Handbook of clinical anesthesia seventh edition barash paul g cullen md bruce f stoelting md robert
Handbook of Clinical Anesthesia
Seventh Edition Barash Paul G Cullen
Md Bruce F Stoelting Md Robert K
Cahalan Md Michael K Stock Md M
Christine Ortega Md Rafael
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Handbook of clinical anesthesia / [edited by] Paul G. Barash . . . [et al.]. 7th ed. p. ; cm.
Includes bibliographical references and index.
Summary: “The Handbook of Clinical Anesthesia, Seventh Edition, is a companion to the parent textbook, Clinical Anesthesia, Seventh Edition. This widely acclaimed reference parallels the textbook and presents content in a concise outline format with additional appendices. The Handbook makes liberal use of tables, graphics, and clinical pearls, to enhance rapid access of the subject matter. This comprehensive, pocket-sized reference guides you through virtually every aspect of perioperative, intraoperative, and postoperative patient care.”—Provided by publisher.
ISBN 978-1-4511-7615-5 (alk. paper)
I. Barash, Paul G. II. Clinical Anesthesia.
[DNLM: 1. Anesthesia—Handbooks. 2. Anesthetics—Handbooks. WO 231]
617.996–dc23
2012051809
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations.
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FOR ALL StuDentS OF AneStheSiOLOGy
CONTRIBUTING AUTHORS
The authors would like to gratefully acknowledge the efforts of the contributors to the seventh edition of the textbook Clinical Anesthesia.
Saint Adeogba, MD
Shamsuddin Akhtar, MD
Michael L. Ault, MD, FCCP, FCCM
Douglas R. Bacon, MD
Gina C. Badescu, MD
Dalia Banks, MD, FASE
Honorio T. Benzon, MD*
Christopher M. Bernards
Marcelle E. Blessing, MD
Michelle Y. Braunfeld, MD
Ferne R. Braveman, MD
Brenda Bucklin, MD
Asokumar Buvanendran, MD
Levon M. Capan, MD
Louanne M. Carabini, MD
C. Richard Chapman, PhD
Amalia Cochran, MD
Edmond Cohen, MD
Christopher W. Connor, MD, PhD
C. Michael Crowder
Marie Csete, MD, PhD
Anthony Cunningham, MD
Armagan Dagal, MD, FRCA
Albert Dahan, MD
Steven Deem, MD
Timothy R. Deer, MD
Stephen F. Dierdorf, MD
Karen B. Domino, MD, MPH
François Donati, MD, PhD
Michael B. Dorrough, MD
Randall O. Dull, MD, PhD
Thomas J. Ebert, MD, PhD
Jan Ehrenwerth, MD
John H. Eichhorn, MD
James B. Eisenkraft, MD
Matthew R. Eng, MD
Alex S. Evers, MD
Ana Fernandez-Bustamante, MD, PhD
Lynne R. Ferrari, MD
Scott M. Fishman, MD
Lee A. Fleisher, MD
Michael A. Fowler, MD, MBA
Kevin Friede, BA
J. Sean Funston, MD
Tong J. Gan, MD
Steven Gayer, MD, MBA
Kevin J. Gingrich, MD
Kathryn E. Glas, MD, MBA
Loreta Grecu, MD
Jay S. Grider, DO, PhD
Dhanesh K. Gupta, MD
Steven C. Hall, MD
Matthew R. Hallman, MD
Tara Hata, MD
J. Steven Hata, MD
Laurence M. Hausman, MD
Jeana E. Havidich, MD
Thomas K. Henthorn, MD
Simon C. Hillier, MB, ChB
Robert S. Holzman, MD
Harriet W. Hopf, MD
Terese T. Horlocker, MD
Lucy S. Hostetter, MD
Robert W. Hurley, MD, PhD
Michael P. Hutchens, MD, MA
Adam K. Jacob, MD
Girish P. Joshi, MBBS, MD, FFARCSI
John P. Kampine, MD, PhD
Jonathan D. Katz, MD
Sandra L. Kopp, MD
Catherine Kuhn, MD
Arthur M. Lam, MD, FRCPC
Jerrold Lerman, MD, FRCPC, FANZCA
Jerrold H. Levy, MD, FAHA, FCCM
Adam D. Lichtman, MD
J. Lance Lichtor, MD
Yi Lin, MD, PhD
Larry Lindenbaum, MD
Spencer S. Liu, MD
David A. Lubarsky, MD, MBA
Stephen M. Macres, PharmD, MD
Gerard Manecke, MD
Joseph P. Mathew, MD
Michael S. Mazurek, MD
Kathryn E. McGoldrick, MD
Sanford M. Miller, MD
Timothy E. Miller, MB, ChB, FRCA
Peter G. Moore, MD, PhD
Michael J. Murray, MD, PhD, FCCM, FCCP
Charles D. Nargozian, MD
Steven M. Neustein, MD
Marieke Niesters, MD
Erik Olofsen, MSc
Charles W. Otto, MD, FCCM
Frank Overdyk, MD, FCCM
Nathan Leon Pace, MD, Mstat
Paul S. Pagel, MD, PhD
Ben Julian Palanca, MD, PhD
Albert C. Perrino, Jr., MD
Andrew J. Pittaway, FRCA
Mihai V. Podgoreanu, MD
Wanda M. Popescu, MD
Karen L. Posner, PhD
Donald S. Prough, MD
Glenn Ramsey, MD
Kevin T. Riutort, MD, MS
G. Alec Rooke, MD, PhD
Stanley H. Rosenbaum, MA, MD
Meg A. Rosenblatt, MD
William H. Rosenblatt, MD
Richard W. Rosenquist, MD
Aaron Sandler, MD, PhD
Barbara M. Scavone, MD
Katie Schenning, MD, MPH
Jeffrey J. Schwartz, MD
Harry A. Seifert, MD, MSCE
Aarti Sharma, MD
Andrew Shaw, MB, FRCA, FCCM
Benjamin Sherman, MD
Nikolaos J. Skubas, MD, FASE
Todd J. Smaka, MD
Hugh M. Smith, MD
Terry Smith, PhD
Karen J. Souter, MB, BS, FRCA
Bruce D. Spiess, MD, FAHA
Mark Stafford-Smith, MD, CM, FRCP (C), FASE
Andrew F. Stasic, MD
Randolph H. Steadman, MD
David F. Stowe, MD, PhD
Wariya Sukhupragarn, MD
Santhanam Suresh, MD
Christer H. Svensen, MD, PhD, DEAA, MBA
Paul C. Tamul, DO
Stephen J. Thomas, MD
Merriam Treggiari, MD
Ban C.H. Tsui, MSc, MD, FRCP(C)
J. Scott Walton, MD
Mary E. Warner, MD
Denise J. Wedel, MD
Paul F. White, MD, PhD, FANZCA
Scott W. Wolf, MD
Cynthia A. Wong, MD
James R. Zaidan, MD, MBA
Welcome to the 7th Edition of the Handbook of Clinical Anesthesia. The Handbook fulfills the requests of health care providers to have the essential information contained in the parent textbook, Clinical Anesthesia in a more ‘portable format’. Even with the advent of personal computers, smart phones and tablets, the Handbook continues to have a vital role.
Dr. Robert Stoelting has shepherded the Handbook from its inception in 1991 to this, his final edition. Each of the Editors personally thanks him for the time and effort and more importantly serving as our role model.
This edition of the Handbook contains a new chapter on Laparoscopic and Robotic Surgery. In addition, the Appendices on Electrocardiography and Pacemakers/Implantable Defibrillators are presented in a new graphic interface to improve reader comprehension of these important subjects. Further, approximately twenty percent of the Chapters are written by new contributors to the parent textbook. We would like to acknowledge the contributors to the textbook Clinical Anesthesia. Although the Handbook of Clinical Anesthesia is the product of the editors, its chapters were developed from the expert knowledge of the original contributors, reorganized and rewritten in a style necessary for a text of this scope. We also thank our administrative assistants—Gail Norup, Ruby Wilson, Deanna Walker, and Mary Wynn. We would like to thank our editors at Lippincott Williams & Wilkins-Wolters Kluwer, Brian Brown and Lisa McAllister, for their commitment to excellence. Finally, we owe a debt of gratitude to Nicole Dernoski—Managing Editor at LWW, Chris Miller—Production Manager at Aptara, Lisa Lawrence—Marketing Manager at LWW whose day-to-day management of this endeavor resulted in a publication that exceeded the Editor’s expectations.
