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 Contents

Preface

PART 1: THE CLINICAL METHOD OF

NEUROLOGY
1 Approach to the Patient With Neurologic Disease
2 Diagnostic Testing in Neurologic Disease
PART 2: CARDINAL MANIFESTATIONS OF
NEUROLOGIC DISEASE
SECTION 1 Disorders of Motility

3 Paralysis and Weakness

4 Disorders of Movement and Posture
5 Ataxia and Disorders of Cerebellar Function
6 Disorders of Stance and Gait
SECTION 2 Pain and Disorders of Somatic Sensation

7 Pain
8 Disorders of Non-Painful Somatic Sensation
9 Headache and Other Craniofacial Pains
10 Pain in the Back, Neck, and Extremities
SECTION 3 Disorders of the Special Senses
11 Disorders of Smell and Taste
12 Disturbances of Vision
13 Disorders of Ocular Movement and Pupillary Function
14 Deafness, Dizziness, and Disorders of Equilibrium
SECTION 4 Epilepsy and Disorders of Consciousness

15 Epilepsy and Other Seizure Disorders

16 Coma and Related Disorders of Consciousness
17 Faintness and Syncope
18 Sleep and Its Abnormalities
SECTION 5 Derangements of Intellect, Behavior, and Language
Caused by Diffuse and Focal Cerebral Disease

19 Delirium and Other Acute Confusional States

20 Dementia, the Amnesic Syndrome, and the Neurology
of Intelligence and Memory
21 Neurologic Disorders Caused by Lesions in Specific
Parts of the Cerebrum
22 Disorders of Speech and Language
SECTION 6 Disorders of Energy, Mood, and Autonomic and
Endocrine Functions

23 Fatigue, Asthenia, Anxiety, and Depression

24 The Limbic Lobes and the Neurology of Emotion
25 Disorders of the Autonomic Nervous System,
Respiration, and Swallowing
26 The Hypothalamus and Neuroendocrine Disorders
PART 3: GROWTH AND DEVELOPMENT OF THE
NERVOUS SYSTEM AND THE NEUROLOGY OF
AGING
27 Normal Development and Deviations in Development
of the Nervous System
28 The Neurology of Aging
PART 4: MAJOR CATEGORIES OF NEUROLOGIC
DISEASE
29 Disturbances of Cerebrospinal Fluid, Including
Hydrocephalus, Pseudotumor Cerebri, and Low-
Pressure Syndromes
30 Intracranial Neoplasms and Paraneoplastic Disorders
31 Bacterial, Fungal, Spirochetal, and Parasitic Infections
of the Nervous System
32 Viral Infections of the Nervous System and Prion
Diseases
33 Stroke and Cerebrovascular Diseases
34 Craniocerebral Trauma
35 Multiple Sclerosis and Other Inflammatory
Demyelinating Diseases
36 Inherited Metabolic Diseases of the Nervous System
37 Developmental Diseases of the Nervous System
38 Degenerative Diseases of the Nervous System
39 The Acquired Metabolic Disorders of the Nervous
System
40 Diseases of the Nervous System Caused by Nutritional
Deficiency
41 Disorders of the Nervous System Caused by Alcohol,
Drugs, Toxins, and Chemical Agents
PART 5: DISEASES OF SPINAL CORD,
PERIPHERAL NERVE, AND MUSCLE
42 Diseases of the Spinal Cord
43 Diseases of the Peripheral Nerves
44 Diseases of the Cranial Nerves
45 Diseases of Muscle
46 Disorders of the Neuromuscular Junction, Myotonias,
and Persistent Muscle Fiber Activity
PART 6: PSYCHIATRIC DISORDERS
47 Anxiety Disorders, Hysteria, and Personality
Disorders
48 Depression and Bipolar Disease
49 Schizophrenia, Delusional, and Paranoid States
Index
 Preface

We are very pleased to bring you the 11th edition of Adams and Victor’s
Principles of Neurology. To provide the context for the continued importance
and relevance of a textbook that aspires to such breadth and depth, it may be
compelling to review a patient’s story; an event that took place between the
last edition of this book and this one. Neurologists have always been
particularly attracted to the case history as a method to imprint the fine points
as well as the broad principles that can be gleaned in a clinical encounter. The
originators of this book, Raymond D. Adams and Maurice Victor, insisted
that the basis of the practice of neurology necessarily differs from that of
neuroscience in that neurology is a medical discipline and must always be
related back to the patient. Here is the story:
A 19-year-old college sophomore began to show paranoid traits. She
became convinced that her roommate was listening in on her phone
conversations and planning to alter her essays. She became reclusive and
spent most of her time locked in her room. After much difficulty, her teachers
convinced her to be seen by the student health service. It was believed she
was beginning to show signs of schizophrenia and she was admitted to a
psychiatric hospital, where she was started on antipsychotic medications.
While in the hospital, she had a generalized seizure which prompted her
transfer to our service. Her spinal fluid analysis showed 10 lymphocytes per
mL3. She was found to have an anti-NMDA receptor antibody, which
prompted an ultrasound examination of the pelvis. The left ovary was thought
to show a benign cyst. Because of the neurological syndrome, the ovarian
cyst was resected and revealed a microscopic ovarian teratoma. The
neuropsychiatric syndrome resolved. She has since graduated and obtained an
advanced degree.
This class of disease, autoimmune encephalitis, appeared briefly in the last
edition of this book, and not at all in the previous one, but has become a
major field of modern neurology, now expanded to include antibodies to
many other antigens, occurring de novo or in association with an array of
tumors. What of the patients whose stories approximate this one but do not
have one or two essential components? One wonders how many other
patients harbor curious autoimmune disorders, which will be uncovered in
future editions of Principles of Neurology.
The clinical features of conditions such as cerebral amyloid angiopathy,
posterior reversible encephalopathy syndrome, the neuromyelitis optica
spectrum, and toxicity of treatments such as adaptive cell therapy have all
been expanded. The novel treatments now being applied to cerebrovascular
disease, multiple sclerosis, muscular dystrophy, amyloidosis, and inborn
enzyme deficiencies are among a list of triumphs of science that can only be
applied by careful clinicians. In the present edition there is hardly a category
of disease that has not begun to yield to the molecular biology and genetics.
Outside the laboratory, clinical trials have continued to build the
background of information that applies to large groups of patients with
neurological disease. Clinicians are very aware, however, that the results of a
trial have less certain meaning for an individual patient. It is the skillful use
of this information that this book aims to inform. Will the single patient be
helped or harmed? Because medicine deals with the realities and complexities
of illness, the clinician makes a best approximation of the correct course. The
wise application of science, evidence from trials, and the traditional virtues of
the neurological history and examination—essentially the craft of neurology
—are the main purpose of this edition of Principles of Neurology.
As has been our tradition, the book is written in a conversational style and
we do not eschew stating our personal preferences when they are based on
experience. We continue to find that readers value the uniformity of voice
and approach of a few individual authors, rather than a discursive list of
topics and writers. We thank Drs. Edward Stim, Mehrnaz Fallah, and Tim
Lachman for invaluable assistance in proofreading the text.
For this edition we introduce as a coauthor Dr. Sashank Prasad, a seasoned
general neurologist with special training in neuro-ophthalmology and a
director of our neurology training program. We hope that reading the book
will feel akin to attending our ward rounds, clinics, or morning report, thus
giving the reader an intimate window into demands of practice, without being
prescriptive. We hope this edition allows the physician to use the material as
a basis for continued professional growth and enjoyment. Welcome to our
world.
Allan H. Ropper, MD
 Martin A. Samuels, MD
Joshua P. Klein, MD, PhD
Sashank Prasad, MD
 PART 1
THE CLINICAL METHOD OF
NEUROLOGY
 1

