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Chapter Authors
Contributors
Research and Review
Foreword
Preface
SECTION
Anesthetic Equipment & Monitors
I
3 Breathing Systems
4 The Anesthesia Workstation
5 Cardiovascular Monitoring
6 Noncardiovascular Monitoring
SECTION
II
Clinical Pharmacology
7 Pharmacological Principles
8 Inhalation Anesthetics
9 Intravenous Anesthetics
10 Analgesic Agents
11 Neuromuscular Blocking Agents
12 Cholinesterase Inhibitors & Other Pharmacological Antagonists
to Neuromuscular Blocking Agents
13 Anticholinergic Drugs
14 Adrenergic Agonists & Antagonists
15 Hypotensive Agents
16 Local Anesthetics
17 Adjuncts to Anesthesia
SECTION
Anesthetic Management
III
18 Preoperative Assessment, Premedication, & Perioperative
Documentation
19 Airway Management
20 Cardiovascular Physiology & Anesthesia
21 Anesthesia for Patients with Cardiovascular Disease
22 Anesthesia for Cardiovascular Surgery
23 Respiratory Physiology & Anesthesia
24 Anesthesia for Patients with Respiratory Disease
25 Anesthesia for Thoracic Surgery
26 Neurophysiology & Anesthesia
27 Anesthesia for Neurosurgery
28 Anesthesia for Patients with Neurological & Psychiatric Diseases
29 Anesthesia for Patients with Neuromuscular Disease
30 Kidney Physiology & Anesthesia
31 Anesthesia for Patients with Kidney Disease
41 Obstetric Anesthesia
Michael A. Frölich, MD, MS
42 Pediatric Anesthesia
43 Geriatric Anesthesia
44 Ambulatory & Non–Operating Room Anesthesia
SECTION
Regional Anesthesia & Pain
IV Management
SECTION
Perioperative & Critical Care
V Medicine
54 Anesthetic Complications
55 Cardiopulmonary Resuscitation
N. Martin Giesecke, MD and George W. Williams, MD, FASA, FCCP
56 Postanesthesia Care
57 Common Clinical Concerns in Critical Care Medicine
58 Inhalation Therapy & Mechanical Ventilation in the PACU &
ICU
David C. Mackey, MD
Professor
Department of Anesthesiology and Perioperative Medicine
University of Texas MD Anderson Cancer Center
Houston, Texas
Sarah Madison, MD
Assistant Professor
Department of Anesthesiology, Perioperative & Pain Medicine
Stanford University
Stanford, California
Richard W. Rosenquist, MD
Chairman, Department of Pain Management
Cleveland Clinic
Cleveland, Ohio
Lydia Conlay, MD
Professor
Department of Anesthesia
Texas Tech University Health Sciences Center
Lubbock, Texas
Johannes De Riese, MD
Assistant Professor
Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas
Suzanne N. Northcutt, MD
Associate Professor
Department of Anesthesia
Texas Tech University Health Sciences Center
Lubbock, Texas
Aschraf N. Farag, MD
Assistant Professor
Department of Anesthesia
Texas Tech University Health Sciences Center
Lubbock, Texas
Pranav Shah, MD
Assistant Professor
Department of Anesthesiology
VCU School of Medicine
Richmond, Virginia
Robert Johnston, MD
Associate Professor
Department of Anesthesia
Texas Tech University Health Sciences Center
Lubbock, Texas
Sabry Khalil, MD
Assistant Professor
Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas
Sanford Littwin, MD
Assistant Professor
Department of Anesthesiology
St. Luke’s Roosevelt Hospital Center and Columbia University College of
Physicians and Surgeons
New York, New York
Alina Nicoara, MD
Associate Professor
Department of Anesthesiology
Duke University Medical Center
Durham, North Carolina
Nitin Parikh, MD
Associate Professor
Department of Anesthesia
Texas Tech University Health Sciences Center
Lubbock, Texas
Cooper W. Phillips, MD
Assistant Professor
Department of Anesthesiology
UT Southwestern Medical Center
Dallas, Texas
Elizabeth R. Rivas, MD
Assistant Professor
Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas
Chase Clanton, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas
Aaron Darais, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Medical Center
Lubbock, Texas
Jacqueline E. Geier, MD
Formerly Resident, Department of Anesthesiology
St. Luke’s Roosevelt Hospital Center
New York, New York
Brian Hirsch, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas
Shane Huffman, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Medical Center
Lubbock, Texas
Rahul K. Mishra, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Medical Center
Lubbock, Texas
Cecilia N. Pena, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Medical Center Hospital
Lubbock, Texas
Spencer Thomas, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas
Trevor Walker, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Medical Center
Lubbock, Texas
Charlotte M. Walter, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Medical Center
Lubbock, Texas
Karvier Yates, MD
Formerly Resident, Department of Anesthesiology
Texas Tech University Medical Center
Lubbock, Texas
Shiraz Yazdani, MD
Assistant Professor
Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas
Foreword
My, how time flies! Can half a decade already have passed since we last edited
this textbook? Yet, the time has passed and our field has undergone many
changes. We are grateful to the readers of the fifth edition of our textbook. The
widespread use of this work have ensured that the time and effort required to
produce a sixth edition are justified.
