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PAIN REVIEW
This page intentionally left blank

     
PAIN REVIEW SECOND EDITION

Steven D. Waldman, MD, JD

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

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

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

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as
may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using
any information, methods, compounds, or experiments described herein. In using such information or methods they
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Previous editions copyrighted 2009

Library of Congress Cataloging-in-Publication Data

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

Every long journey begins

with a first step.
—CONFUCIUS
To my children—David Mayo, Corey, Jennifer, and Reid—all of
whom are sick of hearing me invoke the above quote . . . but who
have nevertheless steadfastly followed its
timeless wisdom in their daily lives!
Preface

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

vi
 Contents

SECTION 1 ANATOMY 33. The Brachial Plexus 79

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

vii
viii Contents

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

152. Spasmodic Torticollis 243 198. Metatarsalgia 313

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

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

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

     
 SECTION 1 Anatomy
1 CHAPTER

Overview of the Cranial Nerves

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

1
2 Section 1 Anatomy

Olfactory nerve

Optic chiasm

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

Glossopharyngeal Facial nerve

nerve
Vagus nerve Vestibulocochlear
Accessory nerve nerve

Hypoglossal nerve

Spinal nerve

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

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

2 CHAPTER

The Olfactory Nerve—Cranial Nerve I

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

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

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

F T
A

I. Olfactory nerve
• Sensory
• Smell

Fig. 2-1 Olfactory nerve I.

Bowman's
Schwann cell gland
Connective
tissue

Basal cell

Olfactory
receptor cell

Sustentacular
cell
Dendrite

Olfactory vesicle

Olfactory cilia Microvilli

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

Nerve fibers within the olfactory bulb

Olfactory
bulb Olfactory
Olfactory tract
stem cell
Cribriform plate

Olfactory Columnar
ensheathing epithelial cell
glia

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

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

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

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

3 CHAPTER

The Optic Nerve—Cranial Nerve II

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

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

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

Conjunctiva Lateral rectus

Ora serrata Sclera

Schlemm's
Choroid
canal

Anterior
chamber Retina

Lens Fovea centralis

Cornea Central retinal

artery
Posterior
chamber Central retinal
vein
Iris
Optic nerve

Ciliary body
Medial rectus

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

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

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

Clinical Evaluation of the Optic Nerve and

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

RGC Axonal Length

Lateral
geniculate
93 nucleus
mm
Optic Superior Visual
chiasm colliculus cortex

Optic
nerve Cortical
Optic
cells
tract

Retina

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

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

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

Aneurysmal
Intima

Fragmented internal
elastic lamina
Adventitia

Normal
Endothelial cells
Intima

Internal
elastic lamina
Media
Adventitia

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

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

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

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

Table 3-1 Common Diseases That Result in Visual Impairment

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

4 CHAPTER

The Oculomotor Nerve—Cranial Nerve III

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

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

Table 4-1 Actions of the Extraocular Muscles

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

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

Ciliary ganglion

Caudal branch of the

oculomotor nerve

Cephalic branch of the

oculomotor nerve
Optic nerve
Maxillary nerve

Mandibular nerve

Oculomotor nerve

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

Trochlear nerve [IV] Abducens nerve [VI]

Internal carotid artery

Oculomotor nerve [iii]

Pituitary gland Dura mater

Diaphragma sellae

Sphenoidal (paranasal) sinus

Cavernous (venous) sinus

Ophthalmic division of trigeminal nerve [V1]

Maxillary division of trigeminal nerve [V2]

Fig. 4-3 Exiting the brainstem, the oculomotor nerve (cranial nerve III) passes between the posterior cerebral and
superior cerebellar arteries and then passes through the dura mater to enter the cavernous sinus. The nerve runs
along the lateral wall of the cavernous sinus just superior to the trochlear nerve (cranial nerve IV) and enters the
orbit via the superior orbital fissure. (Reprinted from Drake R, Vogl W, Mitchell A: Gray’s Anatomy for Students, ed
2. London, Churchill Livingstone, 2010; with permission.)
12 Section 1 Anatomy

