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Are multiplication facts imple mented by the left supramarginal and angular gyri Cognitive and praxic de cits in a large family with a genetically transmitted speech and language disorder medications every 8 hours discount 5 mg procyclidine amex. Differential effects of early hippocampal pathology on episodic and semantic memory 5 medications related to the lymphatic system discount 5 mg procyclidine with visa. Knowledge of new English vocabulary in amnesia: An examination of premorbidly acquired semantic memory 9 medications that can cause heartburn discount procyclidine 5 mg otc. Decreased striatal dopamine responsiveness in detoxi ed cocaine-dependent subjects treatment naive generic procyclidine 5mg visa. Testing memory for unseen visual stimuli in patients with extinction and spatial neglect. Attention as inference: Selection is probabilistic; responses are all-or-none samples. Material-speci c lateralization of prefrontal activation during episodic encoding and retrieval. Building memories: Remembering and forgetting of verbal experiences as predicted by brain activity. Cortical plasticity in perceptual learning demonstrated by transcranial magnetic stimulation. Task-induced impairments and enhancements induced by magnetic stimulation of human area V5. The role of semantics in reading and spelling: Evidence for the ‘Summation Hypothesis’. Visual object recognition in patients with right hemisphere lesions: Axes or features Seizures in healthy people with repeated “safe” trains of transcranial magnetic stimulation. Behavioral changes associated with ablations of the amygda loid complex in monkeys. Temporally graded semantic memory loss in amnesia and semantic dementia: Further evidence for opposite gradients. Toward a theory of episodic memory: the frontal lobes and autonoetic consciousness. A history of the brain: How we have come to understand the most complex object in the universe. Both of us disgusted in my insula: the common neural basis of seeing and feeling disgust. The role of the left anterior temporal lobe in exception word reading: Reconciling patient and neuroimaging ndings. Beliefs about beliefs: Representation and the constraining function of wrong beliefs in young children’s understanding of deception. Memory formation and long-term retention in humans and animals: Convergence towards a transformation account of hippocampal-neocortical interactions. Memory consolidation or trans formation: context manipulation and hippocampal representations of memory. Integrated neural representations of odor intensity and affective valence in human amygdala. Common and distinct neural responses during direct and incidental processing of multiple facial emotions. Action generation and action perception in imitation: An instance of the ideomotor principle. Managing incidental ndings in human subjects research: Analysis and recommendations. Fluid intelligence loss linked to restricted regions of damage within frontal and parietal cortex. Proceedings of the National Academy of Sciences of the United States of America, 107(33), 14899–14902. Anticipatory biasing of visuospatial attention indexed by retinotopically speci c alpha-band electroencephal ography increases over occipital cortex. Differential effects of distraction during working memory on delay-period activity in the prefrontal cortex and the visual association cortex. Functional organisation of a visual area in the posterior bank of the superior temporal sulcus of the rhesus monkey. Colour coding in the cerebral cortex: the reaction of cells in monkey visual cortex to wavelengths and colours. Going beyond the information given: the relation of illusory visual motion to brain activity. The spatial representation of numerical and non-numerical sequences: Evidence from neglect. The locus of the effects of sentential-semantic context in spoken word processing. First published 1988 Four Dragons edition 1993 Reprinted 1989, 1992 Reprinted 1994, 1997, 1998 Four Dragons edition 1989 Third edition 1999 Reprinted 1992 Reprinted 2000, 2001, 2002, 2004 Second edition 1993 Fourth edition 2005 Reprinted 1994, 1995, 1996 Library of Congress Cataloging-in-Publication Data Wilkinson, I. Furthermore, the publisher ensures that the text paper and cover board used have met acceptable environmental accreditation standards. Contents Preface to the fourth edition, vii Preface to the rst