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Schwartz’s
PRINCIPLES OF
SURGERY ELEVENTH EDITION
ABSITE AND
BOARD REVIEW
F. CHARLES BRUNICARDI
Me
Graw Dana K. Andersen •Timothy R . Billiar •Karen J. Brasel •Lisa S. Dresner
Hill John G. Hunter •Lillian S. Kao •Jeffrey B. Matthews •Raphael E. Pollock
SCHWARTZ’S
PRINCIPLES OF SURGERY
ABSITE and Board Review
Associate Editors
Dana K. Andersen, MD, FACS Lisa Dresner, MD, FACS
Senior Scientific Advisor Program Director and Vice Chair for Education
Division of Digestive Diseases and Nutrition Associate Professor of Surgery
National Institute of Diabetes and Digestive and Kidney Disease Department of Surgery
National Institutes of Health College of Medicine, SUNY Downstate Health and Sciences University
Bethesda, Maryland Brooklyn, New York
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CONTENTS
17 Breast 137
This 11th edition of Schwartz’s Principles of Surgery: ABSITE and Contributors of the primary book have updated the questions
Board Review marks a new milestone of excellence in surgical for each chapter since the last edition in an effort to continue to
education for the betterment of craft, quality of care, and the edification provide a high level of review on the most up-to-date information
of surgical students and colleagues alike. With 870 questions and techniques currently taught and employed in the operating
spanning the 54 updated chapters of this edition, including five new theater. We have maintained the proven format of providing the
chapters, Optimizing Perioperative Care: Enhanced Recovery and answer-bearing portion of the text immediately following the
Chinese Medicine, Understanding, Evaluating and Using Evidence question and answer as an efficient method for reinforcement and
for Surgical Practice, Ambulatory Surgery, Skills and Simulation, recall. The user may read the question followed by the answer as a
and Web-Based Education and Implications of Social Media, this is form of review, or by covering the right-hand column of the page,
the comprehensive companion text for reviewing and assessing the the user can complete the questions in a more authentic test format
information compiled in the main textbook and for preparation for and uncover the answers for review/scoring.
the American Board of Surgery In-Training Examination (ABSITE)
and Board Review.
ix
To Jason Malley, Peter Boyle, Catherine Saggese, and all at McGraw We wish to thank Katie Elsbury for her dedication to the
Hill, we are thankful for the continued belief in and support for organization and editing of this book.
this book. F. Charles Brunicardi, MD, FACS
xi
W
E reached the riverside—it looked merely a stream—and
found our boat, with the luggage already aboard, looking
most unpromising, despite the efforts of our men. It was a
small river craft about eight feet broad. Bamboo matting not more
than five feet high formed our house-room, with a few planks for a
door in front. Fragments of matting made a partial screen in the
centre. The floor was of a rudimentary character, just a few boards
with large gaps between them, through which one could study the
depth of water over which our luggage was precariously poised on
low props. In order to prevent all our small things from dropping
through the floor, we spread over it our invaluable sheets of oil-
cotton (a kind of waterproof largely used everywhere in China), and
fastened up a curtain at each end of the tiny boat to secure a small
amount of privacy. There was just space for our two carrying-chairs
and our mattresses. One of the chairs we used as a wardrobe, and
the other as a store-cupboard. The bamboo chairs we had procured
at the penitentiary of Chengtu, despite the advice of our friends, as
we found sedan-chairs very irksome, and decided that open ones
would be more comfortable and enable us to see the country better.
With long fur coats and foot muffs we felt that we could brave the
cold, and there was always the resource of walking if we got too
chilly. We never for a moment regretted our decision, and we found
that the men carried the open chairs far better than the heavy
closed ones. We profited at once by the exchange, as they were able
to be used for going to Mount Omi, and we were carried some
distance up the mountain. Under the seat was a box in which we
could carry all our small things, and the coolies hung their coats,
hats, &c., on the back.