Paul G. Barash MD
Bruce F. Cullen MD
Robert K. Stoelting MD
Michael K. Cahalan MD
M. Christine Stock MD
Rafael Ortega, MD
35 Peripheral nerve Blockade 535
36 Anesthesia for neurosurgery 553
37 Anesthesia for thoracic Surgery 580
38 Anesthesia for Cardiac Surgery 597
39 Anesthesia for vascular Surgery 621
40 Obstetrical Anesthesia 637
41 neonatal Anesthesia 658
42 Pediatric Anesthesia 674
43 Anesthesia for Laparoscopic and Robotic Surgeries 696
44 Anesthesia and Obesity 711
45 the Liver: Surgery and Anesthesia 730
46 endocrine Function 749
47 Anesthesia for Otolaryngologic Surgery 770
48 Anesthesia for Ophthalmologic Surgery 780
49 the Renal System and Anesthesia for urologic Surgery 792
50 Anesthesia for Orthopedic Surgery 823
51 transplant Anesthesia 842
52 trauma and Burns 858
53 emergency Preparedness for and Disaster Management of Casualties from natural Disasters and Chemical, Biologic, Radiologic, nuclear, and high-yield explosive (CBRne) events 890
SECTION VIII PeRiOPeRAtive AnD
54 Postanesthesia Recovery 903
55 Critical Care Medicine 918
56 Acute Pain Management 942
57 Chronic Pain Management 964
58 Cardiopulmonary Resuscitation 982
APPENDICES
A Formulas 1003
B Atlas of electrocardiography 1009
C Pacemaker and implantable Cardiac Defibrillator Protocols 1041
D American heart Association (AhA) Resuscitation Protocols 1057
E American Society of Anesthesiologists Standards, Guidelines, and Statements 1078
F the Airway Approach Algorithm and Difficult Airway Algorithm 1095
G Malignant hyperthermia Protocol 1097
H herbal Medications 1100
Index 1109
Introduction to Anesthesiology
CHAPTER
The History of Anesthesia
I
Although most human civilizations evolved some method for diminishing patient discomfort, anesthesia, in its modern and effective meaning, is a comparatively recent discovery with traceable origins dating back 160 years. (An epitaph on a monument to William T. G. Morton, one of the founders of anesthesia, reads: “Before whom in all time Surgery was Agony.”) (Jacob AK, Kopp SL, Bacon DR, Smith HM. The history of anesthesia. In: Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Ortega R, Stock MC, eds. Clinical Anesthesia . Philadelphia: Lippincott Williams & Wilkins; 2013: 1–27.)
I. ANESTHESIA BEFORE ETHER. In addition to limitations in technical knowledge, cultural attitudes toward pain are often cited as reasons humans endured centuries of surgery without effective anesthesia.
A. Early Analgesics and Soporifics (Table 1-1)
B. Almost Discovery: Clarke, Long, and Wells
1. In January 1842, William E. Clarke, a medical student, may have given the first ether anesthetic in Rochester, NY, for a dental extraction.
2. Crawford Williamson Long administered ether for surgical anesthesia to James M. Venable on March 30, 1842, in Jefferson, GA, for the removal of a tumor on his neck. Long did not report his success until 1849 when ether anesthesia was already well known.
3. Horace Wells observed the “analgesic effects” of nitrous oxide when he attended a lecture exhibition by an itinerant “scientist,” Gardner Quincy Colton. A few weeks later, in January 1845, Wells attempted a public demonstration in Boston at the Harvard Medical School, but the experience was judged a failure.
Table 1-1 EARLy ANALgESICS AND SOPORIFICS
Mandragora (soporific sponge)
Alcohol
Diethyl ether (known in the 16th century and perhaps as early as the 8th century)
Nitrous oxide (prepared by Joseph Priestly in 1773)
C. Public Demonstration of Ether Anesthesia. William Thomas Morton Green was responsible for the first successful public demonstration of ether anesthesia. This demonstration, which took place in the Bullfinch Amphitheater of the Massachusetts General Hospital on October 16, 1846, is memorialized by the surgeon’s statement to his audience at the end of the procedure: “Gentlemen, this is no humbug.”
D. Chloroform and Obstetrics
1. James Young Simpson, a successful obstetrician of Edinburgh, Scotland, was among the first to use ether for the pain relief in obstetrics. He became dissatisfied with ether and encouraged the use of chloroform.
2. Queen Victoria’s endorsement of obstetric anesthesia resulted in acceptance of the use of anesthesia in labor.
3. John Snow took an interest in anesthetic practice soon after the news of ether anesthesia reached England in December 1846. Snow developed a mask that closely resembles a modern facemask and introduced a chloroform inhaler.
II. ANESTHESIA PRINCIPLES, EQUIPMENT, AND STANDARDS
A. Control of the Airway
1. Definitive control of the airway, a skill anesthesiologists now consider paramount, developed only after many harrowing and apneic episodes spurred the development of safer airway management techniques.
2. Joseph Clover, an Englishman, was the first person to recommend the now universal practice of thrusting the patient’s jaw forward to overcome obstruction of the upper airway by the tongue.
B. Tracheal Intubation
1. The development of techniques and instruments for intubation ranks among the major advances in the history of anesthesiology.
2. An American surgeon, Joseph O’Dwyer, designed a series of metal laryngeal tubes, which he inserted blindly between the vocal cords of children having diphtheritic crises.
3. In 1895 in Berlin, Alfred Kirstein devised the first directvision laryngoscope.
4. Before the introduction of muscle relaxants in the 1940s, intubation of the trachea could be challenging. This challenge was made somewhat easier, however, with the advent of laryngoscope blades specifically designed to increase visualization of the vocal cords.
5. In 1926, Arthur Guedel began a series of experiments that led to the introduction of the cuffed tube.
6. In 1953, single-lumen tubes were supplanted by doublelumen endobronchial tubes.
C. Advanced Airway Devices. Conventional laryngoscopes proved inadequate for patients with difficult airways. Dr. A. I. J. “Archie” Brain first recognized the principle of the laryngeal mask airway in 1981.
D. Early Anesthesia Delivery Systems. John Snow created ether inhalers, and Joseph Clover was the first to administer chloroform in known concentrations through the “Clover bag.”
Critical to increasing patient safety was the development of a machine capable of delivering calibrated amounts of gas and volatile anesthetics (also carbon dioxide absorption, vaporizers, and ventilators).
E. Two American surgeons, George W. Crile and Harvey Cushing, advocated systemic blood pressure monitoring during anesthesia. In 1902, Cushing applied the Riva Rocci cuff for blood pressure measurements to be recorded on an anesthesia record.
1. The widespread use of electrocardiography, pulse oximetry, blood gas analysis, capnography, and neuromuscular blockade monitoring have reduced patient morbidity and mortality and revolutionized anesthesia practice.
2. Breath-to-breath continuous monitoring and waveform display of carbon dioxide (infrared absorption) concentrations in the respired gases confirms endotracheal intubation (rules out accidental esophageal intubation).
F. Safety Standards. The introduction of safety features was coordinated by the American National Standards Institute Committee Z79, which was sponsored from 1956 until 1983 by the American Society of Anesthesiologists. Since 1983, representatives from industry, government, and health care professions have met as the Committee Z79 of the American Society for Testing and Materials. This organization establishes
voluntary goals that may become accepted national standards for the safety of anesthesia equipment.
III. THE HISTORy OF ANESTHETIC AgENTS AND ADJUVANTS
A. Inhaled Anesthetics. Fluorinated hydrocarbons revolutionized inhalation anesthesia (halothane in 1956, methoxyflurane in 1960, enflurane and isoflurane in the 1970s, desflurane in 1992, and sevoflurane in 1994).
B. Intravenous Anesthetics. Thiopental was first administered to a patient at the University of Wisconsin in March 1934 followed by ketamine (1960s), etomidate, and most recently propofol.
C. Local Anesthetics. Amino esters (procaine in 1905, tetracaine) were commonly used for local infiltration and spinal anesthesia despite their low potency and high likelihood to cause allergic reactions. Lidocaine, an amino amide local anesthetic, was developed in 1944 and gained immediate popularity because of its potency, rapid onset, decreased incidence of allergic reactions, and overall effectiveness for all types of regional anesthetic blocks. Since the introduction of lidocaine, all local anesthetics developed and marketed (mepivacaine, bupivacaine, ropivacaine, levobupivacaine) have been of the amino amide variety.
