of aphasia include
conduction aphasia, in which repetition is impaired
whereas expression and comprehension are intact;
is characterized by paucity of spontaneous speech and transcortical aphasia, in which expressive, receptive,
by the agrammatical and telegraphic nature of the or global aphasia occurs with intact repetition; and
little speech that is produced. Language expression is anomic aphasia, a selective disorder of naming. Lan-
tested by listening for these abnormalities as the patient guage is distinct from speech, the final motor step in
speaks spontaneously and answers questions. Patients oral expression of language. A speech disorder (dysar-
with this syndrome are also unable to write normally or thria) may be difficult to distinguish from aphasia, but
to repeat (tested with a content-poor phrase such as “no always spares oral and written language comprehension
and written expression.
4. Sensory integration—Sensory integration disorders
result from parietal lobe lesions and cause mispercep-
tion of or inattention to sensory stimuli on the side
of the body opposite the lesion, even though primary
5 sensory modalities (eg, touch) are intact. Patients with
parietal lesions may exhibit various signs. Astere-
4 3
2
ognosis is the inability to identify by touch an object
placed in the hand, such as a coin, key, or safety pin.
1 Agraphesthesia is the inability to identify by touch a
number written on the hand. Failure of two-point dis-
crimination is the inability to differentiate between a
single stimulus and two simultaneously applied, adja-
cent but separated, stimuli that can be distinguished by
Motor Language
a normal person (or on the opposite side). For example,
speech area Arcuate comprehension
fasciculus
the points of two pens can be applied together on a fin-
(Broca) area (Wernicke)
gertip and gradually separated until they are perceived
▲ Figure 1-8. Traditional view of brain areas involved
▲
as separate objects; the distance at which this occurs
in language function including the language compre- is recorded. Allesthesia is misplaced (typically more
hension (Wernicke) area, the motor speech (Broca) area, proximal) localization of a tactile stimulus. Extinc-
and the arcuate fasciculus. Lesions at the numbered tion is the failure to perceive a visual or tactile stimulus
sites produce aphasias with different features: (1) when it is applied bilaterally, even though it can be per-
expressive aphasia, (2) receptive aphasia, (3) conduc- ceived when applied unilaterally. Neglect is failure to
tion aphasia, (4) transcortical expressive aphasia, and attend to space or use the limbs on one side of the body.
(5) transcortical receptive aphasia. See also Table 1-1. Anosognosia is unawareness of a neurologic deficit.
(Modified from Waxman SG. Clinical Neuroanatomy. 26th ed. Constructional apraxia is the inability to draw accu-
New York, NY: McGraw-Hill; 2010.) rate representations of external space, such as filling in
 10 CHAPTER 1

measuring visual acuity, and mapping the visual field as

1 2 follows:
3
4 1. Ophthalmoscopy should be conducted in a dark room
4 to dilate the pupils, which makes it easier to see the fun-
dus. Mydriatic (sympathomimetic or anticholinergic)
5 eye drops are sometimes used to enhance dilation, but
6
this should not be done until visual acuity and pupillary
reflexes are tested, nor in patients with untreated closed
7 angle glaucoma or an intracranial mass lesion that might
8 lead to transtentorial herniation. In the latter case, the
9 ability to test pupillary reflexes is essential to detect clini-
10 cal progression. The normal optic disk (Figure 1-10) is
A B

▲ Figure 1-9. Unilateral (left-sided) neglect in a

▲

patient with a right parietal lesion. The patient was

asked to fill in the numbers on the face of a clock (A)
and to draw a flower (B). (Used with permission from
Waxman SG. Clinical Neuroanatomy. 26th ed. New York,
NY: McGraw-Hill; 2010.)

the numbers on a clock face or copying geometric fig-

ures (Figure 1-9).
5. Motor integration—Praxis is the application of motor Optic
learning, and apraxia is the inability to perform previ- Fovea disk
ously learned tasks despite intact motor and sensory
function. Tests for apraxia include asking the patient to Macula Arteriole
simulate the use of a key, comb, or fork. Unilateral aprax- Vein
ias are commonly caused by contralateral premotor fron- A
tal cortex lesions. Bilateral apraxias, such as gait apraxia,
may be seen with bifrontal or diffuse cerebral lesions.

▶ Cranial Nerves
▶

A. Olfactory (I) Nerve

The olfactory nerve mediates the sense of smell (olfaction)
and is tested by asking the patient to identify common
scents, such as coffee, vanilla, peppermint, or cloves. Nor-
mal function can be assumed if the patient detects the
smell, even if unable to identify it. Each nostril is tested
separately. Irritants such as alcohol should not be used
because they may be detected as noxious stimuli indepen-
dent of olfactory receptors.

B. Optic (II) Nerve

The optic nerve transmits visual information from the B
retina, through the optic chiasm (where fibers from the
nasal, or medial, sides of both retinas, conveying informa- ▲ Figure 1-10. The normal fundus. The diagram (A) shows
▲

tion from the temporal, or lateral, halves of both visual
fields, cross), and then via the optic tracts to the lateral
geniculate nuclei of the thalami. Optic nerve function is
assessed separately for each eye and involves inspecting the
back of the eye (optic fundus) by direct ophthalmoscopy,
landmarks corresponding to the photograph (B). (Photo by
Diane Beeston; used with permission from Vaughan D,
Asbury T, Riordan-Eva P. General Ophthalmology. 15th ed.
Stamford, CT: Appleton & Lange; 1999. Copyright ©
McGraw-Hilll.)
 NEUROLOGIC HISTORY & EXAMINATION 11

a yellowish, oval structure situated nasally at the poste-
rior pole of the eye. The margins of the disk and the
blood vessels that cross it should be sharply demar-
cated, and the veins should show spontaneous pulsa-
tions. The macula, an area paler than the rest of the
retina, is located about two disk diameters temporal to
the temporal margin of the optic disk and can be visual-
ized by having the patient look at the light from the
ophthalmoscope. In neurologic patients, the most
important abnormality to identify is swelling of the
optic disk resulting from increased intracranial pres-
sure (papilledema). In early papilledema (Figure 1-11),
the retinal veins appear engorged, and spontaneous
venous pulsations are absent. The disk may be hyper-
emic with linear hemorrhages at its borders. The disk
margins become blurred, initially at the nasal edge. In
fully developed papilledema, the optic disk is elevated
above the plane of the retina, and blood vessels crossing
the disk border are obscured. Papilledema is almost
always bilateral, does not typically impair vision except
for enlargement of the blind spot, and is not painful.
Another abnormality—optic disk pallor—is produced
by atrophy of the optic nerve. It can be seen in patients
with multiple sclerosis or other disorders of the optic
nerve and is associated with defects in visual acuity,
visual fields, or pupillary reactivity.

A B

C D
▲ Figure 1-11. Appearance of the fundus in papilledema. (A) In early papilledema, the superior and inferior mar-
▲

gins of the optic disk are blurred by the thickened layer of nerve fibers entering the disk. (B) Moderate papilledema
with disk swelling. (C) In fully developed papilledema, the optic disk is swollen, elevated, and congested, and the
retinal veins are markedly dilated; swollen nerve fibers (white patches) and hemorrhages can be seen. (D) In chronic
atrophic papilledema, the optic disk is pale and slightly elevated, and its margins are blurred. (Photos used with
permission from Nancy Newman.)
 12 CHAPTER 1

2. Visual acuity should be tested with refractive errors
corrected, so patients who wear glasses should be
examined with them on. Acuity is tested in each eye
separately, using a Snellen eye chart approximately 6 m
(20 ft) away for distant vision or a Rosenbaum pocket
eye chart approximately 36 cm (14 in) away for near
vision. The smallest line of print that can be read is
noted, and acuity is expressed as a fraction, in which
the numerator is the distance at which the line of print
can be read by someone with normal vision and the
denominator is the distance at which it can be read by
the patient. Thus, 20/20 indicates normal acuity, with
the denominator increasing as vision worsens. More
severe impairment can be graded according to the dis-
tance at which the patient can count fingers, discern
hand movement, or perceive light. Red–green color
vision is often disproportionately impaired with optic
nerve lesions and can be tested using colored pens or
hatpins or with color vision plates.
3. Visual fields are tested for each eye separately,
most often using the confrontation technique
(Figure 1-12). The examiner stands at about arm’s
length from the patient, the patient’s eye that is not
being tested and the examiner’s eye opposite it are
closed or covered, and the patient is instructed to fix
on the examiner’s open eye, superimposing the mon-
ocular fields of patient and examiner. Using the index
finger of either hand to locate the peripheral limits of
the patient’s field, the examiner then moves the finger
slowly inward in all directions until the patient
detects it. The size of the patient’s central scotoma
(blind spot), located in the temporal half of the
visual field, can also be measured in relation to the
examiner’s. The object of confrontation testing is to
determine whether the patient’s visual field is coex-
tensive with—or more restricted than—the examin-
er’s. Another approach is to use the head of a hatpin
as the visual target. Subtle field defects may be
detected by asking the patient to compare the bright-
ness of colored objects presented at different sites in
the field or by measuring the fields using a hatpin
with a red head as the target. Gross abnormalities can

A B

C D

▲ Figure 1-12. Confrontation testing of the visual field. (A) The left eye of the patient and the right eye of the exam-
▲

iner are aligned. (B) Testing the superior nasal quadrant. (C) Testing the superior temporal quadrant. (D) Testing the
inferior nasal quadrant. (E) Testing the inferior temporal quadrant. The procedure is then repeated for the patient’s
other eye.
 NEUROLOGIC HISTORY & EXAMINATION 13

be detected in less than fully alert patients by deter-
mining whether they blink when the examiner’s fin-
ger is brought toward the patient’s eye from various
directions. In some situations (eg, following the
course of a progressive or resolving defect), the visual
fields should be mapped more precisely, using perim-
etry techniques such as tangent screen or automated
perimetry testing. Common visual field abnormali-
ties and their anatomic correlates are shown in
Figure 1-13.