As our room was so small we sat mostly on the floor, so as to
have everything within reach without getting up. The cooking was a
somewhat difficult matter, as the brazier on which it was done was
only six inches in diameter, and rather apt to burn a hole in the floor
if it was heated sufficiently to do any cooking. We were glad of its
warmth, as the weather was very cold. Chopsticks were evidently
the correct fireirons, and are just the right size to match the
charcoal. With practice I got fairly expert at making palatable dishes,
as naturally the range of the menu was much limited. From this time
onward I did all the cooking, and I cannot help attributing to this
fact mainly the excellent health we enjoyed throughout the whole
journey.
It was on his way from Chang Te to Mount Omi that the
unfortunate Lieutenant Brooke was murdered by Lolos about a year
later than we were there. We were strongly warned about the care
requisite in dealing with Lolos, and told that it was imprudent even
to mention the name in public, as it is considered a term of
reproach. It was suggested that we should spell it if desirous of
speaking of them. Their country is marked on the maps as
“Independent Lolos,” and covers about 11,000 square miles: no
Chinaman dare penetrate into it without the safe-conduct of a Lolo.
Their speech, dress, customs, religion, and laws are entirely different
from those of the Chinese. No one has yet come into sufficiently
close contact with them to ascertain even approximately the number
of Lolo tribes in existence at the present time, speaking different
dialects. What was true at the time that Baber explored Western
Szechwan is equally true to-day—that practically nothing is known
about them. He gives a graphic description of the Lolos whom he
met, which I quote at length: “They are far taller than the Chinese;
taller probably than any European people. During the journey we
must have met hundreds of them, but we never saw one who could
be called, even from an English standard, short or undersized. They
are almost without exception remarkably straight-built, with thin
muscular limbs. Their chests are deep, as becomes mountaineers:
the speed and endurance with which they scale their native
mountains is a prodigy and a proverb for the Chinese. Their
handsome oval faces, of a reddish brown among those most
exposed to the weather, are furnished with large, level eyes,
prominent but not exaggerated cheekbones, an arched but rather
broad nose, an ordinary mouth, somewhat thin-lipped, and a pointed
and characteristic chin from which the beard has been plucked. The
same process has denuded the upper lip, which is of good
proportion. Their teeth are remarkably white and regular, a
preservation for which they account by asserting that they never eat
roast meat, but always boil their food. Perhaps the most marked
character of their faces is a curious tendency to wrinkles, especially
on the forehead, which is low, but broad and upright. The lowness
of the features may be merely an illusive appearance, since it is
overshadowed by a peculiar style of hairdressing. With very rare
exceptions the male Lolo, rich or poor, free or subject, may be
instantly known by his horn. All his hair is gathered into a knob over
his forehead, and then twisted up into a cotton cloth, so as to
resemble the horn of a unicorn. The horn with its wrapper is
sometimes a good nine inches long.” Baber mentions slave raids
made by the Lolos to capture Chinese children, whom they usually
bring up like their own children. They tattoo the slaves on the
forehead with a blue cross. Apparently it is to have a place of safety
in case of such raids that the Chinese have built towers like the one
I have sketched on the borders of Yünnan. Many of the customs of
the Lolos are peculiar and interesting, and the position of woman is
far above that enjoyed in China. The birth of a girl is more highly
esteemed than that of a boy, and a stranger introduced by a woman
Lolo has the best possible guarantee. Baber considered that a
European would be quite safe in Lololand if properly introduced and
of honest character. The most experienced and successful travellers
always seem to emphasise the importance of the latter fact.
