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G S y
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Editors
Robert B. Lim, MD, FACS, FASMBS
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Daniel B. Jones, MD, MS, FACS

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N Y Ch S F L L M M C y
N D h S J S S p Sy y
Copyright © 2017 by McGraw-Hill Education. All rights reserved. Except as permitted under the United States Copyright
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T is book is dedicated to my amazing wi e, Lisa. She has given
me the strength and grace to pursue a project like this.
—RBL

And to my better hal , Stephanie.

—DBJ
This page intentionally left blank
 Contents

Co n t r ibu t o r s 8. A v Lp py—S I
In t r o d u c t io n h R S y
Jigesh A. Shah and Omar Yuse Kudsi
Pr e a c e
Page 28
Ac k n o wl ed g emen t s v
Ethical and Legal Issues 33
Section 1: General Surgery Section Editor: Robert B. Lim
Anesthesia and OR Concerns 3 9. E h /L I —D M
Section Editor: Robert B. Lim Steve Alcazar and Shawn suda
1. S p Ap Page 35
Ashley D. Willoughby 10. E L C
Page 5 Jenny Lam and Shawn suda
2. M Hyp Page 37
Harry . Aubin Skin and So issue 39
Page 8 Section Editor: Richard Smith
3. F U S E y 11. S C
—F D p A yB p y Jigesh A. Shah and Omar Yuse Kudsi
Paul Wetstein Page 41
Page 11
12. D U
4. A G E Pamela C. Masella and
Roger Eduardo Mark K. Markarian
Page 13 Page 44
Advances in Laparoscopy 17 13. M
Section Editor: Robert B. Lim Amber E. Ritenour and Lauren Greer
5. FLS—A P Page 47
Megan Bowen
14. S Ly ph
Page 19
Joshua S. Ritenour
6. A v Lp py NO ES Page 50
Mark A. Gromski and Kai Matthes
15. h S y—L
Page 21
C —C h
7. R -A S y Ashra A. Sabe
Brenda Schmidt and Gordon Wisbach Page 55
Page 25

vii
vi i i Co n t e n t s

Abdominal Wall, Abdomen, and 28. M U

Gastrointestinal ract 59 Richard M. Peterson
Section Editors: Robert B. Lim, Ronald A. Page 100
Gagliano, Jr., and Richard Smith
29. B S y—Byp —A
16. A W R P
erri L. Carlson Richard M. Peterson
Page 61 Page 103
17. H —U /V hC h 30. S v G yL
Richard M. Peterson Alec C. Beekley
Page 64 Page 106
18. A y p I H 31. B p Dv W hD
Lorenzo Anes-Bustillos S h M O y
Page 67 Matthew J. Martin
19. F H Page 109
Harry . Aubin 32. B S y—
Page 71 N C p
20. I N Marcos Molina
Harry . Aubin and Eric Balent Page 115
Page 73 33. R v B S y
21. H P ph H Hussna Wakily
Steven M. Henriques Page 117
Page 77 34. A j G B C p
22. A h Ashley D. Willoughby
Mary . O’Donnell and E. Matthew Ritter Page 120
Page 79
35. G M
23. G C Douglas Farmer
Brian J. Pottor and Farah A. Husain Page 123
Page 82
36. B yC
24. G S Alexander Malloy
William Cole Page 127
Page 86
37. B y —Ch
25. G Ly ph Harry . Aubin
Cletus A. Arciero Page 130
Page 89
38. Ch y P y
26. G ph R D Alan P. Gehrich
Mary . O’Donnell and E. Matthew Ritter Page 133
Page 94
39. L v M
27. P P p U D Kevin M. Lin-Hurtubise and Robert L. She er
Henry Lin Page 137
Page 98
 Co n t e n t s ix

40. L v C h 52. C ,R , A —R C
Richard Smith Ronald A. Gagliano, Jr.
Page 140 Page 183
41. P P Cy 53. P A
Kiran Lagisetty Alexander Malloy
Page 144 Page 186
42. H P M Breast Disease 189
Richard Smith Section Editor: Richard Smith
Page 146 54. B M
43. Sp /I p h h y p Anita Mamtani
P p Page 191
Ali Linsk and John Paul Sanders
55. D C S
Page 150 Angela Penn
44. S B O Page 195
Patrick Golden
56. I yB C
Page 153 Ranjna Sharma
45. I D -I A P Page 199
Bonnie B. Hunt
57. B R
Page 156 Pamela C. Masella and
46. C Mark K. Markarian
Christopher Yheulon Page 202
Page 160 Endocrine Surgery/Head and Neck
47. M I h umors 207
Danielle E. Ca asso Section Editors: Robert B. Lim and Richard Smith
Page 163 58. A G
48. App Yong Choi
Erik Criman Page 209
Page 167 59. Hyp p hy
49. C C Richard K. Inae
Robert B. Lim Page 212
Page 171 60. hy D
50. C h ’ D Richard K. Inae
Andrew . Schlussel Page 215
Page 176 61. P E
51. D v Jigesh A. Shah and
Erik Roedel Omar Yuse Kudsi
Page 179 Page 217
x Co n t e n t s

62. S v y G 72. O h - —P v F
Maxwell Sirkin and William J. Jordan
William V. Rice Page 262
Page 221
73. H I j
Pediatric Surgery 225 Ahmed B. Bayoumi, Fares Nigim, and
Section Editor: Mary J. Edwards Ekkehard M. Kasper
63. H N P Page 265
Margaret E. Clark 74. N y—Hyp /
Page 227 Hyp
Albert Jesse Schuette
64. Py S
Margaret E. Clark Page 279
Page 232 75. Oph h y
Morohunranti O. Oguntoye and
65. H h p ’D
Robert A. Mazzoli
Mary J. Edwards
Page 282
Page 236
76. h
66. O ph /G h
Booker . King
Paul Wetstein
Page 288
Page 239
77. S p M -O F
rauma Surgery and Critical Care 243
Robert Shawhan, Matthew Eckert, and
Section Editor: Matthew J. Martin
Matthew J. Martin
67. C C —R Page 291
B
Matthew Eckert and Matthew J. Martin 78. M j B S I h
ovy Haber Kamine, Stephen R. Odom, and
Page 245
Booker . King
68. K W Page 297
Laura Mazer
79. S N
Page 249
Julia B. Greer
69. P —M p G h Page 301
W
Erik Criman and Matthew J. Martin 80. B P
Stephen R. Odom
Page 252
Page 304
70. C v Sp C
Matthew R. Fusco, Ajith J. T omas, and 81. N z F
Christopher S. Ogilvy Allyson L. Berglund and John M. Giurini
Page 256 Page 308

71. M E v I 82. G y
P Peter L. Steinberg
Matthew R. Fusco, Ajith J. T omas, and Page 312
Christopher S. Ogilvy
Page 259
 Co n t e n t s xi

83. F y 93. Ov M
Katherine Carlisle Charles S. Dietrich III and
Page 314 Brad ord P. Whitcomb
Page 353
Section 2: Surgical Subspecialties
94. E p P y
ransplantation Surgery 319 Charles S. Dietrich III and
Section Editor: Ronald A. Gagliano, Jr. Brad ord P. Whitcomb
84. p S y—K y Page 358
Joy Sarkar 95. P v I yD
Page 321 Alan P. Gehrich
85. p S y—L v Page 362
Joy Sarkar 96. E
Page 324 Alan P. Gehrich
Vascular Surgery 327 Page 366
Section Editor: Dwight C. Kellicut Neurosurgery 369
86. C O Section Editor: Matthew J. Martin
ony Katras 97. B P /S
Page 329 Albert Schuette
87. A A A y Page 371
Dwight C. Kellicut Orthopedic Surgery 375
Page 331 Section Editor: Matthew J. Martin
88. V A 98. C F
Booker . King Justin . Fowler and Justin Robbins
Page 334 Page 377
89. C p H y 99. Sh
Alexander Malloy Kelly G. Kilcoyne
Page 337 Page 380
90. Ly ph D 100. P M
Robert C. McMurray Kelly G. Kilcoyne
Page 340 Page 383
91. V S D 101. K I j
John illou Jeremy McCallum and Douglas Rowles
Page 343 Page 386
92. h O Sy Urology 393
Courtney E. Barrows Section Editor: Joseph R. Sterbis
Page 347
102. N ph h
Gynecology and Obstetrics 351 Peter L. Steinberg
Section Editor: Alan P. Gehrich Page 395
xii Co n t e n t s

103. B C 106. U I j y
Joseph R. Sterbis Raf aella DeRosa and Joseph R. Sterbis
Page 397 Page 405
104. R 107. P C
Joseph R. Sterbis Joseph R. Sterbis
Page 399 Page 408
105. L p
Joseph R. Sterbis Index 411
Page 402
 Contributors

Steve Alcazar Alec C. Beekley, MD, FACS

U v y N v Sh M A P S y
R ,N v Dv A C S y
Dv B S y
Lorenzo Anes-Bustillos, MD S yK M C T J
P S yF U v y
B Ch ’H p Ph ph , P yv
B ,M h
Allyson L. Berglund, DPM
Cletus A. Arciero, MD, FACS P S
A P S y D p P S y
P D ,B S O yF hp H v V M A ,A
Dv S O y H v M Sh
E yU v yS h M B ,M h
A ,G
Megan Bowen, DO
Harry . Aubin, MD A P
G S yR S y, U H hS v U v y
p A yM C Dv G S y
H ,H S A M yM C
S A ,
Eric Balent, MD
R ,G S y Danielle E. Ca asso, DO, MPH
D p G S y F
p A yM C Dv V E v S y
H ,H N Y -P y H p
W C M
Courtney E. Barrows, MD C U v yM C
G S yR N Y ,N Y
B hI D M C
H v M Sh Katherine Carlisle, MD
B ,M h R Phy ,U y
D p U y
Ahmed B. Bayoumi, MD, MSc p A yM C
Dv N y H ,H
D p S y
B hI D M C
H v M Sh
B ,M h

xiii
xiv Co n t r i b u t o r s

erri L. Carlson, DO Roger Eduardo, MD

R PGY5 R
p A yM C D p S y
D p S y B hI D M C
H ,H H v U v yS h M
B ,M h
Yong Choi, MD, FACS, FASMBS
A P S y Mary J. Edwards, MD
U S v U v y h H hS Ch , P S y
Ch , M yI v v B S y p A yM C
A ,G H ,H