Visual fields

Left Right

L R L R
Temporal Nasal Nasal Temporal

1 2

Retina
3 4
1

Optic nerve
2
5 6
4 Optic tract
5

6 3
7 8

Lateral
geniculate
nucleus
9 7

Optic radiation

Occipital lobe
9

▲ Figure 1-13. Common visual field defects and their anatomic bases. 1. Central scotoma caused by inflammation
▲

of the optic disk (optic neuritis) or optic nerve (retrobulbar neuritis). 2. Total blindness of the right eye from a com-
plete lesion of the right optic nerve. 3. Bitemporal hemianopia caused by pressure exerted on the optic chiasm by
a pituitary tumor. 4. Right nasal hemianopia caused by a perichiasmal lesion (eg, calcified internal carotid artery).
5. Right homonymous hemianopia from a lesion of the left optic tract. 6. Right homonymous superior quadran-
tanopia caused by partial involvement of the optic radiation by a lesion in the left temporal lobe (Meyer loop). 7.
Right homonymous inferior quadrantanopia caused by partial involvement of the optic radiation by a lesion in the
left parietal lobe. 8. Right homonymous hemianopia from a complete lesion of the left optic radiation. (A similar
defect may also result from lesion 9.) 9. Right homonymous hemianopia (with macular sparing) resulting from
posterior cerebral artery occlusion. Defects are shown in black.
 14 CHAPTER 1

C. Oculomotor (III), Trochlear (IV), and Abducens Superior Inferior

(VI) Nerves rectus oblique

These three nerves control the action of the intraocular

(pupillary sphincter) and extraocular muscles.
Lateral Medial
1. Pupils—The diameter and shape of the pupils in ambi- rectus rectus
ent light and their responses to light and accommoda-
tion should be ascertained. Normal pupils average
≈3 mm in diameter in a well-lit room, but can vary
from ≈6 mm in children to <2 mm in the elderly, and Inferior Superior
can differ in size from side to side by ≈1 mm (physio- rectus oblique
logic anisocoria). Pupils should be round and regular
in shape. Normal pupils constrict briskly in response to
direct illumination, and somewhat less so to illumina-
tion of the pupil on the opposite side (consensual
response), and dilate again rapidly when the source of
illumination is removed. When the eyes converge to ▲ Figure 1-14. The six cardinal positions of gaze for
▲

focus on a nearer object such as the tip of one’s nose
(accommodation), normal pupils constrict. Pupillary
constriction (miosis) is mediated through parasympa-
thetic fibers that originate in the midbrain and travel
with the oculomotor nerve to the eye. Interruption of
this pathway, such as by a hemispheric mass lesion pro-
ducing coma and compressing the oculomotor nerve as
it exits the brainstem, produces a dilated (≈7 mm)
unreactive pupil. Pupillary dilation is controlled by a
three-neuron sympathetic relay, from the hypothala-
mus, through the brainstem to the T1 level of the spinal
cord, to the superior cervical ganglion, and to the eye.
Lesions of this pathway result in constricted (≤1 mm)
unreactive pupils. Other common pupillary abnormali-
ties are listed in Table 1-2.
2. Eyelids and orbits—The eyelids (palpebrae) should
be examined with the patient’s eyes open. The distance
between the upper and lower lids (interpalpebral fis-
sure) is usually ≈10 mm and approximately equal in the
two eyes. The upper lid normally covers 1 to 2 mm of
the iris, but this is increased by drooping of the lid (pto-
sis) due to lesions of the levator palpebrae muscle or
its oculomotor (III) or sympathetic nerve supply. Ptosis
occurs together with miosis (and sometimes defective
sweating, or anhidrosis, of the forehead) in Horner
syndrome. Abnormal protrusion of the eye from the
orbit (exophthalmos or proptosis) is best detected by
testing eye movement. The eye is adducted by the
medial rectus and abducted by the lateral rectus. The
adducted eye is elevated by the inferior oblique and
depressed by the superior oblique; the abducted eye
is elevated by the superior rectus and depressed by
the inferior rectus. All extraocular muscles are inner-
vated by the oculomotor (III) nerve except the superior
oblique, which is innervated by the trochlear (IV) nerve,
and the lateral rectus, which is innervated by the abdu-
cens (VI) nerve.
standing behind the seated patient and looking down
at his or her eyes.
3. Eye movements—Movement of the eyes is accom-
plished by the action of six muscles attached to each
globe, which act to move the eye into the six cardinal
positions of gaze (Figure 1-14). Equal and opposed
actions of these muscles in the resting state place the
eye in mid- or primary position (looking directly for-
ward). When the function of an extraocular muscle is
disrupted, the eye is unable to move in the direction
of action of the affected muscle (ophthalmoplegia)
and may deviate in the opposite direction because of
the unopposed action of other extraocular muscles.
When the eyes are thus misaligned, visual images of
perceived objects fall at a different place on each retina,

Table 1-2. Common Pupillary Abnormalities.

Reactivity Reactivity
Name Appearance (light) (accommodation) Site of Lesion

Adie (tonic) pupil Unilateral large pupil Sluggish Normal Ciliary ganglion
Argyll Robertson pupil Bilateral small, irregular pupils Absent Normal Midbrain
Horner syndrome Unilateral small pupil and ptosis Normal Normal Sympathetic innervation of eye
Marcus Gunn pupil Normal Consensual > direct Normal Optic nerve
 NEUROLOGIC HISTORY & EXAMINATION 15

creating the illusion of double vision or diplopia. The

extraocular muscles are innervated by the oculomotor
(III), trochlear (IV), and abducens (VI) nerves, and
defects in eye movement may result from either muscle
or nerve lesions. The oculomotor (III) nerve innervates
all the extraocular muscles except the superior oblique,
which is innervated by the trochlear (IV) nerve, and
the lateral rectus, which is innervated by the abducens A End-position B Nystagmus in
(VI) nerve. Because of their differential innervation, nystagmus primary position
the pattern of ocular muscle involvement in patho-
▲ Figure 1-15. Nystagmus. A slow drift of the eyes
logic conditions can help to distinguish a disorder of
▲

away from the position of fixation (indicated by the

the ocular muscles per se from a disorder that affects
broken arrow) is corrected by a quick movement back
a cranial nerve.
(solid arrow). The direction of the nystagmus is named
Eye movement is tested by having the patient look
from the quick component. Nystagmus from the pri-
at a flashlight held in each of the cardinal positions of
mary position is more likely to be pathologic than
gaze and observing whether the eyes move fully and
that from the end position. (Used with permission from
in a yoked (conjugate) fashion in each direction. With
LeBlond RF, Brown DD, DeGowin RL. DeGowin’s Diagnostic
normal conjugate gaze, light from the flashlight falls
Examination. 9th ed. New York, NY: McGraw-Hill; 2009.)
at the same spot on both corneas. Limitations of eye
movement and any disconjugacy should be noted. If
the patient complains of diplopia, the weak muscle
D. Trigeminal (V) Nerve
responsible should be identified by having the patient
gaze in the direction in which the separation of images The trigeminal nerve conveys sensory fibers from the face
is greatest. Each eye is then covered in turn and the and motor fibers to the muscles of mastication. Facial touch
patient is asked to report which of the two (near or and temperature sensation are tested, respectively, by touch-
far) images disappears. The image displaced farther ing and by placing the cool surface of a tuning fork on both
in the direction of gaze is always referable to the weak sides of the face in the distribution of each division of the
eye. Alternatively, one eye is covered with translucent trigeminal nerve—ophthalmic (V1, forehead), maxillary
red glass, plastic, or cellophane, which allows the eye (V2, cheek), and mandibular (V3, jaw) (Figure 1-16). The
responsible for each image to be identified. For exam- patient is asked if the sensation is the same on both sides
ple, with weakness of the left lateral rectus muscle,
diplopia is maximal on leftward gaze, and the leftmost
of the two images seen disappears when the left eye is
covered.
4. Ocular oscillations—Nystagmus, or rhythmic oscilla-
tion of the eyes, can occur at the extremes of voluntary
gaze in normal subjects. In other settings, however, it
Ophthalmic
may be due to anticonvulsant or sedative drugs, or reflect
division
disease affecting the extraocular muscles or their inner-
vation, or vestibular or cerebellar pathways. The most
common form, jerk nystagmus, consists of a slow phase
of movement followed by a fast phase in the opposite
direction (Figure 1-15). To detect nystagmus, the eyes
are observed in the primary position and in each of the
cardinal positions of gaze. If nystagmus is observed, it Maxillary
should be described in terms of the position of gaze in division
which it occurs, its direction, its amplitude (fine or
coarse), precipitating factors such as changes in head Mandibular
position, and associated symptoms, such as vertigo. The division
direction of jerk nystagmus (eg, leftward-beating nystag-
mus) is, by convention, the direction of the fast phase.
Jerk nystagmus usually increases in amplitude with gaze
in the direction of the fast phase (Alexander law). A less ▲ Figure 1-16. Trigeminal (V) nerve sensory divisions:
▲

