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Contributing Authors

MARINA BOUSHRA, MD M. SCOTT MOORE, DO

Resident, Department of Emergency Medicine Research Fellow
East Carolina University/Vidant Medical Center Affiliated Dermatology

THEODORE CRISOSTOMO-WYNNE JUN YEN NG, MD

F. Edward Hébert School of Medicine Intern
Class of 2017 Central Queensland Hospital and Health Services

MATTHEW S. DELFINER SATYAJIT REDDY, MD

New York Institute of Technology College of Osteopathic Medicine Resident, Department of Internal Medicine
Class of 2017 Temple University Hospital

ANGELA GAUTHIER VADIM ROSIN

Yale School of Medicine University of Michigan Medical School
Class of 2018 Class of 2017

BENJAMIN GOUGH, DO SARAH SCHIMANSKY, MB BCh BAO

Resident, Department of General Surgery Academic Foundation Doctor
Christiana Care Health System North Bristol NHS Trust

JAN ANDRE GRAUMAN, MD, MA ZACHARY G. SCHWAM, MD

Family Medicine Resident, Northern Remote Stream Resident, Department of Otolaryngology
University of Manitoba Icahn School of Medicine at Mount Sinai

JESSICA F. JOHNSTON, MSc NINO SIKHARULIDZE, MD

Yale School of Medicine Department of Endocrinology
MD/PhD Candidate Tbilisi State Medical University

JAMES N. McCOY VAISHNAVI VAIDYANATHAN

Texas A&M Health Science Center University of Missouri-Kansas City School of Medicine
Class of 2017 Class of 2018

IMAGE AND ILLUSTRATION TEAM

RYAN W. HADDEN RENATA VELAPATIÑO

University of Alabama School of Medicine San Martín de Porres University
Class of 2017 School of Medicine

vii
Associate Authors
JAMES E. BATES, MD JESSE D. SENGILLO
Resident, Department of Radiation Oncology SUNY Downstate College of Medicine
University of Florida School of Medicine Class of 2018

REED GILBOW, MD WENHUI ZHOU

Resident, Department of Otolaryngology–Head and Neck Surgery Tufts University School of Medicine
University of Virginia School of Medicine MD/PhD Candidate

RYAN KELSCH
Midwestern University Chicago College of Osteopathic Medicine
Class of 2017

IMAGE AND ILLUSTRATION TEAM

NAKEYA KHOZEMA DEWASWALA

Lokmanya Tilak Municipal Medical College
Class of 2016

viii
Faculty Advisors

MARK A.W. ANDREWS, PhD CHARLES S. DELA CRUZ, MD, PhD

Lake Erie College of Osteopathic Medicine at Seton Hill Assistant Professor, Department of Pulmonary and Critical Care Medicine
Greensburg, PA Yale School of Medicine

MARIA ANTONELLI, MD CONRAD FISCHER, MD

Clinical Faculty, Division of Rheumatology Associate Professor, Medicine, Physiology, and Pharmacology
Case Western Reserve University School of Medicine Touro College of Medicine

HERMAN SINGH BAGGA, MD JEFFREY J. GOLD, MD

Urologist, Allegheny Health Network Associate Professor, Department of Neurology
University of Pittsburgh Medical Center Assistant Professor, University of California, San Diego School of Medicine

ADITYA BARDIA, MBBS, MPH RAYUDU GOPALAKRISHNA, PhD

Attending Physician, Massachusetts General Hospital Associate Professor, Department of Cell and Neurobiology
Harvard Medical School Keck School of Medicine of University of Southern California

PAULETTE BERND, PhD RYAN C.W. HALL, MD

Professor, Department of Pathology and Cell Biology Assistant Professor, Department of Psychiatry
Columbia University College of Physicians and Surgeons University of South Florida

SHELDON CAMPBELL, MD, PhD LOUISE HAWLEY, PhD

Associate Professor of Laboratory Medicine Immediate Past Professor and Chair, Department of Microbiology
Yale School of Medicine Ross University School of Medicine

BROOKS D. CASH, MD MARGARET M. HAYES, MD

Professor of Medicine, Division of Gastroenterology Instructor of Medicine
University of South Alabama School of Medicine Harvard Medical School

SHIVANI VERMA CHMURA, MD JEFFREY W. HOFMANN, MD, PhD

Adjunct Clinical Faculty, Department of Psychiatry Resident, Department of Pathology
Stanford University School of Medicine University of California, San Francisco School of Medicine

PETER V. CHIN-HONG, MD BRIAN C. JENSEN, MD

Professor, Department of Medicine Assistant Professor of Medicine and Pharmacology
University of California, San Francisco School of Medicine University of North Carolina Health Care

CHRISTINA E. CIACCIO, MD, MSc CLARK KEBODEAUX, PharmD

Assistant Professor, Departments of Pediatrics and Medicine Clinical Assistant Professor, Pharmacy Practice and Science
The University of Chicago Pritzker School of Medicine University of Kentucky College of Pharmacy

LINDA S. COSTANZO, PhD MICHAEL R. KING, MD

Professor, Physiology & Biophysics Instructor, Department of Pediatric Anesthesiology
Virginia Commonwealth University School of Medicine Northwestern University Feinberg School of Medicine

ANTHONY L. DeFRANCO, PhD KRISTINE KRAFTS, MD

Professor, Department of Microbiology and Immunology Assistant Professor, Department of Basic Sciences
University of California, San Francisco School of Medicine University of Minnesota School of Medicine

ix
GERALD LEE, MD MELANIE SCHORR, MD
Assistant Professor, Department of Pediatrics Research Fellow, Department of Medicine
University of Louisville School of Medicine Massachusetts General Hospital

KACHIU C. LEE, MD, MPH NATHAN W. SKELLEY, MD

Assistant Clinical Professor, Department of Dermatology Assistant Professor, Department of Orthopaedic Surgery
Brown University, Providence, Rhode Island University of Missouri, The Missouri Orthopaedic Institute

WARREN LEVINSON, MD, PhD SHEENA STANARD, MD, MHS

Professor, Department of Microbiology and Immunology Hospitalist
University of California, San Francisco School of Medicine State University of New York Upstate Hospital

PETER MARKS, MD, PhD HOWARD M. STEINMAN, PhD

Center for Biologics Evaluation and Research Assistant Dean, Biomedical Science Education
US Food and Drug Administration Albert Einstein College of Medicine

J. RYAN MARTIN, MD STEPHEN F. THUNG, MD

Assistant Professor of Obstetrics, Gynecology, and Reproductive Sciences Associate Professor, Department of Obstetrics and Gynecology
Yale School of Medicine The Ohio State University College of Medicine

DOUGLAS A. MATA, MD, MPH RICHARD P. USATINE, MD

Brigham and Women’s Hospital Professor, Dermatology and Cutaneous Surgery
Harvard Medical School University of Texas Health Science Center San Antonio

VICKI PARK, PhD PRASHANT VAISHNAVA, MD

Associate Professor, Pediatrics and Medical Education Assistant Professor, Department of Medicine
University of Tennessee Health Science Center Mount Sinai Hospital and Icahn School of Medicine

JEANNINE RAHIMIAN, MD, MBA J. MATTHEW VELKEY, PhD

Associate Professor, Obstetrics and Gynecology Assistant Dean, Basic Science Education
David Geffen School of Medicine at UCLA Duke University School of Medicine

SOROUSH RAIS-BAHRAMI, MD BRIAN WALCOTT, MD

Assistant Professor, Urology and Radiology Clinical Instructor, Department of Neurological Surgery
The University of Alabama at Birmingham School of Medicine University of California, San Francisco

SASAN SAKIANI, MD TISHA WANG, MD

Assistant Professor, Department of Medicine Associate Clinical Professor, Department of Medicine
Case Western Reserve University School of Medicine David Geffen School of Medicine at UCLA

ROBERT A. SASSO, MD SYLVIA WASSERTHEIL-SMOLLER, PhD

Professor of Clinical Medicine Professor Emerita, Department of Epidemiology and Population Health
Ross University School of Medicine Albert Einstein College of Medicine

JOSEPH L. SCHINDLER, MD ADAM WEINSTEIN, MD

Assistant Professor, Neurology and Neurosurgery Assistant Professor, Pediatric Nephrology and Medical Education
Yale School of Medicine Geisel School of Medicine at Dartmouth

x
Preface
With the 27th edition of First Aid for the USMLE Step 1, we continue our commitment to providing students with
the most useful and up-to-date preparation guide for the USMLE Step 1. This edition represents an outstanding
revision in many ways, including:
ƒ 30+ entirely new facts with continued expansion of quality improvement principles, safety science, and healthcare
delivery to align more closely with the USMLE Content Outline.
ƒ Hundreds of major fact updates culled from thousands of student and faculty contributions.
ƒ Extensive text revisions, new mnemonics, clarifications, and corrections curated by a team of more than 25
medical student and resident physician authors who excelled on their Step 1 examinations and verified by a team
of expert faculty advisors and nationally recognized USMLE instructors.
ƒ Complete reorganization of the neurology chapter to better distinguish normal physiology from neuropathology
and to emphasize the special senses.
ƒ Improved Rapid Review section with page numbers to the text, to quickly find these high-yield concepts in
context.
ƒ Updated with more than 100+ new or revised full-color photos to help visualize various disorders, descriptive
findings, and basic science concepts. In particular, imaging photos have been labeled and optimized to show
both normal anatomy and pathologic findings.
ƒ Updated with dozens of new and revised diagrams. We continue to expand our collaboration with USMLE-Rx
(MedIQ Learning, LLC) to develop and enhance illustrations with improved information design to help
students integrate pathophysiology, therapeutics, and diseases into memorable frameworks.
ƒ A revised exam preparation guide with updated data from the USMLE and NRMP. The guide also features new
evidence-based techniques for efficient and effective test preparation. The updated supplemental guide for IMGs,
osteopathic and podiatry students, and students with a disability can be found at our blog, www.firstaidteam.com.
ƒ An updated summary guide to student-recommended USMLE Step 1 review resources, including mobile apps
for iOS and Android. The full resource guide with detailed descriptions can be found at our blog.
ƒ Real-time Step 1 updates and corrections can also be found exclusively on our blog.
We invite students and faculty to share their thoughts and ideas to help us continually improve First Aid for the
USMLE Step 1 through our blog and collaborative editorial platform. (See How to Contribute, p. xvii.)