Margaret E. Clark, MD Douglas Farmer, MD, MS

G S yR R
p A yM C G S y, p A y M C
H ,H H ,H

William Cole, MD Justin . Fowler, MD

S R O h p S
G S yD p M A yM C
p A yM C O h p S yS v
H ,H ,W h

Erik Criman, MD Matthew R. Fusco, MD

R Phy ,G S y A P ,N S y
D p S y V U v yM C
p A yM C N hv ,
H ,H
Ronald A. Gagliano, Jr., MD, FASCRS, FACS
Ra aella DeRosa, MD A P S y
U yR C h U v yS h M
p A yM C Ch ,D p S y
H ,H D yH h M G pA z
Ph ,A z
Charles S. Dietrich III, MD
P D , OBGYN R y Alan P. Gehrich, MD, COL, MC
Gy O yS v Ch , F P v M R v
p A yM C S y
H ,H A Ch , D p O /Gy
p A yM C
Matthew Eckert, MD H ,H
A S A P
M A yM C U S v U v y h H hS
,W h W h , DC
 Co n t r i b u t o r s xv

John M. Giurini, DPM Richard K. Inae, MD, FACS, MC, FSs

A P S y G S y
H v M Sh Ch W A yC yH p
Dv P S y F S ,G
D p S yB h I D M
C William J. Jordan, MD
B ,M h S S
S R O h p Sp M
Patrick Golden, DO T W ,
S S
B h A yC yH p ovy Haber Kamine, MD
F C p ,K y Ch R
D p S y
Julia B. Greer, MD, MPH B hI D M C
A P ,M B ,M h
D p M
Dv G y, H p y Ekkehard M. Kasper, MD
N Dv N y, D p S y
U v y P hS h M P h B hI D M C
P h, P yv H v M Sh
B ,M h
Lauren Greer, MD
S S ony Katras, MD, RV , FACS, COL, MC, USAR
p A yM C S V S yC
H ,H p AMC C P S y USUHS
D
Mark A. Gromski, MD USUHS M S S yC hpS
C F V S
G y A v E py S C H p
Dv G y H p y H ,H
I U v yS h M
I p ,I Dwight C. Kellicut, MD, FACS
A P
U S v U v y h H hS
Steven M. Henriques, MD
D p S y
G M yI v v S y
p A yM C
M D S G p
H ,H
M ,F

Kelly G. Kilcoyne, MD
Bonnie B. Hunt, DO A P S y
S yR U S v U v y h H hS
p A yM C D p O h p S y
H ,H W B A yM C
E P ,
Farah A. Husain, MD, FACS, FASMBS
A P ,S y Booker . King, MD, COL, MC
Dv B S v D US A y B C
O H h S U v y US A y I S R h
P ,O F S H ,
xvi Co n t r i b u t o r s

Omar Yuse Kudsi, MD, MBA, FACS Anita Mamtani, MD

A P S y S R S y
f U v yS h M D p S y
B ,M h B hI D M C
H v M Sh
Jenny Lam, MD B ,M h
G S yR
U v y C Mark K. Markarian, MD, MSPH
S D ,C Dv P S y
B ,M h
Kiran Lagisetty, MD
R Matthew J. Martin, MD, FACS, FASMBS
B hI D M C A P S y
B ,M h U S v U v y h H hS
D p S y
Henry Lin, MD, FACS M A yM C
A P J B L -M Ch
U S v U v y h H hS W h
C p ,M C p ,U S N vy
D p H G S y U y Pamela C. Masella, DO
N v H p C pL J p A yM C
C pL J ,N h C H ,H

Kevin M. Lin-Hurtubise, MD, FACS, MAJ, MC, Kai Matthes, MD, PhD
USAR A P A h
Ch , I Rv B , PRMC H v M Sh
A C P S y, J h A. B A j S ,B Ch ’H p
Sh M (JABSOM) B ,M h
S S O P v P A h
D p S y AMGI M , H
p A yM C
H ,H Laura Mazer, MD, MS
S E F
Ali Linsk, MD D p S y
G S yR S U v y
D p S y S ,C
B hI D M C
B ,M h Robert A. Mazzoli, MD, FACS, COL(Ret), MC
D ,E , ,S ,
Alexander Malloy, DO R
S R D D-VA V C E
G S y Oph h P ,R v, O
p A yM C S y
H ,H A P Oph h y
U S v U v y h H hS
(USUHS)
M A yM C
,W h
 Co n t r i b u t o r s xvii

Jeremy McCallum, MD, CP , MC Angela Penn, MD, FACS

D p S y, O h p D p S y
p A yM C p A yM C
H ,H H ,H

Robert C. McMurray, MD, CP Richard M. Peterson, MD, MPH, FACS, FASMBS

D p G S y A P ,S y
p A yM C Dv M yI v v G S y
H ,H U v y H hS C S A
S A ,
Marcos Molina, MD
R Brian J. Pottor , MD
B hI D M C G S
B ,M h C H h Phy G p
C ,C
Fares Nigim, MD
Dv N y, D p S y William V. Rice, MD
B hI D M C A P D ,G S yR y
H v M Sh W B A yM C
B ,M h A P S y
P LF Sh M
Mary . O’Donnell, MD E P ,
Ch R ,G S A P S y
ACS AEI E F U S v U v y h H hS
USUHS h F B h ,M y
W R N M yM C
B h ,M y Amber E. Ritenour, MD, FACS
G S y
Stephen R. Odom, MD p A yM C
A P S y H ,H
D p S y
B hI D M C Joshua S. Ritenour, MD, FACS
B ,M h G S y
p A yM C
Christopher S. Ogilvy, MD H ,H
P ,N y
B hI D M C E. Matthew Ritter, MD, FACS
H v M Sh A P S y
B ,M h V Ch ,E
P D
Morohunranti O. Oguntoye, MD N Cp C G S yR y
C p h v Oph h P D
D p Oph h y ACS A S E /S
M A yM C F hp
,W h T D p S y U S v
U v y h H hS h W R
N M yM C
B h ,M y
xvi i i Co n t r i b u t o r s

Justin Robbins, MD Jigesh A. Shah, DO

O h p S C A ,S y
M A yM C D p S y
O h p S yS v S .E z h’ M C
,W h f U v yS h M
B ,M h
Erik Roedel, MD
A S Ranjna Sharma, MD, FACS
p A yM C I S y
H ,H H v M Sh
Dv S O y
Douglas Rowles, MD, CDR B hI D M C
D p S y, O h p B ,M h
p A yM C
H ,H Robert Shawhan, MD
S yR
Ashra A. Sabe, MD M A yM C
B hI D M C ,W h
B ,M h
Robert L. Shef er, MD, COL, MC
John Paul Sanders, MD D p y IRB Ch
C RD A yM C C C F y, I M R y
F H , S M O ,D p M
A P S y p A yM C
U S v U v y h H hS H ,H
B h ,M y
Maxwell Sirkin, MD
Joy Sarkar, MD G S yR , PGY4
R S D p G S y
D p G S y W B A yM C
p A yM C E P ,
H ,H
Richard Smith, MD, FACS
Andrew . Schlussel, DO A P ,S y
D p G S y D p G S y
M A yM C U v y H
,W h H ,H

Brenda Schmidt, MD Peter L. Steinberg, MD

D p G S y U ,B h I D M C
N v M C S D A P (S y)
S D ,C H v M Sh
B ,M h
Albert Jesse Schuette, MD, FAANS
N y Ch I v Joseph R. Sterbis, MD
N y P D ,U yR y
W R N M yM C p A yM C
B h ,M y H ,H
 Co n t r i b u t o r s xix

Ajith J. T omas, MD Brad ord P. Whitcomb, MD

A P ,N y Ch
B hI D M C Gy O yS v
H v M Sh p A yM C
B ,M h H ,H

John illou, MD Ashley D. Willoughby, DO

G S yR D p G S y
D p S y p A yM C
B hI D M C /H v H ,H
M Sh
B ,M h Gordon Wisbach, MD, MBA, FACS
A P S y
Mike ran, MD U S v U v y h H hS
S yR F. E H Sh M
B hI D M C B h ,M y
H v M Sh D p G S y
B ,M h N v M C S D
S D ,C
Shawn suda, MD, FACS
A P S y Christopher Yheulon, MD
Ch , D v M yI v v B A P ,S y
S y U S v U v y H hS
U v y N v Sh M B h ,M y
L V ,N v D p S y
p A yM C
Hussna Wakily, MD H ,H
S S
L H M S H p
N Y ,N Y

Paul Wetstein, MD
S yR
p A yM C
H ,H
This page intentionally left blank
 Introduction

A y H h H T .I y .
y y ABSI E - I y h p .I
?T v p p h h q / .T
. y p
T v p hp .
h p p y j . R h , h
R v y p , .I ,y y
h q .T v h p .I j y
h h h h h v h h h y h .
p h p. T h P j y h v .
h p h h
y y p h Daniel B. Jones, MD
.

xxi
This page intentionally left blank
 Pre ace

I v yh h .T B h q G
I v v p y S h q
p h h h y. F h
.I ’ h I ’ v h q ,h h h v -
h p h - y h .T v -
p I h h v h p p h
p y h - h B C h p
.A I p ,I z h p .W h h , h y y
y h h h y
p .T p v .
p v
. Robert B. Lim, MD

xxiii
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 Acknowledgements

T E P h h h v h p v
v h p p :

Chris Barrett, MD
William Cole, MD
James Greenwood
ovy Haber Kamine, MD
Brian Nguyen, MD
Erik Roedel, MD

W z Mike ran, MD h .

xxv
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 SECTION 1

General Surgery
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Anest h esia a nd OR Co nc er ns
Robert B. Lim
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 1
Sleep Apnea