common form of nystagmus is pendular nystagmus, ophthalmic (V1), maxillary (V2), and mandibular (V3).
which usually begins in infancy and is of equal velocity (Used with permission from Waxman SG. Clinical Neuro-
in both directions. anatomy. 26th ed. New York, NY: McGraw-Hill; 2010.)
 16 CHAPTER 1

and, if not, on which side the stimulus is felt less well, or as
less cool. To test the corneal reflex, a wisp of cotton is swept
lightly across the cornea overlying the iris (not the sur-
rounding white sclera) on the lateral surface of the eye (out
of the subject’s view). The normal response, which is medi-
ated by a reflex arc that depends on trigeminal (V1) nerve
sensory function and facial (VII) nerve motor function, is
bilateral blinking of the eyes. With impaired trigeminal
function, neither eye blinks, whereas unilateral blinking
implies a facial nerve lesion on the unblinking side. Tri-
geminal motor function is tested by observing the symme-
try of opening and closing of the mouth; on closing, the jaw
falls faster and farther on the weak side, causing the face to
look askew. More subtle weakness can be detected by asking
the patient to clench the teeth and attempting to force the
jaw open. Normal jaw strength cannot be overcome by the
examiner.
With a central (eg, hemispheric) lesion, the forehead is
spared, and some ability to close the eye is retained. This
discrepancy is thought to result from dual cortical motor
input to the upper face. Bilateral facial weakness cannot
be detected by comparison between the two sides. Instead,
the patient is asked to squeeze both eyes tightly shut,
press the lips tightly together, and puff out the cheeks. If
strength is normal, the examiner should not be able to
pry open the eyelids, force apart the lips, or force air out
of the mouth by compressing the cheeks. Facial weakness
may be associated with dysarthria that is most pro-
nounced for m sounds. If the patient is normally able to
whistle, this ability may be lost with facial weakness. To
test taste sensation, cotton-tipped applicators are dipped
in sweet, sour, salty, or bitter solutions and placed on the
protruded tongue, and the patient is asked to identify the
taste.

E. Facial (VII) Nerve F. Vestibulocochlear (VIII) Nerve

The facial nerve supplies the facial muscles and mediates
taste sensation from about the anterior two-thirds of the
tongue (Figure 1-17). To test facial strength, the patient’s
face should be observed for symmetry or asymmetry of
the palpebral fissures and nasolabial folds at rest. The
patient is asked to wrinkle the forehead, squeeze the eyes
tightly shut (looking for asymmetry in the extent to
which the eyelashes protrude), and smile or show the
teeth. Again the examiner looks for symmetry or asym-
metry. With a peripheral (facial nerve) lesion, an entire
side of the face is weak, and the eye cannot be fully closed.
The vestibulocochlear nerve has two divisions—auditory
and vestibular—which are involved in hearing and equilib-
rium, respectively. Examination should include otoscopic
inspection of the auditory canals and tympanic mem-
branes, assessment of auditory acuity in each ear, and
Weber and Rinne tests performed with a 512-Hz tuning
fork. Auditory acuity can be tested crudely by rubbing
thumb and forefinger together approximately 2 in from
each ear.
If the patient complains of hearing loss or cannot hear
the finger rub, the nature of the hearing deficit should be

Right Left
Motor cortex

Sweet
Brainstem
(CN VII nuclei) Salt
V (SA) VII (VA)
Facial (VII)
Sour
nerve

Bitter
IX (SA)
IX (VA)
Epiglottis

A B
▲ Figure 1-17. Facial (VII) nerve. (A) Central and peripheral motor innervation of the face. The motor cortex projects
▲

to both sides of the forehead, but only to the contralateral lower face (eyes and below). (B) Somatic afferent (SA, touch)
and visceral afferent (VA, taste) innervation of the tongue by trigeminal (V), facial (VII) and glossopharyngeal (IX) nerves.
(Used with permission from Waxman SG. Clinical Neuroanatomy. 26th ed. New York, NY: McGraw-Hill; 2010.)
 NEUROLOGIC HISTORY & EXAMINATION
Air
Bone
Rinne test Weber test
Hearing loss Rinne test Weber test
(Conduction) (Localization)
None Air > bone Midline
Sensorineural Air > bone Normal ear
Conductive Bone > air Affected ear
▲ Figure 1-18. Tests for hearing loss.
▲ tested by asking the patient to rotate the head against resis-
explored. To perform the Rinne test (Figure 1-18), the base
of a lightly vibrating tuning fork is placed on the mastoid
process of the temporal bone until the sound can no longer
be heard; the tuning fork is then moved near the opening of
the external auditory canal. In patients with normal hearing
or sensorineural hearing loss, air in the auditory canal con-
ducts sound better than bone, and the tone can still be
heard. With conductive hearing loss, the patient hears the
bone-conducted tone, with the tuning fork on the mastoid
process, longer than he or she hears the air-conducted tone.
In the Weber test (see Figure 1-18), the handle of the
vibrating tuning fork is placed in the middle of the fore-
head. With conductive hearing loss, the tone will sound
louder in the affected ear; with sensorineural hearing loss,
the tone will be louder in the normal ear.
In patients who complain of positional vertigo, the
Nylen–Bárány or Dix–Hallpike maneuver (Figure 1-19)
can be used to try to reproduce the precipitating circum-
stance. The patient is seated on a table with the head and
eyes directed forward and is then quickly lowered to a
supine position with the head over the table edge, 45 degrees
below horizontal. The test is repeated with the patient’s head
and eyes turned 45 degrees to the right and again with the
head and eyes turned 45 degrees to the left. The eyes are
observed for nystagmus, and the patient is asked to note the
onset, severity, and cessation of vertigo, if it occurs.
G. Glossopharyngeal (IX) and Vagus (X) Nerves
The glossopharyngeal and vagus nerves innervate muscles
of the pharynx and larynx involved in swallowing and
17
phonation. The glossopharyngeal nerve also conveys touch
from the posterior one-third of the tongue, tonsils, tym-
panic membrane, and Eustachian tube, as well as taste from
the posterior one-third of the tongue. The vagus nerve
contains sensory fibers from the larynx, pharynx, external
auditory canal, tympanic membrane, and posterior fossa
meninges.
Motor function of these nerves is tested by asking the
patient to say “ah” with the mouth open and looking for
full and symmetric elevation of the palate. With unilateral
weakness, the palate fails to elevate on the affected side;
with bilateral weakness, neither side elevates. Patients with
palatal weakness may also exhibit dysarthria, which affects
especially k sounds. Sensory function can be tested by the
gag reflex: the back of the tongue is touched on each side
in turn using a tongue depressor or cotton-tipped applica-
tor, and differences in the magnitude of gag responses are
noted.
H. Spinal Accessory (XI) Nerve
The spinal accessory nerve innervates the sternocleido-
mastoid and trapezius muscles. The sternocleidomastoid is
tance provided by the examiner’s hand, which is placed on
the patient’s jaw. Sternocleidomastoid weakness results in
decreased ability to rotate the head away from the weak
side. The trapezius is tested by having the patient shrug the
shoulders against resistance and noting any asymmetry.
I. Hypoglossal (XII) Nerve
The hypoglossal nerve innervates the tongue muscles. It can
be tested by having the patient push the tongue against the
inside of the cheek while the examiner presses on the out-
side of the cheek. With unilateral tongue weakness, the abil-
ity to press against the opposite cheek is reduced. There may
be also deviation of the protruded tongue toward the weak
side, although facial weakness may result in false-positive
tests. Tongue weakness also produces dysarthria with prom-
inent slurring of labial (l) sounds. Finally, denervation of the
tongue may be associated with wasting (atrophy) and
twitching (fasciculation).
▶ Motor Function
▶
Motor function is governed by both upper and lower
motor neurons. Upper motor neurons arise in the cerebral
cortex and brainstem, and project onto lower motor neu-
rons in the brainstem and anterior horn of the spinal cord.
They include projections from cortex to spinal cord (corti-
cospinal tract) including the part of the corticospinal tract
that crosses (decussates) in the medulla (pyramidal tract).
The motor examination includes evaluation of muscle
bulk, tone, and strength. Lower motor neurons project
from brainstem and spinal cord, via motor nerves, to
innervate skeletal muscle. Lesions of either upper or lower
motor neurons produce weakness. As discussed later,
 18 CHAPTER 1