Louisville Tao Le
Boracay Vikas Bhushan
Philadelphia Matthew Sochat
New York City Yash Chavda
Ann Arbor Andrew Zureick
Pittsburgh Mehboob Kalani
San Francisco Kimberly Kallianos

xi
Special Acknowledgments
This has been a collaborative project from the start. We gratefully acknowledge the thousands of thoughtful
comments, corrections, and advice of the many medical students, international medical graduates, and faculty who
have supported the authors in our continuing development of First Aid for the USMLE Step 1.
We provide special acknowledgment and thanks to the following individuals who made exemplary contributions to this
edition through our voting, proofreading, and crowdsourcing platform: Anosh Ahmed, Kashif Badar, Humood Boqambar,
Anup Chalise, Wendy Chen, Francis Deng, Anthony J. Febres, Okubit Gebreyonas, Richard Godby, Christina Govas, Eric
Irons, Nikhar Kinger, Katherine Kramme, Jonathan Li, Micah Mathai, Nicolaus Mephis, Ryan Meyer, Joseph Mininni,
Iraj Nasrabadi, Jimmy Tam Huy Pham, Keyhan Piranviseh, Anthony Purgianto, Casey Joseph Rosenthal, Sana Sheraz,
Avinainder Singh, Paul Walden, Isabella Wu, and Xuebao Zhang. For illustration contributions, we also thank Wendy
Abbott.
For support and encouragement throughout the process, we are grateful to Thao Pham, Jinky Flang, and Jonathan
Kirsch, Esq. Thanks to Louise Petersen for organizing and supporting the project. Thanks to our publisher, McGraw-
Hill, for the valuable assistance of its staff, including Christina Thomas, Jim Shanahan, Laura Libretti, Midge
Haramis, and Jeffrey Herzich.
We are also very grateful to Dr. Fred Howell and Dr. Robert Cannon of Textensor Ltd for providing us extensive
customization and support for their powerful Annotate.co collaborative editing platform (www.annotate.co), which
allows us to efficiently manage thousands of contributions. Thanks to Dr. Richard Usatine for his outstanding
dermatologic and clinical image contributions. Thanks also to Jean-Christophe Fournet (www.humpath.com), Dr.
Ed Uthman, and Dr. Frank Gaillard (www.radiopaedia.org) for generously allowing us to access some of their striking
photographs. We especially thank Dr. Kristine Krafts for many insightful text and image contributions throughout the
extensive revision.
For exceptional editorial leadership, enormous thanks to Christine Diedrich, Emma Underdown, and Catherine
Johnson. Thank you to our USMLE-Rx/ScholarRx team of editors, Linda Davoli, Jacqueline Mahon, Janene
Matragrano, Erika Nein, Isabel Nogueira, Rebecca Stigall, Ashley Vaughn, and Hannah Warnshuis. Many thanks to
Tara Price for page design and all-around InDesign expertise. Special thanks to our indexer Dr. Anne Fifer. We are
also grateful to our medical illustrator, Hans Neuhart, for his creative work on the new and updated illustrations. Lastly,
tremendous thanks to Rainbow Graphics, especially David Hommel and Donna Campbell, for remarkable ongoing
editorial and production support under time pressure.

Louisville Tao Le
Boracay Vikas Bhushan
Philadelphia Matthew Sochat
New York City Yash Chavda
Ann Arbor Andrew Zureick
Pittsburgh Mehboob Kalani
San Francisco Kimberly Kallianos

xii
General Acknowledgments

Each year we are fortunate to receive the input of thousands of medical students and graduates who provide new material, clarifications,
and potential corrections through our website and our collaborative editing platform. This has been a tremendous help in clarifying
difficult concepts, correcting errata from the previous edition, and minimizing new errata during the revision of the current edition. This
reflects our long-standing vision of a true, student-to-student publication. We have done our best to thank each person individually
below, but we recognize that errors and omissions are likely. Therefore, we will post an updated list of acknowledgments at our website,
www.firstaidteam.com/bonus/. We will gladly make corrections if they are brought to our attention.

For submitting contributions and corrections, many thanks to Mohammed Abed, Asif Abidi, John David Adame, Poppy Addison, Onaola
Adedeji, Comfort Agaba, Vivian Agumadu, Bilawal Ahmed, Zoey Akah, Hamed Akbari, Pegah Akbari, Marwan Alahiri, Fadi Al-Asadi,
Lourdes Alberty, Christian Alch, Erica Alcibiade, Majed Alghamdi, Mohammed Alhaidar, Nasir Alhamdan, Albert Alhatem, Alaa
Alibrahim, Mohammed Alsaggaf, Luai M. Alsakaf, Khaled Al-Sawalmeh, Vaidehi Ambai, Kevin An, Anna Anderson, Christopher
Anderson, Mehdi Ansari, Nelson Arellano, Gabriel Arom, Immad Attique, Nicholas Austin, Mary Ayad, Cho New Aye, Marwan Azzam,
Ram Baboo, Rahaf Baker, Brian Baksa, Vijay Balakrishnan, Vyshnavy Balendra, Melissa Banez, Gauri Barlingay, Ross Barman, Frances M.
Marrero Barrera, Josh Barrick, Jason Batey, Priya Batta, Rosemary Noel Beavers, Sean Behan, Jorge Martinez Bencosme, Kene Ben-
Okafor, Elodie Marie Betances, Maria Betances, Shea Bielby, Johnathon Bishop, Aaron Blackshaw, Edgar Blecker, Cary Blum, Peter
Boateng, Nwamaka Bob-Ume, Victoria Bone, Stephanie Borinsky, Adam Bortner, Chantal Brand, Shannon Brougher, Sareena Brown,
Rob Brumer, Ryan Brunetti, Takur Buck, Alejandro Bugarini, Nimerta Burmhi, James Butz, Jennifer Byrd, Stefan Campbell, Fiorella B.
Castillo, Harold Cedeño, Kenan Celtik, Yusuf Chao, Kyriakos Chatzopoulos, Jessica Chen, Julia Chen, Stephanie Yi-Tsi Chen, Willie Chen,
Charlie Cheng, Olivia Cheng, Shani Chibber, Tiffany Chomko, Manita Choudhary, Eric Christie, Melissa Chung, Casey Lane Clark, Beth
Clymer, Sam Cochran, Lauren Coleman, Benjamin Comora, Jensyn Cone, Zachary R. Conley, Sarah Corral, Eliana Costantino, Ian Cox,
Robert Cox, Crosby Culp, John Cummins, Helen Dainton, Christopher Dallo, Jonathan Dang, Laura Dankovich, Atman Dave, Eric Davied,
Joshua Davis, Danielle Davis, Solomon Dawson, Ezra Dayan, Ryan DeAngelis, Kathryn Demitruk, Jessie Dhaliwal, Rahim Dhanani, Travis
Dice, Abiot Didana, Cheri Dijamco, Ozan Dikilitas, Isaac M. Dodd, Kirsten Dowling, Mitch Dunklebarger, Khanh Duong, Marco Duverseau,
Josh East, Jeremy Eckes, Elise Edoka, Rachel Einarsson, Hannah Eisen, Tyler Emerson, Jon Erdman, Cynthia Estrada, Matthew Fadus,
Giselle Falconi, Tabbassum Fayyaz, Ravali Feeramachaneni, Kaveh Fekri, Albert Fernandez, Maria Vanessa Ferrer, Roberto Hurtado Fiel,
Nicholas Field, Ryan Finn, Helen Francis, Daniel Franco, Cameron Frederick, Eli Fredman, Sheri Frickey, Gianfranco Frojo, Malak Fuad,
James Fuqua, Anita Gade, Sudha Gade, Nicholas Gamboa, Avi Gandi, Jared Gans, Russell Garcia, P. M. Gayed, Nicholas Geiger, Alejandro
Gener, John George, Maikel Ragaei Fahmi Gerges, Imran Ghare, Gaby Ghobrial, Javid Ghomashi, Gino Giannone, Lizz Gilmore, Priscilla
Alvarez Gonzalez, Luis Fernando Gonzalez-Ciccarelli, Ashwani Gore, Sophie Gott, Crystal D. Green, Brian Grice, John Grotberg, Li Guiqin,

