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Pharmacology for Nurses
A Pathophysiological Approach

Michael Patrick Adams

Professor of Anatomy and Physiology

St. Petersburg College

Formerly Dean of Health Professions
Pasco-Hernando State College

Carol Quam Urban

Director, School of Nursing

Associate Dean, College of Health and Human Services

Associate Professor

George Mason University

Rebecca E. Sutter
Assistant Professor, College of Health and Human Services School of

Nursing George Mason University

Mohamed El-Hussein

Associate Professor, School of Nursing & Midwifery

Department of Health, Community & Education

Mount Royal University

Joseph Osuji
Professor, School of Nursing & Midwifery

Department of Health, Community & Education

Mount Royal University
Third Canadian Edition
Copyright
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with any queries on this content.

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9780135562628 (Student Edition)

9780136746454 (Loose Leaf Version)

ScoutAutomatedPrintCode

Library and Archives Canada Cataloguing in Publication

Title: Pharmacology for nurses : a pathophysiological approach / Michael

Patrick Adams, (Professor of Anatomy and Physiology, St. Petersburg

College, Formerly Dean of Health Professions, Pasco-Hernando State

College), Carol Quam Urban (Director, School of Nursing, Associate

Dean, College of Health and Human Services, Associate Professor,

George Mason University), Rebecca E. Sutter (Assistant Professor,

College of Health and Human Services, School of Nursing, George Mason

University), Mohamed El-Hussein (Associate Professor, School of Nursing

& Midwifery, Department of Health, Community & Education, Mount

Royal University), Joseph Osuji (Associate Professor, School of Nursing &

Midwifery, Department of Health, Community & Education, Mount Royal

University).
Names: Adams, Michael, 1951- author. | Urban, Carol Q. (Carol Quam),
author. | Sutter, Rebecca E., author. | El-Hussein, Mohamed, author. |

Osuji, Joseph, author.

Description: Third Canadian edition. | Includes bibliographical

references and index.

Identifiers: Canadiana 20190203927 | ISBN 9780135562628 (softcover)

Subjects: LCSH: Pharmacology—Textbooks. | LCSH: Nursing—

Textbooks. | LCGFT: Textbooks.

Classification: LCC RM301 .A33 2020 | DDC 615.1—dc23

About the Authors

Mohamed Toufic El-Hussein, RN, BSN, MSN, PhD, NP, is an Associate

Professor of Nursing in the Department of Health, Community &

Education at Mount Royal University in Calgary. Dr. El-Hussein is a

recipient of the distinguished teaching faculty award in the Bachelor of
Nursing program at Mount Royal University, School of Nursing &

Midwifery. Dr. El-Hussein is also an adjunct Associate Professor at the

University of Calgary in the faculty of Nursing.

He has initiated and implemented several innovative teaching approaches

that have contributed immensely to the critical thinking, analytical, and

clinical skills of nursing students. Dr. El-Hussein’s passion for teaching

emerged while working as a Registered Nurse in critical care settings,
where he was selected to facilitate and deliver lectures in the Department

of In-Service Education at different hospitals. He completed his Master’s

in Critical Care and Trauma at the University of KwaZulu-Natal, South

Africa, and earned a PhD in Nursing from the University of Calgary, then
enrolled in the post-Master’s Nurse Practitioner (NP) program at the

University of Calgary and earned his NP diploma. Currently, Dr. El

Hussein practices as an Acute Care Nurse Practitioner in the Medical
Cardiology Coronary Care Unit at Rockyview General Hospital. His

research program focuses on clinical reasoning in nursing practice and

the use of innovative teaching strategies to enhance critical thinking
among nursing students. Dr. El-Hussein has authored several

publications and conference presentations that discuss clinical reasoning

processes and highlight innovative teaching strategies designed to bridge
the theory-practice gap in nursing and to help students deconstruct and

assimilate complex concepts.

Joseph Chinyere Osuji, RN, BScN, MN, PhD, is Professor at the School

of Nursing & Midwifery, Mount Royal University, Calgary. He is a

Carnegie scholar and holds a visiting scholar appointment with the
University of Nigeria, Nsukka. His current teaching assignments are
Medical-Surgical Nursing, Pharmacology, Pathophysiology, Community

Health, Chronic Disease Management, and Advanced Biostatistics. Dr.

Osuji has published widely, has authored and contributed chapters on

Medical/Surgical Nursing, Research Methods, Pharmacology, and

Chronic Disease Management. Professor Osuji has received major

fellowship awards, research nominations, and academic awards for his

work. He is interested in research questions that deal with the social

determinants of health, homelessness, social justice and poverty, soft

computing modelling and informatics, teaching and learning processes in

students, clinical reasoning among Registered Nurses, and nursing

workforce turnover and retention determinants. He has been published in

several peer-reviewed journals and has presented on related topics in

conferences, both locally and internationally. Dr. Osuji is the proud

husband of Mrs. Genevieve Osuji and the father of three girls and two

boys.
Preface
When students are asked which subject in their nursing program is the
most challenging, pharmacology and pathophysiology always appear near

the top of the list. The study of pharmacology demands that students
apply knowledge from a wide variety of the natural and applied sciences.

The successful prediction of drug action requires a thorough knowledge

of anatomy, physiology, chemistry, and pathology, as well as knowledge
of the social sciences of psychology and sociology. Current knowledge of

drug actions, mechanisms, interactions, and legislation is mandatory for

nurses to provide safe and effective care to their clients in all healthcare

settings. Lack of proper application of pharmacology can result in

immediate and direct harm to the client; therefore, the stakes in learning
pharmacotherapeutics in nursing are high.

Pharmacology can be made more understandable if the proper

connections are made to knowledge learned in other disciplines; that’s

the impetus for starting every unit of the book with a review of the

physiology of the related system or a discussion of the principles that

inform pharmacotherapy. The vast majority of drugs in clinical practice

are prescribed for specific diseases, yet many pharmacology texts fail to
recognize the complex interrelationships between pharmacology and
pathophysiology. When drugs are learned in isolation from their

associated diseases or conditions, students have difficulty connecting

pharmacotherapy to therapeutic goals and client wellness. The
pathophysiology approach of this text gives the student a clearer picture

of the importance of pharmacology to disease, and ultimately to client

care. The approach and rationale of this text focus on a holistic

perspective to client care, which clearly shows the benefits and

limitations of pharmacotherapy in curing, managing symptoms, or
preventing illness. Although challenging, the study of pharmacology is

truly a fascinating, lifelong journey.

The third Canadian edition continues the tradition of providing a unique

Canadian perspective on pharmacotherapeutics, geared towards the
education of Canadian undergraduate nursing students and their

curriculum. During the editorial process, the text content was thoroughly
reviewed and scrutinized by Canadian nurse educators and seasoned
Canadian clinical pharmacists. The authors adapted the content of the

U.S. edition of the text to fit the Canadian nursing context. The technical
review process helped ensure accurate information on Canadian drug
names, and their respective doses and routes of administration, including

common Canadian Trade names for drugs. The review also highlighted
drugs that are exclusively available and approved for use in Canada.
Pregnancy categorizations of drugs were updated based on Canadian

standards. Tables and illustrations to help students better assimilate

pharmacotherapeutic concepts were also added to the respective

chapters. We were intentional about adding recommendations for

therapeutics driven by Canadian guidelines in the updated chapters. For
example, research from Thrombosis Canada led to the addition of a

section on direct oral anticoagulants (DOACs) in Chapter 56 . The 2017

Comprehensive Update of the Canadian Cardiovascular Society Guidelines for

the Management of Heart Failure were used to add updated content to

Chapter 54 . Diabetes Canada clinical practice guidelines were

integrated into Chapter 28  to ensure its currency. The Canadian

Cardiovascular Society’s dyslipidemia guidelines were used to add the

most recent drugs used to treat lipid disorders in Chapter 49 .

