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t Loc. supra cit , Fig«. 449, 453.



REMOVAL OF THE SCAPULA. 139

As it is the first of the above which chiefly raise the question of re-
moval of the bone, and which present the greatest difficulties, it is to
removal of the scapula for new growths that most of the following re-
marks will apply.

Partial Removal of the. Scapula.— In a very few cases {e.g.,

for a simple exostosis, or where the surgeon is certain that he is deal-
ing with an unmixed enchondroma in an early stage) a more limited
operation may be sufficient. The chief essential points here are— (1)
to freely expose the growtli by appropriate flails, so that the limits
may be clearly defined ; (2) to be provided with reliable instruments
of keen temper, owing to the exceeding hardness which ma_y be met
with here.

While some Continental writers* have given elaborate directions for
partial removal of the scapula, it is only in the above very few cases
that this operation is likely to be used by English surgeons. Mr. Pol-
lock, in his paperf on two cases of removal of the scapula, thus advises
on this matter : " If a portion of the scapula be removed, it should
only be the lower portion. But even if this be attempted, the loss of
blood would probably be much greater than if the whole bone were
removed; for the wound is more confined, and the wounded arteries
are more apt to retract behind the bone above, and offer great obsta-
cles to their being secured. However, should the lower angle be alone
the seat of the disease, the attempt to remove the lower portion only
is justifiable. It must, however, be borne in mind that, when a lione
is once the seat of disease which requires removal, the disease is very
apt to recur in the portion left, and less liable to do so if the whole
bone DC removed. Such was not, however, the case in which Sir W.
FergussonlJ: operated, though the disease returned in Mr. Liston's§
patient. As the removal of the whole bone is not a more formidable
operation than the removal of a iM:)rtion of it, and as the patient has
less chance of a recurrence of his disease if the whole bone be taken

* E.g., M. A. Demandre, Des Tameurs de V Omoplale (Paris, 1873).

t St. George^s Hosp. Report'^, vol. iv. ]>. 23G.

;J: Lectures on the Progress of Anatomy mid Surgery, p. 45. Tlie mention of this is
extremely brief — namely, that the tumor was nearly the size of a list, and involved the
lower angle of the scapula. Nothing is said as to its nature. It appears to me very
probable that this case is identical witli another one of partial removal by Sir W. Fer-
gusson, mentioned below, in which recnri-ence did tai\e place.

§ Ed. Med. and Surg. Journ., vol. xvi. p. fiG. The tumor, in a boy aged sixteen, had
grown in three months from the size of a filbert to that of an orange, and subsequently
extended witli great rapidity over tlie lower two-thirds of the scapula. On attempting
to separate itsattaclnnent to thes[)ine, nKTit profuse hfemoriliage occurred. Tlie scap-
ula was sawn across so as to leave merely its upper portion on a level with about a
third of the spine. Recurrence took place within six weeks of the operation, and killed
the patient.



140 OPERATIONS ON THE UPPER EXTREMITY.

away, it should be in a very exceptional case, and on some very pecu-
liar merits of its own, that the surgeon ought to undertake the removal
of a portion of the scapula."

The above remarks of iSIr. Pollock are entirely borne out by theliis-
tories of cases which have been watched after partial removal of the
scapula for any growth save an exostosis.

Thus, in January, 1S65, Sir W. Fergusson* removed the lower two-
thirds of the scapula for a sarcomatous growth. Recurrence took
place, and, in the fotlowing November, the rest of the scapula, the
greater part of the chivicle, and the upper extremity were taken
away.

Dr. Bird, of Stockport,t removed the lower two-thirds of the scap-
ula for a growth the size of an orange in the infra-spinous fossa, in a
child aged ten, the bone being sawn through behind the neck in a line
with the supra-scapular notch. A year and a half later the growth
recurred and grew quickly, the rest of the scapula being now taken
away together with the hea(J of the humerus, which had become adhe-
rent to the scapula, and thus also required removal. A year and a half
later the child remained w^ell, the use of the hand "in sewing and writ-
ing being very little impaired."

Mr. Cock X removed a myeloid tumor, the size of a foetal head, from
the scapula, the greater part of the spine being removed and the
acromial end of the clavicle. A recovery took place, but the history
is not carried on beyond a few months.

So, too, in a case of myxochondroma removed by Prof. Billroth,§
where the lower angle was left together with the teres major and
minor, the last note of the case is six weeks after the operation.

In the case of growths, removal of tlie scapula alone or together with
the upper extremity may be called for.