xiii
Nita Gupta, Gail Gutman, Samuel Guyer, Natalia Guzmman-Seda, Fuad Habbal, Sean M. Hacking, Erik Haley, Oday Halhouli, Martin
Halicek, Isaiah Hammonds, Nicola Hampel, Brian Handal, Roy Handelsman, Jamison Harvey, Hunaid Hasan, Makenzie Hatfield Kresch,
Joel Hayden, Mona Hdeib, Kasey Helmlinger, Katy Helms, Michelle Herberts, Cinthia Marie Gonzalez Hernandez, Ariana Hess, Mitchell
Heuermann, Richard Hickman, Tiffany Hinojosa, Joyce Ho, M. Ho, Patrick Holman, Jeffeory Howard, Paige Hoyer, Jonathan C. Hu, Ann
Hua, Jack Hua, I-Chun Hung, Frank S. Hurd, Ibrahim Hyder, David Ianacone, Jouzif Ibrahim, Taylin Im, Saira Iqbal, Josh Isserman,
Mimoza Isufi, Kelechi Izunobi, Pegah Jahangiri, Sakshi Jain, Maryam Mohammed Jallo, Mitra Jamshidian, Neetu Jamwal, Paige Jarmuz,
Zahran Jdaitawi, Kyu-Jin Jeon, Benjamin Hans Jeuk, Jose F. Jimenez, Sally Jo, Alfredo Joffre, Andrew Johnson, Jordan E. Johnson, Kai
Johnson, Katherine Joltikov, Gavin Jones, Saman Doroodgar Jorshery, Vaidehi Joshi, Shirley Ju, Michael Kagan, Hanna Kakish, Kirill
Karlin, Michael Karp, Aaron R. Kaufman, LaDonna Kearse, Sorena Keihani, Shamim Khan, Tamer Khashab, Mitra Khosravi, Amin
Khosrowpour, Neharika Khurana, Beom Soo Kim, Christina Kim, Robert Kim, Yoo Jung Kim, Megan King, Vladimer Kitiashvili, David E.
Klein, Mohammed Sammy Knefati, George Koch, Noah Kojima, Amol Koldhekar, Samantha Kops, Sai Krishna Korada, Zachary Koretz,
Heather Kornmehl, David Kowal, Kathleen Kramer, Akash Kroeger, Elan Krojanker, Matthew Kurian, Anita Kurre, Rachel Kushner,
Eustina Kwon, Michael Larson, George Lasker, Evangelia Lazaris, Aaron A. Lebron Burgos, Christina Dami Lee, James Lee, Jennifer Lee,
Erica Lee, Rachel Leeman, Ryan Lena, Stacy Leung, Guanqun Li, Yedda Li, Ramon Li, Guohua Liang, Soobin Lim, Meng-Chen Vanessa
Lin, Matthew Lippmann, Selina Liu, Alnardo Lora, Yancheng Luo, Ahmed Lutfi, Martin Ma, Ahmad Mahadeen, Nandita N. Mahajan,
Gajendra Maharjan, Megan Maier, Nodari Maisuradze, Rohail Malik, Andrew Martella, Beatriz Martinez, Eden Marx, Christy Mathew,
Aletha Anisha Mathias, Alex McDonald, Robert McKenna, Maggie Meier, Wendy Mejia, Theresa Meloche, Elizabeth Mertilus, Jersey
Mettille-Butts, Marielle Meurice, Sarah Michelson, Austin Mike-Mayer, Nardine Mikhail, Vincent Mirabile, Ahmed Mohamed, Hassan
Reyad Mohsen, Nate Moore, Rose Mueller, Amer Muhyieddeen, Natia Murvelashvili, Anadarajan Nadarajan, Louai Naddaf, Shane
Naidoo, Khushabu Nayak, Mai-Trang Nguyen, Michael Nguyen, Thomas Nienaber, Bharati Nimje, Cynthia Noguera, Albert Nwabueze,
Devon O’Brien, Lola Ogunsuyi, Ololade Ogunsuyi, Olguta Olea, Wilson Omesiete, Michael Osinski, Vasily Ovechko, Jordan Owens, Devon
Pace, Zonghao Pan, Khang Wen Pang, Olga Paniagua, Silvia Paola, Erika Parisi, Andrew Park, Madhumithaa Parthasarathy, Ishan Patel,
Saikrishna Patibandla, Iqra Patoli, David Patterson, Lanieka Peck, Alexander Pennekamp, Luisa Peress, Max Petersen, Romela
Petrosyan, Patryk Piekos, Sarah Pietruszka, Luis Pina, Yuval Pinto, Andrew Piropato, Phillip Plager, Netanya Pollock, Gautham
Prabhakar, Will Preston, Grace Pryor, Audrey Pulitzer, Tyler Putnam, Connie Qiu, Brian Quaranto, Fatima Quddusi, Carlos Quinonez,
Maria Qureshi, Samir Rahman, Saad Rahmat, Alia Raja, Vinaya Rajan, Arun Rajaratnam, Ferza Raks, Juhi Ramchandani, Judith Ramel,
Josean Ramos, Cesar Augusto Hernandez Rangel, Dhakshitha Rao, Mohsin Raza, Sushma Reddy, Dave Reyes, Lenisse Miguelina Reyes,
Robert Riggio, Ernest James Rin, Julia Ringel, Moshe Roberts, Clara Robertson, Sam Robinson, Agalic Rodriguez, Juliana D. Rodriguez,
Jorge Roman, Luis Rosario, Alexander Rowan, Julietta Rubin, Daniel Rubinger, Martin Runnström, Nicholas Russo, David Rutenberg,
Sean Saadat, Stuart Sacks, Rorita Sadhu, Atin Saha, Haneen Salah, Mohamad Saleh, Rafael E. Valle Salinas, Jacqueline Sanchez, Natalia
Santiago-Morales, Steven Sapozhnikov, Ashley Sareen, Jason Sarte, Claire Sathe, Darya Savel, Osama Sbeitan, Ghil Schwarz, Caleb
Seavey, Roopak Sekhon, Anna Sevilla, Anand Sewak, Akash Shah, Anna Shah, Muneeb Shah, Sherina Shahbazian, Abdulla Shaheen,
Ojochide Shaibu, Mhd Tayseer Shamaa, Bryan Shapiro, Dolly Sharma, Demetrio Sharp, Jia Shi, Helen Shi, Ryan Sieli, Tyler Simpson, Vikal
Singh, Chandandeep Singh, Ramzi Skaik, Omar Abu Slieh, Joey Sneij, Navjot Sobti, Tom Soker, Jun Song, Sushant Soni, Mihir Soparkar,
Vlasios Sotirchos, Amelia St.Ange, Mac Staben, Clay Stafford, Allan Stolarski, Sonia A Sugumar, Mark Anthony Sy, Angela Taeschner,
Dawood Tafti, Nitin Tandan, David Taylor, Abiolah Telesford, George Terre, Sam Thomas, Akhilesh Thota, Sandra Tomlinson-Hansen,
Carlos E. Velez Torres, Derrick Tran, Vi Tran, Michael Troutman, Cindy L. Tsui, Harika R. Tula, Michael Turgeon, Esonoes Tururu, Marcia
Uddoh, Daniel Udrea, Nkechi Ukeekwe, Sara Usman, Akash Vadhavana, Royson L. Vallliyil, Leah D. Vance, Blanca Vargas, Alexander

xiv
Vartanov, Jayalakshmi Venkateswaran, Bhanu Verma, Shawn Verma, Andrea Victorio, Anthony Viola III, Miriam Volosen, Habiba Wada,
Benjamin Warren, Juliana Watson, Hannah Wellman, Stanley J. Welsh, Pang Khang Wen, Richard Whitlock, Jimbo Wilhite, Michael
Winter, Jonathan Wolfson, John Worth, Eva Wu, Birdy Xu, Antonio Yaghy, Jehan Yahya, Xiaofeng Yan, Rebecca Ye, Raquel Yokoda,
Alexander Yuen, William Yuen, Alan Zats, Billy Zhang, Park Zheng, and Andrew Zilavy.

xv
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How to Contribute

This version of First Aid for the USMLE Step 1 incorporates thousands of contributions and improvements suggested
by student and faculty advisors. We invite you to participate in this process. Please send us your suggestions for:

ƒ Study and test-taking strategies for the USMLE Step 1

ƒ New facts, mnemonics, diagrams, and clinical images

ƒ High-yield topics that may appear on future Step 1 exams

ƒ Personal ratings and comments on review books, question banks, apps, videos, and courses

For each new entry incorporated into the next edition, you will receive up to a $20 Amazon.com gift card as well as
personal acknowledgment in the next edition. Significant contributions will be compensated at the discretion of the
authors. Also, let us know about material in this edition that you feel is low yield and should be deleted.

All submissions including potential errata should ideally be supported with hyperlinks to a dynamically updated Web
resource such as UpToDate, AccessMedicine, and ClinicalKey.

We welcome potential errata on grammar and style if the change improves readability. Please note that First Aid style
is somewhat unique; for example, we have fully adopted the AMA Manual of Style recommendations on eponyms
(“We recommend that the possessive form be omitted in eponymous terms”) and on abbreviations (no periods with
eg, ie, etc).

The preferred way to submit new entries, clarifications, mnemonics, or potential corrections with a valid,
authoritative reference is via our website: www.firstaidteam.com.

This website will be continuously updated with validated errata, new high-yield content, and a new online platform
to contribute suggestions, mnemonics, diagrams, clinical images, and potential errata.

Alternatively, you can email us at: [email protected].

Contributions submitted by May 15, 2017, receive priority consideration for the 2018 edition of First Aid for the
USMLE Step 1. We thank you for taking the time to share your experience and apologize in advance that we cannot
individually respond to all contributors as we receive thousands of contributions each year.

xvii
 `
NOTE TO CONTRIBUTORS

All contributions become property of the authors and are subject to editing and reviewing. Please verify all data and
spellings carefully. Contributions should be supported by at least two high-quality references.

Check our website first to avoid duplicate submissions. In the event that similar or duplicate entries are received,
only the first complete entry received with valid, authoritative references will be credited. Please follow the style,
punctuation, and format of this edition as much as possible.