Approach to the Patient With

Neurologic Disease

INTRODUCTION
Neurology is the practice and study of diseases of the nervous system. It is
among the most complex and exacting medical specialties and yet it is
perhaps the most rewarding, encompassing as it does all aspects of human
behavior, cognition, memory, movement, pain, sensory experience, and the
homeostatic functions of the body that are under nervous control. Among the
provocative aspects of neurology is the manner in which diseases disrupt the
functions of the mind, but the field also encompasses study of the diseases of
nerves, muscles, spinal cord, and cerebral hemispheres.
The neurologist occupies a special role by using extensive synthetic and
analytical skill to explain neurological symptoms and findings. Neurology is
distinctive in allowing a type of detailed interpretation of signs and symptoms
that, as a result of the fixed structure of the nervous system, provides
certainty in diagnosis that is not possible in other fields. This is the method of
localization that is almost unique to neurology.
Part of the excitement of modern neurology is the incorporation of
advances in imaging, and in the neurosciences including neurogenetics,
neurochemistry, neuroepidemiology, and neuropathology, which now offer
deep insights into the fundamental nature of disease. The close connections
among neurology and the fields of internal medicine, psychiatry,
neuropathology, developmental medicine and pediatrics, critical care,
neurorehabilitation, and neurosurgery extend the purview of clinical
neurology. As has occurred in other branches of medicine, increased
understanding of disease and therapeutic options has led to the emergence of
numerous subspecialties of neurology (Table 1-1).

Table 1-1
NEUROLOGICAL SUBSPECIALTY

Neurological symptoms, of course, do not present themselves as

immediately referable to a part of the nervous system and the neurologist
must therefore be knowledgeable in all aspects of nervous system function
and disease. The authors believe that a successful application of medical
knowledge is attained by adhering to the principles of the clinical method,
which has been retained to a greater degree in neurology than in other fields
of medicine. Even the experienced neurologist faced with a complex clinical
problem uses this basic approach.
 THE CLINICAL METHOD
In most cases, the clinical method consists of an orderly series of steps:

1. The symptoms and signs are secured with as much confidence as

possible by history and physical examination.
2. The symptoms and physical signs considered relevant to the problem at
hand are interpreted in terms of physiology and anatomy—i.e., one
identifies the disorder of function and the anatomic structures that are
implicated.
3. These analyses permit the physician to localize the disease process, i.e.,
to name the parts of the nervous system affected. This is the anatomic,
or topographic diagnosis, which often allows the recognition of a
characteristic clustering of symptoms and signs, constituting a
syndrome.
4. From the anatomic diagnosis and other specific medical data—
particularly the mode of onset and speed of evolution of the illness, the
involvement of nonneurologic organ systems, the relevant past and
family medical histories, and the imaging and laboratory findings—one
deduces the etiologic diagnosis and its pathogenesis.
5. Finally, the physician should assess the degree of disability and
determine whether it is temporary or permanent (functional diagnosis);
this is important in managing the patient’s illness and judging the
potential for restoration of function (prognosis).

The likely causes of a neurologic disease are judged in the context of a

patient’s personal and demographic characteristics, including their age, sex,
race, ethnicity, and geographic circumstances. Knowledge of the incidence
and prevalence of diseases among populations defined by these factors (base
rates) is a valuable component of the diagnostic process. These change over
time as for example, during epidemics, and may differ even within
neighborhoods or regions of one country.
In recent decades, some of these steps have been eclipsed by imaging
methods that allow precise localization of a lesion and, furthermore, often
characterize the category of disease. Parts of the elaborate examination that
were intended to localize lesions are no longer necessary in every patient.
Nonetheless, insufficient appreciation of the history and examination and the
resulting overdependence on imaging leads to diagnostic errors and has other
detrimental consequences. A clinical approach is usually more efficient and
far more economical than is resorting to imaging. Images are also replete
with spurious or unrelated findings, which elicit unnecessary further testing
and needless worry on the part of the patient.
All of these steps are undertaken in the service of effective treatment, an
ever-increasing aspect in neurology. As is emphasized repeatedly in later
chapters, there is always a premium in the diagnostic process on the
discovery of treatable diseases. Even when specific treatment is not available,
accurate diagnosis may in its own right function as a therapy, as uncertainty
about the cause of a neurologic illness may be as troubling to the patient than
the disease itself.
Of course, the solution to a clinical problem need not always be
schematized in this way. The clinical method offers several alternatives in the
order and manner by which information is collected and interpreted. In fact,
in some cases, adherence to a formal scheme is not necessary at all. In
relation to syndromic diagnosis, the clinical picture of Parkinson disease, for
example, is usually so characteristic that the nature of the illness is at once
apparent. In other cases, it is not necessary to carry the clinical analysis
beyond the stage of the anatomic diagnosis, which, in itself, may virtually
indicate the cause of a disease. For example, when vertigo, cerebellar ataxia,
unilateral Horner syndrome, paralysis of a vocal cord, and analgesia of the
face occur with acute onset, the cause is an occlusion of the vertebral artery,
because all the involved structures lie in the lateral medulla, within the
territory of this artery. Thus, the anatomic diagnosis determines and limits the
etiologic possibilities. Some signs themselves are almost specific for a
particular disease. Nonetheless, one is cautious in calling any single sign
pathognomonic as exceptions are found regularly.
Ascertaining the cause of a clinical syndrome (etiologic diagnosis)
requires knowledge of an entirely different order. Here one must be
conversant with the clinical details, including the speed of onset, course,
laboratory and imaging characteristics, and natural history of a multiplicity of
diseases. When confronted with a constellation of clinical features that do not
lend themselves to a simple or sequential analysis, one resorts to considering
the broad division of diseases in all branches of medicine, as summarized in
Table 1-2.
 Table 1-2
THE MAJOR CATEGORIES OF NEUROLOGIC DISEASE