D. Opioids are used routinely in the perioperative period, in the management of acute pain, and in a variety of terminal and chronic pain states. Meperidine, the first synthetic opioid, was developed in 1939 followed by fentanyl in 1960 and sufentanil, alfentanil, and remifentanil. Ketorolac, a nonsteroidal antiinflammatory drug (NSAID) approved for use in 1990, was the first parenteral NSAID indicated for postoperative pain.
E. Muscle relaxants entered anesthesia practice nearly a century after inhalational anesthetics. Curare, the first known neuromuscular blocking agent, was originally used in hunting and tribal warfare by native peoples of South America. Clinical application had to await the introduction of tracheal intubation and controlled ventilation of the lungs. On January 23, 1942, Griffith and his resident, Enid Johnson, anesthetized and intubated the trachea of a young man before injecting curare early in the course of an appendectomy. Satisfactory abdominal relaxation was obtained, and the surgery proceeded without incident. Griffith and Johnson’s report of the successful use of curare in a series consisting of 25 patients launched a revolution in anesthetic care. Succinylcholine was prepared by
the Nobel laureate Daniel Bovet in 1949 and was in wide international use before historians noted that the drug had been synthesized and tested in the early 1900s. Recognition that atracurium and cis-atracurium undergo spontaneous degradation by Hoffmann elimination has defined a role for these muscle relaxants in patients with liver and renal insufficiency.
F. Antiemetics. Effective treatment of patients with postoperative nausea and vomiting (PONV) evolved relatively recently and has been driven by incentives to limit hospitalization expenses and improve patient satisfaction. The antiemetic effects of corticosteroids were first recognized by oncologists treating patients with intracranial edema from tumors. Recognition of the role of the serotonin 5-HT3 pathway in PONV has led to a unique class of drugs (including ondansetron in 1991) devoted only to addressing this particular problem.
IV. ANESTHESIA SUBSPECIALTIES
A. Regional Anesthesia. The term “spinal anesthesia” was coined in 1885 by a neurologist, Leonard Corning, although it is likely that he actually performed an epidural injection. In 1944, Edward Tuohy of the Mayo Clinic introduced the Tuohy needle to facilitate the use of continuous spinal techniques. In 1949, Martinez Curbelo of Havana, Cuba, used Tuohy’s needle and a ureteral catheter to perform the first continuous epidural anesthetic. John J. Bonica’s many contributions to anesthesiology during his periods of military, civilian, and academic service at the University of Washington included development of a multidisciplinary pain clinic and publication of the text The Management of Pain.
B. Cardiovascular Anesthesia. Many believe that the successful ligation of a 7-year-old girl’s patent ductus arteriosus by Robert Gross in 1938 served as the landmark case for modern cardiac surgery. The first successful use of Gibbon’s cardiopulmonary bypass machine in humans in May 1953 was a monumental advance in the surgical treatment of complex cardiac pathology. In 1967, J. Earl Waynards published one of the first articles on anesthetic management of patients undergoing surgery for coronary artery disease. Postoperative mechanical ventilation and surgical intensive care units appeared by the late 1960s. Transesophageal echocardiography helped to further define the subspecialty of cardiac anesthesia.
C. Neuroanesthesia. Although the introduction of agents such as thiopental, curare, and halothane advanced the practice of anesthesiology in general, the development of methods to measure
brain electrical activity, cerebral blood flow, and metabolic rate put neuroanesthesia practice on a scientific foundation.
D. Obstetric Anesthesia. Social attitudes about pain associated with childbirth began to change in the 1860s, and women started demanding anesthesia for childbirth. Virginia Apgar’s system for evaluating newborns, developed in 1953, demonstrated that there was a difference in the neonates of mothers who had been anesthetized. In the past decade, anesthesiarelated deaths during cesarean sections under general anesthesia have become more likely than neuraxial anesthesia-related deaths, making regional anesthesia the method of choice. With the availability of safe and effective options for pain relief during labor and delivery, today’s focus is improving the quality of the birth experience for expectant parents.
V. PROFESSIONALISM AND ANESTHESIA PRACTICE
A. Organized Anesthesiology. The first American medical anesthesia organization, the Long Island Society of Anesthetists, was founded by nine physicians on October 6, 1905. Members had annual dues of $1.00. One of the most noteworthy figures in the struggle to professionalize anesthesiology was Francis Hoffer McMechan. He became the editor of the first journal devoted to anesthesia, Current Researches in Anesthesia and Analgesia, the precursor of Anesthesia and Analgesia, the oldest journal of the specialty. Ralph Waters and John Lundy, among others, participated in evolving organized anesthesia.
B. Academic Anesthesia. In 1927, Erwin Schmidt, a professor of surgery at the University of Wisconsin’s medical school, encouraged Dean Charles Bardeen to recruit Dr. Ralph Waters for the first American academic position in anesthesia.
C. Establishing a Society. The New York Society of Anesthetists changed its name to the American Society of Anesthetists in 1936. Combined with the American Society of Regional Anesthesia, the American Board of Anesthesiology was organized as a subordinate board to the American Board of Surgery in 1938, and independence was granted in 1940. Ralph Waters was declared the first president of the newly named American Society of Anesthesiologists in 1945.
2
Scope of Practice
Medical practice, including its infrastructure and functional details, is changing and evolving rapidly in the United States (Eichhorn JH, Grider JS. Scope of practice. In: Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Ortega R, Stock MC, eds. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins; 2013: 28–60). Traditionally, anesthesia professionals were minimally involved in the management of the many components of their practice beyond the strictly medical elements.
I. ADMINISTRATIVE COMPONENTS OF ALL ANESTHESIOLOGY PRACTICES
A. Operational and Information Resources
1. The American Society of Anesthesiologists (ASA) provides extensive resource materials to its members regarding practice management (www.asahq.org) (Table 2-1).
2. These documents are updated regularly by the ASA through its committees and House of Delegates.
3. The Web site for the Anesthesia Patient Safety Foundation (www.apsf.org) is useful in promoting safe clinical practice.
B. The Credentialing Process and Clinical Privileges
1. The system of credentialing a health care professional and granting clinical privileges is motivated by the assumption that appropriate education, training, and experience, along with an absence of an excessive number of adverse patient outcomes, increase the likelihood that the health care professional will deliver high-quality care.
2. Models for credentialing anesthesiologists are offered by the ASA.
3. An important issue in granting clinical privileges, especially in procedure-oriented specialties such as anesthesiology, is whether it is reasonable to grant “blanket” privileges (i.e., the right to do everything traditionally associated with the specialty).
C. Maintenance of Certification in Anesthesiology
1. Anesthesiologists certified as diplomats by the American Board of Anesthesiology after January 1, 2000, are issued a “time-limited” board certification valid for 10 years. A formal process culminating in the recertification of an
Table 2-1 PRACTICE MANAGEMENT MATERIALS PROVIDED BY THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS
The Organization of an Anesthesia Department
Guidelines for Delineation of Clinical Privileges in Anesthesiology
Guidelines for a Minimally Acceptable Program of Any Continuing Education Requirement
Guidelines for the Ethical Practice of Anesthesiology
Ethical Guidelines for the Anesthesia Care of Patients with Do-NotResuscitate Orders or Other Directives that Limit Treatment
Guidelines for Patient Care in Anesthesiology
Guidelines for Expert Witness Qualifications and Testimony
Guidelines for Delegation of Technical Anesthesia Functions for Nonphysician Personnel
The Anesthesia Care Team
Statement on Conflict of Interest
Statement on Economic Credentialing
Statement on Member’s Right to Practice
Statement on Routine Preoperative Laboratory and Diagnostic Screening
anesthesiologist for an additional and then subsequent 10-year intervals is designated Maintenance of Certification in Anesthesiology (MOCA).
2. The MOCA program introduced in 2000 is subdivided into four components or modules that include professional standing, lifelong learning and self-assessment, cognitive examination, and practice performance assessment and improvement.
D. Professional Staff Participation and Relationships
1. Medical staff activities are increasingly important in achieving a favorable accreditation status from The Joint Commission (JC).