`
JOIN THE FIRST AID TEAM

The First Aid author team is pleased to offer part-time and full-time paid internships in medical education and
publishing to motivated medical students and physicians. Internships range from a few months (eg, a summer) up
to a full year. Participants will have an opportunity to author, edit, and earn academic credit on a wide variety of
projects, including the popular First Aid series.

For 2017, we are actively seeking passionate medical students and graduates with a specific interest in improving our
medical illustrations, expanding our database of medical photographs, and developing the software that supports our
crowdsourcing platform. We welcome people with prior experience and talent in these areas. Relevant skills include
clinical imaging, digital photography, digital asset management, information design, medical illustration, graphic
design, and software development.

Please email us at [email protected] with a CV and summary of your interest or sample work.

xviii
How to Use This Book
CONGRATULATIONS: You now possess the book that has guided nearly two million students to USMLE success
for over 25 years. With appropriate care, the binding should last the useful life of the book. Keep in mind that putting
excessive flattening pressure on any binding will accelerate its failure. If you purchased a book that you believe
is defective, please immediately return it to the place of purchase. If you encounter ongoing issues, you can also
contact Customer Service at our publisher, McGraw-Hill Education, at https://www.mheducation.com/contact.html.

START EARLY: Use this book as early as possible while learning the basic medical sciences. The first semester of
your first year is not too early! Devise a study plan by reading Section I: Guide to Efficient Exam Preparation, and
make an early decision on resources to use by checking Section IV: Top-Rated Review Resources. Note that First Aid
is neither a textbook nor a comprehensive review book, and it is not a panacea for inadequate preparation.

CONSIDER FIRST AID YOUR ANNOTATION HUB: Annotate material from other resources, such as class
notes or comprehensive textbooks, into your book. This will keep all the high-yield information you need in one
place. Other tips on keeping yourself organized:

ƒ For best results, use fine-tipped ballpoint pens (eg, BIC Pro+, Uni-Ball Jetstream Sports, Pilot Drawing Pen,
Zebra F-301). If you like gel pens, try Pentel Slicci, and for markers that dry almost immediately, consider
Staedtler Triplus Fineliner, Pilot Drawing Pen, and Sharpies.

ƒ Consider using pens with different colors of ink to indicate different sources of information (eg, blue for
USMLE-Rx Step 1 Qmax, green for UWorld Step 1 Qbank).

ƒ Choose highlighters that are bright and dry quickly to minimize smudging and bleeding through the page
(eg, Tombow Kei Coat, Sharpie Gel).

ƒ Many students de-spine their book and get it 3-hole-punched. This will allow you to insert materials from other
sources, such as course syllabi.

INTEGRATE STUDY WITH CASES, FLASH CARDS, AND QUESTIONS: To broaden your learning strategy,
consider integrating your First Aid study with case-based reviews (eg, First Aid Cases for the USMLE Step 1), flash
cards (eg, First Aid Flash Facts), and practice questions (eg, the USMLE-Rx Step 1 Qmax). Read the chapter in the
book, then test your comprehension by using cases, flash cards, and questions that cover the same topics. Maintain
access to more comprehensive resources (eg, First Aid for the Basic Sciences: General Principles and Organ Systems
and First Aid Express videos) for deeper review as needed.

PRIME YOUR MEMORY: Return to your annotated Sections II and III several days before taking the USMLE
Step 1. The book can serve as a useful way of retaining key associations and keeping high-yield facts fresh in your
memory just prior to the exam. The Rapid Review section includes high-yield topics to help guide your studying.

CONTRIBUTE TO FIRST AID: Reviewing the book immediately after your exam can help us improve the next
edition. Decide what was truly high and low yield and send us your comments. Feel free to send us scanned images
from your annotated First Aid book as additional support. Of course, always remember that all examinees are under
agreement with the NBME to not disclose the specific details of copyrighted test material.

xix
Selected USMLE Laboratory Values

* = Included in the Biochemical Profile (SMA-12)

Blood, Plasma, Serum Reference Range SI Reference Intervals

*Alanine aminotransferase (ALT, GPT at 30°C) 8–20 U/L 8 –20 U/L

Amylase, serum 25–125 U/L 25–125 U/L
*Aspartate aminotransferase (AST, GOT at 30°C) 8–20 U/L 8–20 U/L
Bilirubin, serum (adult)
Total // Direct 0.1–1.0 mg/dL // 0.0–0.3 mg/dL 2–17 μmol/L // 0–5 μmol/L
*Calcium, serum (Total) 8.4–10.2 mg/dL 2.1–2.8 mmol/L
*Cholesterol, serum (Total) < 200 mg/dL < 5.2 mmol/L
*Creatinine, serum (Total) 0.6–1.2 mg/dL 53–106 μmol/L
Electrolytes, serum
Sodium 136–145 mEq/L 136–145 mmol/L
Chloride 95–105 mEq/L 95–105 mmol/L
* Potassium 3.5–5.0 mEq/L 3.5–5.0 mmol/L
Bicarbonate 22–28 mEq/L 22–28 mmol/L
Magnesium 1.5 mEq/L 0.75–1.0 mmol/L
Gases, arterial blood (room air)
PO 2 75–105 mm Hg 10.0–14.0 kPa
PCO2 33–44 mm Hg 4.4–5.9 kPa
pH 7.35–7.45 [H+] 36–44 nmol/L
*Glucose, serum Fasting: 70–110 mg/dL 3.8–6.1 mmol/L
2-h postprandial: < 120 mg/dL < 6.6 mmol/L
Growth hormone − arginine stimulation Fasting: < 5 ng/mL < 5 μg/L
provocative stimuli: > 7 ng/mL > 7 μg/L
Osmolality, serum 275–295 mOsm/kg 275–295 mOsm/kg
*Phosphatase (alkaline), serum (p-NPP at 30°C) 20–70 U/L 20–70 U/L
*Phosphorus (inorganic), serum 3.0–4.5 mg/dL 1.0–1.5 mmol/L
Prolactin, serum (hPRL) < 20 ng/mL < 20 μg/L
*Proteins, serum
Total (recumbent) 6.0–7.8 g/dL 60–78 g/L
Albumin 3.5–5.5 g/dL 35–55 g/L
Globulins 2.3–3.5 g/dL 23–35 g/L
*Urea nitrogen, serum (BUN) 7–18 mg/dL 1.2–3.0 mmol/L
*Uric acid, serum 3.0–8.2 mg/dL 0.18–0.48 mmol/L
(continues)

xx
Cerebrospinal Fluid Reference Range SI Reference Intervals

Glucose 40–70 mg/dL 2.2–3.9 mmol/L

Hematologic

Erythrocyte count Male: 4.3–5.9 million/mm3 4.3–5.9 × 1012/L

Female: 3.5–5.5 million/mm3 3.5–5.5 × 1012/L
Erythrocyte sedimentation rate (Westergen) Male: 0–15 mm/h 0–15 mm/h
Female: 0–20 mm/h 0–20 mm/h
Hematocrit Male: 41–53% 0.41–0.53
Female: 36–46% 0.36–0.46
Hemoglobin, blood Male: 13.5–17.5 g/dL 2.09–2.71 mmol/L
Female: 12.0–16.0 g/dL 1.86–2.48 mmol/L
Hemoglobin, plasma 1–4 mg/dL 0.16–0.62 μmol/L
Leukocyte count and differential
Leukocyte count 4500–11,000/mm3 4.5–11.0 × 109/L
Segmented neutrophils 54–62% 0.54–0.62
Band forms 3–5% 0.03–0.05
Eosinophils 1–3% 0.01–0.03
Basophils 0–0.75% 0–0.0075
Lymphocytes 25–33% 0.25–0.33
Monocytes 3–7% 0.03–0.07
Mean corpuscular hemoglobin 25.4–34.6 pg/cell 0.39–0.54 fmol/cell
Mean corpuscular volume 80–100 μm3 80–100 fL
Partial thromboplastin time (activated) 25–40 seconds 25–40 seconds
Platelet count 150,000–400,000/mm3 150–400 × 109/L
Prothrombin time 11–15 seconds 11–15 seconds
Reticulocyte count 0.5–1.5% of red cells 0.005–0.015
Sweat

Chloride 0–35 mmol/L 0–35 mmol/L

Urine

Proteins, total < 150 mg/24 h < 0.15 g/24 h

xxi
 First Aid Checklist for the USMLE Step 1

This is an example of how you might use the information in Section I to prepare for the USMLE Step 1. Refer
to corresponding topics in Section I for more details.

Years Prior
□ Select top-rated review resources as study guides for first-year medical school courses.
□ Ask for advice from those who have recently taken the USMLE Step 1.

Months Prior
□ Review computer test format and registration information.
□ Register six months in advance. Carefully verify name and address printed on scheduling permit. Call
Prometric or go online for test date ASAP.
□ Define goals for the USMLE Step 1 (eg, comfortably pass, beat the mean, ace the test).
□ Set up a realistic timeline for study. Cover less crammable subjects first. Review subject-by-subject
emphasis and clinical vignette format.
□ Simulate the USMLE Step 1 to pinpoint strengths and weaknesses in knowledge and test-taking skills.
□ Evaluate and choose study methods and materials (eg, review books, question banks).

Weeks Prior
□ Simulate the USMLE Step 1 again. Assess how close you are to your goal.
□ Pinpoint remaining weaknesses. Stay healthy (exercise, sleep).
□ Verify information on admission ticket (eg, location, date).

One Week Prior

□ Remember comfort measures (loose clothing, earplugs, etc).
□ Work out test site logistics such as location, transportation, parking, and lunch.
□ Call Prometric and confirm your exam appointment.