The malignancy of the growths, mostly sarcomata, wliich may call
for either of these steps is well known, together with their tendency to
involve surrounding parts and to creep into regions inaccessible to the
surgeon. Early operation is imjDeratively required.

In the case of operation, the prognosis will be best, however large
the growth, when the rate of progress has been slow, when the growth
is uniformly hard, or if only a certain amount of elasticity is combined
with the hardness (as in unmixed enchondroma), when the outline is
distinct and well defined, and the mass movable upon the ribs.jj

- Lancet, 1865, vol. ii. p. 591. t H^i^-, P- 69i3.

X Guys Hasp. Reports, 1856, p. 1.

I Keported by Dr. Nedorpil, Lond. Med. Record, March 15, 1878 ; and Arch. f. klin.
Chir., Bd. XX i.

II That this mobility is a matter of some importance is shown by the following case,
quoted by M. Sfeiillot at i). 550 of his Traite de MHeclne nperatoire : " Nous refiisanies



REMOVAL OF THE SCAPULA. 141

On the other hand, the prognosis is less and less favorable in pro-
portion as the outline is nniform rather than nodulated or bossed, the
feel semi-elastic and obscurely fluctuating instead of hard, the prog-
ress rapid and attended with pain, the different parts of the scapula
much obscured'i' and its mobility much impaired, the outline of the
growth ill defined and lost indistinctly in the axilla. Pulsation and
bruit, enlarged glands, and tendency to infiltration of the skin aie also,
of course, of evil omen.

A. Removal of the Entire Scapula by itself (e.g., cases

where the growth is primary from the sca])ula, and where there is no
extension to the humerus or into the axilla). — Preparations against
shock should be taken, the extremities being bandaged in cotton-
wool, the head kept low, ether given, and subcutaneous injections of
ether and brandy being in readiness. The patient is placed at the
edge of the table and rolled over to the opposite side. If the growth
is very vascular, the patient weakly, pressure on the subclavian is of
importance, or if, from the extension of the growth, it is rendered diffi-
cult, this may be effected by making an incision down to and through
the deep fascia over the artery itself, in order to enable an assistant to
put the thumb or finger directly upon it.f This may be done by a
separate incision, or by an extension of that by which the clavicle is
divided.

Flaps are freely turned back, usually by a T-shaped incision, one
limb running from the acromion process inwards to the superior angle
of the scapula, while the other and longer is made at right angles to
the first down to the angle of the scapula. In another case the sur-
geon may prefer to make an incision along the vertebral border of the
scapula, and the other at right angles to it across the centre of the

un jour d'ojierer nn jeune honitiie atteint cl'un cancer ^noinie dii scapulum, dont les
limites iretaient pas iiettenient fixees, et nous dumes tioiis applaudir de notre absten-
tion en deconvrant pins tard, a la necropsie, cpie la tnmenr avait pen^tre dans la poitrine
et envahi nn lobe pulmonaire."

* In a very large scapular sarcoma on wliich Mr. Pollock operated, it is stated that
■'the mass extended over the upper portion of the scapula, which could not here be
traced, and over the outer part of the clavicle, which could not be felt ; and also so far
into the lower triangle of the neck that tiie subclavian artery could not be distinguished
or reached by the finger." The whole njass was removed, but the patient, aged forty-
seven, died on the sixth day, of ciironic bronchitis.

t As adoi)ted by Prof. Hyme in performing the old operation in a case of axillary
aneurism, p. in. If the clavicle is going to be removed, the subclavian can be com-
manded by cutting down on the clavicle, freeing it from its attacliments in its inner
third, [wssing a flat director carefully beneath it, sawing through the bone here, and
removing a portion of it, the finger being thus placed directly on tlie subclavian ( Jeaf-
freson, Lancet, 1874, vol. i. p. 759).



142 OPERATIONS OX THE UPPER EXTREMITY.

growth.-'^ Flaps thus shaped are dissected quickly back, care being
taken not to oi)en the capsule of the tumor. f

A\'hen the whole mass is thoroughly exposed, the muscles on the
vertebral border are first severed. The subclavian being now firmly
compressed, the trapezius, levator anguli, and the rhomboidei are cut
through, ;|: the posterior scapular artery secured, and the serratus mag-
nus divided, being first made tense by lifting the scapula of!" the ribs
upwards and outwards. The muscles on the upper border are next§
attacked — viz., the deltoid, the omo-hyoid, and the supra spinatus —
and the supra-scapular artery secured. The acromio-clavicular joint
is next opened, or else the acromion or clavicle, || according to the
extension of the growth in this direction, severed by bone-forceps or a
narrow saw. If the acromion can be safely left, the resulting deform-
ity — viz., dropping of the shoulder and entire loss of trapezius action
— will be lessened.

