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 “To interventional fellows and colleagues
everywhere for their hard work and dedication to
patient care; to my parents for their infinite
patience, love, and understanding; and to
Suchandra, for her love and support.”
—DEBABRATA MUKHERJEE

“To interventional fellows worldwide who will use

this text to expand their knowledge and advance
our field … and to my parents, wife and sons
who’ve taught me more about issues of the heart
than any cardiology text.”
—RICHARD A. LANGE

“To my parents, my wife and my daughter—who

inspire me to keep learning—and to my
innumerable mentors over the years.”
—SAURAV CHATTERJEE

“With gratitude to the interventional fellows at

Cleveland Clinic past, present, and future for their
dedication and hard work.”
—LESLIE CHO

“To our chapter authors and interventional

cardiology teachers worldwide; thoughtful
questions and thorough answers will continue to
advance the field and guide us all in contemporary
medical practice.”

8
—DAVID J. MOLITERNO

9
 PREFACE

Insightful questions have been used throughout the ages as a metric to

assess one’s knowledge, but when coupled with carefully delivered
answers, they can become a powerful teaching tool. This book of questions
and annotated answers covering the field of interventional cardiology is
meant to serve as a helpful resource for individuals preparing for the
interventional cardiovascular medicine board exam, as well as for
clinicians who wish to perform an in-depth self-assessment on individual
topics or the full spectrum of cardiovascular medicine. The book has many
key features, which we believe will make the reader successful in passing
the boards and improving clinical practice.
Of foremost importance, the areas covered are relevant not only to the
day-to-day practice of interventional cardiology but have also been
modified to fit the scope and content of the actual board examination. The
book begins with several chapters dedicated to the anatomy and
physiology associated with interventional cardiology and the pathobiology
of atherosclerosis and inflammation. This corresponds to the 15% of the
board examination, which targets material in the basic sciences. The
subsequent chapters focus on the essential interventional pharmacotherapy
of antiplatelets, anticoagulants, and other commonly used medications in
the catheterization laboratory and outpatient setting for patients with
atherosclerosis. These chapters correspond to the next 15% of the boards
centering on pharmacology. A similar-sized 15% of the board examination
is directed toward imaging; this book includes specific chapters on
radiation safety, catheterization laboratory equipment and technique,
contrast agents, and intravascular ultrasound. The two largest areas of the
examination, each covering 25% of the content, include case selection
management and procedural techniques. This review book dedicates
several chapters to comprehensively cover these areas as well. Finally, we
have included chapters for the miscellaneous remaining areas covered by
the board examination, including peripheral vascular disease,
cerebrovascular and structural heart interventions, ethics, statistics, and
epidemiology, as well as a chapter directed at improving test-taking skills.

10
 Also essential to the quality and appropriateness of the questions and
annotated answers is the expertise of the chapter authors. We are fortunate
to have assembled the “who’s who” of academic interventional cardiology.
The contributing authors from leading medical centers around the world
have over 8,000 articles cited in PubMed. We are greatly indebted to these
authors who are recognized both for their interventional expertise and for
their teaching skills. In the end, the true value of this textbook is not only
the relevance of the questions and the outstanding quality of the authors
but also the value of the annotated answers. The text includes more than
1,000 questions and over 400 figures and tables. The corresponding
answers have been appropriately detailed to provide relevant facts,
information, and up-to-date journal citations.
The practice of interventional cardiology is exciting, rewarding, and a
privilege each of us enjoys. Likewise, it has been our privilege to work
with the superb contributors, our colleagues in interventional cardiology,
and Ms. Nadia Whitehead at Texas Tech University Health Sciences
Center El Paso and Ms. Mary Goodman at Wolters Kluwer for their
editorial assistance. It is our personal hope that you will enjoy this book
and that it will be a valuable resource to you in passing the board
examination and providing the highest quality care possible to your
patients

Debabrata Mukherjee, MD
Richard A. Lange, MD, MBA
Saurav Chatterjee, MD
Leslie Cho, MD
David J. Moliterno, MD

11
 CONTRIBUTORS

Harsh Agrawal, MD
Division of Cardiology
Paul L. Foster School of Medicine
Texas Tech University Health Sciences Center El Paso
El Paso, Texas

Robert J. Applegate, MD
Cardiovascular Medicine
Wake Forest School of Medicine
Medical Center Boulevard
Winston-Salem, North Carolina

Subhash Banerjee, MD
University of Texas Southwestern Medical Center
Division of Cardiology
Veterans Affairs North Texas Health Care System
Dallas, Texas

Olivier F. Bertrand, MD, PhD

Québec Heart-Lung Institute
Laval University
Department of Mechanical Engineering
McGill University
Québec City, Québec, Canada

Sorin J. Brener, MD
Cardiac Catheterization Laboratory
New York—Presbyterian Brooklyn Methodist Hospital
Weill Cornell Medical College
Brooklyn, New York

12
Saurav Chatterjee, MD
Fellow, Interventional Cardiology
Temple University Hospital
Philadelphia, Pennsylvania

Adnan K. Chhatriwalla, MD
University of Missouri—Kansas City
Saint Luke’s Mid America Heart Institute
Kansas City, Missouri

Leslie Cho, MD
Director, Women’s Cardiovascular Center
Preventive Cardiology & Rehabilitation
Cleveland Clinic Foundation
Cleveland, Ohio

Joaquin E. Cigarroa, MD
Knight Cardiovascular Institute
Oregon Health & Science University
Portland, Oregon

Antonio Colombo, MD
Interventional Cardiology Unit
San Raffaele Scientific Institute
EMO-GVM Centro Columbus Hospital
Milan, Italy

Harold L. Dauerman, MD
University of Vermont College of Medicine
Burlington, Vermont

Ali Denktas, MD
Division of Cardiology
Department of Medicine
Baylor College of Medicine
Houston, Texas