One Day Prior

□ Relax.
□ Lightly review short-term material if necessary. Skim high-yield facts.
□ Get a good night’s sleep.
□ Make sure the name printed on your photo ID appears EXACTLY the same as the name printed on your
scheduling permit.

Day of Exam
□ Relax. Eat breakfast. Minimize bathroom breaks during the exam by avoiding excessive morning caffeine.
□ Analyze and make adjustments in test-taking technique. You are allowed to review notes/study material
during breaks on exam day.

After the Exam

□ Celebrate, regardless.
□ Send feedback to us on our website at www.firstaidteam.com.

xxii
SECTION I

Guide to Efficient
Exam Preparation

“A mind of moderate capacity which closely pursues one study must ` Introduction 2
infallibly arrive at great proficiency in that study.”
—Mary Shelley, Frankenstein ` USMLE Step 1—The
Basics 2
“Finally, from so little sleeping and so much reading, his brain dried up
and he went completely out of his mind.” ` Defining Your Goal 12
—Miguel de Cervantes Saavedra, Don Quixote
` Excelling in the
“Sometimes the questions are complicated and the answers are simple.” Preclinical Years 13
—Dr. Seuss
` Timeline for Study 14
“He who knows all the answers has not been asked all the questions.”
—Confucius ` Study Materials 18
“It’s what you learn after you know it all that counts.”
` Test-Taking
—John Wooden
Strategies 20
“A goal without a plan is just a wish.”
` Clinical Vignette
—Antoine de Saint-Exupéry
Strategies 21

` If You Think You

Failed 22

` Testing Agencies 22

` References 23

1
2 SEC TION I GUIDE TO EFFICIENT EXAM PREPARATION

`
INTRODUCTION

Relax.

This section is intended to make your exam preparation easier, not harder.
Our goal is to reduce your level of anxiety and help you make the most of
your efforts by helping you understand more about the United States Medical
Licensing Examination, Step 1 (USMLE Step 1). As a medical student, you
are no doubt familiar with taking standardized examinations and quickly
absorbing large amounts of material. When you first confront the USMLE
Step 1, however, you may find it all too easy to become sidetracked from your
goal of studying with maximal effectiveness. Common mistakes that students
make when studying for Step 1 include the following:

ƒ Starting to study (including First Aid) too late

ƒ Starting to study intensely too early and burning out
ƒ Starting to prepare for boards before creating a knowledge foundation
ƒ Using inefficient or inappropriate study methods
ƒ Buying the wrong resources or buying too many resources
ƒ Buying only one publisher’s review series for all subjects
ƒ Not using practice examinations to maximum benefit
ƒ Not understanding how scoring is performed or what the score means
` The test at a glance: ƒ Not using review books along with your classes
ƒ 8-hour exam ƒ Not analyzing and improving your test-taking strategies
ƒ Total of 280 multiple choice items ƒ Getting bogged down by reviewing difficult topics excessively
ƒ 7 test blocks (60 min/block) ƒ Studying material that is rarely tested on the USMLE Step 1
ƒ Up to 40 test items per block ƒ Failing to master certain high-yield subjects owing to overconfidence
ƒ 45 minutes of break time, plus another 15 ƒ Using First Aid as your sole study resource
if you skip the tutorial ƒ Trying to prepare for it all alone

In this section, we offer advice to help you avoid these pitfalls and be more
productive in your studies.

`
USMLE STEP 1—THE BASICS

The USMLE Step 1 is the first of three examinations that you must pass in
order to become a licensed physician in the United States. The USMLE is
a joint endeavor of the National Board of Medical Examiners (NBME) and
the Federation of State Medical Boards (FSMB). The USMLE serves as the
single examination system for US medical students and international medical
graduates (IMGs) seeking medical licensure in the United States.
 Another Random Document on
Scribd Without Any Related Topics
 ‘many a day
In these, to me, deserted towers,
Ere called but for a time away,
Affection’s mingling tears were ours?
Ours, too, the glance none saw beside;
The smile none else might understand;
The whispered thought: the walks aside;
The pressure of the thrilling hand;
The kiss so guiltless and relined,
That Love each warmer wish forbore;
Those eyes proclaimed so pure a mind,
Ev’n Passion blushed to plead for more.
The tone that taught me to rejoice,
When prone, unlike thee, to repine;
The song, celestial from thy voice,
But sweet to me from none but thine;
The pledge we wore—I wear it still,
But where is thine? Ah! where art thou?
Oft have I borne the weight of ill,
But never bent beneath till now!’
Six days after these lines were written Byron left Newstead. Writing
to Hodgson from his lodgings in St. James’s Street, he enclosed
some stanzas which he had written a day or two before, ‘on hearing
a song of former days.’ The lady, whose singing now so deeply
impressed Byron, was the Hon. Mrs. George Lamb, whom he had
met at Melbourne House.
In this, the second of the ‘Thyrza’ poems, the allusions to Mary
Chaworth are even more marked. Byron says the songs of Mrs.
George Lamb ‘speak to him of brighter days,’ and that he hopes to
hear those strains no more:
‘For now, alas!
I must not think, I may not gaze,
On what I am—on what I was.
 The voice that made those sounds more sweet
Is hush’d, and all their charms are fled.
* * * * * *
‘On my ear
The well-remembered echoes thrill;
I hear a voice I would not hear,
A voice that now might well be still.
* * * * * *
‘Sweet Thyrza! waking as in sleep,
Thou art but now a lovely dream;
A Star that trembled o’er the deep,
Then turned from earth its tender beam.
But he who through Life’s dreary way
Must pass, when Heaven is veiled in wrath,
Will long lament the vanished ray
That scattered gladness o’er his path.’
In Byron’s imagination Mary Chaworth was always hovering over him
like a star. She was the ‘starlight of his boyhood,’ the ‘star of his
destiny,’ and three years later the poet, in his unpublished fragment
‘Harmodia,’ speaks of Mary as his
‘melancholy star
Whose tearful beam shoots trembling from afar.’
The third and last of the ‘Thyrza’ poems must have been written at
about the same time as the other two. It appeared with ‘Childe
Harold’ in 1812. Byron, weary of the gloom of solitude, and tortured
by ‘pangs that rent his heart in twain,’ now determined to break
away and seek inspiration for that mental energy which formed part
of his nature. Man, he says, was not made to live alone.
‘I’ll be that light unmeaning thing
That smiles with all, and weeps with none.
It was not thus in days more dear,
It never would have been, but thou
Hast fled, and left me lonely here.’
Byron’s thoughts went back to the days when he was sailing over
the bright waters of the blue Ægean, in the Salsette frigate,
commanded by ‘good old Bathurst’[35]—those halcyon days when he
was weaving his visions into stanzas for ‘Childe Harold.’
‘On many a lone and lovely night
It soothed to gaze upon the sky;
For then I deemed the heavenly light
Shone sweetly on thy pensive eye:
And oft I thought at Cynthia’s noon,
When sailing o’er the Ægean wave,
“Now Thyrza gazes on that moon”—
Alas! it gleamed upon her grave!

‘When stretched on Fever’s sleepless bed,

And sickness shrunk my throbbing veins,
“’Tis comfort still,” I faintly said,
“That Thyrza cannot know my pains.”
Like freedom to the timeworn slave—
A boon ’tis idle then to give—
Relenting Nature vainly gave
My life, when Thyrza ceased to live!