▲ Figure 1-19. Test for positional vertigo and nystagmus. The patient is seated on a table with the head and eyes
▲

directed forward (A) and is then quickly lowered to a supine position with the head over the table edge, 45 degrees
below horizontal. The patient’s eyes are then observed for nystagmus, and the patient is asked to report any vertigo.
The test is repeated with the patient’s head and eyes turned 45 degrees to the right (B), and again with the head and
eyes turned 45 degrees to the left.

upper motor neuron lesions also cause increased muscle
tone, hyperactive tendon reflexes, and Babinski signs,
whereas lower motor neuron lesions produce decreased
muscle tone, hypoactive reflexes, muscle atrophy, and
fasciculations.
A. Bulk
The muscles should be inspected to determine whether
they are normal or decreased in bulk. Reduced muscle bulk
(atrophy) is usually the result of denervation from lower
motor neuron (spinal cord anterior horn cell or peripheral
nerve) lesions. Asymmetric atrophy can be detected by
comparing the bulk of individual muscles on the two sides
by visual inspection or by using a tape measure. Atrophy
may be associated with fasciculations—spontaneous mus-
cle twitching visible beneath the skin.
B. Tone
Tone is resistance of a muscle to passive movement at a
joint. With normal tone, there is little such resistance.
 NEUROLOGIC HISTORY & EXAMINATION
Abnormally decreased tone (hypotonia or flaccidity) may
accompany muscle, lower motor neuron, or cerebellar dis-
orders. Increased tone takes the form of rigidity, in which
the increase is constant over the range of motion at a joint,
or spasticity, in which the increase is velocity-dependent
and variable over the range of motion. Rigidity is associ-
ated classically with diseases of the basal ganglia and spas-
ticity with diseases affecting the corticospinal tracts. Tone
at the elbow is measured by supporting the patient’s arm
with one hand under the elbow, then flexing, extending,
pronating, and supinating the forearm with the examiner’s
other hand. The arm should move smoothly in all direc-
tions. Tone at the wrist is tested by grasping the forearm
with one hand and flopping the wrist back and forth with
the other. With normal tone, the hand should rest at a
90-degree angle at the wrist; with increased tone the angle
is greater than 90 degrees. Tone in the legs is measured
with the patient lying supine and relaxed. The examiner
places one hand under the knee, and then pulls abruptly
upward. With normal or reduced tone, the patient’s heel is
lifted only momentarily off the bed or remains in contact
with the surface of the bed as it slides upward. With
increased tone, the leg lifts completely off the bed. Axial
tone can be measured by passively rotating the patient’s
head and observing whether the shoulders also move,
which indicates increased tone, or by gently but firmly
flexing and extending the neck and noting whether resis-
tance is encountered.
C. Strength
Muscle strength, or power, is graded on a scale according
to the force a muscle can overcome: 5, normal strength; 4,
decreased strength but still able to move against gravity
plus added resistance; 3, able to move against gravity but
not added resistance; 2, able to move only with the force
of gravity eliminated (ie, horizontally); 1, flicker of move-
ment; 0, no visible muscle contraction. What is normal
strength for a young person cannot be expected of a frail,
elderly individual, and this must be taken into account in
grading muscle strength. Strength is tested by having the
patient execute a movement that involves a single muscle
or muscle group and then applying a gradually increasing
opposing force to determine whether the patient’s move-
ment can be overcome (Figure 1-20). Where possible, the
opposing force should be applied using muscles of similar
size (eg, the arm for proximal and the fingers for distal
limb muscles). The emphasis should be on identifying
differences from side to side, between proximal and distal
muscles, or between muscle groups innervated by differ-
ent nerves or nerve roots. In pyramidal weakness (due to
lesions affecting the corticospinal tract), there is prefer-
ential weakness of extensor and abductor muscles in the
upper and flexor muscles in the lower extremity. Fine
finger movements, such as rapidly tapping the thumb
and index finger together, are slowed. With the arms
19
▲ Figure 1-20. Technique for testing muscle strength.
▲
In the example shown (biceps), the patient flexes the
arm and the examiner tries to overcome this movement.
(Used with permission from LeBlond RF, Brown DD,
DeGowin RL. DeGowin’s Diagnostic Examination. 9th ed.
New York, NY: McGraw-Hill; 2009.)
extended, palms up, and eyes closed, the affected arm
falls slowly downward and the hand pronates (pronator
drift). Bilaterally symmetrical distal weakness is charac-
teristic of polyneuropathy, whereas bilaterally symmetri-
cal proximal weakness is observed in myopathy. Tests of
strength for selected individual muscles are illustrated in
the Appendix.
▶ Sensory Function
▶
Somatic sensation is mediated through large sensory fibers
that travel from the periphery to the thalamus in the pos-
terior columns of the spinal cord and brainstem medial
lemniscus, and small sensory fibers that ascend to the
thalamus in the spinothalamic tracts. Light touch sensation
is conveyed by both pathways, vibration and position sense
by the large-fiber pathway, and pain and temperature sense
by the small-fiber pathway. Because most sensory disor-
ders affect distal more than proximal sites, screening
should begin distally (ie, at the toes and fingers) and pro-
ceed proximally, until the upper border of any deficit is
reached. If the patient complains of sensory loss in a spe-
cific area, sensory testing should begin in the center of that
area and proceed outward until sensation is reported as
normal. Comparing the intensity of or threshold for sensa-
tion on the two sides of the body is useful for detecting
lateralized sensory deficits. When sensory deficits are
more limited, such as when they affect a single limb or
truncal segment, their distribution should be compared
with that of the spinal roots and peripheral nerves (see
Chapter 10, Sensory Disorders) to determine whether
involvement of a specific root or nerve can explain the
deficit observed. Some tests of somatosensory function are
illustrated in Figure 1-21.
 20 CHAPTER 1
“Sharp” “Dull”
A Testing pain B Testing sense
discrimination
▲ Figure 1-21. Tests of somatosensory function. (A) Touch (using finger or dull end of safety pin) and pain (sharp
▲
end of safety pin). (B) Joint position sense. (C) Vibration sense (using 128-Hz tuning fork). (Modified from LeBlond RF,
Brown DD, DeGowin RL. DeGowin’s Diagnostic Examination. 9th ed. New York, NY: McGraw-Hill; 2009.)
A. Light Touch
Touch perception is tested by applying a light stimulus—
such as a wisp of cotton, the teased-out tip of a cotton swab,
or a brushing motion of the fingertips—to the skin of a
patient whose eyes are closed and who is asked to indicate
where the stimulus is perceived. If a unilateral deficit is
suspected, the patient can be asked to compare how
intensely a touch stimulus is felt when applied at the same
site on the two sides.
B. Vibration
Vibration sense is tested by striking a low-pitched (128-Hz)
tuning fork and placing its base on a bony prominence,
such as a joint; the fingers of the examiner holding the
tuning fork serve as a normal control. The patient is asked
to indicate whether the vibration is felt and, if so, when the
feeling goes away. Testing begins distally, at the toes and
fingers, and proceeds proximally from joint to joint until
sensation is normal.
C. Position
To test joint position sense, the examiner grasps the sides of
the distal phalanx of a finger or toe and slightly displaces the
joint up or down. The patient, with eyes closed, is asked to
report any perceived change in position. Normal joint posi-
tion sense is exquisitely sensitive, and the patient should
detect the slightest movement. If joint position sense is
diminished distally, more proximal limb joints are tested
until normal position sense is encountered. Another test of
position sense is to have the patient close the eyes, extend
the arms, and then touch the tips of the index fingers
together.
D. Pain
A disposable pin should be used to prick (but not punc-
ture) the skin with enough force for the resulting sensation
to be mildly unpleasant. The patient is asked whether the
C Testing
of position vibratory sense
stimulus feels sharp. If a safety pin is used, the rounded end
can be used to demonstrate to the patient the intended
distinction between a sharp and dull stimulus. Depending
on the circumstance, the examiner should compare pain
sensation from side to side, distal to proximal, or derma-
tome to dermatome, and from the area of deficit toward
normal regions.
E. Temperature
This can be tested using the flat side of a cold tuning fork
or another cold object. The examiner should first establish
the patient’s ability to detect the cold sensation in a pre-
sumably normal area. Cold sensation is then compared on
the two sides, moving from distal to proximal, across der-
matomes, and from abnormal toward normal areas.
▶ Coordination
▶
Impaired coordination (ataxia), which usually results from
lesions affecting the cerebellum or its connections, can
affect the eye movements, speech, limbs, or trunk. Some
tests of coordination are illustrated in Figure 1-22.
A. Limb Ataxia
Distal limb ataxia can be detected by asking the patient to
perform rapid alternating movements (eg, alternately tap-
ping the palm and dorsum of the hand on the patient’s
other hand, or tapping the sole of the foot on the examin-
er’s hand) and noting any irregularity in the rate, rhythm,
amplitude, or force of successive movements. In the finger-
to-nose test, the patient moves an index finger back and
forth between his or her nose and the examiner’s finger;
ataxia may be associated with intention tremor, which is
most prominent at the beginning and end of each move-
ment. Impaired ability to check the force of muscular
contraction can also often be demonstrated. When the
patient is asked to raise the arms rapidly to a given
height—or when the arms, extended and outstretched in
Another random document with
no related content on Scribd:
Pues bien: el hombre busca siempre, para su pareja, la mujer de
mejores formas, más amable y menos escrupulosa.
Lo que esto quiere decir, me excusa de lo que callo por respeto á
vosotras, que, dicho sea de paso, me arañaríais de buena gana si
me tuviérais á mano.
Pero sospecho que, por lo crudo de esta aseveración, sois capaces
de recusarme por apasionado. Lo cierto es que pocos se han
atrevido á hablar tan claro en tan revuelto asunto. Veamos si hallo
una razón que no tenga vuelta.
El baile es una sociedad como otra cualquiera, regida por leyes
especiales y con sus costumbres propias.
Tratemos de formar con ellas un cuadro exacto y compendiado, de
modo que de una sola mirada se aprecie el asunto en su verdadero
valor; y con este objeto, examinemos el salón, reparemos lo que los
concurrentes hacen, y escribamos el resumen de nuestras
impresiones.
Hele aquí:
—«El baile es una república en que no tienen autoridad ni derechos
los padres y los maridos sobre sus hijas y mujeres respectivas.
Éstas pertenecen al público, que puede necesitarlas para bailar, al
tenor de los siguientes dos preceptos:
Deberes de la mujer: Ésta, sin faltar á la buena educación, no puede
negarse al que primero la solicite.
Derechos del hombre: El hombre es dueño de elegir la mujer que
más le guste, y, ya en la arena, puede estrecharla entre sus brazos;
poner en íntimo contacto con ella, por lo menos, todo el costado
derecho, desde la coronilla á los talones; pisarle los pies, romperle
el vestido y limpiarle el sudor de la cara con las patillas, si no con el
bigote, sin faltar á las leyes de la decencia; pues contando con la
agitación y la bulla de la fiesta, no es posible establecer un límite á
los puntos de contacto, ni amojonar el cuerpo para decir al hombre:
«aquí no se toca».
Nota.—Las anteriores prescripciones se observan rigorosamente,
desde el hombre más feo y antipático, hasta la mujer más linda y
exigente».
Repárese que en la tal república, donde el hombre tiene derechos
tan peregrinos, la mujer no tiene más que deberes.
Creo que esta fidelísima fotografía que acabo de hacer del baile,
completa sobradamente mi propósito.
Una observación en honor del hombre culto.—No hay padre ni
marido que repare en enviar sus hijas y su mujer al baile; pero la
sociedad se escandaliza el día en que una soltera atraviesa sola, de
acera á acera, la calle en que vive.
Fundándome en mejor lógica, establecería yo la siguiente
«Jurisprudencia: Los padres y los maridos que proveen los bailes
con sus hijas y sus mujeres, no tendrán derecho á ampararse á las
leyes de la justicia ni del honor, en los casos de agravio... de mayor
cuantía; se les negará la sal y el fuego, y, con un cencerro al cuello,
expiarán su estupidez... de baile en baile».
Consignado así mi voto, no debo insistir en nuevas deducciones, y
doy por acabada mi corta tarea.
Porque creo que se necesita mucho menos que sentido común,
para condenar el baile bajo el aspecto puramente estético, y no hay
necesidad de que yo gaste tinta ni paciencia en ello.
Un hombre de frac y chistera, máxime si peina canas, y una mujer
bonita, muy prendida y remilgada, dando brincos como dos salvajes
de Mozambique, sudando el quilo y sacando la lengua de
cansancio, solamente los puede uno soportar delante sin echarse á
reir, cuando considera... que el fin justifica los medios.