Irrespective of the intellectual process that one utilizes in solving a

particular clinical problem, the fundamental steps in diagnosis always involve
the accurate elicitation of symptoms and signs and their correct interpretation
in terms of disordered function of the nervous system. Most often when there
is uncertainty or disagreement as to diagnosis, it is found later that the
symptoms or signs were incorrectly interpreted in the first place. Repeated
examinations may be necessary to establish the fundamental clinical findings
beyond doubt. Hence the aphorism: In a difficult neurologic case, a second
examination is the most helpful diagnostic test.
It is advantageous to focus the clinical analysis on the principal symptom
and signs and avoid being distracted by minor signs and uncertain clinical
data. Of course, as mentioned, if the main sign has been misinterpreted—if a
tremor has been taken for ataxia or fatigue for weakness—the clinical method
is derailed from the start.
Expert diagnosticians make successively more accurate estimates of the
likely diagnosis, utilizing pieces of the history and findings on the
examination to either affirm or exclude specific diseases. It is perhaps not
surprising that the method of successive estimations works well; evidence
from neuroscience reveals that this is the mechanism that the nervous system
uses to process information. As the lessons of cognitive psychology have
been applied to medical diagnosis, several heuristics (cognitive shortcuts)
have been identified as both necessary to the diagnostic process and as
pitfalls for the unwary clinician (see Tversky and Kahneman). Awareness of
these heuristics offers the opportunity to incorporate corrective strategies. We
openly discuss these heuristics and their pitfalls with our colleagues and
trainees in order to make them part of clinical reasoning. Investigators such
as Redelmeier have identified the following categories of cognitive mistakes
that are common in arriving at a diagnosis:

1. The framing effect reflects excessive weighting of specific initial data in

the presentation of the problem.
2. Anchoring heuristic, in which an initial impression cannot be
subsequently adjusted to incorporate new data.
3. Availability heuristic, in which experience with recent cases has an
undue impact on the diagnosis of the case at hand.
4. Representative heuristic refers to the lack of appreciation of the
frequency of disease in the population under consideration, a restatement
of the Bayes theorem.
5. Blind obedience, in which there is undue deference to authority or to the
results of a laboratory test.

With our colleague Vickery, we have reviewed the workings of these

heuristics in neurological diagnosis. Any of these shortcuts produce a
tendency to come to early closure in diagnosis. Often this is the result of
premature fixation on some item in the history or examination, closing the
mind to alternative diagnostic considerations. The first diagnostic formulation
should be regarded as only a testable hypothesis, subject to modification
when new items of information are secured.
When several of the main features of a disease in its typical form are
lacking, an alternative diagnosis should always be entertained. In general,
however, one is more likely to encounter rare manifestations of common
diseases than the typical manifestations of rare diseases (another paraphrasing
of the Bayes theorem). Should the disease be in a stage of transition, time
will allow the full picture to emerge and the diagnosis to be clarified.
As pointed out by Chimowitz, students tend to err in failing to recognize a
disease they have not seen, and experienced clinicians may fail to appreciate
a rare variant of a common disease. There is no doubt that some clinicians are
more adept than others at solving difficult clinical problems. Their talent is
not intuitive, as sometimes is presumed, but is attributable to having paid
close attention to the details of their experience with many diseases and
having catalogued them for future reference. The unusual case is recorded in
memory and can be resurrected when another one like it is encountered. To
achieve expert performance in all areas, cognitive, musical, and athletic, a
prolonged period of focused attention to the subject and to personal
experience is required.

PREVALENCE AND INCIDENCE OF

NEUROLOGIC DISEASE
To offer the physician the broadest perspective on the relative frequency of
neurologic diseases, estimates of their approximate impact in the world, taken
from the Global Burden of Disease Study, commissioned by the World
Health Organization and World Bank, published in Lancet and updated in
2010 are summarized in Fig. 1-1. The main analysis was of disability-
adjusted life years (DALYs), which represent the years or life lost from
premature death summed with the years of life lived with disability.
Neurologic disease accounts for 8.6 percent of the total global DALY
(including infections such as meningitis and encephalitis, and
noncommunicable diseases such as stroke, epilepsy, dementia, and headache,
but excluding traumatic brain injury). In summary, hemorrhagic stroke,
ischemic stroke, and meningitis together account for approximately two-
thirds of the total global burden caused by neurologic conditions. In relative
terms, conditions such as Parkinson disease and multiple sclerosis were
smaller contributors to the total global burden. Of course, these statistics
differ markedly between developing and developed areas of the world. In
addition, many neurologic conditions encountered in daily practice are not
accounted for in these surveys and these frequencies of disease throughout
the world were ascertained by various methods and must be considered
approximations.
Figure 1-1. Contribution of neurologic conditions to the global burden of
neurologic disease. The analysis, from WHO, includes communicable and
noncommunicable diseases, but does not include traumatic brain injury or
spine disease. (Modified from Chin and Vora.)

Donaghy and colleagues have provided a more detailed listing of the

incidence of various neurologic diseases that are likely to be seen in the
outpatient setting by a physician practicing in the United Kingdom. They
note stroke as far and away the most commonly encountered condition. More
focused surveys, such as the one conducted by Hirtz and colleagues, give
similar rates of prevalence, with migraine, epilepsy, and multiple sclerosis
being the most common neurologic disease in the general population (121,
7.1, and 0.9 per 1,000 persons in a year); stroke, traumatic brain injury, and
spinal injury occurring in 183, 101, and 4.5 per 100,000 per year; and
Alzheimer disease, Parkinson disease, and amyotrophic lateral sclerosis
(ALS) among older individuals at rates of 67, 9.5, and 1.6 per 100,000 yearly.
Data such as these assist in allocating societal resources, and they may be
helpful in leading the physician to the correct diagnosis insofar as they
emphasize the oft-stated dictum that “common conditions occur commonly”
and therefore should be considered a priori to be more likely diagnoses
(Table 1-3).