‘My Thyrza’s pledge in better days,

When Love and Life alike were new!
How different now thou meet’st my gaze!
How tinged by time with Sorrow’s hue!
The heart that gave itself with thee
Is silent—ah, were mine as still!
Though cold as e’en the dead can be,
It feels, it sickens with the chill.’
Byron here suggests that the pledge in question was given with the
giver’s heart. Lovers are apt to interpret such gifts as ‘love-tokens,’
without suspicion that they may possibly have been due to a feeling
far less flattering to their hopes.
 ‘Thou bitter pledge! thou mournful token!
Though painful, welcome to my breast!
Still, still, preserve that love unbroken,
Or break the heart to which thou’rt pressed.
Time tempers Love, but not removes,
More hallowed when its Hope is fled.’
These three pieces comprise the so-called ‘Thyrza’ poems, and, in
the absence of proof to the contrary, we may reasonably suppose
that their subject was Mary Chaworth. This is the more likely
because the original manuscripts were the property of Byron’s sister,
to whom they were probably given by Mary Chaworth, when, in later
years, she destroyed or parted with all the letters and documents
which she had received from Byron since the days of their childhood.
Byron did not give up the hope of winning Mary Chaworth’s love
until her marriage in 1805. Two months later he entered Trinity
College, Cambridge, and from that time, until his departure with
Hobhouse on his first foreign tour, those who were in constant
intercourse with him never mentioned any other object of adoration
who might fit in with the Thyrza of the poems. If such a person had
really existed, Byron would certainly, either in conversation or in
writing, have disclosed her identity. Moore makes it clear that the
one passion of Byron’s life was Mary Chaworth. He tells us that there
were many fleeting love-episodes, but only one passion strong
enough to have inspired the poems in question. If Byron’s heart,
during the two years that he passed abroad, had been overflowing
with love for some incognita, it was not in his nature to have kept
silence. From his well-known effusiveness, reticence under such
circumstances is inconceivable.
Finally, as there were no poems, no letters, and no allusion to any
such person in the first draft of ‘Childe Harold,’ we may confidently
assume that the poet, in the loneliness of his heart, appealed to the
only woman whom he ever really loved, and that the legendary
Thyrza was a myth.
It will be remembered that the ninth stanza in the second canto of
‘Childe Harold’ was interpolated long after the manuscript had been
given to Dallas. It was forwarded for that purpose, three days after
the date of the poem ‘To Thyrza,’ and essentially belongs to that
period of desolation which inspired those poems:
‘There, Thou! whose Love and Life, together fled,
Have left me here to love and live in vain—
Twined with my heart, and can I deem thee dead,
When busy Memory flashes on my brain?
Well—I will dream that we may meet again,
And woo the vision to my vacant breast:
If aught of young Remembrance then remain,
Be as it may Futurity’s behest,
Or seeing thee no more, to sink to sullen rest.’[36]
It is difficult to believe that this stanza was inspired by a memory of
the dead. Are we not told that ‘Love and Life together fled’—in other
words, when Mary withdrew her love, she was dead to him?
He tells her that in abandoning him she has left him to love and live
in vain. And yet he will not give up the hope of meeting her again
some day; this is now his sole consolation. Memory of the past
(possibly those meetings which took place by stealth, shortly before
his departure from England in 1809) feeds the hope that now
sustains him. But he will leave everything to chance, and if fate
decides that they shall be parted for ever, then will he sink to sullen
apathy.
We may remind the reader that at this period (1811) Byron had no
belief in any existence after death.
‘I will have nothing to do with your immortality,’ he writes to
Hodgson in September; ‘we are miserable enough in this life,
without the absurdity of speculating upon another. If men are to live,
why die at all? and if they die, why disturb the sweet and sound
sleep that “knows no waking”?
‘“Post mortem nihil est, ipsaque Mors nihil ... quæris quo jaceas post
obitum loco? Quo non Nata jacent.”’
Even when, in later years, Byron somewhat modified the views of his
youth, he expressed an opinion that
‘A material resurrection seems strange, and even absurd, except for
purposes of punishment, and all punishment which is to revenge
rather than correct must be morally wrong.’
It is therefore tolerably certain that, on the day when he expressed a
hope that he might meet his lady-love again, the meeting was to
have been in this world, and not in that ‘land of souls beyond the
sable shore.’ It must also be remembered that the eighth stanza in
the second canto of ‘Childe Harold’ was substituted for one in which
Byron deliberately stated that he did not look for Life, where life may
never be. The revise was written to please Dallas, and does not
pretend to be a confession of belief in immortality, but merely an
admission that, on a subject where ‘nothing can be known,’ no final
decision is possible.
In the summer of 1813 Byron underwent grave vicissitudes, mental,
moral, and financial. His letters and journals teem with allusions to
some catastrophe. It seemed as though he were threatened with
impending ruin. In his depressed state of mind he found relief only,
as he tells us, in the composition of poetry. It was at this time that
he wrote in swift succession ‘The Giaour,’ ‘The Bride of Abydos,’ and
‘The Corsair.’ It is clear that Byron’s dejection was the result of a
hopeless attachment. Mr. Hartley Coleridge assumes that Byron’s
innamorata was Lady Frances Wedderburn Webster. But that bright
star did not long shine in Byron’s orbit—certainly not after October,
1813—and it is doubtful whether they were ever on terms of close
intimacy. Her husband had long been Byron’s friend. Byron had lent
him money, and had given him advice, which he seems to have
sorely needed. It is difficult to understand why Lady Frances
Webster should have been especially regarded as Byron’s Calypso.
There is nothing to show that she ever seriously occupied his
thoughts. Writing to Moore on September 27, 1813, Byron says:
‘I stayed a week with the Websters, and behaved very well, though
the lady of the house is young, religious, and pretty, and the master
is my particular friend. I felt no wish for anything but a poodle dog,
which they kindly gave me.’
So little does Byron seem to have been attracted by Lady Frances,
that he only once more visited the Websters, and then only for a few
days, on his way to Newstead, between October 3 and 10, 1813.
On June 3 of that year Byron wrote to Mr. John Hanson, his solicitor,
a letter which shows the state of his mind at that time. He tells
Hanson that he is about to visit Salt Hill, near Maidenhead, and that
he will be absent for one week. He is determined to go abroad. The
prospective lawsuit with Mr. Claughton (about the sale of Newstead)
is to be dropped, if it cannot be carried on in Byron’s absence. At all
hazards, at all losses, he is determined that nothing shall prevent
him from leaving the country.
‘If utter ruin were or is before me on the one hand, and wealth at
home on the other, I have made my choice, and go I will.’
The pictures, and every movable that could be converted into cash,
were, by Byron’s orders, to be sold. ‘All I want is a few thousand
pounds, and then, Adieu. You shan’t be troubled with me these ten
years, if ever.’ Clearly, there must have been something more than a
passing fancy which could have induced Byron to sacrifice his
chances of selling Newstead, for the sake of a few thousand pounds
of ready-money. It had been his intention to accompany Lord and
Lady Oxford on their travels, but this project was abandoned. After
three weeks—spent in running backwards and forwards between
Salt Hill and London—Byron confided his troubles to Augusta. She
was always his rock of refuge in all his deeper troubles. Augusta
Leigh thought that absence might mend matters, and tried hard to
keep her brother up to his resolve of going abroad; she even
volunteered to accompany him. But Lady Melbourne—who must
have had a prurient mind—persuaded Byron that the gossips about
town would not consider it ‘proper’ for him and his sister to travel
alone! As Byron was at that time under the influence of an
irresistible infatuation, Lady Melbourne’s warning turned the scale,
and the project fell through. Meanwhile the plot thickened.
Something—he told Moore—had ruined all his prospects of
matrimony. His financial circumstances, he said, were mending; ‘and
were not my other prospects blackening, I would take a wife.’
In July he still wishes to get out of England. ‘They had better let me
go,’ he says; ‘one can die anywhere.’
On August 22, after another visit to Salt Hill, Byron writes to Moore:
‘I have said nothing of the brilliant sex; but the fact is, I am at this
moment in a far more serious, and entirely new, scrape, than any of
the last twelve months, and that is saying a good deal. It is unlucky
we can neither live with nor without these women.’
A week later he wrote again to Moore:
‘I would incorporate with any woman of decent demeanour to-
morrow—that is, I would a month ago, but at present....’
Moore suggested that Byron’s case was similar to that of the youth
apostrophized by Horace in his twenty-seventh ode, and invited his
confidence:
‘Come, whisper it—the tender truth—
To safe and friendly ears!
What! Her? O miserable youth!
Oh! doomed to grief and tears!
In what a whirlpool are you tost,
Your rudder broke, your pilot lost!’
Recent research has convinced the present writer that the incident
which affected Byron so profoundly at this time—about eighteen
months before his marriage—indirectly brought about the separation
between Lord and Lady Byron in 1816. A careful student of Byron’s
character could not fail to notice, among all the contradictions and
inconsistencies of his life, one point upon which he was resolute—
namely, a consistent reticence on the subject of the intimacy which
sprang up between himself and Mary Chaworth in the summer of
1813. The strongest impulse of his life—even to the last—was a
steadfast, unwavering, hopeless attachment to that lady. Throughout
his turbulent youth, in his early as in his later days, the same theme
floats through the chords of his melodious verse, a deathless love
and a deep remorse. Even at the last, when the shadow of Death
was creeping slowly over the flats at Missolonghi, the same wild,
despairing note found involuntary expression, and the last words
that Byron ever wrote tell the sad story with a distinctness which
might well open the eyes even of the blind.
When he first met his fate, he was a schoolboy of sixteen—
precocious, pugnacious, probably a prig, and by no means
handsome. He must have appeared to Mary much as we see him in
his portrait by Sanders. Mary was two years older, and already in
love with a fox-hunting squire of good family. ‘Love dwells not in our
will,’ and a nature like Byron’s, once under its spell, was sure to feel
its force acutely. There was romance, too, in the situation; and the
poetic temperament—always precocious—responded to an impulse
on the gossamer chance of achieving the impossible. Mary was
probably half amused and half flattered by the adoration of a boy of
whose destiny she divined nothing.
There is no reason to suppose that there was any meeting between
Byron and Mary Chaworth after the spring of 1809, until the summer
of 1813. Their separation seemed destined to be final. Although
Byron, in after-years, wished it to be believed that they had not met
since 1808, it is certain that a meeting took place in the summer of
1813. Although Byron took, as we shall see presently, great pains to
conceal that fact from the public, he did not attempt to deceive
either Moore, Hobhouse, or Hodgson. In his letter to Monsieur
Coulmann, written in July, 1823, we have the version which Byron
wished the public to believe.
‘I had not seen her [Mary Chaworth] for many years. When an
occasion offered, I was upon the point, with her consent, of paying
her a visit, when my sister, who has always had more influence over
me than anyone else, persuaded me not to do it. “For,” said she, “if
you go, you will fall in love again, and then there will be a scene;
one step will lead to another, et cela fera un éclat,” etc. I was guided
by these reasons, and shortly after I married.... Mrs. Chaworth some
time after, being separated from her husband, became insane; but
she has since recovered her reason, and is, I believe, reconciled to
her husband.’
At about the same time Byron told Medwin that, after Mary’s
separation from her husband, she proposed an interview with him—
a suggestion which Byron, by the advice of Mrs. Leigh, declined. He
also said to Medwin:
‘She [Mary Chaworth] was the beau-idéal of all that my youthful
fancy could paint of beautiful; and I have taken all my fables about
the celestial nature of women from the perfection my imagination
created in her—I say created, for I found her, like the rest of her
sex, anything but angelic.’
It is difficult to see how Byron could have arrived at so unflattering
an estimate of a woman whom he had only once seen since her
marriage—at a dinner-party, when, as he has told us, he was
overcome by shyness and a feeling of awkwardness! But let that
pass. Byron wished the world to believe (1) that Mary Chaworth,
after the separation from her husband in 1813, proposed a meeting
with Byron; (2) that he declined to meet her; (3) that, after his
unfortunate marriage, Mary became insane; and (4) that he found
her, ‘like the rest of her sex, anything but angelic.’
It is quite possible, of course, that Byron may have at first refused to
meet the only woman on earth whom he sincerely loved, and more
than likely that Mrs. Leigh did her utmost to dissuade him from so