We were escorted by two soldiers, as usual. Our progress was
far from rapid, as the river is extremely low at this season. For the
first two days we were generally able to see to the bottom, and
often we scraped the stones if we did not actually stick fast. The
men seemed to spend nearly as much time in the river, pushing and
pulling us, as on the boat. It was a picturesque and interesting
journey, as we continually came to the dams made for irrigation
purposes. We much regretted that we were unable to visit Kwan
Hsien (thirty-six miles north of Chengtu), where the system of
irrigation of the plain can be seen at its source. As we were short of
time, and also heard that we should not see much at this time of the
year, it did not seem worth while going there. The Min River flows
from the Min Hills, and just near Kwan Hsien a cutting was made in
order to divide it into two large branches. These again were
subdivided into many others, forming a network to irrigate the whole
of the plain in which Chengtu lies. This was done by an able
governor more than 200 years b.c., and the original system, which is
still in use to-day, has turned an unproductive plain into one of great
fertility. Naturally, there have been many improvements made in the
course of centuries, and dams and dikes have been erected to
regulate the flow of water. We were able to see quite a number of
these after leaving Chengtu, and to marvel at their simple and
successful construction. They are mostly made of bamboo crates,
filled with stones, and rising about three feet above water. These are
placed in long lines, and the temporary dike is made of sand. The
channels have to be cleaned regularly, and large sums have to be
spent on repairs. The farmers pay a tax of about ½d. an acre, and,
in order to get the money in regularly, they are compelled to pay
double if it is not paid before a certain date. For about a month
yearly the river below Chengtu is closed, and there is always a great
crowd of boats at that time, both above and below the dam, waiting
for the re-opening. The opening of a big dam, such as the “Frog’s
Chin,” is an imposing ceremony, preceded by a day of worship at the
temples and the inspection of dikes. All the officials attend, and
when the sluice is opened the runners of the officials lash the water,
and the women and the children throw stones in to make the water
run faster to irrigate the fields!
HOUSE ON MIN RIVER
Throughout the plain there are many water-wheels to raise the
water to higher levels, and some also are apparently used for
grinding corn. At the close of our first day’s journey on the river
there was a great deal of loud talk when we halted for the night,
added to the tiresome beating of the drums by the night watchmen,
who patrol the towns and big villages all night long. It turned out
that a man had come to try and persuade our captain to undertake a
bigger job than ours. On being warned that the interpreter would
hear what he said, he remarked that it did not matter, as he would
not be able to understand the dialect. Mr. Ku, however, had studied
the dialect when he was at college, and thoroughly understood the
plan that was being devised. This was that we should slip down the
river in the middle of the night, while the escorts were away sleeping
at the inn. Then some story would be trumped up that the boat
could not take us any farther, and we should have been obliged to
find another one. Mr. Ku had the good sense to go ashore at once
and apply to the Yamen for a couple of soldiers to come and sleep
on board, so that there was no opportunity for the captain to
undertake the new job even if he had been willing to do so, and we
had no further trouble. Certainly, one could hardly be surprised if the
captain wished to make a little more money, for he receives about
6s. for a trip which lasts four days, and out of this money he has to
pay and feed two other men besides feeding our two. We hear that
a man can live (without starving) on a penny a day for food, and the
regular allowance of soldiers is only 2d. per day.
We passed many picturesque villages, some built in lath and
plaster, which, at a little distance, might almost have been taken for
Cheshire villages, if it were not for the beautiful blue figures flitting
about; for blue is the universal colour of the clothing here. We were
much interested to see a large number of fishing cormorants at one
place; but unfortunately they were not at work. Very light rafts are
used for this purpose, turned up at one end, as in the sketch. We
also twice saw otters used for the same purpose. The Chinese
declared to us that the otter brings the fish up in its paws, and not
in its mouth; but they always invent an answer so glibly to your
question, whether they know the answer or not, that I should
certainly not believe the above without further corroboration. We
were surprised to see in one place that the cormorants (after diving)
were fished up to the surface in baskets very much the same shape
as the birds, and evidently made for the purpose.
OTTER FISHING ON MIN RIVER
About forty miles below Chengtu, the two main branches of the
river unite and form something more worthy of the name of river.