As was true for the fifth edition, the sixth edition represents a significant
revision. A few examples are worth noting:
• Those familiar with the sequence and grouping of content in the fifth edition
will notice that chapters have been reordered and content broken out or
consolidated to improve the flow of information and eliminate redundancy.
• The alert reader will note that the section on critical care medicine has been
expanded, reflecting the increasing number of very sick patients for whom
we care.
• Enhanced recovery after surgery has progressed from an important concept to
a commonly used acronym (ERAS), a specialty society, and (soon) standard
of care.
• Ultrasound has never been more important in anesthesia practice, and its use
in various procedures is emphasized throughout the textbook.
Some things remain unchanged:
• We have not burdened our readers with large numbers of unnecessary
references. We hope that long lists of references at the end of textbook
chapters will soon go the way of the library card catalog and long-distance
telephone charges. We assume that our readers are as fond of (and likely as
facile with) Google Scholar and PubMed as are we, and can generate their
own lists of references whenever they like. We continue to provide URLs for
societies, guidelines, and practice advisories.
• We continue to emphasize Key Concepts at the beginning of each chapter
that link to the chapter discussion, and case discussions at the end.
• We have tried to provide illustrations and images whenever they improve
the flow and understanding of the text.
Once again, the goal expressed in the first edition remains unchanged: “to
provide a concise, consistent presentation of the basic principles essential to the
modern practice of anesthesia.” And, once again, despite our best intentions, we
fear that errors will be found in our text. We are grateful to the many readers
who helped improve the last edition. Please email us at mm6edition@gmail.com
when you find errors. This enables us to make corrections in reprints and future
editions.
1
The Practice of Anesthesiology
KEY CONCEPTS
Oliver Wendell Holmes in 1846 was the first to propose use of the term
anesthesia to denote the state that incorporates amnesia, analgesia, and
narcosis to make painless surgery possible.
Ether was used for frivolous purposes (“ether frolics”) and was not used
as an anesthetic agent in humans until 1842, when Crawford W. Long
and William E. Clark independently used it on patients. On October 16,
1846, William T.G. Morton conducted the first publicized
demonstration of general anesthesia for surgical operation using ether.
The original application of modern local anesthesia is credited to Carl
Koller, at the time a house officer in ophthalmology, who demonstrated
topical anesthesia of the eye with cocaine in 1884.
Curare greatly facilitated tracheal intubation and muscle relaxation
during surgery. For the first time, operations could be performed on
patients without the requirement that relatively deep levels of inhaled
general anesthetic be used to produce muscle relaxation.
John Snow, often considered the father of the anesthesia specialty, was
the first to scientifically investigate ether and the physiology of general
anesthesia.
The “captain of the ship” doctrine, which held the surgeon responsible
for every aspect of the patient’s perioperative care (including
anesthesia), is no longer a valid notion when an anesthesiologist is
present.
The Greek philosopher Dioscorides first used the term anesthesia in the first
century AD to describe the narcotic-like effects of the plant mandragora. The
term subsequently was defined in Bailey’s An Universal Etymological English
Dictionary (1721) as “a defect of sensation” and again in the Encyclopedia
Britannica (1771) as “privation of the senses.” Oliver Wendell Holmes in 1846
was the first to propose use of the term to denote the state that incorporates
amnesia, analgesia, and narcosis to make painless surgery possible. In the United
States, use of the term anesthesiology to denote the practice or study of
anesthesia was first proposed in the second decade of the twentieth century to
emphasize the growing scientific basis of the specialty.
