Surgery PreTest Self-Assessment and

Review, 14E 14th Edition Edition Lillian

Kao
Visit to download the full and correct content document:
https://ebookmass.com/product/surgery-pretest-self-assessment-and-review-14e-14th
-edition-edition-lillian-kao/
https://t.me/MBS_MedicalBooksStore
 Surgery
Pre-Test Self-Assessment and Review

FM.indd 1 15-11-2019 12:13:22

 Notice

Medicine is an ever-changing science. As new research and clinical experience broad-

en our knowledge, changes in treatment and drug therapy are required. The authors
and the publisher of this work have checked with sources believed to be reliable in
their efforts to provide information that is complete and generally in accord with the
standards accepted at the time of publication. However, in view of the possibility of
human error or changes in medical sciences, neither the authors nor the publisher
nor any other party who has been involved in the preparation or publication of this
work warrants that the information contained herein is in every respect accurate
or complete, and they disclaim all responsibility for any errors or omissions or for
the results obtained from use of the information contained in this work. Readers
are encouraged to confirm the information contained herein with other sources.
For example and in particular, readers are advised to check the product information
sheet included in the package of each drug they plan to administer to be certain that
the information contained in this work is accurate and that changes have not been
made in the recommended dose or in the contraindications for administration. This
recommendation is of particular importance in connection with new or infrequently
used drugs.

FM.indd 2 15-11-2019 12:13:22

 Surgery
Pre-Test Self-Assessment and Review
Fourteenth Edition

Lillian S. Kao, MD, MS

Professor
Department of Surgery
McGovern Medical School at the University of
Texas Health Science Center at Houston

Casey B. Duncan, MD
Assistant Professor
Department of Surgery
McGovern Medical School at the University of
Texas Health Science Center at Houston

Ethan Taub, DO
Assistant Professor
Department of Surgery
McGovern Medical School at the University of
Texas Health Science Center at Houston

New York  Chicago  San Francisco  Athens  London  Madrid  Mexico City  

Milan  New Delhi  Singapore  Sydney  Toronto

FM.indd 3 15-11-2019 12:13:22

Copyright © 2020 by McGraw-Hill Education. All rights reserved. Except as permitted under the
United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in
any form or by any means, or stored in a database or retrieval system, without the prior written permis-
sion of the publisher.

ISBN: 978-1-26-014362-1
MHID: 1-26-014362-7

The material in this eBook also appears in the print version of this title: ISBN: 978-1-26-014361-4,
MHID: 1-26-014361-9.

eBook conversion by codeMantra

Version 1.0

All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after
every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit
of the trademark owner, with no intention of infringement of the trademark. Where such designations
appear in this book, they have been printed with initial caps.

McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and
sales promotions or for use in corporate training programs. To contact a representative, please visit the
Contact Us page at www.mhprofessional.com.

TERMS OF USE

This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the
work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976
and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse
engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate,
sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent.
You may use the work for your own noncommercial and personal use; any other use of the work is
strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms.

THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS
MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COM-
PLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING
ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK
OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED,
INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR
FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill Education and its licensors do not warrant
or guarantee that the functions contained in the work will meet your requirements or that its operation
will be uninterrupted or error free. Neither McGraw-Hill Education nor its licensors shall be liable to
you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any
damages resulting therefrom. McGraw-Hill Education has no responsibility for the content of any
information accessed through the work. Under no circumstances shall McGraw-Hill Education and/or
its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages
that result from the use of or inability to use the work, even if any of them has been advised of the
possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever
whether such claim or cause arises in contract, tort or otherwise.
 Student Reviewers
Jacob Nouriel
Wayne State University School of Medicine
Class of 2019

FM.indd 5 15-11-2019 12:13:22

 This page intentionally left blank

FM.indd 6 15-11-2019 12:13:22

 Contents
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Pre- and Postoperative Care

Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Critical Care: Anesthesiology, Blood Gases, and

Respiratory Care
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Skin: Wounds, Infections, and Burns;

Plastic Surgery
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Trauma and Shock

Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Transplant, Immunology, and Oncology

Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

Endocrine Problems and the Breast

Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

Gastrointestinal Tract, Liver, and Pancreas

Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

vii

FM.indd 7 15-11-2019 12:13:22

 viii   Contents

Cardiothoracic Problems
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

Vascular Surgery
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

Urology
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

Orthopedics
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

Neurosurgery
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276

Otolaryngology
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

Pediatric Surgery
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

FM.indd 8 15-11-2019 12:13:23

 Introduction
Surgery: PreTest Self-Assessment and Review, Fourteenth Edition, is intended
to provide medical students, as well as house officers and physicians, with a
convenient tool for assessing and improving their knowledge of surgery. The
450+ questions in this book include multiple-choice, matching, and quick fire
questions. The multiple-choice questions are similar in format and complexity
to those included in Step 2 of the United States Medical Licensing Examination
(USMLE). They may also be a useful study tool for Step 3.
For multiple-choice questions, the one best response to each question
should be selected. For matching sets, a group of questions will be preceded by a
list of lettered options. For each question in the matching set, select one lettered
option that is most closely associated with the question. The quick fire ques-
tions have free text answers. Each question in this book, except for the quick fire
questions, has a short discussion of various issues raised by the question and its
answer. A listing of references for the entire book follows the last chapter.
To simulate the time constraints imposed by the qualifying examinations
for which this book is intended as a practice guide, the student or physician
should allot about 1 minute for each question. After answering all questions in
a chapter, as much time as necessary should be spent in reviewing the explana-
tions for each question at the end of the chapter. Attention should be given to
all explanations, even if the examinee answered the question correctly. Those
seeking more information on a subject should refer to the reference materials
listed or to other standard texts in medicine.

ix

FM.indd 9 15-11-2019 12:13:23

 This page intentionally left blank

FM.indd 10 15-11-2019 12:13:23

 Pre- and Postoperative
Care
Questions

1. A 48-year-old woman develops constipation postoperatively and self-

medicates with milk of magnesia. She is noted to have an elevated serum
magnesium level. Which of the following represents the earliest clinical
indication of hypermagnesemia?
a. Loss of deep tendon reflexes
b. Flaccid paralysis
c. Respiratory arrest
d. Hypotension
e. Stupor

2. An asymptomatic middle-aged woman is found to have a serum sodium

level of 125 mEq/L after routine laparoscopic cholecystectomy. Which of
the following is the most appropriate management strategy for this patient?
a. Administration of hypertonic saline solution
b. Administration of normal saline
c. Administration of sodium chloride tablets
d. Restriction of free water
e. Diuresis with furosemide