The branch which flows through Chengtu is called the “Walking
Horse River” at its division from the main current—a very dangerous
spot for navigation, and one where there are constant disasters. It is
said that the rafts generally carry coffins with them in consequence;
and certainly the number of those carrying coffins which passed us
going upstream gives colour to the story. It was curious to see the
boats being towed along by men walking beside them in the water
harnessed as trackers. Lower down, the river becomes deeper, and
some of the rapids look very pretty, as the water is a bluish-green
colour and the rocks are red sandstone. Sometimes the road from
the riverside leads up precipitous hills by long stone staircases. The
reflections of the common blue clothes of the people, as seen in the
river, are an exquisite turquoise colour. The scenery becomes
increasingly beautiful as one proceeds down the river. Our escort
was changed daily, and one man brought a fowling-piece on board
with which to beguile the time. He tried to shoot the wild ducks,
which are the size and colour of our tame ones, but he had not the
smallest success. We were interested to see the loading of the
weapon, which had a piece of smouldering rope finally thrust down
the barrel, preparatory to its being fired off. The gun had to be
balanced on a bundle of sticks while careful aim was taken at a very
near bird sitting quite still. Even then, the bird was in no danger, so
far as we could see, but ineffectual attempts to shoot kept the man
busy all day. The soldier wore a silver ring, of which he was
extremely proud. This had to be entrusted to the other soldier each
time that he fired his weapon. Part of the way we had police
boatmen, who spent some time in rowing, and were of material
assistance to us; but unfortunately this was only a rare occurrence.
Kiating was the first large town we reached, and here we left the
boat in order to make our expedition to Mount Omi.
CHAPTER XVII
Mount Omi
W
E reached Kiating in the morning, and set to work at once
on our preparations for the next day. The people there
considered us very extraordinary for wishing to make the
ascent at such an unusual time of year, and told us that it would be
worse than useless, for we should certainly see nothing at all from
the top. They pointed out how arduous an ascent it would be, as the
snow would make climbing extremely difficult. The weather had
been cloudy for some time, and we were in the land of mists, but
nothing would deter us from our intention. We had read
discouraging accounts of other travellers who had been up there,
and it certainly sounded as if we should find the ascent beyond our
strength, but we determined, at all events, to try. We arranged to
take as little luggage as possible, but it was necessary to take food
for six days, as on the sacred mountain there are no inns. There are
plenty of monasteries, which give you reasonable accommodation,
but it was quite unlikely we should get food there. The first day we
travelled across the plain some twenty miles to the foot of the
mountain. The scenery was pretty, but nothing remarkable was to be
seen at this time of the year. One of the principal objects of interest
is the white wax tree, a sort of ash, called by the Chinese “Pai-la-
Shu.” The white wax insects are bred in the celebrated valley of the
Chien-ch’ang, some 200 miles away among the mountains. When
they reach the right stage of development they are put in paper
boxes, in bamboo trays, and brought to the plain of Kiating by the
swiftest runners. These men only travel by night, as it is essential
that the process of development should not proceed too rapidly. The
boxes have to be opened every day and ventilated, and the men
secure the best rooms in the inns, so that other travellers have much
to suffer if they are on the road at the same time. Finally, the
education of the grub is finished in the plain round Kiating.
TIGER SHRINE
It was interesting to find on Mount Omi the two great Chinese
symbols of power, the dragon and the tiger. As Laurence Binyon puts
it: “In the superstitions of literal minds the Dragon was the genius of
the element of water, producing clouds and mists; the Tiger the
genius of the Mountains, whose roaring is heard in the wind that
shakes the forest. But in the imagination of poets and of artists
these symbols became charged with spiritual meanings, meanings
which we should regard as fluid rather than fixed, and of imports
varying with the dominant conceptions of particular epochs. In the
Dragon is made visible the power of the spirit, the power of the
infinite, the power of change; in the Tiger the power of material
forces.”
It is worthy of note that the Buddhists selected mountains
already sacred, where they might establish themselves and form
Buddhist sanctuaries. They tolerated the gods in possession, so that
they still continue to be worshipped simultaneously with the Buddha.
The mixing up of religions is seen everywhere in China, but nowhere
did we notice it so grotesquely carried out as here. We counted no
fewer than twelve tiger shrines on the way up the mountain, many
of them with vivacious beasts half out of their shrines, as if they
were tired of their rôle and were meditating a raid on their
worshippers. In the evening the Abbot had prepared a feast for us,
but we declined it, so he sent in a tray of nuts and sweets instead.