The lower angle and the latissimus dorsi (if iiivolved) being freed,
the scapula can now be dragged away from the chest by slipping two
or three fingers over the upper or vertebral border. Thus, by tilting
the scapula outwards, the axillary border can be inspected, the teres
and infra-spinatus muscles severed, the position of the sub-scapular
artery defined by a finger passed beneath it, and this vessel secured, if
possible, before it is cut. The scapula being still farther pulled away
from the chest, the muscles attached to the coracoicl process are next
severed, and the scapula removed by cutting into the shoulder-joint
and severing the caj^sular tendons and the biceps and triceps. The
coracoid process may become detached at this stage if partially eroded

* If tlie skin is involved or nlcerated, tlie flaps must be so .shMi)ed as to isolate this.

t Pollock, St. George's Hasp. Reports, vol. iv. p. 237.

X It is a bad sign if any of tlie muscles severed are infiltrated with growth. That
this, however, is not incompatible with a good recovery is shown by the second of Prof.
Syme's i-d'^es [Excision of the Scapula, ]). 28), in which it is stated that "the tumor
weighed between 4 and 5 pounds ; it had a soft consistence and very suspicious aspect,
which was strengthened by microscopical examination, as the muscular substance that
was taken away along with the growth a|ipeared to be loaded with the germs of future
disease; but fifteen months having elapsed since the operation was performed, without
the slightest appearance of relapse, it may be hoped that the recovery will prove per-
manent."

§ If the upper bordereau be taken before the axillary one is dealt with, the subcla-
vian can be better controlled when the subscapular artery (a source of free hiemor-
rhage) is severed.

II Prof. Spence (Ed. Med. Journ., August, 1S72, p. 178) recommends that the clavicle
should be left, not sawn through, otherwise the head of the humerus tends to project
through the incision, there being nothing but skin left, the overhanging arch of bone
having been removed. On the other hand, sawing the clavicle, while it leaves a cut
surface of bone as a possible source of irritation, facilitates the operation somewhat, as
it exposes better the large vessels and the muscles attached to the coracoid process.



EEMOVAI. OF THE SCAPULA. 143

by extension of growth* If this happen, it mwst be carefully dis-
sected out afterwards.f Every vessel must be thoroughly secured
when it is severed ; otherwise, oozing is very likely to take place a few
hours later.;}: If the anastomoses are free, double ligatures will be
required.

Ha;'morrhage may be best avoided by attention to the following
points : (1) Adequate pressure on the subclavian, this being effected
by a special incision, if needful, to command the vessel. (2) Taking
care not to cut into the tumor itself (3) Dealing with the axillary
border and sub-scapular artery last. (4) By some it is recommended
to make the incisions gradually, not larger than are required at the
time, as a means of minimizing the hajmorrhage. It must be remem-
bered, with regard to this point, that small and cramped incisions
interfere with a free and rapid hand and sufficient exposure of the
parts, conditions which conduce to thorough dealing with bleeding
points, and thus facing one of the chief difficulties of this important
operation.

Adequate drainage is now provided, the flaps united, and the arm
secured to the side for a few days, after which it may be supported in
a sling if the head of the humerus does not tend to protrude.

Condition of the Limb after Removal of the Scapula.- — A
limb thus preserved will be strong and useful. If the clavicle has not
been much interfered with, the clavicular fibres of the deltoid will
remain, and these, together with the latissimus dorsi and pectoralis
major, will probably confer a fair amount of motion on the limb. In
one of Prof. Syme's cases, after removal of the scapula and the outer
third of the clavicle, and, by a previous operation, the head of the
humerus, the patient was able to lift heavy weights, and to fill the
appointment of provincial letter-carrier.

In a very successful case of Mr. Symonds' (Clin. Soc. Trans., vol. xx.
p. 24), in which the scapula was removed for osteo-sarcoma, the man
was in good health two years and a half after the operation. " He

* Especially if the patient be a yoini<f one, as in a case of Mr. Pollock's.

t If the growth has involved theaxilhiry vessels and nerves, this outlying portion
may be dealt with later on, after the main mass has been separated and removed If it
is desired to remove this extension of the disease now while in continnity with tiie
scapular growth itself, the surgeon will have both his hands free for what is a troub-
lesome dissection, by asking an assistant to drag the main mass strongly backwards.
To facilitate this step, Prof. Sy me {he. supracit., p. 26) placed a piece of cord round the
divided extremity of the clavicle, for the assistant to pull upon. The greatest care
must i>e taken, when dealing with projections into the axilla, to keep the knife, or
blunt dissector, very close to the growth, for fear of opening the large vessels.

