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This month, three years ago, I had the honor of showing 
a case of interscapulo- thoracic amputation before the Phila¬ 
delphia Academy of Surgery, and of detailing a new method 
of technique for its accomplishment (Annals of Surgery, 
August, 1899). At that time I had absolute confidence in the 
safety of the method, and the belief that no serious accidents 
could occur during the performance of the operation. To-dav, 
my confidence in the method is still unshaken, provided it is 
carried out with good judgment, but errors of judgment may 
bring about complications of the most serious character. It is 
for the purpose of detailing mv own errors in this line that I 
again bring up the subject. 

The safety of this operation for malignant disease lies 
in the control of haemorrhage, particularly of the venous bleed¬ 
ing, for in some cases the venous channels exposed are as large 
as the ascending cava. For the purpose of exposing these 
veins as thoroughly as possible. I have advised the disarticu¬ 
lation of the sternal end of the clavicle instead of a resection 
of that bone. When the veins are of normal size, the opera¬ 
tion may perhaps be performed safely by either method; but 
when the veins are enormously increased in size, the greatest 
exposure of the part gives none too much room for their liga¬ 
tion. It was at this point of the operation in the following 
case that I erred in judgment, and my errors nearly cost the 
patient his life. 

1 Read before the Philadelphia Academy of Surgery, May 5, 1902. 




T. D., aged eighteen years, white, school-boy, born in Phila¬ 
delphia, was admitted to the Pennsylvania Hospital, April 2, 
1902. Family history negative. He has always been quite healthy, 
though never very robust. 

Present Condition .—One year ago, while at school, he was 
frequently pummelled on the right arm by some of the boys, 
causing a feeling of soreness for several days. During the sum¬ 
mer, while playing baseball, he noticed that he could not throw 
as far as formerly, and as time went on his ability to throw a 
ball diminished. In October he noticed a stiffness of the arm, 
with a tendency to flexion at the elbow, with slight pain on mo¬ 
tion. Not until January was he aware that the arm was increasing 
in size. This enlargement was at first gradual and painless, and 
the flexion at the elbow increased slowly until two weeks before 
admission, when very rapid growth set in, accompanied by severe 
pain, especially at night, and a feeling of discomfort and distress 
from the weight and bulk of the arm, which rendered the limb 
useless and overbalanced him when moving about. 

On admission the patient was pale, very slightly built, weigh¬ 
ing 118 pounds; eyes prominent; temperature and respiration 
normal, but cardiac action much accelerated, pulse ranging from 
120 to 130; no murmurs present. Lungs, other organs, and 
urine negative to examination. Blood count: red blood-cor¬ 
puscles, 5,136,000; white corpuscles, 12,400; haemoglobin, 87 per 
cent. The prominent eyes with rapid heart action were strongly 
suggestive of exophthalmic goitre. 

The right arm reveals a growth about the size and shape of a 
large ham. (Figs. 1 and 2.) The tumor seems limited to the 
confines of the humerus, as the forearm, shoulder, and axilla are 
not visibly affected. Axillary glands not enlarged. The growth 
is hard and tense, and the skin over it brawny and markedly 
striated. The elbow is flexed almost to a right angle and cannot 
be extended. Movements of the hand and fingers on the affected 
side are limited, with a very pronounced wrist-drop, and a weak 
radial pulse. 

Measurements. —Circumference: Right elbow, twelve and 
one-half inches; left elbow, nine inches. Right biceps, twenty- 
two inches ; left biceps, eight inches. Right axilla, fifteen inches ; 
left axilla, twelve and one-half inches. 

April 24, ether administered. An incision was made through 

Fig. 2.—Same patient, side view. 