Although anesthesia now rests on scientific foundations comparable to those
of other specialties, the practice of anesthesia remains very much a mixture of
science and art. Moreover, the practice has expanded well beyond rendering
patients insensible to pain during surgery or obstetric delivery (Table 1–1).
Anesthesiologists require a working familiarity with a long list of other
specialties, including surgery and its subspecialties, internal medicine, pediatrics,
palliative care, and obstetrics, as well as imaging techniques (particularly
ultrasound), clinical pharmacology, applied physiology, safety science, process
improvement, and biomedical technology. Advances in scientific underpinnings
of anesthesia make it an intellectually stimulating and rapidly evolving specialty.
Many physicians entering residency positions in anesthesiology will already
have multiple years of graduate medical education and perhaps certification in
other medical specialties.
TABLE 1–1 Aspects of the practice of medicine that are included within the
scope of anesthesiology.1
This chapter reviews the history of anesthesia, emphasizing its British and
American roots, and considers the current scope of the specialty.
INHALATION ANESTHESIA
Because the hypodermic needle was not invented until 1855, the first general
anesthetics were destined to be inhalation agents. Diethyl ether (known at the
time as “sulfuric ether” because it was produced by a simple chemical reaction
between ethyl alcohol and sulfuric acid) was originally prepared in 1540 by
Valerius Cordus. Ether was used for frivolous purposes (“ether frolics”), but not
as an anesthetic agent in humans until 1842, when Crawford W. Long and
William E. Clark independently used it on patients for surgery and dental
extraction, respectively. However, neither Long nor Clark publicized his
discovery. Four years later, in Boston, on October 16, 1846, William T.G.
Morton conducted the first publicized demonstration of general anesthesia for
surgical operation using ether. The dramatic success of that exhibition led the
operating surgeon to exclaim to a skeptical audience: “Gentlemen, this is no
humbug!”
Chloroform was independently prepared by Moldenhawer, von Liebig,
Guthrie, and Soubeiran around 1831. Although first used by Holmes Coote in
1847, chloroform was introduced into clinical practice by the Scot Sir James
Simpson, who administered it to his patients to relieve the pain of labor.
Ironically, Simpson had almost abandoned his medical practice after witnessing
the terrible despair and agony of patients undergoing operations without
anesthesia.
Joseph Priestley produced nitrous oxide in 1772, and Humphry Davy first
noted its analgesic properties in 1800. Gardner Colton and Horace Wells are
credited with having first used nitrous oxide as an anesthetic for dental
extractions in humans in 1844. Nitrous oxide’s lack of potency (an 80% nitrous
oxide concentration results in analgesia but not surgical anesthesia) led to
clinical demonstrations that were less convincing than those with ether.
Nitrous oxide was the least popular of the three early inhalation anesthetics
because of its low potency and its tendency to cause asphyxia when used alone
(see Chapter 8). Interest in nitrous oxide was revived in 1868 when Edmund
Andrews administered it in 20% oxygen; its use was, however, overshadowed by
the popularity of ether and chloroform. Ironically, nitrous oxide is the only one
of these three agents still in use today. Chloroform superseded ether in popularity
in many areas (particularly in the United Kingdom), but reports of chloroform-
related cardiac arrhythmias, respiratory depression, and hepatotoxicity
eventually caused practitioners to abandon it in favor of ether, particularly in
North America.
Even after the introduction of other inhalation anesthetics (ethyl chloride,
ethylene, divinyl ether, cyclopropane, trichloroethylene, and fluroxene), ether
remained the standard inhaled anesthetic until the early 1960s. The only
inhalation agent that rivaled ether’s safety and popularity was cyclopropane
(introduced in 1934). However, both are highly combustible and both have since
been replaced by a succession of nonflammable potent fluorinated hydrocarbons:
halothane (developed in 1951; released in 1956), methoxyflurane (developed in
1958; released in 1960), enflurane (developed in 1963; released in 1973), and
isoflurane (developed in 1965; released in 1981).