A l y D. W ll ug by

A 54-year-old male presents to his perioperative D. T e critical closing pressure o this patient’s
appointment to undergo elective inguinal hernia repair. airway is higher than non-OSA patients.
T e patient has a BMI o 38 with a height o 72 in E. T e patient should be placed in the rendelen-
(1.83 m) and a weight o 127 kg (280 lb). He has a his- burg position.
tory o hypertension currently being managed with a
calcium channel blocker. His wi e reports increasing 3. W p lb yw g b
snoring at night with noticeable gasps or air when lying JD R b f mul ?
supine. Patient denies increasing daytime drowsiness. A. 75 kg
He has no history o prior surgeries and no amily his- B. 98 kg
tory o complications with anesthesia. C. 64 kg
On physical exam, he has a neck circum erence o D. 106 kg
44 cm and a Mallampati score o 3. No cardiovascular or E. 86 kg
respiratory abnormalities are observed. His abdomen is
obese with no evidence o caput medusa. Right inguinal 4. W f f ll w g w ul b b p
ring weakness palpated on exam. f p ly g p ?
A. Vecuronium
1. W f f ll w g NOT f B. Cistracurium
b y yp v l y m (OHS)? C. Rocuronium
A. Obesity (BMI > 30 Kg/m 2) D. Pancuronium
B. Neck circum erence o > 48 cm E. Atracurium
C. Daytime hypoventilation
D. Hypercapnia with PaCO2 > 45 mm Hg 5. W f f ll w g u g g p -
E. Hypoxia with PaO2 < 70 mm Hg p v m gm p w up OSA?
A. T e patient should be placed in the supine position
2. W f f ll w g u g g OSA while recovering to protect the surgical site.
p p v p v v lu B. CPAP should be immediately available or use
m g m f p ? in postoperative patients with known or sus-
A. T is patient has 2 out o 3 risk actors or OSA and pected OSA.
there ore does not require polysomnography. C. Opioid dosing should be based on BW rather
B. Face mask pre-oxygenation will create a higher than IBW.
tidal volume than nasal prongs. D. T e use o thoracic epidural post-operatively is
C. T e Mallampati score o 3 is not a risk or a contraindicated in OSA patients.
di cult intubation. E. Use o CPAP post-operatively could increase the
risk o complications.
6 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
ANSWERS
1. B. Patients with a neck circum erence o > 48 cm
have a high probability o developing obstructive sleep
apnea (OSA); however it is not a criterion or OHS.
OHS results in hypoventilation and hypoxemia due to
the obesity, while OSA is the blockage o airway that
occurs during sleep. Many obese patients have both.
Patients with OHS are at a higher risk or periopera-
tive morbidity and mortality. T ese patients are at a
higher risk o airway collapse, blunted central respira-
tory stimulation, and pulmonary hypertension there-
ore placing these patients at a higher surgical risk.
Criteria or OHS:
a. Obesity (BMI > 30 kg/m 2)
b. Serum bicarbonate > 27 mEq/L
c. SpO2< 93%
d. ABG demonstrating hypercapnia PaCO 2
> 45 mm Hg and hypoxemia PaO2 < 70 mm Hg
e. An alternative cause o hypoventilation cannot
be identi ed
2. D. I the surgery is elective, is likely to require large
doses o anesthetic agent or opioids intraoperatively,
and i there is a high suspicion o undiagnosed OSA
in the perioperative period, it should be postponed
with imminent evaluation and treatment as needed
preoperatively. Evidence has shown that pre-oxygen-
ation via nasal CPAP mask is superior to ace mask
oxygenation, despite potential air leaks i the mouth is
allowed to be open. Nasal CPAP increases the pressure
CLASS 1 CLAS S 2
MALLAMPATI CLASS IFICATION
CLASS 1: Soft palate , fa uce s , uvula, pilla rs
CLASS 2: Soft palate , fa uce s , portion of uvula
CLASS 3: Soft palate , bas e of uvula
CLASS 4: Hard pala te only
gradient between the nasopharyngeal and oropharyn-
geal cavities pushing the so palate and tongue orward
and there ore opening the airway; whereas the positive
pressure through the ace mask will induce an obstruc-
tion. Mallampati score o 3 includes visualization o the
so palate and base o uvula. Mallampati scores o
3 and 4 demonstrate di culty intubation; however
they cannot predict di culty o BVM ventilation.
T e upstream pressure o the pharynx at which air
entry/ ow ceases is considered the critical closing pres-
sure. T is pressure can be increased by increase in lateral
pillar at pads compressing the airway, sleep resulting in
muscle relaxation or induced by anesthesia. T e ideal
positioning or a patient with OSA is the ramped posi-
tion o intubation or the lateral recumbent, i possible
and in reverse rendelenburg position to ease ventila-
tion, increase total lung capacity, and decrease the lon-
gitudinal tension on the upper airway.
3. A. JD Robinson ormula states:
Man: 52 Kg (115 lbs) + 1.9 Kg (4.2 lbs) per inch
over 60 in;
Woman: 49 Kg (108 lbs) + 1.7 Kg (3.7 lbs) per
inch over 60 in.
T is calculation is use ul in this patient to deter-
mine optimal paralytic, anesthetic, and opioid dosing
as well as mechanical ventilation control intraopera-
tively and post-operatively as needed.
4. C. All non-depolarizing neuromuscular blockers
act by antagonizing the acetylcholine receptor in a
CLASS 3 CLASS 4

reversible/competitive manor. A rapid onset, short
acting non-depolarizing agent would be the best
option in this patient. Out o the options listed Rocu-
ronium has an onset o 45 to 60 sec and duration o
30 to 60 min and would be the most ideal. Also obe-
sity has not been ound to alter the pharmacokinetics
o Rocuronium and there ore can be dosed on IBW
or actual body weight. Pancuronium is the longest
acting and is used in patients that require paralysis
> 1 hr and in patients with normal hepatic and renal
unction. Cistatracurium and atracurium undergo
Hof man elimination with an onset o 1 to 2 min and
are intermediate acting. T ese agents would be rec-
ommended in patients with renal or hepatic insu -
ciency. Vecuronium is also an intermediate acting
NMBA and would be recommended in patients with
cardiovascular disease as it has the least adverse side
ef ect pro le. Prolonged duration o paralysis can
occur when using actual body weight in dosing atra-
curium and vecuronium. Avoidance o prolonged
paralysis or large doses o longer acting neuromus-
cular blockers is key.
5. B. CPAP should be available or patients in the
immediate post-operative period i OSA is known
or suspected. I OSA is suspected, introducing CPAP
in the immediate post-operative period can induce
anxiety due to the discom ort o the mask and con-
usion rom the remaining sedatives on board. T e
proper positioning or optimal airway patency is in
the upright and lateral decubitus position i possi-
ble. Opioid dosing should be based on IBW rather
C H AP TER 1 S LEEP AP N EA 7
than BW due to potential or prolonged duration o
action with BW in obese patients resulting in sup-
pression o respiratory drive and decrease pharyn-
geal muscle stimulation. T e use o a post-operative
epidural can be bene cial in patients undergoing a
large abdominal operation at risk or requiring large
doses o opioids or pain control. T e use o CPAP
in the post-operative period has not been shown to
increase complications, speci cally the positive pres-
sure ventilation has not been proven to increase leak
rates in bariatric surgery patients.
BIBLIOGRAPHY
Chau EHL, Mokhlesi B, Chung F. Obesity hypoventilation
syndrome and anesthesia. NIH Sleep Medicine Clinics.
2013; 8(1):135–147.
Hillman et al. Obstructive sleep apnea and anaesthesia. Sleep
Medicine Reviews. Elsevier. 2004;8:459–71.
Oto et al. Continuous positive airway pressure and ventilation
are more ef ective with a nasal mask than a ull ace mask
in unconscious subjects: a randomized controlled trial.
Critical Care. 2013;17:1–11.
Puhringer FK et al. Pharmacokinetics o rocuronium bromide
in obese emale patients. European Journal of Anaesthesiology.
1999;16(8):507.
Robinson JD et al. Determination o ideal body weight or
drug dosage calculations. American Journal of Hospital
Pharmacology. 1983; Jun; 40(6):1016–9.
Schumann R. Anaesthesia or bariatric surgery. Best Practice
and Research Clinical Anaesthesiology. 2011;25:83–93.
ietze K. Use o neuromuscular blocking medications in critically
ill patients. http://www.uptodate.com/contents/use-o -
neuromuscular-blocking-medications-in-critically-ill-
patients. J Pharm D. 2013.
 2
Malignant Hypertension

Harry T. Aubin

A 59-year-old emale with poorly controlled hyperten- C. emperature > 38.5

sion on three antihypertensive medications including a D. Pulmonary edema
beta-blocker, angiotensin converting enzyme inhibitor, E. achycardia > 100
and a calcium channel blocker, presents or a routine
surgery. At her preoperative visit, she is instructed to 3. Regarding the medication nitroprusside, which o
hold her home ACE inhibitor the day o surgery. She the ollowing is a eared side e ect with excessive
then undergoes an otherwise uncomplicated cholecys- use?
tectomy with intraoperative cholangiogram. However, A. Cyanide toxicity
in the postoperative care unit, she develops hyperten- B. remor
sion with readings o 200/140. Her other vital signs are C. Stroke
within the normal range. T e anesthesia provider per- D. Myocardial in arction
orms an eye exam and notes papilledema. Nitroprus- E. Angina pectoris
side is administered IV or treatment.
4. Regarding medications to treat malignant hyper-
1. Regarding the immediate management o this tension acutely, which o the ollowing is most
patient’s malignant hypertension, which o the likely to cause ref exive tachycardia?
ollowing is correct? A. Labetolol
A. Goal BP is reduction to normal rage o SBP B. Hydralazine
< 120, DBP < 80 as soon as possible to prevent C. Metoprolol
stroke. D. Clevidipine
B. Reduction o DBP to 100-105 over 3 hours with E. Fenoldapam
maximum all in BP by 25% over 24 hours is
needed to prevent stroke. 5. Regarding underlying causes o poorly controlled
C. Heart rate control is acutely needed to prevent hypertension, which o the ollowing is the most
worsening cerebral edema. likely cause in this patient?
D. Blood pressure should be maintained at current A. Pheochromocytoma
elevated levels. B. Cushing’s syndrome
C. Renal artery stenosis
2. Regarding malignant hypertension, which o the D. T yroid storm
ollowing is a clinical sign o this diagnosis? E. Glomerulonephritis
A. Blood pressure > 150/110
B. Papilledema