3. A 52-year-old morbidly obese man with no other medical problems is

scheduled to undergo an elective sigmoid colectomy for recurrent diverticu-
litis. Which of the following is part of an enhanced recovery after surgery
protocol?
a. Nasogastric tube until return of bowel function
b. Foley catheter for at least 48 hours postoperatively
c. Intravenous fluids until return of bowel function
d. Sugar-free gum 3–4 times per day
e. Daily suppository administration

ch01.indd 1 15-11-2019 10:48:02

 2   Surgery

4. Following surgery a patient develops oliguria. Which of the following

values supports the diagnosis of hypovolemia?
a. Urine sodium of 28 mEq/L
b. Urine chloride of 15 mEq/L
c. Fractional excretion of sodium less than 1
d. Urine/serum creatinine ratio of 20
e. Urine osmolality of 350 mOsm/kg

5. A 75-year-old man with unstable angina, peripheral vascular disease

with symptoms of claudication after walking half a block, hypertension, and
diabetes presents with a large ventral hernia that he desires to be repaired.
Which of the following is the most appropriate next step in his preoperative
workup?
a. Exercise stress test
b. Persantine thallium stress test
c. Transesophageal echocardiography
d. Cardiac catheterization
e. Coronary artery bypass

6. A previously healthy 55-year-old man undergoes elective right hemico-

lectomy for a stage I (T2N0M0) cancer of the cecum. He has a prolonged
postoperative ileus requiring nasogastric decompression for 5 days. Physical
examination reveals diminished skin turgor, dry mucous membranes, and
orthostatic hypotension. Pertinent laboratory values are as follows:
Arterial blood gas: pH 7.45, Pco2 50 mm Hg, Po2 85 mm Hg
Serum electrolytes (mEq/L): Na+ 132, K+ 3.1, Cl− 80; HCO3− 42

What is the patient’s acid–base abnormality?

a. Uncompensated metabolic alkalosis
b. Uncompensated respiratory acidosis
c. Respiratory acidosis with metabolic compensation
d. Metabolic alkalosis with respiratory compensation
e. Combined metabolic and respiratory alkalosis

ch01.indd 2 15-11-2019 10:48:02

 Pre- and Postoperative Care   3

7. An 18-year-old previously healthy man with multiple fractures after a

motor vehicle collision develops a left femoral deep venous thrombosis on
hospital day 5 despite being on prophylactic low-molecular-weight hepa-
rin since admission. His platelet count was noted to have dropped from
385,000/μL on admission to 90,000/μL. In addition to cessation of all anti-
coagulation therapy, which of the following is the most appropriate next
management step?
a. No additional therapy
b. High-dose warfarin
c. Low-molecular-weight heparin
d. Argatroban
e. Platelet transfusion

8. A 65-year-old man undergoes a technically difficult abdominal–

perineal resection for a rectal cancer during which he receives 3 U of packed
red blood cells. Four hours later, in the intensive care unit (ICU), he is bleed-
ing heavily from his perineal wound. Emergency coagulation studies reveal
normal prothrombin, partial thromboplastin, and bleeding times. The fibrin
degradation products are not elevated, but the serum fibrinogen content is
depressed and the platelet count is 70,000/μL. Which of the following is the
most likely cause of his bleeding?
a. Delayed blood transfusion reaction
b. Autoimmune fibrinolysis
c. Inadequate surgical hemostasis
d. Factor VIII deficiency
e. Hypothermic coagulopathy

9. A 78-year-old man with a history of coronary artery disease and an

asymptomatic reducible inguinal hernia requests an elective hernia repair.
Which of the following would be a valid reason for delaying the proposed
surgery?
a. Coronary artery bypass surgery 3 months earlier
b. A history of cigarette smoking
c. Jugular venous distension
d. Hypertension
e. Transient ischemic attack 3 years prior

ch01.indd 3 15-11-2019 10:48:02

 4   Surgery

10. A 30-year-old otherwise healthy woman in her last trimester of preg-

nancy is diagnosed with a right common femoral deep venous thrombosis.
Which of the following is the best treatment option until delivery?
a. Aspirin
b. Subcutaneous heparin
c. Subcutaneous low-molecular-weight heparin
d. Warfarin
e. Inferior vena cava filter

11. A 65-year-old man undergoes a low anterior resection for rectal can-
cer. On the fifth day in hospital, his physical examination shows a tempera-
ture of 36.5°C (97.7°F), blood pressure of 130/80 mm Hg, pulse of 75 beats
per minute and regular, and respiratory rate of 16 breaths per minute. His
midline incision shows a localized area of erythema and induration. White
blood cell count is 9000/mm3. Which of the following is the best treatment
option?
a. Topical antibiotics alone
b. Intravenous antibiotics alone
c. Incision and drainage alone
d. Incision and drainage and topical antibiotics
e. Incision and drainage and intravenous antibiotics

12. A 62-year-old woman undergoes a pancreaticoduodenectomy for a pan-

creatic head cancer. A jejunostomy tube is placed to facilitate nutritional
repletion as she is expected to have a prolonged recovery. Which of the fol-
lowing is a contraindication to enteral feeding via the jejunostomy tube?
a. Delirium
b. Delayed gastric emptying
c. Acute pancreatitis
d. Pancreatic leak
e. Ileus

ch01.indd 4 15-11-2019 10:48:02

 Pre- and Postoperative Care   5

13. A 71-year-old man develops dysphagia for both solids and liquids
and weight loss of 60 lb over the past 6 months. He undergoes endoscopy,
demonstrating a distal esophageal lesion, and biopsies are consistent with
squamous cell carcinoma. He is scheduled for neoadjuvant chemoradiation
followed by an esophagectomy. Preoperatively he is started on total paren-
teral nutrition, given his severe malnutrition reflected by an albumin of
less than 1. Which of the following is most likely to be a concern initially in
starting total parenteral nutrition in this patient?
a. Hyperkalemia
b. Hypermagnesemia
c. Hypoglycemia
d. Hypophosphatemia
e. Hypochloremia

14. An elderly diabetic woman with chronic steroid-dependent broncho-

spasm has an ileocolectomy for a perforated cecum. She is taken to the ICU
intubated and is maintained on broad-spectrum antibiotics and a rapid ste-
roid taper. On postoperative day 2, she develops a fever of 39.2°C (102.5°F),
hypotension, lethargy, and laboratory values remarkable for hypoglycemia
and hyperkalemia. Which of the following is the most likely explanation for
her deterioration?
a. Sepsis
b. Hypovolemia
c. Adrenal insufficiency
d. Acute tubular necrosis
e. Diabetic ketoacidosis