13
Steven P. Dunn, PharmD
Heart and Vascular Center
University of Virginia Health System
University of Virginia School of Medicine
Charlottesville, Virginia

Mouhammad Fathallah, MD
Department of Cardiovascular Medicine
Duke University Medical Center
Durham, North Carolina

Stephan D. Fihn, MD, MPH

Departments of Medicine and Health Services
University of Washington
Seattle, Washington

Giuseppe Gargiulo, MD
Department of Cardiology, Inselspital
Bern University Hospital
Bern, Switzerland

Jay Giri, MD, MPH

Interventional Cardiology & Vascular Medicine
Division of Cardiovascular Medicine
Perelman School of Medicine
University of Pennsylvania
Philadelphia, Pennsylvania

Kashish Goel, MBBS

Department of Cardiovascular Diseases
Mayo Clinic
Rochester, Minnesota

Ziyad M. Hijazi, MD, MPH

Weill Cornell Medical College
Cornell University
Department of Pediatrics

14
Sidra Medical and Research Center
Doha, Qatar

Terence Hill, MD
Department of Cardiovascular Medicine
Heart and Vascular Institute
Cleveland Clinic Foundation
Cleveland, Ohio

Elizabeth M. Holper, MD, MPH

Interventional Cardiology
Interventional Cardiology Research
The Heart Hospital Baylor Plano
Plano, Texas

Samuel E. Horr, MD
Department of Cardiovascular Medicine
Heart and Vascular Institute
Cleveland Clinic
Cleveland, Ohio

Sei Iwai, MD
Westchester Medical Center
New York Medical College
Hawthorne, New York

Alice K. Jacobs, MD
Cardiac Catheterization Laboratory
Boston University School of Medicine
Boston, Massachusetts

Hani Jneid, MD
Interventional Cardiology Research
Michael E. DeBakey VA Medical Center
Baylor College of Medicine
Houston, Texas

15
Ankur Kalra, MD
Division of Cardiovascular Medicine
Department of Medicine
Case Western Reserve University School of Medicine
Harrington Heart & Vascular Institute
University Hospitals Cleveland Medical Center
Cleveland, Ohio

David E. Kandzari, MD
Piedmont Heart Institute
Piedmont Healthcare
Atlanta, Georgia

Ryan Kaple, MD
Interventional Cardiology
Westchester Medical Center
New York Medical College
Valhalla, New York

Dimitri Karmpaliotis, MD, PhD

Columbia University Medical Center
New York Presbyterian Hospital
New York, New York

Waleed Kayani, MD
Division of Cardiology
Department of Medicine
Baylor College of Medicine
Houston, Texas

Morton J. Kern, MD
Division of Cardiology
Veterans Affairs Long Beach HealthCare System
Long Beach, California
University of California Irvine Medical Center
Orange, California

16
Richard A. Krasuski, MD
Adult Congenital Heart Disease Center
Duke University Medical Center
Durham, North Carolina

Richard A. Lange, MD, MBA

President and Dean
Paul L. Foster School of Medicine
Texas Tech University Health Sciences Center El Paso
El Paso, Texas

Azeem Latib, MD
Interventional Cardiology Unit
San Raffaele Scientific Institute
EMO-GVM Centro Columbus Hospital
Milan, Italy

John J. Lazarus, MD
Department of Internal Medicine
University of Michigan Medical School
Ann Arbor, Michigan

Glenn N. Levine, MD
Cardiac Care Unit
Michael E. DeBakey VA Medical Center
Baylor College of Medicine
Houston, Texas

Tracy E. Macaulay, PharmD

College of Pharmacy
University of Kentucky
Lexington, Kentucky

Rajendra H. Mehta, MD, MS

Duke Clinical Research Institute
Duke University Medical Center
Durham, North Carolina

17
Timothy A. Mixon, MD
Interventional Cardiology, Division of Cardiology
Texas A&M College of Medicine
Scott & White Medical Center
Temple, Texas

David J. Moliterno, MD
Gill Heart and Vascular Institute
University of Kentucky
Lexington, Kentucky

Pedro R. Moreno, MD
Mount Sinai Health System
New York, New York

Debabrata Mukherjee, MD
Chairman and Professor
Department of Internal Medicine
Paul L. Foster School of Medicine
Texas Tech University Health Sciences Center El Paso
El Paso, Texas

Srihari S. Naidu, MD
Hypertrophic Cardiomyopathy Program
Interventional Cardiology
Westchester Medical Center
New York Medical College
Long Island, New York

Brahmajee K. Nallamothu, MD
Department of Internal Medicine
University of Michigan
Ann Arbor, Michigan

Craig R. Narins, MD
Divisions of Cardiology and Vascular Surgery
University of Rochester School of Medicine

18
Rochester, New York

Stephane Noble, MD
Division of Cardiology
University Hospital of Geneva
Geneva, Switzerland

Hussein Othman, MD
Central Michigan University College of Medicine
Detroit, Michigan

Devin Patel, MD
Division of Cardiovascular Medicine
Vanderbilt University Medical Center
Nashville, Tennessee

Timir K. Paul, MD, PhD

Department of Internal Medicine
Quillen College of Medicine
East Tennessee State University
Johnson City, Tennessee

Guillaume Plourde, MD, PhD

Québec Heart-Lung Institute
Université Laval
Québec, Canada

Abhiram Prasad, MD
Department of Cardiovascular Diseases
Mayo Clinic
Rochester, Minnesota

Mark Robbins, MD
Division of Cardiovascular Medicine
Vanderbilt University Medical Center
Nashville, Tennessee

19
Marco Roffi, MD
Division of Cardiology
University Hospital of Geneva
Geneva, Switzerland

Sonia Samtani, MD
Division of Cardiology
Irvine School of Medicine
University of California
Memorial Care Heart & Vascular Institute
Long Beach, California