edition, viii Acknowledgements, ix Abbreviations, x 1 Clinical skills, physical signs and anatomy, 1 2 Stroke, 25 3 Brain tumour, 40 4 Head injury, 55 5 Parkinsonism, involuntary movements and ataxia, 67 6 Paraplegia, 83 7 Multiple sclerosis, 99 8 Cranial nerve disorders, 111 9 Nerve root, nerve plexus and peripheral nerve lesions, 137 10 Motor neurone disease, peripheral neuropathy, myasthenia gravis and muscle disease, 155 11 Unconsciousness, 175 12 Epilepsy, 192 13 Headache and facial pain, 213 14 Dementia, 224 15 Infections of the nervous system, 238 Answers to case histories, 255 Index, 269 v Preface to the fourth edition the three previous editions of this book were written by only one of us. The addition of a younger and enthusiastic second au thor has undoubtedly improved the book. Both authors have been single minded in their intention to present, clearly and concisely, that neurology and neurosurgery which is required by medical students at the time of graduation. The revision of diagrams, use of colour, clari cation of text, and inclusion of illustrative case histories have all helped, but it is the authors’ discipline to adhere closely to the title of the book, Essential Neurology, which makes them hope that the textbook remains helpful to its readers. In writing this textbook, I have been preoccupied with the following questions: • Have I kept to basic principles There is no section in the book speci cally dedicated to ‘How to examine the nervous system’. I believe each student has to learn this by apprenticeship to clinical neurologists in the ward and in the clinic. Every effort has been made to ensure that this book lives up to its name, in setting out clearly all that the student needs to know about the common neurological and neurosurgical conditions. At the end of the chapter are a few brief case histories, given to illustrate the principles which are outlined above and itemized in detail throughout the chapter. Our response to a patient telling us that his left leg isn’t work ing properly must not just consist of the methodical asking of many questions, and the ritualistic performance of a complex, totally inclusive, neurological examination, hoping that the diagnosis will automatically fall out at the end. Nor must our re sponse be a cursory questioning and non-focused examination, followed by the performance of a large battery of highly sophis ticated imaging and neurophysiological tests, hoping that they will pinpoint the problem and trigger a management plan. No, our response should be to listen and think, question and think, examine and think, all the time trying to match what the patient is telling us, and the physical signs that we are elicit ing, with the common patterns of neurological malfunction described in this chapter. If the patient mentions wasting, our ideas will possibly start to concentrate on lower motor neurone trouble. We will learn that if he says it’s stiff, our thoughts will move to the possibility of an upper motor neurone or extrapyra midal lesion. If he can’t feel the temperature of the bath water properly with the other (right) leg, it is clear that we should start to think of spinal cord disease. We will ask the patient to use as many adjectives as he can to describe the problem. Very important indeed in neurological diagnosis is detail of the mode of onset of the patient’s symptoms. Let’s say the left leg is not working properly because of a lesion in the right cerebral hemisphere. This same neurological de cit will be present whatever the nature of the pathology at this site. If this part of the brain isn’t working there is an inevitability about the nature of the neurological de cit. It is the history of the mode of evolution of the neurological de cit which indicates the nature of the pathology (Fig. Components of the nervous system required for normal function; their anatomy; physical signs indicating the presence of a lesion in each component; and the common patterns in which things go wrong the basic components of the nervous system required for normal movement are shown on the simple diagram below. Normal basal ganglia, cerebellar and sensory function is es sential background activity of the nervous system for normal movement. Lesions in these parts of the nervous system do not produce weakness or paralysis, but make movement imperfect because of stiffness, slowness, involuntary movement, clumsi ness or lack of adequate feeling.