15. Ten days after an exploratory laparotomy and lysis of adhesions, a

patient, who previously underwent a low anterior resection for rectal cancer
followed by postoperative chemoradiation, is noted to have succus drain-
ing from the wound. She appears to have adequate source control—she is
afebrile with a normal white blood count. The output from the fistula is
approximately 150 cc per day. Which of the following factors is most likely
to prevent closure of the enterocutaneous fistula?
a. Previous radiation
b. Previous chemotherapy
c. Recent surgery
d. History of malignancy
e. More than 100-cc output per day

ch01.indd 5 15-11-2019 10:48:02

 6   Surgery

16. A 26-year-old man is resuscitated with packed red blood cells follow-
ing a motor vehicle collision complicated by a fractured pelvis and resultant
hemorrhage. A few hours later the patient becomes hypotensive with a nor-
mal central venous pressure (CVP), oliguric, and febrile. Upon examination,
the patient is noted to have profuse oozing of blood from his intravenous
(IV) sites. Which of the following is the most likely diagnosis?
a. Hypovolemic shock
b. Acute adrenal insufficiency
c. Gram-negative bacteremia
d. Transfusion reaction
e. Ureteral obstruction

17. A 63-year-old man undergoes a partial gastrectomy with Billroth II

reconstruction (gastrojejunostomy) for intractable peptic ulcer disease.
He presents several months postoperatively with a megaloblastic anemia.
Which of the following is the best treatment for this surgical complication?
a. Packed red blood cell transfusion
b. Oral iron supplementation
c. Oral vitamin B12 supplementation
d. Intravenous vitamin B12 supplementation
e. Oral folate supplementation

18. A 52-year-old woman undergoes a sigmoid resection with primary

anastomosis for recurrent diverticulitis. She returns to the emergency
room 10 days later with left flank pain and decreased urine output; lab-
oratory examination is significant for a white blood cell (WBC) count of
20,000/mm3. She undergoes a CT scan that demonstrates new left hydro-
nephrosis, but no evidence of an intra-abdominal abscess. Which of the
following is the best test to confirm the diagnosis?
a. Urinalysis
b. Renal ultrasound
c. Intravenous pyelogram
d. Renal scintigraphy
e. Cystoscopy

ch01.indd 6 15-11-2019 10:48:02

 Pre- and Postoperative Care   7

19. A 23-year-old woman undergoes total thyroidectomy for carcinoma of

the thyroid gland. On the second postoperative day, she begins to complain
of a tingling sensation in her hands. She appears quite anxious and later
complains of muscle cramps. Which of the following is the most appropriate
initial management strategy?
a. Intravenous magnesium
b. Oral vitamin D
c. Oral levothyroxine
d. Intravenous calcium gluconate
e. Oral calcium gluconate

20. A 78-year-old woman on steroids for rheumatoid arthritis is planned

for an elective right hemicolectomy for colon cancer. In addition to intrave-
nous antibiotics within an hour prior to incision, which of the following is
indicated to reduce the risk of surgical site infections?
a. No additional intervention
b. Preoperative oral antibiotics only
c. Preoperative mechanical bowel prep only
d. Preoperative oral antibiotics and mechanical bowel prep
e. Postoperative intravenous antibiotics

21. A 72-year-old man undergoes a subtotal colectomy for a cecal perfora-

tion due to a sigmoid colon obstruction. He has had a prolonged recovery
and has been on total parenteral nutrition (TPN) for 2 weeks postopera-
tively. After regaining bowel function, he experienced significant diarrhea.
Examination of his abdominal wound demonstrates minimal granulation
tissue. He complains that he has lost his taste for food. He also has increased
hair loss and a new perioral pustular rash. Which of the following deficien-
cies does he most likely have?
a. Zinc
b. Selenium
c. Molybdenum
d. Chromium
e. Thiamine

ch01.indd 7 15-11-2019 10:48:02

 8   Surgery

22. A 45-year-old woman undergoes an uneventful laparoscopic cholecys-

tectomy for which she received appropriate antibiotic prophylaxis. One week
later, she returns to the emergency room with abdominal pain and watery
diarrhea. She is afebrile and has no peritoneal signs on abdominal examina-
tion. Her white blood cell count is 12,000/mm3. Stool studies are pending.
Which of the following is the appropriate initial management strategy?
a. Supportive care only
b. Oral ciprofloxacin
c. Oral vancomycin
d. Oral metronidazole
e. Loperamide

23. A 65-year-old woman develops acute kidney injury postoperatively. She

is oliguric and her potassium is 7.5. ECG shows peaked T-waves. Which of
the following therapies should be administered to stabilize the myocardium?
a. Insulin and glucose
b. Bicarbonate
c. Calcium gluconate
d. Kayexalate
e. Furosemide

Quick Fire Questions

24. What is the treatment of minor bleeding after minor surgery in a

patient with von Willebrand disease?

25. What factor should be administered in a patient with hemophilia A

with severe bleeding?

26. How many kilocalories per kilogram per day should the average surgical
patient receive?

27. What is the most common complication of overly rapid infusion of

total parenteral nutrition?

28. What is the most devastating long-term complication of total paren-

teral nutrition?

29. What complication occurs with overly rapid correction of

hyponatremia?

30. What complication occurs with overly rapid correction of

hypernatremia?

ch01.indd 8 15-11-2019 10:48:02

 Pre- and Postoperative
Care
Answers

1. The answer is a. The earliest clinical indication of hypermagnese-

mia is loss of deep tendon reflexes, which tends to be seen with a mod-
est hypermagnesemia, over about 4 mEq/L. States of magnesium excess
are characterized by generalized neuromuscular depression. Clinically, severe
hypermagnesemia is rarely seen except in those patients with advanced
renal failure treated with magnesium-containing antacids. However, hyper-
magnesemia is produced intentionally by obstetricians who use parenteral
magnesium sulfate (MgSO4) to treat preeclampsia. MgSO4 is administered
until depression of the deep tendon reflexes is observed. Greater elevations
of magnesium produce progressive weakness, which culminates in flaccid
quadriplegia. Other cardiorespiratory complications include respiratory
failure or arrest secondary to respiratory muscle dysfunction, and hypoten-
sion may be secondary to the direct arteriolar relaxing effect of magnesium.
Changes in mental status occur in the late stages of the syndrome and are
characterized by somnolence that progresses to coma.