2. Anesthesiologists should be active participants in medical staff activities (Table 2-2).
E. Establishing Standards of Practice and Understanding the Standard of Care
1. American anesthesiology is one of the leaders in establishing practice standards that are intended to maximize the quality of patient care and help guide anesthesiologists make difficult decisions, including those about the risk–benefit and cost–benefit aspects of specific practices (Table 2-3).
2. The standard of care is the conduct and skill of a prudent practitioner that can be expected at all times by a reasonable patient.
Table 2-2 ExAMPLES OF ANESTHESIOLOGISTS AS PARTICIPANTS IN MEDICAL STAFF ACTIVITIES
Credentialing
Peer review
Transfusion review
Operating room management
Medical direction of same-day surgery units
Medical direction of postanesthesia care units
Medical direction of intensive care units
Medical direction of pain management services and clinics
Table 2-3 MATERIALS PROVIDED BY THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS DESIGNED TO ESTABLISH PRACTICE STANDARDS
Standards (Minimum Requirements for Sound Practice)
Basic Standards for Preanesthesia Care
Standards of Basic Anesthetic Monitoring
Standards for Postanesthesia Care
Guidelines (Recommendations for Patient Management)
Guidelines for Ambulatory Surgical Facilities
Guidelines for Critical Care in Anesthesiology
Guidelines for Nonoperating Room Anesthetizing Locations
Guidelines for Regional Anesthesia in Obstetrics
Practice Guidelines
Practice Guidelines for Acute Pain Management in the Perioperative Setting
Practice Guidelines for Management of the Difficult Airway
Practice Guidelines for Pulmonary Artery Catheterization
Practice Guidelines for Difficult Airway
Practice Parameters
Pain Management
Transesophageal Echocardiography
Sedation by Nonanesthesia Personnel
Preoperative Fasting
Avoidance of Peripheral Neuropathies
Fast-Track Management of Coronary Artery Bypass Graft Patients
a. Failure to meet the standard of care is considered malpractice.
b. Courts have traditionally relied on medical experts to give opinions regarding what the standard of care is and whether it has been met in an individual case.
3. Leading the Way. Anesthesiologists have been very active in publishing standards of care (see Table 2-3).
4. Practice Guidelines. A practice guideline has some of the same elements as a standard of practice but is intended more to guide judgment, largely through algorithms.
a. Practice guidelines serve as potential vehicles for helping to eliminate unnecessary procedures and to limit costs.
b. Guidelines do not define the standard of care, although adherence to the outlined principles should provide anesthesiologists with a reasonably defensible position.
5. JC standards focus on credentialing and privileges, verification that anesthesia services are of uniform quality, continuing education, and documentation of preoperative and postoperative evaluations.
6. Review Implications. Another type of regulatory agency is the peer review organization, whose objectives include issues related to hospital admissions, utilization, and quality of care.
F. Policy and Procedure
1. An important organizational aspect of an anesthesia department is a policy and procedure manual.
2. This manual includes specific protocols for areas mentioned in the JC standards, including preanesthetic evaluation, safety of the patient during anesthesia, recording of all pertinent events during anesthesia, and release of the patient from the postanesthesia care unit (PACU).
3. A protocol for responding to an adverse event is useful (Anesthesia Patient Safety Foundation Newsletter, 2006:21:11, www.apsf.org).
G. Meetings and Case Discussion
1. There must be regularly scheduled departmental meetings.
2. The JC requires that there be at least monthly meetings at which risk management and quality improvement activities are documented and reported.
H. Support Staff. There is a fundamental need for support staff in every anesthesia practice.
I. Anesthesia Equipment and Equipment Maintenance. Compared with human error, overt equipment failure rarely causes critical intraoperative incidents. The Anesthesia Patient Safety Foundation advocates that anesthesia departments develop a process to verify that all anesthesia professionals are
trained to use new technology being introduced in the operating room.
1. Service. Equipment maintenance and service may be provided by factory representatives or in-house engineers.
2. Replacement of obsolete anesthesia machines (10 years often cited as the estimated useful life) and monitoring equipment is a key element in a risk-modification program.
J. Malpractice Insurance
1. Occurrence means that if the insurance policy was in force at the time of the occurrence of an incident resulting in a claim, the physician will be covered.
2. Claims made provide coverage only for claims that are filed when the policy was in force. (“Tail coverage” is needed if the policy is not renewed annually.)
3. A new approach in medical risk management and insurance is advocating immediate full disclosure to the victim or survivors. This shifts the culture of blame with punishment to a just culture with restitution.
K. Response to an Adverse Event
1. Despite the decreased incidence of anesthesia catastrophes, even with the very best practice, it is statistically likely that an anesthesia professional will be involved in a major anesthesia accident at least once in his or her professional life.
2. A movement to implement immediate disclosure and apology reflects as shift from the “culture of blame” with punishment to a “just culture” with restitution. Laudable as the policy of immediate full disclosure and apology may sound, it is recommended for the anesthesia professional to confer with the involved liability insurance carrier, the practice group, and the facility administration before pursuing this policy.
II. PRACTICE ESSENTIALS
A. The “job market” for anesthesia professionals is being influenced by the number of residents being trained, the geographic maldistribution of anesthesiologists, and marketplace forces as reflected by managed care organizations and the real and potential impact on the numbers of surgical procedures.
B. Types of practice include academic practice, private practice in the marketplace, private practice as an employee, practice as a hospital employee (rather than subsidize an independent practice), practice for a management company, and practice in an office-based setting.
C. Billing and collecting may be based on calculations according to units and time, a single predetermined fee independent of time, or fees bundled with all physicians involved in the surgical procedure.
1. All practices should have detailed compliance programs in place to ensure correct coding for services rendered.
2. Billing for specific procedures becomes irrelevant in systems with prospective “capitated” payments for large numbers of patients (a fixed amount per enrolled member per month).
3. The federal government has issued a new regulation allowing individual states to “opt out” of the requirement that a nurse anesthetist be supervised by a physician to meet Medicare billing requirements.
D. Antitrust Considerations
1. The law is concerned solely with the preservation of competition within a defined marketplace and the rights of consumers.
2. The market is not threatened by the exclusion of one physician from the medical staff of a hospital.
E. Exclusive service contracts state that anesthesiologists seeking to practice must be members of the group holding the exclusive contract.
1. In some instances, members of the group may be terminated by the medical staff without due process.
2. Economic credentialing (which is opposed by the ASA) is defined as the use of economic criteria unrelated to quality of care or professional competency for granting and renewing hospital privileges.
F. Hospital Subsidies. Modern economic realities may necessitate anesthesiology practice groups to recognize that after overhead is paid, patient care revenue does not provide sufficient compensation to attract and retain the number and quality of staff members necessary.
1. A direct cash subsidy from the hospital may be negotiated to augment practice revenue to maintain benefits while increasing the pay of staff members to a market-competitive level.
2. The ASA’s Washington, DC, office maintains lists of consultants to help anesthesiologists and groups dealing with hospital subsidies.
III. EVOLVING PRACTICE ARRANGEMENTS
A. Even though the impact of managed care plans has waned somewhat, various iterations still exist and have ongoing impact on anesthesiology practice.
B. Prospective Payments. In this arrangement, each group of providers in the managed care organization receives a fixed amount per member per month and agrees, except in unusual circumstances (“carve-outs”), to provide care.
C. Changing Paradigm. There is an emerging trend for private contracting organizations to tie their payments for professional services to the government’s Medicare rate for specific CPT-4 codes.
D. Pay for performance is the concept supported by commercial indemnity insurance carriers and the Centers for Medicaid and Medicare Services to reduce health care costs by decreasing expensive complications of medical care.
1. Accountable Care Organizations were created by the Patient Protection and Affordable Care Act that was signed into law in 2010. To ensure the importance of preoperative care of the surgical patient in these provisions, the ASA is advocating a “surgical home” model of care.
2. Management Intricacies. The complexities of modern medical practice have spawned management consultants that offer their services to anesthesiology group practices.
IV. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
A. Implementation of the privacy rule of the Health Insurance Portability and Accountability Act (HIPAA) creates significant changes in how medical records and patient information are handled. Under HIPPA, patients’ names may not be used on an “operating room (OR) board” if there is any chance that anyone not directly involved in their care could see them.
B. Electronic Medical Records (EMR). Basic EMR implementation has been problematic for practices (e.g., expense, obvious savings, acceptable software), but true electronic anesthesia information management systems have been even more difficult to implement.
