·11 will w SAMUEL WOOD Whose Aron with the shoulder blade was torn oftly a Mill yº 234 of Aug 17:37 He was brought to f* Thomas's Hospital ze ñeat dar where he was Cured, ty 17 Ferna Peblertid by Jamuel Höst Monding to act court Parlement near the

·The
Forequarter Amputation
BY
H. F. MOSELEY
MA,DM, M Ch (Oxon), FRCS(Eng and Canada), FACS
Hunterian Professor, Royal College of Surgeons of
England ; Assistant Professor of Surgery, McGill
University; Associate Surgeon, Royal Victoria
Hospital, Montreal, Canada
ILLUSTRATED BY
HELEN T MACARTHUR, BA
With 11 Plates in Colour
and 25 Figures in Black and White
E. & S. LIVINGSTONE LTD.
EDINBURGH AND LONDON
1957

·THIS WORK IS DEDICATED TO JOHN THOBURN WILLIAMSON BA, MSc, Ph D D Sc Graduate of McGill University, and Canadian Geologist whose scientific knowledge, industry, and spirit of adventure guided him to his life's work in the diamond fields of Tanganyika Printed in Great Britain ·Preface The incentive to assemble these materials for publication originated when three patients requiring a forequarter amputation presented in close sequence On consulting the literature, it appeared that a contribution would be made by providing a short monograph covering the historical aspects, the anatomical considerations, indications, and operative procedures, with the chief emphasis placed on the detailed surgical anatomy of this region as it applies to the forequarter amputation whether performed by the Berger or the Littlewood technique As the project developed, the inclusion of scapulectomy seemed necessary in order to define the indications more accurately and to review the knowledge on this partial ablation of the shoulder girdle Further, it seemed worth while to include a chronological case recording of the traumatic avulsions of the forequarter, since such an up-to-date listing did not appear in the surgical literature This tabulation is as complete as seemed practical and justifiable in relation to this project Statistical studies relating to the operative procedures for neoplastic disease will be found in the articles of Rogers, Buchanan, de Nancrede, Pack, and others quoted in the text and reference list The coverage of this monograph thus appeared to be a logical extension of the author's publication “Shoulder Lesions,” yet too detailed and specialised to include in a future edition of that work Although in the future radical surgery for neoplastic disease may be largely outmoded by chemotherapeutic advances such as we have witnessed for infective processes, it is hoped that this work will assist those who must undertake these major procedures in the intervening period H F MOSELEY Montreal, Canada 1957 ·Acknowledgments During the assembly and review of the materials for this monograph the author has been keenly aware of the assistance, readily visible throughout this volume, which he has received from various individuals and numerous sources of reference In the first place, appreciation must be extended to Miss Helen MacArthur, Medical Illustrator at the Royal Victoria Hospital, who has not only produced all the beautiful and accurate drawings but has also assisted in the dissections, library research, and integration of the materials Her valuable help on this project, which represents our sixth book publication together, is herein recorded Those acquainted with the surgical literature will realise the debt that the profession and the present author owe to Dr George T Pack, whose writings are the modern classics on this interesting subject His advice has been of the greatest assistance in preparing this work, which reflects many of his contributions Further materials have been provided by Dr Charles O Bechtol, Dr James C Callahan, Dr Bradley Coley, Dr G E Haggart, Dr Harrison McLaughlin, Dr E S James, Dr E J Tabah, Dr Paul Weil, and Dr W W Werley Such contributions have been acknowledged where possible in the text Anatomical dissections which formed the basis of most of the colour plates and drawings were facilitated by Dr S M Banfill of the Department of Anatomy of McGill University The literary research was executed through the libraries of the McGill Medical School, of the Royal College of Surgeons of England of the American College of Surgeons and the National Library of Medicine in Washington The services of Mr W R le Fanu and Mr Samuel Wood of the Library of the Royal College of Surgeons were utilised to provide the greater part of the case records of the traumatic avulsions of the forequarter Mrs Max Slapack has been responsible for the careful preparation of the manuscript The publication of this monograph has been assisted by a grant-in-aid from McGill University through the kind services of Principal Cyril Jamcs. which is gratefully acknowledged Finally my appreciation extends to Mr Charles Macmillan and E&S Livingstonc Ltd, who have accepted these materials for publication and produced them in their present form H F M VI ·Table of Contents CHAPTER PAGE PREFACE у ACKNOWLEDGMENTS VI I HISTORICAL ASPECTS 1 II ANATOMICAL CONSIDERATIONS 8 III INDICATIONS 18 IV OPCRATIVE PROCEDURES 21 V POST-OPERATIVE CONSIDERATIONS 51 VI ILLUSTRATIVE CASES 53 VII TRAUMATIC FOREQUARTER AMPUTATIONS 61 VIII CONCLUSIONS 71 REFERENCES 72 INDEX 77 Th18 booh 18 protected under the Berne Convention It may not be reproduced by any means, in whole or in part, without per m188101 Applncation with regard to 1 epi oduction should be addrc8sed to the Publrshers © E&S Livingstone Ltd, September 1957 ·Colour Plates PLATE PAGE I Anterior relations of the shoulder girdle 9 II Anterior relations in the supraclavicular region 12 III Posterior relations of the shoulder girdle 15 IV The lymphatic system in relation to the forequarter amputation 17 V Lines of incision Exposure and resection of body of clavicle 27 VI Exposure of the subclavian vessels 29 VII Completion of the anterior dissection 31 VIII The sternal end of the clavicle 32 IX Completion of the posterior dissection 35 X The forequarter amputation from the posterior aspect (Littlewood's technique) 39 XI The forequarter amputation from the posterior aspect (Littlewood's technique) 40 VIII ·I Historical Aspects . < in. . IT!! IT:.! "! FIG 1 Professor Paul Berger Commemorative medallion (in possession of author) SEARCH of the surgical literature on the at that time and contributed to the evo subject of the forequarter amputation and thought, but only the recorded word persi: of partial and total scapulectomy quickly us cognisance Thus to-day most writers the wealth of knowledge and understand- to Paul Berger (Fig 1) the operation of h remains dormant in our libraries until quarter amputation because in 1887 he dent, stimulated by the netessity of appre- monograph monograph detailing all aspects of thi more about a problem, undertakes to learn However, the student will realise that no · lessons of the past The more detailed involved originated with him, and his co culous the investigation, the more certainly was the assembly of materials and focusi come apparent that the ideas and techniques gical interest on this particular subject gradual evolution Certain periods will be this realisation that the present author s len the particular subjects came into focus, his endeavour after several years' study of e periods will be found to coincide with the interesting field on in written form of the available know Our history begins with the case record that time Such classic works when studied Wood (Fig 2). a miller whose arm became on to the period will reveal that many indi in the rope of his mill-wheel and who were interested in the particular problem traumatic avulsion of the whole limb anı 1 ·101010 THE TOREQUARTER AMPUTATION ti 188 intit Mit 1.02 Allir 7 FIG 2 Chescidens illustration of Samuel Wood 1 Prominence of clavicic, 2 The wound 3 Subscapularis musclc, 4 Fractures of the radius and ulna in two places shock or hæmorrhage occurred at the time was recorded by Belchicri14 and again Chicselden, c accident and the patient was taken to St The Anatomy of the Human Body, 1768" This ke's Hospital London, where he made a rapid case served to demonstratc that the human body iry with simple dressings (1737) An account could withstand the shock of such a major mutila s remarkable case with an excellent engraving lion Periodic reports of similar cases have appeared 2 ·HISTORICAL ASPECTS in the medical journals from that time up to the communication reference is made to a case seen in present day, and an attempt has been made to list Greenwich Hospital twenty-one years previously the published cases in chronological order in Chap- (1808) (Fig 3, A) Later correspondence indicated ter VII of this book 110 172 that the examination was made at St Bartholomew's AMPUTATION OF THE SCAPULA, &c. REMOVAL OF THE ARM, SCAPULA, AND CLAVICLE. To the Editor of the London Medical Gazelle Sın, In the last number of the Gazette, I bave read with much interest a detailed account of the partial excision of the scapula, by Mr Luke, of the London Hospital, on account of medullary sarcoma having taken root on a portion of that bone, and wluch appears to have been performed successfully, and in a masterly manner, by that gentleman I do not know whetber the case be published, but in 1808, whilst doing duty at Greenwich Hospital, a young sailor, about 21 years of age, presented himself for a pension on account of the total removal, by operation, of the arm, scapula, and clavicle, and I perfectly remember our sending the man to the College of Surgeons, or to some one of the London bospitals, to be there examined as to the successful result of this formidable operation Gun-shot wound, I think, was the injury inflicted, and the operation was determined on and performed by Dr. Ralph Cuiniog, then surgeon to the Naval Hospital at antigua. Should you deern this notice of the case worthy of record, I beg you may insert it in your valuable journal. Your's, A COPLAND HUTCHISON. #1803 Pachese Street, Portland Place, 230 Nov 1829 To the Editor of the London Medical Gazette. SIR, In your next number I will thank you to explain to your correspondent, J M that you were the aggressor, by beading a note with my signature afixed to it, as if I had been the operator, by which he professes himself to have been a disappointed reader , -and at the same time inform bim that the case in question was sent to tbe surgeons of St Bartholomew's Hospital for examination. Should your correspondent J M. wish for information as to the profes- 810nal character of the operator mentioned in my note (Gazette, 28th Nov. 1829), refer him to the “ Naval, Military, and Private Practitioners Emanuensis, Medicus et Chirurgicus, &c. by Ralph Cuming, MD. R.N Medical Superintendent of his Majesty's Naval Hospital, Antigua ; published by Mathews and Leigh, 18, Strand, 1806" Yours, A COPLAND HUTCHISON Jun. 18, 1830 [The heading alluded to was on the wrapper, which we are faio to leave to the discretion of the printer. A notice of the case in question will be found in the edition of Cooper's Surgical Dictionary just publishicd, page 564 We are informed by Mr Hutchison, how. ever, that though the injury requiring the operation was inficted by the shot, yet that the amputation of the humerus scapula and clavicle was performed by the surgeon. This le ascertained by a reference to the origmal document] FIG 3B 104 --V FIG 3A Fig 3 Original references to the first case of forequarter amputation for a gunshot injury The first surgical removal of the forequarter is Hospital and that the forequarter was removed by generally attributed to a young English naval sur- operation and not by the original gunshot trauma geon and was performed for a gunshot wound (Fig 3, B) Keevil:* has investigated and published the historical In 1819 partial scapulectomy was successfully basis of this priority, which rests largely on letters executed by Listonº of Edinburgh The infraspinous of A Copland Hutchison, FRCS, to the London portion was removed for “osteo-aneurysm Great Medical Gazette 1829 and 1830 49 50 In the first hæmorrhage was encountered, but the patient withw ·THE TOREQUARTER AMPUTATION THE FIRST OPERATION ON RECORD JOR TIL ILXOTAL OF THE ENTIRE ARM, SCAPULA, AND TIIREE FOURTIIS OF THE CLAVICLE, BY THE LATE DIXI CROSBY, MD, LLD, Professor of Surgery in the Dartmouth Bicutical College REPORTED, TITIL COXNESTA, BY HIS SOV, A B CROSBY, A. M, MD, . Prol of Surgery Dartmouth Medial College, Pror of daatomy Bellerue llougital Bledical College frad Hefore the stoty Port Cowaty Mindkal Skiety, ike sew Hampshire Slase Medral Saciety, and the Ilkite Porxlarn afedical Sourly CONCORD, N II PITFD DY TNF REPUDLICAN TNESS ASSOCIATION 1875 FIG 4 Title page from the publication descnbing Dr Diri Crosby's casc, the first forcquarter imputation for ncoplasm stood the operation When a recurrence of the Dr Dixi Crosby, *" an American surgcon first tumour occurred Lision proposed resection of the removed " the cntirc arm, scapuli, and three-fourthis remuning poruon of the scapula but failed to obtain of the clavicle" for a malignant growih (1836) II the vinction of his collcagucs Thc pulient dicd five is reported as an ostco-sarcoma " which wcighed months following the initial operation from repcatcd twenty-fivc pounds after removal The patient sur- Hemorrhages vived the operation only to dic twenty-eight months ·HISTORICAL ASPECTS years later later from paraplegia presumably due to metastases matous growth (1856) The patient, aged 70, made (Fig 4) a good recovery from the operation but succumbed In the following year, 1837, Mussey," who had ten weeks later from “ senility refused to operate on the preceding case because of The second case is of greater interest as it the formidable procedure involved, records total scapulectomy with removal of the outer end of the clavicle for a recurperformed the first total scapulectomy with the clavicle for a recurrent rent tumour for which the humeral head chondroma Previously disarticulahad previously been resected The patient tion at the shoulder joint had been survived and worked as a postman A line done The patient was followed and drawing of this patient showing the coswas free of recurrence thirty metic appearance and functional qualities of the residue of the upper limb forms the The priority for the first frontispiece of Syme's monograph (Fig 5) total scapulectomy with The significance of this case in the evolupreservation of the tion of thought on our subject was its use upper limb is generally by later writers35 93 and authorities to accredited von Langenregard total scapulectomy as the essence of beck (1855) This case conservative surgery for malignant growth was reported by his of the scapula, and much preferable to the assistant Fock,40 and gross mutilation resulting from the interwas performed on a boy scapulo-thoracic amputation aged 12 years whose whole scapula Syme also recorded a third case which was involved in was a forequarter amputation for a recura malignant turent tumour previously treated by resection mour, presumof the upper end of the humerus ably an osteo- These cases constitute some of the early genic sarcoma publications bearing on the subject of our Primary healing exposition The courage of these surgeons was secured but in the days before anæsthesia, antiseptic recurrence foland aseptic surgery, the antibiotics, and lowed in seven blood transfusion commands weeks and our respect and admiration death 109 days Such records constitute the after the opera- NS- del!. foundation of our present-day tion FIG 5 practice Certain auth. The frontispiece of Syme's monograph depicting the appearance In time summaries of the and function of the upper limb after total scapulectomy ors have regardextant knowledge began to aped Symeløs of Edinburgh as the first to perform total pear In 1868 Dr Stephen Rogers' reviewed the scapulectomy for a tumour This probably resulted history of total scapulectomy, and stated that the from the ready availability of his monograph, operative procedure was standardised meriting a Ercision of the Scapula, 1864 The first case pre- definite place in the surgical treatment of malignant sented is one of total scapulectomy for an angio- disease web minit 5 ·THE TOREQUARTER AMPUTATION r L'AMPUTATION DU NEIBRE SUPERIEUR DANS LA CONTIGUITÉ DU TRONC (AMPUTATION INTERSCAPULO-TUORACIQUE) PAR PAUL BERGER CHIRURGIEX DELHORITAL TERON PROFESSEUR AONTOL A LA FACULTÉ DE YEDECINE YEIBNI DE LA SOCIETE DE CHIRUNOIL Avec figures dans le texte Ata ucie en chromolithograpblo PARIS GASSON, EDITEUR LIBRATHE L ACADÉMIE E NENE CINE 11 beslenend Sulat-Gerpalo eo face de récole do Iddeclas DE - 1887 Fio 6 The titlc prcc of Bergers classic monograph on thc (orcquarter amputation Paul Berger's classic monograph L'Amputation indications, and techniquc of the operative produ sfemihre Spirieur dans la contiguiti du Tronc cedure, stressing the necessity of preliminary ligation (-101 puranon llerscapulo-Thoracique): appeared of the subclavian artery and vein originally practised in 1887 (Tigo) This has been the basis of most by Ollier ^3 This publication occurring in the postwriting since that period as it details the history. Listerian cra which cnjoyed the devclopment of 6 ·HISTORICAL ASPECTS as anæsthesia stimulated surgeons to undertake these Pack86 48690 and Dr Bradley Coley”: and their colmajor ablations for malignant disease in increasing leagues from the Memorial Hospital for Cancer and numbers Allied Diseases, New York, have given the profes- At the turn of the century the published articles sion the most carefully compiled and accurate show that greater attention was being directed to information yet available on the indications and the selection of cases and to the study of the end results to be expected from the various operative results obtained procedures under consideration for neoplastic dis- Careful statistical tables such those of ease Their publications also bear witness to the Buchanan (1900) and Fowler*1 42 listed the pub- great advance in surgical technique available to the lished cases with the follow-up recorded where patient at the present day In twenty-nine recorded possible De Nancrede (1909) 32 33 reviewed the forequarter amputations before 1881 (pre-Listerian) position of total scapulectomy for sarcoma and con the mortality was 38 per cent In Berger's series up cluded that this operation held little promise for to 1887 the rate was approximately 20 per cent in such neoplasms involving this bone and must be a series of twenty-two cases Buchanan details 141 regarded as palliative in nature He postulated a operations up to 1900 with a figure of 12 per greater chance of survival for such patients from the cent 19 21 Pack (1942) adds an additional 180 cases more radical forequarter amputation from the literature with a mortality of 5 per cent, In view of the failure of total scapulectomy for but in his own personal series of thirty-one cases malignant disease spreading from the scapula, the there was not a single operative death In 1956 interscapulo-thoracic resection* was proposed by Pack's series contains eighty-eight cases of fore- Ashhurst," Tikoff,107 later Bauman, and Linberg, for those patients who refused the total ablation of quarter amputation and 140 other cases of major the extremity exarticulations of the lower limb at the hip joint A further contribution to the technical aspects and hindquarter amputations without operative of the forequarter amputation was advanced by mortality, surely a triumph for the progress of Littlewood (1922), 71 who advocated this major surgical technique ablation from the posterior aspect To-day these major procedures can be safely In recent years the papers of Dr George T performed, the problem resolving itself to a careful selection of the cases and choice of the procedure most likely to cure or relieve the pathological lesion Removal of the scapula, upper end of the humerus, and portion of the clavicle under treatment 69 * 7 ·II Anatomical Considerations N this chapter the surgical anatomy necessary III will illustrate the anatomy from the posterior for understanding the various partial and com- aspect pictc ablations of the shoulder girdle will be To simplify the description and illustrations, the described in detail The method employed is that lymphatic vessels and glands and the fascial planes utilised by the author in previous publications,** 81 related to the subclavian and aullary vessels will namely to build up the anatomical structures from be omitted from the first three plates Thc lymphatic the deeper to the superficial planes while in the structures will be seen in a separate drawing (Plato operative procedures which follow the dissection IV), while the fascial planes will be best considered will be reversed in order In this manner the in the operative series (Plates VI and VII) An important relations will be fully covered when the understanding of the fasciæ in this region is essential two chapters are correlated in the exposure of the neurovascular structures by Platcs I and II will depict the relations of the the anterior approach shoulder girdle from the anterior aspect, while Plate PLATE I ANTERIOR RELATIONS OF THE SHOULDER GIRDLE In this plato three illustrations build up the ana is of especial interest, originating on the first and tomical relationships of the shoulder girdle to the second ribs near the anterior border of the scalenus trunk and detail the neurovascular structures in medius and scalenus posterior and passing bachvolved in the forcquarier amputation in their posi- wards to attach to the superior angle of the scapula hons relative to the thoracic operculum and basc as shown in Figure B of the neck The lymphatic glands and channels The subclavian artcry is seen passing upwards have been omitted for simplicity (sce Plate IV) from the superior mediastinum over the dome of the In Figure A our vision should bc centred on the pleura For descriptive purposes it is divided into first rib on to which the scalcnus anterior is inscried thrcc parts by the scalenus anterior part one in Above thus rib and on the deepest planc the domc cludes that portion cxtending from its origin from of the pleura covered by Sibson's fascia is noted the innominatc artery on the right side (or from the Muscles which form a pirt of our story arc the inter orta on the Icft sidc) to the medial border of the costals, the subclavius arising at the costochondral muscle, part two lics behind the muscle, and pari junction of the first rih. the sectoralis minor arising three cxtends from the latcral border of the scalenus from the second, third, and fourth (and fifth) ribs, anterior to the latcral border of the first rib where and the serratus anterior arising by chgitations from the subclavian becomes thc axillary aricry or the the upper cirhi to nine rih Thc superior chgitation various branches of the subclavian artery. two 8 ·A -scalenus ant subclav Ceva common carotid a znnominate cu serratus ant -- dome of pleura int jugular B innominate v phrenic subclavius • first rzo scalen medius post suprascap brachial plexus unt mamm pectoralis rainor coracoclavicular ligs acromio-thoracic axis cephalic v long thoracica' lat thoracica coracoid membrane tetorar Branch acrom thor CLS pectoralis minor c mazor trapezius С accessory (XI) cephalic v in sternomastoid delto-pectoral interval deltoid ext x't jugularu ant'juqular u omohyoid pectoralis major 2 $ 1 to more than Phaserthur PLATE I 3 ·THE FOREQUARTER AMPUTATION especially are encountered in the forequarter ampu- 2 The suprascapular nerve, (C.), Cs, C., which tation, ie, the transverse cervical and the supradescends to enter the suprascapular notch scapular arteries Some variability in the transverse below the artery and vein, all of which are cervical artery will be found Further information severed in the forequarter amputation (see on these vessels will be given in the legend for Plate Also Plates X, XI) II 3 The long thoracic nerve of Bell, Cs, C6, C, The axıllary vein, after being joined by its tribu (Cs), descending behind the brachial plexus tary the cephalic vein, runs proximally over the first and the axillary artery and vein to run upon rib to become the subclavian vein The subclavian and supply the serratus anterior (see also vein lies on a more anterior and inferior plane than Plates X, XI) the artery and is joined by the external jugular vein The pectoralis major, the pectoralis minor, and before joining the internal jugular to become the the subclavius muscles with their related deep innominate vein behind the sternoclavicular joint fasciæ are seen in section on the right hand side of As will be found at operation, the subclavian vein the drawing They form with the clavicle the main on its posterior and inferior aspects is firmly fixed anterior barrier to the subclavian vessels and are to the first rib by a strong fascia and also to the transected in the operation Details of the fascial lateral edge and posterior surface of the rhomboid planes will be described under the operative pro- (costoclavicular) ligament In the early operative cedure (Plate VI) Branches of the acromiothoracic reports, tearing of the vein in this area complicated axis supplying the pectoral muscles are seen in by severe hæmorrhage and air embolism was some part in this drawing, but do not create any serious times the cause of death problem at operation In Figure B part of the structures of the shoulder In Figure c the superficial musculature and venous girdle have been applied The middle third of the channels are added The deltoid and pectoralis major clavicle the underlying subclavius muscle and the form one massive muscle sheet separated by an related fasciæ have been omitted to permit depiction indefinite deltopectoral cleft in which the cephalic of the neurovascular structures as seen in the second vein courses in variable manner The trapezius step of the classic Berger interscapulo-thoracic laterally and the sternomastoid medially attach to amputation The scalenus medius and posterior are the clavicle in extents corresponding roughly to added, and in the cleft formed with scalenus anterior those of the deltoid and pectoralis major respecthe brachial plexus is found Note the coraco- tively A venous channel may connect the cephalic clavicular (conoid and trapezoid) ligaments which and external jugular veins over the bare central bind the clavicle to the coracoid process In scapul- portion of the clavicle The superficial connection cctomy it may be preferable to section the clavicle of the anterior with the external jugular vein is medial to these ligaments rather than to disarticulate shown, the latter passing deeply to enter the subat the acromioclavicular joint and sever these liga- clavian vein It should be noted that these large monts veins provide difficulties in the anterior dissection Threc nerves should be studied since they are when performing the amputation under considerafound at operation' tion Furthermore, gross enlargement and variations 1 The phrenic nerve, a localısıng landmark on in both the arteries and veins will be found which the scalenus anterior which can be palpated the area is exposed in the presence of massive iligitally tumours 10 ·ANATOMICAL CONSIDERATIONS PLATE II ANTERIOR RELATIONS IN THE SUPRACLAVICULAR REGION The purpose of this illustration is to give in greater This group of structures is sectioned in the detachdetail and from a more superior viewpoint the ment of the scapula (see also Plate XI) relationships depicted in Figure B of the preceding The subclavian artery in its close relation to the plate Again the lymphatics and fasciæ have been dome of the pleura can be seen passing behind the excluded for diagrammatic purposes For the cor scalenus anterior At operation it is secured in its relation with the forequarter amputation performed third portion and one can understand the possibility in the classic Berger manner, one notes here chiefly of entering the pleural space when freeing its posthe positions and interrelationships of the brachial terior surface plexus and the subclavian vessels with their branches Two branches of the subclavian artery are separ- The viewer should first study the longitudinal ately tied in the interscapulo-thoracic amputation muscles From before backwards these are the (1) the suprascapular artery, and (2) the transverse scalenus anterior, passing to its insertion on the first cervical artery Some mention should be made conrib, on whose superficial surface the phrenic nerve cerning the variations of this latter vessel Somecourses downwards and medially posterior to the times the thyreocervical trunk arising from the first subclavian vein to join the internal mammary part of the subclavian artery gives off two posteriorly vessels in their passage to the mediastinum, the directed branches, the suprascapular and the transscalenus medius and posterior descending to insert verse cervical arteries This latter artery divides into on the first and second ribs, and most posteriorly an ascending ramus (OT superficial cervical) and the levator anguli scapulæ which inserts on the a descending ramus (OT posterior scapular) In superior angle of the scapula In relation to the this arrangement branches of both ramı will be tied levator scapulæ note the spinal accessory (cranial in our operation The variation occurs when, as in XI) nerve This nerve descends from the surface of our illustrations, the descending ramus arises as a the transverse process of the atlas in the deep sub- separate branch from the third (or second) part of stance of the sternomastoid muscle, leaving the pos- the subclavian artery and courses through the cords terior border thereof at the junction of its superior of the brachial plexus This descending branch is and middle thirds to course across the posterior then called the descending scapular artery, and the triangle in a downwards and backwards direction separate ascending branch the superficial cervical It enters and supplies the trapezius muscle on its artery In this instance both the superficial cervical deep surface at the junction of the middle and and the descending scapular arteries will require inferior thirds of its anterior border The horizon- ligation at operation (see also Plates X, XI) tally directed muscles, the supraspinatus and the Attention should now be directed to the subfirst digitation of the serratus anterior, should be clavian vein and its tributaries The ligation of the especially studied The superior portion of the long main vessel just distal to its junction with the interthoracic nerve can be seen on the surface of this nal jugular is usually the most difficult step in the digitation The cords of the brachial plexus are found operation It is closely adherent to the first rib and in the cleft between the scalenus anterior and scale- to the costoclavicular (rhomboid) ligament The nus medius Note the suprascapular nerve which is vein wall is easily torn in the dissection and, as joined by the suprascapular vessels running in close previously mentioned, serious hæmorrhage and air association with the posterior belly of the omohyoid embolism have been frequently reported. Puncture muscle to the region of the suprascapular notch of the vein can also be produced by the sharp cut 11