X In a case of this kind, Mr. Berkeley Hill transfused twice, but unsuccessfully, tlie
patient dying of shock and acute sepiictemia in forty-five hours (Brit, Med. Juum.,
1880, vol. i. p. 487).



144



OPERATIONS ON THE UPPER EXTREMITY



was able to do all the lighter work of a carpenter, including the use
of a plane. Overhead work he could not do." In this case the artic-
ular surface of the humerus had also been removed about a month
later, as it was thought to be the cause of prolonged suppuration sub-
sequent to the first operation.

B. Removal of the Scapula, together with the Upper

Extremity (Fig. 40). — This operation is re(iuired in cases where a
growth has involved the axilla and humerus us well as the scapula, and

Fig. 40.*




(After Heatli.)

in a few cases of machinery accidents. In the former case it may be
performed on the following lines, modified to suit the case (Fig.
40).

The patient being prepared and placed as directed at p. 141, the sur-
geon commences his incision over the outer third of the clavicle, and
thus can now either proceed to secure the subclavian artery at once,
or enable an assistant to put his finger directly upon the vessel. In
the former case the soft parts must be separated with a raspatory, the
subclavius divided, and the vessels found beneath it. From the end
of this incision, over the acromio-clavicular joint, another is made
curving outwards over the shoulder and upper part of tlie arm,
and then sweeping back to the inferior angle of the scapula. This
curved oval flap is then raised towards the spine, the muscles on the

* This drawing is based upon one of a patient of Mr. Heath's (Brit. Med. Journ.,
1886, vol. i. p. 66). The outline of the flaps has here been brought somewhat too low
down upon the arm.



REMOVAL OF SCAPULA AND UPPER EXTREMITY. 145

vertebral and upper borders of the scapula divided, and the posterior
and supra-scapular vessels secured. The scapula, with the arm, is
next carried boldly forwards towards the axilla,* and the sub-scapular
vessels secured and divided, together with the muscles in the axillary
border. A second incision, the extremities of which meet the first, is
then made over the front of the shoulder and arm, curving back across
the axilla. When the anterior flap, thus marked out, has been suffi-
ciently dissected up, the large vessels, if not already dealt with, are
found and secured before their division, and the limb and scapula
removed.

All haemorrhage being securely arrested, the flaps are next submit-
ted to careful scrutiny for any suspicious infiltration, and the axilla
examined for any enlarged glands or outlying masses of growth. If,
owing to the necessarily prolonged operation or for fear of shock, no
sprayt has been used, the flaps should be sponged over with zinc-chlo-
ride solution (gr. xx-^j) before being adjusted, due drainage being
also provided.

Age of the Patient. — It may be not uninteresting to some to know
that the scapula has been successfully removed for growth at ages
varN'ing between "about seventy " and " about eight." The former
was a patient of Prof. Syme,J who died about two months after the
operation, apparently of internal deposits. The latter case occurred in
India, § the upper extremity being removed at the same time.

Dangers of the Operation and Causes of Death.— Tliese are
chiefly —

1. Haemorrhage.

2. Shock.

3. Septicaemia.

4. Entrance of air into veins. This very nearly proved fatal in a
case in which Mr. Jessop, some years ago, removed the scapula, outer
half of the clavicle, and the upper extremity (Brit. Med. Journ.. 1874,
vol. i. p. 12). In this case the scapula seems to have been removed
owing " to considerable deficiency of cover "after removal of an upper
limb much damaged by a machinery accident. " Whilst cutting
through the last attachments of the scapula, two distinct loud whiff's
were heard, caused bv the rush of air into the subclavian vein." The



* During these or other necessary manipuhitions, the humerus, if much invaded by
growth, may give way.

t If possible, a very efficient substitute for this may be used by irrigatintj, occasion-
ally, tiie wound as made, with a h)tion of mercury perchloride, glycerine, and water.

X Loc. supra cit.

I A very brief mention of this case is c^iven in a letter, L(mcet,1^7i, vol. i. p. 819..
It is not stated whether the patient was a native or no.

lU



146 OPERATIONS ON THE UPPER EXTREMITY.

operation was completed while artificial respiration was being per-
formed, and the lad recovered.