We believe that using the aforementioned guidelines ensures the

currency and validity of the textbook. Finally, we also updated the NCLEX

questions to reflect the current NCLEX test plan and blueprints.

Organization: A Body System and Disease
Approach
Pharmacology for Nurses: A Pathophysiological Approach, third Canadian

edition, is organized according to body systems (units) and diseases

(chapters). This edition of the text has been expanded with new
information. We have added more details to new chapters introduced in

the second Canadian edition and included NCLEX Success Tips within

each chapter to assist the student with making connections to the new
NCLEX exam requirement for Canadian registered nurses. This

component, that was introduced in the second Canadian edition, was

well received and commended by students and faculty. The first chapter
in each unit (except in Units 1, 2, and 3) provides a brief discussion of the

physiology of the corresponding body system. Each chapter provides

complete information on the drug classifications used to treat the diseases

discussed in that chapter. Specially designed headings cue students to

each classification discussion.

The pathophysiology approach clearly places the drugs in context in

terms of how they are used therapeutically. The student is able to easily

locate all relevant anatomy, physiology, pathology, and pharmacology in

the same chapter in which the drugs are discussed. This approach
provides the student with a clear view of the connections between

pharmacology, pathophysiology, and the nursing care learned in other

clinical courses.

NCLEX Success Tips

The third Canadian edition of Pharmacology for Nurses: A

Pathophysiological Approach expands on more chapters to address the

rapidly growing needs of students practising in the Canadian healthcare

system. Before we started writing the text, we collected feedback from

university professors, asking specifically about their experience using

other pharmacology texts and their perceptions of an ideal text. These

professors shared some of the challenges their students face while taking
a pharmacology course. An emerging but immediate need that echoed at

a national level was the need to prepare Canadian nursing students to

pass the NCLEX exam. Although students can take NCLEX courses after

graduation or just before taking the exam, we believe that early

introduction of NCLEX format and concepts will give the students ample
time to understand and assimilate these concepts. Our textbook is the

first nursing pharmacology text to incorporate NCLEX Success Tips.

We experienced challenges while trying to address all stakeholder

concerns, as well as student needs, and at the same time keeping the text

to a reasonable length. As a result, we reviewed several NCLEX texts and

designed tips based on the latest NCLEX exam blueprints. We have

presented the new content in a concise and succinct format and have

used tables, figures, and illustrations to explain concepts.

Prototype Approach to Learning Drugs

The number of drugs available in clinical practice is staggering. To

facilitate learning, we use prototype drugs and provide detailed

introductions to the one or two most representative drugs in each

classification. Students are less intimidated when they can focus their
learning on one representative drug in each class. Prototype Drug boxes

clearly describe these important medications. Within these boxes, the

actions and uses of the drug are succinctly presented, including

administration alerts, and specific nursing responsibilities that highlight

vital information related to the administration of that drug and treatment

of overdose and antidotes when known. Pharmacokinetics information

regarding the absorption, distribution, metabolism, excretion, and half-

life of drugs is included when known. Adverse effects and interactions

are also included when necessary.

Focused Coverage of the Nursing Process
This text features a focused approach to the nursing process, which

allows students to quickly find the content that is essential for safe and

effective drug therapy. Nursing Implications for Practice sections appear

within the discussion of each drug class. These sections discuss the major

needs of the client, including general assessments, interventions, and

client teaching for the class of drugs. Client education discussions provide

students with the essential information that they need to convey to their

clients. Integrated rationales for nursing actions help students to learn

the reasoning that is key to the development of critical thinking skills.

Nursing Practice Application charts provide a succinct, easy-to-read

view of the most commonly prescribed drug classes for the disease. Need-

to-know nursing actions are presented in a format that reflects the “flow”

of the nursing process: nursing assessment, pattern identification and

potential nursing diagnoses, planning, interventions, client education and

discharge planning, and evaluation. Rationales for interventions are

included in parentheses. The Nursing Practice Application charts identify

clearly the nursing actions that are most important. Some prototype drugs

have important nursing actions that are specific to that drug; in these

instances, we provide a Nursing Practice Applicationchart in the text

devoted solely to the prototype drug.

Holistic Pharmacology
Our new edition examines pharmacology from a holistic perspective. The

Special Considerations and Lifespan Considerations features present

pharmacology and nursing issues related to cultural, ethnic, age, gender,

and psychosocial aspects. These features remind students that a drug’s

efficacy is affected as much by its pharmacokinetics as by the uniqueness

of the client. In addition, pediatric and geriatric considerations are

integrated throughout the text.
Natural Therapies features present a popular herbal or dietary

supplement that may be considered along with conventional drugs.

Although the authors do not recommend the use of these alternative

treatments in lieu of conventional medicines, many clients use

complementary and alternative therapies and the nurse must become

familiar with how they affect client health. Herb-drug interactions are

also included within the Prototype Drug boxes when relevant. Non-

pharmacological methods for managing many diseases, including lifestyle

and dietary modifications, are also integrated into the chapters.

Learning Pharmacology Through Visuals

For nearly all students, learning is a highly visual process. This text

incorporates the generous use of artwork to illustrate and summarize key

concepts. Pharmacotherapy illustrations provide students with a visual

overview of a drug therapy process, showing specifically how the drug

acts to counteract the effects of disease on the body.

The chapters on Medication Incidents and Risk Reduction and

Toxicology, Bioterrorism, and Emergency Preparedness include

important content on the promotion of client safety, management of

medication incidents, and role of the nurse in situations that involve

toxicity and biochemical emergencies.

Key Concepts outline what students should have learned in each chapter.

Scenarios with Critical Thinking Questions connect the student to a

client at the end of most chapters. The student learns details about the

client’s health history and participates in critical thinking questions about

the scenario. This allows for application of the knowledge obtained in the
chapter.
NCLEX Practice Questions prepare students for course exams on chapter

content and expose them to NCLEX-style questions. Answers and

rationales are provided in Appendix A .

A Note About Terminology

The term healthcare provider is used to denote the physician, nurse

practitioner, registered nurse, or any other health professional who is

legally authorized to prescribe drugs.

Acknowledgments
Authoring the third Canadian edition of this text has been a major
undertaking made possible by the contributions of many individuals.

First, we would like to acknowledge the efforts of the authors of the

original Canadian edition and those of Pharmacology: Connections to

Nursing Practice (4th U.S. Edition). Their work provided an excellent

foundation for this text.

Thanks to the dedicated and talented team at Pearson Canada: executive

portfolio manager, Cathleen Sullivan; senior marketing manager, Kim

Teska; senior content manager, John Polanszky; content developer,

Darryl Kamo; and project manager, Ainsley Somerville. Thanks also go to

the copyeditor, Joanne Boehme, and proofreader, Hardik Popli.

We would like to thank Kaitlyn Harnden, RPH, PharmD, CDE, for her

keen eye as she conducted the technical review of our book.

Finally, a huge thank you to our spouses and children for their support

and sacrifice throughout the writing of the new edition.

Mohamed El-Hussein

Joseph Osuji
Learning Pharmacology in Context
The vast majority of drugs are prescribed for specific diseases, yet many

pharmacology texts fail to recognize the complex interrelationships

between pharmacology and disease. Learning drugs in the context of

their associated diseases will make it easier for you to connect

pharmacotherapy to therapeutic goals and client wellness. The

pathophysiology approach of this text gives you a clearer picture of the

importance of pharmacology to disease and, ultimately, to nursing care.

NCLEX Success Tips. Addressing the need to prepare Canadian nursing

students for the NCLEX exam, NCLEX Success Tips introduce the format

and concepts of the NCLEX exam early enough to give students ample

time to understand and assimilate them.