ANSWERS
1. B. T e goal in malignant hypertension is reduction
in DBP to 100-105 with maximum all in by 25% o
highest BP value over 24 hours. T is slow decrease
prevents re exive vasoconstriction via normal body
auto-regulatory mechanisms leading to stroke. Reduc-
tion o blood pressure to the normal range increases
the risk o stroke and is not recommended.
Heart rate control is not a main goal o care in malig-
nant hypertension. T e mechanism o cerebral edema
is elt to be overcoming the body’s auto-regulatory
mechanism o vasoconstriction with increase in MAP
allowing or a relatively constant end organ per usion
pressure. When BP increases above 180 systolic, auto-
regulatory vasoconstriction’s ails, and vasodilation is
seen leading to an increase in blood ow to the brain.
BP control, not heart rate, prevents cerebral edema
by reducing cerebral per usion pressure (intracranial
pressure – mean diastolic pressure) and permitting
auto-regulation thus reducing end organ damage.
2. B. Malignant hypertension is de ned by blood pres-
sure > 180/120 with signs o cerebral edema and/or
end organ damage. Cerebral edema is characterized
by clinical signs o brain swelling. Papilledema is the
most worrisome sign. However, retinal hemorrhages
and retinal exudates are indicative o hypertension
causing damage to arterioles and capillary beds. Other
end organ ndings include acute kidney injury, myo-
cardial in arction, aortic dissection or bowel ischemia.
achycardia is not a criterion or diagnosing
malignant hypertension. achycardia is commonly
seen in postoperative patients and could be attrib-
uted to catecholamine release rom the stressors o
surgery, pain, intravascular depletion, medications,
arrhythmias, and/or atelectasis. Its presence necessi-
tates close observation and thorough work-up.
3. A. Nitroprusside is an artrio-venous dilator that has
rapid onset and short hal -li e. It, as well as ast act-
ing medications like clevidipine, nicardipine, labeto-
lol, and enoldapam, are used or acute treatment o
hypertension. With over administration o nitroprus-
side, cyanide toxicity can develop as this medication
contains cyanide groups (carbon triple bonded with
nitrogen). Cyanide toxicity is detrimental to aerobic
metabolism at the cellular level by inhibiting the last
enzyme in oxidative phosphorylation, cytochrome
oxidase (a3). Cyanide toxicity can present with
headache, nausea, emesis, and ushing, hepatic and/
C H AP TER 2 MAl i g n An T H y P ERTEn s i o n 9
or renal ailure. T e treatment o cyanide toxicity is
multimodal and includes sodium nitrite, hyperbaric
oxygen, and sodium thiosul ate.
remor is not a known side e ect o nitroprusside,
but hypere exia is commonly seen in toxic levels o
this drug leading to cyanide toxicity.
Stroke, myocardial in arction, and angina pectoris
are not published side e ects o nitroprusside. T ese
are more characteristic o malignant hypertension
itsel due to end organ damage rom capillary and
arteriole damage to the heart.
4. B. Hydralazine is a direct arteriolar vasodilator. It
has rapid onset and short hal -li e administered
IV. It can commonly cause re exive tachycardia by
two mechanisms. Re exive catecholamine release
in response to vasodilation and decreased vascular
resistance directly stimulates the cardiac myocytes
by beta-1 adrenergic receptors leading to tachycar-
dia. Additionally, due to decrease in renal blood ow,
the juxtaglomerular apparatus secretes renin leading
to increased aldosterone secretion. Aldosterone is a
potent vasoconstrictor that decreases venous return.
As a compensatory mechanism, heart rate increases
to compensate and keep cardiac output constant (CO
= HR × SV). Re exive tachycardia is commonly
seen in patients who are not concomitantly on beta
blockers and angiotensin-converting enzyme (ACE)
inhibitors.
Labetolol is both and alpha-1 and beta-1 antago-
nist. It has rapid onset and is ideal or patients with
tachycardia and some hypertension. It does not
cause re ex tachycardia due to inhibition o beta-1
receptors.
Metoprolol is a beta-blocker and will decrease
heart rate. It is ideal in atrial brillation, with little
e cacy in malignant hypertension.
Clevidipine is a dihydropyridine calcium channel
blocker. It has rapid onset, very short hal -li e, and is
administered intravenously. Because it works periph-
erally, it does not cause re exive tachycardia.
Fenoldapam is a dopamine-1 receptor agonist. It
commonly causes ushing and hypotension. It does
not cause tachycardia because it works peripherally.
5. C. Renal artery stenosis is a common underlying
cause o malignant hypertension and is requently
seen in Caucasians who have poor blood pressure
control despite multimodal therapy. Renal artery ste-
nosis can present as worsening azotemia in relatively
young individuals, poorly controlled hypertension,
10 g En ERAl s U Rg ERy EXAM i n ATi o n An D Bo ARD REVi EW
and/or malignant hypertension. It is diagnosed non-
invasively via renal artery duplex and can be treated
with renal artery stenting. However, this treatment is
becoming more controversial given the recent publi-
cation o the CORAL trial (Hermann SM et al. 2013)
arguing or medical management alone.
Pheochromocytoma is a catecholamine releas-
ing tumor that can cause hypertension. It is usually
episodic and can present with ushing, palpitations,
diaphoresis, and other signs o catecholamine release.
It is diagnosed clinically by history and urine VMA’s.
Cushing’s syndrome can cause hypertension due
to cortisol excess, but is not as common as renal
artery stenosis in malignant hypertension. Conn’s
Syndrome or hyperaldosteronism is the over pro-
duction o aldosterone by the adrenal gland can also
cause hypertension.
T yroid storm typically presents with tachycardia.
It is treated typically with nonselective beta-blockade
and propylthiouracil (P U).
Glomerulonephritis seen in nephritic syndrome
can cause hypertension and renal ailure. Additionally,
both renal artery stenosis and malignant hypertension
alone can cause renal ailure. However, renal artery
stenosis and not GN is associated with malignant
hypertension.
BIBLIOGRAPHY
Armario P, Dernandez del Rey R, Pardell H. Adverse E ects
o Direct-acting Vasodilators. Drug Saf. 1994; Aug; 11(2):
80–5.
Davis B, Crook J, Vestal R, Oates J. Prevalence o renovascular
hypertension in patients with grade III or IV hypertensive
retinopathy. N Engl J Med. 1979;301(23):1273.
Hermann S, Saad A, extor S. Management o atherosclerotic
renovascular disease af er Cardiovascular Outcomes in
Renal Atherosclerotic Lesions (CORAL). Nephrology Dial-
ysis Transplant. 2014; Epub ahead o print.
Kaplan NM. Management o Hypertensive Emergencies. Lancet.
1994;344(8933):1335.
Marik PE, Varon J. Hypertensive crises: challenges and man-
agement. Chest. 2007;131(6):1949.
Pasch , Schulz V, Hoppelshauser G. Nitroprusside-induced
ormation o cyanide and its detoxi cation with thiosulphate
during deliberate hypotension. J Cardiovasc Paharmacol.
1983;(5):77–85.
Strandgaard S, Paulson O. Cerebral blood ow and its patho-
physiology in hypertension. Am J Hypertension. 1989;
2(6 Pt 1):486.
 3
Fundamentals or Use o
Surgical Energy—Fire During
emporal Artery Biopsy
Paul Wetstein
A 74-year-old emale with COPD and a baseline oxygen
requirement presented to the emergency department with
subjective evers, headache, and jaw claudication. Labora-
tory evaluation was notable or an erythrocyte sedimen-
tation rate (ESR) o 56 mm/hr. A non-contrast C o the
head was obtained which revealed no acute pathology. T e
patient was admitted to the internal medicine service and
started on high dose prednisone with a working diagnosis
o giant cell (temporal) arteritis. During a temporal artery
biopsy, an operating room re occurs.
1. Which o the ollowing is correct regarding
operating room f res?
A. wo o the three components o the classically
described “ re triad” must be present or an OR
re to occur.
B. T e most common OR re uel is the monopolar
electrosurgical cautery “Bovie”.
C. An oxidizer enriched atmosphere o en exists in
the entire operating room.
D. Alcohol containing prep solutions need to be
completely dry be ore starting a procedure.
E. Fiberoptic light sources or endoscopic surgery
do not serve as an ignition source.
2. Which o the ollowing is correct regarding this
scenario?
A. Surgery on the head and neck should be identi ed
preoperatively by the surgeon and anesthesiolo-
gist as “low risk”.
B. Intraoperative communication between the sur-
geon and anesthesiologist is not needed in a case
o expected short duration.
C. Sedation with open gas delivery device would be
pre erred to general endotracheal anesthesia in
this patient to prevent an OR re.
D. Surgical drapes should be con gured in a manner
as to minimize the accumulation o oxidizers.
E. Moistening surgical sponges has no impact in
preventing an OR re.
3. In the event o f re involvement o the airway or
breathing circuit, the best f rst step is to:
A. Stop the f ow o all gases to the airway.
B. Remove all uels rom the airway.
C. Activate re alarm.
D. Per orm beroptic bronchoscopy with the endo-
tracheal tube in place.
E. Pour saline into the airway.
12 G EN ERAL S U RG ERY EXAM IN ATI O N AN D BO ARD REVIEW
ANSWERS
1. D. In order or a re to occur, all three components
o the “ re triad” must be present. T ese include
uel, and oxidizer, and an ignition source. Fuel or
re is plenti ul in the operating room. Some exam-
ples include drapes, patient’s hair, surgical gowns,
blankets, endotracheal tubes, and lyngeal mask air-
ways and volatile surgical compounds (e.g., alcohol
containing prep solutions, acetone, etc.). It has been
shown that alcohol containing prep solutions with
as little as 20% alcohol can ignite with diathermy
or hot wire cautery and so they must be allowed to
dry be ore surgical electricity is used. Oxidizers in
the operating room are generally either oxygen or
nitrous oxide. T ese oxidizers can accumulate and
orm an oxidizer enriched atmosphere in closed or
semi-closed breathing systems and rom tenting o
surgical drapes. Ignition sources in the operating
room are equally as plenti ul. Some common exam-
ples include electrosurgical devices, heated probes,
lasers, beroptic light cables, argon beam coagula-
tors, drills and de brillator pads.
2. D. According to the American Society o Anesthe-
siologists 2013 ask Force on operating room res,
an endotracheal tube or LMA should be considered
in patients undergoing moderate to deep sedation
or that have a baseline oxygen requirement. Head
and neck surgery should be considered “high risk”
or an OR re and as such, communication between
the surgeon and the anesthesiologist is mandatory
regardless o the length o the procedure. Surgical
drapes should be arranged to prevent an accumula-
tion o oxidized air. Moistened surgical sponges can
help prevent OR res.
3. A. Immediate actions to be per ormed in the event
o an airway re include rst removing the endotra-
cheal tube or LMA, then stopping the f ow o ALL
gases, removal o uel sources away rom the airway,
and pouring saline into the airway. Once the re has
been extinguished, actions should include ventilation
o the patient while avoiding oxidizer-enriched envi-
ronments, inspection o the tracheal tube or LMA to
ensure no ragments remain in the patients airway,
and consideration o bronchoscopy. Bronchoscopy is
a relatively sa e procedure in experienced hands in
diagnosing inhalational injury but is not part o the
immediate management o an airway re.
BIBLIOGRAPHY
Ap elbaum JL, Caplan RA, Barker SJ, et al. Practice advisory
or the prevention and management o operating room
res: an updated report by the American Society o Anes-
thesiologists ask Force on Operating Room Fires. Anes-
thesiology. 2013; Feb; 118(2):271–90.
Bai C, Huang H, Yao X, et al. Application o f exible bronchos-
copy in inhalation lung injury. Diagnostic Pathology. 2013;
Oct 21:8:174.
Briscoe CE, Hill DW, Payne JP. Inf ammable antiseptics and
theatre res. Br J Surg. 1976; Dec; 63(12):981–3.
DeMaria S, Schwartz AD, Narine V, et al. Management o
Intraoperative Airway Fire. Simulation in Healthcare: T e
Journal of the Society for Simulation in Healthcare. 2011;
Dec(6):360–3.
 4
Argon Gas Embolism
Roger Eduardo
T e patient is a 37-year-old emale without any signi cant
past medical history undergoing a laparoscopic partial
right hepatic lobectomy or a large symptomatic hepatic
adenoma in segment VI o the liver. Endotracheal intuba-
tion is per ormed without complication and the abdomen
is entered via the Hassan technique. T e lesion is identi-
ed on the in eromedial aspect o segment VI. o dissect
the lesion away rom the liver parenchyma, an argon beam
coagulator is used. wo hours a er the start o the proce-
dure, there is an abrupt decrease in the patient’s E CO2
rom 30 to 10 mm Hg and spO2 rom 100% to 40%. T is is
rapidly ollowed by a decrease in arterial blood pressure to
60/25 mm Hg and heart rate rom 80 to less than 20.
1. Why is the argon beam coagulator used over other
types of electrocautery?
A. T e ow o gas clears the site o uids and blood,
enhancing visibility.
B. Rapid non-contact uni orm tissue coagulation
over a large area
C. Less adjacent tissue damage rom reduced depth
o penetration
D. Less generation o surgical smoke
E. All o the above
2. What was the most likely cause of this patient’s
decrease in ETCO2 and arterial blood pressure?
A. Acute myocardial in arct
B. Decreased venous return secondary to pneumo-
peritoneum
C. Aspiration
D. Gas embolism
E. Severe cerebral vascular accident
3. What is the most important factor associated with
an increased risk of venous gas embolism when
using argon beam coagulation?
A. Use under pneumoperitoneum
B. High ow rate o argon gas
C. Holding the tip o the electrode at a right angle to
the tissue
D. Placing tip o argon beam electrode in direct
contact with tissue sur ace
4. What steps can be taken to reduce these risk
factors?
A. Never place the electrode tip less than several
millimeters rom the surgical site.
B. Limit argon ow settings to lowest level that pro-
vides the desired clinical e ect.
C. Move the hand piece away rom the tissue a er
each activation.
D. Flush abdominal cavity with CO2 between
extended activation periods o use.
E. All o the above
5. What would be your next step in management of
this patient?
A. Continue the surgery.
B. Administer atropine and initiate vasopressors.
C. Discontinue pneumoperitoneum and place patient
in Durant’s position.
D. Per orm emergent EE to diagnose a gas embolism.
E. Begin immediate volume resuscitation.
14 G EN ERAL S U RG ERY EXAM I N ATIO N AN D BO ARD REVI EW
ANSWERS
1. E. Argon beam coagulation has gained popularity
among surgeons as a use ul tool to achieve hemosta-
sis in bleeding sur aces o highly vascularized organs
such as the liver and spleen. It utilizes a monopolar
electrode to partially ionize a stream o argon gas
that is directed towards the tissue or coagulation.
T e ionized argon beam acts as an e cient pathway,
conducting a high- requency electric current rom
the electrode to the target tissue resulting in a ne
spray o electrical sparks.
As the electrical beams directed rom the electrode
to the target tissue causes desiccation, the electrical
conductivity o the targets tissue is lost. I continu-
ally applied, the beams automatically move to nearby
non-desiccated and still electrically conductive tissue
allowing or rapid uni orm coagulation over a large
area without any tissue contact. Furthermore, as a
result o the loss o electric conductivity at a treated
site, the depth o penetration o the electrical energy
is reduced. T is, coupled with the act that the use o
argon gas, due to its inert nature, neither carbonizes
nor vaporizes biologic tissue so that the thermal e ects
are limited, results in less adjacent tissue damage.
2. D. With use o the argon beam coagulation system
in laparoscopic procedures, the argon system acts
as a secondary source o pressurized gas and argon
can accumulate in the closed peritoneal cavity. With
damage to any signi cant blood vessels, the gas under
pressure can enter the vasculature posing a risk o
embolism that could be a mixture o both argon and
carbon dioxide. Moreover, the argon gas stream that
ows between the electrode and the tissue can cross
any disrupted mucosal membrane sur ace and be
ushed directly into the microvasculature.
Although argon is physiologically inert, it is 17
times less soluble than carbon dioxide (0.029 ver-
sus 0.495 ml gas ml−1 blood) and as such, argon-rich
emboli are not as readily absorbed rom the blood
stream as CO2 and may pass into the systemic cir-
culation. At the standard ow setting o 4 L/min
used typically or hemostasis in highly vascularized
organs, the argon beam electrode can produce 67 ml
o gas in only one second which, i embolized, can
lead to signi cant cardiopulmonary dys unction
and be potentially lethal in an average size adult.
Furthermore, at such a high ow rate argon gas
clearly exceeds pressure in the venous system and
can embolize not only through major veins but also
through small peripheral veins.
3. D. T e rst ew cases o venous embolism with use
o the argon beam were reported during laparoscopic
procedures and there ore, the theory o over-insuf a-
tion and over-pressurization o the abdominal cav-
ity caused by the accumulation o argon gas under
pneumoperitoneum was thought to lead to these
embolic events. However, given that venous emboli
have occurred in several cases o patients undergo-
ing procedures without pneumoperitoneum, this
theory cannot ully explain the incidence o these
events. Ikegami et al. ( J Hepatobiliary Pancreat Surg.
2009;16(3):394–8) compared seven reported cases o
venous embolism using argon beam coagulation and
identi ed the ollowing risk actors:
1. Using the argon gas under pneumoperitoneum;
2. Puncturing the liver parenchyma (hepatic needle
biopsy);
3. Possible injury to the hepatic venous system; and
4. Placing tip o argon beam electrode in direct
contact with tissue sur ace.
On review o the literature, it appears that more
important than the issue o use under pneumoperi-
toneum is that o placing the tip o the argon beam
electrode in close or direct contact with the tissue that
is being treated. Multiple cases have been described,
without the use o penumoperitoneum, where this
is clearly the issue and in the series described above,
though only three cases described this, it is possible
that more might have had this condition and simply
not reported.
When used at ow rates o 0.2 to 2 L/min and a
power o 20 to 80 W as described in the eld o inter-
ventional pulmonology or ablation o small lesions,
the argon beam system can penetrate the tissue up to
5 mm in depth. However, when used or the purpose
o hemostasis in highly vascularized tissues such
as the spleen or hepatic parenchyma, a ow rate o
4 L/min and power o 150 W is typical. T is allows
or even urther penetration and when coupled with
direct sur ace contact could allow or vessel damage
and or the argon gas to be ushed directly into the
venous system.
4. E. T e cautions o the manu acturer include:
1. Never place the electrode tip less than several
millimeters rom the surgical site.