rash a proceeding. But it is on record that Byron incautiously
admitted to Medwin that he did meet Mary Chaworth after his return
from Greece.[37] It will be remembered that he returned from Greece
in 1811. Their intimacy had long before been broken off by Mr. John
Musters; and, as we have seen, Mary, faithful to a promise which
she had made to her husband, kept away from Annesley during the
period (1811) when the ‘Thyrza’ poems were written. It is doubtful
whether they would ever again have met if her husband had shown
any consideration for her feelings. But he showed her none. When,
nearly forty years ago, the present writer visited Annesley, there
were several people living who remembered both Mary Chaworth
and her husband. These people stated that their married life, so full
of grief and bitterness, was a constant source of comment both at
Annesley and Newstead. The trouble was attributed to the harsh and
capricious conduct, and the well-known infidelities, of one to whose
kindness and affection Mary had a sacred claim. She seems to have
been left for long periods at Annesley with only one companion, Miss
Anne Radford, who had been brought up with her from childhood.
This state of things eventually broke down, and when, in the early
part of 1813, Mary could stand the strain no longer, a separation
took place by mutual consent.
In the summer of that year Byron and this unhappy woman were
thrown together by the merest accident, and, unfortunately for both,
renewed their dangerous friendship.
Byron’s friend and biographer, Thomas Moore, took great pains to
suppress every allusion to Mary Chaworth in Byron’s memoranda and
letters. He faithfully kept the secret. There is nothing in Byron’s
letters or journals, as revised by Moore, to show that they ever met
after 1808, and yet they undoubtedly did meet in 1813, after Mary’s
estrangement from her husband. That they were in constant
correspondence in November of that year may be gathered from
Byron’s journal, where Mary’s name is veiled by asterisks.
On November 24 he writes:
‘I am tremendously in arrear with my letters, except to * * * *, and
to her my thoughts overpower me: my words never compass them.’
‘I have been pondering,’ he writes on the 26th, ‘on the miseries of
separation, that—oh! how seldom we see those we love! Yet we live
ages in moments when met.’
Then follows, on the 27th, a clue:
‘I believe, with Clym o’ the Clow, or Robin Hood,
‘“By our Mary (dear name!) thou art both Mother and May,
I think it never was a man’s lot to die before his day.”’
It is attested, by all those who were acquainted with Mary Chaworth,
that she always bore an exemplary character. It was well known that
her marriage was an unhappy one, and that she had been for some
time deserted by her husband. In June, 1813, when she fell under
the fatal spell of Byron, then the most fascinating man in society,[38]
she was living in deep dejection, parted from her lawful protector,
with whom she had a serious disagreement. He had neglected her,
and she well knew that she had a rival in his affections at that time.
It was in these distressing circumstances that Byron, with the world
at his feet, came to worship her in great humility. As he looked back
upon the past, he realized that this neglected woman had always
been the light of his life, the lodestar of his destiny. And now that he
beheld his ‘Morning Star of Annesley’ shedding ineffectual rays upon
the dead embers of a lost love, the old feeling returned to him with
resistless force.
‘We met—we gazed—I saw, and sighed;
She did not speak, and yet replied;
There are ten thousand tones and signs
We hear and see, but none defines—
Involuntary sparks of thought,
Which strike from out the heart o’erwrought,
And form a strange intelligence,
 Alike mysterious and intense,
Which link the burning chain that binds,
Without their will, young hearts and minds.
I saw, and sighed—in silence wept,
And still reluctant distance kept,
Until I was made known to her,
And we might then and there confer
Without suspicion—then, even then,
I longed, and was resolved to speak;
But on my lips they died again,
The accents tremulous and weak,
Until one hour...
* * * * * *
‘I would have given
My life but to have called her mine
In the full view of Earth and Heaven;
For I did oft and long repine
That we could only meet by stealth.’
In the remorseful words of Manfred,
‘Her faults were mine—her virtues were her own—
I loved her, and destroyed her!...
Not with my hand, but heart—which broke her heart—
It gazed on mine and withered.’
Without attempting to excuse Byron’s conduct—indeed, that were
useless—it must be remembered that he was only twenty-five years
of age, and Mary was very unhappy. After all hope of meeting her
again had been abandoned, the force of destiny, so to speak, had
unexpectedly restored his lost Thyrza—the Theresa of ‘Mazeppa.’
‘I loved her then, I love her still;
And such as I am, love indeed
In fierce extremes—in good and ill—
But still we love...
 Haunted to our very age
With the vain shadow of the past.’
Byron’s punishment was in this world. The remorse which followed
endured throughout the remaining portion of his life. It wrecked
what might have proved a happy marriage, and drove him, from
stone to stone, along life’s causeway, to that ‘Sea Sodom’ where, for
many months, he tried to destroy the memory of his crime by
reckless profligacy.
Mary Chaworth no sooner realized her awful danger—the madness
of an impulse which not even love could excuse—than she recoiled
from the precipice which yawned before her. She had been
momentarily blinded by the irresistible fascination of one who, after
all, really and truly loved her. But she was a good woman in spite of
this one episode, and to the last hour of her existence she never
swerved from that narrow path which led to an honoured grave.
Although it was too late for happiness, too late to evade the
consequences of her weakness, there was still time for repentance.
The secret was kept inviolate by the very few to whom it was
confided, and the present writer deeply regrets that circumstances
have compelled him to break the seal.
If ‘Astarte’ had not been written, there would have been no need to
lift the veil. Lord Lovelace has besmirched the good name of Mrs.
Leigh, and it is but an act of simple justice to defend her.
When Mary Chaworth escaped from Byron’s fatal influence, he
reproached her for leaving him, and tried to shake her resolution
with heart-rending appeals. Happily for both, they fell upon deaf
ears.
‘Astarte! my beloved! speak to me;
Say that thou loath’st me not—that I do bear
This punishment for both.’
The depth and sincerity of Byron’s love for Mary Chaworth cannot be
questioned. Moore, who knew him well, says:
‘The all-absorbing and unsuccessful (unsatisfied) love for Mary
Chaworth was the agony, without being the death, of an unsated
desire which lived on through life, filled his poetry with the very soul
of tenderness, lent the colouring of its light to even those unworthy
ties which vanity or passion led him afterwards to form, and was the
last aspiration of his fervid spirit, in those stanzas written but a few
months before his death.’
It was, in fact, a love of such unreasonableness and persistence as
might be termed, without exaggeration, a madness of the heart.
Although Mary escaped for ever from that baneful infatuation, which
in an unguarded moment had destroyed her peace of mind, her
separation from Byron was not complete until he married. Not only
did they correspond frequently, but they also met occasionally. In
the following January (1814) Byron introduced Mary to Augusta
Leigh. From that eventful meeting, when probable contingencies
were provided for, until Mary’s death in 1832, these two women,
who had suffered so much through Byron, continued in the closest
intimacy; and in November, 1819, Augusta stood sponsor for Mary’s
youngest daughter.
In a poem which must have been written in 1813, an apostrophe ‘To
Time,’ Byron refers to Mary’s resolutions.
‘In Joy I’ve sighed to think thy flight
Would soon subside from swift to slow;
Thy cloud could overcast the light,
But could not add a night to Woe;
For then, however drear and dark,
My soul was suited to thy sky;
One star alone shot forth a spark
To prove thee—not Eternity.
That beam hath sunk.’
It is of course true that matters were not, and could never again be,
on the same footing as in July of that year; but Mary Chaworth was
constancy itself, in a higher and a nobler sense than Byron attached
to it, when he reproached her for broken vows.
‘Thy vows are all broken,
And light is thy fame:
I hear thy name spoken,
And share in its shame.’
During the remainder of Byron’s life, Mary took a deep interest in
everything that affected him. In 1814, believing that marriage would
be his salvation, she used her influence in that direction. We know
that she did not approve of the choice which Byron so recklessly
made, and she certainly had ample cause to deplore its results.
Through her close intimacy with Augusta Leigh—an intimacy which
has not hitherto been suspected—she became acquainted with every
phase in Byron’s subsequent career. She could read ‘between the
lines,’ and solve the mysteries to be found in such poems as ‘Lara,’
‘Mazeppa,’ ‘Manfred,’ and ‘Don Juan.’
We believe that Byron’s love for Mary was the main cause of the
indifference he felt towards his wife. In order to shield Mary from the
possible consequences of a public investigation into conduct prior to
his marriage, Byron, in 1816, consented to a separation from his
wife.
After Byron had left England Mary broke down under the strain she
had borne so bravely, and her mind gave way. When at last, in April,
1817, a reconciliation took place between Mary and her husband, it
was apparent to everyone that she had, during those four anxious
years, become a changed woman. She never entirely regained either
health or spirits. Her mind ‘had acquired a tinge of religious
melancholy, which never afterwards left it.’ Sorrow and
disappointment had subdued a naturally buoyant nature, and
‘melancholy marked her for its own.’ Shortly before her death, in
1832, she destroyed every letter she had received from Byron since
those distant fateful years when, as boy and girl, they had wandered
on the Hills of Annesley. For eight sad years Mary Chaworth survived
the lover of her youth. Shortly before her death, in a letter to one of
her daughters, she drew her own character which might fitly form
her epitaph: ‘Soon led, easily pleased, very hasty, and very relenting,
with a heart moulded in a warm and affectionate fashion.’
Such was the woman who, though parted by fate, maintained
through sunshine and storm an ascendancy over the heart of Byron
which neither time nor absence could impair, and which endured to
the end of his earthly existence. We may well believe that those
inarticulate words which the dying poet murmured to the bewildered
Fletcher—those broken sentences which ended with, ‘Tell her
everything; you are friends with her’—may have referred, not to
Lady Byron, as policy suggested, but to Mary Chaworth, with whom
Fletcher had been acquainted since his youth.
We have incontestable proof that, only two months before he died,
Byron’s thoughts were occupied with one whom he had named ‘the
starlight of his boyhood.’ How deeply Byron thought about Mary
Chaworth at the last is proved by the poem which was found among
his papers at Missolonghi. In six stanzas the poet revealed the story
that he would fain have hidden. A note in his handwriting states that
they were addressed ‘to no one in particular,’ and that they were
merely ‘a poetical scherzo.’ There is, however, no room for doubt
that the poem bears a deep significance.
I.
‘I watched thee when the foe was at our side,
Ready to strike at him—or thee and me
Were safety hopeless—rather than divide
Aught with one loved, save love and liberty.’
We have here a glimpse of that turbulent scene when Mary’s
husband, in a fit of jealousy, put an end to their dangerous intimacy.
 II.
‘I watched thee on the breakers, when the rock
Received our prow, and all was storm and fear,
And bade thee cling to me through every shock;
This arm would be thy bark, or breast thy bier.’
This brings us to that period of suspense and fear, in 1814, which
preceded the birth of Medora. In a letter which Byron at that time
wrote to Miss Milbanke, we find these words:
‘I am at present a little feverish—I mean mentally—and, as usual, on
the brink of something or other, which will probably crush me at last,
and cut our correspondence short, with everything else.’
Twelve days later (March 3, 1814), Byron tells Moore that he is
‘uncomfortable,’ and that he has ‘no lack of argument to ponder
upon of the most gloomy description.’
‘Some day or other,’ he writes, ‘when we are veterans, I may tell you
a tale of present and past times; and it is not from want of
confidence that I do not now.... All this would be very well if I had
no heart; but, unluckily, I have found that there is such a thing still
about me, though in no very good repair, and also that it has a habit
of attaching itself to one, whether I will or no. Divide et impera, I
begin to think, will only do for politics.’
When Moore, who was puzzled, asked Byron to explain himself more
clearly, he replied: ‘Guess darkly, and you will seldom err.’
Thirty-four days later Medora was born, April 15, 1814.
III.
‘I watched thee when the fever glazed thine eyes,
Yielding my couch, and stretched me on the ground,
When overworn with watching, ne’er to rise
From thence if thou an early grave had found.’
Here we see Byron’s agony of remorse. Like Herod, he lamented for
Mariamne:
 ‘And mine’s the guilt, and mine the hell,
This bosom’s desolation dooming;
And I have earned those tortures well
Which unconsumed are still consuming!’
In ‘Manfred’ we find a note of remembrance in the deprecating
words:
‘Oh! no, no, no!
My injuries came down on those who loved me—
On those whom I best loved: I never quelled
An enemy, save in my just defence—
But my embrace was fatal.’