between the choroid and the sclera, these postganglionic fibers innervate the
ciliary muscles, which alter the shape of the lens, as well as the constrictor
muscle of the iris, which constricts the aperture of the iris (see Fig. 4-2).
Disorders of the oculomotor nerve can be caused by central lesions that
affect the oculomotor or Edinger-Westphal nuclei such as stroke or space-
A occupying lesions such as tumor, abscess, or aneurysm. Increased intracra-
nial pressure due to subdural hematoma, sagittal sinus thrombosis, or ab-
scess can compromise the nuclei and/or the efferent fibers of the oculomotor
nerve as they exit the brainstem and travel toward the orbit, with resultant
abnormal nerve function. Traction on the oculomotor nerve due to loss of
cerebrospinal fluid has also been implicated in cranial nerve III palsy. Small
B vessel disease due to diabetes or vasculitis associated with temporal arteritis
may cause ischemia and even infarction of the oculomotor nerve with resul-
tant pathologic symptoms.
In almost all disorders of the oculomotor nerve, symptoms will take the
form of either a palsy of the extraocular muscles presenting as diplopia,
strabismus, or an inability to look upward or downward or by a ptosis of the
C eyelids (Fig. 4-4). Compromise of the visceral fibers of the oculomotor
nerve can result in anisocoria, the loss of the direct or consensual light re-
flex, and/or the loss of accommodation. Examples of these abnormalities
include the Argyll Robertson pupil most frequently associated with syphi-
lis, Adie’s pupil, and the Marcus Gunn pupil.

Suggested Readings
Brazis PW: Isolated palsies of cranial nerves III, IV, and VI, Seminars in Neurology,
29 (2009), pp 14–28.
Prasad S, Volpe NJ: Paralytic strabismus: third, fourth, and sixth nerve palsy,
Neurologic Clinics Volume 28(3):803–833, 2010 August.
Rucker JC, Rudich DS: Oculomotor nerve (cranial nerve III). In: Daroff RD, Aminoff MJ
D (eds): Encyclopedia of the Neurological Sciences, ed 2. 2014, pp 633–635.
Waldman SD: Post-dural puncture headache. In: Waldman SD (ed): Atlas of Un-
Fig. 4-4 A, B, C, D In almost all disorders of the oculomotor nerve, symptoms common Pain Syndromes, ed 3. Philadelphia, Saunders, 2015.
will take the form of either a palsy of the extraocular muscles presenting as
diplopia, strabismus, or an inability to look upward or downward or by a ptosis
of the eyelids. (From Prasad S, Volpe NJ: Paralytic strabismus: third, fourth, and
sixth nerve palsy. Neurol Clin 2010; 28[3] pp 803-833.)

5 CHAPTER

The Trochlear Nerve—Cranial Nerve IV

The trochlear nerve (cranial nerve IV) is composed of somatic general effer- of the trochlear nerve then exit the dorsal surface of the brainstem just below
ent motor fibers and is denoted by the Roman numeral IV. It innervates the the contralateral inferior colliculus, where they then curve around the brain-
superior oblique extraocular muscle of the contralateral orbit (Fig. 5-1). stem, leaving the subarachnoid space along with the oculomotor nerve (cra-
Contraction of the superior oblique extraocular muscle intorts (rotates in- nial nerve III) between the superior cerebellar and posterior cerebral arteries
ward), depresses, and abducts the globe. As outlined in Chapter 4, the (Fig. 5-2). The trochlear nerve then enters the cavernous sinus and runs an-
­superior oblique extraocular muscles work in concert with the five other teriorly along the lateral wall of the sinus with the oculomotor (cranial nerve
extraocular muscles to allow the eye to perform its essential functions of III), trigeminal (cranial nerve V), and abducens (cranial nerve VI) nerves.
tracking and fixation on objects. Exiting the cavernous sinus, the trochlear nerve enters the orbit via the
The fibers of the trochlear nerve originate from the trochlear nucleus, superior orbital fissure. Unlike the oculomotor nerve, the trochlear nerve
which is just ventral to the cerebral aqueduct in the tegmentum of the mid- does not pass through the tendinous ring of the extraocular muscles but
brain at the level of the inferior colliculus. As the trochlear nerve leaves the passes just above the ring (Fig. 5-3). The trochlear nerve then crosses medi-
trochlear nucleus, it travels dorsally, wrapping itself around the cerebral aque- ally along the roof of the orbit above the levator palpebrae and superior
duct to then decussate in the superior medullary velum. The decussated fibers rectus muscles to innervate the superior oblique muscle (see Fig. 5-2).
 Chapter 5 The Trochlear Nerve—Cranial Nerve IV 13

H
A O

V O

IV
G O

V IV. Trochlear

F T
A

IV. Trochlear nerve

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

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

Fig. 5-2 The relationship of the trochlear nerve and the superior oblique extraocular muscle. (From Smoker WRK,
Reede DL: Denervation atrophy of motor cranial nerves. Neuroimaging Clinics of North America 2008 May;
18[2]:387-411.)
14 Section 1 Anatomy

V3

OA V2

V1

III

ON IV
Fig. 5-5 Clinical examination: right fourth nerve palsy in a 65-year-old man
Fig. 5-3 The course of the trochlear nerve. (From Iaconetta G, Notaris MD with a 6-month history of vertical image separation. Note reduced downward
Galino AP: Chapter 21 - Anatomy of the Trochlear Nerve. In: Tubbs RS, Rizk E, and inward gaze of the right eye. (From Smoker WRK, Reede DL: Denervation
Shoja MM, et al [eds]. Nerves and Nerve Injuries. San Diego, Academic Press, atrophy of motor cranial nerves. Neuroimag Clin N Am 2008 May; 18[2]:
2015, pp 311-317.) 387-411.)

