Dr. J. B. Nichols for examination; the pathological report was "Large round cell sarcoma."

The interscapulothoracic amputation was decided upon because of the malignancy of the growth, and because it was deemed best to keep as far away as possible from the seat of disease in securing flaps.

TECHNIQUE OF OPERATION.-Nitrous-oxide-ether anesthesia by Dr. Abbe. The first incision was made from the acromion to the insertion of the sterno-mastoid muscle, and the periosteum of the clavicle with its muscular attachments was dissected off the clavicle was next divided with a Gigli saw at the junction of the middle and inner third. After freeing it from all attachments it was grasped with heavy forceps and forcibly twisted back and removed from its union with the scapula. The subclavian artery and vein were next exposed by a careful dissection and separated. Two heavy silk ligatures were placed on the artery and tied, and the artery cut between them. Three additional ligatures were placed on the proximal end for safety, as the

vessel seemed very friable. The arm was then elevated to allow it to empty itself, and the vein was tied and cut between ligatures. A second incision was now made from the acromial end of the first incision around the shoulder, across the axilla and terminating at the lower angle of the scapula, and the tissues divided. The big nerve trunks of the brachial plexus were injected with a few drops of a one per cent. solution of cocaine before division, after the method of Crile and Cushing, and divided at the point of injection, and the axillary gland and surrounding tissues were removed. A third incision was now carried from the junction of the first and second over the dorsum of the scapula and meeting the second at the lower angle. The scapula with its muscular attachments was quickly dissected out, bleeding points ligated; a hot compress stopped all oozing, and the wound was closed with interrupted silk-worm gut, with a rubber-tissue drain in the lower angle. There was absolutely no shock, and no loss of blood save a little remaining in the removed extremity, and the patient left the table in excellent condition. Time, 1 hour 10 minutes.

The drain was removed on the third day and recovery was uneventful up to the seventh day, the patient sitting up on the sixth. On the seventh day she went into a profound stupor, at first not clearly understood, but soon recognized as due to cerebral embolism. July 4, the third day of stupor, the condition was much improved and the stitches were removed. July 9th she was much improved, smiled and talked a little. 11th, embolism symptoms much worse, face drawn, involuntary stools and urination; limbs responded slowly or not at all to irritation; she took nourishment but could not talk. On the 12th the temperature suddenly rose to 108.6 and as quickly dropped again, showing that the heat centers were involved, as there was no corresponding rise in either pulse or respiration. She died July 15, three weeks from day of operation.

The important points in the operation are, the control of hemorrhage and the prevention of shock from dividing the great nerve trunks. Death from this operation will usually be due to shock with or without hemorrhage. In my case it was shown that shock could be prevented entirely by controlling hemorrhage so that practically no blood was lost, and by adopting the method of Crile and Cushing, of injecting a weak solution of cocaine into

the large nerve trunks of the brachial plexus before dividing them. It is a well known fact that one of the great factors in shock from surgical operations is the division of the great nerve trunks, the brachial plexus, the sciatic and anterior crural nerves. Crile has shown by his experiments and practical work that if, before dividing the nerves, a few drops of a weak solution of cocaine be injected directly into the nerve trunk, the division of the nerves has no perceptible effect on the pulse rate or volume. Cushing has written at length on the prevention of shock in major amputations by the use of this method, and reports two cases of interscapulothoracic amputation in which he had used it with apparent success. Lund reports a case of this form of amputation for sarcoma in which he followed this method, and in his opinion it was very effective.

The difficult part of this operation, and the part which took the longest time, was the ligating of the subclavian artery and vein preliminary to removing the extremity. The dissection was necessarily slow and careful, but was much facilitated by the subject not being large or fat, and by the entire absence of disease in the clavicular region, so that the dissection was through normal tissues.

The control of hemorrhage is an all important factor in this operation, and that method which most speedily and safely exposes the third portion of the subclavian artery and vein should be adopted. The method of resecting the clavicle at its inner third was chosen because no good reason was seen for adopting the more dangerous method of disarticulating the clavicle at the sternal joint, and the operation as outlined is essentially that described by Berger in 1887.