Symptoms of Hypermagnesemia

Magnesium level
(mEq/L) Manifestation(s)
1.5–2.1 Normal
2.1–4.2 Typically asymptomatic
4.2–5.8 Lethargy, drowsiness, flushing, nausea and vomiting, diminished
deep tendon reflexes
5.8–10 Somnolence, loss of deep tendon reflexes, hypotension, ECG
changes
>10 Complete heart block, cardiac arrest, apnea, paralysis, coma

Source: McEvoy C, Murray PT. Electrolyte disorders in critical care. In: Jesse B. Hall, et al. (eds.).
Principles of Critical Care, 4th ed. New York, NY: McGraw-Hill, 2014.

ch01.indd 9 15-11-2019 10:48:02

 10  Surgery

2. The answer is d. The initial, and often definitive, management of

an asymptomatic patient with hyponatremia is free water restriction.
Symptomatic hyponatremia, which occurs at serum sodium levels less than
or equal to 120 mEq/L, can result in headache, seizures, coma, and signs
of increased intracranial pressure and may require infusion of hypertonic
saline. Since this patient is asymptomatic, she does not require hypertonic
saline. Rapid correction of hyponatremia should be avoided so as not to
cause central pontine myelinolysis, manifested by neurologic symptoms
ranging from seizures to brain damage and death. Additionally, a search for
the underlying etiology of the hyponatremia should be undertaken. Acute
severe hyponatremia sometimes occurs following elective surgical proce-
dures due to a combination of appropriate stimulation of antidiuretic hor-
mone and injudicious administration of excess free water in the first few
postoperative days. Other potential etiologies include hyperosmolarity with
free-water shifts from the intracellular to the extracellular compartment
(eg, hyperglycemia), sodium depletion (eg, gastrointestinal or renal losses,
insufficient intake), dilution (eg, drug-induced), and the syndrome of inap-
propriate secretion of antidiuretic hormone (SIADH).

3. The answer is d. Sham feeding or chewing of sugar-free gum 3 to 4 times

per day may be associated with early flatus and bowel movements after
colorectal surgery and is included in many enhanced recovery after surgery
protocols. First pioneered for patients undergoing elective colorectal
procedures, enhanced recovery protocols have been demonstrated to
reduce postoperative complications and reduce hospital length of stay
without increasing the rate of readmissions. Although the individual
components of enhanced recovery protocols may differ between surgeons
or institutions, there are many shared components that focus on hastening
recovery in the preoperative, perioperative, and postoperative phases (see
the below table). Daily suppository administration is not part of enhanced
recovery protocols.

ch01.indd 10 15-11-2019 10:48:02

Another random document with
no related content on Scribd:
 East. At Pao-Ting Fu, where women were said to have suffered
indescribable brutalities before being slain, investigation by
an American military officer convinced him that "there is no
evidence of any peculiar atrocities committed upon the persons
of those who were slain"; and the American Board of
Commissioners for Foreign Missions has publicly announced:
"While forced to believe that our missionaries in Shan Si and
at Pao Ting Fu were put to death by the Chinese, we have never
credited the published reports concerning atrocities connected
with their slaughter."

CHINA: A. D. 1901 (March).

Withdrawal of American troops, excepting a Legation guard.

The following order was sent by cable from the War Department
at Washington to General Chaffee, commanding the United States
forces in China, on the 15th of March: "In reply to your
telegram Secretary of War directs you complete arrangements
sail for Manila with your command and staff officers by end
April, leaving as legation guard infantry company composed of
150 men having at least one year to serve or those intending
re-enlist, with full complement of officers, medical officer,
sufficient hospital corps men and, if you think best, field
officer especially qualified to command guard. Retain and
instruct officer quartermaster's department proceed to erect
necessary buildings for guard according to plan and estimates
you approve."

CHINA: A. D. 1901 (March-April).

Discussion of the question of indemnity.
Uneasiness concerning rumored secret negotiations of
Russia with the Chinese government relative to Manchuria.

As we write this (early in April), the reckoning of

indemnities to be demanded by the several Powers of the
Concert in China is still under discussion between the
Ministers at Peking, and is found to be very difficult of
settlement. There is understood to be wide differences of
disposition among the governments represented in the
discussion, some being accused of a greed that would endeavor
to wring from the Chinese government far more than the country
can possibly pay; while others are laboring to reduce the
total of exactions within a more reasonable limit. At the
latest accounts from Peking, a special committee of the
Ministers was said to be engaged in a searching investigation
of the resources of China, in order to ascertain what sum the
Empire has ability to pay, and in what manner the payment can
best be secured and best made. It seems to be hoped that when
those facts are made clear there may be possibilities of an
agreement as to the division of the total sum between the
nations whose legations were attacked, whose citizens were
slain, and who sent troops to crush the Boxer rising.

Meantime grave anxieties are being caused by rumors of a

secret treaty concerning Manchuria which Russia is said to be
attempting to extort from the Chinese government [see, in this
volume, MANCHURIA], the whispered terms of which would give
her, in that vast region, a degree of control never likely to
become less. The most positive remonstrance yet known to have
been made, against any concession of that nature, was
addressed, on the 1st of March, by the government of the
United States, to its representatives at St. Petersburg,
Berlin, London, Paris, Vienna, Rome, and Tokio, as follows:

"The following memorandum, which was handed to the Chinese

Minister on February 19, is transmitted to you for your
information and communication to the government to which you
are accredited: "The preservation of the territorial integrity
of China having been recognized by all the powers now engaged in
joint negotiation concerning the injuries recently inflicted
upon their ministers and nationals by certain officials and
subjects of the Chinese Empire, it is evidently advantageous
to China to continue the present international understanding
upon this subject. It would be, therefore, unwise and
 dangerous in the extreme for China to make any arrangement or
to consider any proposition of a private nature involving the
surrender of territory or financial obligations by convention
with any particular power; and the government of the United
States, aiming solely at the preservation of China from the
danger indicated and the conservation of the largest and most
beneficial relations between the empire and other countries,
in accordance with the principles set forth in its circular
note of July 3, 1900, and in a purely friendly spirit toward
the Chinese Empire and all the powers now interested in the
negotiations, desires to express its sense of the impropriety,
inexpediency and even extreme danger to the interests of China
of considering any private territorial or financial
arrangements, at least without the full knowledge and approval
of all the powers now engaged in negotiation.
HAY."