Table 1-3
PREVALENCE OF THE MAJOR NEUROLOGIC DISORDERS IN
THE UNITED STATES

TAKING THE HISTORY

In neurology, the physician is highly dependent on the cooperation of the
patient for a reliable history, especially for a description of those symptoms
that are unaccompanied by observable signs of disease. If the symptoms are
in the sensory sphere, only the patient can tell what he sees, hears, or feels.
The first step in the clinical encounter is to enlist the patient’s trust and
cooperation and make him realize the importance of the history and
examination procedure. Of course, no matter how reliable the history appears
to be, verification of the patient’s account by a knowledgeable and objective
informant is always desirable. When the patient’s cooperation is not possible,
as for example in a comatose or confused individual or in a young child, an
attempt should be made to acquire the necessary information from other
sources.
The following points about taking the neurologic history deserve further
comment:

1. Special care must be taken to avoid suggesting to the patient the

symptoms that one seeks. The patient should be discouraged from
framing his symptom(s) in terms of a diagnosis that he may have heard;
rather, he should be urged to give a simple description—being asked, for
example, to choose a word that best describes his pain and to report
precisely what he means by a particular term such as dizziness,
imbalance, or vertigo. Otherwise there is disposition on the part of the
patient to emphasize aspects of the history that support a superficially
plausible diagnosis. This problem is now amplified by the wide array of
medical information available to patients through various sources such
as the Internet. The patient who is given to highly circumstantial and
rambling accounts can be kept on the subject of his illness by directive
questions that draw out essential points. One should avoid suggesting
terms to the patient, particularly those that prematurely confirm the
physician’s preconceived diagnoses (“leading the witness”).
2. The setting in which the illness occurred, its mode of onset and
evolution, and its course are of major importance. One must attempt to
learn precisely how each symptom began and progressed. Often the
nature of the disease process can be decided from these data alone, such
as the typical sudden onset of stroke. If such information cannot be
supplied by the patient or his family, it may be necessary to judge the
course of the illness by what the patient was able to do at different times
(e.g., how far he could walk, when he could no longer negotiate stairs or
carry on his usual work) or by changes in the clinical findings between
successive examinations.
 3. In general, one tends to be careless in estimating the mental capacities of
patients. Attempts are sometimes made to take histories from patients
who are cognitively impaired or so confused that they have no idea why
they are in a doctor’s office or a hospital. Young physicians and students
have a natural tendency to “normalize” the patient’s cognitive
performance, often collaborating with a hopeful family in the
misperception that no real problem exists. This attempt at sympathy does
not serve the patient and may delay the diagnosis of a potentially
treatable disease. A common error is to pass lightly over inconsistencies
in history and inaccuracies about dates and symptoms, only to discover
later that these flaws in memory were the essential features of the illness.
4. Asking the patient to give his own interpretation of the possible meaning
of symptoms sometimes exposes concern, depression, anxiety,
suspiciousness, or even delusional thinking. This also may allow the
patient to articulate fears about certain diseases such as brain tumor,
dementia, motor neuron disease, or multiple sclerosis. Exposing these
fears allows the physician to allay these concerns forthrightly.

THE NEUROLOGIC EXAMINATION

The neurologic examination begins with observations in the waiting room,
and continues as the patient proceeds to the examination room and while the
history is being obtained. The manner in which the patient tells the story of
his illness may betray confusion or incoherence in thinking, impairment of
memory or judgment, or difficulty in comprehending or expressing ideas. A
more extensive examination of attention, memory, cognitive ability, and
language is undertaken if the history or the manner in which it is given
indicates the problem lies in those spheres. Otherwise, asking the date and
place, repeating and recalling words, and simple arithmetic are adequate
screening procedures. One then proceeds from an examination of the cranial
nerves to the testing of motor, reflex, and sensory functions of the upper and
lower limbs. This is followed by an assessment of gait and station (standing
position) are observed before or after the rest of the examination.
The thoroughness and focus of the neurologic examination must be
governed by the type of clinical problem presented by the patient. To spend a
half hour or more testing cerebral, cerebellar, cranial nerve, and sensorimotor
function in a patient seeking treatment for a simple compression palsy of an
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Charmes, M., contributor of Débats, 355.
Cholera, 23, 166, 325.
Christ Church, Duns, 397.
Christina, Queen, 11.
Cockburn, Lord, 2.
Commercial Convention, advantages of a, 168; basis of the Treaty, 179;
ratification, 182; revision, 338, 343, 348, 360.
Constantinople, 30.
Copenhagen, 66.
Curzon, Robert, 49.

Dad i Sirr Island, 292.

Daha, 128.
Dar Aklau, 85.
Dar-el-Baida, 314, 340; number of deaths from cholera, 325.
Dar-Mulai-Ali, 341.
Davidson, 317.
Denmark, King of, confers the order of the Grand Cross on Sir J. D. Hay, 71,
363.
Derby, Lord, 317, 353; his Eastern policy, 319.
Diosdado, Señor, 343.
Doyle, Percy, 30, 49.
Dra, 127.
Drummond, Dean, Rector of Hadleigh, 5.
Dufferin, Lord, 336.
Dukála, Governor of, 105.
Duns, 397.
Dupplin Castle, 5.
Dwarf, The, 40; his wife, 41.

‘Eating up,’ the practice of, 233.

Edinburgh, 1.
Egypt, plague in, 22.
El Araish, 87, 136.
El Kántara, 179.
El Kra, a lake or marsh, 89.
El Ksar battle, 241.
El Kus river, 87.
Eleg, 128.
Erhamna district, 106, 266.
Escazena, 112, 116.
E’Sfi, or the pure, 285.
E’Suizi, Governor, 93.
‘Etymons of the English Language,’ 5.