Ahora bien: ¿por qué escribo yo esto? ¿Aspiro á la austeridad del

anacoreta?
No tengo, desgraciadamente, tanta virtud: me gusta la carne más
que las raíces.
Si en el baile encuentro un filón de verdaderas gangas, ¿por qué, en
vez de procurar su destrucción, no le exploto callandito?
Veamos si mis lectoras, cuyos pies beso á pesar de lo dicho, hallan
la respuesta en la siguiente

MORAL DEL CUENTO

Yo he bailado también; pero preguntándome con horror á cada
vuelta:
¿Me casaré yo algún día?
Y si me caso, ¿habrá bailado mi mujer?
¿Llegaré á tener hijas?
Y si las tengo, ¿dejaré que me las bailen?
Temiendo ser tan padre y tan marido como todos los demás, he
escrito estos renglones: quiero tenerlos delante de los ojos cada vez
que mi ceguera de marido y de padre vaya á hacerme merecedor
del castigo á que condeno á todos los mansos del gran rebaño de la
sociedad danzante.
1853.
 LOS BUENOS MUCHACHOS

Lector, cualquiera que tú seas, con tal que procedas de uno de ésos
que llamamos centros civilizados, me atrevo á asegurar que estás
cansado de codearte con los personajes de mi cuento.
Así y todo, pudiera suceder que no bastase el rótulo antecedente
para que desde luego sepas de qué gente se trata; pues aunque
ciertas cosas son en el fondo idénticas en todas partes, varían en el
nombre y en algunos accidentes exteriores, según las exigencias de
la localidad en que existen.
Teniendo esto en cuenta, voy á presentarte esos chicos definidos
por sí mismos.
—«Yo soy un hombre muy tolerante: dejo á todo el mundo vivir á su
gusto; respeto los de cada uno; no tengo pretensiones de ninguna
clase; me amoldo á todos los caracteres; hago al prójimo el bien que
puedo, y me consagro al desempeño de mis obligaciones».
Esta definición ya es algo; pero como quiera que la inmodestia es un
detalle bastante común en la humanidad, pudiera aquélla, por
demasiado genérica, no precisar bien el asunto á que me dirijo.
Declaro, aun á riesgo de perder la fama de buen muchacho, si es
que, por desgracia, la tengo entre algunos de los que me leen, que
soy un tanto aprensivo y malicioso en cuanto se trata de gentes que
alardean de virtuosas.
Esta suspicacia que, de escarmentado, á más de montañés, poseo,
es la causa de que los llamados por ahí «buenos muchachos»
hayan sido repetidas veces, para mí, objeto de un detenido estudio.
Por consiguiente, me encuentro en aptitud de ser, en datos y
definiciones, tan pródigo como sea necesario hasta que aparezca
con todos sus pelos y señales lo que tratamos de definir.
Pero como no ha de ser interminable esta tarea, he de reducir la
infinita procesión de ejemplares que veo desfilar ante mis ojos, á
tres grandes modelos, en cada uno de los cuales se hallan reunidas
las condiciones típicas que andan repartidas entre todos sus
congéneres.
Primer modelo.—Buen muchacho que ya cumplió los cuarenta años.
—Señas particulares, indefectibles: es gordo, colorado, nada
garboso, muy escotado de cuello y de chaleco, recio de barba y
escaso de pelo. Habla mucho y se escucha.
Segundo modelo.—Buen muchacho que no ha cumplido los treinta y
cinco.—Señas particulares: enjuto, macilento, cargado de entrecejo
y de espaldas, vestido de obscuro, muy abrochado, largo de
faldones y pasado de moda. Este ejemplar tiene, necesariamente, á
la vista y como si fuera marca de ganadería, una señal indeleble:
verbigracia, un lobanillo junto á la oreja, un lunar blanco en el pelo,
una verruga entre cejas y la nuez muy prominente, ó toda la cara
hecha una criba de marcas de viruelas. Habla bastante y con timbre
desagradable, casi siempre en estilo sentencioso, y á menudo con
humos de gracioso.
Tercer modelo.—Buen muchacho que raya en los veinticinco.—
Señas infalibles: rollizo, frescote como un flamenco, y miope.
Rompe mucha ropa, y procura llevarla muy desahogada; es hombre
de poco pelo y de no mucha barba; habla más que una cotorra, muy
recio y con los términos más escogidos del diccionario.—Detalle
peculiarísimo: antes de adquirir en público el título de «buen
muchacho», ha gozado, durante seis años, entre las diversas tribus
de su familia, la opinión de hombre precoz.
En vista de todos estos datos, podemos sentar la siguiente regla
general:
La edad de los «buenos muchachos» varía entre veinticinco y
cincuenta años.
Como detalles comunes á los tres modelos, pueden apuntarse los
siguientes:
Son mesurados en el andar; saludan muchísimo, descubriendo toda
la cabeza; en sus paseos buscan la compañía de los señores
mayores, y en tales casos, miran con aire de lástima á los jóvenes
que á su lado pasan, si van muy alegres ó muy elegantes; usan á
todas horas sombrero de copa, y se calzan con mucho desahogo;
temen de lumbre los tacones altos, y por eso los gastan anchos y
muy bajos; sacan chanclos y paraguas al menor asomo de nube en
el horizonte, y en cuanto estornudan tres veces seguidas, guardan
cama por dos días y se lo cuentan después á todo el mundo; no
fuman, ó fuman muy poco, pero chupan caramelos de limón y saben
dónde se venden un vinillo especial de pasto y garbanzos de buen
cocer; conservan con gran esmero las amistades tradicionales de
familia, y al hacer las visitas de pascuas ó cumpleaños, llaman á la
visitada «mi señora doña Fulana»; la preguntan minuciosamente por
todo el catálogo de sus achaques físicos, y siempre tienen algún
remedio casero que recomendarla; se dedican á negocios lucrativos,
mejor dicho, están asociados, y en segunda fila, á personas que
saben manejarlos bien; y, por último, se perecen por echar un
párrafo en público y familiarmente con las primeras autoridades de
la población, y se rechupan por formar parte de cualquiera
corporación oficial ú oficiosa, con tal que ella transcienda á
influyente y á respetable.
Hasta aquí, algo de lo que el menos curioso debe haber visto en
esos personajes; desde aquí, lo que todo el mundo puede ver en los
mismos si se toma la molestia de levantar los pliegues de la capa
con que la señora fama parece haberse empeñado en protegerlos
contra críticas y murmuraciones.