----------CHINA: End--------

CHINESE TAXES.

See (in this volume)

LIKIN.

CHING, Prince:
Chinese Plenipotentiary to negotiate with the allied Powers.

See (in this volume)

CHINA: A. D. 1900 (AUGUST-DECEMBER).

CHITRAL: A. D. 1895.
The defense and relief of.

See (in this volume)

INDIA: A. D. 1895 (MARCH-SEPTEMBER).

CHITRAL:A. D. 1901.
 Included in a new British Indian province.

See (in this volume)

INDIA: A. D. 1901 (FEBRUARY).

CHOCTAWS, United States agreements with the.

See (in this volume)

INDIANS, AMERICAN: A. D. 1893-1899.

CHRISTIAN ENDEAVOR, The Young People's Society of.

The nineteenth annual international convention of Young

People's Societies of Christian Endeavor was held in the
Alexandra Palace, London, England, from the 13th to the 20th
of July, 1900, delegates being present from most countries of
the world. Reports presented to the convention showed a total
membership of about 3,500,000, in 59,712 societies, 43,262 of
which were in the United States, 4,000 in Canada, some 7,000
in Great Britain, 4,000 in Australia, and smaller numbers in
Germany, India, China, Japan, Mexico, and elsewhere.

{145}

The first society, which supplied the germ of organization for

all succeeding ones, was formed in the Williston
Congregational Church of Portland, Maine, on the 2d of
February, 1881, by the Reverend Francis E. Clark, the pastor
of the church. The object, as indicated by the name of the
society, was to organize the religious energies of the young
people of the church for Christian life and work. The idea was
caught and imitated in other churches—Congregational,
Presbyterian, Methodist, Baptist, and others—very rapidly,
and the organization soon became, not only widely national,
but international. In 1898, it was reported that Russia then
remained the only country in the world without a Christian
Endeavor Society, and the total was 54,191. In the next year's
 report Russia was announced to have entered the list of
countries represented, and the number of societies had
advanced to 55,813. In 1900, the numbers had risen to the
height stated above. The Epworth League is a kindred
organization of young people in the Methodist Church.

See (in this volume)

EPWORTH LEAGUE.

CHRISTIANS AND MOSLEMS:

Conflicts in Armenia.

See (in this volume)

TURKEY: A. D. 1895.

CONFLICTS IN CRETE.

See (in this volume)

TURKEY: A. D. 1897 (FEBRUARY-MARCH).

CHUNGKING.

"Chungking, which lies nearly 2,000 miles inland, is, despite

its interior position, one of the most important of the more
recently opened ports of China. Located at practically the
head of navigation on the Yangtze, it is the chief city of the
largest, most populous, and perhaps the most productive
province of China, whose relative position, industries,
population, and diversified products make it quite similar to
the great productive valley of the upper Mississippi. The
province of Szechuan is the largest province of China, having
an area of 166,800 square miles, and a population of
67,000,000, or but little less than that of the entire United
States. Its area and density of population may be more readily
recognized in the fact that its size is about the same as that
of the States of Ohio, Indiana, Illinois, and Kentucky combined,
but that its population is six times as great as that of those
 States. Its productions include wheat, tobacco, buckwheat,
hemp, maize, millet, barley, sugar cane, cotton, and silk."

United States, Bureau of Statistics,

Monthly Summary, March, 1899, page 2196.

CHURCH OF ENGLAND: A. D. 1896.

Papal declaration of the invalidity of its ordinations.

See (in this volume)

PAPACY: A. D. 1896 (SEPTEMBER).

CIVIL CODE: Introduction in Germany.

See (in this volume)

GERMANY: A. D. 1900 (JANUARY).

-------CIVIL-SERVICE REFORM IN THE UNITED STATES: Start-----

CIVIL-SERVICE REFORM IN THE UNITED STATES: A. D. 1893-1896.

Extensions of the Civil-Service rules by President Cleveland.

"Through the extensions of the Federal classification during

President Cleveland's second administration, the number of
positions covered by the civil-service rules was increased
two-fold. On March 3, 1893, the number classified was 42,928.
By a series of executive orders ranging from March 20, 1894,
to June 25. 1895, 10,000 places were added to the list,
bringing the total, approximately, to 53,000. Meanwhile, the
Civil Service Commission had recommended to the President a
general revision that would correct the imperfections of the
original rules and extend their scope to the full degree
contemplated by the Pendleton Act. After much correspondence
and consultation with department officers, and careful work on
the part of the Commission, the rules of May 6 [1896] were
promulgated. They added to the classification about 29,000
more places, and by transferring to the control of the
Commission the system of Navy Yard employment, established by
Secretary Tracy, brought the total number in the classified
service to 87,117. The positions in the Executive branch
unaffected by these orders included those classes expressly
excluded by the statute—persons nominated for confirmation by
the Senate and those employed 'merely as laborers or
workmen'—together with the fourth-class postmasters, clerks in
post-offices other than free delivery offices and in Customs
districts having less than five employees, persons receiving
less than $300 annual compensation, and about 1,000
miscellaneous positions of minor character, not classified for
reasons having to do with the good of the service—91,600 in
all. Within the classified service, the list of positions
excepted from competitive examination was confined to the
private secretaries and clerks of the President and Cabinet
officers, cashiers in the Customs Service, the Internal
Revenue Service and the principal post-offices, attorneys who
prepare cases for trial, principal Customs deputies and all
assistant postmasters—781 in all. The new rules provided for a
general system of promotion, based on competitive examinations
and efficiency records, and gave the Commission somewhat
larger powers in the matter of removals by providing that no
officer or employee in the classified service, of whatever
station, should be removed for political or religious reasons,
and that in all cases like penalties should be imposed for like
offenses. They created an admirable system, a system founded
on the most sensible rules of business administration, and
likely to work badly only where the Commission might encounter
the opposition of hostile appointing officers. President
Cleveland's revised rules were promulgated before the
Convention of either political party had been held, and before
the results of the election could be foreshadowed. The
extensions were practically approved, however, by the
Republican platform, which was adopted with full knowledge of
the nature of the changes, and which declared that the law
should be 'thoroughly and honestly enforced and extended
wherever practicable.' … Mr. McKinley, in his letter of
 acceptance and in his inaugural address, repeated the pledge
of the Republican party to uphold the law, and during the two
months of his administration now past he has consistently done
so. He has been beset by many thousands of place-seekers, by
Senators and Representatives and by members of his own
Cabinet, all urging that he undo the work of his predecessor,
either wholly or in part, and so break his word of honor to
the nation, in order that they may profit. … At least five
bills have been introduced in Congress, providing for the
repeal of the law. … Finally, the Senate has authorized an
investigation, by the Committee on Civil Service and
Retrenchment, with the view of ascertaining whether the law
should be 'continued, amended or repealed,' and sessions of
this Committee are now in progress. … Mr. McKinley, by
maintaining the system against these organized attacks, will
do as great a thing as Mr. Cleveland did in upbuilding it."