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THE FOREQUARTER AMPUTATION
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PLATE II

·ANATOMICAL CONSIDERATIONS end of the lateral fragment of the clavicle when the removed, it is absolutely necessary to dissect directly limb is manipulated away from the body The close on the bony surface relationship with the posterior aspect of the sterno Our comments on surgical anatomy associated clavicular joint and sternal end of the clavicle should with this plate should therefore leave the reader with be emphasised The sternohyoid and sternothyroid knowledge of the variations in the branches of the muscles serve as buffers In the classic Berger subclavian artery concerned in our operative prooperation the sternal end of the clavicle is left in situ cedures, the complexity of the subclavian vein in its and this is recommended unless the lymphatic glands relation to the first rib and sternal end of the clavicle, in this area require removal as in carcinomatous and the proximity of the pleural dome which may lesions of the upper extremity with axillary meta be entered in securing the vascular supply and drain- If the sternal end of the clavicle must be age of the upper limb PLATE III POSTERIOR RELATIONS OF THE SHOULDER GIRDLE The relations of the shoulder girdle to the trunk final posterior dissection of the forequarter amputaposteriorly are much less complicated than those tion performed from the anterior aspect, in the first we have observed anteriorly The important neuro- stage of the same operation executed from behind. vascular channels are found on the anterior aspect, or in the operations of partial or total scapulectomy and muscular branches only will be sectioned pos or interscapulo-thoracic resections teriorly in the operative procedures, whether in the In Figure A the basic musculoskelctal structures 13 ·THE FOREQUARTER AMPUTATION on which the scapula rests will be seen The serratus on the outer third of the clavicle can be considered posterior superior arising from the spines of cervical the superior portion This clavicular insertion can 6, 7 and thoracic 1 is seen extending as a thin, apo- be subperiosteally resected in all the procedures neurotic sheet to insert at the angles of the second under discussion The medial portion arises from the to fifth ribs It covers the deep paravertebral cervical and upper thoracic spinous processes It muscles of the cervico-dorsal region, ie splenius is largely aponeurotic in nature in the vertebral arca capitis, splenius cervicis, and uliocostalis cervicis and extends transversely to insert on the spine of Just anterior to the last muscle is the posterior mem the scapula intimately fused with the deltoid ongin ber of the scalene group, the scalenus posterior The inferior portion of the trapezius ascends from The only major vessels which will be encountered, its origin on the dorsal spinous processes as low as unless large anastomotic channels have developed, thoracic 12 thoracic 12 It covers the upper half of the vertebral are the muscular branches to the trapezius and border of the scapula and forms a tendinous rhomboid muscles from the superficial cervical and insertion on a tubercle at the base of the spinous descending scapular arteries These form a rich process It will be seen that this complete sheet can anastomosis with the vessels related to the scapula be subperiosteally detached from the scapula and and its intrinsic muscles, the supraspinatus, infra- clavicle when required or sectioned through its sub spinatus, teres minor, teres major, and the subscapu- stance (see Plate X) laris (see also Fig 14) These anastomoses achieve The second large muscle is the latissimus dorsi, grcat surgical importance in large neoplasms involv- which crosses and attaches itself to the lower angle ing the scapula itself or its intrinsic muscles of the scapula before passing to its insertion on the The scapula with its musculature is applied in humerus in intimate relationship to the teres major Figure B The spine rests at the level of the third rib These two muscles form the posterior boundary of and the lower angle is opposed to costa VII The the axilla The latissimus dorsi must be detached levator anguli scapulæ is added and we note that from the inferior angle of the scapula and transected the transverse cervical vessels and the spinal acces- just beyond this point to free the scapula in ablations sory nerve (cranial XI) pass over its surface before of this bone entering the decp surface of the trapezius and the The third and final muscle for consideration is substance of the rhomboids At the superior angle the deltoid Its origin from the spine of the scapula, of the scapula the first digitation of the serratus as likewise from the acromion and clavicle, can well anterior can be seen in close proximity to the origin be resected subperiosteally when necessary Howof the supraspinatus Figure B therefore illustrates ever, in the forequarter amputation, whether perthe deep plane of muscles which must be sectioned formed from the anterior or the posterior aspect, it to free the scapula posteriorly, 1 c from above down is only the trapezius and latissimus dorsi muscles wards, the levator anguli scapulæ and the rhomboids which must be transected together with the deeper minor and major group described above, ie the levator scapula and The large flat superficial muscles are added in rhomboids minor and major Once these two groups Figure c Notc the extensive origin of the trapezius are divided the scapula will wing forwards permitfrom the base of the skull to thoracic 12 Its origin ting section of the serratus anterior, the final bond and insertion are best considered in three parts The holding the scapula to the trunk on the posterior origin from the base of the skull with its insertion aspect (see also Plate X) 14