In their model treatment of scabies order 5 mg procyclidine free shipping, the dorsal posterior-anterior gradient is linked speci cally to treatment xanax withdrawal discount 5 mg procyclidine overnight delivery action planning (perhaps by virtue of connectivity to treatment 5th metatarsal base fracture procyclidine 5 mg otc the parietal lobes) symptoms early pregnancy buy procyclidine 5mg low cost, whereas the ventral posterior-anterior gradient is linked to, among others, language and objects (perhaps by virtue of connectivity to the temporal lobes). They suggest that its speci c role is to act as a “gateway” between stimulus-driven cognition. Patients with lesions limited to the frontal poles are impaired on tasks of multi-tasking and on tasks of social cognition (theory-of-mind, under Monitoring the process of relating standing Faux pas) but perform well on many other tests of executive function information currently held (Roca et al. It is also less apparent in the functional imaging data of humans (Duncan & Owen, 2000). Even here, it is to be noted, that the dissociations tend to be relative rather than absolute: i. That is, “classical” dissociations tend not to be observed (to use the terminology of Shallice, 1988). This may also explain why the functional imaging data is not so clear-cut in this regard; i. One of the main models regarding hemispheric specializations of executive function originates from Stuss and colleagues (Stuss et al. As noted previously, these problem-solving tasks tend to be more impaired after damage to the left frontal lobe irrespective of whether the stimuli are verbal. Task monitoring is linked to the notion of sustained attention and involves keeping “on task” and maintaining the currently relevant rules. However, a left-right hemispheric dissociation is found for different versions of administering it. In the standard version, the participant is given no information about the three rules or when they will change. In a modi ed version, the patient is told of the rules, is given a starting rule (sort by color) and is told when the rules will change (after every 10 trials). In the standard/open-ended version, the performance limitations may stem primarily from task setting (taxing the left hemisphere more), whereas in the more constrained version performance limitations may come from monitoring the current rule (taxing the right hemisphere more). Patients with both left and right prefrontal lesions are impaired at task switching but for different reasons (Aron et al. The rules can change unexpectedly, and the rules themselves are more abstract than in the Wisconsin Card Sorting Test. Patients with left lateral prefrontal lesions were impaired at inducing the rules, and that this dif culty was found irrespective of whether they had a working memory impairment (as assessed by their memory of successive spatial positions). In a second phase of the experiment, the sequence of blue circles was interspersed with sequences of red circles that followed a different rule. Patients with right lateral pre frontal lesions (and those with anterior cingulate lesions) failed to revert back to the blue rule after the interfering red sequence, despite being instructed to do so. It suggests that this region will be recruited more when the task parameters are not strongly constrained. For instance, this region is activated more when Patients are shown a sequence of cards containing ten numbered circles. In this example, the rule shifts from +1 to alternation (between circles 1 and 6). The region is also active when participants are free to select when to make a response (Jahanshahi et al. There is a tendency, particularly under time pressure, for randomness to break down and participants start generating familiar sequences from memory, such as consecutive runs (4, 5, 6; X, Y, Z) or stored knowledge. The previous responses were displayed on a monitor so they need not be held in mind. Monitoring is the process of relating inform ation currently held in mind back to the task Activity in the left dorsolateral prefrontal cortex (a) is associated requirements. When responses ascertain whether retrieved or perceived inform are required at a fast rate, the activity decreases and the ation is valid. The region may be important both responses start to deviate substantially from randomness. As such, it appears as if the region is related more to monitoring and attending than to memory or perception per se. An alternative view of the function of the right (inferior) lateral prefrontal cortex is that it functionally specialized for response inhibition (Aron et al. The inhibition explanation is not straightforward to separate from the monitoring account as a failure to monitor adequately would tend to lead to the automatic “go” response on No-Go trials. Evaluation Although contemporary models of executive function retain their earlier character. The notion of a general workspace that is essentially undifferentiated in character is not supported by the weight of evidence. The Multiple Demand Network (Duncan, 2010) is also largely an undifferentiated workspace, but it is certainly not to be considered synonymous with the entire prefrontal cortex (but rather the mid-lateral regions and certain parietal regions). Although we could conceptualize, from rst principles, that a diverse range of tasks such as the Stroop, multi-tasking, and reversal learning all require the same kind of control mechanism. The distinction between cognitive versus affective control is well-supported empirically and suggests a division according to the type of information processed. There is some evidence of a posterior-anterior difference in prefrontal functioning that depends on whether single or multiple tasks are being simultaneously performed (and possibly ner gradients within that). The next section will consider in more detail another region, not strictly part of the prefrontal cortex, but strongly connected to it and implicated in other aspects of executive function: namely the anterior cingulate cortex. A more dorsal region is termed the “cognitive division” and may be related to executive functions. This may explain why these regions tend to be activated together in functional imaging studies. A more rostral “affective division” is connected with limbic and orbitofrontal regions. The remainder of this section will focus on the cognitive/executive region of the anterior cingulate, and further use of the term “anterior cingulate” in this chapter will be used to refer to this region unless stated otherwise. One postulated role of the anterior cingulate in executive functions is in the detection of errors (Carter et al. In human reaction time experiments, the trial immediately after an error (error + 1) tends to be slower and more accurate than after a correct trial (correct + 1) (Rabbitt, 1966). This implies the existence of some cognitive mechanism that monitors for errors and recalibrates task performance accordingly. In macaque monkeys with anterior cingulate lesions, errors are more likely on “error + 1” trials than “correct + 1” trials (Rushworth et al. This suggests that no such adjustment is made following errorful behavior, and errors are more likely to follow errors. This response is called an error-related negativity and its onset is simultaneous with the error being made and peaks around 100 ms after the response (Gehring et al. The studies cited above are ambiguous as to whether the anterior cingulate is important just for the detection of the error, or also for the subsequent compensatory behavior. This suggests that the anterior cingulate’s role is limited to error detection and not compensation, and the lateral prefrontal cortex is responsible for adjusting ongoing behavior. Patients with lesions in this region the anterior cingulate cortex lies above the corpus callosum on perform poorly on the task (Alexander et al. As such, one more general account of anterior cingu late functioning is that it generates a con ict signal both in situations of likely error as well as after an actual error. An alternative way of conceptualising the role of the anterior cingulate is that it is involved in motivation (Kouneiher et al. Errors are motivationally salient events (that people work to avoid) as are rewards and punishments. Within these blocks, there were either regular trials or “bonus trials” in which an even higher payoff could be obtained. High-incentive blocks were linked to greater sustained activity of the anterior cingulate. The role of executive functions is typically described as “supervisory” or “controlling. Patients with lesions here may have dif culties in problem solving, overcoming habitual responses, multi-tasking, and so on. Emotions are one way of tagging certain stimuli to ensure that they receive priority treatment and are responded to appropriately.