Report of the Executive Committee of the New York

Civil Service Reform Association, 1897.

{146}

In his annual Message to Congress, December, 1896, President

Cleveland remarked on the subject:

"There are now in the competitive classified service upward of

eighty-four thousand places. More than half of these have been
included from time to time since March 4, 1893. … If
fourth-class postmasterships are not included in the
statement, it may be said that practically all positions
contemplated by the civil-service law are now classified.
Abundant reasons exist for including these postmasterships,
based upon economy, improved service, and the peace and quiet
of neighborhoods. If, however, obstacles prevent such action
at present, I earnestly hope that Congress will, without
increasing post-office appropriations, so adjust them as to
permit in proper cases a consolidation of these post-offices,
 to the end that through this process the result desired may to
a limited extent be accomplished. The civil-service rules as
amended during the last year provide for a sensible and
uniform method of promotion, basing eligibility to better
positions upon demonstrated efficiency and faithfulness."

United States, Message and Documents (Abridgment),

1896-1897, page 33.

CIVIL-SERVICE REFORM IN THE UNITED STATES: A. D. 1894.

Constitutional provision in New York.

See (in this volume)

CONSTITUTION OF NEW YORK.

CIVIL-SERVICE REFORM IN THE UNITED STATES: A. D. 1897-1898.

Onslaught of the spoils-men at Washington.
Failure of the Congressional attack.

"During the four months following the inauguration [of

President McKinley] the onslaught of place-seekers was almost
unprecedented. Ninety-nine out of every hundred of them
discovered that the office or position he desired was
classified and subject to competitive examination. The tenure
of the incumbent in each case was virtually at the pleasure of
the department officers; removals might easily be made; but
appointments to the places made vacant could be made only from
the eligible lists, and the lists were fairly well filled. It
is true that the rules permitted the reinstatement without
examination of persons who had been separated from the service
without personal fault within one year, or of veterans who had
been in the service at any time, and that some removals were made
to make room for these. But the appointments in such cases
went but a very little way toward meeting the demand. The
result was that almost the whole pressure of the
office-hunting forces and of their members of Congress was
directed for the while toward one end—the revocation or
material modification of the civil service rules. President
McKinley was asked to break his personal pledges, as well as
those of his party, and to take from the classified service
more than one half of the 87,000 offices and positions it
contained. … But the President yielded substantially nothing.
… The attack of the spoils-seekers was turned at once from the
President to Congress. It was declared loudly that the desired
modifications would be secured through legislation, and that
it might even be difficult to restrain the majority from
voting an absolute repeal. In the House the new movement was
led by General Grosvenor of Ohio; in the Senate by Dr.
Gallinger of New Hampshire. … The first debates of the session
dealt with civil service reform. The House devoted two weeks to
the subject in connection with the consideration of the annual
appropriation for the Civil Service Commission. … The effort
to defeat the appropriation ended in the usual failure. It was
explained, however, that all of this had been mere preparation
for the proposed legislation. A committee was appointed by the
Republican opponents, under the lead of General Grosvenor, to
prepare a bill. The bill appeared on January 6, when it was
introduced by Mr. Evans of Kentucky, and referred to the
Committee on Reform in the Civil Service. It limited the
application of the civil service law to clerical employees at
Washington, letter carriers and mail clerks, and employees in
principal Post Offices and Customs Houses, proposing thus to
take from the present classified service about 55,000
positions. A series of hearings was arranged by the Civil
Service Committee, at which representatives of this and other
Associations, and of the Civil Service Commission, were
present. A sub-committee of seven, composing a majority of the
full committee, shortly afterward voted unanimously to report
the bill adversely. About the same time, the Senate Civil
Service Committee, which had been investigating the operation
of the law since early summer, presented its report. Of the
eight members, three recommended a limited number of
exceptions, amounting in all to probably 11,000; three
recommended a greatly reduced list of exceptions, and two
 proposed none whatever. All agreed that the President alone
had authority to act, and that no legislation was needed. …
The collapse of the movement in Congress has turned the
attention of the spoilsmen again toward the President. He is
asked once more to make sweeping exceptions."

Report of the Executive Committee of the

New York Civil Service Reform Association, 1898.

CIVIL-SERVICE REFORM IN THE UNITED STATES:A. D. 1897-1899.

Temporary check in New York.
Governor Black's law.
Restoration of the merit system under Governor Roosevelt.

"In June [1897]—after the Court of Appeals … had declared that

the constitutional amendment was self-executing, and that
appointments made without competitive examination, where
competitive examinations were practicable, must be held to be
illegal—steps were taken to secure a reduction of the exempt
and non-competitive positions in the State Service. A letter
was addressed to Governor Morton, by the officers of the
Association, on June 8, asking that the service be
reclassified, on a basis competitive as far as practicable.
The Governor replied that he had already given the subject
some thought, and that he would be glad to give our
suggestions careful consideration. On the 4th of August he
instructed the Civil Service Commission to prepare such a
revision of the rules and classification as had been proposed.
On the 11th of November this revision, prepared by
Commissioner Burt, was adopted by the full Commission, and on
the 9th of December the new rules were formally promulgated by
the Governor and placed in immediate operation. … The
Governor, earlier in the year, had reversed his action in the
case of inspectors and other employees of the new Excise
Department, by transferring them from the non-competitive to
the competitive class. … This marked the beginning of a
vigorous movement against the competitive system led by
 chairmen of district committees, and other machine
functionaries.
{147}
Governor Morton's sweeping order of December completed the
discomfiture of these people and strengthened their purpose to
make a final desperate effort to break the system down. The
new Governor, of whom little had been known prior to his
unexpected nomination in September, proved to be in full
sympathy with their plan. In his message to the legislature,
Mr. Black, in a paragraph devoted to 'Civil Service,' referred
to the system built up by his predecessor in contemptuous
language, and declared that, in his judgment, 'Civil service
would work better with less starch.' He recommended
legislation that would render the examinations 'more
practical,' and that would permit appointing officers to
select from the whole number on an eligible list and not
confine them to selections 'from among those graded highest.'
Such legislation, he promised; would 'meet with prompt
executive approval.' Each house of the legislature referred
this part of the message to its Judiciary Committee, with
instructions to report a bill embodying the Governor's ideas.
… Within a few days of the close of the legislative session,
the measure currently described as 'Governor Black's bill was
Introduced. … The bill provided that in all examinations for
the State, county or municipal service, not more than 50 per
cent. might be given for 'merit,' to be determined by the
Examining Boards, and that the rest of the rating,
representing 'fitness,' was to be given by the appointing
officer, or by some person or persons designated by him. All
existing eligible lists were to be abolished in 30 days, and
the new scheme was to go into operation at once. … A hearing
was given by the Senate Committee on the following day, and
one by the Assembly Committee a few days later. … The bill,
with some amendments, was passed In the Senate, under
suspension of the rules, and as a party measure. … It was
passed in the Assembly also as a caucus measure."
 Report of the Executive Committee of the
New York Civil Service Reform Association, 1897.