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·THE FOREQUARTER AMPUTATION PLATE IV THE LYMPHATIC SYSTEM IN RELATION TO THE FOREQUARTER AMPUTATION The forequarter amputation may be indicated in jugular trunk Various channels arise in the thoracic cases of carcinoma and melanosarcoma involving cavity, but the principal channels are the right and the upper limb and shoulder region, and also in left bronchomediastinal trunks The internal mamcertain cases of brachial lymphædema with intract- mary channels draining the internal manmary chains able pain associated with carcinoma of the breast of glands are important in the spread of carcinoma For this reason an understanding of the lymphatic of the breast glands and channels is valuable The basic pattern is The lower drawing shows that the lymphatic illustrated in diagrammatic fashion on this plate, drainage of the upper limb follows the blood-vessels where the main groups of glands are shown in the and converges on the axilla The lateral, central, principal drawing while the collecting channels with infraclavicular, and apical glands provide filters their confluence with the venous system are repre- before the neoplastic cells can enter the venous sented in the smaller diagram Reference to detailed circulation It can be readily perceived that once studies of the lymphatic system will reveal the great the apical glands are involved, venous dissemination variability in the number and size of the glands of of neoplastic cells is imminent the diſſerent groups and of their collecting channels The lymphatic spread of carcinoma of the breast Similarly the terminal arrangements of the lymphatic can be understood from this illustration Here again ducts and channels show many variations Meticu- the main drainage is to the axillary glands, first the lous detail in this connection is not deemed necessary pectoral and subscapular groups, thence to the in this presentation, but such detail can be obtained central and apical glands and finally to the subby recourse to the appended references *5 94 95 clavian trunk The drainage of the medial sectors of In the upper drawing the junction of the lymph- the breast is also to the internal mammary chain of atic and venous systems is shown This takes place glands which is part of a rapid and direct comwhere the subclavian and internal jugular veins munication with the venous system through the unite to form the innominate vein It will be noted It will be noted internal mammary trunk that the thoracic duct, which constitutes the main The reader should note the external jugular andrainage of the lower part of the body, empties on terior jugular, inferior decp cervical, spinal accesthe left side The lymphatic channels for each upper sory, and transverse cervical chains They may limb unite to form the subclavian trunk while those require block dissection when the forcquarier am. from the head and neck on cach side produce the putation is performed in cases of mclanosarcoma 16 ·R I subclav trunk ---Jugular trunn broncho medast trunks subclavian trunk R lymphatic duct Om int mammary trunk I l-int mammary trunk MAIL --thoracic duct ext jugular chain spinal accessory charn -107ť deep cervical glands transverse cervical chain tant ugular chain intraclav glands- Jly -int mammary charn 3 . 135** **** *****ICIE***** apical central lateral pectoral subscapular axillary glands Red PLATE IV ·III Indications T General Considerations All cases should receive a completc pre-operative HE complete removal of the upper limb with evaluation to exclude extension of the growth to the shoulder girdle is a grossly deforming and other areas such as the lungs, which would generally disabling operative procedure and the patient preclude the radical treatment of the primary usually recoils in horror when it is suggested This growth instinctive reaction delays the definitive treatment and valuable time is lost In some cases the patient Specific Indications refuses to accept the loss of limb and the surgeon may substitute local excision, scapulectomy, or the Generally speaking, the forequarter anıputation intcrscapulo-thoracic resection which is second best is indicated for certain primary lesions produced by The responsible surgeon has therefore a difficult trauma, infection, or neoplasm or the sequela of task to make the correct decision and to influence such processes In the present era the most common the patient and relatives to accept this advice when group of cases is associated with malignant discasc given in present-day hospital practice great benefit accrues from presenting such unusual cases before Trauma (sce Chapter VII) thc gencral staff for discussion In this way the combined experience is pooled, and this should in- Trauma in its various forms has been responsible clude the advice of pathologist and radiotherapist for many cases of forequarter amputation, some of Such a course rcassures both patient and surgcon which are recorded in the medical literature 110179 and Icads to mutual confidence and peace of mind In civilian life the most common causc has been Statistical studies have shown that in the carefully entanglement of the limb in machinery Avulsions selected case primary forequarter amputation affords of the limb at the girdle may be complete, and when a greater freedom from recurrence and superior surthis occurs the result is similar to the case of Wood vival results when compared with secondary fore- previously mentioned The major arteries develop quarter amputation performed after initial local spasm and the blood loss and shock arc frcquently crcision of the tumour resection of the upper end not cicessive Some avulsions may bc parcial, and of the humerus scapulectomy. amputation through the patient is brought to hospital where the decision thc upper arm, or disarticulation at the shoulder to preserve or ablate the limb must be made In Therefore, when indicated, the earliest possible this connection the deciding factors are the viability primary forcquarter amputation is the idcal It is and future usefulness of the limb of the brachal regrettable that a large percentage of the present- plexus has been avulsed, restoration of associated day amputations is being performed for palliative disrupted major vessels by operative means will not purposes and as a last resort after all other probe justifiable Similar considerations must be given cedures have failed by the surgeon in the cvaluation of cascs presenting The patient should be assured that this major after gunshot wounds, automotive and other rrunsoperation can be safely crccuted with the bencfits port accidents, and the wounds inflicted by savage of present day anacstlicsia and transfusion service animals 18 ·INDICATIONS Extensive burns of thermal, electrical or chemical to such procedures for extensive pyogenic and tubernature must be similarly evaluated Often the time culous osteomyelitis involving the shoulder girdle interval will be the determining factor A conserva and threatening the life of the patient Some surtive and expectant attitude is often best when the geons will recall a well-known colleague who undercase is seen at an early stage, but in the later stages went scapulectomy for typhoid osteitis of this bone where the life of the patient is threatened a definitive prior to the antibiotic era course must be adopted The author has seen one case of severe electric burn with gangrene of the Neoplasms upper limb where a forequarter amputation might Three groups of malignant growths may necessihave been life saving tate the forequarter ablation 1 Carcinoma and melanoma of the upper limb Infection with axillary metastases Certain cases of There are few indications to-day where infection carcinoma of the breast with gross lymphby itself would justify these major procedures Early ædema and pain in the upper limb treatment with the antibiotic agents has removed 2 Sarcomata of the soft tissues of the shoulder this problem The older literature contains reference region TABLE I Histologic Type of Tumour 14 Total cases Tumours of skin, primary in the extremity Melanoma Carcinoma Tumours of skin, primary elsewhere Melanoma Carcinoma Tumours of soft somatic tissues, primary in the extremity Rhabdomyosarcoma Fibrosarcoma Synovioma Sarcoma unclassified Malignant neurlemoma Angiosarcoma Liposarcoma Rcticulum cell sarcoma Dermatofibrosarcoma protuberans Kaposi's sarcoma Extraosseous osteogenic sarcoma Alveolar soft-tissue sarcoma Extra-abdominal desmoid Tumours of bone primary in the extremity Osteogenic sarcoma Chondrosarcoma Endothelial myeloma Periostcal fibrosarcoma Neuroblastoma Reticulum cell sarcoma Interscapulo-thoracic Amputation No Per cent 88 100.0 26 29 5 20 227 6 68 7 8.0 2 22 5 57 47 53.4 15 9 8 91 7 80 6 68 5 57 4 45 11 11 0 00 0 00 0 00 0 00 11 8 9.1 3 34 2 23 11 0 00 11 11 1 1 1 ܝܝܙ 1 (By courtesy of Dr G T Pack and the Journal of Bonc and Joint Surgery ) 19 ·THE TOREQUARTER AMPUTATION 3 Sarcomata of the bones of the shoulder girdle Scapulectomy has been successfully performed The above are listed in accordance with the fre- for radionecrosis of this bone with extensive sinus quency of their occurrence, but this major operation formation following radiation for overlying cpithelihas been performed more frequently for sarcomata oma The operation has afforded relief from intractof the soft tissues than for carcinomata and melano able pain and long-term survival is recorded mata, and least frequently for sarcomata involving the upper end of the humerus, scapula, or clavicle Sarcoma of the Soft Tissues The histologic type of tumour can best be realised The various types of soft tissue sarcomata are by reference to Dr Pack's table of eighty-eight cases recorded in the table Most cases are best trcated which is the largest and best documented series in by the forequarter operation, and local excision and the surgical literature scapulectomy should be avoided as they give inferior Malignant Disease of the Skin results Pre-operative and post-operative radiation must be considered and have an important place in Patients with malignant disease arising in the skin the treatment of certain types of sarcoma of the upper limb form a group of increasing size Of these, carcinoma arising in the peripheral part Sarcomata of Bone with lymphatic spread to the axıllary glands constitutcs a surgical problem which can only be cured by Although sarcomata of the upper end of the forcquarter amputation (see Figs 22 and 23) This humerus and scapula treated by the forcquarter 15 true of epithelioma developing in radiodermatitis amputation do not present any five-year survivals in of the hands or in thermal burns in which the car Dr Pack's series, the freedom from local recurrence cinoma has spread proximally Certain cases of and length of survival is highest with the major melanoma of the upper limb and shoulder region procedures (see Fig 21) Previous local operations with axıllary lymphatic involvement are also candı- increase the local recurrence rate and lessen the time dates for this major procedure, with associated block of survival Scapulectomy affords little hope in the dissection of the cervical nodes when indicated sarcomata arising in this bone, with the exception Some surgeons have ablated the limb and girdle of chondrosarcoma especially of secondary developas a palliative procedure in cases where radical ment Scapulectomy has also a place for large amputation for carcinoma of the breast has been chondromata arising in connection with the scapula followed by gross lymphædema of the limb and Scapulectomy in association with irradiation conintractablc pain from involvement of the brachial stitutes the treatment of ancurysmal bone cysts and plcxus by carcinomatous infiltration hæmangiomata arising in the scapula (sce Fig 25). 20 ·IV Operative Procedures Pre-operative Considerations N operation of this magnitude requires considerable planning and attention to detail to ensure a successful result As in all operations, each case must be individually evaluated and A ml ) should be available during the operation and possibly in the post-operative period The blood loss during the operation in the average case can be judged from the following case record hairline mandible axillary preparation FIG 7 Arca of skin preparation for major operative procedures involving the shoulder girdle The skin preparation for the forequarter amputation interscapulothoracic resection or scapulectomy should be extensive and include, both anteriorly and posteriorly, the whole neck and trunk to the iliac crests, the whole of the upper extremity including the hand on the affected side and to just above the elbow on the opposite side Careful shaving and meticulous preparation of the axilla is required on the side of the ablation special consideration given to the predominant variants of the case under treatment Routine factors include the following 1 Attention to the haematological and electrolytic status of the patient Pre-operative transfusions may be required to bring the blood hæmoglobin to the range of 80 per cent Blood (1500-2500 Blood Loss Study (courtesy Dr Paul Weil) This record demonstrates the amount of blood lost in the average forequarter amputation The determination may be made directly by calculating the loss from increase in weight of the sponges during operation, or indirectly by measuring the blood volume by using 21 ·THE FOREQUARTER AMPUTATION A B TG 8 Posturing and draping for the forcquarter amputation performed from the anterior as pect A The patient is pos. turul in thc semi- Supine position As thc palicnt will receiic the anesthetic hy intubrtion a los anys. thetic screen is used closing of the ants. thoric apparatus from thc opcratic ficid B 7hc limb 15 hold clear of tie sterile loucls hy an orderly while the operative ricld is framed by the Toucls C The band has been received into a sterilo touch and the whole urict linh thien cn closed in stockinetto he free for inanipula. lion during ihic opera. tion Noic that the whole ericnt of the clauclo ind ilic whole citoni or the staruls arc crrinisd to the surfcon rinint or the aperit ini inhie con facilitate the surgical prokcjure с 1910 8 22 ·OPERATIVE PROCEDURES A B FIG 9 Posturing and draping for the forequarter amputation performed from the posterior aspect and for scapulectomy A The patient is pos: tured in the left latcral position The anæsthetic screen is in place B An orderly supports the upper limb by the hand while the foundalion draping is arranged C The hand is received into a sterilc towcl and the wholc upper limb cnclosed in stockinet so as to be frec for manipulation A laparotomy sheet is used as a coverall and its opening frames the field of operation Again, the tablc can be tilted and the limb manipulated when the surgcon passes to the anterior aspect for the anterior dissection the forequarter operation с in FiG 9 23 ·THE TOREQUARTER AMPUTATION > + radioactive iodinated human serum albumin amount of blood transfused was sufficient to (RIHSA method) The calculations in the prevent shock from a reduced blood volume present case, made by the indirect method, are At a subsequent operation (resection of a Pre-operanie Post-operative carcinomatous nodule in the scar) during which Plasma volume 2440 ml 2110 ml neither method was used and no transfusions Red cell mass 1640 1250 Total blood volume 4080 3360 given, the patient developed post-operative Assuming the amputated arm contained ap shock An infusion of lævophed and a trans proximately 300 ml of blood the blood volume fusion of blood were required to restore the deficit at the end of the operation was no more than that contained in a bottle of blood (420 2 Meticulous pre-operative skin preparation of the ml ) operative field (Fig 7) The amount of blood lost measured 13003 General anæsthesia with intubation A carcful ml Conscquently three bottles of blood each recording of the blood pressure throughout the containing 500 ml were administered Both operation is routine clinically as judged by maintenance of normal 4 Attention to correct posturing and draping to blood pressure and pulse, and as shown by facılıtate the operative procedure (Figs 8 and blood volume studies, tabulated above, the 9) Antibiotic coverage blood pressure 24 ·OPERATION FROM THE ANTERIOR ASPECT ·THE FORCQUARTER AMPUTATION PLATE V LINES OF INCISION EXPOSURE AND RESECTION OF BODY OF CLAVICLE: Figure A illustrates a diagrammatic cross section begins Froni (a) of the primary incision, the anterothrough the right side of the chest and shoulder inferior incision runs in racquet fashion to the girdle at the level of the second rib The heavy black anterior border of the axılla (c) Again the comlinc and arrows indicate the sites of muscular section pletion of the anterior incision (c- c') is delayed and the plane of fascial separation which have until the posterior limb (b-c) of the superoposterior been found most useful for the interscapulo-thoracic flap and severance of the posterior musculaturc arc ablation of the shoulder girdle in continuity with made thc upper limb Figure c shows the body of the claviclc cxposed The anterior muscular section traverses the pec- after incision of the periostcum along its length A toralcs major and minor to the plane of the thoracic vein of variable size joining the cephalic and c- Cuge covered by the serratus anterior With tran- ternal jugular systems, as illustrated here, will soncsection of the clavicle and its related soft tissucs the times be encountered The sites of section of the girdle falls away from the chest wall, and severance clavicle for the classic Berger operation'" 1' arc posteriorly of the muscles attached to the vertebral shown After section at (1) with the circular or Gigli border of the scapula ie, the trapezius, rhomboids saw, the lateral cut end is retracted anterolaterally and serratus anterior, completes the detachment of with a bone hook or forceps and sectioned at (2) thic girdle in the horizontal planc If the complete sternal cnd must be removed, onc In Figure B the lines of incision arc indicated finds it technically casier to make this resection of These must be varicd when necessitated by the press the body before proceeding with this additional cncc of a large neoplasm Two incisions ant skin dissection Dups are depicted. In Figure D the heavy dotted line shows where 1 Supcropostcrior, and the pectoralis major should be scctioned to expose ? Antcroinfcrior thc costocoracoid membrane This cxposure will The operator will usually make his first incision assist the surgcon in finding the plane and visualis. (n-1) thc Icngth of the clavicic Thc postcrior limb ing the axillary vessels and infraclavicular portion (-) will be clayed until the posterior dissection of the brachial plcrus 26 ·А. vertebral border of scapula trapezius rhomboids paravertebral muscles neuro-vascular bundle subscap deltoid B serratus post sup serratus ant supero-post incision 1 1 cephalic v in rzb II delto-pectoral groove minor pectoralis major plane of separation of shoulder girdle from trunk < anterointerior incision С lanes of section ext wugular v sterno mastord 2 deltold 28 cephalco pectoralis major D line of detachment separation of pect major Hines Center PLATE V ·THE TOREQUARTER AMPUTATION PLATE VI EXPOSURE OF THE SUBCLAVIAN VESSELS The five drawings on this plate continue the fascia by following the citcrnal jugular vein to its operation from the anterior aspect and illustrate the communication with the subclavian vein exposure of the subclavian vessels The Vicwer In Figure c the window has been made in the should note that the plane of the major vessels can costocoracoid membrane and the axillary vessels be found by approaching from cither above or below exposed The lateral anterior thoracic nervc supplythe clavicular bed ing thc pectoralis major has been found useful in In Figure A the general topography of the region this exposure and can be followed through the fascia is shown The body of the clavicle has been removed, to the lateral side of the axıllary artery A Kocher and for diagrammatic purposes the superficial layer dissector has been passed upwards in the planc of the musculature formed by the pectoralis anterior to the vessels and is seen to appear above major, deltoid, sternomastoid, and trapezius has the omohyoid muscle Note that its lip lies just been omitted superficial to the third part of the subclavian artery The second layer of musculature and fascia and the brachial plexus The tissues superficial to includes the omolyoid, its related fascia the sub- this dissector must be severed to give the wide exclavius, cosiocoracoid membrane and pectoralis posure of the subclavian vessels which is desirablo minor Superficial to this layer and passing through This is best accomplished by picccmeal isolation 11 to join the subclavian and axillary veins are major and severance of these tissues This inferior approach venous radicals of the crternal jugular, anterior has been found casier than that through the omojugular, and cephalic systems These require meticu- hyoid fascia and has been recommended by authors lous attention at operation to prevent major blood such as Lc Contest of and Kocher loss The scalenus anterior is an important landmark In Figure D the arrows depict these two an. in this operation It is covered by a layer of fibro- proaches as illustrated in the sagittal planc (a) fatty tissuc called the scalenc fat pad which is easily through the omohyoid fascia; (b) through the puslica aside or tcascd apart by blunt dissection costocoracoid membranc The phrenic nerve on the scalenus anterior is The lightly shaded area denotes the tissues finally digitally palpable transected 10 give the gencral exposure of the vessels In Figure R a window has been cut in the omo. which can be studiсd in Figure e In this final draw. hyod (scia to crpose the subclavian voin us it lies ing of the plate the sternomastoid and trapezius on the tondinous insertion of the scalenus anterior above the clavicle and the delioid and pectoralis *ind first rih Observe the relation of the tendinous major below the clavicle are represented in situ intersection of the two hellics of the omohyoid to The pectoralis major has been partially reficcted 10 the colonils inlcrior wind the subclavian icin It 15 facılıtatc thc exposurc (Review Figure D of the sometimes useful in dissect through the omohyoid preceding plate) 28 ·brachial plexus ext jugular А. phrenic n scalenus ant ant belly of omohyoid with tascia clavicular attachments of trapezius e deltoid ant jugular u clavicular Cattachments ct sterno mast É pect major tta cephalic -- coracord process' acromio-thoracic subclavius axis trans cervical v desc scapa costocoracord membrane pectoralis minor suprascap av B D omohyoid I'WINDOW brach IN plex post OMOHYOID berly of FASCIA omónyord subclavian vea subclau ubcl I APPROACH THROUGH OMOHYOID FASCIA על G 219 clavicle subclaviu's II APPROACH THROUGH COSTOCORACOID MEMBRANE 2.) W pectoralis minor & major } E axillary II WINDOW IN 'COSTOCORACOID MEMBRANE av С subclav GEV sectzoned omokyord, subclavius, pectoralis major) sectioned subclavius E pect major rib I PLATE VI ·THE TOREQUARTER AMPUTATION PLATE VII COMPLETION OF THE ANTERIOR DISSECTION The drawings on this platc dctail the ligation of recommend the removal of the sternal end of the the subclavian artery followed by that of the sub- clavicle, and this is advisable in cases of lymphatic clavian vein Some surgcons clevate the limb to involvement from carcinomata arising in the skin of drain the blood into the general circulation before the extremity or in the breast where the most radical the vein is tied, but in cases of sarcoma many prefer removal of lymphatic tissucs is contemplatcd Most to avoid this step for fear of possible dissemination complications in the past have arisen during the of tumour cells ligation of the subclavian vein These have been In Figure A thc external jugular vein is seen fatal hæmorrhage and air cmbolism Such problems ligated and divided ncar ils entry into the subclavian can be avoided by recognising the presence of a thin, vein adjacent to the first rib As previously stated, dense fascia fixing the vein to the first rib and to the final exposure of the subclavian vessels by the lateral and posterior aspects of the rhomboid division of the second layer of muscles and fascia is (costoclavicular) ligament A further factor to usually accompanied by ligation of these venous remember is the thin and friable wall of the vein communications, as also by section of the supra- Slow and painstaking isolation of the vein especially scapular artcry and vein which run in this fascial on its posterior and inferior aspects is therefore layer required Ligation and transfixion is then accom- It is usual to ligatc first the artery, and this is plished in the same manner as for the artery secured in its third part just distal to the scalenus In Figure D the linc for division of the brachial anterior It is cncircled and ligated in two places plexus is indicated Some surgeons prefer to inject with strong silk divided between and the proximal procaine hydrochloride into cach nerve root bcforc end transfired and tied with a third strong silk liga- division, others add the injection of absolute turc ws shown in Figures B and C Note again how alcohol , yet others ligate cach root proximally with the lateral anterior thoracic nerve may be used as fine silk None of these procedures would appear guide to the artery to the author to afford a proven advantage The In published reports some surgcons have found line of division of the pectoral muscles is also shown difficulty in locating the thurd part of the subclavian This will be varied with the lesion under treatment artery They prefer to cxpose the axillary artery by It is best accomplished, as in radical amputation or Kochin of the rectoral muscles us suggested by the brcast, by passing the inder ſinger under thic Kosher The fine part of the axillary artery can be inferior border of the muscic, followed by division liyated or it can be utilised in guide the plane of first of the pectoralis major and then of the pectoralis classion to the third portion of the suhclavian minor This step will complete the anterior discc. tion with the cxccption of the anterior portion of Timurerskou the 1.1mc technique employed for the axillary tissues, which remains for final schon thu uhlien rein in this drassing the sternal end after the posterior dissection is completed or the chile remins in SL 75 in thc classic Figurer illustrates thic opcration at the compleann pxs.lion de esix by Berger Le Conic and others of the anterior dissection ricry 30 ·A SECTION OF EXT JUGULAR V É SUPRASCAPULAR А. phrenic a scalenus ant on trapezius B deltoid subclavian a& LIGATION OF omohyoid Ć subclavius SUB CLAVIANI neitt lat ant thoracic n. sectioned clavicle, subclavius & costo-coracord membrane pectoralis minor & major D LINES OF DIVISION OF BRACHIAL PLEXUS С PECTORALIS MAIOR E AB II- LIGATION OF SUBCLAVIAN VEIN trapezza's E the thio crub I rzo II COMPLETION OF ANTERIOR DISSECTION ot PLATE VII ·THE TORCQUARTER AMPUTATION gubclava (3rd part) and v scalenus anterior zrut jugular u ext jugular o subclava (3rd.paru C-subclav şterno-thyroid şterno-hyoid artic .meniscus Cat juga ribi 10 sterno-hyord sterno-thyroid rhomboid 229 sternal end or clavicle Thombord lig & capsular tissues origin of subclavius A superior vena cavá لا PLATE VIII PLATE VIII THE STERNAL END OF THE CLAVICLE AO The detailed relations of the sternal end of the Rentoval of this portion of the bonc in association clavicle arc visualised on this platc, a study of which with the forequarter amputation is cspecially inde will assist the surgcon should the operative pro- cated in cases of carcinoma with spread 10 the cedure necessitate the total removal of the claviclc lymphatics at the base of the neck in these cases Further information can be obtained from other the most radical ablation of lymphatic tissue possible publications by the author is desired The operator will best achieve the safe The most important structures to be considered removal of the sternal end of the claviclc by disuccl are the large icnous channels The subclavian vein, ing directly on the bonc and by cutting under direct vision Section of the soft 115sues anteriorly subefore its junction with the internal jugular vein, as closely adherent to the first rib and costoclavicular pcriorly and inferiorly should precede the final posterior dissection Most accidents will result in (rhomboid) ligament Other branches chiefly the tcars of the venous channels of forcible avulson of large citernal jugular radical, cmpty into the sub- this portion of the clavicle is attempted clvan vein in this area Some protection is afforded Figures A and B show the appearances before and the large veins medully by the sternothyroid and after removal of the sternul end of the choice stermiyod muscles liichi serve as a buller behind depicted from nblique and direcils amferior til lernil end of the cl.liicle rospectively 32 ·1 + 1 ir om ܕ A cords of brach plex ext V. jug omohyoid A int Jug scar ant lat end of claircte suprascar Évéssels a. Ts deltora V KO Rhod -sternal end of clav subclay αεν mirno cephalici Ano B FIG 10 The retro-clavicular structures from the anterior aspect Compare with Ius I II V VI VII and VIII Dissection showing the subclavan artery and vein and their tributaries together with the cords of the brachial plcxus The nuddle third of the clavicle and the related fascia have been removed B Diagrammatic key to the above dissection Note orientating inset 33 5 ·THE FOREQUARTER AMPUTATION PLATE LX COMPLETION OF THE POSTERIOR DISSECTION The three drawings on this plate illustrate the Figure B, the levator scapulæ and shombord minor section of the muscles from the clavicle and scapula and major are divided in quick succession near the and the final section of the axillary tissues to com vertebral border of the scapula If thc superior anglc plete the ablation of the girdle with the limb As of the scapula is lifted by the assistant away from the main blood supply has been secured hæmorrhage the chest wall and the whole limb drawn forwards is not excessive, and ligation and division of the across the trunk, this step will be much casier Using transverse cervical vein and the superficial cervical the same technique, the inscrtion of the scrratus and descending scapular arteries will secure the anterior is next divided along its scapular attachimportant points of blood loss ment Thc posterior limb of the superoposterior skin The aullary portion of the skin incision joining incision is made extending to the inferior angle of the posterior and anterior dissections is now made the scapula The flaps are dissected in the plane of The finger is placed beneath the latissimus dorsi. the trapezius and the whole spine and vertebral which is detached from the lower angle of the border of the scapula exposed The second step is the separation of the trapezius from the outer third scapula and divided just anterior to this point of the claviclc and spine of the scapula The ſinger The whole upper extremity can now be removed can be inserted bencath this muscle layer and from the body, and the appearances are as seen in division rapidly completed with scissors (Figure A) Figure c As this stcp proceeds, an assistant using a hook or a The large muscles are approximated and fixed to finger can draw the outer end of the clavicle lateral- the soft tissues of the chest wall as found best The wards and posteriorly, thus facilitating the opera- skin wound is closed and dependent drainage urlion Once the trapezius is scparated, as shown in ranged ft How FIG 11 Closure of wound with dependent drainage A pressure dressing must be applied 34 ·trapezius clavicle supraspinatus acromion. deltoid-- DETACHMENT OF TRAPEZIUS FROM CLAVICLE AND SPINE OF SCAPULA sectionea pectorals sectioned neurovascular Hundle women 3 superior digitation of serratus anterior sectioned trans cervical v and supt cervical trapezius desc scapular aa B. sectioned clavicle, brachzal plexus & subclavian aev sternomastoid posterior 1/3 of deltoid С intraspinatus 1 trapezius -- levatorscapulae scalenus ant rhomboid minor € major tong-- thoracic be lines of section of levator scapulae interior 1/3 ot bI trapezius and rhombord minor & major line or section or latiss dorsz serratus ant pectorales minor latissit dorsz major scapular attachment , or latissimus dorsz external oblique PLATC IX