Superioris rectus m.
Superior oblique m.
Trochlear nerve

C
Fig. 5-4 The relationship of the terminal trochlear nerve to the orbit and ten- Fig. 5-6 A 7-year-old girl with bilateral congenital fourth nerve palsy. Brain
dinous ring of the extraocular muscles. MRI was normal. (A) Normal alignment in primary gaze. (B) Left hypertropia in
right gaze, with left inferior oblique overaction. (C) Right hypertropia in left gaze,
with right inferior oblique overaction. (From Prasad S, Volpe NJ: Paralytic strabis-
mus: third, fourth, and sixth nerve palsy. Neurol Clin 2010 Aug; 28[3]:803-833.)

Disorders of the trochlear nerve can be caused by central lesions that may note extorsion (outward rotation) of the affected eye because of the
affect the trochlear nucleus such as stroke or space-occupying lesions such unopposed action of the inferior oblique muscle (Fig. 5-6). In an effort to
as tumor, abscess, or aneurysm. Increased intracranial pressure due to sub- compensate, the patient may deviate his or her face forward and downward
dural hematoma, sagittal sinus thrombosis, or abscess can compromise the with the chin rotated toward the affected side in order to look downward.
nucleus and/or the efferent fibers of the trochlear nerve as they exit the
brainstem and travel toward the orbit, with resultant abnormal nerve func- Suggested Readings
tion. Traction on the trochlear nerve due to loss of cerebrospinal fluid has Brazis PW: Isolated palsies of cranial nerves III, IV, and VI, Seminars in Neurology
also been implicated in cranial nerve IV palsy. Small vessel disease due to 29:14-28, 2009.
diabetes or vasculitis associated with temporal arteritis may cause ischemia Iaconetta G, Notaris M: Galino, AP: Anatomy of the trochlear nerve. In: Tubbs RS,
Rizk E, Shoja MM, Loukas M, Barbaro N (eds): Nerves and Nerve Injuries, San
and even infarction of the trochlear nerve, with resultant pathologic
Diego, Academic Press, 2015, pp 311–317.
symptoms.
Prasad S, Volpe NJ: Paralytic strabismus: third, fourth, and sixth nerve palsy,
In almost all disorders of the trochlear nerve, symptoms will take the Neurologic Clinics 28:803–833, 2010 August.
form of a palsy of the superior oblique muscle, most commonly presenting Rucker JC, Rudich DS: Trochlear nerve (cranial nerve IV). In: Daroff RB, Aminoff MJ
as the inability to look inward and downward (Fig. 5-5). Often, the patient (eds): Encyclopedia of the Neurological Sciences, ed 2. 2014, pp 534–535.
will complain of the difficulty in walking down stairs because of the inabil- Waldman SD: Post-dural puncture headache. In: Waldman SD (ed): Atlas of Un-
ity to depress the affected eye or eyes. On physical examination, the clinician common Pain Syndromes, ed 3. Philadelphia, Saunders, 2015.
 Chapter 6 The Trigeminal Nerve—Cranial Nerve V 15

6 CHAPTER

The Trigeminal Nerve—Cranial Nerve V

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

V T
V3

F V. Trigeminal V1, Ophthalmic nerve

A V2, Maxillary nerve
Fig. 6-1 The trigeminal nerve is the fifth cranial nerve and is denoted by the
V3, Mandibular nerve
Roman numeral V. The trigeminal nerve has three divisions and provides sensory
innervation for the forehead and eye (ophthalmic V1), cheek (maxillary V2), and Fig. 6-2 The sensory divisions and peripheral branches of the trigeminal nerve.
lower face and jaw (mandibular V3), as well as motor innervation for the muscles (From Waldman SD: Atlas of Interventional Pain Management, ed 4. Philadelphia,
of mastication. Saunders, 2015; Fig. 16-1.)
Exploring the Variety of Random
Documents with Different Content
acusan injustamente de haber ofendido á un amigo, ven aquí, Galo,
pródigo de tu sangre y de tu vida.
Vé ahí las sombras que deben juntarse á la tuya, si todavía la
sombra de un cuerpo es alguna cosa; porque á sus cantos de amor
tú has unido los tuyos, elegante Tíbulo. ¡Que tus huesos descansen
tranquilos y á salvo en la urna! ¡Que la tierra sea lijera á tu ceniza!

NOTAS AL PIE:

[11] Instrumento músico.

 ELEGIA DÉCIMA.
ARGUMENTO.