Fairlie, 232.
Falcons, hunting with, 266; legend, 267.
Fas, 93; first mission to, in 1868, 236; second mission in 1875, 307; third
mission in 1880, 329; the ladies of, 237.
Fatmeh, 190.
Féraud, M., 354.
Ferguson, 3.
Ferry, M., 345, 351.
Ford, Sir Francis Clare, 11.
—, Mr., his ‘Handbook of Spain,’ 11.
Forde, Mr., 214.
Forster, Henry, 20.
France, relations with Morocco, 66, 133, 135, 345; demands of, 69.
Franciscan Brotherhood, Father Superior of the, 343.
Frost, J., 99 note.
Fum Ajrud stream, 158.

Gaulois, charges against the Foreign Representatives, 346, 351.

Ghaba Sebaita, 366.
Ghamára mountains, 158.
Gharbía, Kaid Sheikh of, 85.
Ghásats E’Nil, or the Garden of the Nile, 112, 118.
Ghemáts river, 291.
Gibraltar, question of the exchange for Ceuta, 233; measures against the
cholera, 325, 326.
Gibraltar Chronicle, extract from, on the Moorish loan, 220.
Gla, a stream, 88.
Glaui, heights of, 292.
Glücksberg, Duc de, 68.
Gordon, Captain, 6.
Gordon, Hon. A., letter from Sir J. D. Hay on his mission to Sultan Mulai
Abderahman, 76.
Goschen, Mr., 336.
Granville, Lord, interview with Sir J. D. Hay, 350; his defence of him in the
House of Lords, 351.
Green, Mr., 207, 226.
Gregorio de Borgas y Tarius, Don, 7.
Grey, Admiral, 233.
—, Mrs., 9 note.

Habor, 128.
Hadj Abdallah Lamarti, 148, 376.
Hadj Abdallah Tif, Governor of Rabát, 93.
Hadj Abderahman Ben el Amri, 90.
Hadj Abd Selam, 104, 109.
Hadj Alarbi, 312, 378.
Hadj Gabári, the jester, 116.
Hadj Hamed Lamarti, 296, 376; illness, 365.
Hadj Kassem, 100.
Hadj Kassim, 161-164.
Haffa wood, 377, 378.
Haha, Governor of, 284.
Hajara el Ghaghab, or rock of ravens, 224.
Hajot, 315.
Hall, Captain, 148, 152.
Hamádsha, dances of the, 91, 177.
Hammond, Lord, 20.
Hara, or village of lepers, 107, 111.
Hashef river, 85.
Hassan, Mosque of, 92.
Hastings, Marquess of, 5.
Havelock, 4.
Hay, Lady, 296, 312, 328; letter from Hans Christian Andersen, 225.
—, Sir Edward, 6.
—, Sir John Hay Drummond, birth, 1; at the Edinburgh Academy, 2;
Charterhouse, 4; at Tangier, 7; under the tuition of Don Gregorio, 8; meets
José Maria, 11; proficiency in Arabic, 16; his ‘Western Barbary,’ 17; his
fortune told by Leila, 17; appointed Attaché at Constantinople, 20; at
Marseilles, 22; fear of the plague, 22; attacked by cholera, 24; at
Alexandria, 24; purchases a gem, 26; at Constantinople, 30; his first
dispatch, 30; life at the Embassy, 42; at the Armenian banker’s, 45; effect
of the narghileh, 47; selected confidential Attaché to Sir S. Canning, 50;
sent to Broussa, 51; receives hospitality from a Turk, 52-57; obtains leave
of absence, 58, 66; at Paris, 60; Egypt, 63; Stockholm, 66; Tangier, 67; his
letter to Sir S. Canning on the state of affairs in Tangier, 68-71; appointed
Political Agent and Consul-General in Morocco, 74; starts on his mission to
Sultan Mulai Abderahman in 1846, 77; an Arab serenade, 91; reception at
Rabát, 92-96; attacked by a mob at Salli, 101; at Marákesh, 108; received
by the Sultan, 113, 118, 216, 217, 232, 270; conferences with Uzir Ben
Dris, 115, 117; his return to Tangier, 124; on the habits of the Moors, 124;
the Jews, 125; promoted to the rank of Chargé d’Affaires, 134; his efforts
to develop trade, 134, 140, 168; his ride from El Araish, 136; adventure
with a Moslem, 138; his firm policy, 139; marriage, 142; influence over the
natives, 142, 363; love of sport, 143, 365; suppression of piracy among the
Rifians, 144; his kindness during the famine, 164; on the advantages of a
Commercial Convention, 168; his second mission to Marákesh in 1855,
169; reception at Azamor, 169; at Shawía, 171; result of his mission, 179;
 ratification of the Treaty, 181; created a C.B., 183; on the downfall of
Benabu, 184-192; gift of a leopard, 199; on the outbreak of hostilities with
Spain, 206; his efforts to protect property, 208; attack of influenza, 213; his
mission to Meknes, 214; terms of the proposed loan, 218; nominated
K.C.B., 219; suffers from his eyes, 219; the British Legation, 221; ‘The
Wilderness,’ 223; his summer residence, 224; acts of kindness, 226; third
mission to Marákesh in 1863, 230; at Rabát, 230; on the exchange of
Gibraltar for Ceuta, 233; at Fas, 236; audiences of the Sultan, 238;
proposed reforms, 238; Minister Plenipotentiary, 264; fourth mission to
Marákesh in 1872, 264; legend of the falcon, 267; enters Marákesh, 269;
dinner with Sid Musa, 272; the menu, 273; his final interview with the
Sultan, 276-282; entry into Mogador, 284; crossing the bar at Saffi, 286;
expedition to the Atlas mountains, 289; mission to Fas in 1875, 307;
proposes various reforms, 314, 317; reception by Sultan Mulai Hassan,
315; at the feast of the Mulud, 316; on the Sahara scheme, 317; his annual
holidays, 318; on the crisis in Turkey, 319; on Sir H. Layard’s appointment,
320; on the question of Protection, 321; famine, 324; cholera, 325; the
quarantine regulations, 325; illness of his son, 327; third mission to Fas in
1879, 329; interview with Uzir Mokhta, 330-333; reforms agreed to, 334;
promoted to the rank of Envoy Extraordinary, 335; letters from M. Tissot,
336; failure of his project for the exportation of grain, 339; at Marákesh,
340; on the state of Morocco, 344, 347; on the relations between France
and Morocco, 345, 349; charges against him, 346; interview with Lord
Granville, 350; G.C.M.G. conferred, 350; exoneration in the House of
Lords, 350-353; his impression of M. Féraud, 354; weariness of his work,
356; on the system of slavery, 357; prison reform, 358; fails to obtain a
revision of the Commercial Treaty, 360; delight at leaving, 360; letter from
the Sultan’s Prime Minister, 361-363; Privy Councillor, 363; accounts of
boar hunts, 366-389; introduces pigsticking, 373; hunting a lion, 390;
death, 397.
—, Mr. E. A. Drummond, 1, 5, 28, 293; appointed Political Agent and Consul-
General in Morocco, 6; his mission to Marákesh, 66; illness and death, 68.
—, Mr. R. Drummond, 293, 296; consul at Mogador, 324; illness, 327.
—, Mr. R., 8.
—, Mr. R. W., 139.
—, Mrs., 4.
—, Mrs. R. Drummond, 237, 328.
—, Miss, 237, 240, 312; extracts from her diary, 284, 289; received by the
Sultan, 342.
—, Miss A., 266.
—, Louisa, 9.
Hiazna, Governor of, 72.
‘Hill,’ the, 224.
Hitchcock, Major, 296.
Hodges, Colonel, 21, 24.
Hooker, Sir Joseph, letters from Sir J. D. Hay, 264, 318, 324.