II
Hallábame yo, no ha mucho, cerca de un pequeño círculo de
murmuradores de mayor edad, con quienes ningún lazo de amistad
íntima, ni siquiera de simpatía personal, me ligaba; y dicho está que
yo oía, veía y callaba. Hablábase á la sazón de un suceso ocurrido
recientemente en el pueblo, con sus vislumbres de escandaloso,
cuando entró en escena un personaje muy conocido mío, y muy
amigo, al parecer, de aquellos murmuradores. Parecía el tal fundido
en uno de los tres modelos que dejo registrados; y no digo en cuál,
porque no es necesario.
—Aquí llega... Fulano, que podrá darnos algunos pormenores más
del suceso,—dijo un murmurador.
—Voy muy de prisa, señores—respondió el aludido,—y sólo me he
acercado á ustedes con el objeto de saludarlos... Pero, en fin, ¿de
qué se trata?
—Pues, hombre, de la novedad del día... de cierta joven que ha
desobedecido la paterna autoridad.
—Efectivamente: tengo entendido algo que suena á eso mismo;
pero como no me gusta meterme en la hacienda del vecino, y dejo á
cada uno vivir á su antojo, no he querido enterarme muy á fondo.
—Pero es lo cierto que usted sabe algo...
—De manera que algo, algo, por muy sordo que uno se haga...
—Vamos, que ya sabrá usted más que nosotros.
—Les aseguro á ustedes que no. Soy de lo menos dado á chismes y
murmuraciones, como es bien notorio... Pero entendámonos: ¿se
refieren ustedes á la chica mayor de don Geroncio?
—Cabales.
—¿De la cual se dice que dos horas antes de ir á la iglesia á
casarse con el chico menor de don Atanasio, se plantó y dijo: «no
me caso ya», por lo que su padre la amenazó iracundo, de lo cual
no hizo ella caso maldito, y resultó un escándalo, y se deshizo la
boda?...
—¡Justamente... eso es!... ¡Ven ustedes cómo... Fulano sabía los
pormenores del lance?
—Repito que no sé una palabra más de lo que de público se dice.
Hay asuntos, como éste, que, sin saber por qué, me repugnan...
Pero observo que ustedes me miran con recelo, como si me callara
cosas muy graves.
—¡Hombre, no!
—Pues á mí se me antoja que sí; y, señores, yo soy muy delicado
en ciertas materias: está por medio la reputación de una joven que
puede lastimarse con una sola suposición injuriosa, y esto es
bastante á mis ojos para que, en descargo de mi conciencia, me
apresure á contar la verdad del caso, es decir, lo que á mí se me ha
referido:—Saben ustedes que hace quince días tuve un golpe de
sangre á la cabeza, por lo cual, ya repuesto, me ordenó el médico
que paseara de madrugada cuando la temperatura lo permitiera.
Salía yo esta mañana á cumplir este precepto, con el cual, por
cierto, me va muy bien, cuando ¡plaf! tropiezo, al volver la esquina
de la plaza, con doña Severa, que, como no ignoran ustedes, por
parte de su difunto marido don Estanislao es prima política de la
señora (que esté en gloria) de don Geroncio, y, por consiguiente,
tiene motivos poderosos para estar al tanto de los asuntos
particulares de esta familia, aparte de que á doña Severa siempre
se la ha considerado mucho en aquella casa, por su capacidad y
don de gobierno. Pues, señor, como daba la casualidad de que no
veía yo á esta señora lo menos hacía... sí, ¡vaya! ¡yo lo creo!... lo
menos... lo menos... quince días... ¿qué digo! aguárdense ustedes y
perdonen: el día de San Lorenzo fué cuando la vi; estamos hoy á...
veintitrés días justos hace que la saludé á la puerta de su casa...
cabalmente tenía yo que preguntarla dónde había comprado una
pasta para matar ratones, que ella usaba con gran éxito, y allí
mismo me dió la receta de memoria, porque resultó que la tal pasta
era invención suya, digo, de un choricero extremeño que se la confió
en secreto por no sé qué favores que la debía... Pues á lo que iba:
encuentro esta mañana á doña Severa, y—«¿Cómo está usted,
señora mía?—la pregunto.—Bien; ¿y usted, don Fulano?—Pues
para servir á usted.—¿Y la familia?—Tan buena, gracias...
¡Caramba, cuántos días hace que no la veo á usted!—Pues no he
perdido una misa desde que no nos vemos. Precisamente es hoy el
día en que debí haberme quedado en cama, siquiera hasta las diez.
—Efectivamente: la encuentro á usted algo pálida y desmejorada.—
Le aseguro á usted que no sé cómo me tengo de pie.—¿Se
encuentra usted mal?—Mal, precisamente, no; pero ayer tuve un
disgusto con la cocinera, y estoy sufriendo hoy las consecuencias.
Figúrese usted que á mí me gusta mucho la merluza: pues, señor, la
condenada (Dios me perdone) de la chica, dale con que había de
traerme siempre abadejo. Chocándome, como era natural, tanta
obstinación, pues yo sabía muy bien que no faltaba merluza en la
plaza, indago por aquí, pregunto por allá, y averiguo ayer que la muy
pícara daba todos los días las sobras del principio á un soldado, su
novio, que se pela por el abadejo. ¡Imagínese usted cómo yo me
pondría al saberlo!... Por supuesto que lo primero que hice fué
plantarla de patitas en la calle, y tan de prisa, que la dije que
volviera más tarde por el baúl y la cuenta. ¡En mal hora á mí se me
ocurrió semejante idea! ¿Creerá usted, Fulanito, que, la muy
sinvergüenza, se me presentó á las dos horas acompañada del
soldadote para que éste repasara la suma, y que entre los dos me
pusieron como hoja de perejil sobre si faltaban ó dejaban de faltar
seis maravedís?—Nada me choca, doña Severa, de cuanto usted
me dice, que algo parecido podía añadir yo de lo ocurrido en mi
casa: el ramo de sirvientas está perdido.—¡Ay, Fulano, lo peor es
que el de amas no está mucho más ganado!—También es cierto.—
Vea usted á mi pobre primo Geroncio: ¡qué horas está pasando por
causa de esa hija á quien ha mimado tanto!—En efecto, he oído
anoche que esa chica ha roto, por un capricho, su proyectado
casamiento.—¿Capricho, eh? ¡buen capricho me dé Dios!—Así se
dice al menos.—Así se dice, porque de alguna manera decente ha
de tapar la familia el pastel descubierto.—¿Luego ha pasado algo
grave?—¡Gravísimo... Fulano!... y ya ve usted si yo lo sabré cuando
he sido y estoy siendo el paño de lágrimas del desdichado Geroncio.
—No lo dudo... Pero ahora caigo en que, siendo secretos de familia
esos sucesos, estoy pecando de indiscreto al hacer ciertas
preguntas.—De ningún modo, Fulano; usted es una persona muy
decente, y hasta debe conocer esa clase de líos para ejemplo y
escarmiento en el día de mañana, si se resolviera á casarse.—
Usted me favorece demasiado, doña Severa.—Le hago á usted
justicia, Fulano.—Gracias, señora.—Repito que no hay por qué
darlas; y sepa usted (por supuesto, con la debida reserva) que si la
boda de mi sobrina no se ha llevado á cabo, es porque el novio
descubrió á última hora que la muy taimada había tenido un año
antes relaciones íntimas, muy íntimas, entiéndalo usted bien, con un
joven andaluz que estuvo aquí veraneando.—Pero ¿tan íntimas
fueron, señora?—Tan íntimas, que faltando horas nada más para ir
á la iglesia, se plantó el novio al conocerlas, y dijo que nones.—
¿Luego no fué ella quien se opuso?—¡Qué había de ser, hombre!...
eso se ha dicho para tapar»... Y etcétera, señores—añadió el
narrador, con una sonrisita que apenas tenía malicia;—por ahí fué
hablándome doña Severa, y lo que acabo de referir es lo único que,
en substancia, hay de cierto sobre el particular.
—¡Que no es poco!—objetó un chismoso, con diabólica expresión.
—¡Cuando yo decía que usted sabía grandes cosas!
—Hombre, si bien se mira, no es tanto como parece—continuó el
suavísimo Fulano.—Y de todas maneras, señores, conste que lo he
referido aquí en el seno de la confianza y teniendo en cuenta,
además de lo que dije al empezar, que una cosa leve callada con
misterio, autoriza á suponer otra muy grave: que la mayor parte de
ustedes son padres de familia que no echarán el ejemplo en saco
roto.
—¡Bravo!—exclamaron algunos oyentes casi enternecidos con este
rasgo.
—Conque, señores, vuelvo á recomendar la reserva, y me voy á mis
quehaceres,—saltó casi ruborizado el amiguito de doña Severa.
Y se marchó.
—¡Qué discreta observación!—dijo uno de los que se quedaron.
—¡Qué juicio tan aplomado!—añadió otro.
—¡Es un gran muchacho!—exclamaron todos
—¡Valiente infame!—dije yo, y era lo menos que podía decir, con
esta franqueza que Dios me ha dado, largándome también, y sin
despedirme, por más señas.
Nada se me contestó en el acto; pero me consta que, refiriéndose á
mí, se dijeron luego en el corrillo primores como los siguientes:
—¡Qué víbora!
—¡Qué lengua de acero!
—Con veneno semejante es imposible que haya en la sociedad una
sola virtud incólume.