Jacqueline Saw, MD
Interventional Cardiology
Vancouver General Hospital
University of British Columbia
Vancouver, Canada

Karen Segerson, MD
Department of Medicine
University of Washington
Seattle, Washington

Arnold H. Seto, MD
Division of Cardiology
Veterans Affairs Long Beach Health Care System
Long Beach, California
University of California Irvine Medical Center
Orange, California

Madhan Shanmugasundaram, MD
Sarver Heart Center
University of Arizona College of Medicine
Southern Arizona Veterans Affairs Health Care System
Tucson, Arizona

Mehdi Shishehbor, DO, PhD, MPH

20
Director, Cardiovascular Interventional Center
Co-Director, Vascular Center
University Hospitals Harrington Heart & Vascular Institute
Cleveland, Ohio

Michael H. Sketch Jr., MD

Department of Medicine
Duke University
Durham, North Carolina

Paul Sorajja, MD
Center for Valve and Structural Heart Disease
Minneapolis Heart Institute
Abbott Northwestern Hospital
Minneapolis, Minnesota

Hussam S. Suradi, MD
Rush Center for Structural Heart Disease
Rush University Medical Center
Structural Heart & Valve Center
St. Mary Medical Center
Munster, Indiana

Rajesh V. Swaminathan, MD
Duke University Medical Center
Duke Clinical Research Institute
Durham, North Carolina

Jay Thakkar, MD
Vancouver General Hospital
University of British Columbia
Vancouver, Canada

Marco Valgimigli, MD, PhD

Bern University Hospital
University of Bern
Bern, Switzerland

21
Amit N. Vora, MD, MPH
Department of Medicine
Duke University
Durham, North Carolina

Frederick G.P. Welt, MD

Division of Cardiovascular Medicine
Department of Medicine
Cardiac Catheterization Laboratory
University of Utah Health Sciences Center
Salt Lake City, Utah

Katherine Yu, MD
Olive View-UCLA Medical Center
University of California, Irvine
Long Beach, California

Khaled M. Ziada, MD
Interventional Cardiology
Gill Heart and Vascular Institute
University of Kentucky
Lexington, Kentucky

22
 CONTENTS

Preface
Contributors
Abbreviations

1 Vascular Biology
Frederick G.P. Welt and Pedro R. Moreno

2 Anatomy and Physiology

Richard A. Lange and Joaquin E. Cigarroa

3 Principles of Radiation Use, Protection, and Basic Physics

Concepts
Guillaume Plourde and Olivier F. Bertrand

4 Inflammation and Arterial Injury

Jay Giri and Harold L. Dauerman

5 Antiplatelet, Antithrombotic, and Thrombolytic Agents

David J. Moliterno and Tracy E. Macaulay

6 Pharmacogenomics and Drug—Drug Interactions

Timir K. Paul

7 Antiarrhythmics, Sedatives, and Lipid-Lowering Agents

Steven P. Dunn and David J. Moliterno

8 Inotropes, Vasopressors, and Vasodilators

Tracy E. Macaulay and David J. Moliterno

9 Guide Catheter Selection for Coronary Interventions

Timothy A. Mixon and Elizabeth M. Holper

23
10 Intravascular Contrast Agents
John J. Lazarus and Brahmajee K. Nallamothu

11 Elective Coronary Intervention

Rajesh V. Swaminathan

12 Percutaneous Coronary Intervention for Acute Coronary

Syndromes
Madhan Shanmugasundaram

13 Primary, Rescue, and Facilitated Angioplasty

Amit N. Vora and Michael H. Sketch, Jr.

14 Periprocedural Myocardial Infarction, Emboli Protection,

and Mechanical Thrombectomy
Terence Hill and Mehdi H. Shishehbor

15 Chronic Total Occlusions

David E. Kandzari and Dimitri Karmpaliotis

16 Ostial and Bifurcation Lesions

Antonio Colombo and Azeem Latib

17 Long Lesions and Diffuse Disease

Subhash Banerjee

18 Restenosis and Percutaneous Options

Craig R. Narins

19 Orbital and Rotational Atherectomy, Cutting and Scoring

Balloon Angioplasty, and Laser
Robert J. Applegate

20 Stents and Stent Thrombosis

Giuseppe Gargiulo and Marco Valgimigli

21 Drug-Eluting Stents and Local Drug Delivery for the

Prevention of Restenosis
Samuel E. Horr and Leslie Cho

24
22 Percutaneous Interventions in Aortocoronary Saphenous
Vein Grafts
Stephane Noble and Marco Roffi