V. ExPANSION INTO PERIOPERATIVE MEDICINE, HOSPITAL CARE, AND HYPERBARIC MEDICINE
A. Formalized preoperative screening clinics operated and staffed by anesthesiologists may replace the historical practice of sending patients to primary care physicians or consultants for “preoperative clearance.”
B. Anesthesiologists may become the coordinators of postoperative care, especially in the realm of providing comprehensive pain management.
VI. OPERATING ROOM MANAGEMENT
A. The current emphasis on cost containment and efficiency requires anesthesiologists to take an active role in eliminating dysfunctional aspects of OR practice (e.g., first-case morning start times).
1. Anesthesiologists with insight, overview, and a unique perspective are best qualified to provide leadership in an OR.
2. An important aspect of OR organization is materials management.
B. Scheduling Cases
1. Anesthesiologists need to participate in scheduling of cases because the number of anesthesia professionals depends on the daily caseload, including “offsite” diagnostic areas.
2. The majority of ORs use block scheduling (preassigned guaranteed OR time with an agreed cutoff time), open scheduling (first come, first serve), or a combination.
3. Computerization will likely benefit every OR.
C. Preoperative Clinic. Use of an anesthesia preoperative evaluation clinic usually results in more efficient running of the OR and avoidance of unanticipated cancellations and delays.
D. Anesthesiology Personnel Issues. In light of the current and future shortage of anesthesia professionals, managing and maintaining a stable supply promises to dominate the OR landscape for years.
E. Cost and Quality Issues
1. Health care accounts for approximately 14% of the US gross domestic product, and anesthesia (directly and indirectly) represents 3% to 5% of total health care costs.
2. Anesthesia drug expenses represent a small portion of the total perioperative costs, but the great number of doses administered contributes substantially to the aggregate total cost to the institution.
a. Reducing fresh gas flow from 5 to 2 L/min whenever possible would save approximately $100 million annually in the United States.
b. More expensive techniques and drugs may reduce indirect costs (e.g., propofol is infusion more expensive but may decrease PACU time and reduce the patient’s nausea and vomiting).
c. For long surgical procedures, newer and more expensive drugs may offer limited benefits over older and less expensive longer acting alternatives.
d. It is estimated that the 10 highest expenditure drugs account for more than 80% of the anesthetic drug costs at some institutions.
Occupational Health
The health care industry has the dubious distinction of being one of the most hazardous places to work in the United States (health care is second only to manufacturing in the number of occupational illnesses and injuries sustained by their workers (Katz JD, Holzman RS. Occupational health. In: Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Ortega R, Stock MC, eds. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins; 2013: 61–89).
I. PHYSICAL HAZARDS
A. Anesthetic Gases
1. Concerns about the possible toxic effects of occupational exposure to inhalational anesthetics have been expressed since their introduction into clinical practice.
2. Several studies testing for chromosomal aberrations, sister chromatid exchanges, or changes in peripheral lymphocytes have found no evidence of cellular damage among clinicians exposed to the levels of anesthetic gases that are encountered in an adequately ventilated operating room (OR).
3. Nitrous oxide exposure is a special situation as this gas can irreversibly oxidize the cobalt atom of vitamin B12 to an inactive state. This inhibits methionine synthetase and prevents the conversion of methyltetrahydrofolate to tetrahydrofolate, which is required for DNA synthesis, assembly of the myelin sheath, and methyl substitutions in neurotransmitters. At adequate clinically used concentrations of nitrous oxide, this inhibition could result in anemia and polyneuropathy. As with the halogenated hydrocarbon anesthetics, these effects with nitrous oxide have not been demonstrated in adequately scavenged ORs with effective waste gas scavenging.
B. Reproductive Outcomes
1. There is no increased risk of spontaneous abortion in studies of personnel who work in scavenged environments where waste gases were scavenged.
2. It is likely that other job-associated conditions (e.g., stress, infections, long work hours, shift work, radiation exposure)
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many instances the lack of teachers is greater in those provinces which are most thickly populated and whose people are most highly civilized. …
"While most of the small towns have one teacher of each sex, in the larger towns and cities no adequate provision is made for the increased teaching force necessary; so that places of 30,000 or 40,000 inhabitants are often no better off as regards number of teachers than are other places in the same province of but 1,500 or 2,000 souls. The hardship thus involved for children desiring a primary education will be better understood if one stops to consider the nature of the Philippine 'pueblo,' which is really a township, often containing within its limits a considerable number of distinct and important villages or towns, from the most important of which the township takes its name. The others, under distinct names, are known as 'barrios,' or wards. It is often quite impossible for small children to attend school at the particular town which gives its name to the township on account of their distance from it. …
"The character and amount of the instruction which has heretofore been furnished is also worthy of careful consideration. The regulations for primary schools were as follows: 'Instruction in schools for natives shall for the present be reduced to elementary primary instruction and shall consist of
1. Christian doctrine and principles of morality and sacred history suitable for children.
2. Reading.
3. Writing.
4. Practical instruction in Spanish, including grammar and orthography.
5. Principles of arithmetic, comprising the four rules for figures, common fractions, decimal fractions, and instruction in the metric system with its equivalents in ordinary weights and measures.
6. Instruction in general geography and Spanish history.
7. Instruction in practical agriculture as applied to the products of the country.
8. Rules of deportment.
9. Vocal music.'
"It will be noted that education in Christian doctrine is placed before reading and writing, and, if the natives are to be believed, in many of the more remote districts instruction began and ended with this subject and was imparted in the local native dialect at that. It is further and persistently charged that the instruction in Spanish was in very many cases purely imaginary, because the local friars, who were formerly 'ex officio' school inspectors, not only prohibited it, but took active measures to enforce their dictum. … Ability to read and write a little of the local native language was comparatively common. Instruction in geography was extremely superficial. As a rule no maps or charts were available, and such information as was imparted orally was left to the memory of the pupil, unaided by any graphic method of presentation. The only history ever taught was that of Spain, and that under conventional censorship. The history of other nations was a closed volume to the average Filipino. … The course as above outlined was that prescribed for boys. Girls were not given instruction in geography, history, or agriculture, but in place of these subjects were supposed to receive instruction 'in employments suitable to their sex.'
"It should be understood that the criticisms which have been here made apply to the provincial schools. The primary instruction given at the Ateneo Municipal at Manila, under the direction of the Jesuits, fulfilled the requirements of the law, and in some particulars exceeded them. … The only official institution for secondary education in the Philippines was the College of San Juan de Letran, which was in charge of the Dominican Friars and was under the control of the university authorities. Secondary education was also given in the Ateneo Municipal of Manila, by the Jesuit Fathers, and this institution was better and more modern in its methods than any other in the archipelago. But although the Jesuits provided the instruction, the Dominicans held the examinations. … There are two normal schools in Manila, one for the education of male and the other for the education of female teachers. … The only institutions for higher education in the Philippines have been the Royal and Pontifical University of Santo Tomas, and the Royal College of San José, which has for the past twenty-five years been under the direction of the university authorities."
Report of the Philippine Commission, January 1, 1900, volume 1, part 3.
EDUCATION: Porto Rico: A. D. 1898. Spanish schools and teachers.
See (in this volume)
PORTO RICO: A. D. 1898-1899 (AUGUST-JULY).
EDUCATION: Porto Rico: A. D. 1900. First steps in the creation of a public school system.
See (in this volume)
PORTO RICO: A. D. 1900 (AUGUST-OCTOBER).
EDUCATION: Russia:
Student troubles in the universities.
See (in this volume)
RUSSIA: A. D. 1899 (FEBRUARY-JUNE); 1900; and 1901.
EDUCATION: Tunis: Schools under the French Protectorate.
See (in this volume) TUNIS: A. D. 1881-1898.
EDUCATION: United States: Indian schools.
See (in this volume) INDIANS, AMERICAN: A. D. 1899-1900.
EDUCATION: United States: A. D. 1896. Princeton University.
The one hundred and fiftieth anniversary of the founding of the institution at Princeton, New Jersey, which had borne the name of "The College of New Jersey," was celebrated on the 20th, 21st, and 22d of October, 1896, with ceremonies in which many representatives from famous seats of learning in Europe and America took part. The proceedings included a formal change of name, to Princeton University.
{195}
EDUCATION: United States: A. D. 1900. Women as students and as teachers.
See (in this volume) NINETEENTH CENTURY: THE WOMAN'S CENTURY.
EDWARD VII., King of England.
Accession.