Ibdaua, Sheikh of, 87.

Ibrahim Pasha, 30.
Isly, battle of, 79.

Jamah Makra village, 390.

Jebar, the Khalífa of Wazan, 345.
Jebel Habíb hills, 371.
Jebel Kebír, 207 note, 224.
Jebel Musa, 224.
Jebíla hills, 105, 269.
Jelab, torture of the, 186 note.
Jewesses, the, 129, 271; dress, 130, 271.
Jews, the, of Morocco, 125, 271; number of, 129; despotic rules, 130; oath,
131.
Jin, or evil spirit, 389, 391.
João, the Portuguese Gunsmith, story of, 241-263.
Joinville, Prince de, 67, 68.
José, Don, 101.
José Maria, the famous brigand, 11; account of his pardon, 12; his robberies,
13; his horse, 14; his death, 15.
‘Journal of the Society for Psychical Research,’ extract from, 327.
Judah Azalia, 126; his memorandum about the Jews, 127-129.
Judah El Hayugni, 129.
Kab ghazal, or gazelle hoofs, 273.
Kaddor, 109.
Kaid Abbas Emkashéd, 161.
Kaid Abd-el-Kerim, 77, 109; his account of the battle of Isly, 79-81.
Kaid Ben Abu, 78, 98.
Kaid Ben Tahir, Governor of Azamor, 169.
Kaid Bu Aiesh, 269.
Kaid ‘Bu Jebel,’ 78.
Kaid-el-Meshwa, or High Chamberlain, 216.
Kaid Erha, meaning of the term, 265.
Kaid E’Susi, 96.
Kaid Maclean, 327.
Kaid Madáni, 112.
Kaid Maimon and the lion, 303-306.
Kaid Meno, theft of a horse, 308-311.
Kaid Serbul, 87.
Kasba Faráo, 214.
Kasba Jedída, 342.
Kenneth III, King of Scots, 267.
Khamás mountains, 158.
Kholj river, 85.
Kinnoull, Earl of, 1, 5.
Kubbats E’Suiera, or the ‘Picture Cupola,’ 112.
Kus, 317.
Kutubía Mosque, 106, 108, 111, 269.

‘Lab-el-barod,’ 311, 313.

Lahleh, 128.
Lalande, Admiral, 60; his message to Lord Ponsonby, 61; death, 63.
Lamarti, Selam, 17.
Lambton, Colonel, 296.
Lane, E. W., his ‘Manners and Customs of the Modern Egyptians,’ 77.
Lasakia, 129.
Lasats, 129.
Laurin, M., 27.
Layard, Sir Henry, letters from Sir J. D. Hay on the exchange of Gibraltar for
Ceuta, 233; on his reception by the Sultan, 288; on the accession of Mulai
Hassan, 307; on laying a cable, 314; appointed Ambassador at
Constantinople, 320.
Leech, 4.
Legation, the British, at Tangier, 221.
Leila predicts Sir J. D. Hay’s fortune, 17-19.
Lerchundi, Padre, 344.
Liddell, Mr., 207.
Lion and the lark, anecdote of the, 84; hunting a, 390.
Lively, H.M.S., 264, 285.
Loncarty battle, 267.
Londonderry, Lady, 36; her interview with the Sultan, 37.
Londonderry, Lord, 36.
Lorimer, Dr., 23.
Lynedoch, Lord, 1.

Maada or sedge canoe, 89, 90.

Mactavish, 49.
Madrid, conference on the system of protection in Morocco, 323.
Mahazen river, 243.
Mahmud Canal, 25.
Mahmud, Sultan, his dwarf, 40.
Maimon, the leopard, 199.
Malmesbury, Lord, 198, 353.
Marákesh, 66, 105, 108; first mission to, in 1846, 77; second mission in 1855,
169; third mission in 1863, 230; fourth mission in 1873, 264; in 1882, 340.
Marcussen, Mme., letters from Sir J. D. Hay, 138, 139.
Marseilles, 22.
Marshan plateau, 268.
Matra, James Mario, 221.
Mauboussin, M., 60.
Maule, William, 49.
Mazagan, 264, 314.
McKenzie & Co., 317.
Mehemet Ali, 24, 44.
Meknes, mission to, in 1861, 214.
Melilla fortress, 144.
Mesfíwa village, 106, 291, 292.
Meteor, the, 124.
Miranda, H.M. frigate, 148.
Mishra-el-Hashef river, 137, 239.
Mogador, Island of, 69, 123; famine in, 324.
Mohammed Ben Abdallah, Sultan, 123.
— Ben El Amrani, bastinadoed, 105.
— Gharrit, letter of farewell to Sir J. D. Hay, 361.
Mokhta, the Uzir, 329; questions of etiquette, 331; interview with Sir J. D. Hay,
332; his palace, 333.
Mona, system of, 86, 340.
‘Moorish Prince, a story of a,’ 300-303.
Moors, habits of the, 124; their reception in England, 135.
Morocco, introduction of the plague in 1826, 24; famine in, 164; decline of
trade, 167; population, 167; advantages of a Commercial Convention, 168;
ratification of the Treaty, 182; cattle-lifting, 193; punishment of, 194;
proposed loan, 214; terms of the payment, 218; final settlement, 220;
slavery in, 357.
—, Sultan of, 113, see Mulai Abderahman.
Mujáhidin or ‘Warriors of the Faith,’ 185.
Mul Meshwa, or chief Usher, 71, 112.
Mulai Abdelmalek, 241.
Mulai Abderahman, Sultan of Morocco, 71, 72, 113, 144; receives Sir J. D. Hay,
113, 118, 180; appearance and dress, 114; harem, 119; his fondness for
animals, 199, 202; death, 205.
Mulai Abderahman Ben Hisham, Sultan, 300.
Mulai Ahmed, 242, 300-303.
Mulai Ali, 129, 341.
Mulai Hashem, 129.
Mulai Hassan, Sultan of Morocco, accession, 307; reception of Sir J. D. Hay,
315, 330, 340; appearance, 315.
Mulai Ismael, 119.
Mulai Mohammed, Sultan of Fas, 241.
Mulai Sliman, 274.
Mulai Soliman, 110.
Mulai Yazid, tomb of, 110.
Mulud, feast of the, 316.
Murray, Mr. H., 68.
—, John, 4.
Murray’s Magazine, Sir J. D. Hay’s reminiscences, 367.