"Early [in 1898] after time had been allowed for the act to
prove its capabilities in practice, steps were taken toward
commencing a suit to test its constitutionality in the courts.
… Pending the bringing of a test suit, a bill was prepared for
the Association and introduced in the Legislature on March
16th, last, one of the features of which was the repeal of the
unsatisfactory law. … The bill … was passed by the Senate on
March 29th. On the 31st, the last day of the session, it was
passed by the Assembly. … On the same date it was signed by
the Governor and became a law. This act has the effect of
exempting the cities from the operation of the act of 1897,
restoring the former competitive system in each of them."

Report of the Executive Committee of the

New York Civil Service Reform Association, 1898.

"As a result of the confusing legislation of [1897 and 1898]

at least four systems of widely differing character had come
into existence by the first of [1899]. New York city had its
charter rules, … the state departments were conducted under
two adaptations of the Black law, and in the smaller cities
the plan of the original law of 1883 was followed. In his
first annual message, Governor Roosevelt directed the
attention of the Legislature to this anomalous condition and
strongly urged the passage of an act repealing the Black law
and establishing a uniform system, for the state and cities
alike, subject to state control. Such an act was prepared with
the co-operation of a special committee of the Association. …
After some discussion it was determined to recast the measure,
adopting a form amounting to a codification of all previously
existing statutes, and less strict in certain of its general
provisions. … The bill was … passed by the Senate by a
majority of two. … In the Assembly it was passed with slight
amendments. … On the … 19th of April the act was signed by the
 Governor, and went into immediate effect. … The passage of
this law will necessitate the complete recasting of the civil
service system in New York, on radically different lines."

CIVIL-SERVICE REFORM IN THE UNITED STATES: A. D. 1899.

Modification of Civil Service Rules by President McKinley.
Severe criticism of the order by the National Civil
Service Reform League.

On the 29th of May, 1899, President McKinley was persuaded to

issue an order greatly modifying the civil service rules,
releasing many offices from their operation and permitting
numerous transfers in the service on a non-competitive
examination. This presidential order was criticised with
severity in a statement promptly issued by the Executive
Committee of the National Civil Service Reform League, which
says: "The National Civil Service Reform League, after mature
consideration, regards the order of President McKinley, of May
29, changing the Civil Service rules, as a backward step of
the most pronounced character. The order follows a long
succession of violations, of both the spirit and the literal
terms of the law and rules, in various branches of the
service, and must be considered in its relations to these. Its
immediate effects, which have been understated, may be set
forth as follows:

(1) It withdraws from the classified service not merely 3,000

or 4,000 offices and positions, but, as nearly as can be now
estimated, 10,109. It removes 3,693 from the class of
positions filled hitherto either through competitive
examination or through an orderly practice of promotion, and
it transfers 6,416 other positions in the War Department,
filled hitherto through a competitive registration system,
under the control of the Civil Service Commission, to a system
to be devised and placed in effect by the present Secretary of
War.
 (2) It declares regular at least one thousand additional
appointments made temporarily, without examination—in many
cases in direct disregard of the law—in branches that are not
affected by the exceptions, but that remain nominally
competitive.

(3) It permits the permanent appointment of persons employed

without examination, for emergency purposes during the course
of war with Spain, thus furnishing a standing list of many
thousands which positions in the War Department may be filled,
without tests of fitness, for a long time to come.

(4) It alters the rules to the effect that in future any

person appointed with or without competitive examination, or
without any examination, may be placed by transfer in any
classified position without regard to the character or
similarity of the employments interchanged, and after
non-competitive examination only.

{148}

(5) It permits the reinstatement, within the discretion of the

respective department officers, of persons separated from the
service at any previous time for any stated reason.

The effect of these changes in the body of the rules will be

of a more serious nature than that of the absolute exceptions
made. It will be practicable to fill competitive positions of
every description either through arbitrary reinstatement—or
through original appointment to a lower grade, or to an
excepted position without tests of any sort, or even by
transfer from the great emergency force of the War Department,
to be followed in any such case by a mere 'pass' examination.
As general experience has proven, the 'pass' examinations, in
the course of time, degenerate almost invariably into farce.
It will be practicable also to restore to the service at the
incoming of each new administration those dismissed for any
cause during the period of any administration preceding. That
such a practice will lead to wholesale political reprisals,
and, coupled with the other provisions referred to, to the
re-establishment on a large scale of the spoils system of
rotation and favoritism, cannot be doubted."

In his next succeeding annual Message to Congress the

President used the following language on the subject: "The
Executive order [by President Cleveland] of May 6, 1896,
extending the limits of the classified service, brought within
the operation of the civil-service law and rules nearly all of
the executive civil service not previously classified. Some of
the inclusions were found wholly illogical and unsuited to the
work of the several Departments. The application of the rules to
many of the places so included was found to result in friction
and embarrassment. After long and very careful consideration
it became evident to the heads of the Departments, responsible
for their efficiency, that in order to remove these
difficulties and promote an efficient and harmonious
administration certain amendments were necessary. These
amendments were promulgated by me in Executive order dated May
29, 1899. All of the amendments had for their main object a
more efficient and satisfactory administration of the system
of appointments established by the civil-service law. The
results attained show that under their operation the public
service has improved and that the civil-service system is
relieved of many objectionable features which heretofore
subjected it to just criticism and the administrative officers
to the charge of unbusinesslike methods in the conduct of
public affairs. It is believed that the merit system has been
greatly strengthened and its permanence assured."