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·OPERATION FROM THE
POSTERIOR ASPECT
37

·THE TORIQUARTER AMPUTATION PLATE X THE FOREQUARTER AMPUTATION FROM THE POSTERIOR ASPECT (LITTLEWOOD'S TECHNIQUE)' tn, ? The forcquarter amputation from the anterior especially the spine of the scapula with the attachaspect has been acccpied, with varying modifica ment of the trapezius and also the posterior third tions to suit the particular case, since the time of of the deltoid This drawing illustrates the line of Berger Somc surgeons had performed this major section of the trapezius which constitutes the more ablation from the posterior aspect but the publica- superficial layer of the related musculaturc. The tion of Littlicwood" scrved to bring this technique trapezius can be separated at its attachment to the into grciter prominence In cases not requiring clavicle and spine of the scapula, or more rapidly block dissection of the lymphatic glands at the base still by placing the finger beneath it and cutting of the neck, therc seems little doubt that the Little between clamps with scissors along the dotted lino wood technique can be performed more rapidly The vicwer should also note in this drawing thic once the anatomical relationships are accurately tercs major at the lower angle and thic related latissiunderstood However, it must never be forgotten mus dorsi with its scapular attachment Thus latter that the subclavian artery and vcin are at a consider- musclc will be separated and scctioncd along the able depth when the operation is performed from line indicated in the final step of the anterior dissecthe postcrior aspect, and if the clavicle is sectioned tion, but it is included here for completeness near its sternal cnd care must be taken when the As shown in Figure c, after section of the tralumb is manipulated away from the trunk since the pezius, the deeper layer of the musculaturc attached scctioned lateral cnd of the clavicle may casily to the superior angle and vertebral border of the puncture the venous wall scapula comes into vicw These muscles, the levator These two plates illustrating the Littlewood tech. scapular and the rhomboids minor and major, are mique cover the steps of the posterior dissection up readily identified by drawing the scapula away from to the section of the cords of the brachial plexus the chest wall with hook or retractor and passing and the ligation of the artery and vein These latter the finger bencath this layer Scction is performed icchnical aspects together with the anterior dissccrapidly with scissors tion arc identical with those for the operation from In the severance of these two layers of musclcs, the interior espect and can readily bc reviewed in branches of the superficial cervical and inc dcscend- Plates V. VI. VII and IX ing scapular vessels will be encountered and will Figure A shows the patient postured in the left require ligation The superior digitation of the scrlateral position for the operation on thc right side ratus anterior will be severed close to the superior The surgcon stands facing the back of the patient for the posterior dissection, passing in the opposite angle of the scapula as this bond is drwn away from the chest wall The remaining insertion of this Silc for the anterior dissection and the final ablation of the extremity. The line of the superoposterior muscle should be divided close 10 its attachment inciunn i depicted but may be altered to suit thic 10 thc vcricbral border to complete the posterior particulır circumstances of the individual case division of the muscles binding the scapula to the In riure it the shin flips have been undermined from llir clavicle superioris to the infcrior angle of In the superior part of the incision the neuro the capul. in illo serlical direction and from the vascular bundle will be found onib:ddel in a bed of cricbral border of the scapula vell across the fosse libro-fatty tissue It is closely relucu to the superior of the supula in the transerse direction Notc digitation of the serralus anterior thoracic casc ·1 11. AN А SUPERO~POSTERIOR INCISION 3 A. deltoid teres major spice 1 of scapula } B nom w mar 1 1 ne of incision through trapezzis line of incision through latissimus dorsz infraspinatus line ot incuszon through superzo drgitation ot serratus anterior С کہ اس سے OS 5 ! neuro vascular bunales } scapular attachment ot latissimus dorsz line ot incision through levator scapulae rhomboid minor e major supt cervical Amac Arthaen PLATE X ·* D sectioned levator capulae rinore major 3 sectiogled trapezi 119 4 vascular bundid desc SCCP a suprascapular E vessels omohyozd he presenting clavicle brachial Plexus subclav (axillary). ws subclavius cat jugular origin or CE,6 iong thoracici, piercing calon719 modris supe cerv cheap DII IT] و ایران را داریم 1 PLATI XI ·OPERATION FROM THE POSTERIOR ASPECT PLATE XI THE FOREQUARTER AMPUTATION FROM THE POSTERIOR ASPECT (LITTLEWOOD'S TECHNIQUE) of C., CG 11 : With the completion of the division of the pos- remembered as it is easily perforated during the terior muscles binding the scapula to the thorax, the dissection of the neurovascular structures surgeon should proceed to expose the neurovascular More anteriorly the posterior belly of the omostructures which are embedded at a considerable hyoid accompanied by the suprascapular nerve and depth in fibro-fatty tissue At this point the descend- vessels can be seen in their relationship to the supraing scapular vessels, which bear a close relationship scapular notch The final localısıng landmark anto the cords of the brachial plexus, may be encoun- teriorly is the clavicle with the related subclavius tered The artery usually passes between the cords muscle The fasciæ which invest these structures while the vein may course around the anterior aspect have been omitted for the sake of clarly but can be reviewed in Plate VI In Figure d the general relationships will be seen To complete this stage of the operation, each cord while in Figure e this important area is magnified of the plexus is individually dissected ..' Added and shown in considerable detail with or without preliminary injection If the viewer proceeds in Figure e postero- hydrochloride The artery, followed b. 1 anteriorly he should note in sequence the branches then secured, ligated, divided, and the i". of C5, Co perforating the scalenus medius to join transfixed The omohyoid muscle and with a branch from C, to form the long thoracic scapular vessels and external jugular van nerve (Bell) which supplies the superior digitation after and all other parts of the serratus anterior The preliminary vessel ligation So.. cords of the brachial plexus then come into view transect the clavicle near its sternal end or They largely cover the subclavian artery as it comes late the bone at the sternoclavicular joint pour forward between the scalenus anterior and medius division of the neurovascular structures, wh: 0111** in its third part to cross the first rib and becomes the prefer to delay this step until the importam vessels axıllary artery Although the second rib can be are divided and carry out the clavicular division as easily localısed, the first rib can only be found by part of the anterior dissection palpation and the artery is best recognised by its With the completion of the division of the neuropulsation against this tib The subclavian vein lies vascular structures, the surgeon passes to the opmore anteriorly, therefore more deeply, and in this posite side of the patient and the anterior dissection position it is joined by the external jugular vein is performed as can be understood from Plates V. The close proximity of the pleural dome should be VI, VII, and IX 41

·THT I ORLQL'ARTIR AMPUTATION
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·OPERATION FROM THE POSTERIOR ASPECT 4. A trapezius sudrascapin retracted cords of brach plexus retracted subclav atele a subclbu desc scapv And B FIG 13 The brachial plerus and subclavian vessels from the posterior aspect A Identical with Figure 12, A, except for retraction of cords of brachial plerus and subclavian artery to ciposc subclavian vein B Diagrammatiches to above dissection 43 ·THE TORFQUARTER AMPUTATION THE ARTERIAL PATTERN IN RELATION TO THE FOREQUARTER AMPUTATION The two line drawings in Figure 14 serve to illu 5 The acromial branch of the acromiothoracic rale in diagrammatic fashion the arterial pattern artcry in relation to the forcquarier amputation as per- Thcsc arteries with their accompanying icins formed from the anterior aspect. The information provide a rich vascular network in the soft tissucs depicted can also he adapted to assist our under- of the subscapular, supraspinous, and infraspinous sianding when the operation is performed from the fosse posterior aspect or when partial ablation such as The principal drawing illustrates the arterial patscapulectomy or the interscapulo thoracic rcscction tern in relation to the claviclc, scapula, and upper is cleuited Study of the anastomoscs will cnablc third of the humcrus The points of illic arterial the surgeon to visualise the probablc abnormal col. scction necessitated by the forcquartcr ampulation lutcrals which will cnlarge in rapidly developing as depicted on Plates V. VI. VII, and IX arc indi. sarcomata, involving the tissues of this region cates. The artcrial channels which are removed The upper drawing shows the arterial anasto when the forcquarter is ablated are shown as crossmuses around the scapula which in light of the hatched, while those wluch remain arc indicated as precling illustrations can be tabulated as follows solid black As also found in the accompanying | The suprascapulur artery drawing certain collateral vessels are included The 2. The descending scapuler artery (dccp branch vicwer should noic thic internal mammary and of the transverse cervical artery) superior intercostal artcrics which form anstomoses Thic subiscipulur uriery and its circumfler through the intercostals These may be cnlarged in scipul ir branchi crtcnsive ncoplasms Further, these channels are A branch of the posterior humeral circumſer accompaniej by lymph channels (Pulc 1V) which artery should be sludicd in relation to neoplastic spread ·wwujui Stettinum THE ARTERIAL PATTERN suprascapular a acromial branch of acromion thoracic axis ARTERIAL ANASTOMOSES AROUND post humeral circumtrex circumtrex THE SCAPULA circumtex scapular a desc scapular superficial cervical a humeral circumflex aa ant post Nuimmnnmariti desc scapa suprascapa -thyreocervica? trunk common carotid a subclaviana innominate nidine 7 ? rat thoracica 1144 a subscapular profunda brachzz a. *new t a internal mammarya e intercostals pectoral branch ot acromo-thoracic axes Fig 14 The arterial pattern in relation to the forcquarter amputation 45 ·THIE TORTOLARTER AIPUTATIOS SCAPULECTOMY The three drawings in Figure 15 serve to comple- vessels will require higation up to this point lhc ment the information already given on Plates III, inferior angle of the scapula is then cleared by IX. X. and XI concerning the anatomical relation- detaching the latissimus dorsi, after which the scarships which determine the technique of partial or ula can be rotated to facilitate the remaining tops total «capulectomy If the axillary border is readily accessible, the When indicated, subperiosteal reflection of the long head of triccps and the teres major are then supraspinatus, infraspinatus, and subscapulans mus. scctioncd In this arca branches of the dorsales cles should be performed, and when this is possible scapulc vessels will require ligation Core should an crccllent functional result ensues as the scapular be taken to avoid injury to thic circumflcı nene and sheicton is often restored in part. especially in young vessels and to the posterior aspect of the neuroindniduals (Fig. 251) However, when these impor- vascular bundlc depicted in Figure A lant muscles are lost for shoulder function. the The scapula is freed from the claviclc by section cientual moicment and power are considerably less through the acromioclavicular joint and corco. als acen from the case of Symc (Fig 5) and the clavicular ligaments, or the clavicle can be acctioned illustrative case (Tig 24) mcdial to the coracoclavicular ligaments as mects When possible. It is valuable to retain the acro the needs of thc surgcon By rotation of the huu mion process with the attached deltoid and the merus the rotator cuff is scrcrcd Icaving a stub, and coracoid with the short head of biceps and coraco the remaining attachments including the cornco. brachialis. These muscles with the long head of brachialis and biceps. pectoralis minor, omohoid triccps should be anchorcd to the clavicle and chest and related suprascapular nerve and vessels arc Hall to give whatever suspension of the upper limb divided is possiblc and practical Thc scapula with its related muscles and including: the Icsion under trcatnicnt can then be removed Steps in Scapulcctomy Thc structures ablated can bc understood from The posterior aspect of the scapula will be Figures B and C which show the scapula from thic cxpircil through one of the incisions illustrated on posterior and anterior aspects with the related Figure 16 The precise arrangement of thc lines of muscles, nerves, and vessels labelled for review (ie incision will be determined in the case of large ncoalso Fig 141 plastia by the penition of the growth and the condi- In closing the wound, consideration must be rucn tom of the overlying shin to the problems of providing s16pxnsion for the Tlapsarc made exposing the scrtcbral and axillary burcler, tlic spine and superior ungle Again, the upper limb The coracobrachiules and biceps. ass vulso the long hcad of triceps, arc best lived in the claviclc, cu.ch uppruach for freeing the scapula will be determined by the lesson under treatment For thic The deltoid should be sutured to the cut edge of the majority of l.les thc carly stops can be followe: trapezius in Minie X The traperius sith the deltoid may be Some of the anilomical points underlying the epilepttmuo'lly rcllicicd from the spine and acronion interscapulo-thor.CIC resection (Fig 171 can be or disison of the triperius muy he made as illu undersjoox} from this figurc . ! scen that the rated on tii plate upper end of the humerus could readily Ike sonuç Thc laullorcapult rhonhoids minor and major, with the scipula by substituting action of the litt. wod finalls the error internus 1re then schoncd incrus at the required site for action of the revistas Orlu rein branches of the descending serpular cult 46 ·SCAPULCCTOMY omohyoid trapezius neurovascular bundle sectzoned coraco-clavic ligs clavicular facet sectioned cutta POST VIEW AFTER SCAPULECTOMY 4--deltord sert zev scap ant NIMET rhombords circumflex vessels en teres major HL radialn . N long e lateral OM heads of triceps latiss dors branch ot desc scap pect minore major ιον scap coraco-clavic ligs suprascap vessels en omohyoid rotatori cuft rhomb minor. serr ant coracoprache biceps major Spect minor VIUN subscap Cu subscap long tendon 'ot triceps teres minor & major B branch of dors scapa С And POST VIEW OF SCAPULA ANT VIEW OF SCAPULA PORTES FI 15 Total scapulectomy 47

·THE FOREQUIRTIR AMPUTATION
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·INTERSCAPULO-THORACIC RESECTION This procedure, which includes removal of the scapula, the upper end of the humerus, and a varying portion of the lateral end of the clavicle, has been described by Tikoff, Linberg, Bauman, and Pack As its uses are extremely rare, detailed coverage is unnecessary. It may be indicated in cases where the neurovascular bundle is free of disease and the patient refuses a forequarter amputation Figure 17 illustrates the case of Dr George T Pack where the procedure was used for a squamous cell carcinoma involving the scapula, which had received intensive radiotherapy with resultant sinuses, radionecrosis of the scapula, suppurative arthritis of the glenohumeral joint, and chronic fibrosing from the clavicle and the neurovascular bundle The pectoralis major and deltoid are detached osteitis of the upper end of the humerus exposed from the anterior aspect as in the early steps The technique differs only in moderate degree of the forequarter amputation performed by the from that described for scapulectomy The racquet- Kocher technique The transverse cervical and suprashaped incision extends along the clavicle and down scapular vessels are secured and divided the medial border of the biceps for three to four inches, thence superolaterally across the upper third The posterior incision extends along the axillary border of the scapula, and from the inferior angle of the arm thereof the incision extends superiorly and laterally across the upper third of the arm to join the anterior Incision The remaining steps are as for scapulectomy except that the rotator cuff is not divided but the humerus is sectioned through the surgical neck The radial nerve and the circumflex nerve and vessels should be located and carefully preserved (Fig 15) In closing the wound, suspension of the limb is more difficult but suture of the coracobrachialis and biceps to the stump of the pectoralis major and the long head of triceps to the remaining soft tissues of the chest wall should be attempted Further details of this procedure can be obtained from the references appended * (9 11 7 49

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·Post-Operative Considerations of excessive blood loss from the wound V FIG 18 Plastic shoulder cap with short arm stump to give cosmetic symmetry in clothing (After R D Aylesworth) HE immediate post-operative care in the The question of the cosmetic appearance in recovery room will include early recognition clothes may be uppermost in the patient's mind In the early stages, the tailor or dressmaker can arrange drainage and any fall of blood pressure The pressure a pad to afford symmetry to the upper trunk and dressing may require replacement shoulder area Later the decision as to the necessity The primary dressing should be changed after for a light plastic shoulder cap with upper arm stump twenty-four to forty-eight hours and the drain short- (Fig 18) or a dress prosthesis (Fig 19) can be ened or removed depending on the amount of settled In cases where the operation has been perdrainage Early ambulation is desirable Antibiotic formed for palliation, a soft pad is often all that is therapy should be continued until all possibility of required, but in others where long-term survival is infection has been removed expected a light-weight dress prosthesis is beneficial Wound healing is usually rapid and the patient from a cosmetic and psychological point of view may be ready for discharge after ten to fourteen although its function is minimal The definitive care days At this time the arrangements for a course of such patients includes their rehabilitation (sce of post-operative irradiation must be concluded Case LXVII)