English estimate of his character.
See (in this volume)
ENGLAND: A. D. 1901 (JANUARY-FEBRUARY).
Opening of his first Parliament. The Royal Test Oath.
EDWARD VII., King of England.
See (in this volume)
ENGLAND: A. D. 1901 (FEBRUARY).
----------EGYPT: Start--------
EGYPT:
Recent Archæological Explorations and their result. Discovery of prehistoric remains. Light on the first dynasties.
See (in this volume)
ARCHÆOLOGICAL RESEARCH: EGYPT: RESULTS.
EGYPT: A. D. 1885-1896.
Abandonment of the Egyptian Sudan to the Dervishes. Death of the Mahdi and reign of the Khalifa. Beginning of a new Anglo-Egyptian movement for the recovery of the Sudan. The expedition to Dongola.
After the failure to rescue General Gordon from the Mahdists at Khartoum (see, in volume 1, EGYPT: A. D. 1884-1885), the British government, embarrassed in other quarters, felt compelled to evacuate the Sudan. Before it did so the Mahdi had finished his career, having died of smallpox in June, 1885, and one of his three chief commanders, styled khalifas, had acquired authority over the Dervish army and reigned in
his place. This was the Khalifa Abdullah, a chieftain of the Baggara tribe. Khartoum had been destroyed, and Omdurman, on the opposite side of the river, became his capital. The rule of the Khalifa was soon made so cruelly despotic, and so much in the interest of his own tribe, that incessant rebellions in many parts of his dominions restrained him from any vigorous undertaking of the conquest of Egypt, which was the great object of Dervish desire. But his able and energetic lieutenant in the Eastern Sudan, Osman Digna, was a serious menace to the Egyptian forces holding Suakin, where Major Watson, at first, and afterwards Colonel Kitchener, were holding command, under General Grenfell, who was then the Egyptian Sirdar, or military chief. Osman Digna, however, was defeated in all his attempts. At the same time the Khalifa was desperately at war with the Negus. John, of Abyssinia, who fell in a great battle at Galabat (March, 1889), and whose death at the crisis of the battle threw his army into confusion and caused its defeat. Menelek, king of the feudatory state of Shoa, acquired the Abyssinian crown, and war with the Dervishes was stopped. Then they began an advance down the Nile, and suffered a great defeat from the British and Egyptian troops, at Toski, on the 17th of August, 1889. From that time, for several years, "there was no real menace to Egypt," and little was heard of the Khalifa. "His territories were threatened on all sides: on the north by the British in Egypt; on the south by the British in Uganda: on the west by the Belgians in the Congo Free State, and by the French in the Western Soudan; whilst the Italians held Kassala on the east; so that the Khalifa preferred to husband his resources until the inevitable day should arrive when he would have to fight for his position."
A crisis in the situation came in 1896. The Egyptian army, organized and commanded by British officers, had become a strong fighting force, on which its leaders could depend. Its Sirdar was now Major-General Sir Herbert Kitchener, who succeeded General Grenfell in 1892. Suddenly there came news,
early in March, 1896, of the serious reverse which the Italians had suffered at Adowa, in their war with the Abyssinians (see, (in this volume) ITALY: A. D. 1895-1896).
"The consternation felt in England and Egypt at this disaster deepened when it became known that Kassala, which was held by the Italian forces, was hemmed in, and seriously threatened by 10,000 Dervishes, and that Osman Digna was marching there with reinforcements. If Kassala fell into the hands of the Dervishes, the latter would be let loose to overrun the Nile valley on the frontier of Egypt, and threaten that country itself. As if in anticipation of these reinforcements, the Dervishes suddenly assumed an offensive attitude, and it was rumoured that a large body of Dervishes were contemplating an immediate advance on Egypt. … A totally new situation was now created, and immediate action was rendered imperative. Everything was ripe for an expedition up the Nile. Whilst creating a diversion in favour of the Italians besieged at Kassala, it afforded an opportunity of creating a stronger barrier than the Wady Halfa boundary between Egypt and the Dervishes, and it would moreover be an important step towards the long-wished-for recovery of the Soudan. The announcement of the contemplated expedition was made in the House of Commons on the 17th of March, 1896, by Mr. Curzon, Under-Secretary for Foreign Affairs. It came as a great surprise to the whole country, which, having heard so little of the Dervishes of late years, was not prepared for a recrudescence of the Soudan question. [But a vote of censure on the Egyptian policy of the government, moved by Mr. John Morley in the House of Commons, was rejected by 288 to 145.] …
"An unexpected difficulty arose in connection with the financing of the expedition. This is explained very plainly and concisely in the 'Annual Register,' 1896, which we quote at length:
'In order to defray the cost of the undertaking, it being obviously desirable to impose as little strain as possible on
the slowly recovering finances of Egypt, it was determined by the Egyptian Government to apply for an advance of £500,000 from the General Reserve Fund of the Caisse de la Dette, and the authorities of the Caisse obligingly handed over the money. … However, the French and Russian members of the Caisse de la Dette protested against the loan which the Caisse had made. … In December (1896) the International Court of Appeal required the Egyptian Government to refund to the Caisse the £500,000 which they had secured. The very next day Lord Cromer offered an English loan to make good the advance. The Egyptian Government accepted his offer, and repaid immediately the £500,000 to the Caisse, and the result of this somewhat absurd transaction is that England has thus strengthened her hold in another small point on the Government of Egypt.'"
H. S. L. Alford, and W. D. Sword,
The Egyptian Soudan, its Loss and Recovery, chapter 4 (London: Macmillan & Company). {196}
On the 21st of March, the Sirdar left Cairo for Assouan and Wady Halfa, and various Egyptian battalions were hurried up the river. Meantime, the forces already on the frontier had moved forward and taken the advanced post of the Dervishes, at Akasheh. From that point the Sirdar was ready to begin his advance early in June, and did so with two columns, a River Column and a Desert Column, the latter including a camel corps and a squadron of infantry mounted on camels, besides cavalry, horse artillery and Maxim guns. Ferket, on the east bank of the Nile, 16 miles from Akasheh, was taken after hard fighting on the 7th of June, many of the Dervishes refusing quarter and resisting to the death. They lost, it was estimated, 1,000 killed and wounded, and 500 were taken prisoners. The Egyptian loss was slight. The Dervishes fell back some fifty miles, and the Sirdar halted at Suarda during three months, while the railroad was pushed forward, steamers dragged up the cataracts
and stores concentrated, the army suffering greatly, meantime, from an alarming epidemic of cholera and from exhausting labors in a season of terrific heat. In the middle of September the advance was resumed, and, on the 23d, Dongola was reached. Seeing themselves outnumbered, the enemy there retreated, and the town, or its ruins, was taken with only a few shots from the steamers on the river. "As a consequence of the fall of Dongola every Dervish fled for his life from the province. The mounted men made off across the desert direct to Omdurman, and the foot soldiers took the Nile route to Berber, always being careful to keep out of range of the gunboats, which were prevented by the Fourth Cataract from pursuing them beyond Merawi."
C. Hoyle,
The Egyptian Campaigns, new and revised edition, to December, 1899, chapter 70-71.
The Emir who commanded at Dongola was a comparatively young man, Mohammed Wad el Bishara, who seems to have been possessed by a very genuinely religious spirit, as shown in the following letter, which he had written to the Dervish commander at Ferket, just before the battle there, and which was found by the British officers when they entered that place:
"You are, thank God, of good understanding, and are thoroughly acquainted with those rules of religion which enjoin love and unison. Thanks be to God that I hear but good reports of you. But you are now close to the enemy of God, and have with you, with the help of God, a sufficient number of men. I therefore request you to unite together, to have the heart of a single man founded on love and unity. Consult with one another, and thus you will insure good results, which will strengthen the religion and vex the heathen, the enemies of God. Do not move without consulting one another, and such others, also, in the army who are full of sense and wisdom. Employ their plans and
tricks of war, in the general fight more especially. Your army, thank God, is large; if you unite and act as one hand, your action will be regular: you will, with the help of God, defeat the enemies of God and set at ease the mind of the Khalifa, peace be on him! Follow this advice, and do not allow any intrigues to come between you. Rely on God in all your doings; be bold in all your dealings with the enemy; let them find no flaw in your disposition for the fight. But be ever most vigilant, for these enemies of God are cunning, may God destroy them! Our brethren, Mohamed Koku, with two others, bring you this letter; on their return they will inform me whether you work in unison or not. Let them find you as ordered in religion, in good spirits, doing your utmost to insure the victory of religion. Remember, my brethren, that what moves me to urge on you to love each other and to unite is my love for you and my desire for your good. This is a trial of war; so for us love and amity are of utmost necessity. You were of the supporters of the Mahdi, peace be on him! You were as one spirit occupying one body. When the enemy know that you are quite united they will be much provoked. Strive, therefore, to provoke these enemies of religion. May God bless you and render you successful."