A Céres: se lamenta de que no le sea permitido asistir á sus

misterios con su señora.
Vé aquí el aniversario de las fiestas de Céres; la jóven bella
reposa sola en su lecho no dividido. Rubia Céres, cuya fina
cabellera es coronada de espigas, ¿por qué, pues, el dia de tu
fiesta, nos privas tú el placer? Sin embargo, oh diosa, las naciones
hablan de tu munificencia, y ninguna otra divinidad es más propicia
á los mortales.
Antes de tí, los groseros habitantes de los campos no cocian pan,
y el área era un nombre desconocido entre ellos. Pero los robles,
primeros oráculos, producian la bellota: la bellota y la yerba tierna
eran todo el alimento de los mortales. Céres, la primera, les enseñó
á confiar á la tierra el grano que debia allí multiplicarse, y á segar
con la hoz las espigas doradas; la primera que forzó á los toros á
llevar el yugo, y partió, con el corvo diente del arado, la tierra largo
tiempo ociosa. ¿Quién podria creer, después de esto, que quiera ver
correr las lágrimas de los amantes, y ser honrada con sus tormentos
y su continencia? Ciertamente que para gozar la vida activa de los
campos no tiene aspereza, y su corazon no está cerrado al amor.
Tomo por testigo á los cretenses, y todo no es pura fábula en esta
Creta tan ufana por haber alimentado á Júpiter. Allí se crió el
soberano del imperio celeste: allí mamó con infantiles lábios una
leche bienhechora. Los testigos son aquí dignos de fé: su hijo de
leche es el que garantiza su veracidad, y Céres convendrá, segun
creo, en una debilidad muy conocida.
La diosa habia visto, al pié del monte Ida, al jóven Yasio, cuya
mano segura cazaba las bestias feroces. Ella lo vió, y de pronto un
fuego secreto se introdujo en sus venas delicadas. De un lado el
pudor, y de otro el amor se disputaban su corazon; el amor triunfó
del pudor. Desde entonces hubiéseis visto secarse los surcos; y la
tierra apenas dió tantos granos como se la habian confiado.
Despues de haber, con ayuda de azadas, revuelto bien sus campos,
y abierto, con la reja del arado, el regazo rebelde de la tierra;
despues de haberla en todas partes igualmente sembrado el
confiado labrador veia defraudados sus deseos.
La diosa que preside á las mieses vivia retirada en lo más espeso
de las selvas. Las coronas de espigas se habian desprendido de su
larga cabellera. La Creta sola tuvo un año fértil y cosechas
abundantes. Todos los lugares por donde la diosa habia pasado,
estaban cubiertos de mieses. La misma Ida habia visto sus bosques
llenarse de espigas amarillentas, y el feroz jabalí se alimentaba de
trigo. El legislador Minos deseó muchos años semejantes; deseó
que el amor de Céres fuese de larga duracion.
La pena que tú hubieras experimentado, rubia diosa, si te hubiese
sido preciso descansar lejos de tu amante, estoy precisado á sufrirla
en este dia consagrado á tus misterios. ¿Por qué es necesario que
esté triste, cuando tú has vuelto á encontrar á una hija, á una reina
que no es inferior á Juno más que por el capricho de la suerte? Los
dias festivos invitan á la voluptuosidad, á los cantos y á los festines:
tales son los presentes que conviene ofrecer á los dioses señores
del universo.
 ELEGIA UNDÉCIMA.
ARGUMENTO.