5. Recurrence. This takes place usually within six or twelve
months. In a case of Mr. Heath's (loc. swpra cit.), recurrence took
place seven months after extirpation of arm and scapula in a lad aged
sixteen, with two years' history of the growth, an " osteo-sarcoma."
The recurrent growth was removed, but two years and a half after the
original operation recurrence again took place, and was dealt with
about five months later. A rapid recovery took place, and at the time
of this the latest operation, no signs of extension to the internal organs
could be detected, and the patient was in robust health.

Removal of the scapula for caries* needs no especial mention. The
parts being sufficiently exposed, the operation will be conducted, as
far as possible, sub-periosteally, by means of appropriate blunt dis-
sectors or periosteal elevators.



CHAPTER VIII.
OPERATIONS ON THE CLAVICLE.

REMOVAL OF THE CLAVICLE.

Removal may be required for new growths or necrosis. In either
case it is very rarely called for. That for necrosis differs in no way,
save for the importance of surrounding parts, from the same operation
elsewhere.

Removal of Clavicle for New Growths. — No better idea of
the kind of operation required, and the difficulties likely to be encoun-
tered, can be gained than from the account of Prof. Mott's celebrated
case.f

A youth, aged nineteen, consulted Prof Mott in 1828 for a tumor
about 4 inches in diameter, very hard, firmly attached to the clavicle,
which had been noticed about four months, and which was fungating
owing to irritation by escharotics, etc.

An incision, begun over the sterno-clavicular joint, was carried, in a
semicircular direction, as close to the fungating part as was safe, to
hear the acromio-clavicular joint. In dividing the pectoralis major,

* A good case of this kind is recorded by Sir. W. Fergusson {Med. Chir. Trans., vol.
xxxi. p. 310). An exquisite drawing of tiie scapula — one of the very best by the hands
of the Baggs — will be fonnd in the same author's Practical Surgery, 4tli ed. p. 309, Fig.
144.

t Amer. Journ. Med. Sci. (O S.), vol. iii. p. 100.



REMOVAL OF THE CLAVICLE. 147

arteries sprang in every direction ; anumber of large venous branches,
under the muscle, also required ligature. Care was taken to avoid
the cephalic vein, which was drawn outwards. Finding it impossible,
from the size of the tumor and its close proximity to the coracoicl pro-
cess, to get under the clavicle in this direction, an incision was made
from the outer edge of the external jugular, over the tumor, to the top
of the shoulder. After dividing the skin, platysma, and part of the
trapezius, a sound part of the clavicle Avas exposed nearer to the acro-
mion than the coracoid process. A steel director, very much curved,
was now cautiously j^assed under the bone from above, great care being
taken to keep the instrument in close contact with the bone. The
great depth of the clavicle from the surface rendered it somewhat diffi-
cult to accomplish this safely; an eyed probe, similarly curved, con-
veyed along the groove of the director a chain saw, which, when moved,
showed that nothing intervened between it and the bone ; the clavicle
was then readily sawn through.

The first rib being next exposed under the sternal end of the clavi-
cle, below the pectoralis major, the rhomboid ligament was divided
and the joint opened. This gave great and encouraging mobility to
the diseased mass.

The saAvn end of the clavicle being a little elevated and the parts
around it loosened, the surgeon tried to discover the subclavius mus-
cle, but it could not be seen, being incorporated with the diseased
mass. Had this muscle l>een found, the separation of the tumor
would have been much less difficult and tedious, as, by keeping above
it, the subclavian vein is, of course, protected. The origin of this mus-
cle was seen and divided, but it was almost immediately afterwards
obliterated in the tumor.

The omo-hyoid was found under the sterna-mastoid, and traced to
its origin on the scapuhi. In separating the tumor from the cellula-r
and fatty tissue between the omo-hyoid and the subclavian vessels, a
number of large arteries were divided, which bled freely, particularly
a large branch from the inferior thyroid.

The anterior part of the upper incision was now made from the
sternal end of the clavicle, and carried over the tumor, until it met the
other at the external jugular vein. This vein was then cut between
two fine ligatures.

The clavicular part of the sterno-mastoid was next cut about 3
inches above the clavicle, and the anterior scalene exposed by careful
dissection.

The subclavian vein from the edge of the scalenus to the coracoid



Online LibraryW. H. A JacobsonThe operations of surgery; a systematic handbook for practitioners, students and hospital surgeons .. → online text (page 14 of 115)