Currently, sevoflurane is by far the most popular inhaled agent in developed
countries. It is far less pungent than isoflurane and has low blood solubility. Ill-
founded concerns about the potential toxicity of its degradation products delayed
its release in the United States until 1994 (see Chapter 8). These concerns have
proved to be theoretical. Sevoflurane is very suitable for inhaled inductions and
has largely replaced halothane in pediatric practice. Desflurane (released in
1992) has many of the desirable properties of isoflurane as well as more rapid
uptake and elimination (nearly as fast as nitrous oxide). Sevoflurane, desflurane,
and isoflurane are the most commonly used inhaled agents in developed
countries worldwide.
Before they embraced, they bent low each of them three times in reverence, and
the Queen took off her hat, so that she remained in her coif with her face
uncovered; and the King came to her and embraced her and kissed her on the
cheek. Afterwards he went to his daughter and embraced and kissed her also,
making the sign of the cross in token of his blessing.
Isabel remained with the Christian forces for the rest of the
campaign; while in the following spring she and Ferdinand collected
a new army at Cordova, mainly recruited from the levies of
Andalusia. It was their intention to attack the town of Velez-Malaga,
now left high and dry, but then a flourishing seaport, situated at the
extremity of a long ridge of mountains stretching down to the
Mediterranean. Its capture would not only lay bare the fertile valley
to the west, but would also insert a hostile wedge between the
important city of Malaga some five miles distant and the capital,
where El Zagal maintained his uneasy throne.
The relations between the rival Sultans had not been improved by
the capitulation of Loja; and soon afterwards an unsuccessful
attempt on the part of the uncle to poison his nephew had led to
renewed struggles in Granada itself. Boabdil, in his eagerness for
revenge had appealed to Ferdinand for help; but the commander of
the Christian troops sent to the scene of action, while pretending to
lend support, contented himself with fomenting the discord that he
found, thus encouraging the “King of the Alhambra” and the “King of
the Albaycin” to work their mutual destruction.
When the news came that the Christian army had pitched its camp
before Velez-Malaga, bringing with it all its heavy guns, “El Zagal”
was torn with indecision. To go to the assistance of the besieged was
to leave his palace of the Alhambra exposed to Boabdil’s attack; to
stay was to sacrifice an important harbour, besides losing his
popularity with the inhabitants of Granada, who looked to him for
the deeds of valour befitting his name. His choice was that of the
warrior; and the despairing inhabitants of Velez-Malaga who were on
the point of surrender rejoiced to see the mountains lit up with
bonfires, warning them of their Sultan’s approach. The Christians on
their part were fully prepared to defend their camp; the bravest of
their chivalry under the Marquis-Duke of Cadiz opposed themselves
again and again to the Moorish onslaughts, until “El Zagal” was
beaten back in confusion from Velez-Malaga as Hamet “El Zegri” had
been from Ronda.
The capitulation of the town followed at the end of April, 1487; and
then the Christian army pushed forward to Malaga, a port famous for
its commerce from the days of Phœnician traders. The enthusiasm of
the troops was raised to white heat by success and by the personal
bravery of Ferdinand, who, on one occasion during the late siege,
seeing a company of Castilians about to retreat, had hurled himself
on the enemy armed only with his breastplate and sword. On the
remonstrances of his generals, who besought him in future to
remember what his death would cost them, he replied: “I cannot see
my men in difficulties and not go to their aid.” It was an answer more
likely to endear him to Castilian hearts than any act of legislation.
The courage that inspired the Christians was not lacking in
Malaga, where the fierce Hamet “El Zegri” and his garrison had
pledged themselves to starve rather than yield. The fire of the heavy
lombards, disembarked from the Castilian ships and pointed on the
Moorish towers and ramparts, was answered by cannon equally
deadly in their aim; the mines planted deep behind trenches were
met by counter-mines; the Christian raids on the suburbs by
midnight sallies of such unexpected ferocity that often massacre
ensued, until reinforcements at length drove the invaders back to
their walls.