·THE TOREQUARTER AMPUTATION
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52

·VI
Illustrative Cases
53

·THE FOREQUARTER AMPUTATION
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·ILLUSTRATIVE CASES 4 } MEUR DES ARTS E F Fig 20 Berger's classic case of massive enchondroma of the superior extremity of the humerus Patient alive and well four years post-operatively A Anterior view of patient, age 27 years Note that an amputation through the lower forcarm had been performed at the age of 12 years for an enchondroma arising on the little finger B Posterior Circumference of tumour 95 cm View C Lines of incision used by Berger and attributed to Farabeuf D Post-operative appearance, anterior View E. Post-operative appearance, posterolateral view F The prosthesis, anterolateral view G The prosthesis, posterolatcral view G 55 ·THE FOREQUARTER AMPUTATIOV $ A B FIG 21 Case of Dr James I Callahın Malc patient, aged 37 scirs; history of pain in the right shoulder region of six months duration Biopsy rescaled an ostcogenic sarcoma A Clinical appearancc hefore operation Intensilc pre operative X-ray Ircatment glen, resulting in thrombosis of the right subclausn artery and vein B Radiological appearance C Post operativc photograph Post-operalive lony trcalment has given Patient allic ten years later Microscopic studies showed chondrosarcoma 21 2 C 56 ·ILLUSTRATIVE CASES 1 FIG 22 Authors case male agc 47 Patient had severe burn of the left upper limb and thorax at the age of 16 years Carcinomatous changes occurred which necessitated upper arm amputation in 1952 In December 1952 biopsy of an axillary mass showed squamous cell carcinoma Referred to the author January 1953 1 A Pre-operative appearance B and C Appearance after secondary forequarter amputation performed January 1953 Death occurred eleven months later from cerebral metastases There was evidence of local recurrence 2 2 A no راپلین ها 3 1 ! > $ 1 1 B C S 57 ·THE FORCQUARTER AMPUTATION FIG 33 Authors casc female 35c 73 Eight nionths previously, local resection of squamous cell carcinoma present an dorsum of hand for siricon months Rapidly derclored epi trochlear mciastases which were biopsied. Multiple recurrences developed in this area and in the arilla Intensic radiation had heen given to the axillan and cpitrochlear regions Rc'erred to author for forequarter amputation sit months after biopsy of cpi trochlear glands A and B Appearance following forequier amputation Dind thiriccn months postoperatively from local ind pulmonary mu17 stascs C Radiological appearancc post-operatiicly 11 A کلیه همه طبا بعد 6 B FIG 24 Case of Drs H L Mclaughlin W W Wericy and R R. Impink Malc patient. age 42 had a mass arising from the asıllary border of the right scapula luch on hiopsy showed fibrosarcoma Scapulcctomy by Dr Mclaughlin October 1950 Palicnt alive and well at the time of this publication A X-ray appetrance with arm in 114 resting position Note that the acromion process has heen fired to the chvicic to site dahil ity to the deltoid and that the coracoid process Hith its attached muulcs remains in sitt B Shows the position of thic humcrus in maximum abduction ( Clinical photograph shouns cosmictie apstirince arm in resting position 1) Photogrph showing maximum deuse abduction, interior cu r Posterior cu.resting position 1 Postcrios SICK, marimuni abfolution Fio 23 58 1 ·ILLUSTRATIVE CASES 5 3 19 A L 7 с c 2 F A- FIG 24 59

·THE I ORIQUARTER ANPL'TATION
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6o

·VII Traumatic Forequarter Amputations (in chronological order) CASE I adhesive strips constituted the dressing in two w the wound was almost healed, entirely so in eight w 1737 Belchuer 110 Male, age 26, left side A witness of the accident stated that the mai The man, Samuel Wood, was carrying a rope which had been temporarily stopped by the resistance o caught in the cogs of a large mill-wheel and his body patient's body, and experiments showed that this ri was raised from the ground until checked by a beam, ance amounted to a weight of 839 lb whereupon his arm and shoulderblade were torn off He was able to descend a narrow ladder and walk eighty CASE IV yards before fainting from loss of blood Later in the 1829 James, G W 113 Male, age 10, side (?) day d surgeon could not find the large vessels, and as The boy was caught by a chain attached to a st there was no further hæmorrhage he brought the fleshy engine There was no great hæmorrhage and little parts of the wound together by needle and ligature and he walked twenty to thirty yards to his father applied a dressing Next day he was admitted to St fainted Two days of exhaustion were follower Thomas's Hospital where the dressing was not disturbed irritative fever and large suppuration Treatmen for four days, when Mr Ferne opened the wound and tonics and opium cured the patient in three months finding no blood-vessels “ dressed him up again” Cure was complete in two months (See Frontispiece, Fig 2, CASE V and also pp 1-2) 1832 Scarnell, S F 11 Male, age 13, right side This boy was caught by a chain in the upper si CASE II of a mill, and being drawn against the roof his arm 1808 Cuming, R 11 Male, age 21, side not stated scapula with all its muscles were dragged off and Dr Copland Hutchison saw this patient in 1808 The body fell The finger-like projection of the clavicle operation had been performed by Dr Ralph Cuming, removed, vessels secured and wound covered with Surgeon to the Naval Hospital at Antigua (See Fig 3) integuments as remained, and a light dressing apr The general health suffered very little He was ab CASC III walk at the end of a fortnight, and on the third Su went to church 1819 Mussey, R D 112 Male, age 16, left side This lad was caught by a machine in a cotton factory CASC VI Two hours after the accident the surgeon found a large 1833 Bratlıwaite, J Male, age 12, right side oval-shaped wound covered with a material resembling On 12th July 1832 the boy was caught by the : white of egg and with the collar bone projecting at the of a carding machine Hæmorrhage was not prof upper part, less than a pint of blood had been lost the artery was secured by a single strong silk thread Hanging from the wound were two large nerves 20 in the vein also ligatured Thc flaps were adjusted long, and when these were cut off the patient complained secured by two ligatures and plaster straps and ban of pain which he referred to the hand on the injured applied Healthy purulent discharge occurred on side A little below the collar bone was a coagulation eighteenth day and granulations were encourager s large as the finger tip which bcat as a pulse No injecting a solution of alum one drachm to a pint ligature was applied to any vessel nor were stitches was successful after seton had failed Thc patient employed in the wound, compression bandage and perfectly well three months later 61 115 ·THE FORCQUARTER AMPUTATION CISF VII Fergusson said the case occurred many years ago 1836 Pirond S " Mule ago 14. left side during his connection with the Royal Infirmary in Edin. In the report on his own case (1855) Pironde recalls burgh The boy came under the care of Mr Lizars What slule visiting the Edinburgh hospitals in 1836 hc SJH child of 10 years whose right arm had been torn Casr VI off hy a machine together with the scapula claviclc, 1842 Cooper.13" Male', age 7. and the soft tissues of the shoulder. which were separ- This boy suffered a machine accident in which thic ated from the trunk as if by dissection Hæmorrhagc arm and two-thirds of the scapula were torn of The was negligible, and at the twelfth day cicatrisation was clavicle and remains of scapula were removed by operiucll advanced tion Patient made a rapid recovery 11 Casi III CASE VIII 18.38 Gactan-Ben 11° Male (içc 14, left side 1843 hing, A" Male, age 15, left sule On 31st December 1838 the boy was working at a foundry and was the victim of an cxplosion which On 10th October 1843 the boy was caught in a milllaccratcd his armi. shoulder, and scrotumi Tlie left shed After the accident hc fainted for a few seconds Total loss of blood was not morc than two ic.cupfuls Spermatic cord was sccred by thic flying metal and the hons structures of the shoulder so smashed that amputa- The nerves were torn and the sliglitest irritation calc tion was necessary The lacerated intcguments were rise to acute suffering Thc axillary artery was secured fushioned to forni a coi cring to the cxtensive wound by a ligature and the integuments drawn together by and in fifty-five days after the operation the patient had adhesivc plaster Reaction was trilling and on the tenth completely recovered day thic boy was lively and cheerful, though in terror when the exposed plcxus of nerves was touched The Cisi 11 ligaturc lay in contact with thic nervous mass and was 1838 Larret 18 Male, age 14 left to drop off with the sphacclatcd nerves about the This boy had a gunshot comminution of the boncs sixth week, when the patient was in perfect health of the scapula und arm These were removed by operatron Casi XIV It was reported that this subjcct rcccrvcd so scierc 1845 LOWS, WW an injury of the scrotum at the same linic that castration Patient suffered multiplc injuries in a machine acci. 11 is necessary Thc patient recovered dent Interscapulo-thoracic amputation was performed. but paticnt dicd from shock soon afterwards CASI 1842 Caririq 113 Male, age 14. left side Casa V In the museum at King's College there is a prepara- 185.5 Pirom,S"Malc, aço 39. left wide. tian (made before 1842) from which the annored figure (131) 11.75 tolon The patient, « lad of 14 years of agc. On 29th Junc 1855 the man was crushed by the mill W. under the care of Mr Curlu right of the Middlesex of a large stone and suffered multiple injuries The liospital and made a good recovery slioulder joint was mashed but the artery had escaped damage and was seen bcating strongly in the milla (198 v Having impulated thic arn the artcry Has tied as hrogla 1,872 Lizure!!! Nole oiky 13 as possible and the conininutcd scpula removed The I hen boy was the victim of a machine aident The wound 1,15 covered hy a large posterior fup and the vllir socis ad neric hung loosely from the anterior part by soft tissuc that had escaped injury sounul thiute ut little bleeding and no shock The Little blond was lose and the patient's conditio: 8,5 listriert ** lifutured the edges of the shin Satisfactory alter the operation but soon after le sini breught watciler is closely as presibile und the patient und died Post-mortcm ciamunition rescalcu. lutsc milers droconary luccrulion of the night lung and much blooxt in the chicot 63 ·TRAUMATIC FOREQUARTER AMPUTATIONS CASC XVI crushed that it was necessary to perform the inte 1856 Parise, M 122 Male, age 161, right side scapulo-thoracic operation The patient made an u, eventful recovery On 26th August 1856 the youth's arm and shoulder were crushed in a machine accident. The brachial plexus was denuded as if by dissection The subclavian artery CASE XX and vein were tied and the arm, scapula, and external 1864 Jackson, V 125 Male, age 35, right side part of the clavicle removed Recovery was uneventful In December 1864 this man was struck on the bac except for suppuration, which lasted two months The with the buffer of an engine, the wheel of which ra patient had robust health until 1882, but became alco over and crushed his arm with the loss of a considerab, holic and committed suicide in 1885 amount of blood As the scapula was comminuted it removal, except for the acromion process, was per CASE XVII formed Four vessels were tied, each being ligatur Between 1856 and 1869 Parise, M 122 immediately it was cut Flaps were approximated ar Male, age 14, left side held with wire sutures and water dressing applied The arm and shoulder were crushed in the gears of Patient died next morning a machine The flaps of a large wound extended anteriorly above the clavicle and posteriorly to the lower CASE XXI part of the neck Comminuted fractures of the humerus 1866 Lowe 126 Male, age 18 and scapula were present Parise tied the subclavian On 16th May 1866 the man was caught in a cardin, artery, but the proximal end of the avulsed subclavian machine and his entire upper limb torn to pieces w. vein could not be found as it had retracted into the very little hæmorrhage When admitted to hospital h. superior opening of the thorax The whole upper limb, was in a state of collapse, the artery and vein wer“ the scapula, and half the clavicle were removed and the denuded and lying in the wound Under chloroform flaps closed The wound became infected and the patient the vessel was ligatured and the exposed part cut off as died on the twelfth day Autopsy disclosed phlebitis of well as that of the nerve plexus The outer third of the the left subclavian vein extending to the superior vena clavicle was removed and the flap brought together and cava The stump of the subclavian vein was full of pus held by three loose stitches and a dressing applied Five days later there was much delirium, followed by CASE XVIII a copious discharge together with some large pieces of 1857 Horlbech, H B 123 Male, age 35-40, slough which came from the interior of the wound right side Delirium had now ceased and patient was ordered On 11th Scptember or December 1857 this man, a mutton chops, etc, ad libitum He steadily improved muscular negro, was pounding resin when his arm was and was discharged cured in five weeks drawn into the machine and he was carried round till his body was stopped by a beam, when the arm and CASE XXII scapula were stripped from the trunk, which fell to the floor There was little hæmorrhage or pain except for a 1866 Buchanan, G": remale, age 17 burning" in the wound for which tincture of opium This patient was caught in a milling machine on 26th was given The patient suffered no shock, rested well, December 1866 Under chloroform the compound comand lost not a drop of blood during treatment, which minuted scapula was removed, the auillary artery having consisted of bringing the skin edges together after been previously secured There was very little hæmorcleansing the wound and securing them in position by rhage and the patient partly rallied but soon became means of adhesive strips Healing was complete by the exhausted and died of shock sixth weck when the patient resumed his work CASE XXIII 1869 Jones, T [13* Male, age 11, riglur side 1860 Niepce 124 Male, age 32, Icft side In November 1869 the boy was entangled in a rope On 17th December 1860 the man had his arm torn and was drawn between an iron rod and a wooden franic off by a wheel and the bones of the shoulder were so 6 in apart, his arm and scapula being thus separated CASC XIN 63 ·THI. TOREQUARTER AMPUTATION from the bodi Hc lost some blood, fuinted and was in third day when carbolised dressings were abundoned 3 state of shock for six lours The modun und ulnar Patient was discharged cured after seventy-four days nchies were then cut what and the axillary artery treatment secured Two inchus of the clavicle were removed and CASL '\VII the soft parts brought together by metallic sutures , 1870, Luu 13) Mal, age 4 right side wound was dressed cvery four hours with carbolic lotion Healing was compleic in three weels and in two months On 29th August 1870 Wm C was caught in tlic the boy was perfectly sell und running about spoles of a curt wheel and his arm and scapula were torn from all attachments to the body crept the skin CASE W of the axilla Ho ncncs of the brachual plenus and the 1859 Paris, 11. Male, age 35. left side. Latissimus dorsi muscle There was no hemorrhage : In 1869 the man suffered a machine injury which the torn end of the artery lay twisted in the round The necessitated the surgical removal of the left arm, more flaps hcalcd in grcal part by first intention, and three than half of the clavicle and the greater part of the wecks after the accident thic child was running shoul scapul. The subclavian srtcry and vein were ligatured the Ward while thic posterior border of the scapula, being un. CASE XVIII injureil. was preserved with its attachments in the hope 1870 Charles, J J." Mule, age 10, nghe side that suppuration in this region, which had occurred in a former case, would be prevenicd but the patient dicd In the morning of 14th September 1870 the hos 1.5 on the cighth day of pneumonia caught in the wooden roller of a mill rive hours later At the post-mortem examination it was found that thic surgcon found him cold and wcall with the greiler suberal ribs were fractured tuo of which had pierced part of the upper third of the hunicrus and whole of Ilic scapula almost forn away The lumb was separated the lungs Also present was a fracture of the fifth ccrvifrom the body, and flaps as large as possible made from cal vertebro the soft tissues of the shoulder The edges were adjusted CASE W and sutured and the wound covered with a water 1899 Tha cr S2: Male ve 1? dressing there being no carbolic acid at home Two days later patient's condition had much improved, and Thic accident occurred in the summer of 1869. and in three wecks the sound was ncarly houled and lus iliere wat niorc hemorrhage than usual in these cases strength and activity regained The suheluvan artery was ligatured and the outer end of the cluncle removed The patient had seicral frac- Casi wa tures od vas badlı confused in various parts of the 1871 Karholtsh, p 13 Mul, one 37. right de boily but made a perfect recovery On 21st May 1871 tlc mun. J S. was caught by a lieavy cast being hoisted and was carried against a C1101 bcam such stripped off his arm and shoulder blade 1839 15mfen, Il **** Male om 13. 11f side with little ha morrhage No pulsating or bleeding ressus On 23rd March 1569 John Rwas working inspirer could be seen, but the Icast contact with the ci posed full when bus atm Bas caught beluccn two pinion nervous plc uses gave greit pain, which was a promita wheels. At the Royal Infirmary. Edinburgh he was nent feature in this case lis flim were brought plicti milor chloroform und wus found to bic sulle-cu together and held by four steel pins and in the thirty fulsion of the mi the shouldır almost donuded of Tifth cay the patient was able to walk out shin, nx the mules und luscio coposed as if by disa Cisil culton 1873 Jussos Wale i 1. lili auto. In orter to oh I found 670,105 1t 1.75 Neustury On 28th April 1871 Jolin Clark's om west cusht tampistil th: •4ipuland clasicle During the serra. bonucun cog-u heels and then released he was able to ter than 104+) ter lied but not nuore than 2 (/ Hulhu les bands and then tunted This oll 11.411.21 o blogu tak Innt ih bo HIT 54 usled out with connecting linh sisih tli: front ucre :lmost cofirely In curbolic so volutou am the clues were brought destroyed but there was kille hemorrhase Operaba toilet and maintains! I'rn,'904 1.6+ slot want the thir!. '. p-sformed under ether during shock 115910% of the ·TRAUMATIC FOR EQUARTER AMPUTATIONS shoulder were dissected to make flaps and joint opened CASE XXXIV To form the posterior flap it was necessary to remove 1878 George, W H 136 Male, age 29, right side the scapula, during which air entered the subclavian A Mexican miner had his right arm and scapula 1 vein The patient became deadly pale and pulseless, off by descending mine shaft on 4th September 18 and restorative measures were applied while the opera- Little hæmorrhage occurred No vessels required I tion was being completed For the first few days after tion and the skin flaps were drawn together with suti operation the boy was feverish and delirious, and there and adhesive straps was sloughing of flap which necessitated skin grafting, The wound was practically healed on the thirtybut by the nineteenth day the wound had healed per- day except for a small cavity under the projecting p fectly of the clavicle which remained in situ CASE XXXV CASC XXXI 1880 Wheelhouse 139 Male 1874 Hendry, G 133 Male, age not giveni, left side This patient was treated at Leeds Infirmary for in Samuel Watson's left arm was caught between the for which interscapulo-thoracic amputation was belt and pulley in a shingle mill He was carried around the shaft four times before the arm was torn off and quired No further details published he was thrown to the floor CASE XXXVI The scapula and outer 1 in of clavicle were removed 1880 Ellis-Jones, J 140 Male, age 17, right side The vessels, which had bled very little, were ligatured On 10th September 1880, Wm L, a miner, suffe The wound was cleansed and the skin sutured a machine accident He was conveyed three mile: Infection supervened and some of the skin sloughed, his home where the surgeon sawed off the outer t shin grafting was required, but the wound finally healed thirds of the clavicle and ligatured the main arte little blood had been lost The flaps were fairly brou CASE XXXII together and dressings applied wetted with carb 1876 Gundrum, F 136 Male açıd (140) On 2nd December 1876 boy John suffered a gunshot Wound healed except for a little gaping at the mi wound and several days had elapsed before a surgeon where there was scarcity of skin Infrequent dress was called in He found the arm black and “mummiwere continued and in a month the patient was fied,” and the sloughing process had extended over a to take open-air exercise great part of the shoulder After giving the patient 2 oz of French brandy, ether was administered and CASE XXXVII operation undertaken to remove the entire scapula with 1881 Lewis, R F 141 Male, age 26, right side the carious end of the clavicle and remaining portion His shirt sleeve was caught in the cogs of a mach of dead humerus During the operation four vessels and his right arm was completely avulsed carry were ligatured and ten smaller ones twisted The enorwith it the entire scapula denuded of all muscular tis mous wound was washed out with carbolised water, Little biecding occurred, about 8 in of the me closed with silk stitches, and dressed with lint and nerve hung from the wound The patient made colion wool Healing proceeded rapidly, patient was uninterrupted recovery The article contains an illus up in a week and made an excellent recovery tion of the appearance Casc YXIII CASC XXXVIII 1876 Wemlecher 137 Male, age 16. left side 1883 Will, 1 C 0.12 Temale, age 18, right sidde On 20th July 1876 this lad fell asleep at his rolling On 5th January 1883, Lizzie W, mill worher. machine and his arm was caught and separated from injured by a flax-spinning machine There was his body There was much damage to skin and muscle hæmorrhage and the axillary artery was seen lying and comminution of the scapula necessitating its removal the surface of the wound, pulsating feebly, having b together with the remainder of the shoulder girdle In closed by torsion Patient was seriously collapsed spite of antiseptic treatment and skin grafting progress the acromial end of the clavicic was removed with was very slow and eighteen nionths clapsed before the anæsthetic Wound was washed out with 1 30 carb patient was fully recovered lotion and the flaps brought together and suture: 65 ·THE FORQARTER AMPUTATION the third to fifth day discharge Hals purulent, but then Casi un1 the patient res.ined strength and was discharged from 1885 Sulmidi, [." Malc. arca 7. left side. hospital nincteen days after the accident This young patient sustained in a railroad injuna Yo part of the am or scapula could be cranuned as compound comminuied fracture of the radius and ulna; they were reduced to pulp bcforc the machine could be extensive lacerations in the left shoulder with the sopred humeral head torn from the glenoid cruity. the arm CASI XL hung only by the brachial plcxus and sonic strips of 1894. Lucas-Champ onnere, J." Atale age 38 siin, compound comminuted fracture of the middle of left side. the left clavicle and of the Icft scapul. The ribs were On 30th June 1884 this men was caught in a machine widely crposed interiorly, laterally, and posteriorly The hand was mangled The whole forcquarter, includiand his arm torn oil there was little hemorrhage lodoform and a carbolised dressing were applied to the sed dressing were applied to the ing two-thirds of the clavicle, las removed under general an.csthesia wound until patient recovered from shock. which lasted There were associated injuries to the right hand with ihrec dels At operation the clavicle was stripped and loss of three fingers Extremc shock was present during divided, the subclavian muscle scicrcd, and the artery und vein ligatured , ncrics were cut off as high as posthe operation but the palicni cicntually made a perfect sible The pectoral muscles being disided the shoulder recovery uns roversed to detach it from the thornt Much blccd. Case XLII ing from small artcrics was controlled with forceps. 1886 Alaconi, Galanta Hound Has Haslied out several times with strong car. bolic lotion Pauicnt collapsed on the operating table On 24th July 1886 coniminutcd fracture of the left Hihere he had to remain for the hours with head low arn and scapula interscapulo-thoracic mputation Suppuration occurred during the next weck but from (without the clavicle and part of the scapula) death the tenth day there was a notable improvement which at the end of thirty hours Transfusion Stimulation 15.15 in untained und in a month the patient was walking Ligature of the subclusian artery Death from adema in the wordt of lungs and acule anaemid Cist CASE NIIV 1864 rornari, riu Mule, agc 21 luft side 1887 Joannel! Niale, are 26, left sider Thumun sulfered a gunshot wound of the upper arm Durch ncime gangrenous At the first operation the On 24th April 1887 a lion savnged this man's armi and shoulder The subclavian story and vein Herc mm acromion and coracoid process ucrc removed, but neurosis of the serpula necessitated its complete resecligatured and the following day amputation was per formed 110m also Less than 200 grams of bloo: were lost but the CIVI patient died three and a half hours after operation ISS Jomech Alalc.inse 36. le ja sude Onlich July 1985 the man's arm was caught in a CASI VIV cihlc and Illallic from tlic body together with th: 1887 Kirmisson Blu Aioli', ok 27. 1. lt suit. spol. There was no lirnorth are the nenes slowed On 23rd August 1887 thus man suffered gunshot in fairy tale rings on the surface of the round, which wound of the arilla Thero 1.5 much hamorruage anil meitired 19 cm long hi 10 cm bule, the edges his was udmitted in hospital four hours lister will aftreil enn 411 15 12 h of scalpel Under chloro. 107* Ili: nutcr pirt ni th: clavicle 24 removed the profound shock Next day thc byny structures of the 117) Jill d d s ' cc.uun the axillary c*c's khoulder were found to ix crusheil, no pulcs in thi lehuset, 131047d Trsteni.in sim Ligatures are placed on the alliry and cul Ir kan in thik injury the patient's left cor #15 Classin anicnics and the .hipolution performed 2017141) 2017 od iller yri, frustrast. but on the miort thin 10 grams of blool were lost, but at the end 51 hith out for gitt top st! In ser uscir tbijt rifectly of the operation the patient home cyanosed and din in half an hour.