United States, Message and Documents

(Abridgment), 1890-1900, volume 1.

At its next annual meeting, December 14, 1900, in New York,

the National Civil Service Reform League reiterated its
 condemnation of the order of President McKinley, declaring:
"The year has shown that the step remains as unjustified in
principle as ever and that it has produced, in practical
result, just the injuries to the service that were feared, as
the reports of our committee of various branches of the
service have proved. The league, therefore, asserts without
hesitancy that the restoration of very nearly all places in
every branch of the service exempted from classification by
this deplorable order is demanded by the public interest and
that the order itself should be substantially revoked."

CIVIL-SERVICE REFORM IN THE UNITED STATES: A. D. 1900.

Civil Service Rules in the Philippine Islands.

"An Act for the establishment and maintenance of an efficient

and honest civil service in the Philippine Islands" was
adopted, on the 19th of September, by the Commission which now
administers the civil government of those islands. The bill is
founded on the principles of the American civil service in
their stricter construction, and its provisions extend to all
the executive branches of the government. The framing of rules
and regulations for the service are left to the Civil Service
Board provided for in the act. A correspondent of the "New
York Tribune," writing from Manila on the day after the
enactment, states: "W. Leon Pepperman, who has long been
connected with the civil service in the United States, and who
has made a personal study of the systems maintained by Great
Britain, France, and Holland in their Eastern colonies, will
be on this board, as will be F. W. Kiggins of the Washington
Civil Service Commission. The third member probably will be a
Filipino. President Taft had selected for this post Dr.
Joaquin Gonzalez, an able man, but that gentleman's untimely
death on the eve of his appointment has forced President Taft
to find another native capable of meeting the necessary
requirements. Mr. Kiggins probably will act as Chief Examiner,
and Mr. Pepperman as Chairman of the board:" According to the
same correspondent: " Examinations for admittance to the
 service will be held in Manila, Iloilo, and Cebu, in the
Philippines, and in the United States under the auspices and
control of the Federal Civil Service Commission." At the
annual meeting of the National Civil Service Reform League of
the United States held in New York, December 13, 1900, the
above measure was commended highly in the report of a special
committee appointed to consider the subject of the civil
service in our new dependencies, as being one by which, "if it
be persevered in, the merit system will be established in the
islands of that archipelago, at least as thoroughly and
consistently as in any department of government, Federal,
State or municipal, in the Union. This must be, in any case,
regarded as a gratifying recognition of sound principles of
administration on the part of the commission and justifies the
hope that, within the limits of their jurisdiction at least,
no repetition of the scandals of post-bellum days will be
tolerated. The ruling of the several departments that the
provisions of the Federal offices established in the
dependencies which would be classified if within the United
States is also a matter to be noted with satisfaction by the
friends of good government."

{149}

CIVIL-SERVICE REFORM IN THE UNITED STATES: A. D. 1901.

The "spoils system" of service in the House of Representatives.

The "spoils system" maintained by Congressmen among their own

immediate employees, in the service of the House of
Representatives, was depicted in a report, submitted February
28, 1901, by a special committee which had been appointed to
investigate the pay of the House employees. The report,
presented by Mr. Moody, of Massachusetts, makes the following
general statements, with abundance of illustrative instances,
few of which can be given here: "The four officers elected by
the House, namely, the Clerk, Sergeant-at-Arms, Doorkeeper,
and Postmaster, appoint the employees of the House, except the
clerks and assistant clerks of members and committees, four
elevator men, the stenographers, and those appointed by House
resolutions. The appointments, however, are made on the
recommendation of members of the House, and very largely,
though not entirely, of members of the dominant party in the
House. If a member upon whose recommendation an appointment is
made desires the removal of his appointee and the substitution
of another person, the removal and substitution are made without
regard to the capacity of either person. In case a member upon
whose recommendation an appointment has been made ceases to be
a member of the House, an employee recommended by him
ordinarily loses his place. Thus the officers of the House,
though responsible for the character of the service rendered
by the employees, have in reality little or no voice in their
selection, and, as might reasonably be expected, the results
obtained from the system which we have described are in some
cases extremely unsatisfactory. This method of appointing
House employees has existed for many years, during which the
House has been under the control of each party alternately. We
believe that candor compels us to state at the outset that
some of the faults in administration which we have observed
are attributable to the system and to the persistence of
members of the House in urging upon the officers the
appointment of their constituents and friends to subordinate
places, and that such faults are deeply rooted, of long
standing, and likely to continue under the administration of
any political party as long as such a system is maintained."

The committee found nothing to criticise in the

administration of the offices of the House Postmaster or
Sergeant-at-Arms. With reference to the offices of the Clerk
and the Doorkeeper they say: "We have found in both
departments certain abuses, which may be grouped under three
heads, namely: Transfers of employees from the duties of the
positions to which they were appointed to other duties,
unjustifiable payments of compensation to employees while
absent from their posts of duty, and divisions of salary.
"First. Transfers of employees from the duties to which they
were appointed to other duties.—Some part of this evil is
doubtless attributable to the fact that the annual
appropriation acts have not properly provided for the
necessities of the House service. An illustration of this is
furnished by the case of Guy Underwood, who is carried on the
rolls as a laborer at $720 per annum, while in point of fact
he performs the duty of assistant in the Hall Library of the
House and his compensation is usually increased to $1,800 per
annum by an appropriation of $1,080 in the general deficiency
act. Again, a sufficient number of messengers has not been
provided for the actual necessities of the service, while more
folders have been provided than are required. As a result of
this men have been transferred from the duties of a folder to
those of a messenger, and the compensation of some has been
increased by appropriation in deficiency acts. But evils of
another class result from transfers, some examples of which we
report. They result in part, at least, from an attempt to
adjust salaries so as to satisfy the members that their
appointees obtain a just share of the whole appropriation,
instead of attempting to apportion the compensation to the
merits of the respective employees and the character of the
services which they render. …

"Second. Payments of compensation to employees while

absent.—The duty of many of the employees of the House ceases
with the end of a session, or very soon thereafter. Such is
the case with the reading clerks, messengers, enrolling
clerks, and many others who might be named. Their absence from
Washington after a session of Congress closes and their duties
are finished is as legitimate as the absence of the members
themselves. But many employees who should be at their posts
have been from time to time absent without justification, both
during sessions and between sessions. In the absence of any
record it is impossible for the committee to ascertain with
anything like accuracy the amount of absenteeism, but in our