The summer months passed slowly; and hunger and pestilence
added their gaunt spectres to the sufferings of the besieged. In vain
Ferdinand, courting a speedy surrender, sent messengers to offer
generous terms, such as he had granted at Ronda and Loja; in vain
he threatened the alternative of slavery in case of prolonged
resistance; in vain the more peace-loving citizens pleaded with their
governor to accept a settlement that would save the prosperity of
their port. Hamet “El Zegri” returned a scornful refusal. Soon, he
declared the rainy season would begin, and the Christian camp
would be turned into a swamp, fit breeding-ground for death in all its
forms. Malaga had only to hold firm to triumph. What matter if the
victory cost her the ruin of her commerce? It was a question to which
garrison and merchants returned a different answer.
In the meanwhile Isabel had appeared in person at the Christian
camp, not, as the Moors expected, to persuade her husband to raise
the siege, but to second his efforts. Her presence was heralded by the
fire of all the guns at once, a thunder that shook Malaga to its
foundations and filled Castilian hearts with pride. Fanaticism was
now to play its part in the history of the siege, persuading Hamet “El
Zegri” and his supporters of divine interposition, when all human aid
had failed them. Their first would-be saviour was a certain Abraham
“El Gerbi,” a dervish of holy life imbued with a hatred of the
Christians. This man, gathering to his standard some four hundred
warriors of Guadix, whom he had inspired with the belief that he was
protected by the angels of Mahomet, led them to an attack on the
camp before Malaga. Had his efforts ended here the incident would
have been speedily forgotten, for in spite of its bravery the band of
fanatics was too small to create more than a momentary panic.
Abraham “El Gerbi,” however, was captured alive. No one suspected
in that saintly face and wasted form the man who had planned the
mad expedition; and when the old dervish declared himself a
prophet, and begged for an interview with the King and Queen that
he might explain how Malaga could be taken, the Marquis-Duke of
Cadiz led him at once to headquarters.
There was some delay in seeing the sovereigns, so the prisoner was
made to wait in a neighbouring tent, where a Portuguese Prince, Don
Alvaro, a cousin of the Queen, and Beatriz de Bobadilla, Marchioness
of Moya, were playing chess. Unable to understand Castilian, the
dervish believed the players the object of his fanatical hatred, and,
drawing a knife he had concealed in the folds of his cloak, he
attacked the Prince, wounding him in the head. Next he hurled
himself on the Marchioness of Moya, but before he could achieve his
purpose the swords of those standing by had ended his life. That
night the body of Abraham “El Gerbi” was hurled by Christian
catapults into the Moorish town.
It would seem as if Malaga’s faith in dervishes might have been
shaken; but a new prophet shortly appeared, this time within the
city, pledging himself by a certain sacred banner to bring victory to
Moorish arms. His preaching, seconded by Hamet “El Zegri’s” fiery
patriotism, stirred the flagging energy of the besieged to a more
desperate sally than any that had yet been made. Out of the city they
poured, the white standard floating at their head, and before this
unexpected avalanche of spears and scimitars the Christians for the
moment quailed; the next, their courage returning, they closed upon
their foes from all sides. The battle wavered, then a stone from a
catapult struck the dervish prophet down, and with a shout of
triumph the Christians saw the sacred banner fall and drove back the
Moors, routed and dismayed, within the walls of Malaga.
The city was doomed. Even Hamet “El Zegri” acknowledged this,
and leaving the citizens to their fate, withdrew with some of his
warriors into the fortress of the Gibralfaro; but the offers of peace
and safety he had before derided could be no longer claimed.
Fanaticism had left its mark also on the Christian camp; and
amongst the Castilian soldiery the enemy’s entreaties for life and
freedom were met by threats of a general massacre.
Since hunger and not goodwill prompts you to the surrender of your city [said
the Chief Commander, of Leon, replying to an embassy from Malaga], either
defend yourselves or submit to whatever sentence shall be pleasing to the King and
Queen;—to wit, death to those for whom it is destined, slavery to those for whom
slavery.
MALAGA TO-DAY
Thus it was that the Christian demands were met by defiance, and
the sovereigns provided with an excuse for prosecuting the war to its
bitter end. The Moorish messengers had found them in Seville,
whither they had gone in April, 1490, to celebrate the betrothal of
their daughter Isabel with Don Alfonso, the heir to the Portuguese
throne; but, this concluded, Ferdinand collected an army and,
crossing the Sierra Elvira, proceeded to ravage the plains of Granada.
Within sight of the city he knighted his son Prince John, on whom so
many hopes were centred, that in this last act of the crusade,
inheritance of his race, the boy of twelve might receive initiation into
a great future.