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As for Gracq medicine disposal procyclidine 5mg amex, he had written medications similar to lyrica 5mg procyclidine free shipping, in 1960 medicine 5658 cheap procyclidine 5 mg without a prescription, a text on Chateaubriand symptoms 9f anxiety buy 5mg procyclidine with amex, “The Great Peacock,” which ends with this admission: “We owe him almost everything. I will go back into the house that a famous magician, a divine friend always seals over his loyal supporter. At the end of this account, it, in fact, seemed assured that I should find the house and know the girl of the Vale of No Return. She only takes life (or exists) at midnight, when the doors become ethereal until dawn crumples faces into pale sheets. In 1947, I remember often telling Vera [Herold] that I was Tristan, the abbreviation given to my first name—Stan instead of Stanislas— being the last syllable of Tristan. But I trust too much to fate to not recognize that, if it permeates my being, objective chance—beautiful as the encounter of a rudder and a white wing splattered with blood on the edge of the sea—has justified it. To run the risks of this adventure with the minimum chance of imposture, I decided to henceforth attribute myself another figure who had been much less exploited by art, a figure who under another name would all the same be as often mixed up with intrigue as with an interlacing path and to whom—by the admission of his legend—potions and hypnotic sleeps were not spared: Stanislas Rodanski, 1927–19. Lancelot, the “jack with white weapons,” associated with the shamrock, is the emblem of water spirits, and, ironically, of luck. Lancelot is also “the utopian and sympathetic Lancelot” Mac’Horn, 35 the husband of Florine Allespic in Maurice Fourre’s La Marraine du Sel, the very same author whose pen left these words to be read: I am a man of the West A small dark Celt the sun and fog share my heart My soul under the changing sky Colors With a thousand fires Smiling among the tombs I weep Among the flowers Ever a pilgrim of something else Pilgrim Of 36 Always Something Else. But, of all these young men who Charles Estienne says “walk on the shore like the first men and 37 who find again the spirit of the Picts, Scots, and Celts of the megaliths in their works,” it is undoubtedly Yves Elleouet who best awakens the myths that are dearest to the Bretons (of all Celtic lands). In an article published in Surrealisme, issue 2 (June 1977), Markale takes pains to state, “The Celtic myth is there in all its splendor [and] Elleouet is permeated by it as no poet ever before,” then adds, “Falc’hun lurks on the border of two kingdoms, those of the living and the dead, with no clear idea as to which is his. This is clearly their challenge and their quest is imbued with this fantastic demand, thereby intersecting with the errantry of the ancient Celts in search of the Blessed Isles. Writing about Elleouet to Aube Breton in a 1983 letter, Per-Jakez Helias said, “If there is a metaphysic for us Celts—which I believe—Yves is certainly the man who felt it most strongly. He said it would be a parody, bringing him down to the level of “all the Breton imagery for cracker boxes, a la Theodore Botrel. On the other side of the English Channel we have Ithell Colquhoun, who deserves a place apart. She was directly influenced by Robert Graves’s monumental study (himself a writer of Celtic origin) the White Goddess, which is about the pre-Christian deity who ruled over the Tuatha de Danaan and governs the inspiration of poets. Graves writes: A true poem is necessarily an invocation of the White Goddess, the Muse, the Mother of All Living, with the ancient power of arousing fright and lust—the female spider or queen bee whose 41 embrace is death. In a word, she is the incarnation of the magical powers with which the surrealists adorned women 42 in their erotica: “Every woman is the Lady of the Lake. An official Druidess and a member of the Order of the Keltic Cross, this artist, who was a descendent of the great Scottish clan of Colquhoun, whose lands occupy the west bank of Loch Lomond north of Glasgow, attended numerous gorsedds (assemblies) in Brittany and Cornwall, where she ended her days in the Valley of Lamorna, between the finis terrae of Land’s End and Saint Michael’s Mount. Taking into account the dual Masonic and Druidic affiliation