Cansado en fin de los numerosos desprecios de su señora, el

poeta hace aquí el juramento de no volver á amar.
Mucho y por mucho tiempo he sufrido: tu perfidia ha puesto á
prueba mi paciencia. ¡Huye de mi fatigado corazon, vergonzoso
amor! Esto es hecho, me he sustraido al yugo, y he quebrantado mis
cadenas: estos hierros que llevé sin vergüenza, tengo vergüenza al
presente de haberlos llevado. Triunfo y pisoteo al Amor vencido. Es
muy tarde, es verdad, que el bochorno me sube á la cara. ¡Vamos,
valor y energía! Estos males tendrán un dia su recompensa. Los
enfermos han debido frecuentemente su curacion á los venenos
más amargos.
¡Qué! ¡yo he podido, yo, despues de tantas humillaciones,
olvidarme hasta el punto de dormir en el suelo de tu puerta! ¡Qué!
¡yo he podido, yo, para no sé cuál amante que tú estrechabas entre
tus brazos, hacerme, como un esclavo, el guardian de la casa que
me estaba cerrada! Yo mismo lo he visto salir fatigado de tu casa,
con el paso de un veterano gastado por el servicio. Aun he sufrido
menos de verlo que de ser visto. ¡Ojalá semejante afrenta sea
reservada para mis enemigos!
¿Cuándo has paseado tú sin encontrarme á tu lado, á mí, tu
guardian, á mí, tu amante, á mí, tu inseparable compañero? mucho
agradabas á las gentes, acompañada por mí; y mi amor te ha valido
buen número de amantes. ¿Por qué recordaré los vergonzosos
engaños de tu mentirosa lengua, y los dioses testigos de tantos
juramentos violados para perderme? ¿Por qué diré aquellas señas
de inteligencia, dirigidas durante la corrida, á jóvenes amantes, y
aquellos términos convencionales para disfrazar el sentido de
nuestras palabras? Un dia se me dijo que ella estaba enferma: yo
corro á su casa enteramente perdido, enteramente fuera de mí; llego
y no estaba enferma para mi rival.
 Vé ahí, sin hablar de otras muchas, las afrentas que he tenido que
sufrir frecuentemente. Busca hoy dia otro que pueda soportarlas en
mi lugar. Ya mi popa, adornada de una corona votiva, vé, sin
conmoverse, el fracaso de las olas que se levantan tras ella. Basta
de caricias y de palabras otras veces poderosas: es trabajo perdido:
no soy tan loco como lo fuí. Siento luchar en mi corazon, muy lijero y
diversamente agitado, el amor á la vez y el ódio: y si no me engaño
es el amor quien le enoja. Yo aborreceré, si puedo; si no yo amaré
únicamente mi defendido cuerpo. El toro tampoco ama el yugo: lo
aborrece y sin embargo lo lleva.
Huyo de su perfidia: su belleza es la que vuelve mis pasos hácia
atrás. Aborrezco los vicios de su alma; amo los hechizos de su
cuerpo. Así yo no puedo vivir ni sin tí, ni contigo; y yo mismo no sé
lo que deseo. Yo querria que tú fueses ó menos bella ó menos
pérfida. Tantos hechizos se aunan mal con tanta perversidad. Tu
conducta escita el ódio, tu belleza encomienda al amor.
¡Desgraciado soy! sus atractivos pueden más que sus defectos.
Perdóname, yo te conjuro por los derechos de aquella cama que
nos fué comun, por todos los dioses (¡pudiesen frecuentemente
dejarse engañar por tí!), por tu semblante que adoro como una
divinidad poderosa, por tus ojos que han cautivado los mios: como
sea, siempre serás mi amiga. Escoje solamente si quieres que te
ame por gusto ó por fuerza. ¡Ah! despleguemos cuanto antes las
velas y aprovechemos los vientos favorables; porque á pesar de mis
esfuerzos, no me veria yo menos obligado á amar.
 ELEGIA DUODÉCIMA.
ARGUMENTO.

Siente que sus escritos hayan dado demasiado á conocer á su

bella.
Decidme, lúgubres aves, ¿qué dia fué aquel en que no me
augurásteis sino amores desgraciados? ¿Qué astro supondré sea
hostil á mis deseos? ¿Qué dioses debo acusar de hacerme la
guerra? Aquella que no há mucho se llamaba toda mia; aquella de
quien fuí el primero y solo amante, temo no poseerla sino con mil
rivales.
¿Me engañé? ¿O es que mis escritos no la han hecho demasiado
conocer? Ella era toda mia; mi genio poético ha hecho de ella una
cortesana. Y yo lo he merecido: ¿tenia yo necesidad, en efecto, de
preconizar su belleza? si ella se vende hoy, la falta es mia. Por mi
mediacion ella agrada: soy yo quien le trae amantes; mis propias
manos le abren la puerta. ¿Son útiles los versos? esta es una
cuestion: ciertamente ellos me han sido siempre funestos; son los
que han atraido sobre mi tesoro las miradas de la envidia.
Cuando yo podia cantar á Thebas, Troya ó los altos hechos de
César, solo Corina encendió mi genio. ¡Ojalá las Musas hubiesen
sido rebeldes á mis primeros esfuerzos, y Febo me hubiese
abandonado en medio de mi carrera! Y sin embargo, como es
costumbre tomar por testigos á los poetas, que hubiese preferido
que la medida hubiera faltado á mis versos.
Nosotros somos los que hemos mostrado á Scyla, arrancando á
su anciano padre el cabello fatal, condenada á ver salir de sus
entrañas perros furiosos. Somos nosotros quienes hemos puesto
alas á los piés, y dado serpientes á la cabellera. A nosotros debe el
victorioso pequeño hijo de Abas el hendir los aires sobre un caballo
alado. Nosotros hemos dado á Tityo su prodigiosa grandeza, y á
Cerbero sus tres bocas y su crin de serpientes. Encélada ha recibido
de nosotros mil brazos para lanzar sus dardos, y por nosotros un
jóven májico somete los héroes á sus encantamientos. Nosotros
hemos cerrado los vientos eólicos en los odres del rey de Itaca;
gracias á nosotros el indiscreto Tántalo padece sed en el seno
mismo de las aguas; Nicole se cámbia en peñasco, y una jóven
vírgen en osa; gracias á nosotros el ave de Cécrops canta el
Odrysio Itys; Júpiter se transforma en ave ó en oro; ó, convertido en
toro, hiende las ondas, llevando sobre su espinazo una vírgen
tímida. ¿A qué recordar no solo á Protea, sino aquellos dientes de
donde nacieron los Tebanos? ¿Diré que fué de los toros que
vomitaban llamas? ¿ó que lágrimas de ámbar corrieron de los ojos
de tus hermanas, desgraciado Faeton? ¿que embarcaciones han
sido cambiadas en diosas del mar? ¿que el sol retrocedió de horror,
por miedo de alumbrar el horrible festín de Atrea? ¿que los más
duros peñascos fueron sensibles á los acordes de una lira?
El vuelo del fecundo genio de los poetas no conoce límites; no se
sujeta á la fidelidad de la historia. Tambien se hubieran debido mirar
como falsas las alabanzas que daba á mi señora: vuestra credulidad
es hoy dia la causa de mi desdicha.
 ELEGÍA DÉCIMOTERCIA.
ARGUMENTO.