IV.
‘The earthquake came, and rocked the quivering wall,
And men and Nature reeled as if with wine:
Whom did I seek around the tottering hall?
For thee. Whose safety first provide for? Thine.’
We now see Byron, at the supreme crisis of his life, standing in
solitude on his hearth, with all his household gods shivered around
him. We perceive that not least among his troubles at that time was
the ever-haunting fear lest the secret of Medora’s birth should be
disclosed. His greatest anxiety was for Mary’s safety, and this could
only be secured by keeping his matrimonial squabbles out of a court
of law. It was, in fact, by agreeing to sign the deed of separation
that the whole situation was saved. The loyalty of Augusta Leigh on
this occasion was never forgotten:
‘There was soft Remembrance and sweet Trust
In one fond breast.’

‘That love was pure—and, far above disguise,

Had stood the test of mortal enmities
Still undivided, and cemented more
 By peril, dreaded most in female eyes,
But this was firm.’
In the fifth stanza we see Byron, eight years later, at Missolonghi,
struck down by that attack of epilepsy which preceded his death by
only two months:
V.
‘And when convulsive throes denied my breath
The faintest utterance to my fading thought,
To thee—to thee—e’en in the gasp of death
My spirit turned, oh! oftener than it ought.’
In the sixth and final stanza, probably the last lines that Byron ever
wrote, we find him reiterating, with all a lover’s persistency, a belief
that Mary could never have loved him, otherwise she would not have
left him.
VI.
‘Thus much and more; and yet thou lov’st me not,
And never will! Love dwells not in our will.
Nor can I blame thee, though it be my lot
To strongly, wrongly, vainly love thee still.’
The reproaches of lovers are often unjust. Byron either could not, or
perhaps would not, see that in abandoning him Mary had been
actuated by the highest, the purest motives, and that the
renunciation must have afforded her deep pain—a sacrifice, not
lightly made, for Byron’s sake quite as much as for her own. That
Byron for a time resented her conduct in this respect is evident from
a remark made in a letter to Miss Milbanke, dated November 29,
1813. After saying that he once thought that Mary Chaworth could
have made him happy, he added, ‘but subsequent events have
proved that my expectations might not have been fulfilled had I ever
proposed to and received my idol.’[39]
What those ‘subsequent events’ were may be guessed from
reproaches which at this period appear among his poems:
 ‘The wholly false the heart despises,
And spurns deceiver and deceit;
But she who not a thought disguises,
Whose love is as sincere as sweet—
When she can change, who loved so truly,
It feels what mine has felt so newly.’
In the letter written five years after their final separation, Byron
again reproaches Mary Chaworth, but this time without a tinge of
bitterness:
‘My own, we may have been very wrong, but I repent of nothing
except that cursed marriage, and your refusing to continue to love
me as you had loved me. I can neither forget nor quite forgive you
for that precious piece of reformation. But I can never be other than
I have been, and whenever I love anything, it is because it reminds
me in some way or other of yourself.’
‘The Giaour’ was begun in May and finished in November, 1813.
Those parts which relate to Mary Chaworth were added to that
poem in July and August:
‘She was a form of Life and Light,
That, seen, became a part of sight;
And rose, where’er I turned mine eye,
The Morning-Star of Memory!’
Byron says that, like the bird that sings within the brake, like the
swan that swims upon the waters, he can only have one mate. He
despises those who sneer at constancy. He does not envy them their
fickleness, and regards such heartless men as lower in the scale of
creation than the solitary swan.
‘Such shame at least was never mine—
Leila! each thought was only thine!
My good, my guilt, my weal, my woe,
My hope on high—my all below.
Earth holds no other like to thee,
 Or, if it doth, in vain for me:
... Thou wert, thou art,
The cherished madness of my heart!’

‘Yes, Love indeed is light from heaven;

A spark of that immortal fire
With angels shared, by Alla given,
To lift from earth our low desire.
I grant my love imperfect, all
That mortals by the name miscall;
Then deem it evil, what thou wilt;
But say, oh say, hers was not Guilt!
And she was lost—and yet I breathed,
But not the breath of human life:
A serpent round my heart was wreathed,
And stung my every thought to strife.’
Who can doubt that the friend ‘of earlier days,’ whose memory the
Giaour wishes to bless before he dies, but whom he dares not bless
lest Heaven should ‘mark the vain attempt’ of guilt praying for the
guiltless, was Mary Chaworth. He bids the friar tell that friend
‘What thou didst behold:
The withered frame—the ruined mind,
The wreck that Passion leaves behind—
The shrivelled and discoloured leaf,
Seared by the Autumn blast of Grief.’
He wonders whether that friend is still his friend, as in those earlier
days, when hearts were blended in that sweet land where bloom his
native valley’s bowers. To that friend he sends a ring, which was the
memorial of a youthful vow:
‘Tell him—unheeding as I was,
Through many a busy bitter scene
Of all our golden youth hath been,
In pain, my faltering tongue had tried
 To bless his memory—ere I died;
I do not ask him not to blame,
Too gentle he to wound my name;
I do not ask him not to mourn,
Such cold request might sound like scorn.
But bear this ring, his own of old,
And tell him what thou dost behold!’
The motto chosen by Byron for ‘The Giaour’ is in itself suggestive:
‘One fatal remembrance—one sorrow that throws
Its bleak shade alike o’er our Joys and our Woes—
To which Life nothing darker nor brighter can bring,
For which Joy hath no balm—and affliction no sting.’
On October 10, 1813, Byron arrived at Newstead, where he stayed
for a month. Mary Chaworth was at Annesley during that time. On
his return to town he wrote (November 8) to his sister:
‘My dearest Augusta,
‘I have only time to say that my long silence has been occasioned by
a thousand things (with which you are not concerned). It is not Lady
Caroline, nor Lady Oxford; but perhaps you may guess, and if you
do, do not tell. You do not know what mischief your being with me
might have prevented. You shall hear from me to-morrow; in the
meantime don’t be alarmed. I am in no immediate peril.
‘Believe me, ever yours,
‘B.’
On November 30 Byron wrote to Moore:
‘We were once very near neighbours this autumn;[40] and a good
and bad neighbourhood it has proved to me. Suffice it to say that
your French quotation (Si je récommençais ma carrière, je ferais tout
ce que j’ai fait) was confoundedly to the purpose,—though very
unexpectedly pertinent, as you may imagine by what I said before,
and my silence since. However, “Richard’s himself again,” and,
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