the skin and superficial fascia from the sternum, along the clavicle 
to its middle, and then curved downward to the anterior axillary 
fold. The clavicle was disarticulated from the sternum with 
blunt, curved scissors, the rhomboid ligament and the clavicular 
portion of the sternomastoid muscle were divided, and the clavicu¬ 
lar portion of the pectoralis major separated with the finger from 
the costal portion of that muscle up to the anterior axillary fold. 
The clavicle was now pulled upward and the subclavius muscle 
divided at the first rib. The pectoralis minor was then exposed, 
divided, and the coracoid portion reflected upward with the clavi¬ 
cle. Enormous venous channels immediately presented surround¬ 
ing the anterior scalene muscle. A careful dissection revealed 
that the greatly enlarged cephalic vein joined the subclavian just 
in front of the anterior scalene muscle, and the vessel formed by 
this union was from an inch to an inch and a quarter in width. 
An attempt was made to expose the third portion of the sub¬ 
clavian artery or the first part of the axillary by retracting the 
veins, but it failed, and the vessel could not have been ligated 
in these positions unless the great venous channels had first been 
dealt with and severed. If the artery was to be secured first, and 
the blood in the arm saved to the patient, it seemed to me neces¬ 
sary to pass the ligature at about the junction of the first and 
second portion of the subclavian. This was done, and the vessel 
firmly secured with a chromicized catgut ligature, but unfortu¬ 
nately the pleura was also opened. In the presence of such enor¬ 
mous veins, which were now very turgid and flaccid with every 
inspiration and expiration, the noise of the air rushing in and 
out of the pleura was most alarming and terrifying, resembling 
my ideas of the sound of air entering a vein. A gauze sponge 
was packed deeply in the cavity over the pleural rent, the arm 
was elevated, and ligatures were passed around the veins,—-one 
around the subclavian at a point which corresponded to the first 
portion of the artery, one at its distal portion before it had been 
joined by the cephalic, and one around the cephalic. These liga¬ 
tures were tied when the arm had become fairly well blanched, 
and the vessels, together with a part of the brachial plexus of 
nerves, were divided. The ligature around the cephalic vein 
slipped and the wound was instantly flooded with blood. The 
haemorrhage was quickly stopped with the finger and the vessel 
secured with two haemostatic forceps and ligated. While dividing 



the remainder of the brachial plexus of nerves, another large vein 
was opened, which produced a very alarming haemorrhage. This 
was also controlled by direct pressure, and the vessel secured with 
haemostatic forceps and ligated. It proved to be a large commu¬ 
nicating branch from the cephalic to the jugular vein. These two 
haemorrhages occurring with such a short interval between, and 
with the loss of several ounces of blood in a few seconds, rendered 
the condition of the patient most precarious. He was almost 
pulseless, and respiration was shallow and irregular. Hypoder¬ 
mics of strychnine and digitalin were given, while an assistant 
opened a vein in the left leg and introduced two quarts of hot 
normal salt solution. During these procedures the rent in the 
pleura was stitched up with catgut, the patient turned on his 
left side, and an incision dropped to the lower angle of the 
scapula and up to the anterior axillary fold. The scapula was 
rapidly freed from its attachments, and the two skin incisions 
joined through the axilla, completing the detachment of the 
upper extremity. Three or four vessels required a ligature. The 
wound was closed with silkworm gut, a rubber drainage tube 
coming out at the lower angle, and at the sternal angle a wick 
of gauze led down to the pleural rent. The time of operation 
was fifty-five minutes, and the patient’s condition at the close 
was fairly good. 

For a week following the operation the patient’s temperature 
ranged from 99 0 to ioi° F., the pulse-rate from no to 140, 
the cardiac action being accelerated under the slightest exertion. 
On the third day the gauze wick and the drainage tube were 
removed, and on the ninth the stitches were taken out, and the 
wound found in excellent condition, with good union. At both 
these dressings there was evidence of a right-sided pneumothorax 
of slight degree, the expansion of the chest being about equal 
on both sides, and the heart in its normal position. Dr. Frederick 
A. Packard very kindly saw the patient with me, and concurred 
in the belief that Graves’s disease was also present. For these 
reasons the patient has been kept quiet in bed, and will now be 
placed on small doses of suprarenal gland. Dr. Longcope, the 
resident pathologist of the hospital, has kindly furnished me with 
the following notes of the tumor. 

Report of Pathologist, No. S33S-—The specimen consists of the entire 
right arm amputated with scapuia and clavicle attached. The upper arm 



presents an enormous fusiform swelling reaching from the head of the 
humerus to the elbows. The arm weighs 7000 grammes. The skin over 
the swelling is discolored bluish, and there is a streaking somewhat similar 
to the line* atrophicse of the abdomen. The elbow-joint is slightly swollen, 
but the forearm and hand appear normal. The swelling is hard and firm. 
On section, the tumor is found to be an enormous growth, arising evi¬ 
dently from the periosteum of the humerus. It is fusiform in shape, and 
reaches its greatest thickness about the middle of the humerus, where it 
surrounds the bone in a collar 8.5 centimetres in thickness, being separated 
from the skin only by the superficial fascia and subcutaneous fat. The 
growth is generally firm, pearly white, and slightly translucent, having 
an irregular outline, which in some places is fairly well circumscribe 1, 
but in others appears to infiltrate between the muscle bundles. 