Napier, Admiral Sir Charles, 30, 145.

—, and Ettrick, Lord, 49, 73.
— of Magdala, Lord, 353.
Nares, Captain, 318.
Nelson, Lord, 235.
Nicolas, Commander, 218.
Nion, M. de, 68.
Norderling, Mrs., letters from Sir J. D. Hay on his reception from Sultan Mulai
Hassan, 315; on the Sahara scheme, 317.

Ofran, 128.
Ordega, M., 345; recalled, 354.
Oriental phraseology, specimen of, 361.
Orléans, Duc de, at Tangier, 203; his letter to Sir J. D. Hay, 203.
Oscar, King of Sweden, 66.

Palmerston, Lady, 75.

—, Lord, 17, 20.
Peñon fortress, 144, 148.
Pisani, Etienne, 49.
—, Mr. Frederick, Chief Dragoman of the Embassy, 31, 49, 73.
Plague, the, in Egypt, 22, 24.
Ponsonby, Lady, 33, 42, 75.
—, Lord, 25, 30, 42; his address to the Sultan, 32; entertains Bosco at dinner,
33; charm of manner, 43; his policy, 44; reply to Admiral Lalande, 63; his
letter to Sir J. D. Hay on his appointment in Morocco, 74.
Pontet, M., 44.
Poole, Stanley Lane, his ‘Life of Sir S. Canning,’ 73.
Porter, Commodore, 63.
—, Mr. George, 64.
Protection, system of, 322; Conference on, 323.

Rabát, 62, 217, 230.

Raeburn, 1.
Rahma, 247.
Ras-ed-Daura lake, 89.
Ras-el-Ain fountain, 129.
‘Ravensrock,’ Sir J. D. Hay’s summer residence, 224.
Reade, Mr., 207.
Reshid, Governor of Shawía, 171.
Reshid Pasha, 36.
Rif country, 144, 158; population, 158; inhabitants, 159.
Rifians, piracy of the, 144, 146; costume, 152; parley with Sir J. D. Hay, 153-
157; industry, 159; courage, 160; morality, 160.
Robinson and Fleming, Messrs., 220.
Roche, M., 95.
Rosebery, Lord, 360.
Russell, Lord John, 205; his defence of Sir J. D. Hay, 207.

Sabbatyon river, 131.

Saffi port, 285, 292, 314.
Sahara scheme, 317.
Sahel or plain, 242.
Salamis, H.M.S., 340.
Salisbury, Lord, 322; his estimation of Sir J. D. Hay, 352.
Salli, 100; Governor of, 102.
San Stefano village, 64.
Sawle, Captain, 296, 298.
Scott, Sir Walter, 3.
‘Scraps from my Note-Book,’ 367, 396.
Sebastian, King of Portugal, 241.
Sebu river, 238.
Senya el Hashti, or Spring of Hashti, 223.
Serruya, Mr. J., 92.
Seville, 11, 225.
Sharf village, 193.
Sharf el Akab, 371.
Shashon, Sheikh, 243.
Shawía district, 104, 170.
Shebá, 368.
Shebenía, 378.
Shedma district, 122.
Shella, 99.
Sherarda, Governor of, 214.
Sheridan, 4.
Shirreff, Miss, her recollection of Sir J. D. Hay’s early home, 8.
Shloh tribe, 291; the women, 295, 299; hospitality, 295, 298.
Sicsu, Mr. David, the Interpreter, 88, 109, 131, 216.
Sid Abd-el-Malek, 78.
Sid Alarbi Mokta, 113.
Sid Bel-Abbas, tomb of, 110.
Sid Ben Yahia, 88.
Sid Buselham, 136.
Sid Buselham Ben Ali, 68.
Sid Dris Ben Yamáni, 275.
Sid Mogdul, 123.
Sid Mohammed, Sultan of Morocco, 79, 216; reception of Sir J. D. Hay, 216,
231, 237, 270; final interview, 276-282; his entry into Rabát, 230; method
of quelling a rebellion, 233; death, 307.
Sid Mohammed Bargash, 321.
— — Ben Dris, 72; manner of his death, 72.
— — Khatíb, 180, 181.
Sid Musa, the Hajib, 272, 289.
Simpson, Dr., 90, 101, 103.
Slavery in Morocco, 357.
Smith, General, 30.
‘Snabi,’ 376.
Spain, question regarding Ceuta, 68; declares war with Morocco, 205; peace
concluded in 1860, 213; claims indemnity, 214.
Spanish chapel, protection of, 208-211; ‘three-decker,’ model of a, 192.
Spartel, Cape, 192, 390.
St. Leger, 89, 112.
Stockholm, 66.
Stopford, Admiral Sir Robert, 62.
Stunmer, Baron, 36.
Suanni, 78, 148.
Suánnia, 105.
Suiera, 123.
Sus, 122, 291.
‘Sweet Waters,’ 39.
Symes, 2.