·TRAUMATIC FOREQUARTER AMPUTATIONS 150 151 CASE XLVI Topical dressings were employed for eleven days when the whole arm was sloughing and foul smelling At 1887 Bourgougnon Male, age 30, right side On 25th January 1887 patient suffered a machine operation the subclavian artery was exposed and tied The attachments of the scapular muscles to the trunk injury There was little hæmorrhage but shock lasted were divided and the scapula and outer fragment of six hours The comminuted scapula was removed, the the clavicle removed with the arm Three days after wound sutured, drainage tube inserted, and antiseptic dressing applied Two days later there was moderate operation the patient became delirious with high temfever but little discharge from the wound The patient perature and died walked on the fifteenth day and had fully recovered in CASEL a month 1899 Marshall, E 154 Male, age 12, right side CASE XLVII On 16th June 1899 the boy, A V H, was caught in 1889 Eiselsberg, F von Male, age 63, the belt of a machine At operation all bony fragments right side were removed and part of the clavicle sawn off The On 1st December 1889 the man, while in a drunken subclavian artery was ligatured and the parts cleansed state, fell under a tramcar which ran over his upper with bichloride solution 1 5000 There was little inarm and shoulder Brought quickly to hospital, the flammation, and on the tenth day the patient walked patient was found to be completely unconscious and across the floor On the twentieth day after the accident suffering from a crush injury of the shoulder in which he walked nearly half a mile all the bones were involved and with extensive injury of skin and muscles, pulse not perceptible CASE LI Without anæsthesia the subclavian artery and vein were ligated, the arm amputated, and the splintered 1903 Pozzan, T 155 Male, age 20, left side scapula resected as well as the outer two-thirds of the On 25th June 1903 the man, P G, put his hand clavicle Skin flaps were insufficient to close the wound, between the teeth of a carding machine revolving at which was loosely packed with iodoform gauze At- great speed In an instant his arm was caught and tempts were then made to restore the pulse, but ten dragged out by the roots with but little hæmorrhage hours elapsed before it reappeared The patient's condition was such as to ncgate opera- The patient recovered slowly with periods of restless tion, but by the third day gangrene and septicæmia ness, there was a partial gangrene of the skin flaps, obliged the surgeon to intervene as a last chance to save which were replaced by Thiersch grafts and the wound the man's life The operation field having been prepared hcaled completely though slowly by antiseptics, a portion of the clavicle was sawn off and this made it possible to trace and ligature the CASC XLVIII subclavian artery which was buried in ædematous 1895 Chavasse, T F 159 Male, age 32, left side tissue The scapulo-thoracic amputation performed on On 7th May 1895 the patient, MW, was entangled textbook lines, occupied forty minutes and little blood in the driving band of machinery by which the forearm was lost Finally, the wound was washed out with was cut off and the skin of the arm torn in strips as chloride of sodium solution a drain inserted, and the high as the shoulder joint, muscles in this region were flap and skin sutured The patient was able to walk in contused and infiltrated with blood The brachial artery ten days and was discharged after thirty-five days with and axıllary vessels were exposed and cords of brachial the wound almost healed plexus crushed To obtain adequate covering for the wound, amputation was performed within an hour of CASE LII the injury The skin sutures of silkworm gut were removed a weck later and in a month the patient was 1904 Northrop, H L lub Male, age 19 months, walking out of doors right side This young child was injured in an elevator accident and the whole shoulder girdle was severed through the 1895 Fowler, G R 133 Malc, age 55, left side middle of the claviclc and along the line of insertion On 27th November 1895 the patient, P R , suffered of the serratus anterior to the thoracic wall The only burns of the entire surface of his arm and forcarm connection with the trunk was one cord of the brachial CASE \LIX 67 ·THE TOREQUARTIR AMPUTATION plerus Thus was severed and the subclavian vessels fifteen-foot ladder and walked three hundred yards 10 ligatured the office On cramination it was found that the blood. The patient. houcrcr, died presumably of pulmonan vessels and neries had been torn off and had receded embolism Photographic records of the case are pre. There had been no hæmorrhage or pain Thc wound sented Was swabbed out with tincture of iodine and a drainage tubs inserted Recovery was une entful CASL 1111 1905 Sable M" Male ave 50 right side CASC LVII This chauffeur had his arm caught in machinery 1915 Pullot de Rond Male, right side and the forcarm was avulsed from the humcrus The B Francois was wounded in the right shoulder on humerus which was intact was, however drested of 26th September 1915 First-aid was given and two days muscles over its lower thurd as if detached by a rugine later he was evacuated with a high temperature and The muscles of the upper third were crushed and torn adema of the shoulder region The wound was explored There was considerablc shock Under general ants and gross suppuration was found around the comminthetic a forcquarter amputation was performed from uted scapula which was removed His condition conwhich the patient cscntually recoi cred tinued to deteriorate and the limb was amputated at the trunk In spite of multiplc pyenic abscesses and CISTI erysipelas the patient eventually made a satisfactory 1907 André 1' Male, age 17 left side recovery This patient's left hand was caught in a transmission CASE LVIII belt wuch dragged him around a tree three times before throwing hini to the ground His left upper limb com- 1917 Wall. G A 11: Male left side pletely avulsed, remained wound around the trec Hc Left arm caught in revolving machinery with complete uttered a single cry, did not lose consciousness, nor did avulsion of the upper limb including the scapula The any hæmorrhage occur The whole accident occurred in clavicle remained in situ The patient was brought to three or four seconds Thc clavicle remained in situ hospital in severe shock from which he recovered On At the time of the operation the patient did not com the following day, under gencral anesthesia, the wound piun of pain and the pulse was 72 The outer two-thirds was loosely sutured after removal of redundant issues of the clavicle was removed and the subclavian vessels Later skin grafting was required but the patient made ucre liguted The wound wus sutured with drainage a good recovery Healing wis conipicic in fifteen days and the patient made an uninterrupted recovery Casr LIX 1920 Mosicih " Mulc, age 14. right side CASTI This boy, Paul J, was caught in a machine which 1912 Run CSMale au 14. luft side wrenched off his arm and shoulder blad He lay sense- Accident occurred in a coconut fibre mull in Ceylon loss for twenty minutes before being found and brought Patient brought to hospital conscious but in shock onc to hospital, by which time he had rccoscred conscious. hour following the accident The whole upper limb was ness with no hamorrhage or sign of shock After mingled nasilatıng immediate operation Under removal of dirt and blood the stunip of the atıllary general anzsthesia the forcquarter was removed There artery was scen in the depth of the wound Ilus was *as dimiculty in closing the shin but the patient made ligated and the outer half of the clavicle removed in an uninterrupted recovery and was discharged from order to bring the skin flaps together Thc round hospolil scicnly-inno disfter the uccident lic.lcd and during lus stay in hospital (period not stated) the boy learned to use the left hand as csils 15 he had used the right 1914. Dich um GK" Male uge 3 roolit suite Cics i On 1411 January 1014 thu mun, S 7.. whilc oiling 1938 10.1') and Radcline 13945 Michunen wirin tight ani cught in a coul copies or Jule. as 32, ricinde 112 mucler ne MT«nhcel off clou in th: txxis und On 26th March 1938 the man. DX.. Cupht thir 1319 ccnl: loro Tier this injury he greended billeen a bale and roller und his arm stad out of ·TRAUMATIC FOREQUARTER AMPUTATIONS 160 his body The patient was very shocked, but in four trimmed, vessels and nerves ligated, and the wound and a half hours he had recovered sufficiently for opera closed except for drainage tube Blood transfusion was tion There was practically no bleeding The skin edges given and penicillin and sulphadiazine therapy instiwere excised and the brachial plexus crushed and tied tuted Subsequent progress was smooth and patient was as high as possible, the artery was also ligated in two discharged forty days after the accident places The outer half of the clavicle was sawn off, the skin edges approximated with sutures, and a drainage CASE LXIV tube inserted A part of the wound discharged pus for 1947 (?) Phillips, C L 168 Hawanan male, uge 38. a considerable time, but the patient's general condition left side was satisfactory during his three months in hospital Left upper limb caught in conveyor belt in rock quarry and whole upper limb and scapula avulsed CASE LXI Clavicle remained in situ Little bleeding or shock , 1938 Killinger, R R 165 Male, age 23, 11ght side treated immediately in hospital and transfusion given This foreman's fingers were caught between the rollers Vessels ligated and nerves severed Wound packed with and belt of a large conveyor of gypsum rock The arm vaseline gauze Forty-eight hours later packing removed with the scapula was avulsed when the body was and wound closed with two drains arrested by the grating The patient was brought to St Patient made an uninterrupted recovery and photos Luke's Hospital in Jacksonville, Florida, where the are available showing the healed wound with an X-ray wound was débrided and closed Antishock therapy, of the region showing the intact clavicle antitetanic, and anti-gas-gangrene sera were given The patient made an excellent recovery A photograph and CASE LXV X-ray show the post-operative appearances 1948 Millar, J D C 16 Male, age 23, right side This man, a miner, was caught between a roller and CASE LXII belt and twisted round so that his arm was avulsed from 1940 Henson, E B 106 Male, right side the body, no serious hæmorrhage On admission he Right hand caught in a revolving wheel in a coal was shocked but not in a serious condition At operafactory Lost consciousness when the limb was drawn in tion two and a half hours later it was found that the to elbow level, but was able to pull himself loose after scapula and lateral half of the clavicle were missing a few moments and only portions of the shoulder muscles were present He walked up twenty steps and turned off the electric except the latissimus dorsi, which was intact The aulswitch, and then went two hundred feet to find the lary artery and vein were ligated and the brachial plexus forcman before sitting down He was brought immedi cut short and injected with 2 per cent procainc Antiately to the hospital Blood pressure before anaesthetic tetanic and anti-gas-gangrene sera were given and a 90/60, pulse 120, respiration 28 Collapse of right lung course of penicillin started He was in hospital fourteen due to open wound and fracture of fifth and sixth ribs days and complained only of pain in his phantom Wound cleansed under local anæsthetic and necrotic limb tissue removed A drain was placed in the open chest Vessels were ligated Right clavicle was intact Patient CASE LXVI made an uninterrupted recovery 1951 War, W V 10 Male, age 38, right side On 15th November 1951 the man L D was caught in a cement machine and his arm was ripped out at 1947 Chen Mın 16 Male, age 55, left side the axilla together with the scapula and attached On 25th April 1947 this man was run over by a train muscles A doctor, quichly on the spot pached the and his shoulder severely injured The scapula and head actively bleeding axıllary and subclavian area, which of the humerus were both badly fractured and a small was completely bare picce of skin was all that united the avulsed fore On admission to hospital the patient was in a state quarter with the trunk There had been considerable of deep shock for which plasma and wholc blood were blccding, and when seen four hours after the accident given as soon as possible. The exposed nerve ends of he was semi-conscious and in a state of shock At the brachial plexus were cut short and the axillary vein operation the forequarter was removed, torn muscles and artery tied, the wound was then thoroughly CASE LXIII 69 ·THE FOREQUARTER AMPUTATION cleansed by irrigation and the flaps brought together die on the spot, nevertheless transported him with all Condition was critical after the operation, but in four speed to the hospital of Ste Menehould, where he days temperature had dropped to normal arrived in fifteen minutes and came under the care of The only complaint was of " phantom" pain which M and Madame Quennec, who specialised in resuscitasubsided, but Horner's syndrome remained constant tion procedures The patient was discharged twenty-three days after On examination he showed no signs of life except a operation and resumed work a month later feeble respiration, but with immediate treatment by oxygen and blood transfusion his condition improved, CASE LXVII and at the end of three hours repair of the multiple 1952 Otey, BT, and Skinner, E F 171 lesions was performed in the following order suture Female, age 47, right side of the stomach , of the diaphragm , of the pericardium , This woman was accidentally drawn into a roller in and of the lung, part of which was lying free in the a Memphis factory Right arm with girdle and breast pleural cavity avulsed Fractured ribs (1 - 10) with open chest on The lacerated parts of the muscles were then removed, right side Compound comminuted fracture of left and this was followed by ligature of the axıllary vessels humcrus with avulsion of brachial plexus, artery, and and nerve trunks after injection of procaine Finally Case record gives complete details of managemuscles and skin were approximated without traction mont, including rehabilitation of this remarkable case and sutured Penicıllın and streptomycin were freely Photographs demonstrate the result and function of the employed during these procedures prosthetic replacement on the left side At the end of the operations, lasting three hours, the patient's condition was satisfactory but deteriorated CASE LXVIII several times during the next three weeks owing to fluid 1956 Quennec, André and Jocelyne 1-2 collecting in the chest At the end of this period a Male, age 17, left side copious flow occurred at the site of the drainage tube, This youth, GG, was engaged in sawing tree trunks which was followed by a definite fall of temperature in the Argonne forest when his foot slipped and he fell and closure of the opening under a saw which sliced off his shoulder Hæmorrhage The patient left the hospital three and a half months was profuse and his comrades, though expecting him to after the accident for convalescence and re-education vein 70 ·VIII Conclusions 1 1 Primary forequarter amputation offers the only 3 There is a place for scapulectomy in a limited hope of cure in certain cases of primary skin cancer field, especially for large chondromata, secondary and melanoma of the upper extremity, in certain chondrosarcomata, in cases of aneurysmal bone cysts, and hæmongiomata primarily involving the cases of sarcomata of the soft tissues of the shoulder scapula Records of scapulectomy in cases of radioregion, and in sarcomata arising in the bones of the necrosis following radiation therapy for overlying shoulder girdle In Dr Pack's series of eighty-eight skin carcinoma show good survival rates and satiscases, 37 per cent of those having a secondary forefactory function quarter amputation for residual or recurrent car- 4 There is a small place for interscapulo-thoracic cinoma are living and well at the time of his end resection in selected cases of malignant disease when result study Further, he records that the five-year the neurovascular bundle is not involved and the cure rates after this radical treatment for malignant patient refuses loss of limb skin tumours primary in the upper limb is 22 2 per 5 Traumatic avulsion of the forequarter has been cent , for soft part sarcomata of the shoulder region recorded from time to time in the surgical literature 39 3 per cent, but for sarcomata arising in the upper and can occur with little hæmorrhage or shock It end of the humerus or scapula there is no record of is probable that the cases recorded have tended to survivals of that duration be those in which recovery has occurred, and that 2 The primary operation is preferable to the those that died have passed unnoticed With present secondary forequarter amputation and should be surgical facilities, death from such an injury should performed at the earliest possible moment be unusual 71 ·General References 32 1 ADELMANN VOV (1878) Zur Geschichte und Statistik der totalen Entfernung des Schulterblattes Verh dtsch Ges Clur 7 (pt. 1) 137-48 2 ADELMANN, G F B (1879) Zur Geschichte und Statistik der theilweisen und vollständigen Schulterblattresectionen Vjschr prakı Heilh., Prag n F 4, 1-96 * ADELMANN G (1888) Die operative Entfernung des Anochernen Brustgurtels Arch hlin Chir 37, 681-708 - ARMSTRONG, GE (1895-96) Amputation of the upper crtremity together with the scapula and outer twoibirds of the clavicle Montreal med 1 24, 666-67 ASHHURST, JOHN (1881-83) The International Encyclopedia of Surgery-Excisions of the clavicle and scapula, vol iv, pp 465-73, and Amputation above the shoulder, vol 1, pp 647-48 New York, William Wood • AYLESWORTH R DEANE (1952) Manual of Upper Extremity Prosthetics Los Angeles Dept of Engineering, Univ of California i BASSETT, DAVID L (1951-) A Stereoscopic Atlas of Human Anatomy Part II Head and neck 1954, Part III The upper citremity 1955 Portland Oregon Sawyer s, Inc * BAUMAN P K (1914) Sluchai rezektsu verhhnei honechnosti v oblasti plechei ogo sustava (Resection of the upper cxtremity in the region of the shoulder joint) Khur Arhh Veliaminora 30, 145-49 9 BELL, CHARLES (1821) Mustrations of the Great Operations in Surgery London, Longman and others in BERGER, P (1883) Amputation du membre superieur dans la contiguité du tronc (désarticulation de l'omoplate) Bill Soc Chur Paris 9, 656 11 BERGER, P (1886) Amputation du membre supérieur dans la contiguité du tronc Manuel opératoire Rev Chur Paris 6, 955-56 12 BERGER P (1887) L amputation du membre superieur dans la conugmté du tronc (Amptation Interscapulo-Thor acique) Paris G Masson 17 BERGER, P (1891) Sarcomc déniostique de l'extrémité supérieur de l'humerus Bull Soc Chir Paris 17, 120-24 "' BERGER, P (1893) Osteo nyélite chronique d'emblée chez une jourc fille de 16 ans Bull Soc Chur Paris 19, 410-15 15 BERGER P (1897) Les tumeurs malignes de l extrémité supéricur de l humerus et l'amputation unterscapulothoraciquc Bull n.ed Paris 11. 