Disease and Body System Approach. The organization by body systems

(units) and diseases (chapters) clearly places the drugs in context in terms
of how they are used therapeutically. You can easily locate all relevant

anatomy, physiology, pathophysiology, and pharmacology in the same

chapter in which we present complete information for the drug

classifications used to treat the diseases in each chapter. This

organization builds the connection between pharmacology,

pathophysiology, and the nursing care you learn in your clinical nursing

courses.
Prototype Approach and Prototype Drug Boxes. The number of drugs

available in clinical practice is staggering. To help you learn them, we use

a prototype approach in which we introduce the one or two most

representative drugs in each classification in detail. It can be less

intimidating to focus your learning on one representative drug in each

class. Prototype Drug boxes clearly summarize these important

medications, presenting:

Actions and Uses

Administration Alerts

Pharmacokinetics (including onset of action, duration, half-life, and

peak effect, when known)

Adverse Effects and Interactions (with drugs, herbs, and food)

Providing a Nursing Focus
Once you understand how a drug works on the body—that is, its actions,

therapeutic effects, potential side effects and interactions, and more—you

begin to understand the “why” of the interventions you will take as a

nurse. Each chapter guides you to the content that is essential in order for

you to provide safe and effective drug therapy.

Nursing Implications for Practice appear within each drug class section

and discuss the major needs of the client, including:

General Assessments

Interventions

Lifespan Considerations

Client Education for all drugs in that classification, when applicable

Nursing Practice Application charts present need-to-know nursing

actions in the nursing process—assessment, nursing diagnoses, planning,

implementation with interventions and rationales, evaluation—and

include client teaching and discharge planning.

Special Considerations boxes present a variety of special issues related to
ethnicity, gender, and psychosocial concerns that nurses must consider

during drug therapy.

Cultural Considerations boxes explore issues specifically related to

clients’ cultural backgrounds, which may affect their responses to illness

and their attitudes to drug therapy.

Lifespan Considerations boxes specifically address client care issues

across the lifespan.

Natural Therapies boxes present popular herbal or dietary supplements

that clients may use along with conventional drugs. As a nurse, you need

to assess clients to see if they are using any natural remedies that may

have interactions with medications they are taking.

Teaching Through Visuals
For nearly all students, learning is a highly visual process. Therefore, we

use numerous visuals to help you review the anatomy and physiology of

body systems as well as understand the principles of drug action on the

body.

Vivid and Colourful Illustrations help you to review specific anatomy,

physiology, and pathophysiology for a body system and better

understand the impact of disease on that system.

Putting It All Together
The tools at the end of each chapter and on MyLab Nursing help you to

test your understanding of the drugs and nursing care presented in that

chapter. Using these tools will help you to succeed in your pharmacology

course, in the clinical setting, on the NCLEX exam, and ultimately in your

professional nursing practice.

Key Concepts Summary provides expanded summaries of concepts that

correlate to sections within the chapter. You can use this succinct

summary to ensure that you understand the concepts before moving on

to the next chapter. The numbering of these concepts helps you to easily

locate that section within the chapter if you need further review.
NCLEX Practice Questions allow you to test your knowledge. Answers

are available in Appendix A  at the end of your text. Selected questions

are also available for use in class with our Learning Catalytics tool.

Critical Thinking Questions help you to apply the essential components

of nursing care through case-based scenarios. Appendix B  provides

answers to these questions.

Chapter 1
Introduction to Pharmacology and
Drug Regulations in Canada
Introduction to Pharmacology and
Drug Regulations in Canada
 Chapter Outline

Pharmacology: The Study of Medicines 

Pharmacology and Therapeutics 

Classification of Therapeutic Agents as Drugs, Biologics,

or Natural Health Products 

Prescription and Over-the-Counter Drugs 

Drug Regulations and Standards 

Federal Drug Legislation 

Approval Process for Prescription Drugs 

Pricing and Access to Prescription Drugs Across

Canada 

 Learning Outcomes

After reading this chapter, the student should be able to:

1. Define pharmacology.

2. Discuss the interdisciplinary nature of pharmacology.

3. Compare and contrast therapeutics and pharmacology.

4. Compare and contrast conventional drugs, biologics, and natural

health products.
 5. Identify the advantages and disadvantages of prescription and
over-the-counter (OTC) drugs.

6. Identify key Canadian drug regulations that help to ensure the

safety and efficacy of medications.

7. Discuss the role of Health Canada and the Health Products and

Food Branch (HPFB) of Health Canada and its Therapeutic

Products Directorate in the drug approval process.

8. Describe the stages of approval for therapeutic and biologic drugs

in Canada.

Key Terms
biologics, 2

clinical trials, 4

Compendium of Pharmaceuticals and Specialties (CPS), 5

complementary and alternative therapies, 2

drug, 2

Drug Identification Number (DIN), 4

Drug Product Database, 5

formulary, 5

Health Canada, 3

medication, 2

natural health products (NHPs), 2

New Drug Submission (NDS), 4

Notice of Compliance (NOC), 4

patent protection, 4

pharmacology, 2

pharmacotherapy (pharmacotherapeutics), 2

preclinical investigation, 4

Special Access Program (SAP), 6

therapeutics, 2

More drugs are being prescribed to consumers than ever before. About

500 million prescriptions are dispensed each year in Canada. According

to Statistics Canada, prescription medications are the second most costly

component of Canadian healthcare expenditure, accounting for almost

14% ($29 billion) each year. Laws govern all aspects of the drug approval,

labelling, marketing, manufacturing, and distribution process. The

purpose of this chapter is to introduce the subject of pharmacology and to

emphasize the role of government in ensuring that drugs, herbals, and

other natural alternatives are safe and effective for public use.
Pharmacology: The Study of
Medicines
1.1 Pharmacology is the study of medicines. It includes how
drugs are administered and how the body responds.

The word pharmacology  is derived from two Greek words: pharmakon,

which means “medicine, drug,” and logos, which means “study.” Thus,
pharmacology is most simply defined as the study of medicines.

Pharmacology is an expansive subject ranging from understanding how

drugs are administered, to where they travel in the body, to the actual

responses produced. To learn the discipline well, nursing students need a

firm understanding of concepts from various foundation areas such as

anatomy and physiology, chemistry, microbiology, and pathophysiology.

More than 11 000 brand name, generic, and combination agents are

currently available. Each has its own characteristic set of therapeutic

applications, interactions, side effects, and mechanisms of action. Many

drugs are prescribed for more than one disease, and most produce

multiple effects on the body. Further complicating the study of

pharmacology is the fact that drugs may elicit different responses

depending on individual client factors such as age, gender, body mass,

health status, and genetics. Indeed, learning the applications of existing

medications and staying current with new drugs introduced every year is
an enormous challenge for the nurse. The task, however, is a critical one

for both the client and the healthcare provider. If used properly, drugs
can dramatically improve quality of life, but the consequences of
improper use of drugs can be devastating.
Pharmacology and Therapeutics
1.2 The fields of pharmacology and therapeutics are closely
connected. Pharmacotherapy is the application of drugs to
prevent disease and ease suffering.

A thorough study of pharmacology is important to healthcare providers

who prescribe or administer drugs. Although federal and provincial laws
sometimes limit the kinds of drugs marketed and the methods used to

dispense them, all nurses are directly involved with client care and are
active in educating, managing, and monitoring the proper use of drugs.

This applies not only for nurses in clinics, hospitals, and home healthcare

settings, but also for nurses who teach and for new students entering the
nursing profession. In all of these cases, a thorough knowledge of

pharmacology is necessary for them to perform their duties. As nursing

students progress toward their chosen specialty, pharmacology is at the

core of client care and is integrated into every step of the nursing process.

As new drugs and research findings emerge, nurses are challenged to

evaluate the information and incorporate relevant knowledge into

evidence-based practice.