Tafilelt, 128.
‘Taherdats’ river, 368.
Taheret, 129.
Tait, Archbishop, 3.
Takulebat, 129.
Tama, history of the son of, 82.
Tamista plain, 242.
Tangier, 7; condition of, 68: arsenal, 192; bridge, 193; quarantine regulations,
325.
Tápia, 99 note.
Taza, 289.
Telin, 128.
Tensift river, 106, 269, 292.
Tetuan, 144, 180.
Thackeray, 4.
Thala, 128.
Thomson, Captain J., 5; his ‘Etymons of the English Language,’ 5.
Times, leader in the, 346; extract from, 351.
Tissot, M., 288; letters to Sir J. D. Hay, 336.
Torras, 355, 360.
Torribat, 129.
Trafalgar, battle of, 192.
Tres Forcas, Cape, 144.
Tsemsalla village, 243.
Turkey, the Sultan of, receives Lord Ponsonby and suite, 31; interview with
Lady Londonderry, 37.
Uhara, 86.
Ujda, 69.
Uríka, 289, 293.
Urquhart, Mr., 99.

Vaden, 127, 128.

Vakka, 128.
Valenciennes, 1.
Veneno, 13; kills José Maria, 15.
Vesuvius, H.M.S., 180.
Villiers, 360.
Vismes et de Ponthieu, Prince de, 5.

Wad el Halk river, 192.

Wad Nefis, 67.
Wadan, 127.
Wadnun, 317.
Wales, Prince of, 318; his visit to Tangier, 203.
‘Washington, Mount,’ 207.
Wazan, Sheríf of, 345.
Weber, 356.
Wedderburn Castle, death of Sir J. D. Hay at, 397.
‘Western Barbary,’ 17, 86 note, 177.
Winton, Major de, 296.

Yaden, 127.

Zacchian, 129.
Zarhon district, 160.
Zarhoni, Ben Taieb and Ben Nasr, dialogue between, 81.
Zebdi, Governor, 93.
Zerhóna, the, 214.
Zinat Kar Mountain, 292, 296.
Zinats village, 196, 228.
Zouche, Lord, 49; his defence of Sir J. D. Hay, 351.

THE END.
 OXFORD: HORACE HART
PRINTER TO THE UNIVERSITY
 FOOTNOTES:

[1]Henry Cockburn, one of the Senators of the College of

Justice, and a leading member of the literary and political society
in Edinburgh of that day.
[2]Mrs. Grey.
[3]Mrs. Norderling.
[4]It was thought improper to speak about any woman to the
Sultan.
[5]Sultan Mulai Abderahman was renowned for his
extraordinary strength.
[6]Life of Stratford Canning, by Stanley Lane-Poole, vol. ii. p.
116.
[7]His uniform.
[8]A species of shad.
[9]See description of Shemis in Hay’s Western Barbary.
According to Tissot, in his Itinéraire de Tanger à Rabat, 1876,
scarcely a trace of these ruins remains.
[10]According to Mr. J. Ball the ‘Elaeoselinum (Laserpitium)
humile.’
[11]Tápia is a kind of cement formed of lime, mixed with small
stones, beaten down in blocks by means of large wooden cases.
The Moorish castle at Gibraltar is built with tápia, and still looks as
solid as if new.—J. H. D. H.
[12]The Sultan Assuad referred to was the seventh of his
dynasty. He was buried at Shella, where his tomb bears an
inscription, of which the following translation has been kindly
supplied by J. Frost, Esq., British Vice-Consul at Rabát:—‘This is
the tomb of our Master the Sultan, the Khalifah, the Imam, the
Commander of the Muslims and Defender of the Faith, the
Champion in the path of the Lord of the worlds, Abulhasan, son of
our Master the Sultan, the Khalifah, the Imam, &c., &c. Abu Said,
son of our Master the Sultan, the Khalifah, the Imam, &c., &c.,
Abu Yusuf Ya’kub, son of ’Abd al-Hakk, may God sanctify his
spirit and illumine his sepulchre. He died (may God be pleased
with him and make him contented) in the mountain of Hintatah in
the night of (i.e. preceding) Tuesday, the 27th of the blessed
month of Rabi ’al-Awwal, in the year 752, and was buried in the
Kiblah of the Great Mosque of Al-Mansor, in Marakesh (may God
fill it with His praise). He was afterwards transferred to this
blessed and sainted tomb in Shella. May God receive him into His
mercy and make him dwell in His paradise. God bless our
Prophet Mahammad and his descendants.’
[13]Zizyphus lotus.
[14]Elaeodendron argan.
[15]2 Kings xviii. 9.
[16]Dra.
[17]Akka.
[18]? Flirgh.
[19]An orange dye.
[20]The White Fast.
[21]Tiseret.
[22]The French Representative.
[23]In consequence of the immunity he had claimed under
protection of the horse.
[24]The population of Morocco have never accepted, like other
Mohammedans, the Sultan of Turkey—who is not a descendant
of the Prophet—as ‘Kaliph Allah.’
[25]No attempt was made to land troops, neither was a gun
fired.
 [26]Afterwards General Buceta, a very distinguished officer.
[27]Written in 1887.
[28]‘Cedrus atlantica.’
[29]Term generally applied to Europeans.
[30]Term used for horses of great speed, fed on dates.
[31]The torture of the wooden jelab is only resorted to in
extreme cases to extort a confession about wealth supposed to
be hidden. The instrument of torture is made of wood, and
resembles the outer hooded garment of a Franciscan friar. It is
placed upright, and the victim is squeezed into it in a standing
position; points of iron project in various parts preventing the
inmate from reclining or resting any part of his body without great
suffering. There he is left upon bread and water, to pass days and
nights, until he divulges where his wealth is hidden.
[32]Mohammedans believe that dates of all deaths are written
in a book by Allah.
[33]Fatmeh is dead. He was a spendthrift, and the bags of gold
were soon squandered in dissipation.
[34]There are no remains of houses or other buildings within
the solid walls which were erected on the north and west side of
this small arsenal. There are two wide gates adjoining each other
through which the galleys were hauled up and placed in safety.
The gateways are of beautiful solid brick masonry; the north wall
is of stone; on the south-eastern side high ground rises from this
enclosure. On the top of the hill there are the remains of a rude
‘Campus Aestivus.’ About a mile up the river are the ruins of a
Roman bridge leading to Tangier, the Tingis of the Romans; the
chief arch of this interesting monument fell in 1880. The date of
the arsenal and bridge is, I believe, the year 1 A.D.
[35]About twenty miles from Trafalgar.
[36]House of succour.
[37]Readers may be shocked that such barbarities are
practised by the Moors; but they are a thousand years behind the