Vol. 8. 1922 
PATHOLOGY: W. S. HALSTED 
183 
The immediate cause of the swelling was undoubtedly the local infec- 
tion, for during the three years and three months prior to this and sub- 
sequent to the operation there had been nothing to indicate a blocking 
by recurrent disease of the lymph channels. 
Eight days after the second admission (June 1, 1920), the patient was 
operated upon by Dr. Mont Reid, our resident surgeon. The second and 
a part of the third portion of the axillary vein were found to be completely 
occluded by the new growth, which was continuous with the larger of the 
two cancerous nodules in the skin. The axillary vein and the recurrent 
growth were excised in one piece, the disease being given a wide berth. 
On examination of the specimen it seemed quite clear that the vein had 
been invaded from without, and had surely been occluded long before 
the attack of infection. After this operation the swelling rapidly sub- 
sided and in the course of two months the arm had almost regained its 
normal dimensions. 
In this case, as in a number of others observed in our clinic, the occlusion 
of the axillary vein plus the excision of the axillary lymphatics was not 
followed by any swelling of the arm. 
I have under observation several patients who each year following the 
operation have had one or two or more attacks of the kind described, 
each attack being followed by an increase in the size of the arm. 
Only four days ago I received an announcement of the death of a patient 
whose story subsequent to an operation for cancer of the breast sustains 
the view that swelling of the arm may be due to infection even when local 
and general signs of inflammation are wanting. This patient was operated 
upon by me five years ago. About nine months after the operation she 
consulted me in regard to a rather acute but inconsiderable swelling of 
the arm on the affected side, which theretofore had not been swollen. 
She could not recall having had constitutional symptoms and was quite 
sure there had been no inflammatory redness of the arm coincident with 
first appearance of its enlargement. From the time of this interview 
until her death, four years and three months later, there had been no 
augmentation of the swelling. She died of carcinomatous metastases 
in the bones. There was no recurrence of the disease either locally or in 
lymphatic glands which could have affected the circulation of the arm. 
Hence the swelling which occurred nine months after the operation could 
not have been due to the blocking of lymphatics by cancer. 
Operations upon the glands of the groin may be followed by elephantiasis 
of the scrotum. One patient in this category was operated upon by me 
about forty years ago. During all this period he has each year had mild 
local attacks of an infection resembling erysipelas and with each attack 
a slight, transient, increase in the elephantiasis. 
Now if redness or even a faint blushing of the arm always accompanied 