Fiesta de Juno.
Siendo mi mujer originaria del fértil pais de los Faliscos, hemos
visto aquellos muros en otro tiempo vencidos por tí, ilustre Camilo.
Las sacerdotisas de la casta Juno se disponian á celebrar su fiesta
con juegos solemnes y con el sacrificio de una vaquilla indígena.
Poderoso motivo para mí de detenerme; yo queria ver aquella
ceremonia, aunque no se llega al lugar en que se hace, más que por
un camino montuoso y difícil.
Es un antiguo bosque sagrado, cuya espesura le hace
impenetrable al dia; no es menester más que verle para reconocer
que una divinidad reside allí. Un altar recibia las súplicas y el
incienso ofrecido por la piedad, un altar hecho sin arte por las
manos de nuestros antepasados. Allí es de donde á los primeros
acentos de la trompeta cada año el cortejo de Juno parte y avanza
por los caminos tapizados. Conduce, en medio de los aplausos del
pueblo, blancas vaquillas alimentadas con los crasos pastos de
Falisca, jóvenes becerros cuya frente no está aun armada ni
amenazante, el humilde puerco, víctima más modesta, y el jefe del
rebaño con la cabeza dura y adornada de cuernos encorvados. Solo
la cabra es odiosa á la potente diosa, despues que en un bosque
espeso descubrió la presencia de Juno, y la obligó á detenerse en
su huida. Además los niños, hoy dia aun, persiguen con sus flechas
á la cabra indiscreta, y el primero que la ha herido la obtiene en
premio de su destreza.
En todas partes por que la diosa debe pasar, tiernos muchachos y
vírgenes tímidas cubren de tapiz los verdes caminos. El oro y las
pedrerías brillan en los cabellos de las jóvenes, y una ropa
magnífica desciende hasta caer sobre sus piés donde brilla el oro. A
la manera de los griegos, sus padres, marchan vestidas de blanco, y
llevan sobre su cabeza los objetos del culto confiados á sus
cuidados. El pueblo guarda silencio durante la marcha del brillante
cortejo. En fin, á continuacion de las sacerdotisas aparece la misma
diosa.
La fisonomía de este espectáculo es enteramente griega.
Despues del asesinato de Agamemnon, Haleso no pensó más que
en huir del teatro del crímen y de los ricos dominios de sus padres.
Despues de arriesgadas carreras por tierra y por mar, edificó, bajo
felices auspicios, una ciudad rodeada de altas murallas. De él han
aprendido los Faliscos á celebrar las fiestas de Juno. ¡Que ellas me
sean siempre favorables! ¡que ellas lo sean siempre á su pueblo!
 ELEGIA DÉCIMOCUARTA.
ARGUMENTO.