LeConte enumerates as many as eight or nine different methods of controlling hemorrhage, several of them depending upon compression of the subclavian vessels with or without resection of the clavicle. Most of these are uncertain and unsafe. There are .only three surgical ways to efficiently control the hemorrhage : 1. Ligation without resection of the clavicle. 2. Ligation after removal of the outer of the bone. 3. Ligation after disarticulation of the clavicle from the sternum and removal of the entire bone. LeConte has written at length advocating this latter method. His reasons are that it is needed to give the best exposure and decreases the accidents of ligation. The writer can

see no reason for choosing this method except in cases of large tumors encroaching upon the tissues at the base of the neck, in which cases it may be doubtful whether any operative procedure is justifiable. Disarticulation of the clavicle at the sternal end must invariably be a more dangerous procedure than resection at the junction of the inner and middle thirds; the risk of wounding the innominate vein or the pleura is considerable; the attachments of the sternomastoid are practically gone, and the deep fascia of the neck in all probability opened. From the writer's limited experience it would seem that the method of choice in those cases where operation is justifiable, is the subperiosteal resection of the clavicle at the junction of the middleand inner thirds preliminary to ligation of the vessels. This method will give room enough.

As regards the statistics previously quoted, if the patient is in sound physicial conditions in other respects, and the growth is limited to the arm or shoulder, with little infiltration into the tissues at the base of the neck, and if in the operation proper technical attention is given to the control of the hemorrhage and the prevention of shock as described above, it would seem rational to say that in the great majority of cases this operation can be done with safety, probably with just as much safety as amputation of the upper extremity at the shoulder joint.

Dr. Balloch said that he had had the pleasure of witnessing the operation and of watching the progress of the case. He had been struck by the ease with which the subclavian was exposed for ligation by resection of the clavicle; Dr. Hasbrouck certainly made no mistake in choosing this method of approach. Dr. Balloch's interest had been especially aroused by the complete absence of shock following the cocainization of the nerve trunks; the case completely bore out the value of the nerve block as advocated by Crile and Cushing. The site for amputation was well chosen, and the unfortunate termination from embolism could not be foreseen and cast no discredit upon the operation. Dr. Hasbrouck was to be congratulated upon the ease and smoothness with which the operation was done.

Dr. Jas. F. Mitchell said that he was particularly interested by the remarks on cocainization of the nerve trunks. He had had the pleasure of assisting Cushing in his first cases in which the method was used. Dr. Mitchell recalled very well a case of roundcell sarcoma of the humerus: in the amputation the brachial plexus was divided twice; at the first division the pulse chart

showed a very sudden jump in the rate, with evidences of shock; at the second division of the nerve trunks, the same phenomena occurred and the patient was taken from the table in collapse. He subsequently recovered. The second case was encountered while hunting in Pennsylvania, and the man was persuaded to go to the Johns Hopkins Hospital for operation. The condition was sarcoma of the shoulder following an injury. The operation was done by the method of Crile, and while the same technic was followed as in the first case, under cocainization of the nerve trunks the pulse rate ran level throughout the whole operation, which consumed the same length of time as the other. Since then he had himself done the amputation twice and had witnessed two others, all without shock, which is the all important accident to avoid.

Most of the cases of sarcoma in this region which he had seen had recurrences after the amputation; the prognosis, therefore, is unfavorable.

CASE OF ECTOPIC PREGNANCY.*

By J. THOMAS KELLEY, M. D.,

Washington, D. C.

Mrs. A., white, age 32; menstruated first at 14; always regular, medium amount and painful.

Two

She married two years ago; no children, no miscarriages; very anxious for children. August 24, 1906, was the time for menstruation and there was a slight show for a few minutes. days after, having walked in the country a good distance, the flow came on very profusely with violent pains in right side. A physician was called in and made a diagnosis of appendicitis and put on an ice-bag. She remained abed more or less during the next month, bleeding continuously from the uterus. Dr. Acker called me in to see her. On examination I found the uterus slightly enlarged, a moderate amount of flow, and a small mass on the right side, probably a tube. There seemed to be only a small quantity of blood in the pelvis, and hoping this would be absorbed, I agreed to curette the patient after two days. The next morning she was taken with violent pains in the right side; pulse very

* Reported, with specimen, to the Medical Society October 10, 1906.