549-53 14 BCRGCR P (1898) Lamputation interscapulo thoracique dans ses rapports avec les tumeurs malignes de lomoplatc Bull med Paris 12 505-8 I BERGER P (1898) De l'amputation interscapulo-thoracique dans le traitement des tumeurs maligncs de l'extrémité supéricur de l'humerus Rei Chuir Paris 18, 861-85 I* BrRGER P (1905) Deux cas d'amputation interscapulo- Thoracique Bull Sor Chur Paris 31, 381-83 19 BERMAN Jacou (1945) Interscapulo-thoracic disarticulauion of the arm Surger 18, 256 66 " Bicr A BRAUN H and KOVVELL H (1920) Chururgische Operationeline Operationen an der skapula Band V rn 117-30 Leipzig Barth ** BUCHANAN J J 11900) Total excision of the scapula alone and with the arm (interscapulo-thoracic amputation) pariiil orcision of the scapula for tumor Plulad med 16, 26-37 73-82 ** Buci PC and Cape CS (1930) Primary hemangioma of bone noner / Roentgenol 23, 1-33 5) CARROIT, WB (1939) Scapulcctomy discussion of EW Ricrsons parer mer med ASS 113, 1958-60 21 CHESLI DIN W (1768) Thir anatom of the Human Body london pointed for H Woodfall et al ** CouBRADLIY I. (1949) Neoplasms of Bolle and Related (ondrions pp 513-15 NCH York Houber 72 26 COLE), BRADLEY L, and HIGINBOTHAM, NL (1948) Con servative surgery in tumors of bone with special reference to segmental resecuon Ann Surg 127, 231-42 " COLEY, BRADLEY L. and HIGINBOTHAM, N L (1954) Secondary chondrosarcoma Ann Surg 139, 547-59 28 COLE), W B (1908) Interscapulo-thoracic amputation for sarcoma, recurrence successfully treated with mixed toxins Ann Surg 47, 807 "! CUSHING, HARVEY (1902) On the avoidance of shock in major amputations by cocainisation of large nerve trunks preliminary to their division Am Surg 36, 321-45 30 CROSB: A B (1875) The first operation on record for the removal of the entire arm, scapula, and three-fourths of the clavicle by the late Dixi Crosby Concord, NH. Republican Press Associauon Also Med Rec N) 10, 753-55 31 DELAUP S DVEY P (1902) Total excision of the scapula with preservation of the upper extremity Am Surg 36, 563-72 DS NANCREDE, CBG (1909) The end results after total excision of the scapula for sarcoma Ann Surg 50, 1-22 33 DE NANCREDE, C B G (1909) Extirpation of the scapula for malignant disease | Amer med Ass 53, 68-69 31 ESMARCH, F H (1877) Zur Resection des Schultergelenles Arch hlin Chur 21, 831-37 Also in Verh disch Ges Clur 6, 61-67 35 FERGUSSON, WILLIAM (1864) Progress of anatomy and surgery during the present century Lancer 1, 689-94 36 FERGUSSON WILLIAM (1865) Recurring fibroid disease of the shoulder Lancet 2, 591-93 37 FERGUSSON, WILLIAM (1865) Removal of the arm, clavicle, and portion (remaining from a previous operation) of the scapula for a recurring tumour Med Timer Ga. 2, 574 38 FERGUSSON, WILLIAM (1867) Removal of the scapula half of the clavicle, and the whole arm, death on the third day Lancet 2, 552-53 30 FERGUSSON, WILLIAM (1867) Removal of the entire left upper extremity including the scapula and outer half of the clavicle Brit med J 2, 361 " FOCK C (1855) Exstirpatio et Resectio scapulae, nebst Mittheilung betreffender Beobachtungen aus dur chirurgischen Klinik des Hrn Geh Med-Raths B Langenbeck Disch Klin 7, 421-26 443-48 di FOWLER, RUSSELL, S (1900) Interscapulo-thoracic amputauon Ann Surg 31, 194-213 +- FOWLER, RUSSELL S (1901) Sarcoma of shoulder-interscapulo-thoracic amputation Brooklyn med J 15, 25 26 13 Gies Tu (1879-80) Beiträge zu den operationen an der scapula Disch Ź Chir 12, 551-88 H GRIMES OF, and BELL H G (1950) Shoulder girdic amputation Surg Gynec Obstet 91, 201-9 15 HAAGENSON C D (1956) Discases of the Breast, pp 27-45 Philadelphia Saunders 46 HAGGART, G E (1940-42) The technic of interscapulothoracic amputation Lahey Clm Bull 2, 16 22 HALSTLAD A E (1904) Interscapulo-thoracic amputation for sarcoma of the scapula Ann Surg 39, 134-38 4* HUMPHREY G M (1882) Sarcomatous tumour of the humcrus involving the parts about the shoulder joint Brit med ) 1, 501 19 HUTCHISON AC (1829) Removal of the arm, scapula and claviclc Lond med Gaz 5, 273 S" HUTCHISON, A C (1830) Amputation of the scapula, cic Lond nicd Gaz 5, 524-25 Si HUTCHISON ) A (1902) Amputation of the upper crirem ity for sarcoma of the shoulder joint Canal Practil 27, 589 ·- r ری 1 cs 161-94 • MOSCLEY H F (1949) Film Surgical Anatomy of the s MOSELEY H F (1950) Film Inferior Relations of the Shoulder Joint Danbury Connecticut, Davis & Geck . MOSELY HF (1952) Ruptures of the Rotator Cuf 10 MOSELEY, H F (1953) Shoulder Lesionis, 2nd ed " MOSEI EY, H F (1955) An Atlas of Musculosheletal Ex- "VUSSEY R D (1837) Removal by dissection of the entire GENERAL REFERENCES 83 OLLIER, L (1885) Communication a la société nationale HUTCHISON, I A. (1903) Sarcoma of the shoulder jointamputation of upper extremity Montreal med'32, de médicine de Lyon Lyon med 48, 157-60 69 84 OLLIER, L (1885) Communication a la société nationale JACKSON, R E (1928) Interscapulo-thoracic amputation for de médicine de Lyon Lyon mid 49, 94-95 recurrent chondroma Amer J Surg 4, 35-48 85 OLLIER, L (1885-91) Traite des Résections ct des opéra- JM (1830) Removal of a tumour from the scapula tions conservatrices qu'on peut Pratiquer sur le Système Lond med Gaz 5, 497-98 Osseur, vol 11 Paris, Masson et Cie KEEN, W W (1894) Amputation of the entire upper ex- 86 Pack, G T, MCNEER, G, and COLLY, B (1942) Intertremity Trans Amer surg Ass 12, 35-70 KEEN, W W (1894) Amputation of the entire upper exscapulo-thoracic amputation for malignant tumours of tremity (including the scapula and clavicle) and of the the upper extremity (A reçoit of 31 consecutive cases) arm at the shoulder joint Amer I med Sci 107, Surg Gynec Obstet 74, 161-75 680 705 87 PACK, G T, EHRLICH, HE, and GENTIL, F DE C (1947) KEEN, W W (1895) Amputation of the entire upper Radical amputations of the extrcnities in the treatment extremity (including the clavicle and scapula) for sarof cancer Surg Gynec Olistet 84, 1105-16 coma following fracture of the clavicle Ann Surg 21, 88 PACK, G T (1954) End results in the treatment of sar- 715-18 comata of the soft scmatic lissucs Bone Ji Surg KEEVIL, J J (1949) Ralph Cuming and the interscapulo- 36A, 241-63 thoracic amputation in 1808 Ì Bone Jt Surg 31B, 89 Pach, G T and BALDWIN, JC (1955) The Tihhor- 589-95 Linberg resection of shoulder girdie Surgery 38, 753-57 KIRK, NORMAN T (1955) Shoulder girdle amputations in 00 PACK, G T (1956) Major cyarticulations for malignant Lewis' Practice of Surgery, volui, chap x, pp 39-42 neoplasms of the extremities 170 rscapulo-thoracic am- Hagerstown, Md, Prior putation, hip-joint disarticulation and ntcrilio-abdominal KNAGGS, R L. (1910) Mr Littlewood's method of performoperation 1 Bone Jt Surg 39:-, 249-62 ing the interscapulo-thoracic amputation Lancet 1, 1298 KOCHER, T (1903) Textbook of Operative Surgery Dis- 91 PERKINS, GEORGE (1947) Forcquarier Amputation in British Surgical Practice, vol 1, pp 197-2012 Carlng Sir ER, articulation of the arm, together with the shoulder and Ross, J P, Editors Lonini Lutterworth girdle, pp 426-29 London, A & C Black LANGDALE-KELHAM, RD, and PERKINS, GEORGE (1942) 02 PHELPS W M (1929) Ambos op op ont.r of the infra- Amputations and Artificial Limbs, pp 85-88 London, spinous portion of the scopulo cut impairment of Humphrey Milford shoulder muscle functior Yo 2 . C 3, 30-42 * LANGENBECK, B VON (1862) Zur Resection des Schulter- 03 PICQUE, L, and DAFTIGUES i19..cromie ou blattes Arch hlin Chur 3, 340-41 ablation primitive et totalu O conserva- ** LE CONTE, R G (1899) Interscapulo-thoracic amputation tion du membre supericui 31-83 Ann Surg 30, 260-66 04 POIRIER, P, CHARPY, A, ai (8) Absgu 58 LE CONTE, Ř G (1900) The technique in the interscapulod'Anatomie Les lymph? thoracic amputation Cong internat de méd Par, sect Paris, Masson et Cie de chur gén 463-67 95 QUIRING, DANIEL P (1949) 12, PP " Le CONTE, R G (1902) Interscapulo-thoracic amputation 108-19 Collateral circulai. Ann Surg 36, 456-58 extremity Philadelphia, . . LE CONTE, Ř. G (1902) A further note on interscapulo- 96 ROGERS, STEPHEN (1858) Co 3710 thoracic amputations Ann Surg 36, 573-78 " LEVINTHAL, DH, and GROSSMAN, A. (1939) Interscapuloscapula Amer j med so 07 ROSENFELD, A. (1931-32) A! thoracic amputation for malignant tumours of the shoulder region Surg Gynec Obstet 69, 234-39 Acta chir scand 69, 129-33 "LINBERG, B E (1928) Interscapulo-thoracic resection for 98 ROUVIÈRE, H (1938) Ergt. malignant tumours of the shoulder joint region J Bone System (A compendiumi Anatomie des Lymphaticus °LISTON, ROBERT (1820) Ossified aneurysmal tumour of the arranged for the use of so subscapular artery Edinb med I 16, 66-70 by M J Tobias ) Ann Arzu "LITTLEWOOD, H (1922) Amputations at the shoulder and 09 ROWLANDS, RP, and TUKNLI', Polly Joon, tions of Surgery, 7th ed, vu!. Churchill shoulder (including interscapulo-thoracic), and advoca- 100 RYERSON, E W (1939) Excisioni víle pa', icport tion of the preliminary ligature of main vessels in other of case with excellent functional resul"; Amel Inc Ass 113, 1958-60 101 SCHULTZ, W (1896) Zur Statistik der Totales. Arttur?'uns the arm, with scapula and part of clavicle Brit med J des Schulterblattes Leipzig, J B Hirocoloid (Also in Dtsch z Chir 43, 443-72, 1896 ) 102 SHEPERD, FJ (1894) A case of interscapulo-inoracic amputation for chondrosarcoma of the shoulder joint Marit med News 6, 394-95 103 SLOCUM, DB (1949) An Atlas of Amputations Amputa- Ruptures of the Rotator tions about the shoulder, op 165-72 St Louis, Moshy 101 SYME, J (1836) Fibrocartilaginous tumour of the humerus removal together with the arm and part of the scapula and clavicle, recovery Edıb med surg ) 46 249-51 105 SYME, JAMES (1864) Ercision of the Scapula Edinburgh, Edmonston & Douglas 106 TESTUT, L (1921) Traite d'Anatomie Humanc 7th ud Angéiologie, vol 11, pp 381-86, 409-10 Paris, Octave New Doin 107 TIXOFF P (1900) Kucheniu ob opulhollalh (To the study of tumours) Medisinskne Obozrienc 53 81-91 108 WAKELEY, C P G (1938) A case of sarcoma of the infraspinatus muscle Brit J Surg 26, 439-42 109 WATSON, B A (1885) A Treatise on Ampujanons not the Amer) med Sci Ertremitics and their Complications Amputation above the shoulder joint, pp 234-36 Philadelphia Blalisten 73 "! l'oper + A- It Surg 10, 344-49 at the bip Brit med J 1, 381-83 "" LOCA WOOD, C B (1910) "' Amputations at the hip and amputations Lancet 1, 1185-89 * MCGILL A F (1880) Note on a case of amputation of 2, 702 MOSELEY, H F (1948) Film Calcified Deposits in the Rotator Cuff Danbury, Connecticut, Davis & Geck MOSELE), H † (1949) film Anterior Dislocations of the Shoulder Danbury, Connecticut, Davis & Geck " MOSELEY H F (1949) Film Cuf Danbury, Connecticut, Davis & Geck Shoulder Danbury, Connecticut, Davis & Geck Springfield, Charles Thomas York, Hoeber posures The clavicle and its articulations, chap ini Philadelphia, Lippincott shoulder blade and collar bone 21, 390-94 10 ·REFERENCES ON TRAUMATIC FOREQUARTER AMPUTATIONS (in chronological order) 110 BELCHIER (1737-38) An account of the man whose arm 133 KATHOLITZKY, F Die ganze rechte obere Extremitåt sammt with the shoulder blade was tom off by a mill on 15th der Schulterblattc durch mechanische Gewalt vom August 1737 Plulos Trans 40, 313-16 Körper gerissen, Heilung (1873) Allg Wien med 111 CUMINO, R. Removal of the arm, scapula, and clavicle Zug 18, 569-70, (1874) Abst med Times Gaz 1, 15 (after gunshot wound) Report by Dr Hutchison 134 JESSOP (1874) Primary amputation of upper extremity (1829-30) Lond mcd Gaz 5, 273 including scapula and outer half of clavicle Brit med 11. Mussey, RD (1837) Arm and shoulder blade torn from 1 1, 12-13 the body Amer 1 med Sci 21, 385-88 13. HENDRY, G (1875) The whole upper extremity torn off, 113 JAMES, GW (1829-30) The arm and scapula torn off recovery _Detroit Rei Med Pharni 10, 723-25 by a steam-cngine Lond_med Gaz 5, 497 136 GUNDRUM, F (1878) Case of exurpation of the scapula 114 SCARNELL, S F (1831-32) Forcible separation of the entire with a portion of clavicle and entire arm Amer] arm from the body Lancet 2, 114 med Sains 76, 98-100 113 BRAITHWAITE, J (1832-33) Arm and scapula torn off 13- WEINLECHNER (1878) Abreissen des Oberarmes durch Lond med Gaz 2, 147-48 Maschinengewalt Enormer Hautverlust, dessen Heilung 116 PIRONDI, S (1855) Lésion traumatique ayant nécessité la nur durch Entfernung des Schulterblattes und der äussedésarticulation du bras et l ablation de l'omoplate et des ren Halfte der Schlüsselbeins sammt Obcrarmstumpfc deux ucrs de la clavicule Rey med -chur Paris 18, ermöglicht wurde Allg Wien med Zig 23, 116-17 49-51 138 GEORGE, W H (1879) Avulsion of the arm and shoulder 11* GAETANI-BEY Desarticulation scapulo-humérale, extraction Eclect med J Cincinnati 39, 69-72. dc l'omoplate, réscction de la clavicule, ablation d'un 130 WHEELHOUSE (Case of extensive injury to shoulder ) Quoted testiclc (1841) Mém Acad roy Méd Paris 9, 96-103, by McGill, A F (1880) Brit med J 2, 702 (1840) Bull Acad roy Méd Paris 5, 438-42 140 ELLIS-JONES, J (1881) Right arm, with scapula attached, 118 LARREY (Case of gunshot comminution of scapula and arm) dragged clean from the body Lancet 2,363 LEWIS, W (Removal of the scapula and clavicle and frag 141 LEWIS, RF (1882) The nght arm forcibly severed from ment of the arm) the body at the shoulder joint N Carolina med J 10, Quoted by Rogers, S (1868) Amer 1 med Sci 56, 197-200 368 142 WILL, J CD (1884) Case of avulsion of the right arm 110 CARTWRIGIIT and scapula , recovery Brit med J 1, 1135 LIZARS (The arm scapula and half the claviclc torn off by 140 LUCAS-CHAMPIONNIÈRE, J (1886) Extirpation totale de machine ) l'épaule après un traumatisme (clavicule, omoplate et Quoted in Fergusson Sir W (1842) A System of Pracmuscles de l'omoplate) Rev Chur Paris 6, 529-43 rical Surgery 1st cd, p 235 London, Churchill 144 FORNARI, F (1884) Resezionc totalc della scapola, senza 124 COOPER (Case of avulsion of arm and scapula) (1843) N Y anestesia , mcdicatura antisettica Raccoglitorc Medico, mied ! 1, 284, and quoted by Rogers, S (1868) Amer Forli 4s 21, 359 Also quoted in Schultz, W (1896) I mied Sci 56, 368 Disch z Chir 43, 443-72, p 454 121 KING A. (1845) Case of avulsion of the left arm and 145 LOUMEAU (1885) Arrachement du bras et de l'omoplate scapula Lond Edinb ) med Sci 5, 96-102 Mém ei Bull Soc med Chir Bordeaux 390-94 1?" PARISE. M Scc Berger, P (1887) L'amputation du Membre 146 SCHMIDT, E (1885-6) Amputation of arm with removal of supérieur dans la Contiguité du Tronc, pp 116-21 Paris, scapula and two-thirds of the claviclc Med Press IV cst Masson Also Trévelot H (1885) Quelques Considéra- NY 1, 101-3 prons sur l Amputation de l'omoplarc avec Résection de 11- MAZZONI, G Comminuted fracture of left arm and scapula la Clavicule dans les cas d'Arrachement du Membre Quoted by Pacı, A (1887) Asportazione totalc c superieur p_18 Paris (Thèse de Paris) 1:3 HORLDECK H B (1860) Ausreissung des Armcs u Schulterresezioni parziali della scapola Lo Sperimentale, 490 148 JCANNEL (1888) Arrachement du bras gauche dévoré par blattcs Schmidis Jh 106, 327-28 un lion, amputation intcrscapulo-thoraciquc Mort 12. Nilice (1864-65) Extirpation du bras, de la clavicule Bull Mem Soc Clair Paris 14, 484-86 gauche et de l omoplatc gauche Bull Acad imp Med 110 KIRMISSON, E (1887) Traumatisme, par coup de feu de Paris 30, 723 1** SACASOV V (1869). Amputation of right arm l'aisselle gauche Désarticulation interscapulo-thoracique at the Mort Bull Mem Soc Chur Paris 13, 522-24 shoulder joint with crcísion of the scapula Brit med 2. 322-23 1 BOURGOUGNON (1888) Arrachement du bras droit, frac- *** Lowr. (1867) Casc of avulsion of the arm and scapula by tures multiples de 1 omoplatc , amputation interscapulomachinery Lancet 2, 611 thoracique, guérison Gaz Hop Paris 61, 334 1** BUCHANAN G (1867) Excision of the scapula (arter avulsion 115 EISELSBERO, F VON (1890) (Crush injury of shoulder ) of the arm at the shoulder joint) Med Times Gaz 1, Wien Alen Ischr 3, 253-54 273 152 CHAVASSE, T F (1896) Case of interscapulo-thoracic am 12* Jours T C (1870) Avulsion of the arm and scapula putation for injury Ann Surg 24, 182-87 Brit inod J 1, 545-46 157 FOWLER, G R (1900) Amputation of cntirc upper cxtrem- 129 113477 R S W (1870) (Thc arm and scapula torn oſſ by ity for extensive burns Ann Surg 31, 211 machinery I N) med 1 10, 514 15+ MARSHALL E (1899) An unusual accident (thc cntirc 130 Watson PH (1869) Amputation of the scapula along shoulder and arm torn from the body) NY nici u with two thirds of the clavicic and the remains of the 70, 730 urni Lomb meid J 15, 124-40 low POZJAN T (1904) Amputazione interscapolo-loracica per 131 LUN (1871) The night arm and scapula torn from all fcrita da strappamento dell'arto supcriorc Gazz Osp attachments to the hods ) Brii inad 1, 340 Clin 25, 165-68 13- CHRIS II (1872) Cise of avulsion of the right arm 1.6 NORTHROP, H L. (1905) Clinical cxperiences llalemun und seisuilu Laincci 1, 216 Mon Philad 40, 351-58 74 ·REFERENCES ON TRAUMATIC FOREQUARTER AMPUTATIONS 15. SABLE, M J (1906) Ecrasement du membre supérieur avec arrachement complet de l'avant-bras et de la peau du bras, désarticulation interscapulo-thoracique, guérison I Sci Méd Lille, 1, 488-95 158 ANDRE (1908) Arrachement total du membre supérieur avec l'omoplate par une machine Jméd Paris 2d ser 20, 206-7 159 RATNAM, CS (1914) Scapulo-thoracic amputation following injury 1 Ceylon Br_Brit med Ass 11, 13-14 160 D CKINSON, GK (1914) Divulsion of arm and scapula Med Rec N Y 85, 985 161 PILLET (1916) Désarticulation inter-scapulo-thoracique pour broiement de l'omoplate par éclat d'obus Extirpation successive de l'omoplate Infection grave du bras Désarticulation Guérison Paris chur 8, 150-52 162 WALL, G A (1918) Complete avulsion of arm and scapula , recovery ] Olla med Ass 11, 315-19 163 MOSZEIK (1920) Fall von Verlust eines Armes nebst Schulterblatt durch Trauma Med Klinik 16, 576 164 LEE, W D, and RADCLIFFE, F (1939-40) A case of accidental avulsion of the forequarter with recovery Brit J Surg 27, 599-603 165 KILLINGER, RR (1939) Total avulsion of the arm and posterior shoulder girdle with recovery Industr Mcd 8, 193-96 166 HENSON, E B (1941) Avulsion of scapula and right upper extremity with recovery W Va med 137, 120-23 167 CHEN MIN (1948) Traumatic forequarter amputation Brit med ) 2, 1122 168 PHILLIPS, CL (1947-48) Traumatic a vulsion of the arm and shoulder girdle Hawan med } 7, 51-52 160 MILLAR, JD C (1948) Instantancous traumatic forcquarter amputation of the right arm Brit med J 2. 559 170 Wax, WV (1953) Traumatic scapulohumeral amputation Amer J Surg 86, 728-31 171 OTEY, B T, and SKINNER E F (1952) Traumatic avulsion of both arms, right clavicle, scapula, breast and pectoral muscles, and multiple rib fractures with open pneumothorax Amer Surgeon 18, 1049-56 172 QUEINNEC, ANDRÉ and JOCELYNE (1956) Section accidentello complète du membre supérieur gauche à sa racinc ct vaste plaie thoraco-abdominale par scie a ruban mcm Acad Clur Paris 82, 545-49 9