Another important area of study for the nurse, sometimes difficult to

distinguish from pharmacology, is the study of therapeutics. Therapeutics

is slightly different from the field of pharmacology, although the

disciplines are closely connected. Therapeutics  is the branch of
medicine concerned with the prevention of disease and treatment of

suffering. Pharmacotherapy , or pharmacotherapeutics , is the

administration of drugs for the purpose of disease prevention or

treatment and relief of suffering. Drugs are just one of many therapies
available to the nurse for preventing or alleviating human suffering.
Classification of Therapeutic Agents
as Drugs, Biologics, or Natural
Health Products
1.3 Therapeutic agents may be classified as traditional drugs,
biologics, or natural health products.

Substances applied for therapeutic purposes fall into one of the following

three general categories:

Drugs or medications

Biologics
Natural health products

A drug  is a chemical agent capable of producing biological responses

within the body. These responses may be desirable (therapeutic) or

undesirable (adverse). A drug that is considered medically therapeutic is

commonly referred to as a medication . Because drugs are defined so

broadly, it is necessary to separate them from other substances that can

alter the body’s biological activities, such as foods, household products,

and cosmetics. Agents such as antiperspirants, sunscreens, toothpastes,
and shampoos might alter the body’s biological activities, but they are not

considered drugs or medications. Sometimes it is not clear whether a

substance is a medication. For example, alcohol (beer, red wine) may be
considered medically therapeutic when used in small amounts for

cardiovascular effects, yet not be therapeutic when used in excess.

While most modern drugs are synthesized in a laboratory, biologics  are

agents naturally produced in animal cells, by microorganisms, or by the
body itself. Examples of biologics include hormones, monoclonal

antibodies, natural blood products and components, interferon, and

vaccines. Biologics are used to treat or prevent a wide variety of illnesses

and conditions.

Other therapeutic approaches include natural health products (NHPs) 

and complementary and alternative therapies. NHPs may include natural

plant extracts, herbals, vitamins, minerals, and dietary supplements.
NHPs are discussed in detail in Chapter 11 . Complementary and

alternative therapies  include therapies such as acupuncture, hypnosis,

biofeedback, and massage. Because of their growing popularity, herbal
and alternative therapies are featured throughout this text. It is important

to ensure that information related to home herbal remedies is shared with

medical professionals, to make certain that the client does not receive two
different forms of the same drug or drugs that may counteract the home

remedy.

The nurse should support the client by facilitating an open discussion on

the client’s intent to use herbal remedy with the physician. This will make
the client feel involved in the decisions related to his or her care. Remind

the client that the herbs may interfere with current medications that he or
she is taking.

NCLEX Success Tips

The nurse should ensure that pregnant women avoid any

medication unless their physician instructs them to use it. This

includes herbal remedies because their effects on the fetus have

not been identified.

Copyright © 2021 Pearson Canada Inc. All Rights Reserved.

Prescription and Over-the-Counter
Drugs
1.4 Drugs are available by prescription or over the counter.
Prescription drugs require an order from a healthcare provider.

Legal drugs are obtained either by a prescription or over the counter

(OTC). There are major differences between the two dispensing methods.
To obtain prescription drugs, a qualified healthcare provider must give an

order authorizing the client to receive the drug. Prescription drugs are

considered potentially addictive or too harmful for self-administration. In

some cases, they are used to treat conditions too complex for self-

diagnosis by the consumer, or the drug may require a skilled nurse or

healthcare provider to administer it. The advantages to requiring an

authorization are numerous. The healthcare provider has an opportunity

to examine the client and determine a specific diagnosis. The healthcare

provider can maximize therapy by ordering the proper drug for the

client’s condition and controlling the amount and frequency of drug to be

dispensed. In addition, the healthcare provider has an opportunity to

teach the client the proper use of the drug and what side effects to expect.

In a few instances, a high margin of safety observed over many years can
prompt a change in the status of a drug from prescription to OTC.

NCLEX Success Tips

Call the healthcare provider immediately if an order is difficult to

read or for any questions about the order. Do not administer a

medication that has an unclear order.
 Under law, nurses are responsible for their own actions. For

example, if a drug order is written incorrectly, the nurse who

administers the incorrect order is responsible for the error.

Copyright © 2021 Pearson Canada Inc. All Rights Reserved.

In contrast to prescription drugs, OTC drugs do not require a

prescription. In most cases, clients may treat themselves safely if they
carefully follow instructions included with the medication. If they do not

follow these guidelines, OTC drugs can have serious adverse effects.

NCLEX Success Tips

Older adults commonly have multiple healthcare provider. The

client needs to inform every healthcare provider about all the

medications being prescribed by all of them.

Copyright © 2021 Pearson Canada Inc. All Rights Reserved.

Clients prefer to take OTC drugs for many reasons. They may be obtained

more easily than prescription drugs because they do not require an order

from a healthcare provider. A key point to remember is that no drug is

without risk; if clients do not follow the guidelines on the label, serious

adverse effects may result.

No appointment with a physician is required, thus saving time and

money. Without the assistance of a healthcare provider, however,

choosing the proper drug for a specific problem can be challenging for an
individual. OTC drugs may react with foods, herbal products, prescription
medications, or other OTC drugs. Individuals may not be aware that
some drugs can impair their ability to function safely. Self-treatment is

sometimes ineffective, and the potential for harm may increase if the

disease is allowed to progress.

Drug Regulations and Standards
1.5 Drug regulations were created to protect the public from
drug misuse and to assume continuous evaluation of safety and
effectiveness.

Until the 19th century, there were few standards or guidelines to protect
the public from drug misuse. The archives of drug regulatory agencies are
filled with examples of early medicines, including rattlesnake oil for

rheumatism; epilepsy treatment for spasms, hysteria, and alcoholism; and

fat reducers for a slender, healthy figure. Many of these early concoctions

proved ineffective, though harmless. At their worst, some contained

hazardous levels of dangerous or addictive substances. It became quite

clear that drug regulations were needed to protect the public.
Federal Drug Legislation
1.6 The regulatory agency responsible for ensuring that drugs
are safe and effective is the Therapeutic Products Directorate of
the Health Products and Food Branch of Health Canada.

The mandate for Health Products and Food Branch (HPFB) of Health
Canada  “mandate is to manage the health-related risks and benefits of
health products and food by minimizing health-risk factors to Canadians

while maximizing the safety provided by the regulatory system for health
products and food.” The HPFB regulates the use of therapeutic products

through directorates, as shown in Figure 1.1 . The Therapeutic Products

Directorate (TPD) authorizes marketing of a pharmaceutical drug or

medical device once a manufacturer presents sufficient scientific evidence

of the product’s safety, efficacy, and quality as required by the Food and

Drugs Act and Regulations. The Biologics and Genetic Therapies

Directorate (BGTD) regulates biologic drugs (drugs derived from living

sources), radiopharmaceuticals, and genetic therapies. Products regulated

by the BGTD include blood products, vaccines, tissues, organs, and gene

therapy products. The Natural and Non-prescription Health Products

Directorate (NNHPD) is the regulating authority for natural health

products for sale in Canada. Natural health products and their regulation
are presented in Chapter 11 .

Figure 1.1 The governance structure for therapeutic products in Canada.

Approval Process for Prescription
Drugs
1.7 Four levels of testing are required for therapeutic drugs and
biologics. These progress from cellular and animal testing to use
of the experimental drug in clients with the disease.

Preclinical investigation  involves extensive laboratory research. Over a

3- to 5-year period, scientists perform many tests on human and

microbial cells cultured in the laboratory. Studies are performed in

different species of animals to examine the drug’s effectiveness at

different doses and to look for adverse effects. Extensive testing on

cultured cells and in animals is essential because it allows scientists to

predict whether the drug will cause harm to humans. Because laboratory
tests do not always reflect the way a human will respond, preclinical

investigation results are always inconclusive. Animal testing may

overestimate or underestimate the actual risk to humans.