2. Limit argon ow settings to lowest level that pro-
vides the desired clinical e ect.
3. Hold the tip o the electrode at an oblique angle.
4. Move the hand piece away rom the tissue a er
each activation.
5. Flush abdominal cavity with CO 2 between
extended activation periods o ABC.
6. Always leave one instrument cannula open to
the atmosphere.
Another recommended tip is the use o a venting
port at all times when operating laparoscopically and
using surgical energy. T is will allow gas to escape
but maintain a pneumoperitoneum.
5. C. In conjunction with appropriate cardiac resus-
citation according to ACLS guidelines i indicated,
the treatment o a patient suspected o having a CO2
or any gas embolism should include immediate dis-
continuation o CO2 insuf ation. T e patient should
be placed in Durant’s position (le lateral decubitus
with steep head down). T is allows the gas to rise into
the apex o the right heart, preventing entry into the
pulmonary artery and keeping it there until it slowly
absorbs. Use o nitrous oxide inhalant should be dis-
continued to allow or hyperventilation with 100%
oxygen to increase clearance o CO2 or any other
gas and to relieve hypoxemia. Volume expansion
with bolus crystalloid may reduce urther gas entry
by elevating CVP. And lastly, placement o a central
venous catheter or attempted aspiration o the gas
rom the right heart may also be per ormed. While a
transesophageal echo ( EE) may be diagnostic in the
event o a venous gas embolism, it is not a priority in
the unstable patient with suspected gas embolism.
C H AP TER 4 ARG O N G AS EM BO LI S M 15
BIBLIOGRAPHY
Cornejo A, Liao L, Kenneth W. Argon gas embolism with
the use o argon beam coagulation during open hepatic
resection. 2009;22(2). Available rom http://ispub.com/
IJS/22/2/7972. T e Internet Journal o Surgery Web site.
Croce E, Azzola M, Russo R, Golia M, Angelini S, Olmi S.
Laparoscopic liver tumour resection with the argon beam.
Endosc Surg Allied echnol. 1994;2(3–4):186–8.
Farin G and Grund KE. echnology o argon plasma coagu-
lation with particular regard to endoscopic applications.
Endosc Surg Allied echnol. 1994;2:71–7.
Feldman L, Fuchshuber P, and Jones DB. T e SAGES Manual
on the Fundamental Use of Surgical Energy. Berlin, Ger-
many: Springer-Verlag; 2012.
Kono M, Yahagi N, Kitahara M, Fujiwara Y, Sha M, Ohmura A.
Cardiac arrest associated with use o an argon beam coag-
ulator during laparoscopic cholecystectomy. Br J Anaesth.
2001;87(4):644–6.
Park EY, Kwon JY, Kim KJ. Carbon dioxide embolism during
laparoscopic surgery. Yonsei Med J. 2012;53:459–66.
Ikegami , Shimada M, Imura S, et al. Argon gas embolism
in the application o laparoscopic microwave coagulation
therapy. J Hepatobiliary Pancreat Surg. 2009;16(3):394–8.
Economic Cycle Research Institute (ECRI). Fatal gas embo-
lism caused by overpressurization during laparoscopic use
o argon enhanced coagulation. Health Devices. 1994 Jun;
23(6):257–9.
Mann C, Boccara G, Grevy V, Navarro F, Fabre JM, Colson P.
Argon pneumoperitoneum is more dangerous than CO2
pneumoperitoneum during venous gas embolism. Anesth
Analg. 1997;85:1367–71.
Min SK, Kim JH, Lee SY. Carbon dioxide and argon gas embo-
lism during laparoscopic hepatic resection. Acta Anaesthe-
siol Scand. 2007;51(7):949–53.
Reddy C, Majid A, Michaud G, Feller-Kopman D, Eberhardt
R, Herth F, et al. Gas embolism ollowing bronchoscopic
argon plasma coagulation: a case series. Chest. 2008; 134(5):
1066–9.
Veyckemans F, Michel I. Venous gas embolism rom an argon
coagulator. Anesthesiology. 1996;85(2):443–4.
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Adva nc es in La pa r o sc o py
Robert B. Lim
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 CHAPTER XX.
The Ship becomes as leaky as before.—All hands in turn at the Pumps.—Means
adopted to reduce the Leaks.—I offend the late Governor, who orders me
before the Mast.—Fall in with the Thisbe a second time, in company with
several Transports.—Unhappy fate of one of them.—Arrive at Spithead.