The following morning we set off betimes on foot, and very soon
the coolies left the carrying-poles behind, and were obliged to carry
our chairs on their backs. Soon the steps became almost continuous
and increasingly slippery. The longest flight was over 1200 steps,
and as the steps sloped downwards and were covered with ice the
ascent was most fatiguing and toilsome. The day was grey and
cloudy, but the shifting mists revealed crags and abysses, and all
along our path there was a wealth of lovely shrubs—camellias,
rhododendrons, bamboos, and ferns. The frost had coated
everything, and the leaves were reproduced in ice, looking exactly
like clear glass; sprays of dead blossom, tall grasses, delicate ferns,
everything was duplicated in ice, and the slight thaw early in the day
detached this ice from the vegetation. We were sorry not to see in
full beauty the flowers and ferns for which Mount Omi is justly
celebrated, but it would have been impossible to conceive anything
lovelier than what we did see.
Our midday halt at a monastery was provokingly long, as the
men’s food had to be cooked, so that we did not start for a couple of
hours. The sight of fowls here was a pleasant surprise to us, as the
Buddhists obviously could have no use for them and our larder
needed replenishing. We secured some eggs, and asked for a fowl
also. When we came to pay for it, however, the monks said that they
did not sell anything. If we liked to put our names down on their
subscription list (which a monk forthwith produced) for the
restoration of the monastery, we should be welcome to a fowl as a
gift, not otherwise. We set out again, and found our way grow more
and more precipitous and slippery. We met Tibetan pilgrims, a wild
and fierce-looking company, toiling painfully upwards like ourselves,
or slithering down. All these are welcomed and entertained in the
monasteries. Our soldier escort was evidently very much afraid of
them, and had a great deal to say of their evil doings, warning us to
keep close together and close to himself. As I approached a group of
pilgrims in one of the monasteries, in order to watch a man blowing
up his fire with a goatskin bellows, one of them scowled at me and
waved me away, as if he feared our sharing his thieving propensities.
This is the season for Tibetan pilgrims, and many of them had
travelled far, bringing their beasts of burden with them. The Chinese
pilgrims come in the spring, and there was a big pilgrimage ten
years ago—so a monk told us. The air grew intensely cold and
dense, and, as twilight fell, our men urged us to halt about two
miles short of the summit, where there was a good monastery. To
this we willingly agreed, the more so as my breathing had grown
extremely difficult, and I was beginning to feel at the end of my
strength. Our lofty room was clean and well built, and the ten beds
around it all stood empty. Soon a large glowing brazier was brought
in, and we were thankful not only to get warm, but also to dry our
clothes, which were heavy with mist.
Mount Omi is 11,000 feet high, and Kiating is only 1200, so we
had come into a wholly different temperature, and when we woke in
the morning it was to find everything frozen hard—sponges like
boards, oranges as hard as bullets, and the water in my sketching-
bottle a lump of ice. But the sun was shining brilliantly, and the
mountain-top was a dazzling vision of loveliness emerging from a
vast ocean of clouds. It took us about an hour to arrive at the
summit, and the priest told us that as the sun shone we were
evidently good people. This was highly satisfactory, as so many
people thought us fools for attempting the ascent at this time of
year, telling us of all the people who had toiled to the top and seen
nothing. We anxiously inquired at what time of day we could see
“Buddha’s Glory,” a sort of Brocken spectre which is rarely seen by
travellers, and which we were told could not be seen at all at this
time of year. Standing on the edge of the summit, you look down a
precipice of more than a mile, and we could only feast our eyes on
the ever-changing scene, the clouds looking as if they were boiling
up from some hidden caldron, now concealing, now revealing the
peaks of distant mountains. On a clear day the far-distant snowy
peaks of Tibet are visible, and the glorious fertile plain out of which
the limestone peak of Mount Omi rises.