If the drug has a desirable effect and is safe for animals, a Clinical Trial

Application (CTA) is made to Health Canada, requesting permission to

start clinical trials. The CTA includes detailed information about the
drug’s ingredients and proposed mechanism of action, the results of

animal testing, and the proposed methodology for the clinical trials.

The manufacturer of a newly developed drug applies for patent

protection  that gives the manufacturer the right to sell the drug without

competition for 20 years. When a patent has expired, competing

pharmaceutical companies are permitted to manufacture and sell generic
(chemically identical) versions of the drug.
Clinical trials , the second stage of drug testing, take place in three

phases. Clinical trials are the longest part of the drug approval process. In
phase I, clinical investigators perform tests on 20 to 100 healthy

volunteers to determine dosage and to assess how the drug is absorbed,

metabolized, and excreted by the body. In phase II, 100 to 300 clients
with the particular disease the drug is intended to treat are given the

medication to determine proper dosage and side effects. In phase III, 1000
to 3000 clients with the disease are given the medication. To eliminate
bias, a double-blind study is generally used in which clients and

investigators do not know whether the treatment the client is receiving is

the drug or a placebo. Only about 10% of investigational drugs tested will
make it to phase III clinical trials. Clinical investigators from different

medical specialties address concerns such as whether the drug is

effective, worsens other medical conditions, interacts unsafely with
existing medications, or affects one type of client more than others.

Clinical trials are an essential component of drug evaluations because of

the variability of responses among clients. A clinical trial may be stopped

if the drug is shown to be unsafe. In this case, the drug may be
abandoned or may undergo further development. If the drug shows

promise but precautions are noted, the process is delayed until the
pharmaceutical company addresses the concerns. If a drug appears to

have dramatic benefits and be without serious side effects, it may be fast-

tracked through the Health Canada approval process. A Priority Review

Process is in place and may permit a drug to be used even sooner in

special cases, with careful monitoring.

A New Drug Submission (NDS)  must be submitted before a drug is

allowed to proceed to the next stage of the approval process. Health

Canada receives about 80 NDSs for new drugs each year and approves

about 10%. Health Canada reviews the submitted information and

evaluates the drug’s safety, efficacy, and quality. If Health Canada
authorizes the drug to be marketed in Canada, a Notice of Compliance
(NOC)  and a Drug Identification Number (DIN)  are issued to

indicate official approval. The DIN must be displayed on the label of all

prescription drugs, as shown in Figure 1.2 . If there is insufficient

evidence to support the safety, efficacy, or quality claims, authorization to

market the drug will not be granted and a Notice of Deficiency or Notice

of Non-Compliance is issued. Drug companies can then submit further

information to support their claims and can appeal the decision not to

authorize the drug.

Figure 1.2
Example of a drug product labelled according to Canadian requirements: the generic drug name,

Drug Identification Number, lot number, expiry date, and ingredients must be displayed.

Source: Roberto Machado Noa/LightRocket/Getty Images.

Once drugs are marketed, the Marketed Health Products Directorate

(MHPD) leads an evidence-based program that works collaboratively

with other organizations in order to conduct post-approval surveillance,

assess health risks, and make further regulatory decisions to manage risks

arising from the use of the medication. Since clinical trials involve a

limited number of individuals during a limited time period, they may

detect only frequent or common adverse drug reactions (ADRs). It has
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 THE ESCURIAL.
EDMONDO DE AMICIS.

BEFORE my departure for Andalusia, I went to see the famous

Convent of the Escurial, the leviathan of architecture, the eighth
wonder of the world, the largest mass of granite upon the earth, and,
if you desire other imposing epithets, then you must imagine them,
for you will not find one that has not been used to describe it. I left
Madrid in the early morning. The village of the Escurial, from which
the Convent received its name, is eight leagues from the city, not far
from the Guadarrama; you pass through an arid and uninhabited
country whose horizon is bounded by snow-covered mountains. A
light, fine, and cold rain was falling when I reached the station of the
Escurial. From it to the village there is a rise of half a mile. I
clambered into an omnibus, and at the end of a few minutes, I was
deposited in a solitary street bordered on the left by the Convent and
on the right by the houses of the village, and shut in by the
mountains. At the first glance you understand nothing; you expect to
see a building and you find a city; you do not know if you are already
in the Convent, or if you are outside; you are hemmed in by walls.
You advance, and find yourself in a square; you look about you and
see streets; you have not yet entered, and already the Convent
surrounds you: you are at your wit’s end, and no longer know which
way to turn. The first feeling is one of depression: the entire edifice is
of mud-coloured stone, and all the layers are marked by a white
stripe; the roofs are covered with lead. You might call it a building
made of earth. The very high walls are naked and pierced by a great
number of windows which resemble barbicans. You might call it a
prison rather than a convent. You find this gloomy colour
everywhere: there is not a living soul here, and the silence is that of
a deserted fortress; and beyond the black roofs, the black mountain,
which seems to be suspended over the building, gives it mysterious
solitude. It seems as if the founder must have chosen the spot, the
plan, and the colours, everything, in fact, with the intention of
producing a sad and solemn spectacle. You lose your gaiety before
entering; you can smile no longer, you are thinking. You pause at the
door of the Escurial with a kind of quaking, as if at the entrance of a
dead city; it seems to you that if the terrible Inquisition is reigning in
any corner of the world, it must be between these walls; for it is here
that you can see its last traces and hear its last echo.

THE ESCURIAL.