of this woman, it is not irrelevant to recall that modern Druidry owes its awakening to a curious figure who was a friend of Jean Theophile Desaguliers, the kingpin of speculative Freemasonry, and to numerous members of the Royal Society like John Toland (1670–1722), for example. Toland, an attentive reader of Giordano Bruno and the author of Pantheisticon (1720), as well as the books A Summary of Ancient Irish Christianity (1718) and A Specimen of the Critical History of the Celtic Religion and Learning (1726), proclaimed the renaissance of Celtism in 1716. Another figure of the Druidic revival of the eighteenth and nineteenth centuries (this time in Wales) was the poet and probably Freemason Iolo Morganwg (born Edward Williams, 1747–1826), who was a friend of William Blake (and the counterpart of the Scotsman James Macpherson). The creation of the gorsedd and the modern image of the Druid by Morganwg was inspired by the myths and structures of Freemasonry, as Andrew 43 Prescott indicated, a process that would culminate a short while later with the Origins of Freemasonry by Thomas Paine, another friend of Iolo Morganwg, who openly proclaimed Masonry *115 as the “conservatory of the religion of the Druids! Tomorrow, we will go to the grove with the skeletons of Ossian draped in white robes,” Jacques Baron wrote in 1922! In 1951, Ithell Colquhoun published a short hermetic narrative (115 pages), probably finished around 1940, that owes much to the gothic novel and to the Grail cycle, as well as to MacGregor Mathers’s the Book of the Sacred Magic of Abra-Melin the Mage—The Goose of Hermogenes, one of the rare names of the philosopher’s stone. Michel Remy explains that it is “an alchemical vision of 44 the transmutation of things,” but it is also a plea on behalf of the now deposed Great Goddess, the embodiment of the sacred feminine. Eric Radcliffe writes, “This book was described as the most sustained surrealist text in the English language” and adds that it was “in fact ‘surreal’ according to Breton’s criteria. These stones were sometimes the subject of her paintings, as in the Dance of the *116 Nine Virgins (1940), Sunset’s Birth (1942), or the Penil des mennirs (1943), the title Ithell Colquhoun herself gave to her painting (see Eric Radcliffe’s book, in English)—some Celtic †117 landscapes Toyen would also paint on a later date with her superb Ile Quellern (1958) —as were their sacred wells or caves, which she regarded as “energy geysers” at the sacred sources of a pantheism that compelled her to write, “I am identified with every leaf and pebble, and any threatened hurt to the wilderness of the valley seems to me like a rape. The Approximate Man is from Tristan Tzara’s collection of the same name, and Communicating Vessels (1941) is inspired by Breton’s Les Vases communicants (1948). Another Englishwoman, to be exact an Anglo-Irish woman, who describes the apocalyptic appearance of the Grail to the residents of a retirement home in her book the Hearing Trumpet, Leonora Carrington was also influenced by the work of Robert Graves and inspired by Celtic art and myths, as indicated by Delmari Romero Keith in a recent study of the artist. In this text he writes: Salomon (Salomon) Grimberg acquired the notion of “magic art” that will be used later by Breton to grasp the works of Leonora, and has meticulously examined the interpretation of Celtic myths. The impressive legacy left by the Celts can be measured by their high mastery in the drawing of flora and fauna. Plants have religious significance in accordance with their shapes as spirals, undulating brambles, lotus or palm leaves, or concentric circles. The images of the deities, hybrid monsters and mythic animals, were adorned with plant motifs. This calligraphy is reminiscent of the Book of Kells, an extremely elaborate manuscript created by eighth-century Irish Christian 45 monks, whose convoluted style is close to Leonora’s. This cultural influence seems to have been large enough to inspire Trieste native Leonor Fini’s painting the Alcove: Interior with Three Women (circa 1939), a portrait of Carrington as a Celtic warrior queen (see plate 11). This is the same Leonor Fini whose heroines, according to Marcel Brion, come down “from the deepest inner kingdom to the kingdom of the Mothers,” again. Her approach can also appear quite close, sometimes, to that of Yves Tanguy, in Constantin