A su señora.
Yo no te prohibo, bella como eres, tener algunas debilidades; lo
que yo no quiero, es el dolor y la necesidad para mí de saberlas. No,
yo no exijo censor rígido, que seas casta y púdica; lo que yo te pido
es que procures parecerlo. No es culpable la que puede negar el
hecho que se le imputa; la confesion que hace es la que la
deshonra. ¿Qué manía es esa, de revelar cada mañana los secretos
de la noche, y proclamar á la luz del dia lo que no haces más que en
la sombra?
La cortesana antes de abandonarse al primero que llega, tiene
cuidado de poner entre ella y el público una puerta bien cerrada. ¡Y
tú, tú divulgas en todas partes tus vergonzosos extravíos, orgullosa
de ser á la vez la delatora y la culpable! Sé en adelante más casta, ó
al menos imita á las mujeres púdicas. Que yo te crea honesta
aunque no lo seas. Culpable ayer, sé culpable hoy; pero no lo
confieses, y no te avergüences en público de hablar un lenguaje
modesto.
Un apartado retiro provoca el desarreglo; que sea el solo teatro de
todos tus placeres, desterrado de allí el pudor. Pero desde que
salgas, no conserves nada de la cortesana, y en tu lecho queden
sepultados tus crímenes. Allí, no te ruborices de quitarle la túnica y
sostener otro muslo apoyado sobre el tuyo. Allí, recibe hasta el
fondo de tu encarnada boca una lengua amorosa, y que para tí el
amor invente mil especies de voluptuosidades. Allí ninguna tregua á
los dulces coloquios, á las palabras halagüeñas, y que tu cama cruja
con los vivos apretones del placer. Toma en seguida, con tus
vestidos, la modesta postura de una virgen tímida, y que el pudor de
tu frente niegue la lascivia de tu conducta. Engaña al público,
engáñame; pero permite al menos que yo lo ignore, y déjame gozar
de mi tonta credulidad.
 ¿Por qué delante de mí, tantos billetes enviados y recibidos? ¿Por
qué tu lecho está batanado á la vez por todos lados? ¿Por qué veo
sobre tus hombros tus cabellos en un desórden que no ha causado
el sueño, y sobre tu cuello la marca de un diente? No te falta más
que hacerme testigo ocular de tu vida licenciosa. ¡Oh! si tú te cuidas
poco de atender á tu reputacion, cuídate de mí al menos. Mi alma
me abandona, y me siento morir todas las veces que tú te
reconoces culpable; y en mis venas corre una sangre helada.
Entonces amo, entonces me esfuerzo en vano en aborrecer lo que
me veo forzado á amar; entonces yo quisiera morir, pero contigo.
No haré yo ninguna averiguacion; no insistiré, desde que te vea
pronta á negar: tu denegacion solo equivaldrá á inocencia. Si no
obstante llegara yo á sorprenderte en flagrante delito, si mis ojos
hubieran de ser un dia testigos de tu vergüenza, lo que yo hubiera
visto demasiado bien, niega que lo haya visto, y mis ojos tendrán
menos autoridad que tus palabras. Así te será fácil vencer á un
enemigo que no pide más que ser vencido. Que solamente tu
lengua se acuerde de decir: «No soy culpable.» Cuando puedes tan
fácilmente triunfar con estas dos palabras, triunfa, si no por la
bondad de tu causa, al menos por la indulgencia de tu juez.
 ELEGÍA DÉCIMOQUINTA.
ARGUMENTO.

Dice adios á su Musa lasciva, para seguir otra más severa.

Busca un nuevo poeta, madre de los tiernos Amores; yo no tengo
más que tocar la meta de mi carrera elegíaca. Estos cantos que he
compuesto, yo, hijo de los campos pelignos, han hecho mis delicias
y mi nombradía. Si este honor es alguna cosa, yo he heredado, del
primero como del último de mis antepasados, el título de caballero, y
no lo debo al tumulto de las armas. Mántua está envanecido de
Virgilio, Verona de Catulo: se me llamará á mí, la gloria del pueblo
Peligno, de este pueblo cuyo amor por la libertad le impuso el santo
deber de combatir, en la época en que Roma inquieta tembló
delante de las armas reunidas para su ruina. Un dia, viendo la
pantanosa Sulmona encerrada en el estrecho circuito de sus muros,
el viajero exclamará: «Villa que has sido cuna de tal poeta, tan
pequeña como eres, te proclamo grande.»
Amable niño, y tú, Vénus, madre de este amable niño, arrancad
de mi campo vuestros dorados estandartes. El dios cuya frente está
armada de cuernos, Baco, agitando cerca de mí su temible tirso, me
apresura á lanzar los corceles vigorosos en una más vasta carrera.
Vosotras, delicadas elegías, y tú, Musa lijera, adios: mi obra me
sobrevivirá.

FIN.
 ÍNDICE DE ESTA OBRA.