Having resumed our voyage with a favouring breeze, and the ship
being, to all appearance, tight and sea-worthy, with a pretty ample
supply of wet and dry provisions, our prospects were now a little
more cheering; and I looked forward with innate satisfaction to the
moment when I should set my foot on English ground, free from the
horrors attending a state of bondage, and at liberty to realize the
ideas I had formed of atoning to society, and to my own conscience
for the manifold errors of my past life.
We had, however, the mortification to find that the repairs the ship
had undergone at Rio de Janeiro, had only produced a temporary
effect; for shortly after leaving that port, the ship again began to leak,
and in a few days made as much water as before. The consequence
was that all hands, except officers, were obliged to take their turn at
the pumps, and it was only by pumping her out every watch that she
could be kept free. I, of course, took my spell at this necessary but
fatiguing labour during the day, without murmuring; but I was not
disturbed in the night, which, indeed, I considered would have been
unfair, as I was on duty all day. The carpenter found, on inspection,
that the principal leak was occasioned by some part of the stem
being loose, where there was a large aperture some feet under
water. Every exertion was made, by lightening her forwards, and
applying what is termed a fothering mat to her bows, to remedy this
evil, but without effect; for the working of the ship occasioned every
particle of the stuffing used on such occasions to wash out
immediately. This expedient, indeed, at first, promised to succeed to
admiration, for it decreased the leak from sixteen to ten inches an
hour; but the experiment was made in a calm, and the first rough
weather undid all that had been done. It was now discovered that
certain parts of the stem, called the fore-hoods, were loose, which
occasioned the principal leak; and this was so far under water, that it
was impossible to repair the defect while the ship was afloat. In fact,
she was altogether in a very decayed state, being an old ship, and
having endured much severe service; so that having now a voyage
of three months before us, and reason to expect bad weather, as we
should approach the English channel in the winter season, those
who were best able to form an opinion entertained serious doubts of
the ship’s capability to perform the voyage; however, these doubts
were not suffered to transpire publicly, and every precaution, which
the experience of Captain King and his officers could dictate, was
made use of. The stem, of the vessel, being the most defective part,
was first secured, by passing very strong ropes over her bows, and
under her keel, which were then boused taut athwart the fore-castle,
and there made fast, in order to lash her bows together; for some
fears existed that by the violent working of the ship in a head sea,
her bows would absolutely part asunder! That she might be strained
as little as possible, it was also determined not to carry a press of
sail on the boltsprit when sailing on a wind. In this manner we
continued our course for several weeks, without any incident worthy
of notice; we had upon the whole pretty favourable winds, but as we
approached the equator they were interrupted by occasional calms.
On the 17th of September, we crossed the equinoctial line, with
the usual ceremonies, in which every officer and passenger cordially
joined, and not a single person (the ladies and Captain King
excepted,) escaped a complete ducking. The weather being
delightfully fine, with a light and favourable breeze, every one was in
high spirits, and the rites of Neptune having been celebrated in due
form, a plentiful allowance of grog succeeded, which, by wetting the
inside, made ample amends for the salt-water baptism, which all
hands had mutually and liberally bestowed on each other without
respect to rank or persons. This was a remarkable day with me, for
on this day my original term of transportation expired. This event
naturally produced a train of reflections in my mind. I took a
retrospect of the miseries and vicissitudes I had undergone within
the last seven years, and I returned fervent thanks to Heaven for my
deliverance from exile, and for the unlimited freedom which I
expected shortly to regain. But, alas! I was soon to experience
another reverse, which, as it was both unexpected and unmerited,
fell with the greater weight upon me: and thus it happened.
Hitherto, as I have before observed, I was not called upon in the
night to take my spell at the pumps, but a few days after our crossing
the line, by what accident I knew not, I was desired by the
boatswain’s mate of the watch, to turn out in the middle of a wet and
windy night, and pump ship. As remonstrance with such a fellow as
this would have availed nothing, I complied; but the next day took an
opportunity of acquainting Captain King, and requested he would
give directions that I should not be disturbed in future. To my great
surprise, however, he informed me, that I had been called upon by
his express orders, and that he was ignorant till that very night of my
being excused from the duty of pumping, but had taken for granted
that I always took my spell. I replied to this by submitting in the most
respectful terms, that as I was employed in writing, &c., from
morning till night, and also assisted in pumping the ship every watch,
it was but fair that I should sleep every night, as all persons under
the denomination of “Idlers” invariably do in king’s ships. Captain
King rejoined that the emergency of the case required every one to
assist; that he had given orders to have no idler or other person
excused, and that he should therefore insist on my compliance. I
observed that he grew warm towards the end of this conference,
though I had preserved the respect due to him, in all I had said;
however, as I was conscious of being in the right, I ventured to hint
that the situation in which I stood, being only a passenger not
belonging to the ship, receiving neither pay nor even the allowance
of spirits common to the meanest cabin-boy in the service, and
which was essentially necessary to support the united hardships of
labour and inclement weather; that all these considerations might, I
submitted, entitle me to some distinction from the class of persons
called idlers, who actually belonged to the ship; and I concluded with
an intimation that the emergency of the case could not be so great
as that my feeble assistance could not be dispensed with, as the
ship was always freed from water with ease in half an hour, and not
one of his (Captain King’s,) domestic servants, who were stout able
men, (five or six in number,) and all receiving pay from the ship, were
ever called upon at all in the night, and but rarely in the day. The
justice of my remonstrances appeared to have exasperated Captain
King, who was of a very irascible temper, and he at length worked
himself up into a violent rage, the consequence of which was (as
usual with him,) a torrent of abuse; and as I knew by experience that
it was in vain to attempt pacifying him, when in this mood, I quitted
the cabin, and retired to my birth between decks. About an hour
after, as I was sitting on my chest ruminating on the unpleasant
situation in which I was placed, and heartily wishing for the moment
which was to free me from a state of dependence, I was accosted by
a master’s mate, who informed me it was Captain King’s orders that I
should do my duty in the larboard watch of the after-guard, and that I
was to be mustered with the watch at eight o’clock the same night. I
now clearly saw the malevolence of Captain King’s designs, and the
illiberal advantage he was about to take of my helpless and
dependent situation. I nevertheless cheerfully obeyed his orders, and
that night kept what is termed the first watch, (from eight to twelve,)
two hours of which I was stationed at the lee-wheel. At twelve o’clock
I retired to my hammock, and was no more interrupted till eight the
next morning, soon after which I was summoned to the cabin of
Captain Houston, the acting commander of the Buffalo under
Captain King, who, on my appearing before him, inquired abruptly, “if
I chose to enter?” I was not surprised at this question, as I had
foreseen in what manner Captain King intended to act, in order to
place me more immediately in his power, and to give him an
authority over me, which as I was before situated he did not
possess. Being, therefore, prepared for such a question, and
knowing the nature of the service, I answered Captain Houston in
the affirmative. The latter then ordered me to attend the captain’s
clerk, and get myself duly entered on the ship’s books. This I
accordingly did, and now found myself suddenly placed in the
capacity of a common sailor on board a king’s ship; and it being war
time, I had before me the disheartening prospect of being drafted, on
our arrival in England, on board some other ship, (without a probable
chance of once setting my foot on shore,) and of being perhaps
immediately ordered abroad to some foreign station from which I
might not return for several years. My motive for voluntarily entering
was this: I was aware that had I refused to do so it was in the power
of Captain King to press me against my will, and I doubt not but such
was his intention. In the latter case I should have been entered as a
pressed man, which might have operated at a future day against my
obtaining leave to go ashore, and by that means effect my escape;
whereas I was now entered as a volunteer, and became entitled to a
small bounty. I am persuaded the reader will view this conduct of
Captain King’s in a very unfavourable light; as I had really been
guilty of no crime, it was taking a most cruel and illiberal advantage
of the power he had over me. Having released me from a state of
banishment, and taken me into his service on the terms he did,
without any immediate compensation, he had of course left me every
reason to expect, not only my liberty at the end of the voyage, but
also his future countenance and protection. Besides, the reader will
remember that he had declined putting me on the ship’s books when
I first joined her at Port Jackson, in which case I should have had
nine months’ pay to receive on my subsequent arrival in England,
and should have also had a daily allowance of spirits during the
passage, for want of which I had suffered much in the cold climate
and severe weather we encountered; instead of which, and after I
had actually become a free-man by servitude, he had forced me into
what may be termed a second bondage, almost equally irksome with
the first, and that too when within six weeks of the end of our
voyage. However, as I am of opinion with Shakspeare, that

“Things without remedy should be without regard.”

