182 
PATHOLOGY: W. S. HALSTED 
Proc. N. a. S. 
that the excessive swelHng must be due to the blocking of lymphatics and 
possibly veins uninjured by the knife. 
About thirteen years ago a modification of the operative procedure 
was made, particularly in the manner of closing the wound, and there- 
after, to our surprise, swollen arms became almost a thing of the past. 
I say "to our surprise," for the modifications in the operation were made 
primarily merely in the hope of securing greater freedom of motion at 
the shoulder joint. 
Now inasmuch as the destruction of lymphatics and veins was iden- 
tically the same in the modified as in the original procedure, we concluded 
that the most thorough excision of the axillary contents could not alone 
produce swelling of the arm, and that whatever the predisposing cause 
might be, the ultimate factor in the production of the swelling must be 
something which had been eliminated in the newer procedure. 
It is a common observation that a moderately swollen arm may after 
an interval of a year or more become markedly increased in size. This 
augmentation is generally and quite properly attributed to a recurrence 
of the disease. Occasionally, but rarely, I have observed an arm that 
for a year or more after the operation had maintained approximately its 
normal size swell quite acutely. The swelling might follow closely upon 
constitutional symptoms — nausea, malaise, chill and fever — and be co- 
incident with a slight or even bright blush of the skin of the shoulder, arm, 
and perhaps chest and forearm. 
For example, in May, 1920, a patient upon whom I had performed a 
radical operation for mammary cancer in November, 1916, consulted me 
in regard to an acute swelling of the arm on the operated side. The arm 
had maintained its normal size prior to an ''attack" in February, 1920, 
in the course of her convalescence from influenza. This attack as she 
terms it was ushered in by nausea, a chill and high fever. The arm promptly 
b)egan to swell and there appeared "redness in streaks" from the shoulder 
to the wrist; in a few days the redness was diffuse and the swelling of the 
arm had become distressingly great; the hand, she said, resembled a "box- 
ing glove," and pressure on it with the fingers produced "deep pits." In 
eight or ten days the redness had vanished and the swelling was decreasing. 
During the three months prior to this her second admission to the Johns 
Hopkins Hospital, there had been a less rapid reduction in the size of the 
affected (left) limb, which about the middle of the arm measured in cir- 
cumference 9.5 cm. more than the other, and at the middle of the forearm, 
3.5 cm. more. No glands were palpable above the clavicle, and there 
seemed to be no abnormal fullness or resistance below it. In the skin 
at the outer-upper edge of the grafted area there was recurrence of the 
carcinoma — two nodules, not ulcerated, one about the size of a filbert, 
the other smaller than a split pea. 