23 Vascular Closure and Devices

Kashish Goel and Abhiram Prasad

24 Management of Intraprocedural and Postprocedural

Complications
Saurav Chatterjee

25 Qualitative and Quantitative Angiography

Sorin J. Brener

26 Intracoronary Doppler and Pressure Monitoring

Morton J. Kern, Arnold H. Seto, Katherine Yu and Sonia Samtani

27 Intravascular Ultrasound
Khaled M. Ziada

28 Approach to Patients with Hemodynamic Compromise

Zoran S. Nedeljkovic and Alice K. Jacobs

29 Peripheral Interventional Procedures

Devin Patel and Mark Robbins

30 Cerebrovascular Interventions
Mehdi Shishehbor and Ankur Kalra

31 Valvuloplasty and Transcatheter Valve Repair and

Replacement
Adnan K. Chhatriwalla and Paul Sorajja

32 Adult Congenital Heart Disease

Mouhammad Fathallah and Richard A. Krasuski

33 Patent Foramen Ovale and Atrial Septal Defect Closure

Hussam S. Suradi and Ziyad M. Hijazi

25
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bridegroom part of the way to the bride’s apartment. So, lifting the
heavy Mohammed, I carried him a few paces. He was evidently
pleased at my doing him this friendly service, and, the form having
been gone through, sprang quickly down, and, taking me and one of
his other friends each by a hand, began to run. Before us sped a
young man; the rest followed. We were breathless when we reached
the caves.
All was in order. A crowd of spectators began to gather
immediately, and we slipped in through the gates and down the
passage, rapidly crossed into the first court, thence through the
underground passage and out into the other court. This was half-
dark, but from one of the caves shone a light. Here we entered. The
vaulted oblong room with its whitewashed walls was brilliantly lit up.
At the far end a carpet hung right across the room, concealing
something on the ground; in front was spread another carpet. Here
Mohammed seated himself, facing the door. There was no other
furniture visible.
On the bridegroom’s left his friend took a seat, pointing to me to
take my place on the right. There was not the slightest sign on the
features of the former expressive of any emotion, either of gladness
or gravity. To the looker-on he appeared merely phlegmatic, and sat,
wrapped in his cloak, staring into vacancy. His friend, who was also
clothed in red, sat, like himself, in silence.
In the open doorway I saw the faces of Belkassim and Mansur,
also some children, Jews, and the men who had followed us. No
women were present.
When we had been seated thus for a while, there appeared, from
the part of the room divided from us by the hangings, a large dish of
kus-kus and, soon after, a pitcher of water. These were placed
before Mohammed, who took a mouthful of the food—the first meal
prepared for him by his bride.
We sat silent a moment longer, then Belkassim dismissed the
spectators from the door, and I rose, shook hands with my friend the
bridegroom, and left. In the doorway I looked back. There sat the
bridegroom, dumb and stiff, but behind him I saw the carpet being
drawn a little aside, and in the dim light beyond it fancied I caught
sight of a woman’s face. Whether it were pretty, young, or smiling, I
know not. I only know that it must have been the bride’s.
In the open air the festival was in full swing. Closely packed in
front of the gate, and all along the approach, sat veiled women. The
banks and hollows were white with spectators. The negroes danced,
played, and drummed. There a mulatto sang a droll ballad; here two
men danced a stick dance, and so on.
I had been requested to take my place amongst the bridegroom’s
friends, who held themselves in a group apart, prepared to show him
this last day’s homage.
About an hour elapsed, then from the bridal cave a muffled gun-
shot was heard; it was scarcely noticeable, as the shrieking and
booming of the music overpowered all sounds. Ali hastily handed me
a gun, which I discharged, and several shots were fired from our
group. Every one of those present knew what this meant, and
rejoiced, but none more so than the family of the bride. They, who
had waited anxiously, were reassured, for she would not now, under
cover of the silent dark night, and wrapped in a grey blanket, be
hunted at a given word out of the village, and driven home to
sorrowing and disgraced parents and relatives.
The festival was not interrupted, but continued as before.
With the Khalifa by my side, and surrounded by his sons, the
sheikhs, and the principal guests, I remained seated all the evening
and far into the night, watching the entertainment, that in course of
time became very monotonous.
Now and again some men stepped forward, either singly or two
together. Over their shoulders hung red cloaks, and they posed in
graceful attitudes, with their heads held high, one foot forward, and
the left arm hidden beneath the burnous and the red cloak, whilst the
right hand was extended. On each side of them crouched a negro,
with the flaps of his burnous spread out before him to catch the coins
shortly to be thrown to him. Round these figures danced other
negroes, whilst the drums played.
 Now one of the red figures raised an arm and threw a coin into the
negro’s lap, then again, slipping his hands into the folds over his
breast, pulled out another coin. This went on incessantly, that all
might witness how much money was distributed.
First it was the turn of the representatives from Beni Sultan, then
from Zaraua, Tamezred, or other villages, who in this way paid the
tribute expected of them on such festive occasions for the benefit of
the negro musicians.
When at last the men ceased, and the chink of coin was no longer
heard, one of the negroes advanced towards the group of women,
and, half-singing, half-declaiming, told them that the men of such
and such villages had given so much, at the same time praising not
only their generosity, but also their other virtues. Now and then his
song was interrupted by the “Yu, yu” of the women, which this
evening, owing to the number of voices, sounded quite imposing.
When he concluded, the applause was deafening.
Now and then a solo was sung, two or three voices joining in the
chorus that followed, the singers sticking their noses as close
together as they could during the performance. These songs are
always sung in a nasal tone, without any modulation, and the time
never varies.
 CHAPTER XI