Everybody knows that the Basilica and the Convent of the

Escurial were founded by Philip II. after the battle of San Quintino to
fulfil his vow made during the war to Saint Laurence when he was
forced to cannonade a church consecrated to this saint. Don Juan
Batista of Toledo commenced the building and Herrera finished it,
and the work upon it lasted for twenty-one years. Philip II. wished the
building to have the form of a gridiron in memory of Saint Laurence’s
martyrdom; and, in reality, this is its form. The plan is a rectangular
parallelogram. Four large square towers with pointed roofs rise at the
four corners, and represent the four feet of a gridiron; the church and
the royal palace, which extend on one side, represent the handle;
and the interior buildings, which are placed across the two long
sides, represent the parallel bars. Other smaller buildings rise
outside of the parallelogram, not far from the Convent, along one of
the long sides and one of the courts, forming two large squares; the
other two sides are occupied by gardens. Façades, doors, and
entrance-halls, are all in harmony with the grandeur and character of
the edifice: it is useless to multiply descriptions. The royal Palace is
magnificent, and in order to keep a clear impression of each
individual building, it is better to see it before you enter the Convent
and Church. This palace is in the north-east corner of the building.
Several halls are filled with pictures, others are hung from the ceiling
to the floor with tapestries, representing bull-fights, dances, games,
fêtes, and Spanish costumes, after Goya; others are decorated and
furnished in princely style; the floor, the doors, and the windows are
covered with marvellous mosaics and dazzling gold-work. But
among all the rooms, that of Philip II. is especially remarkable. It is a
dark and bare cell, whose alcove communicates with the royal
oratory of the church in such a way that, when the doors were open,
from his bed he could see the priest celebrating Mass. Philip II. slept
in this room, had his last illness there, and died there. You can still
see some of the chairs he used, two little benches on which he
rested his gouty leg, and a writing-desk. The walls are white, the
ceiling is unornamented, and the floor is of stone.
When you have seen the royal Palace, you go out of the
building, cross the square, and re-enter the great door. A guide joins
you and you pass through the large entrance to find yourself in the
Kings’ courtyard. Here you gain an idea of the enormous structure of
the building. This court is entirely shut in by walls; opposite the door
is the façade of the Church. Above a wide stairway stand six
enormous Doric columns; each of these supports a large pedestal,
and each pedestal upholds a statue. These six colossal statues are
by Batista Monegro, representing Jehoshaphat, Ezekiel, David,
Solomon, Joshua, and Manasseh. The courtyard is paved and
bunches of damp grass grow here and there; the walls look like
rocks cut in points; everything is rigid, massive, and heavy, and
presents the indescribable aspect of a fantastic edifice hewn by
Titans from a mountain and capable of defying earthquakes and
lightnings. At this point you really begin to understand the Escurial....
After seeing the Church and the Sacristy, you visit the Picture-
Gallery, which contains a large number of paintings by artists of all
countries, not the best examples, however, for these have been
taken to the Madrid gallery, but of sufficient value to merit a
thoughtful visit of half a day. From the Picture-Gallery you go to the
Library by means of the large stairway, over which is rounded an
enormous vaulted ceiling, painted all over with frescoes by Luca
Giordano. The Library is an immense hall adorned with large
allegorical paintings, and contains more than fifty thousand rare
volumes, four thousand of which were given by Philip II., and beyond
this is another hall, which contains a very valuable collection of
manuscripts. From the Library you go to the Convent. Here human
imagination is completely lost. If my reader knows Espronceda’s
Estudiante de Salamanca, he will remember that the persistent
young man, when following the mysterious lady whom he met at
night at the foot of a tabernacle, runs from street to street, from
square to square, and from alley to alley, turning and returning, until
he arrives at a spot where he can no longer see the houses of
Salamanca and where he discovers that he is in an unknown city;
and in proportion as he advances the town seems to grow larger, the
streets longer and the intertwining alleys more tortuous; but he goes
on and on without stopping, not knowing if he is awake or dreaming,
if he is intoxicated or mad; terror begins to enter his brave heart and
the most peculiar phantoms crowd into his distracted mind: this is
what happens to the stranger in the Convent of the Escurial. You
pass through a long subterranean corridor, so narrow that you can
touch the wall with your elbows, so low that your head almost hits
the ceiling, and as damp as a grotto under the sea; on reaching its
end, you turn, and you are in another corridor. You go on, pass
through doors, and look around: other corridors extend as far as your
eye can see. At the end of some of them you notice a feeble light, at
the end of others an open door which reveals a suite of rooms. Every
now and then you hear a footstep: you stop; all is silent; then you
hear it again; you do not know if it is above your head, or to the right,
or the left, or before you, or behind you. You are about to enter a
door; you recoil in terror: at the end of a long corridor you see a man,
motionless as a spectre, who is staring at you. You continue your
journey and arrive in a strange court, surrounded by high walls and
overgrown with grass, full of echoes, and illuminated by a wan light
which seems to come from some strange sun; it reminds you of the
haunts of witches described to you in your childhood. You go out of
the court, walk up a stairway, arrive in a gallery, and look down: there
beneath you is another, and deserted, court. You walk down another
corridor, you descend another stairway, and you find yourself in a
third court; then again more corridors, stairways, suites of empty
rooms, and narrow courts, and everywhere granite, a wan light, and
the stillness of death. For a short time you think you could retrace
your steps; then your memory forsakes you, and you recall nothing:
it seems as if you had walked ten leagues, that you have been in this
labyrinth for a month, and that you will never get out of it. You come
to a court, and exclaim: “I have seen this before!” No you are
mistaken: it is another one. You think you are on one side of the
building and you are on the opposite one. You ask your guide for the
cloister, and he replies: “It is here,” and you continue walking for half
an hour. You fancy you are dreaming: you have glimpses of long
walls, frescoed, and adorned with pictures, the crucifix, and with
inscriptions; you see and you forget; you ask yourself “Where am I?”
You see a light as if from another world: you have never conceived
of such a peculiar light. Is it the reflection of the granite? Is it
moonlight? No, it is daylight; but a daylight sadder than darkness; it
is a false, sinister, fantastic daylight. Let us go on! From corridor to
corridor, from court to court, you look before you with mistrust; you
expect to see suddenly at the turn of a corner a row of skeleton
monks with hoods drawn over their eyes and their arms folded; you
think of Philip II.; you fancy you hear his step growing ever fainter
down the distant passages; you remember all you have read of him,
of his terrors, of the Inquisition; and everything becomes suddenly
plain; you understand it all for the first time: the Escurial is Philip II.,
you see him at every step, and you hear him breathe; for he is here,
living and fearful, and the image of his terrible God is with him. Then
you want to revolt, to raise your thought to the God of your heart and
hope, and to conquer the mysterious terror which this place inspires;
but you cannot; the Escurial envelops you, possesses you, crushes
you; the cold of its stones penetrates into your very bones, the
sadness of its sepulchral labyrinths takes possession of your soul. If
you were with a friend, you would say: “Let us go!”; if you were with
your loved one, you would tremblingly clasp her to your heart; if you
were alone, you would take flight. Finally you ascend the stairway,
and, entering a room, go to the window to salute rapturously the
mountains, the sunshine, liberty, and the great and generous God
who loves and pardons.
How one breathes again at this window!
From it you see the gardens, which occupy a restricted space
and which are very simple, but elegant and beautiful, and in perfect
harmony with the building. You see in them twelve charming
fountains, each surrounded by four squares of box-wood,
representing the royal escutcheons, designed with such skill and
trimmed with such precision that in looking at them from the windows
they seem to be made of plush and velvet, and they stand out from
the white sand of the walks in a very striking manner. There are no
trees, nor flowers, nor pavilions here; in all the gardens nothing is to
be seen but fountains and squares of box-wood and these two
colours—white and green—and such is the beauty of this noble
simplicity that the eye is enchanted with it, and when it has passed
out of sight, the thought returns and rests there with pleasure
mingled with a gentle melancholy....
An illustrious traveller has said that after having spent a day in
the Convent of the Escurial, one should feel happy for the remainder
of his life in thinking that he might be still between those walls, but
that he has escaped. That is very nearly true. Even now, after so
long a time, on rainy days when I am sad I think about the Escurial,
then I look around the walls of my room and I become gay; during
nights of insomnia, I see the courts of the Escurial; when I am ill and
drop into a feverish and heavy sleep, I dream that all night I am
wandering in these corridors, alone and followed by the phantom of
a monk, screaming and knocking at all the doors without finding a
way out, until I decide to go to the Pantheon, where the door bangs
behind me and shuts me in among the tombs.
With what delight I saw the myriad lights of the Puerta del Sol,
the crowded cafés and the great and noisy street of the Alcala!
When I went into the house I made such a noise, that the servant,
who was a good and simple Gallician, ran excitedly to her mistress
and said: “Me parece el italiano se ha vuelto loco.” (I think the Italian
has lost his senses).

La Spagna (Florence, 1873).

 THE TEMPLE OF MADURA.
JAMES FERGUSSON.

THERE does not seem to be any essential difference either in plan

or form between the Saiva and Vaishnava temples in the south of
India. It is only by observing the images or emblems worshipped, or
by reading the stories represented in the numerous sculptures with
which a temple is adorned, that we find out the god to whom it is
dedicated. Whoever he may be, the temples consist almost
invariably of the four following parts, arranged in various manners,
as afterwards to be explained, but differing in themselves only
according to the age in which they were executed:—
1. The principal part, the actual temple itself, is called the
Vimana. It is always square in plan, and surmounted by a pyramidal
roof of one or more storeys; it contains the cell in which the image of
the god or his emblem is placed.
2. The porches or Mantapas, which always cover and precede
the door leading to the cell.
3. Gate pyramids, Gopuras, which are the principal features in
the quadrangular enclosures which always surround the Vimanas.
4. Pillared halls or Choultries, used for various purposes, and
which are the invariable accompaniments of these temples.
 THE TEMPLE OF MADURA.