EGYPT: A. D. 1895. New anti-slavery law.
A convention to establish a more effective anti-slavery law in Egypt was signed on the 21st of November, 1895, "by the Minister of Foreign Affairs, representing the Khedival Government, and the British diplomatic agent and consul-general. … This new convention will supplant that of August 4, 1877, which … was found to be defective, inasmuch as it provided no penalty for the purchaser of a slave, but for the seller only. An Egyptian notable, Ali Pasha Cherif, at that time president of the Legislative Council, was tried for buying slaves for his household, but escaped punishment through a technicality of the law hitherto escaping notice. …
Under the existing regulations, every slave in the Egyptian dominions has the right to complete freedom, and may demand his certificate of manumission whenever he chooses. Thus, all domestic slaves, of whom there are thousands in Cairo, Alexandria, and the large towns, may call upon their masters to set them free. Many choose to remain in nominal bondage, preferring the certainty of food and shelter to the hardships and uncertainty of looking after themselves."
United States, Consular Reports, March, 1896, page 370.
EGYPT: A. D. 1897. Italian evacuation of Kassala, in the eastern Sudan.
See (in this volume)
ITALY: A. D. 1897.
EGYPT: A. D. 1897 (June). Census.
A census of Egypt, taken on the 1st of June, 1897, showed a population of 9,700,000, the area being Egypt up to Wady Haifa. In 1882 an imperfect census gave six and three-quarter millions. Twelve per cent. of the males can write, the rest are totally illiterate. There are, it is said, about 40,000 persons not really Egyptians, but who come from other parts of the Ottoman Empire. The Bedouin number 570,000, but of these only 89,000 are really nomads, the rest being semi-sedentary. Of foreign residents there are 112,500, of whom the Greeks, the most numerous, number 38,000. Then come the Italians, with 24,500. The British (including 6,500 Maltese and 5,000 of the Army of Occupation) are 19,500; and the French (including 4,000 Algerians and Tunisians), 14,000. The Germans only number 1,300. {197}
The classification according to religion shows nearly
9,000,000 Moslems, 730,000 Christians, and 25,000 Jews, The Christians include the Coptic race, numbering about 608,000. Only a very small proportion profess the Roman Catholic and Protestant faiths. Amongst the town populations Cairo contains 570,000, Alexandria 320,000.
EGYPT: A. D. 1897-1898. The final campaigns of the Anglo-Egyptian conquest of the Eastern Sudan.
Desperate battles of the Atbara and of Omdurman.
"The winter of 1896-1897 was passed, undisturbed by the enemy. The extended and open front of the Egyptian army imperatively called for fresh guarantees against a Dervish invasion. The important strategic position of Abu Hamed was then held by the enemy, to dislodge whom was the objective of the 1897 campaign. The railway was boldly launched into the Nubian Desert; the rail-head crept rapidly and surely towards the Dervish post, until within striking distance of Abu Hamed: when the river-column, by a forced march, through difficult country, delivered an attack on 7th August. Abu Hamed was taken by the Egyptian army under Major-General (now Sir Archibald) Hunter, with trifling loss: and the effect of this victory caused the precipitate evacuation of Berber. The Dervishes withdrew: the Egyptians not to lose so favourable an opening advanced. Berber, the key to the Sudan, was promptly re-occupied. The railway was hastened forward; reinforcements were detrained, before the close of the year, at a short distance from Berber: and the Anglo-Egyptian authorities gathered force for the last heat. British troops were called up. In this final struggle [1898] nothing could be risked. An Egyptian reverse would have redoubled the task on the accomplishment of which, having deliberately accepted it, we had pledged our honour. Mahmud, the Dervish emir, and that ubiquitous rascal Osman Digna, with their united forces, were marching on Berber. They, however, held up at the confluence of the Atbara, and comfortably intrenched themselves in a 'zariba.' Here the Sirdar came out
to have a look at them. The Dervish force numbered about 19,000 men. The Anglo-Egyptian army was composed of 13,000 men. The odds were good enough for the Sirdar: and he went for them. Under the demoralization created by some sharp artillery practice, the Anglo-Egyptians stormed the 'zariba,' killed three-fourths of the defenders, and chased the remainder away. This victory [April 8, 1898], which cost over 500 men in killed and wounded, broke the Dervish power for offence and seriously damaged the Khalifa's prestige. With reinforcements, bringing his army up to 22,000 men, including some picked British regiments, the Sirdar then advanced slowly up the river. It was a pilgrimage to the Mahdi's tomb, in sight of which Cross and Crescent combined to overthrow the false prophet. This sanguinary and decisive engagement [before Omdurman] took place on 2nd September, 1898. The Khalifa was put to flight; his forces were scattered and ridden down. On the same evening, the Sirdar entered Omdurman, and released the European captives. Subsequently, the British and Egyptian flags were hoisted together at Khartum; and divine service was celebrated at the spot where Gordon fell."
A. S. White,
The Expansion of Egypt, pages 383-384 (New York: New Amsterdam Book Company).
"The honour of the fight [at Omdurman] must still go with the men who died. Our men were perfect, but the dervishes were superb beyond perfection. It was their largest, best, and bravest army that ever fought against us for Mahdism, and it died worthily of the huge empire that Mahdism won and kept so long. Their riflemen, mangled by every kind of death and torment that man can devise, clung round the black flag and the green, emptying their poor, rotten, homemade cartridges dauntlessly. Their spearmen charged death at every minute hopelessly. Their horsemen led each attack, riding into the bullets till nothing was left but three horses trotting up to
our line, heads down, saying, 'For goodness' sake, let us in out of this.' Not one rush, or two, or ten but rush on rush, company on company, never stopping, though all their view that was not unshaken enemy was the bodies of the men who had rushed before them. A dusky line got up and stormed forward: it bent, broke up, fell apart, and disappeared. Before the smoke had cleared, another line was bending and storming forward in the same track.
"It was over. The avenging squadrons of the Egyptian cavalry swept over the field. The Khalifa and the Sheikh-ed-Din had galloped back to Omdurman. Ali Wad Helu was borne away on an angareb with a bullet through his thigh-bone. Yakub lay dead under his brother's banner. From the green army there now came only death-enamoured desperadoes, strolling one by one towards the rifles, pausing to shake a spear, turning aside to recognise a corpse, then, caught by a sudden jet of fury, bounding forward, checking, sinking limply to the ground. Now under the black flag in a ring of bodies stood only three men, facing the three thousand of the Third Brigade. They folded their arms about the staff and gazed steadily forward. Two fell. The last dervish stood up and filled his chest; he shouted the name of his God and hurled his spear. Then he stood quite still, waiting. It took him full; he quivered, gave at the knees, and toppled with his head on his arms and his face towards the legions of his conquerors. Over 11,000 killed, 16,000 wounded, 4,000 prisoners, that was the astounding bill of dervish casualties officially presented after the battle of Omdurman. Some people had estimated the whole dervish army at 1,000 less than this total: few had put it above 50,000. The Anglo-Egyptian army on the day of battle numbered, perhaps, 22,000 men: if the Allies had done the same proportional execution at Waterloo, not one Frenchman would have escaped. … The dervish army was killed out as hardly an army has been killed out in the history of war. It will shock you, but it was simply unavoidable. Not a man was killed except resisting very few except attacking. Many wounded were
killed, it is true, but that again was absolutely unavoidable. … It was impossible not to kill the dervishes: they refused to go back alive."