Large ragged cavities occur throughout, often measuring 4.5 or seven 
centimetres in diameter, and being filled with a clear yellow fluid. A por¬ 
tion of the free surface of the bone forms the wall of one of these cavi¬ 
ties. The bone is covered with small, soft, tooth-like elevations which 
project like the quills of a porcupine. Some of them are calcified. Near 
the elbow 7 much of the growth above the bone contains areas of calcifi¬ 
cation. At the upper end the growth has broken through the capsule into 
the elbow-joint and forms a lobulated, firm, gray mass near the head of 
the humerus. 

Both the subcutaneous tissue and muscles are greatly oedematous, the 
muscles being exceedingly pale and streaked. They are all so compressed 
by the growth that the various groups of muscles cannot be distinguished. 
The branches of the brachial plexus are compressed by the growth, and 
the musculospiral nerve is lost entirely in the tumor mass. The vessels 
are clear. The axillary glands are enlarged, often the size of beans, 
oedematous, and soft. No macroscopic areas of growth are found in them. 
The growth does not involve the clavicle or scapula. The subscapular 
muscle is unaffected. 

Section through the newer portion of the growth, which is invading 
muscle, shows it to be composed of large, irregular, and round cells 
grouped in a somewhat ill-defined alveolar arrangement. These alveoli 
are only distinguished by a fine stroma or single capillary which runs 
between them. A very fine net-work of stroma is likewise visible between 
the individual cells. The tumor cells are irregularly round or polygonal 
and vary somewhat in size. The nuclei are even more irregular than the 
cells; usually, they are oval or round and vesicular, the nucleoli being 
distinct, but frequently picknosis is present, or the nuclei are very large 
and pale. Both karyolisis and karyokinesis are common, and here and there 
a large multinucleated cell is seen. 

In the older portions of the growth extensive degeneration has taken 
place; here the tumor cells are confined to areas about the blood-vessels, 
and both cytoplasm and nuclei show great irregularity in size and staining 
qualities. Some cells assume an elongated shape; others are very large 
and multinucleated, and the protoplasm contains large numbers of fat 
droplets or is vacuolated. The muscle surrounding the tumor is the seat 




of an extensive interstitial myositis, large areas of muscle have undergone 
degeneration, and show slight infiltration of small round cells, epithelioid, 
and young connective-tissue cells. The muscle cells lying in mall areas 
between the degenerated portions are very small, irregular, and often 
broken. Their nuclei are greatly increased in number, and the striations 
are usually lacking. 

The lymph glands from the axilla show an endothelioid proliferation 
with enlarged lymph channels. The keimcentra are swollen, but no tumor 
cells can be found. 

Diagnosis— Spindle-celled sarcoma. 

To return to the technique of the operation. When the 
veins were exposed, and it was found impossible to ligate the 
third portion of the subclavian artery or the first part of the 
axillary, it was an error to ligate the subclavian at the junction 
of the first and second portions. Owing to its depth, its close 
relation to the pleura, its partial covering by the vein, and the 
close proximity of the phrenic nerve, such a ligation will 
always be attended by an immediate danger to these important 
structures. Secondly, the short distance from the innominate, 
together with the large branches given off in its first portion, 
subjects the patient to the remote danger of a secondary haem¬ 
orrhage, an event which would almost of necessity mean death. 
The ligation of this portion of the subclavian artery was there¬ 
fore a distinct error in judgment, and led to serious complica¬ 

Two other procedures were open to me, either of which 
would have been safe. First, the veins could have been ligated 
first, and after they had been severed the artery would have 
been readily exposed. This would have lost to the patient the 
amount of blood that remained in the arm, of some conse¬ 
quence, perhaps, but a much smaller risk than the one taken. 
Second, a still better procedure would have been to expose the 
axillary artery as high as possible, certainly its third portion 
and probably its second, and tie a temporary ligature about it. 
Then the arm could have been elevated, the veins ligated and 
severed, and a permanent ligature placed around the third part 
of the subclavian, and the artery severed in this portion. This 
could have been quickly and safely done, and would have saved 
to the patient the blood in the part amputated.