Boabdil, in the meanwhile, had not waited to be attacked; and his
generals, taking the offensive, endeavoured to recapture some of the
smaller fortresses that had fallen into Christian hands, besides
stirring up revolt in the larger towns which had lately surrendered,
such as Guadix and Baeza. Both efforts met with a measure of
success; for many of the Moors, who had faithfully served “El Zagal”
throughout his struggles with his nephew, were so disgusted at
seeing his banner in the Christian camp, and at witnessing the soft
complacency of Cid Haya, that they turned willingly from their old
allegiance to the Prince who offered them deliverance from a foreign
yoke.
Their patriotism came too late. The hour had passed when
rebellion could do more than temporarily retard the waning
Crescent; and the punishment of failure was meted out by Ferdinand
and his generals with no unsparing hand. Yet this severity had its
semblance of mercy. The inhabitants of the town in question might
choose between exile with their movable property, or a full judicial
inquiry into their conduct. Who were guilty? The citizens looked at
one another and knew that few would be able to prove complete
innocence before a hostile judgment seat, with racial hatred holding
the balance; and their decision was not long in forming.
From the fairest cities in Granada passed away the population that
had made her fame; and, as the exiles sailed to Africa, Castilians took
possession of their deserted homes. The Curate of Los Palacios, in
the case of Guadix, congratulates himself on Ferdinand’s cleverness
in thus winning this town so completely from the enemies of the
Holy Catholic Faith. “It is one of the mysteries of Our Lord,” he adds,
“who would by no means consent that so noble a city should remain
longer in the power of the Moors.”
Round Granada itself the Christian lines were closing in; and
successful though arduous campaigns into the mountains of the
Alpujarras had cut off the beleaguered city from hope of succour in
that direction. Christian Europe, humbled by the fall of
Constantinople, awaited the issue with expectant joy; and it seemed
in this supreme moment as if the chivalry of both the Crescent and
the Cross, conscious of universal interest, were inspired to a last
emulation in the quest of glory. Never before in the crusade had the
sallies of the besieged or the furious attacks of besiegers exhibited
such contempt of personal danger; never before had schemes
emanating from the council-chamber been supplemented by such
deeds of individual bravery.
Chief hero of these days was the young Castilian noble, Hernando
de Pulgar, “He of the Exploits,” as his countrymen proudly named
him. Already in the earlier stages of the war he had earned a
reputation for reckless daring; but the crowning touch to his fame
was given by his midnight entry into Granada with fifteen
companions of the same hazard-loving temperament. Led by a
converted Moor, the little band of Christians scaled the walls and,
making their way through the town by deserted streets, arrived
unperceived at the principal mosque. Here Hernando de Pulgar drew
from his pocket a strip of parchment, on which were inscribed the
words dear to every Catholic but anathema to the sons of Islam, “Ave
Maria!” and fixed it by his dagger to the door. Before he could follow
up his intention of setting fire to the neighbouring houses, he was
discovered; but nevertheless he and his friends succeeded in making
their escape by dint of hard riding and a liberal use of their swords,
before the majority of the inhabitants were even aware of their
inroad.
It was an action to fire the imagination of all the young hot-bloods
in the camp; and when in the summer of 1491 Isabel and a number of
her ladies-in-waiting appeared at the seat of war, the incentive to
deeds of prowess was redoubled. The sovereigns, though delighted
with Hernando de Pulgar’s exploit, for which they rewarded him with
every mark of honour and favour, were yet too practical to encourage
a needless loss of life. They had long recognized, as we have seen,
that in patience rather than in daring lay their hope of success; and
when a fire broke out in the Queen’s tent and destroyed a good part
of the camp, they determined to prepare for a long siege and to build
more solid accommodation, as they had done at Baeza.
To this end the Spanish soldier was converted into a workman;
and under his willing hands a city arose, not merely of clay and
timber, but of stone. In shape a square, cut into four by wide
crossroads, each quarter with its fine houses contained a block of
marble inscribed with the names of those cities of Spain that had
helped in its construction, the whole being finished within eighty
days from its commencement.
ALHAMBRA, PATIO DE L’ALBERCA
FROM A PHOTOGRAPH BY
ANDERSON, ROME