Besides these, a temple always contains tanks or wells for water

—to be used either for sacred purposes or the convenience of the
priests,—dwellings for all the various grades of the priesthood
attached to it, and numerous other buildings designed for state or
convenience....
The population of southern India in the Seventeenth and
Eighteenth Century was probably hardly less than it is now—some
thirty millions—and if one-third or one-fourth of such a population
were to seek employment in building, the results, if persevered in
through centuries, would be something astonishing. A similar state of
affairs prevailed apparently in Egypt in the time of the Pharaohs, but
with very different results. The Egyptians had great and lofty ideas,
and a hankering after immortality, that impressed itself on all their
works. The southern Indians had no such aspirations. Their
intellectual status is, and always was, mediocre; they had no
literature of their own—no history to which they could look back with
pride, and their religion was, and is, an impure and degrading
fetishism. It is impossible that anything grand and imposing should
come out of such a state of things. What they had to offer to their
gods was a tribute of labour, and that was bestowed without stint. To
cut a chain of fifty links out of a block of granite and suspend it
between two pillars, was with them a triumph of art. To hollow deep
cornices out of the hardest basalt, and to leave all the framings, as if
of the most delicate woodwork, standing free, was with them a
worthy object of ambition, and their sculptures are still inexplicable
mysteries, from our ignorance of how it was possible to execute
them. All that millions of hands working through centuries could do,
has been done, but with hardly any higher motive than to employ
labour and to conquer difficulties, so as to astonish by the amount of
the first and the cleverness with which the second was overcome—
and astonished we are; but without some higher motive true
architecture cannot exist. The Dravidians had not even the
constructive difficulties to overcome which enabled the Mediæval
architects to produce such noble fabrics as our cathedrals. The aim
of architects in the Middle Ages was to design halls which should at
the same time be vast, but stable, and suited for the accommodation
of great multitudes to witness a lofty ritual. In their struggles to
accomplish this they developed intellectual powers which impress us
still through their works. No such lofty aims exercised the intellectual
faculties of the Hindu. His altar and the statue of his god were placed
in a dark cubical cell wholly without ornament, and the porch that
preceded that was not necessarily either lofty or spacious. What the
Hindu architect craved for, was a place to display his powers of
ornamentation, and he thought he had accomplished all his art
demanded when he covered every part of his building with the most
elaborate and most difficult designs he could invent. Much of this
ornamentation, it is true, is very elegant, and evidences of power and
labour do impress the human imagination, often even in defiance of
our better judgment, and nowhere is this more apparent than in
these Dravidian temples. It is in vain, however, we look among them
for any manifestation of those lofty aims and noble results which
constitute the merit and the greatness of true architectural art, and
which generally characterise the best works in the true styles of the
western world....
Immediately in front of his choultrie, Tirumulla Nayak
commenced a gopura, which, had he lived to complete it, would
probably have been the finest edifice of its class in southern India. It
measures 174 ft. from north to south, and 107 ft. in depth. The
entrance through it is 21 ft. 9 in. wide; and if it be true that its
gateposts are 60 ft. (Tripe says 57 ft.) in height, that would have
been the height of the opening. It will thus be seen that it was
designed on even a larger scale than that at Seringham, and it
certainly far surpasses that celebrated edifice in the beauty of its
details. Its doorposts alone, whether 57 ft. or 60 ft. in height, are
single blocks of granite, carved with the most exquisite scroll
patterns of elaborate foliage, and all the other carvings are equally
beautiful. Being unfinished, and consequently never consecrated, it
has escaped whitewash, and alone, of all the buildings of Madura, its
beauties can still be admired in their original perfection.
The great temple at Madura is a larger and far more important
building than the choultrie; but, somehow or other, it has not
attracted the attention of travellers to the same extent that the latter
has. No one has ever attempted to make a plan of it, or to describe it
in such detail as would enable others to understand its peculiarities.
It possesses, however, all the characteristics of a first-class
Dravidian temple, and, as its date is perfectly well known, it forms a
landmark of the utmost value in enabling us to fix the relative date of
other temples.
The sanctuary is said to have been built by Viswanath, the first
king of the Nayak dynasty, A. D. 1520, which may possibly be the
case; but the temple itself certainly owes all its magnificence to
Tirumulla Nayak, A. D. 1622–1657, or to his elder brother, Muttu
Virappa, who preceded him, and who built a mantapa, said to be the
oldest thing now existing here. The Kalyana mantapa is said to have
been built A. D. 1707, and the Tatta Suddhi in 1770. These, however,
are insignificant parts compared with those which certainly owe their
origin to Tirumulla Nayak.
The temple itself is a nearly regular rectangle, two of its sides
measuring 720 ft. and 729 ft., the other two 834 ft. and 852 ft. It
possessed four gopuras of the first class, and five smaller ones; a
very beautiful tank, surrounded by arcades; and a hall of 1000
columns, whose sculptures surpass those of any other hall of its
class I am acquainted with. There is a small shrine, dedicated to the
goddess Minakshi, the tutelary deity of the place, which occupies the
space of fifteen columns, so the real number is only 985; but it is not
their number, but their marvellous elaboration that makes it the
wonder of the place, and renders it, in some respects, more
remarkable than the choultrie about which so much has been said
and written. I do not feel sure that this hall alone is not a greater
work than the choultrie; taken in conjunction with the other buildings
of the temple, it certainly forms a far more imposing group.

History of Indian and Eastern Architecture (New York, 1891).

 THE CATHEDRAL OF MILAN.
THÉOPHILE GAUTIER.