Jelenski’s opinion, as cited by Jocelyn Godard in his Leonor Fini ou les metamorphoses d’une oeuvre. The imaginary society created by Leonor Fini is clearly matriarchal and is so seemingly because she recreates the spiritual organization of primitive societies that were also matriarchal. This is not the sign of feminine dominance but of affiliation with a very old form of worship. Unica Zurn’s “Les Jeux a Deux,” a very odd text more or less written at Hans Bellmer’s instigation and which forms one of the four parts of L’Homme-Jasmin, features a seemingly fragile heroine she calls “Norma,” as fragile as her in any case, who is “a resuscitated woman among the dead, a dead woman whose aura has not left the house,” but also “a Druidess [who] knows she is listening to the forbidden music of the departed Druids, which awakens the desire for death in lovers,” and which gives her companion Flavius “her first intimate confidences like a secret she whispers to him in the language of the Druids. Of all the disasters in the news, this one took place within me slowly, the time it took an ash-filled wind to tarnish the monochrome of fawn(-colored), dark, foggy, or acidic transparencies in which I still expected to see the clearings of the marvelous loom up. But from the very existence of the Vale of No Return or the Lost Rock, the Fountain of Barenton or the Castle of the Lake, each spring restored to the notion of the quest its luxuriant foliage of plant necessity. Brushing past the bark of the trees of Broceliande Forest or rediscovering their black gleaming in the romances of the Round Table, I know that I have drawn from this “gold-spattered, green setting” a physical taste for errantry I could never separate from the sense of poetry. I am speaking of a way of trembling while advancing through the silent water of the air, a certain allure acquired with the assurance that the beat of our temples responds to the blind drums of time, and again the salubrious, mad pleasure of no longer being anything but the terrifying trajectory of the possible, confronting reality until rediscovering the stream of blood, of blood spilled, of blood pearled, of blood exchanged, the 46 breathless blood that irrigates the spaces of desire. These are the very places that were magisterially conjured up with the village of Trehorenteuc, which is the gate of the forest, between Neant (Nothingness) and Folle Pensee (Mad Thought), some fifteen years earlier by Julien Gracq in the Narrow Waters. This subject continues to obsess creators in the surrealist circles of influence, as traces can still be found in the 2000 catalog for the Phases exhibition in Arras in these lines of Gilles Petitclerc’s poem (“Pour Suzel Ania”), a painter of the group working in Saint-Brieuc. You who have drunk all the gold of this Vale of No Return, though without soothing the distress of oblivion, I recognized you in the night of the red man. You bathed him in a little milk and a little 47 honey as you once bathed the moor for whose sake we lost the North. All the characteristic elements of Celtic literature supplied the base material out of which postwar surrealism dreamed of constructing a new mythic image. These themes and their sacred 50 dimension have been present since the movement’s origin. This other world that runs through the work of Tanguy, Matta, and Breton during the 1940s is an unveiling, rather, of the invisible world surrounding us (which is not empty), a kind of new 51 dimension inhabited by beings that interact with the living, the dead, and nature. This Ankou was frequently and magisterially portrayed by Yves Elleouet (who is far from being as well known as he deserves), who installed this myth so deep into the heart of reality, the two became inextricably merged. I go back in time to the land of the long-haired men wearing ribboned hats and pleated breeches over their thighs. They speak in harsh voices and live in thatched huts from which straggles the smell of smoke. Shadows wait at the crossroads for those returning from a distant brawl or drinking binge. It rolls with a loud clatter over the white paths; skulls bang together between its sides. The ghastly coachman stares at the road with his empty eye sockets in a face clenched like a fist. This coachman, Jos l’Ankaw, perhaps “the Great Purveyor,” is “older than memory and voice.

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