Todos estos pormenores forman un detalle que no es de los menos

típicos en los «buenos muchachos».
Veamos otros.
Detestan cordialmente todo cuanto no pertenece al gremio del cual
son, según dicen, humildísimos miembros; y hablan con afectada
lástima, pero con sincera indignación, de los hombres aficionados á
los trabajos del ingenio; se jactan de apreciar la prensa periódica,
sea del matiz político, científico ó literario que se quiera, en mucho
menos que el papel de empaque, y son para ellos novelistas y
poetas sinónimos de gente perdida. Esto, en general; pero cuando
son sus convecinos, sus antiguos condiscípulos, tal vez sus amigos,
los que escriben, los que peroran, los que pintan, ¡de Dios les venga
el remedio á estos desdichados!
—Hoy todo el mundo escribe, todo el mundo charla, todo el mundo
emborrona un lienzo y garrapatea el pentágrama—gritan
escandalizados los «buenos muchachos».—¿Qué es esto? ¿Dónde
estamos? ¿Adónde vamos á parar? Señores, el que más y el que
menos de los que en nada figuramos conocemos algo de esas
materias, y pudiéramos echar en ellas nuestro cuarto á espadas
practicando un poco; pero ¿sería esto suficiente? ¿nos autorizaría
para erigirnos en maestros ni en directores de la opinión pública?
¡No faltaba más!... ¡Pues no son pocas las pretensiones de la gente
del día!
Así se explican; veamos cómo se conducen.
Estarán ustedes cansados de hallar en los periódicos de su pueblo
centenares de remitidos, al tenor del siguiente:

Señor Director de El Vigilante.

«Muy señor mío y de mi mayor consideración: Aunque ajeno por
carácter y por mis habituales ocupaciones á las lides periodísticas,
me tomo la libertad de remitir á usted las adjuntas mal perjeñadas
líneas, por si tiene á bien insertarlas en su apreciable periódico. La
cuestión que las motiva es, en mi humilde sentir, de gran interés
para toda la población, y en ello confío para que usted, etc., etc.,
etc.».
El asunto que se desenvuelve en el remitido y que, según el humilde
sentir del comunicante, encierra gran interés para toda la población,
es un guardacantón que sobresale media pulgada más de lo que
previenen las ordenanzas, ó un árbol que se seca en el paseo... ó si
debe andar cubierto ó en pelo por los claustros, durante la
celebración de la misa, el perrero de la catedral.
Otros tres detalles esencialísimos distinguen siempre á estas
producciones, á saber: lo poco que figuran en ellas los artículos
determinados, y lo demasiado que juega la rosa de vientos, lo cual
da motivo á cada paso á frases del siguiente jaez: «entrando en
mencionado paseo por el lado del Sudeste; tomando la alineación
por la fachada vendaval de repetida casa»... Por último, la firma.
Ésta tiene que ser necesariamente Un curioso, Un contribuyente, Un
vecino, ó Un amante de su país.
Pues bien, lector: cualquiera de estos motes es el modesto velo con
que tapa el rubor de su vera efigies, para dirigirse al público, un
«buen muchacho», es decir, uno de esos hombres sensatos,
aplomados y «sin pretensiones», que detestan la prensa porque no
sabe tratar cuestiones que enseñen algo, porque no es capaz de
exponer teorías de transcendencia ó de universal interés; uno de
esos hombres, en fin, que no hallan jamás otro bastante autorizado
para erigirse en intérprete, ya que no en director de la opinión
pública.
Y no puede quedar la menor duda de que citados artículos
pertenecen á referidos autores, porque éstos, en el mismo día del
alumbramiento, ó en el siguiente, á más tardar, teniendo la bondad
de interesarse mucho por la salud de uno, le abordan en la calle
para enredarle en un diálogo como el siguiente:
—¿Cómo va, amigo mío?
—Pues, hombre, vamos viviendo.
—¡Cuánto me alegro!
—Muchísimas gracias... ¿Usted tan gordo y tan guapo?
—Gracias á Dios... Pero retírese usted un poquito á la derecha.
—¿Qué ocurre?
—Que está usted colocado junto á una losa quebrada, y un pie se
disloca con la mayor facilidad.
—No veo yo la quebradura...
—En efecto, era una ilusión mía... Como en este pueblo anda el
ramo de empedrados peor que en Marruecos... Y, á propósito, ¿ha
visto usted un comunicado que publica ayer El Vigilante?
—¿Sobre Marruecos?
—No, señor: sobre el guardacantón de la calle X...
—Sí que le he visto.
—¿Y qué le ha parecido á usted?
—Pues, hombre... bien.
—Lo celebro infinito, pues como está hecho al correr de la pluma, no
hubiera sido difícil que algún descuidillo...
—Según eso, ¿es de usted?
—Ya que usted lo ha conocido, no lo quiero negar.
—Es usted muy modesto.
—Hombre, no; pero no tengo pretensiones de escritor. Así es que
cuando quiero llamar la atención del público hacia un asunto de
interés tan general como el que ayer saco á relucir en mi escrito,
firmo con un nombre cualquiera... Yo he escrito mucho sobre policía,
¡muchísimo! sólo que no me gusta darme importancia; porque,
vamos, no tengo pretensiones de ninguna clase.
—¡Oh! ya se conoce bien.
—Por lo demás, el artículo de ayer creo que abraza cuanto se
puede decir sobre el particular.
—¡Vaya si abraza!
—Pues me alegro mucho; que eso me ha de animar á concluir otro
que traigo entre manos acerca de la maldita costumbre que hay aquí
de colgar la ropa blanca en los balcones... Por supuesto que es un
trabajillo sin pretensiones de ninguna clase.
—Naturalmente; pero eso no impedirá que yo le lea con gusto.
—Muchas gracias.
—No hay por qué».
También me consta que esos remitidos se leen, por su autor, en
familia, con grande aplauso del severo papá que, rebosando en
satisfacción por todos los poros de su cuerpo, se vuelve hacia su
conjunta para decirle, muy bajo, pero de modo que lo oiga el
elogiado: «Estos muchachos son el mismo demonio. ¡Mira que está
bien hilado el tal impreso!».
Vamos ahora á otro terreno.
Hay una junta de acreedores, de contribuyentes, de vecinos
formales, ó de arraigo; una junta, en fin, en la que se trate del vil
ochavo ó de salvar los intereses de la plaza. Toman la palabra los
más expertos y autorizados; llénanse recíprocamente de piropos,
abordan la cuestión por cien lados diferentes; llégase, tras de
muchos sudores y fatigas, á vislumbrar un acuerdo definitivo; va á
darse por concluida la sesión, y he aquí que se oye una voz
perezosa y afectadamente tímida que pide la palabra. Concédesela
el presidente, y se levanta una persona que comienza á hablar en
estos términos:
—«Señores: como desconozco completamente la ciencia del
derecho, y soy en materia de negocios la más incompetente de
todas las personas que componen esta respetable reunión; y como
tampoco tengo pretensiones de orador, quizá vaya á decir un
disparate al hacer uso de la facultad que me ha concedido el digno
señor presidente; pero, así y todo, me parece á mí que teniendo en
cuenta esto y lo otro (resume desastrosamente cuanto han dicho los
que han hablado antes, y añade cincuenta desatinos de su
cosecha), la dificultad está vencida. Repito, señores, que tal es el
punto desde el cual debe mirarse la cuestión, según mi humilde
entender. He dicho».
«Bravos» por acá y «bravos» por allá. Rumores en todos los
rincones.—¿Quién es ése?—Pues el hijo de don Zutano.—
¡Excelente chico!—Nómbrase la indispensable comisión, y entra en
ella, el primerito, el orador. Al día siguiente no se le puede sufrir.—
Como yo dije, como yo propuse... bien que ya usted me oiría... ¡y
eso que no está uno hecho á esos lances, ni tiene pretensiones de
orador!... ¡Ah! pues si no me tira de la levita don Práxedes, que
estaba á mi derecha, ¡qué cosas salen á relucir! Pero es uno
condescendiente y poco amigo de llamar la atención, ¡que si no!...
Aunque no necesito decir quién es este orador, bueno es que se
tenga presente que pertenece, por su tipo, al tercer modelo.
Veámosle ahora en el teatro. Se acaba de representar un drama
moderno que ha alcanzado un triunfo. Á él no le ha merecido un
solo aplauso. Lejos de ello, se vuelve á su vecino y le dice:
—Amigo, yo no sé si diré un disparate, porque no soy competente
en literatura; pero esta obra, según mi humilde entender, no merece
el ruido que está metiendo. Valerse de una aldeana para el principal
papel, y no haber en toda la comedia más que dos personajes de
buena sociedad, me da muy pobre idea del talento del autor. De ese
modo también yo hago comedias.
El vecino le mira estupefacto, y el censor, creyendo que le apoya,
continúa:
—Desengáñese usted, el teatro va en decadencia; ya no se
escriben comedias como La trenza de sus cabellos y La conquista
de Granada. ¿Pues y los actores? Ahí han estado ustedes
aplaudiendo á ese primer galán como si supiera lo que hace...
¡Donde estaba aquel Lozano!... ¡Ése sí que cortaba el verso! Parece
que le estoy viendo salir, vestido de moro y á caballo, por debajo del
palco del ayuntamiento. Valía más una mirada de aquel hombre, que
toda esta comiquería junta.
Oyendo música, aunque no menos descontentadizos, son más
lacónicos siquiera.
—¿Qué le parece á usted?—se pregunta á uno de ellos.
Y responde necesariamente:
—Hombre, yo no soy del arte; pero por más que ustedes digan, esta
música está tomada, al pie de la letra, de «El Hernani».
Si le buscamos á la esquina de la plaza, se le hallará deteniendo á
un transeúnte para decirle con mucho misterio:
—¿Ve usted aquella chica que está hablando con un cabo de la
guarnición? Pues es la cocinera de don Ruperto Puntales: dos horas
lleva ahí; he tenido la curiosidad de contarlas en mi reló. Buena
andará aquella cocina, ¿eh?
Ó si no:
—Don Aniceto, una palabra: esa doncella que cruza ahora la
esquina y va cargada de cartones, me parece que sirve en casa de
doña Telesfora.
—Bien, ¿y qué?
—Nada, que es la sexta vez que, en hora y media que llevo en esta
esquina, ha salido de ese bazar cargada de género. Sospecho que
el pobre marido de su ama no hace hoy el gasto con dos mil reales.
Después vendrán los apuros... y algo peor. Bien empleado les está.
En un paseo público hacen el mismo papel: comparar las galas que
ven, con los caudales de quienes las lucen, y demostrar siempre, y
donde quiera, que llevan el alza y baja de cuanto respira y se agita
en la población.
Creo que el lector no necesita más noticias para orientarse por
completo en el terreno á que he querido traerle, ni para hallar
pertinente y hasta de alguna transcendencia moral la exposición de
estos apuntes...
Se me olvidaba decir que los buenos muchachos son, por regla
general, solteros. Si les da por casarse, son en el hogar doméstico
unos tiranuelos, chismosos y cascarrabias; y esto es lo único en que
varían al variar de estado.
Otro dato.—Casados ó solteros, son en política conservadores, de
justo medio y ancha base.