THE Cathedral absorbs the attention of every traveller who visits

Milan. It dominates the town, standing in the centre as its chief
attraction and marvel. To it one hastens immediately on arriving,
even on a night when there is no moon, to grasp at least a few of its
outlines.
The piazza del Duomo, irregular enough in its form, is bordered
with houses of which it is customary to speak ill; the guide never
omits telling the traveller that these should be razed to make this a
symmetrical square in the Rivoli taste. I am not of this opinion. These
houses with their massive pillars and their saffron-coloured awnings
standing opposite to some irregular buildings of unequal height,
make a very good setting for the Cathedral. Edifices often lose more
than they gain by not being obstructed: I have been convinced of this
by several Gothic monuments, the effect of which was not spoiled by
the stalls and the ruins which had gathered around them, as might
have been believed; this is not, however, the case with the
Cathedral, which is perfectly isolated; but I think that nothing is more
favourable to a palace, a church, or any regularly constructed
building than to be surrounded by heterogeneous buildings which
bring out the proportions of the noble order.
When we look at the Cathedral from the square, the effect is
ravishing: the whiteness of the marble, standing out from the blue of
the sky, strikes you first; one would say that an immense piece of
silver lace had been placed against a background of lapis lazuli. This
is the first impression, and it will also be the last memory. Whenever
I think of the Duomo of Milan, it always appears like this. The
Cathedral is one of those rare Gothic churches of Italy, yet this
Gothic resembles ours but little. We do not find here that sombre
faith, that disquieting mystery, those dark depths, those severe
forms, that darting up from earth towards the sky, that character of
austerity which repudiates beauty as too sensual and only selects
from a subject what is necessary to bring you a step nearer to God;
this is a Gothic full of elegance, grace, and brilliancy, which one
dreams of for fairy palaces and with which one could build alcazars
and mosques as well as a Catholic temple. The delicacy in its
enormous proportions and its whiteness make it look like a glacier
with its thousand needles, or a gigantic concretion of stalactites; it is
difficult to believe it the work of man.
The design of the façade is of the simplest: it is an angle sharp
as the gable-end of an ordinary house and bordered with marble
lace, resting upon a wall without any fore-part, of no distinct order of
architecture, pierced by five doors and eight windows and striped
with six groups of columns with fillets, or rather mouldings which end
in hollowed out points surmounted by statues and filled in their
interstices with brackets and niches supporting and sheltering figures
of angels, saints, and patriarchs. Back of these spring out from
innumerable fillets, like the pipes of a basaltic grotto, forests of little
steeples, pinnacles, minarets, and needles of white marble, while the
central spire which resembles frost-work, crystallized in the air, rises
in the azure to a terrific height and places the Virgin, who is standing
upon its tip with her foot on a crescent, within two steps of Heaven.
In the middle of the façade these words are inscribed: Mariae
nascenti, the dedication of the Cathedral.
Begun by Jean Galéas Visconti, continued by Ludovico le More,
the basilica of Milan was finished by Napoleon. It is the largest
church known after Saint Peter’s in Rome. The interior is of a
majestic and noble simplicity: rows of columns in pairs form five
naves. Notwithstanding their actual mass, these groups of columns
have a lightness of effect on account of the grace of their shafts.
Above the capitals of the pillars there is a kind of gallery, perforated
and carved, where statues of saints are placed; then the mouldings
continue until they unite at the summit of the vault, which is
ornamented with trefoils and Gothic knots made with such perfection
that they would deceive the eye, if the plaster, which has fallen in
places, did not reveal the naked stone.
In the centre of the cross an opening, surrounded by a
balustrade, allows you to look down into the crypt, where the
remains of Saint Charles Borromeo rest in a crystal coffin covered
with plates of silver. Saint Charles Borromeo is the most revered
saint of the district. His virtues and his conduct during the plague in
Milan made him popular, and his memory is always kept alive.
At the entrance of the choir upon a grille which supports a
crucifix, surrounded by angels in adoration, we read the following
inscription framed in wood: Attendite ad petram unde excisi estis. On
each side there are two magnificent pulpits of wood, supported by
superb bronze figures and ornamented with silver bas-reliefs, the
subjects of which are their least value. The organs, placed not far
from the pulpits, have fine paintings by Procacini, if my memory does
not deceive me, for shutters; above the choir there is a Road to the
Cross, sculptured by Andrea Biffi and several other Milanese
sculptors. The weeping angels, which mark the stations, have a
great variety of attitudes and are charming, although their grace is
somewhat effeminate.
The general impression is simple and religious; a soft light
invites you to reflection; the large pillars spring to the vault with a
movement full of vitality and faith; not a single detail is here to
destroy the majesty of the whole. There is no overcharging and no
surfeit of luxury: the lines follow each other from one end to the
other, and the design of the edifice is understood in a single glance.
The superb elegance of the exterior seems but a veil for mystery and
humility within; the blatant hymn of marble makes you lower your
voice and speak in a hushed tone: the exterior, by reason of its
lightness and whiteness, is, perhaps, Pagan; the interior is, most
assuredly, Christian.
In the corner of a nave, just before ascending the dome, we
glance at a tomb filled with allegorical figures cast in bronze by the
Cavalier Aretin after Michael Angelo in a bold and superb style. You
arrive straightway on the roof of the church after climbing a stairway
decorated at every angle with prohibitive, or threatening inscriptions,
which do not speak well in favour of the Italians’ piety or sense of
propriety.

CATHEDRAL OF MILAN: FLYING BUTTRESSES

 This roof all bristling with steeples and ribbed with flying-
buttresses at the sides, which form corridors in perspective, is made
of great slabs of marble, like the rest of the edifice. Even at this point
it is higher than the highest monuments of the city. A bas-relief of the
finest execution is sunk in each buttress; each steeple is peopled
with twenty-five statues. I do not believe there is another place in the
world that holds in the same amount of space so large a number of
sculptured figures. One could make an important city with the marble
population of the Cathedral statues. Six thousand, seven hundred
and sixteen have been counted. I have heard of a church in the
Morea painted in the Byzantine style by the monks of Mount Athos,
which did not contain less than three thousand figures. This is as
nothing in comparison to the Cathedral of Milan. With regard to
persons painted and sculptured, I have often had this dream—that if
ever I were invested with magical power I would animate all the
figures created by art in granite, in stone, in wood, and on canvas
and people with them a country which would be a realization of the
landscapes in the pictures. The sculptured multitude of this
Cathedral bring back this fantasy. Among these statues there is one
by Canova, a Saint Sebastian, lodged in an aiguille, and an Eve by
Cristoforo Gobi, of such a charming and sensual grace that it is a
little astonishing to see her in such a place. However, she is very
beautiful, and the birds of the sky do not appear to be scandalized by
her Edenesque costume.
From this platform there unfolds an immense panorama: you see
the Alps and the Apennines, the vast plains of Lombardy, and with a
glass you can regulate your watch from the dial of the church of
Monza, whose stripes of black and white stones may be
distinguished....
The ascent of the spire, which is perforated and open to the light,
is not at all dangerous, although it may affect people who are subject
to vertigo. Frail stairways wind through the towers and lead you to a
balcony, above which there is nothing but the cap of the spire and
the statue which crowns the edifice.
I will not try to describe this gigantic basilica in detail. A volume
would be needed for its monograph. As a mere artist I must be
content with a general view and a personal impression. After one
has descended into the street and has made the tour of the church
one finds on the lateral façades and apses the same crowd of
statues, the same multitude of bas-reliefs: it is a terrifying debauch of
sculpture, an incredible heap of wonders.
Around the Cathedral all kinds of little industries prosper, stalls of
second-hand booksellers, opticians selling their wares in the open
air, and even a theatre of marionnettes, whose performances I
promise myself not to miss. Human life with its trivialities swarms
and stirs at the foot of this majestic edifice, which, like petrified
fireworks, is bursting its white rockets in the sky; here, as
everywhere, we find the same contrast of sublimity of idea and
vulgarity of fact. The temple of the Saviour throws its shadow across
the hut of Punchinello.

Voyage en Italie (Paris, new ed., 1884).

 THE MOSQUE OF HASSAN.
AMELIA B. EDWARDS.

THE mosque of Sultan Hassan, confessedly the most beautiful in

Cairo, is also perhaps the most beautiful in the Moslem world. It was
built at just that happy moment when Arabian art in Egypt, having
ceased merely to appropriate or imitate, had at length evolved an
original architectural style out of the heterogeneous elements of
Roman and early Christian edifices. The mosques of a few centuries
earlier (as, for instance, that of Tulûn, which marks the first departure
from the old Byzantine model) consisted of little more than a
courtyard with colonnades leading to a hall supported on a forest of
pillars. A little more than a century later, and the national style had
already experienced the beginnings of that prolonged eclipse which
finally resulted in the bastard Neo-Byzantine Renaissance
represented by the mosque of Mehemet Ali. But the mosque of
Sultan Hassan, built ninety-seven years before the taking of
Constantinople, may justly be regarded as the highest point reached
by Saracenic art in Egypt after it had used up the Greek and Roman
material of Memphis, and before its new-born originality became
modified by influence from beyond the Bosphorus. Its pre-eminence
is due neither to the greatness of its dimensions, nor to the
splendour of its materials. It is neither so large as the great mosque
at Damascus, nor so rich in costly marbles as Saint Sophia in
Constantinople; but in design, proportion, and a certain lofty grace
impossible to describe, it surpasses these, and every other mosque,
whether original or adapted, with which the writer is acquainted.
The whole structure is purely national. Every line and curve in it,
and every inch of detail, is in the best style of the best period of the
Arabian school. And above all, it was designed expressly for its
present purpose. The two famous mosques of Damascus and
Constantinople having, on the contrary, been Christian churches,
betray evidences of adaptation. In Saint Sophia, the space once
occupied by the figure of the Redeemer may be distinctly traced in
the mosaic-work of the apse, filled in with gold tesseræ of later date;
while the magnificent gates of the great mosque at Damascus are
decorated, among other Christian emblems, with the sacramental
chalice. But the mosque of Sultan Hassan built by En Nasîr Hassan
in the high and palmy days of the Memlook rule, is marred by no
discrepancies. For a mosque it was designed, and a mosque it
remains. Too soon it will be only a beautiful ruin.