Over the Mountains and across the Plain

from Hadeij to Metamer

During the night most of the guests wended their way homewards,
but a few still remained next morning; some of whom desired to
accompany me to Beni Sultan.
The bridegroom was expected to emerge from his cave at any
moment, so I lingered awhile, partly in hopes of bidding him farewell,
and also because I had been told he would be received with
rejoicings, and would distribute sweetmeats amongst the village
children. But the time fixed for my departure came, and I had to ride
off without witnessing this concluding scene of the festival.
Mansur’s mule was brought me. The Khalifa himself arranged my
saddle and lengthened the stirrups, thus showing me the final marks
of courtesy. He then gave the guide his instructions, and I took my
leave with warm expressions of thanks to him and to his sons, and
also to the assembled men. I rewarded little Ali for the services he
had rendered me, bowed respectfully to the Khalifa, and rode off with
my heart full of gratitude towards him and his people for their great
hospitality, and with the pleasant impression that my stay in the
Matmata mountains had given me the opportunity of seeing manners
and customs which, to my knowledge, no European had yet
witnessed in these regions. I thankfully recognised my good fortune
in having had the goodwill and assistance of the authorities; and
was, above all, grateful for the great hospitality of the people from
whom I had then just parted, and for their friendship which I flattered
myself I had gained.
 A mule saddle is very broad, and resembles somewhat a pack. Its
peculiarity is that the stirrup-leathers are not secured to it. A leather
strap with a stirrup hung at each end is slung over the saddle, so
that, to mount, one must either vault into the saddle without setting
foot in the stirrup or be lifted into it. To anyone accustomed to the
ordinary English saddle it is an extremely uncomfortable seat, as it is
necessary to bear equally on both stirrups, or one risks losing one’s
balance and falling off; but I must say my mule proved to be
altogether a success on the difficult mountain road.
For nearly an hour we rode along the mountain top, whence we
had a lovely view; then we descended into a long valley in which
were many half-dead olive trees and green palms. Just as we began
the descent, we met a couple of men on their way to Hadeij from
Beni Sultan to complain to the Khalifa that their sheep had been
stolen.
In the valley was a deep, broad river bed, then dry, and the
mountain sides were furrowed with deep watercourses leading
thereto. In these furrows stood a number of palms surrounded by
embankments.
We halted in a lovely grove of olives, amongst which sprung a few
palms. Here some of our guides awaited us. They had crossed the
mountain by a shorter but precipitous path, whilst we had circled
round by a less steep and fatiguing route.
From an eminence some way down the valley we observed a
village looking like an eagle’s nest. This was the ancient Beni Sultan,
now deserted and in ruins, the present village lying on the incline on
the farther side of the mountain. A few of the houses in this deserted
village were excavated in the ground.
We travelled directly across the valley, and by a very dangerous
and slippery path reached the lowest point of the mountain ridge.
From thence we looked down on the valley on the other side. Facing
us were the ruins of the old village, standing picturesquely against
the sky. We rode down in a zigzag line past the farms and houses
scattered on the mountain side; the dwellings were crowded with
domestic animals, with men and women, and especially with
children.
Not till we reached the valley did we halt, close to the descent to a
cluster of cave dwellings belonging to the Sheikh, in absence of
whom I was most cordially received by one of his nearest relatives.
The passage to the cave was not covered, and was cut into steps
where it sloped down into the ground towards the gate. On one side
of the wall by the steps was dug out a vaulted and somewhat
decorated cave; this was the guest-room where I dined. Afterwards I
visited the nearer of the Sheikh’s houses, with permission to
examine them from top to bottom.
In the main these dwellings were on the same plan as those of
Hadeij, but I found several cisterns in both the farms and the ruins.
Water flowed from the mountains into these through canals and
primitive pipes.
The caves were not all dug down and around a courtyard, but
were often high up on a perpendicular wall, and were reached by
steps.
The women offered me dates and showed me their looms. I saw
where they slept, generally on benches like low tables, called by
them “mokera.”
In one of the underground vaults, to which the access was
through a very heavy gate, was an oil-mill, and in another a granary.
After spending a couple of hours in the shelter of the caves, we
again started riding through the valley in a southerly direction, and
passing through large palm and olive groves. Nowhere in the
mountains had I seen such rich vegetation.
Close to the village were some ten women clad in dark blue,
drawing water from one of the few wells on this mountain. Two large
columns, formed of hewn palm stems, were inserted on either side of
the well, so as to slope inwards. These supported another palm stem
placed horizontally on the top of them; this again sustained a
wooden disk by means of which the water was hauled up. This
system of drawing water is rather comical, for the women, instead of
hauling up the bucket by moving their hands on the rope, seize the
latter and take a quick run, the distance covered being equal to the
depth of the well. When they have thus drawn a pitcherful of water
they return to the well to take another run.
We constantly passed spots in the valley planted more or less
largely with olive trees, but some of these were in an unhealthy
condition, showing grey or yellow instead of a deep fresh green. If
rain were not soon to fall these would die, and it would be many
years before others could be grown and bear fruit.
It cut me to the heart to see all this wealth on the verge of
destruction, and the more so when I learnt that the Khalifa owned
many of the trees. Rain had fallen in many other districts, but none in
this.
Quitting the valley we turned to the right, and rode in a westerly
direction amongst colossal cliffs and into a wild ravine, where we
were surrounded to the north, west, and south by towering rock
pinnacles. Only the very centre of this chasm was reached by the
sun, which, hidden behind the mountain, streamed in glorious
radiance through a rift in the wall of the cliff. On either side of this rift,
with the light playing on their roughly piled grey masses, were the
two villages of Tujan, clinging to the precipitous sides like swallows’
nests to a wall. On one side, high up the mountain, I caught a
glimpse of what appeared to be an eagle’s nest as the sunlight
glanced on it. On inquiring what it was I received the reply that in old,
very old, days the village people resided there, before they moved
lower down the slope.
When we arrived at a difficult pass, my guide, “Erzib ben Hamed,”
who had his home in the village, asked me to dismount. So, leading
our animals, we walked slowly up, our feet slipping, and the stones
rattling down behind us. Beneath some olive trees we again
mounted to make our entry.
We were now near enough to discern that the rift was a deep
ravine; on either side was an irregular mass of dreary, grey houses
piled one over the other, above which the nearly perpendicular cliffs
rose steeply to almost the very top of the mountain, broken only in
one place by a flat surface. On the side nearest to us stood the ruins
of the village of bygone days, perched like a mediæval castle on the
summit of the cliff.
I sat in silent contemplation of this imposing sight, till interrupted
by Hamed, the faithful Hamed, who came up dragging his horse
behind him. He told me to turn round and look at the view of the
Mediterranean.
Great heavens! how glorious was the sight when I raised myself
and looked back. It was so beautiful that even Hamed and the Arabs
were awed by its splendour.
Looking down directly over the slopes, the valley, and the