SUMMIT OF MOUNT OMI
I established myself in a sunny nook under the temple eaves,
and sent for hot water with which to sketch the neighbouring crag of
the “10,000 Buddhas.” After lunch I sketched the interior of the
Buddha shrine with all its gaudy, squalid trappings, a harmony in
reds. I was amazed to see the brevity of the worshippers’ prayers;
owing, I think, to their fear of my introducing them into the sketch.
The three figures of the Buddha were behind a large red curtain, in
which were openings through which they could be dimly discerned.
We went back to our former quarters for the night, but had very
little rest, as the coolies went in for a night of revelry, in which we
felt sure the monks shared, although our suggestion to that effect
next day was vehemently repudiated. The descent of the mountain
we found extremely arduous, despite our being shod with straw
sandals and having the support of our pilgrim sticks; it was
dreadfully slippery, and for six and a half hours we toiled steadily
down flights of steps, or glissaded down them on our backs. We
calculated the distance as not much less than twelve miles. The
stiffness produced was not quite so bad as I had anticipated, but it
makes you feel extremely foolish to have to watch each step you
take in order to be sure that your feet are obeying your bidding.
Then you see the coolies pick up the chairs and carry you for
another three hours after you are dead beat as if they had done
nothing. We spent the night at a clean new inn about three miles
from the town of Omi, and for the first time we occupied an upstairs
bedroom in a Chinese house. After this occasion we always used to
try and secure one, but our stiffness then made it extremely painful
to get up the steep staircase. It was like mounting into a loft, and
was a very pleasant variety from any inn we had yet encountered.
The following morning we made an early start, so as to have a
little time in Kiating to collect our belongings and go on board a boat
to take us to Sui Fu. Our temper was sorely tried by the delay of our
men and the changing of some of them at Omi Hsien, which delayed
us about an hour. By dint of offering extra pay, however, we made
up some time, and came upon an interesting sight to beguile us on
the way—namely, cormorants and an otter fishing. When we got to
the Tong River—the third river that we saw at the base of the
mountain—we were rowed down to Kiating, a distance of some four
miles. We were curious to see what the coolies would pay for the
boat journey, as they had arranged the matter. For the four chairs
and the eighteen people, the whole cost was thirty cash—namely,
three farthings. We got back to Kiating soon after four o’clock, and
found that our friends had kindly got everything ready for our
departure. The thought of two quiet days on the boat was not
unacceptable after a somewhat laborious but entirely satisfactory
trip up Mount Omi, and it was many days before we recovered from
our stiffness. Owing to mist, we did not see the impressive view of
Mount Omi as it rises from the plain.
CHAPTER XVIII
From Szechwan into Yünnan
T
HE boat in which we continued our journey down the Min
River was rather larger than the one we had previously, but
still we could not stand upright in it. It is not always easy to
get just what you want in the way of boats, especially at this time of
year; but it was not a long journey, although our men took about
four times as long as they ought to have done, and it was only by
offering extra payment that we managed to do it in two days. We
had one piece of good luck on the way. Our kind friends at Chengtu,
when replenishing our stores, had lamented the non-arrival of a
large case of biscuits sent out by friends in England, mentioning the
name of the firm from which they were coming. As we neared Sui Fu
we were watching divers getting up cases which had evidently been
shipwrecked, and conspicuous amongst them was a large case
bearing the name referred to. On arrival at Sui Fu we reported this
at the mission station where we stayed, and learnt that they had
heard of the wreck and sent to inquire whether the case had been
got up. Shortly afterwards their messenger returned, saying that it
could not be found. Our information being explicit, we described
exactly the spot where we had seen the wreck, a few miles above
the town; the man was sent again and told that he must bring the
case, as we had seen for ourselves that it had been got up. This
time he returned in triumph with it. Probably the divers thought that
they would get a better price by selling the contents, and if we had
not seen it our friends would not have seen it either.
The town of Sui Fu is most charmingly situated, lying at the
junction of the Yangtze and the Min rivers, and is enclosed in a fork
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