Págs.
Los traductores. 7
LIBRO I.
Elegía 1.ª—Argumento.—Por qué el poeta pasa de los versos heróicos 11
á los eróticos.
Elegía 2.ª—Argumento.—Descríbese el triunfo del amor. 13
Elegía 3.ª—Argumento.—Se recomienda á su querida por las 16
excelencias de la poesía, la pureza de sus costumbres y la fidelidad á
toda prueba que ofrece.
Elegía 4.ª—Argumento.—Antes de cenar con su querida le indica las 17
señas con que podrán manifestarse su mutuo amor á presencia del
marido.
Elegía 5.ª—Argumento.—Alégrase de haber poseido á su amiga. 21
Elegía 6.ª—Argumento.—Imprecaciones contra el portero que 22
rehusaba abrirle la puerta.
Elegía 7.ª—Argumento.—Contra sí mismo por haberle pegado á su 26
querida.
Elegía 8.ª—Argumento.—Contra una alcahueta que intentaba enseñar 30
á la querida del poeta las artes de la prostitucion.
Elegía 9.ª—Argumento.—Gracioso paralelo entre la guerra y el amor. 36
Elegía 10.—Argumento.—A una jóven para apartarla de la prostitucion. 39
Elegía 11.—Argumento.—Suplica á Nape lleve un billete amoroso á 43
Corina.
Elegía 12.—Argumento.—Maldice las tabletas portadoras de la 45
respuesta negativa de su dama.
Elegía 13.—Argumento.—A la Aurora, para que no acelere demasiado 46
su marcha.
Elegía 14.—Argumento.—A una muchacha vuelta calva de repente. 49
Elegía 15.—Argumento.—Contra los adversarios de la poesía. 53
LIBRO II.
Elegía 1.ª—Argumento.—Por qué en lugar de la jigantomaquia que 56
tenia comenzada, canta sus amores.
Elegía 2.ª—Argumento.—Al eunuco Bagoas, para que le procure fácil 59
acceso junto á la belleza confiada á su guarda.
Elegía 3.ª—Argumento.—Al mismo que se mostraba inflexible. 63
Elegía 4.ª—Argumento.—Su inclinacion al amor; por qué todas las 64
bellas, sin distincion, le agradaban.
Elegía 5.ª—Argumento.—Dirige reproches á su señora, quien á su vista 67
mientras fingía dormir, habia dado á otro convidado señales
inequívocas de su amor.
Elegía 6.ª—Argumento.—Deplora la muerte del papagayo que habia 71
regalado á su señora.
Elegía 7.ª—Argumento.—A Corina: niega haber tenido jamás ningun 75
comercio con Cipasis.
Elegía 8.ª—Argumento.—A Cipasis le pregunta cómo Corina ha podido 77
saber el secreto de sus amores.
Elegía 9.ª—Argumento.—A Cupido: le exhorta para que no gaste todas 79
sus flechas contra él solo.
Elegía 10.—Argumento.—A Grecino: se puede muy bien, dígase como 82
se quiera, amar á dos mujeres á la vez.
Elegía 11.—Argumento.—Trata de disuadir á Corina de su proyecto de 84
ir á las bayas de Campania.
Elegía 12.—Argumento.—Se goza por fin de haber obtenido los favores 88
de Corina.
Elegía 13.—Argumento.—A Isis: le pide proteja la preñez de Corina. 90
Elegía 14.—Argumento.—A Corina: aprovecha su restablecimiento 92
para exponerle más libremente la gravedad de su falta.
Elegía 15.—Argumento.—Al anillo que él habia enviado como presente 95
á su señora.
Elegía 16.—Argumento.—A Corina induciéndola á que vaya á su casa 97
de campo de Sulmona.
Elegía 17.—Argumento.—Se compadece de Corina, demasiado 100
engreida de su belleza.
Elegía 18.—Argumento.—A Macer: Se justifica de entregarse 102
enteramente á cantos eróticos.
Elegía 19.—Argumento.—A un hombre cuya mujer amaba. 104
LIBRO III.
Elegía 1.ª—Argumento.—La Tragedia y la Elegía se disputan la 109
posesion de Ovidio.
Elegía 2.ª—Argumento.—Los juegos del Circo. 113
Elegía 3.ª—Argumento.—A su amiga, que habia faltado á sus 118
juramentos.
Elegía 4.ª—Argumento.—Exhorta á un marido á no hacer vigilar tan 121
severamente á su mujer.
Elegía 5.ª—Argumento.—Sueño. 124
Elegía 6.ª—Argumento.—A un rio que crecia de repente de una 127
manera prodigiosa, y se oponia al paso del poeta, ansioso de llegar
cerca de su señora.
Elegía 7.ª—Argumento.—Contra él mismo por haber caido en falta con 133
su querida.
Elegía 8.ª—Argumento.—A su señora que habia preferido un amante 138
más rico que Ovidio.
Elegía 9.ª—Argumento.—Sobre la muerte de Tíbulo. 142
Elegía 10.—Argumento.—A Céres: se lamenta de que no le sea 146
permitido asistir á sus misterios con su señora.
Elegía 11.—Argumento.—Cansado en fin de los numerosos desprecios 149
de su señora, el poeta hace aquí el juramento de no volver á amar.
Elegía 12.—Argumento.—Siente que sus escritos hayan dado 152
demasiado á conocer á su bella.
Elegía 13.—Argumento.—Fiesta de Juno. 155
Elegía 14.—Argumento.—A su señora. 157
Elegía 15.—Argumento.—Dice adios á su Musa lasciva, para seguir 160
otra más severa.
 *** END OF THE PROJECT GUTENBERG EBOOK AMORES:
ELEGÍAS AMATORIAS ***

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