mountains on either side, we saw the blue sea far away beyond the
plains. In the evening light all the tints of blue, violet, brown, yellow,
and green were softly blended and intermingled as into a veil which
spread over the whole landscape, and imagination divined more than
was actually visible, thus adding to the fascination of the scene.
By the first house, the Sheikh’s, we halted. Some people came
out, one of whom, I suppose, acted as his representative, since he
invited me in; but Hamed was already off his horse and had gone in
to look at the quarters. He returned and announced that they were
very bad, upon which I inquired whether notice had been given of my
coming, and whether the Sheikh had not directed that I should be
given decent accommodation. The spokesman insisted that there
was no other room available. I suspected this to be false, and
ordered Hamed and Erzib to mount their horses at once, and we
rode up a narrow lane and alighted outside Erzib’s dwelling, where
he had already told me I should be welcome. I heard the man
following us, and saw that a number of people had gradually
assembled.
Erzib’s dwelling lay high up on the side of the cliff, but there were
others that were higher still, and yet others below. In front of these
dwellings ran a narrow path, that, starting from the highest farms, led
in a zigzag course down to those below. The outside of the path was
on the edge of a steep declivity, down which all refuse was thrown,
and was therefore dirty; looking, as did all the other banks when
seen from a distance, as though scored with black stripes. On the
slope below us was a house with a courtyard between it and the cliff
wall. This yard, in which a woman was working, was completely
open to view. Thence the ground fell gradually away till it ended in
palm-grown gorges and valleys; beyond these were low hills, then a
plain, and, last of all, the sea.
Below us, and a little to one side, was the principal edifice of the
village—a little mosque, or Marabout’s tomb, outside which a crowd
of men had gathered to perform their evening devotions. Kneeling
almost simultaneously, they kissed the earth and rose again. A few
of them presently disappeared through the open door of the
Marabout’s tomb, but the remainder stayed outside.
Looking upwards, the eyrie on the summit was visible above
Erzib’s house, that is, one could discern it by stretching one’s neck.
On the opposite side, at the end to the left, lay the other village.
In the evening the women sallied forth in numbers to fetch water
from the cisterns in the valley, and the village dogs barked,
answering each other from every side. Below us, at the foot of the
slope, a crowd of men gathered. I could hear their shouts and see
their gesticulations, as, with extended arms, they pointed to one
figure. Some of them turned and called up the bank to us, one of
them being the man who had met me on the Sheikh’s behalf. They
shouted that I should come down and live wherever I pleased with
the other men, and when I replied that I was well installed, they
informed Erzib that fowls, eggs, and bread would shortly be sent,
that the stranger guest might have a really good meal prepared for
him.
Through a very broad gateway I descended into a court. Opposite
was a long house with its own entrance, to the right another
resembling it; and between the two was a passage leading to a third
dwelling that was situated at the back. To the left was a wall.
On the flat roof of the nearest of these houses stood some
enormous rush-bins for corn, and in the courtyard was another.
There also were two fireplaces, one on either side, screened off with
branches. Behind the screen to the left sat a woman laying small
faggots on the fire to warm her hands, for it was cold since the sun
had set. Some children came out of the door, but fled when they
caught sight of me, wrapped as I was in the folds of Erzib’s burnous.
From the door on the left peeped out an elderly and rather nice-
looking woman.
These two were Erzib’s wives: each had her own house; the
children belonged to the woman I saw seated by the hearth.
Erzib told his wives to come forward. This they did quite naturally
and willingly, retiring again after I had shaken hands with them.
Soon after, I saw people arriving with screaming fowls and a
basket of eggs and bread. Erzib at once drew his knife and vanished
with the hens—his intentions were easy to divine.
In the meanwhile carpets had been spread on the floor of the
house, and a couch arranged for me. I lit a candle which had been
placed in a small square recess in the wall. The room was very
irregularly shaped. The floor was of beaten clay, and the walls not
whitewashed. In the background a door led into another room
containing a loom, and where gala dresses hung on a cord, and
household goods on the wall. Through yet another door in the wall to
the right was a room with a bed in it raised on four slight stumps: this
was made of twigs, and had no coverings.
This dwelling was inhabited by the younger wife and her children
—two boys and a little girl. The wife was pretty and not old.
In the house in the courtyard the elder wife resided. In this the
anteroom was larger, and contained household goods and
implements; behind it was the sleeping apartment.
A grown-up married son, then absent, occupied a house tucked
away at the back, and designed on the same plan as the others. His
wife was at home.
Whilst the pile of wood burnt and crackled in the yard and the
women were busy preparing food, I sat on a bank outside the house
in company of my host and several other men.
 The moon had risen and shone clearly over mountain and vale. I
could see down into a courtyard at the foot of the slope, where a fire
burnt brightly on a hearth. Over it hung a cauldron watched by the
housewife. She was young and pretty, and as she moved to and fro
a couple of little children trotted after her. Now and then she stood
still, shading her eyes with her hand, and gazing up in our direction;
possibly in the stillness of the night our voices reached her, for it was
not likely that she could see us. By the hearth a white dog lay and
growled, and when the woman paused and looked up he moved
restlessly, for he also was watching the stranger.
Erzib’s first wife came out and stood leaning against the doorway.
She did not speak, but was evidently interested in our conversation.
Her husband glanced at her and said abruptly—
“She has a great sorrow, and has grieved and wept for many
years. Ali, her only son, who was in service at Gabés, was sent to
prison, accused of having stolen money from the tradesman he
served. But he was innocent—that we know; he was a good boy, and
his mother loved him. It is now four years and four months since we
heard from him, and eight months more must pass before we can
have him home again.”
“Do you not even know if he lives?”
“Yes, we have learnt through strangers that he is alive, and
supposed to be imprisoned at Bona in Algeria.”
The old woman drew herself along the wall till she was close to
me when she heard of what we were talking.
“Are you from Bona?” she asked, whimpering.
“No,” I replied, “I come from a much more distant place, and have
never been in Bona.”
“Ah! then you do not know Ali,” she said, with a sob.
“No, poor woman,” I replied; “that I do not; but now you will soon
see your son alive. You have waited so long for him that the
remaining time will soon pass ere he return to you and be happy with
you again, for you love him. He will have thought so often of you,
and he will be so good to you that both of you will rejoice.”
“Ah! it was a great misfortune, for he was innocent—I am sure of
that; another must have been the culprit, for he was so young.”
“How old was he?”
“That I do not remember.”
“Don’t you know what year he was born?”
“No, I cannot recollect; we never know anything of that.”
“Don’t you know either, Erzib?”
“No, Sidi; but it was before the strangers came to this country.”[2]
The poor woman sobbed audibly, and Erzib pushed her inside the
door that her weeping might not trouble me, saying, “She is very
unhappy, Sidi.”
“Oh yes, Erzib. Would I were able to help you to get back your
son sooner, or at least to procure you tidings of him. But this I can
promise—I will speak to the Khalifa of Gabés on the subject, and, if