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·AUTHOR INDEX Adelmann, G F B., 72 Gies, Th, 72 André, 68, 75 Grimes, O F, 72 Armstrong, G E, 72 Grossman, A., 73 Ashhurst, J, 7, 72 Gundrum, F, 65, 74 Aylesworth, RD, 51, 72 Haagenson, CD, 72 Baldwin, J C, 50, 73 Haggart, G E, 72 Bassett, DL, 72 Halstead, AE, 72 Bauman, P K, 7, 47, 72 Henson, E B, 69, 75 Belchier, J, 2, 61, 74 Hendry, G, 65, 74 Bell, Sir C, 10, 72 Higinbotham, NL, 72 Bell, H 6,72 Horlbeck, HB, 63, 74 Berger, P, 1, 6, 7, 10, 13, 26, 38, 55 72, Humphrey, Sir GM, 72 74 Hutchison, A C, 3, 61, 72, 74 Berman, J K., 72 Hutchison, J A, 72, 73 Bier, A, 72 Impinh, RR, 58 Bourgougnon, 67, 74 Jackson, R E, 73 Braithwaite, J, 61, 74 Jackson V, 63, 74 Braun, H, 72 James, E S, 60 Buchanan, G, 63, 74 James, G W, 61, 74 Buchanan, JJ, 7, 72 Jeannel, 66, 74 Bucy, PC, 72 Jessop, 64, 74 Callahan, J J, 56 Jones, T E, 63, 74 Capp, C S, 72 Katholitsky, F, 64, 74 Carrell, W B, 72 Keen, WW, 73 Cartwright, 62, 74 Keevil, J J, 3, 73 Charles, J J., 64, 74 Killinger, RR, 69, 75 Charpy, A, 73 King, A, 62, 74 Chavasse, T F, 67, 74 Kirk, N T., 73 Kırmısson, E, 66, 74 Cheselden, W, 2, 72 Knaggs, RL, 73 Kocher, T, 28, 30, 47, 73 Cooper, 62, 74 Kümmell, H, 72 Crosby, A B, 4, 72 Langdale-Kelham, RD, 73 Crosby, D, 4 Langenbeck, B von, 5, 73 Cuming, R., 3, 61, 74 Larrey, 62, 74 Le Conte, RG, 28, 30 73 Lee, W D, 68, 75 Levinthal, DH, 73 Lewis, RF, 65, 74 Lewis, W, 62, 74 Linberg, B E, 7, 47, 73 Liston, R, 3, 4, 73 Littlewood, H, 7, 38, 41 73 Lizars, J, 62, 74 Lockwood, CB, 73 Loumeau, 66, 74 Lowe, 63, 74 Lucas-Championnière, J , 66, 74 Lunn 64, 74 McGill, A, F, 73, 74 McLaughlin, H L 58 McNeer, G, 73 Marshall, E, 67, 74 77 Mazzoni, G., 66, 74 Millar, J DC, 69 75 Moseley, H F, 73 Moszeik, 68, 75 Mussey, RD, 5, 61, 73, 74 Niepce, 63, 74 Northrop, H L, 67, 74 Oller, L, 6, 73 Otey, BT, 70, 75 Pack, G T, 7 19 20, 49 50, 71 73 Parise, M , 63, 64, 74 Perkins, G, 73 Phelps, W M, 73 Phillips, C L, 69, 75 Picqué, L, 73 Pillet, 68, 75 Pirondi, S, 62, 74 Poirier, P, 73 Pozzan, T, 67, 74 Quennec, A, 70, 75 Quennec, J, 70, 75 Quiring, DP, 73 Radcliffe, F, 68, 75 Ratnam, CS, 68, 75 Rogers, S, 5, 73 74 Rosenfeld, A, 73 Rouvière, H, 73 Rowlands, RP, Ryerson, EW, 73 Sablé, M J, 68, 75 Scarnell, S F 61, 74 Schmidt, E, 66, 74 Schultz, W, 73 Sheperd, FJ, 73 Shinner EF, 70 75 Slocum, DB , 73 Syme, J, 5, 46 73 Testut, L, 73 Thayer, SW 64, 74 Tihoff, P, 7, 47 73 Trévelot, H, 74 Turner, P, 73 Wakeley, CPG, 73 Wall, GA, 68 75 Watson, BA, 73 Watson, P H, 64 74 Wax, WV, 69, 75 Weil, P 21 Weinlechner 65, 74 Werley, WW, 58 Wheelhouse 65 74 Will, J CD, 65 74 Wood, S 1 2 61 73 Chen Min, 69, 75 Coley, B L., 7, 72, 73 > Cunco, B. 73 Cushing, H, 72 Dartigues, 73 Delaup, S P., 72 Dc Nancrede, C BG, 7, 72 Dickinson, GK, 68, 75 Eiselsberg, A F von, 67 74 Ellis-Jones J., 65, 74 Ehrlich, H E, 73 Esmarch, F A von, 72 Fergusson, Sir W, 72 74 Foch C., 5, 72 Fornar F, 66, 74 Fowler GR, 7, 67, 74 Fowler, RS, 72 Gaetanı-Bey, 62, 74 Gentil, F de C 73 George W H 65, 74 ·SUBJECT INDEX Acromiothoracic axis, branches of 10 Forequarter amputation, anaesthesia for Mammary vessels, internal 11 Air embolism, 30 cont Melanoma, 19 Anästhesia, 24 illustrative cases, 53-60 Melanosarcoma, 16 Anatomical considerations, 8-16 indications for, 18-20 Mortality of forequarter ampu Arterial pattern in relation to forcquarter Littlewood's technique, 37-43 71 amputation, 44, 45 lymphatic system in relation to, 16, 17 Neoplasms forcquarter - amput: Axillary vcin, 10 mortality of, 7, 71 19, 20 Berger operation, 6 10, 13, 26, 30 (Sce operative procedures, 21-50 histologic types of, 19 also Forcquarter amputation, Inter post-operative considerations, 51 Omohyoid muscle 11 scapulo-thoracic amputation) posturing and draping for, 22-24 Operation from anterior aspect, : Blood loss, 21 24, 30 pre-operative procedures 21-24 from posterior aspect, 37-43 Blood transfusion, 21, 24 rchabilitation after, 51, 70 Operative procedures 21-50 Bonc, sarcomata of, 19, 20 shin preparation, 21, 24 Osteo-aneurysm," " 3 Brachial Ivmphadema, 16 technique of, 21-50 Osteogenic sarcoma, 19 20 Brachial plexus, 10, 11 traumatic, 1, 2 Osteomyelitis, 19 division of, 30 chronological list of recorded cases, Pectoral muscles division of 30 Breast carcinoma, with brachial lymph- 61-70 Pectoralis major, 10 ccdema, 16 references to literature on, 74, 75 Pectoralis minor 8 10 Burns extensivc, as indication for fore types of malignant growths necessitat Phrenic nerve, 10, 11 quarter amputation, 19 ing, 19, 20 Pleural space, possibility of cnt Carcinoma, 16, 19 Hæmorrhage, 21, 24 30 13 Ccphalıc vein, 10 Historical aspects, 1-7 Post-operative considerations 51 Cervical artery superficial, 11 14 lliocostalis cervicis, 14 Posturing and draping for oper transicrsc, 11, 14 Illustrative cases, 53-60 24 Clavicle, cxposure and resection of, in Incision for operation from anterior Pre-operative proccdurcs, 21-24 anterior operation, 26 aspect, 26 Prosthesis, 52 55 sternal end of 13 32 for operation from posterior aspect, 38 Rehabilitation, 51, 70 Conoid ligament 10 for scapulectomy, 46, 48 Rhomboid ligament, 10 11 Coracoclavicular ligaments 10 Indications for forequarter amputation, Rhomboids, 14 Coracoid process, 10 18-20 Sarcoma, ostcogenic 5, 7, 19, 20 Costoclavicular ligament, 10, 11 burns 19 of soft tissuc, 19, 20 Deltoid 10 14 general considerations, 18 Scalenus anterior, 8, 10, 11 Deltopcctoral cleft 10 infection, 19 Scalenus medius, 8, 10, 11 Embolism air, 30 malignant discase of shin 20 Scalenus posterior, 8, 10, 11 14 Tascial plancs 8, 10 neoplasms 19, 20 Scapula, arterial anastomoscs arı Forcquutor amputation, anæsthesia for, sarcomata of bone, 20 45 sarcoma of soft tissucs, 20 with its musculaturc 14 anatomical considerations 8-16 trauma 18 19 Scapular arterios, descending 11, artcral pattern in relation to 44, 45 Infection as indication for forcquarter Scapulcctomy, partial, 3 blood loss in 21, 24 30 amputation 19 technique of, 46, 49 blood transfusion in 21 24 Innominate vein, 10 total, first record of 5 conclusions rcgarding 71 Intercostal muscles, 8 for malignant discasc, 5, 7 cure talcs 71 Interscapulo-thoracic amputation, 6, 10, with preservation of upper lir first surgcal removal 3 13 26 30 Serratus anterior, 8 11 14 from interior aspect, 25-35 Interscapulo-thoracic rcsection, 47, 50 Serratus postcrior superior 14 complction of unicrior dissection 30 first proposal of, 7 Shoulder girdle, antcnor relations completion of posterior dissection 34 Jugular vein anterior, 10 posterior relations of, 13-15 cxposure and resection of body of crtcrnal, 10 Sibson's fascia, 8 cliucic 26 internal, 10 Shin malignant discasc of. 19, 20 ciposure of suhclivian vessels 28 Latissimus dorsi 14 preparation of pre operative, 2 lines of incision, 26 Lcvator anguli scapula, 11, 14 Spinal accessory neric 11. 14 stornil cnd of clavicle 32 Littlewood's technique 37-43 Splenius capitis, 14 from postcrior aspect 7, 37-43 Long thoracic neric of Bell, 10, 11 Splcnius ccrvicis 14 general references to literature on 72 Lymphatic system in relation to forc- Sternoclavicular joint, 10 73 quartcr amputation 16, 17 Sicrnohyoid musclc 17 historical spects of 1-7 Lymphadema brochial 16 Stcrnomastoid 10, 11 13 78 24 ·SUBJECT INDEX Subclavian artery, 8, 10, 11, 13 Suprascapular artery, 10, 11 ligation of, 6, 30 Suprascapular nerve, 10, 11 Subclavian muscles, 10 Suprascapular notch, 11 Subclavian vein, 10, 11, 13 Suprascapular vessels, 11 ligation of, 6, 30 Supraspinatus, 11, 14 Subclavian vessels, 11 exposure of, in anterior operation, 28 Thyreocervical trunk, 11 Subclavius, 8, 10 Transverse cervical artery, 10 Supraclivicular region, anterior relations 'Trapezius, 10, 11, 14 of. 11-13 Trapezoid ligament, 10 Trauma, as indication for forequarter amputation, 18 Traumatic forequarter amputation, chronological list of cases, 61-70 references to Literature on, 74, 75 Tumours, 'as indications for forequarter amputation, 19, 20 histologic types of, 19 ·Printed 1 Tur CENTRA Persy Aberdeen

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