I bore up with fortitude against this unexpected reverse of fortune;

and, conscious of its being unmerited, made no attempt to avert the
blow by mean submission, to which I could not stoop. I therefore
cheerfully took my watch on deck, and, when not so engaged,
amused myself below with a book, or in ruminating (as usual with
me,) on the instability of human affairs, and the vicissitudes of my
own life in particular. It was not the least of my consolations in this
distress, that I received every day at noon half a pint of excellent
rum, with a dram of which I fortified myself occasionally during the
night watches, for as we approached the channel of Old England, we
once more experienced a sudden change of climate, and the
weather became intensely cold.
About a fortnight after the event I have just related, Captain King,
finding I was perfectly reconciled to my new duty, and that I offered
no apology, as he perhaps expected I would, sent for me one
morning, and ordered me to attend in the cabin every day at nine
o’clock, for the purpose of writing as usual. As I did not conceive
myself justified in refusing, I complied, and paid every attention to his
commands. The boatswain’s mates, understanding how I was again
employed, desisted from calling me up to pump ship for several
nights; when by some means Captain King hearing of this fact,
actually gave orders that I should regularly turn out as well as the
other idlers. This I considered such a proof of his determined wish to
oppress and harass me, that I ventured a second remonstrance on
the subject; when he again fell into a violent rage, and cautioned me
not to offend him by a repetition of (what he termed,) my insolence,
reminding me that it was now in his power to flog me, though it was
not before!
He concluded with saying, that he left it to my choice either to write
for him during the day, and take my turn at pumping in the night, or
to do my duty before the mast entirely, and keep my watch in
common with the rest of the crew. I made no hesitation in replying,
that, with his permission, I should prefer doing my duty on deck. To
this he assenting, I made my bow and withdrew. Here ended my
functions in the clerical capacity with Captain King. From this day I
never wrote a line for him; and thus was I rewarded for my past
services. To shew the inconsistency of this treatment, I will just quote
a line from the pardon granted me by himself, when Governor of
New South Wales. In documents of this description, it is
indispensably required to state the grounds, or motives, which
induce the Governor to exercise the power vested in him by His
Majesty’s instructions. The blank left for that purpose, was thus filled
up, “I, Philip Gidley King, Esquire, Captain general, &c. &c., taking
into consideration the good conduct of James Vaux, and to enable
him to serve as my clerk on board His Majesty’s ship Buffalo, Do
hereby absolutely remit, &c.”
Just before we entered the channel, we had the singular fortune to
fall in a second time with the Thisbe frigate, in company with three
sail of transports. On speaking, we ascertained that the latter vessels
had on board a part of the army, lately under the command of
General Whitelocke in the Rio de la Plata, and who had survived the
ill-managed and fatal attack upon Buenos Ayres. We also learnt that
the general himself had been put under arrest for his deficiency and
misconduct on that occasion, and was now on his voyage home to
answer for the same. Captain King now represented to the agent on
board one of these transports, the distressed state of the Buffalo,
and requested the aid of some soldiers to assist in pumping her, as
the leaks daily grew more alarming. Forty privates were accordingly
put on board us, and we continued our voyage in company with the
transports, the Thisbe having outsailed us. About the 5th of
November we made the land, which proved the coast of Cornwall,
near Falmouth. We proceeded along shore to the eastward, and on
the 8th came to an anchor at Spithead, (after a passage of nine
months from port Jackson,) in company with two of the transports,
but the third was missing. We had afterwards the melancholy
information that this vessel (the John and Elizabeth,) had been
wrecked during the preceding night, having struck upon some rocks
in consequence of her keeping too near the shore; and it blowing a
fresh gale, she went to pieces, when upwards of three hundred
persons unhappily perished.
 CHAPTER XXI.
Captain King leaves the Ship, which proceeds to Portsmouth Harbour.—My
melancholy Reflections on my Confinement to the Service.—Preparations for
paying off the Buffalo.—Employed by the Purser in arranging the Ship’s
Books.—Write to London, and receive an answer from my Mother. Obtain
leave to go ashore very unexpectedly, and effect my Escape through the
friendly aid of a total Stranger.

The anchor was no sooner down, than the cutter was hoisted out,
in which Captain King went ashore and immediately proceeded post
to London. The following day the Buffalo weighed, and sailed into
Portsmouth harbour, where she was lashed alongside a hulk near
the shore, and preparations instantly made for clearing and
dismantling her, preparatory to her survey and expected
condemnation. Those persons who had obtained a passage on
various accounts, and were not on the ship’s books, were now
permitted to dis-embark, and depart to their respective homes. I now
felt the full weight of the misery in which I was involved. After an
absence of nearly seven years from my native land, to enjoy once
more the sight of that much-loved spot, and when within a hundred
yards of the shore, to be debarred from a nearer approach, was
mortifying in the extreme, and my situation could only be compared
to that of Tantalus in the Heathen mythology. The purser was now
busily intent upon making up the Buffalo’s books, to be transmitted to
the Navy-office, previous to her being paid, and her crew drafted into
other ships. As these accounts were extensive, and required both
care and expedition, Mr. Sherard, the purser, requested that I would
assist the captain’s clerk of the ship in their arrangement, for which
he obtained the sanction of Captain Houston, promising to reward
me for my trouble. I was now excused from all other duty, and
immediately set about the required task with alacrity, conceiving
hopes that I might by this compliance facilitate my grand object of
escaping from the ship. By dint of unremitting assiduity we
completed the whole of the accounts in about a fortnight, to the
satisfaction of the purser, and I had no sooner acquitted myself of
this duty than Captain Houston requested I would bring up his
journal, which was many months in arrear. I gladly undertook this
service, from the same motives as before, and now wrote from
morning till night in the cabin, Captain King and his family having
totally quitted the ship, and taken lodgings in Portsmouth, as had
also Captain Houston and his lady. The latter officer came on board
daily, and was highly pleased at the progress I made in his journal.
Captain King also came on board occasionally, but did not deign to
notice me, and I preserved the same strangeness towards him.
Soon after our arrival, I had written to an aunt in London, for
information respecting my father, and other relations. About this time
I received, in consequence, a letter from my mother, informing me
that my father and grandmother had been deceased about two
years, and that my venerable grandfather was still living at S⸺ in
health and spirits; she added that herself and my two sisters were
residing in Middle-row, Holborn, and should feel inexpressibly happy
at seeing me again. My whole thoughts were now turned to the
object of getting ashore, but the quo modo was to be considered,
and of this I could form no idea. I could not swim; I had no money to
bribe a waterman to fetch me away; and of gaining my liberty I had
little or no hopes. I still continued assiduous in writing the journal for
Captain Houston and I had reason to build upon some indulgence
from the first lieutenant Mr. Oxley[46], should it rest with him to grant
leave of absence, as I had occasionally written his log, during the
voyage, and he had been pleased to shew me many marks of
kindness.
After the pay-books were completed and sent up to London, I one
day had some conversation with a respectable looking woman, who
attended the ship with a bum-boat, and supplied the sailors with
necessaries on the credit of their approaching pay, which was
considerable, the ship having been six years stationed in New South
Wales. As this woman appeared to possess some sensibility, I
ventured to represent to her the distress I was in at my confinement
to the service, and particularly my fears that I should not obtain leave
to visit my friends before I was sent to sea again. The good woman,
whose name was B⸺y, had sufficient penetration to perceive my
drift, and that I wanted to take French leave of an English man-of-
war. After expatiating on the risk she should incur in case of a
discovery, and many injunctions of secrecy, she declared her
willingness to assist me as far as lay in her power, as she had, she
said, children of her own and pitied my situation. She then advised
me to pack up a suit of clothes, (which I informed her I had by me,)
and commit them to her care, saying, that she would take them
privately to her lodgings, to which she directed me, and that I must
next contrive to get ashore on duty, or by any other means, when I
should immediately come to her, and she would assist me in my
further proceedings. Having treated this worthy creature with a glass
of grog, and overwhelmed her with thanks for her disinterested
kindness, (for such it certainly was,) I hastened to put up my clothes,
consisting of a genteel black coat, boots, &c., which I had preserved
for the purpose, and on her quitting the ship she concealed these
articles among her merchandise without observation. This took place
on a Thursday, and my only concern now, was to make good my
landing. On the following Sunday it was promulgated throughout the
ship, that a certain number of the crew were to be allowed leave to
go on shore in the afternoon. I determined, therefore, to make an
effort, and the dinner hour being over, I heard orders given to man
the cutter for the liberty-men. The latter were in the mean time busily
employed in rigging themselves for the occasion, in their best togs. I,
of course, intended to go in my working dress, consisting of a red
flannel shirt, blue jacket, and tarry trowsers, as I thought the officers
would less suspect me of a design to run away. Full of anxiety but
not without hope, I entered the gun-room, in which were Mr. Oxley,
then commanding officer of the ship, and Mr. Sherard the purser.
The former inquiring my business, I answered, that I wished, with his
permission, to go on shore for two or three hours, having a friend in
Portsmouth, who I was in hopes would supply me with some
necessaries I stood in need of. Mr. Oxley smiled and hesitated,
remarking the shabbiness of my appearance; at length on my urging
my suit, with a trembling voice, (for no one who has not been
similarly situated, can conceive what I then felt,) he inquired if he
might depend on my returning on board at sun-set in the ship’s boat?
I assured him that he might, and he then consented to my going.
Having thanked him from the bottom of my heart, I quitted the gun-
room, but had no sooner closed the door than I was recalled by Mr.
Oxley. Somewhat alarmed lest he should be about to retract, I
returned, and found I was called at the instance of Mr. Sherard, who,
drawing out his purse, presented me with half-a-guinea! saying, he
had promised me something for my late assistance. I thanked him
and again withdrew. I had scarcely shut the door a second time,
when I was again recalled, which still more surprised and alarmed
me. On re-entering, Mr. Oxley said, (but in what I thought a good-
natured way,) “Mind, Mr. Vaux, if you’re not on board by six o’clock, I
shall send the marines after you.” I again promised obedience, and
once more retired. I then hastened to inform a friend of my good
fortune, and gave him the key of my chest, desiring him, in case I did
not return in the evening, to take out such articles as he chose, as
well as my bedding, &c., before they were seized by order of the
captain. On ascending the deck I was again alarmed. The acting
master, who was on the quarter-deck, seeing me about to enter the
boat, called me aft, and inquired where I was going? I answered that
Mr. Oxley had given me leave to go ashore. He replied, “Mr. Oxley, I
am sure, would never give you leave to go ashore in that dirty
dress;” and absolutely forbad my going. It was in vain that I
remonstrated, and referred him to Mr. Oxley; and during the delay
occasioned by this conversation, the boat was on the point of
departure; when, luckily, the master turning his back to give some
orders, I hastily descended to the Waist, and leaping through one of
the midship ports, found myself happily in the cutter, at the moment
when the coxswain gave the word to shove off. I concealed myself in
the foresheets until out of danger, and in about ten minutes was
landed at Common-Hard. I need not labour to paint the joy I felt at
that moment, though it was certainly mixed with anxiety as to my
further success. I immediately left the other liberty-men, who pressed
me in vain to drink with them; and pleading urgent business, ran with
the utmost expedition along the streets, inquiring for the Point, where
having arrived, I found several ferry-boats ready to cross over to
Gosport. A fellow calling out “over, Sir?” I jumped into his boat, and
in a few minutes found myself on Gosport-beach. Thus far, I sailed
before the wind; I walked up the beach, and the first object that
presented itself was the London stage-coach, standing at the door of
the Red Lion Inn. This novel sight which I had not beheld for so
many years, was so gratifying that I admired and examined it for
some minutes, as minutely as a country man would do the King’s
state-coach. I soon found on inquiry, the lodgings of Mrs. B⸺y
which were at a public-house near the Red Lion. On asking for her of
the landlady, I had the mortification to learn that she was out on
board of some ship, and that her return was uncertain. It was now
near four o’clock, and the days being short, my term of leave would
soon expire. However, as there was no remedy but patience, I
entered the tap-room, and calling for a pint of ale and a pipe, sat
down to wait the arrival of my worthy friend. I had scarcely taken a
dozen whiffs when I heard a footstep in the passage of the house;
and my landlady putting out her head, inquired “Is that you, Mrs. B
⸺y?” I had the pleasure to hear that good woman answer, “Yes.”
On the landlady informing her there was a young man waiting for
her, she opened the door; and seeing me, said with a significant
look, and evidently much pleased, “O, is that you, William, step up
stairs with me, and I’ll give you those things.” I paid for my ale, and
followed Mrs. B⸺y, who was accompanied by her husband, and
both of them loaded with goods they had brought from their boat. On
entering their apartment, they expressed much pleasure at my good
luck in getting ashore, and gave me the most cordial welcome. The
old woman put on the tea-kettle, and while it was boiling, she looked
out my clothes, which she set about airing by the fire. Having obliged
me to take a dram, they began to consult on the measures to be
adopted in my favour. Mr. B⸺y informed me that the coach I had
seen would set out at six o’clock; that the inside fare to London was
twenty-four shillings, and the outside seventeen shillings, inquiring,
which I would prefer, and how I stood for cash. I answered that I had
about twenty-four shillings, (namely the half guinea I had brought
from New South Wales, another which I had received from the
purser, and three or four shillings I had acquired since our arrival,)
but that an outside place would answer my purpose, and I should
then have a trifle for expenses. This worthy couple assured me I
should not be lost for a few shillings, if I found myself at all deficient;
but I declined this favour, knowing I could make shift with what I had.
Mr. B⸺y then offered to go himself to the coach-office, and secure
me a place. I accordingly gave him the required sum, and he
hastened to the Red Lion. During his absence Mrs. B⸺y gave me
some warm water to wash myself, which having done, she desired
me to put on all my clothes but my coat; she then put an apron over
my shoulders, and proceeded to dress my hair as well as she could,
and, for want of powder, made use of some flour, with which she
plentifully whitened my head. Having put on my coat, she next threw
some flour over my back, and taking a view of me, declared she
never saw so great an alteration in a man. She complimented me
upon my genteel appearance, and added, that she was sure if I was
met by any of my own officers, they would not know me in this garb.
Her husband now returning, informed me that he had taken a place
for me in the name of Lowe, as I directed, and had told the
coachman to take me up at the Dolphin Inn, near the extremity of the
town. Every thing being now arranged, I anxiously wished for the
hour of six; and though I had not the least grounds for fear, yet I
could not wholly divest myself of it. It is true, as I had landed at
Portsmouth, it was not likely, in case there was any suspicion, that a
search would be set afoot in Gosport, which is on the opposite side
of the harbour; besides, no inquiry was likely to be made for me, till
after six o’clock, at which hour the coach would set off. Having taken
a dish of tea, and the time approaching, I took an affectionate leave
of the good woman, promising to write to her on my arrival in town,
and at a future day to reward her kindness. The old man insisted on
accompanying me to the Dolphin, and seeing me safe off. The
weather being intensely cold, they would have pressed me to accept
a great-coat, but I refused to trespass further on their goodness. At
length we departed, and walked without interruption to the Dolphin;
but I tremble at the approach of every officer or genteel person we
met, so great was my fear of miscarriage on this important occasion.
Having some minutes to wait for the coach, Mr. B⸺y insisted on
my drinking a parting glass at the bar of an adjacent public-house,
which having done, we heard the joyful sound of the horn, and the
rattling of the coach-wheels. In a few minutes I ascended the vehicle,
and as it drove off, I saw my worthy old friend waving his hand at the
corner of the street, apparently as much affected as myself on the
occasion. Having thus described my escape from a state of
thraldom, in which I might otherwise have suffered much vexation
and hardship, I shall here conclude the twenty-first chapter of my
Memoirs.