possible, send you greeting from your son.”
To my regret, however, I must confess that I was unable later to
do anything for these poor folk. Whether the boy is still in prison I
know not, and whether innocent or no, I know less. My sincere hope
is that he may be worthy of his parents’ touching affection.
The repast was now brought and set out in the house, on the clay
floor, where I enjoyed it; the father, surrounded by his children whom
he caressed, sat aside with Hamed and the younger wife.
When I had finished, and Hamed and Erzib had also eaten, we
remained seated. I talked with the wife about her children. The eldest
may have been about ten years old; he was a lively boy, who nodded
continually to me, and was indefatigable in showing me all the
treasures of his home, from an old musket to his father’s agricultural
implements. When I showed surprise at a very primitive and curious
harrow used to break up the soil, his father gave it to me.
 Next in age to the boy was a very pretty little girl about six years
old. Unfortunately she had lost one eye; her father told me that it was
in consequence of a severe attack of inflammation when she was
quite little, and that the eye had fallen out of itself. Here in the south
one meets with an alarming number of people who are blind or
suffering from eye complaints. A doctor told me that many are born
thus; with others it is the result of dust, heat, and uncleanliness.
The youngest child was a bright little fellow of two, who clung to
his father, whose neck he clasped tightly in his arms.
Feeling disposed to take a stroll before retiring to rest, I bade
Erzib follow me. As we crossed the court, he inquired whether I
would not like to see all the dwellings. Accordingly we went first to
visit the elder lady. When we entered with a light we found her
crouching in a corner, her face buried in her hands; beside her lay a
large dog which growled at me.
Thence we went into the son’s house. Asleep on the bed, quite
dressed,—for the natives never undress at night,—was a woman
wrapped in blue clothing; she was evidently the son’s wife.
We walked on and up amongst other houses till we were nearly at
the top of the village. Beneath, we saw the lights and fires in the
courts, and heard the incessant barking of dogs. Shortly after, we
climbed a difficult ascent just over the village, to a ledge or terrace of
some width cut in the side of the cliff, which from thence rose, quite
straight and steep, to the old deserted village that lay in darkness on
the very summit. According to Erzib, we could not reach it from the
side we were on.
I contented myself with examining some real cliff caves, which I lit
up by means of matches. They were excavated from the terrace,
and, according to tradition, had once been inhabited; they were
irregular in form, and not very large.
After an hour’s enjoyment of the beautiful evening, we descended
from this high point.
Wrapping myself in my burnous I lay down on my couch on the
ground; in the same room lay both Hamed and Erzib. In the side
chamber, of which the door remained open, slept the children and
their mother. Just as I was falling asleep a woman came and spread
a covering over me; it warmed me well, and I slept till daybreak, and
was only once disturbed by a little kid coming in through the open
door leading from the courtyard and tripping over me. I heard then
the children, who with their mother were sleeping in the next room,
Hamed and Erzib moving on their beds, and, out of doors, the distant
and continuous barking of dogs. I slept again, and when I awoke saw
that what had been spread over me was a brand new festal garment
that evidently was considered none too good for the guest.
From the doorway overlooking the courtyard I saw through the
gate and down into the valley, where grew a solitary palm, and at the
same time had a view of the flat roofs of several houses, and of the
path where the horses and mules stood ready saddled. From a side
chamber the head of a cow came peering in at the gate, and above
the gateway a white dog lay on the wall watching me.
I gave some money to the children, ate a couple of dates with a
sup of water, and, having thanked the women for their hospitality,
mounted, with Erzib in front and Hamed behind me. As we left, the
women came out to throw refuse down the slope, and vanished
again behind the wall.
From the hearths rose a light blue smoke that was wafted over the
valley beneath us.
We had a view over the mountains of the valley, the plains, and
the Mediterranean Sea, as we followed the route along the western
declivity of the Matmata range, which commands the low-lying land
that extends right away to Tripoli.
For a while we were accompanied by two women who were on
their way to the mountains. They tripped along beside our horses,
and stared at me in astonishment through carelessly drawn veils.
The mountain tops, where lie the villages of Shenini and Sguimi,
are a continuation of the southern range. As I was aware that the
inhabitants of these villages were absent sowing their crops, and
having been told that the dwellings were similar to those I had
already seen, I decided not to visit them. We therefore left them on
one side and rode down the mountain and across a small plain
encircled by hills, behind which lie the great steppes. Towards the
east this plain is bounded by low hills, where water springs are
found, and where we could descry herds grazing. It was here that,
when passing through a little thicket, we spied a covey of partridges
running amongst the bushes. Erzib tried to fire at them from his
horse, but it would not stand long enough, and when he got off it was
too late—the birds had flown.
Before traversing the last of these hills, we halted and partook of
dates, bread, and water, as many hours would elapse before we
could arrive at any place of habitation.
The ride on the mule had tired me, so I preceded the others on
foot, and reached the farther side of the acclivity. There lies an
interminable flat plain stretching as far as the eye can reach from the
east to the north-west; whilst towards the south the mountains fade
away in long undulations. In the midst of the plain I distinguished a
hill, and on its summit what appeared to be a tower or fortress. This
was the signal station near Metamer. It corresponds to the one we
saw near Gabés, and also to another farther south.
I wandered down the gentle slope, through bushes and among
stones, and crossed the bed of the river, that, coming from the
mountains, winds out into the plain. There were many paths, all
leading in an easterly direction. I followed one of these, crossed yet
another stony torrent bed, and continued steadily towards the east,
making the signal station my point of direction; until, looking round, I
discovered the two riders in their white burnouses far away towards
the south. They beckoned to me, as we were compelled to make a
détour to avoid a rough and uneven river bed.
Joining once more my party, we rode farther and farther over the
plain, which becomes dismally desolate and monotonous; with the
exception of the hill and its signal station, nothing breaks the long
line of the horizon.
At last we viewed in the distance a couple of palm trees, and
concluded that the Ksar of Metamer was probably near them, but we
could not see it at all, as it lay in a hollow.
For long, naught but these trees showed on the level horizon.
Then at last the tops of other palm trees appeared, and a little later
some huts; the number of these increased, and proved to be the
outskirts of the town. The huts—of straw and branches—were round,
as a rule, with a pointed thatch. But it was easy to infer that the
inhabitants were absent, as the network which usually encloses the
verandah that runs round each hut had been removed, and only the
centre of the huts remained, their thatched eaves sticking out all
round, so that they resembled thick mushrooms on short stalks.
As the day advanced, the heat became stifling, so that I took off
my gaiters and bared my legs. But after a couple of hours they were
so scorched by the sun that, on arrival at Medinin, I had to ask a
doctor to dress them for me, to ease the pain of the sun-scorch, and
it was eight days before they recovered.
 CHAPTER XII