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The same brilliant writer gives the following description of Omdurman, as the British found it on entering the town after the victory: "It began just like any other town or village of the mean Sudan. Half the huts seemed left unfinished, the other half to have been deserted and fallen to pieces. There were no streets, no doors or windows except holes, usually no roofs. As for a garden, a tree, a steading for a beast any evidence of thrift or intelligence, any attempt at comfort or amenity or common cleanliness, not a single trace of any of it. Omdurman was just planless confusion of blind walls and gaping holes, shiftless stupidity, contented filth and beastliness. But that, we said, was only the outskirts: when we come farther in we shall surely find this mass of population manifesting some small symbols of a great dominion. And presently we came indeed into a broader way than the rest something with the rude semblance of a street. Only it was paved with dead donkeys, and here and there it disappeared in a cullender of deep holes where green water festered. … Omdurman was a rabbit-warren a threadless labyrinth of tiny huts or shelters, too flimsy for the name of sheds. Oppression, stagnation, degradation, were stamped deep on every yard of miserable Omdurman.
"But the people! We could hardly see the place for the people. We could hardly hear our own voices for their shrieks of welcome. We could hardly move for their importunate greetings. They tumbled over each other like ants from every mud heap, from behind every dung-hill, from under every mat. … They had been trying to kill us three hours before. But they salaamed, none the less, and volleyed, 'Peace be with you' in our track. All the miscellaneous tribes of Arabs whom Abdullahi's fears or
suspicions had congregated in his capital, all the blacks his captains had gathered together into franker slavery indiscriminate, half-naked, grinning the grin of the sycophant, they held out their hands and asked for backsheesh. Yet more wonderful were the women. The multitude of women whom concupiscence had harried from every recess of Africa and mewed up in Baggara harems came out to salute their new masters. There were at least three of them to every man. Black women from Equatoria and almost white women from Egypt, plum-skinned Arabs and a strange yellow type with square, bony faces and tightly-ringleted black hair, … the whole city was a huge harem, a museum of African races, a monstrosity of African lust."
G. W. Steevens, With Kitchener to Khartum, chapter 32-34 (copyright, Dodd, Mead & Company, quoted with permission).
"Anyone who has not served in the Sudan cannot conceive the state of devastation and misery to which that unfortunate country has been brought under Dervish rule. Miles and miles of formerly richly cultivated country lies waste; villages are deserted; the population has disappeared. Thousands of women are without homes or families. Years must elapse before the Sudan can recover from the results of its abandonment to Dervish tyranny; but it is to be hoped and may be confidently expected, that in course of time, under just and upright government, the Sudan may be restored to prosperity; and the great battle of September will be remembered as having established peace, without which prosperity would have been impossible; and from which thousands of misguided and wretched people will reap the benefits of civilization."
E. S. Wortley, With the Sirdar (Scribner's Magazine, January, 1899).
EGYPT: A. D. 1898.
The country and its people after 15 years of British occupation.
"The British occupation has now lasted for over fifteen years. During the first five, comparatively little was accomplished, owing to the uncertain and provisional character of our tenure. The work done has been done in the main in the last ten years, and was only commenced in earnest when the British authorities began to realise that, whether we liked it or not, we had got to stay; and the Egyptians themselves came to the conclusion that we intended to stay. … Under our occupation Egypt has been rendered solvent and prosperous; taxes have been largely reduced; her population has increased by nearly 50 per cent.; the value and the productiveness of her soil has been greatly improved; a regular and permanent system of irrigation has been introduced into Lower Egypt, and is now in the course of introduction into Upper Egypt; trade and industry have made giant strides; the use of the Kurbash [bastinado] has been forbidden; the Corvée has been suppressed; regularity in the collection of taxes has been made the rule, and not the exception; wholesale corruption has been abolished; the Fellaheen can now keep the money they earn, and are better off than they were before; the landowners are all richer owing to the fresh supply of water, with the consequent rapid increase in the saleable price of land; justice is administered with an approach to impartiality; barbarous punishments have been mitigated, if not abolished; and the extraordinary conversion of Cairo into a fair semblance of a civilised European capital has been repeated on a smaller scale in all the chief centres of Egypt. To put the matter briefly, if our occupation were to cease to-morrow, we should leave Egypt and the Egyptians far better off than they were when our occupation commenced.
"If, however, I am asked whether we have succeeded in the
alleged aim of our policy, that of rendering Egypt fit for self-government, I should be obliged honestly to answer that in my opinion we have made little or no progress towards the achievement of this aim. The one certain result of our interference in the internal administration of Egypt has been to impair, if not to destroy, the authority of the Khedive; of the Mudirs, who, as the nominees of the Effendina, rule over the provinces; and of the Sheiks, who, in virtue of the favour of the Mudirs, govern the villages. We have undoubtedly trained a school of native officials who have learnt that it is to their interest to administer the country more or less in accordance with British ideas. Here and there we may have converted an individual official to a genuine belief in these ideas. But I am convinced that if our troops were withdrawn, and our place in Egypt was not taken by any other civilised European Power, the old state of things would revive at once, and Egypt would be governed once more by the old system of Baksheesh and Kurbash."
E. Dicey, Egypt, 1881 to 1897 (Fortnightly Review, May, 1898).
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Reviewing the report, for 1898, of Lord Cromer, the British Agent and Consul-General, who is practically the director of the government of Egypt, "The Spectator" (London) has noted the principle of Lord Cromer's administration to be that of "using English heads but Egyptian hands. In practice this means the policy of never putting an Englishman into any post which could be just as well filled by a native. In other words, the Englishman is only used in the administration where he is indispensable. Where he is not, the native, as is only just and right, is employed. The outcome of this is that Lord Cromer's work in Egypt has been carried out by 'a body of officials who certainly do not exceed one hundred in number,
and might possibly, if the figures were vigorously examined, be somewhat lower.' Lord Cromer adds, however, that 'these hundred have been selected with the greatest care.' In fact, the principle has been, never employ an Englishman unless it is necessary in the interests of good government to do so, but then employ a first-class man. The result is that the inspiring force in every Department of the Egyptian State is a first-class English brain, and yet the natives are not depressed by being deprived of their share of the administration. The Egyptians, that is, do not feel the legitimate grievance that is felt by the Tunisians and Algerians when they see even little posts of a couple of hundred a year filled by Frenchmen."
Spectator, April 15, 1899.
EGYPT: A. D. 1898 (September-November).
The French expedition of M. Marchand at Fashoda.
On the 10th of September, eight days after destroying the power of the Khalifa at Omdurman, the Sirdar, Lord Kitchener, left that fallen capital with five gunboats and a considerable force of Highlanders, Sudanese and Egyptians, to take possession of the Upper Nile. At Fashoda, in the Shilluk country, a little north of the junction of the Sobat with the White Nile, he found a party of eight French officers and about a hundred Senegalese troops, commanded by M. Marchand, entrenched at the old government buildings in that place and claiming occupation of the country. It had been known for some time that M. Marchand was leading an expedition from the French Congo towards the Nile, and the British government had been seeking an explanation of its objects from the government of France, uttering warnings, at the same time, that England would recognize no rights in any part of the Nile Valley except the rights of Egypt, which the evacuation of the Egyptian Sudan, consequent on the conquests of the Mahdi and the Dervishes,
had not extinguished. Even long before the movements of M. Marchand were known, it had been suspected that France entertained the design of extending her great possessions in West Africa eastward, to connect with the Nile, and, as early as the spring of 1895, Sir Edward Grey, speaking for the British Foreign Office, in reply to a question then asked in the House of Commons, concerning rumors that a French expedition from West Africa was approaching the Nile, said with unmistakable meaning: "After all I have explained about the claims we consider we have under past Agreements, and the claims which we consider Egypt may have in the Nile Valley, and adding to that the fact that those claims and the view of the Government with regard to them are fully and clearly known to the French Government, I cannot think it is possible that these rumors deserve credence, because the advance of a French expedition under secret instructions right from the other side of Africa into a territory over which our claims have been known for so long would be not merely an inconsistent and unexpected act, but it must be perfectly well known to the French Government that it would be an unfriendly act, and would be so viewed by England." In December, 1897, the British Ambassador at Paris had called the attention of the French government to Sir Edward Grey's declaration, adding that "Her Majesty's present Government entirely adhere to the language that was on this occasion employed by their predecessors."
As between the two governments, then, such was the critical situation of affairs when the Sirdar, who had been already instructed how to act if he found intruders in the Nile Valley, came upon M. Marchand and his little party at Fashoda. The circumstances and the results of the meeting were reported by him promptly as follows: "On reaching the old Government buildings, over which the French flag was flying, M. Marchand, accompanied by Captain Germain, came on board. After complimenting them on their long and arduous journey, I proceeded at once to inform M. Marchand that I was authorized to state that the presence of the French at Fashoda and in the