END OF THE FIRST VOLUME.

Printed by W. CLOWES, Northumberland-court, Strand, London.
 FOOTNOTES
[1]

“Le bien, nous le faisons; le mal, c’est le sort;

“On a toujours raison, le destin toujours tort.”

La Fontaine.

[2] A genealogical account of race-horses.

[3] Two celebrated spots on Newmarket heath.
[4] Proprietor of the celebrated horse Eclipse.
[5] This was prior to the abolition of the Slave Trade.
[6] The small square white patches on each side the collar of a
midshipman’s coat, having an anchor button in the middle of it are
facetiously called Weekly Accompts, from their resemblance to a
flag hoisted by the port admiral, requiring from the ships in
harbour a weekly return of their state and condition. This flag is
blue, with a white field in the middle.
[7] In line-of-battle ships the midshipman’s birth, or cabin, is in
the cockpit.
[8] Candle.
[9] A dram of rum is here meant, to a bottle of which, it seems
the youth was applying for consolation.
[10] Alluding to the uniform of a lieutenant, which is faced with
white.
[11] The ship’s corporal, whose duty it is to see all lights
extinguished at eight o’clock.
[12] His daily allowance of spirits.
[13] The lieutenant of the watch walks the weather-side; the
midshipmen, the lee.
[14] Telescope and speaking-trumpet.
 [15] It appears from this that Mr. Dalton had formerly resided in
London, and been a member of that respectable corps.
[16] Receiver of stolen goods. (Cant.)
[17] The cant name for the House of Correction, in Cold-bath-
fields.
[18] A public-house near the police-office, where prisoners are
confined until their removal to prison by the officers, who seldom
hurry a gentleman, if he behaves like one, as their phrase is.
[19] Thieving.
[20] Highwaymen.
[21] Pickpockets.
[22] Housebreakers.
[23] Persons living by fraud and depredation.
[24] Pocket-books.
[25] To stand or walk in such a situation, close to the person
robbed, as to prevent passengers from noticing the depredation.
[26] Sell.
[27] To go a thieving.
[28] Thieves.
[29] Picking pockets in general.
[30] Robbing carts, or carriages, of bales, trunks, &c.
[31] Entering a house or shop, unobserved, and stealing
whatever is most come-at-able.
[32] Shop-lifting.
[33] Secreting small trinkets of value in a shop, while
pretending to select and purchase something.
[34] Uttering counterfeit money, or forged bank-notes.
[35] Getting in at the lower windows of private houses, and
robbing the apartments of plate or other portable goods.
[36] Breaking a shop-window at night, having first tied the door
to prevent a pursuit, then snatching at any articles of value within
reach.
[37] Cutting a hole in a pane of glass, without noise, in order to
rob the window of something before determined on.
 [38] Defrauding errand boys, or porters, of their load, by false
pretences of various kinds.
[39] Obtaining money from charitable persons, by some
fictitious statement of distress.
[40] Obtaining goods from a tradesman by false pretences, or
by a forged order in writing.
[41] Throwing snuff in the eyes of a shopkeeper, and then
running off with such money or valuable property as may lay
within reach.
[42] See the evidence of William Alderman.
[43] A short confinement is here meant.
[44] The settlement or camp at Hawkesbury, now called, the
town of Windsor.
[45] Governor King was a post-captain in the navy, and
principal commander of the Buffalo, having a second (acting)
captain under him. The Buffalo had been stationed in N.S.W. ever
since the year 1802, and was now relieved by the Porpoise, in
which ship Governor Bligh arrived.
[46] Now Surveyor-General of New South Wales.

MEMOIRS OF JAMES HARDY

VAUX.
IN TWO VOLUMES. VOLUME II.

MEMOIRS
OF
JAMES HARDY VAUX.
 WRITTEN BY HIMSELF.

IN TWO VOLUMES.

VOL. II.

LONDON:
PRINTED BY W. CLOWES, NORTHUMBERLAND-COURT, STRAND.
AND SOLD BY
ALL RESPECTABLE BOOKSELLERS.
1819.
 CONTENTS
OF

THE SECOND VOLUME.

CHAPTER I.
I arrive in London—A sudden alarm—Visit my mother and sisters—
Set out for S⸺shire—Interview with my grandfather—Return
to town—A lucky hit on the road—Obtain a situation in the
Crown-Office, page 1.
CHAP. II.
Quit the Crown-Office, and engage as reader in a printing-office—
Determine to live a strictly honest life—Meet with an old
acquaintance who laughs me out of my resolution—Give up all
thoughts of servitude, and become a professed thief, page 13.
CHAP. III.
Various modes of obtaining money—My regular course of life, when
disengaged from my vicious companions—Meet with an
amiable girl, like myself the child of misfortune—We cohabit
together—Our mutual happiness, page 20.
CHAP. IV.
Adventures in the course of my profligate career—Motives which
induce me to marry my companion—Her exemplary behaviour
—A family misfortune, page 29.
CHAP. V.
Adventure of the silver snuff-box—Its consequences.—My narrow
escape from transportation, which I have since had reason to
regret, page 35.
 CHAP. VI.
Visit Mr. Bilger, an eminent jeweller—His politeness, and the return
I made for it—Perfidy of a pawnbroker—Obliged to decamp
with precipitation, page 52.
CHAP. VII.
Take a house in St. George’s Fields—Stay at home for several
weeks—At length I venture out in quest of money—My
imprudent obstinacy in entering a house of ill repute, against
the advice and entreaties of my wife—I am taken in custody
and carried to the watch-house.—Distress of my wife on the
occasion, page 71.
CHAP. VIII.
Discover that I have been betrayed—Examined at Bow-street, and
committed for trial—Sent to Newgate—Prepare for my defence
—My trial and conviction, page 83.
CHAP. IX.
Account of my companion and fellow-sufferer in the condemned
cells—His unhappy fate—I receive sentence of death—Am
reprieved, and soon afterwards sent on board the hulks—
Some account of those receptacles of human misery, page 97.
CHAP. X.
I embark a second time for New South Wales—Indulgently treated
by the Captain—My employment during the voyage—Arrive at
Port Jackson, after an absence of four years—My reception
from Governor Macquarrie—Assigned by lot to a settler—His
brutal treatment of me—I find means to quit his service, and
return to Sydney, page 113.
CHAP. XI.
Appointed an overseer—Determine to reform my life, and become
a new man—All my good intentions rendered unavailing by an
unforeseen and unavoidable misfortune—I become a victim to
prejudice, and the depravity of a youth in years, but a veteran
in iniquity—I am banished to the coal-river, page 122.