Metamer and Medinin

Arriving at the palm grove in the hollow we had seen from the
distance, we found that it lay by a river bed. The trees were not
particularly well cared for, as could be seen at a glance; they were
far apart, and there were few ditches for irrigation.
On a slope to the east of the valley and above it, there is a village
of peculiar construction, with whitewashed buildings that are dazzling
in the sunlight. This is the “Ksar” Metamer. The ground plan of the
houses is oblong and rectangular, and their raised roofs are vaulted.
They lie lengthwise, as the houses do at home in towns dating from
the Middle Ages—the gable ends turning towards the streets. In
general they are erected round an open square. The fronts of those
facing the plain are without any aperture, except some loop-holes
here and there. In other words, every quarter, and also the town as a
whole, forms a little fortress. This is the style of building adopted
here in the plains; it is, in fact, the same plan as that employed in
cave construction, but in this case carried out aboveground; since
the natives have found it impossible to reach the inaccessible
mountain peaks, or to dig down into the rocky ground. The houses
are very often seven storeys high. On every storey there is a well-
barred door to the inner gable. This is reached by steps or by stones
projecting from the walls. The effect is most peculiar and
picturesque. Each inhabitant carries in his hand a key that he takes
with him everywhere. This locks his rooms, which are mostly used as
corn stores.
Not far from the “Ksar” are barracks for the little garrison, and
shops that supply the needs of the soldiers, not only of the place, but
also of those quartered in the neighbouring town of “Medinin.” I did
not wish to visit the camp just then, so dismounted outside an Arab
dwelling, and was invited to enter and partake of stewed kid.
After a hurried visit to the town, and having taken leave of Erzib,
who desired to ride a long way towards his home that evening, I
procured a new guide and rode eastwards over the plain, so as to
arrive before nightfall at the Ksar of Medinin. As we approached its
neighbourhood we turned into the highroad from Gabés.
Before us and to our left lay the “Ksar” of Medinin, illuminated by
the evening sun. The ends of the houses were turned outwards,
producing the effect of a circular wall scalloped at the top. Above
these vaulted gable ends I caught a glimpse of higher buildings, and
amongst them, in the centre of the town, a large square block. This
was the Kasba. Through a narrow opening in the row of houses I
saw the inner gable ends of dwellings, and doors disposed one
above the other, the whole calling to mind the pictures one sees of
Mexican “pueblos.”
 A STREET IN BENI BARKA.

Parts lay in deep shadow, parts blinding white in the sunshine.

These lights and shadows were mingled in such dazzling contrast
that the eye could scarcely discriminate what it beheld.
We rode along the exterior wall till we came to some palms;
farther on grew others. These plantations are to the south of the
Ksar and between it and the European quarter, which showed up
gradually on the right, and consisted of barracks for the cavalry and
infantry, quarters for the officers, and those occupied by the “Bureau
de Renseignement.” The soldiers work amongst the palms, and have
enclosed a plot of ground as a garden. In the beds I saw tender
young green plants sprouting, which proved to be cress. In the open
square in front of headquarters, and before the other houses, holes
were being dug for plants by soldiers in light linen clothing.
In the future the whole military quarter will be surrounded by a
beautiful palm grove, affording shade to the dwellings now
completely exposed to the glare of the sun.
I rode up to headquarters—a large building—where the flag was
hoisted half-mast high on account of the death of Marshal
MacMahon.
Lieutenant Henry, who was at the Bureau, came out to welcome
me. He told me that I was expected, and added that I should meet
the officers of the 4th Light Brigade, whom I had known well at
Gabés, they having arrived to relieve the southern station. I was
quickly conducted to real bachelor’s quarters, consisting of a couple
of rooms. All over the walls hung weapons and curiosities collected
in these regions. The furniture, though camp-like, was very
comfortable. At last I was able to indulge in the luxury of a bath and
change.
In the meantime Hamed arrived to say farewell. He wished to ride
back to Metamer on his donkey and accompany Erzib as far as
Tujan, whence he hoped to take the donkey back to Hadeij, and
return later to Gabés.
When I was dressed I called on the Commander-in-Chief of the
district, Commandant Billet, a young man, who invited me to be his
guest.
When I told him that I was most anxious to meet some Tuareg if
possible, he replied, to my great joy, that by riding some thirty-two
miles farther south I should probably have my wish gratified, as a
telegram had just arrived from the signal station that two of these