III
Si tratáramos ahora de llamar las cosas por su verdadero nombre,
deduciríamos de todo lo expuesto, dentro de la más inflexible lógica,
que el «buen muchacho» no es otra cosa que un quidam soberbio,
entremetido, fisgón é ignorante. Escandalízase de los hombres que,
sin remilgos ni estudiadas protestas de humildad, se muestran en lo
que valen, y él, con la previa advertencia de que no vale nada, se
atreve á meterse en todas partes para imponer su razón á los
demás. Á nadie concede competencia para nada, al paso que él,
confesándose el último de los hombres, se porta como si la tuviera
para todo; no halla en la pluma ni en los labios de su vecino una
cuestión que le parezca bastante digna de ocupar la atención
pública, y al día siguiente pretende él absorberla entera sacando á
plaza pequeñeces y vulgaridades de portería. Ofende á su
moralidad un pecado oculto, y él, para enmendarlo, le descubre, le
comenta y le propaga; no juega, no jura, no malgasta; pero, con la
mejor intención, se conduele á gritos de Juan y de Pedro, que juran,
no ahorran y, según sus noticias, juegan. En suma, sus labios jamás
se abren para elogiar; siempre para maldecir.
Por lo demás, el ser «buen muchacho» es un gran negocio, máxime
cuando el teatro representa una población lo suficientemente
pequeña para que todos nos codeemos y nos conozcamos.
El vecino de enfrente, persona que tiene el don de discurrir con
alguna claridad más que la multitud, es víctima de una adversidad
cualquiera, acarreada por una serie de sucesos inevitables.—Me
alegro—dice el rumrum:—ese hombre lo tenía bien merecido; es
una mala cabeza, un fatuo, un pretencioso.
Sucédele eso mismo á un «buen muchacho», y dice la Fama:—
¡Pícara suerte, que nunca quiere proteger á los buenos!
Acúsasele por alguien de una acción poco edificante, y dice la
misma señora:—¡Calumnia!... Fulano no puede ser reo de
semejante delito; yo abono su conducta, porque... es un excelente
muchacho.
Al primero se le enreda, al pasar, un botón en los flecos del chal de
una modista, y doña Opinión, la mala, le marca con el dedo como á
un desenfrenado corruptor de la pública moralidad.
Enrédasele al otro la honra entera entre los hechizos de la mujer de
su vecino; asoma el escándalo la oreja, y exclama doña Opinión, la
buena:—«¡Atrás! que es un buen muchacho incapaz de cometer tan
feo delito». Si el escándalo pugna, y forcejea y vence al cabo, la
mujer es la serpiente que le ha seducido: todo menos lastimar en lo
más mínimo la cándida sensibilidad de su amante.
Hay vacante un puesto que exige á quien ha de ocuparle mucho
tacto y mayor experiencia, y, sin saber cómo, empieza á sonar el
nombre de un buen muchacho; crece el ruido, fórmase la atmósfera,
provéese la plaza en un hombre nulo ó sin merecimientos, y apenas
la justicia severa se dispone á condenar la elección, grita el rumor
atronador de la Fama:—Me alegro, porque el elegido es... «un buen
muchacho».
Trátase de una heredera rica que se halla en estado de merecer, y
al punto dice aquella señora:—«¡Qué buena pareja haría esa chica
con... Fulano, que es un gran muchacho!». Y los ecos van repitiendo
la ocurrencia, y se la llevan á la aludida, y se echa ésta á cavilar, y
comienzan las embajadas oficiosas de los aficionados á la
diplomacia casamentera, y aceptan la mediación las partes
beligerantes, y...—«es cosa hecha»—exclama un día con aire de
triunfo la gente.—Y añade:—«y me alegro, no solamente por el
novio, que es un buen muchacho, sino por lo que van á
reconcomerse los otros».
...«Los otros», lector, son los desheredados de la fama de «buenos
muchachos», que tal vez no conocen á la novia, y que, de seguro,
no han cruzado una palabra con ninguno de los que forman la
opinión que tan cordialmente antipática se les presenta.
Cuando un padre sencillo reprende á su hijo por una falta propia de
la edad, vuelve los ojos con envidia á un «buen muchacho»; si éstos
no van al teatro más que dos veces por semana, no se puede ser
hombre de bien yendo tres; cuanto en costumbres es un pecado,
deja de serlo desde el momento en que le comete un «buen
muchacho»; las mamás los miran con un memorial en cada ojo; las
autoridades los saludan como á las mejores garantías del orden...
hasta los agentes de policía los acatan y reverencian, porque ven en
ellos otros tantos futuros concejales...
Júzguese ahora del riesgo que yo corro al estrellarme contra tanta
popularidad... y eso que todavía no he dicho que un «buen
muchacho» es necesariamente tonto de remache.
Y dirá aquí el lector cándido:—¿Cómo puede un tonto adquirir tal
fama de discreto?