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These functions are tested in detail if the patient s history or behavior during the general examination has provided a reason to suspect some defect Questions should then be directed toward determining the patient s orientation in time and place and insight into his current medical problem Attention, speed of response, ability to give relevant answers to simple questions, and the capacity for sustained and coherent mental effort all lend themselves to straightforward observation Useful bedside tests of attention, concentration, memory, and clarity of thinking include the repetition of a series of digits in forward and reverse order, serial subtraction of 3s or 7s from 100, recall of three items of information or a short story after an interval of 3 min, and naming the last six presidents or prime ministers The patient s account of his recent illness, medical consultations, dates of hospitalization, and his dayto-day recollection of medical procedures, meals, and other incidents are excellent tests of memory; the narration of the illness and the patient s choice of words (vocabulary) provide information about his intelligence and coherence of thinking Many other tests can be devised for the same purpose Often the examiner can obtain a better idea of the clarity of the patient s sensorium and soundness of intellect by using these few tests and noting the manner in which he deals with them than by relying on the score of a formal intelligence test If there is any suggestion of a speech or language disorder, the nature of the patient s spontaneous speech should be noted In addition, his ability to read, write, and spell, execute spoken commands, repeat words and phrases spoken by the examiner, name objects and parts of objects, and solve simple arithmetical problems should be assessed The ability to carry out commanded tasks (praxis) has great salience in the evaluation of several aspects of cortical function Bisecting a line, drawing a clock or the oor plan of one s home or a map of one s country, and copying gures are useful tests of visuospatial perception and are indicated in cases of suspected cerebral disease The testing of language, cognition, and other aspects of higher cerebral function are considered in Chaps 21, 22, and 23.

Numerous guides to the examination of the nervous system are available (see the references at the end of this chapter) For a full account of the methods, the reader is referred to the monographs of DeMyer, Ross, Mancall, Bickerstaff and Spillane, Glick, Haerer, and of the staff members of the Mayo Clinic, each of which approaches the subject from a somewhat different point of view An inordinately large number of tests of neurologic function have been devised, and it is not proposed to review all of them here Some are described in subsequent chapters dealing with disorders of mentation, cranial nerves, and motor, sensory, and autonomic functions Many tests are of doubtful value or are repetitions of simpler tests and should therefore not be taught to students of neurology Merely to perform all of them on one patient would require several hours and probably, in most instances, would not make the examiner any the wiser The danger with all clinical tests is to regard them as indisputable indicators of disease rather than as ways of uncovering disordered functioning of the nervous system The fol-

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Satisfactory postoperative analgesia is usually achieved with acetaminophen alone, although some patients required narcotics Nonsteroidal anti-in ammatory agents and aspirin must be avoided for at least 3 to 4 days after surgery to diminish bleeding risks Application of ice compresses often provides additional comfort

The function of the cranial nerves must be investigated more fully in patients who have neurologic symptoms than in those who do not If one suspects a lesion in the anterior fossa, the sense of smell should be tested in each nostril; then it should be determined whether odors can be discriminated Visual elds should be outlined by confrontation testing, in some cases by testing each eye separately; if any abnormality is suspected, it should be checked on a perimeter and scotomas sought on the tangent screen or, more accurately, by computed perimetry Pupil size and reactivity to light and accommodation during convergence, the position of the eyelids, and the range of ocular movements should next be observed Details of these test procedures and their interpretation are given in Chaps 12, 13, and 14 Sensation over the face is tested with a pin and wisp of cotton; also, the presence or absence of the corneal re exes may be determined Facial movements should be observed as the patient speaks

When the N-type material is negative with respect to the P-type, as in Fig 19-4A, electrons flow easily from N to P The N-type semiconductor, which already has an excess of electrons, gets even more; the P-type semiconductor, with a shortage of

Figure 4-3 Schematic illustration of major efferent and afferent connections of the basal ganglia (see text for details; also Fig 4-2) (Reproduced with permission from Kandel ER, Schwartz JH, Jessell TM: Principles of Neural Science, 4th ed New York: McGraw-Hill, 2000)

time was the central role of the ventrolateral and ventroanterior nuclei of the thalamus Together, they form a vital link in an ascending ber system, not only from the basal ganglia but also from the cerebellum to the motor and premotor cortex Thus both basal ganglionic and cerebellar in uences are brought to bear, via thalamocortical bers, on the corticospinal system and on other descending pathways from the cortex Direct descending pathways from the basal ganglia to the spinal cord are relatively insigni cant The foregoing view of basal ganglionic organization has been broadened considerably, the result of new anatomic, physiologic, and pharmacologic data (see in particular the reviews of Gombart, of Crutcher, of DeLong, and of Penney and Young) Whereas earlier concepts emphasized the serial connectivity of the basal

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battery B, resistor R, milliammeter mA, and diode D At A, forward bias results in current flow; at B, reverse bias results in no current

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