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[Extracted from The Medical News, September 20, 1884.] 
 
 ^^ 
 
 A CASE OF SARCOMA OF THE SKIN AND 
 
 CELLULAR TISSUE ABOUT THE ANKLE, 
 
 WITH REMARKS.' 
 
 By FRANCIS J. SHEPHERD, M.D., CM., 
 
 PROFESSOR OF ANATOMY IN MCGILL UNIVERSITY, SURGEON TO THE 
 MONTREAL GENERAL HOSPITAL, 
 
 The clinical interest of the following case furnishes 
 me with a sufficient excuse for its publication. 
 
 Edward M., aged eighteen, native of Switzerland, 
 a delicate- looking youth, came under my care at the 
 Montreal General Hospital in April last, suffering from 
 an ulcerated swelling about the left ankle. No 
 history of struma or rheumatism in his family, and 
 he himself has, with the exception of the present 
 disease, always been healthy. 
 
 He gave the following history of his case : 
 
 Some six years ago, while running, he fell and 
 injured his left ankle-joint. The doctor told him it 
 
 ^ Read before the Montreal Medico-Chirurgical Society, June 
 27, 1884. 
 
V, 
 
 was dislocated, but after six weeks' rest the pain dis 
 appeared, and he could walk as well as ever ; th 
 swelling about the joint due to the injury, howevei 
 never entirely disappeared. A year subsequent t< 
 the above-described accident the ankle again becam 
 painful, and the swelling and tension markedly in 
 creased. His doctor, thinking an abscess had formed 
 opened the swelling, but failed to get pus, blood onl 
 escaping from the incision ; this incision has neve 
 entirely healed, but ever since has remained open z 
 a sinus, discharging a thin sanious pus. Three yeai 
 ago he was kicked by a horse on the affected ankle 
 this caused an aggravation of the pain and swelling 
 The ankle-joint itself since the first accident has appj 
 rently never been affected, and its movements hav 
 always been free and comparatively painless, but th 
 swelling on the inner side has been slowly increasin 
 in size, and at different points sinuses, which dii 
 charge a thin pus, have formed. 
 
 When I first saw him, the parts about the inner side ( 
 the left ankle-joint were of a shiny, dusky-red coloi 
 and considerably swollen. The swelling extende 
 from a point several inches above the tip of the ii 
 ternal malleolus to below the tarsal joint, it also e? 
 tended laterally to the sole of the foot, half way acro! 
 the instep, here the skin over the swelling was quit 
 normal. There was also fulness over the tend 
 Achillis and the parts behind the internal malleolui 
 Near the edge of the swelling were several reddis 
 
iks' rest the pain dis- 
 as well as ever ; the 
 the injury, however, 
 
 year subsequent to 
 e ankle again became 
 tension markedly in- 
 in abscess had formed, 
 :o get pus, blood only 
 is incision has never 
 has remained open as 
 ous pus. Three years 
 »n the affected ankle ; 
 he pain and swelling, 
 rst accident has appa- 
 
 its movements have 
 ively painless, but the 
 Deen slowly increasing 
 ts sinuses, which dis- 
 
 about the inner side of 
 liny, dusky-red color, 
 he swelling extended 
 )ove the tip of the in- 
 tarsal joint, it also ex- 
 le foot, half way across 
 the swelling was quite 
 ness over the tendo 
 the internal malleolus. 
 
 were several reddish 
 
 tuberculous nodules the size of large peas. There 
 were also a number of sinuses in the upper part of 
 the swelling, and near the centre a spot of ulceration 
 the size of a ten-cent piece. The swelling, which 
 was not at all well defined, on pressure gave a sense 
 of fluctuation, or rather felt like a mass of some 
 semifluid substance. During pressure no pus exuded 
 from any of the sinuses. There was but little p'^in in 
 the part, and patient only complained when his foot 
 was handled a little roughly. On probing the sinuses 
 carefully no necrosed or carious bone could be felt. 
 Not feeling perfectly sure of the diagnosis, but sup- 
 posing from the semi-elastic sensation conveyed by 
 pressure, and also the history of the case and the 
 evident healthiness of the ankle-joint itself, that the 
 disease was some form of neoplasm, I decided to 
 place the lad under ether and carefully explore the 
 parts affected. This I did after observing the case 
 for a day or two. I made a free incision in the long 
 axis of the swelling over the inner malleolus, and 
 after cutting through very thick infiltrated skin, came 
 upon a lot of tissue looking like granulation-tissue ; 
 this substance appeared to be in pockets, and could 
 be squeezed out by using some force. The lining 
 membrane of these pockets was smooth and shiny. 
 I cut through the whole thickness of the swelling and 
 was still superficial to the annular ligament of the 
 ankle and the tendons which pass under it ; the 
 movements of the tendons were in no way interfered 
 
with. Feeling sure I had to do with a new growth, 
 I sent some of the substance taken from the pockets 
 to my friend Dr. Wilkins, for microscopical examina- 
 tion, and he pronounced it a very good example oi 
 round-cell sarcoma. 
 
 On consultation with my colleagues, amputation o 
 the leg was decided on. The lad and his friends, or 
 learning the serious nature of the disease and the 
 danger of delay, at once consented to the amputa 
 tion. 
 
 I omitted to mention that the glands in the groir 
 were much enlarged, one, below Poupart's ligament, 
 had increased to the size of a pigeon's egg. I lookec 
 upon this condition of the glands as purely inflam 
 matory, knowing the rarity with which sarcomatoui 
 tumors secondarily affect the glands, and also know 
 ing that they had been enlarged ever since the firs 
 accident. In the interval between the making o 
 the exploratory incision and the amputation, th( 
 swelling had slowly increased in size and extent, an( 
 the incision had rapidly filled up with coarse granula 
 tion-tissue. 
 
 I amputated the leg on May 17th at some distance 
 above the disease, dressing the stump, as I usually d< 
 in amputations, with iodoform and pads of sublimatec 
 jute. In this case I made use of decalcified bon^ 
 drains, which, owing to their collapse, had to be re 
 placed on the second day by rubber tubes. Fron 
 this time the case progressed favorably, the tempera 
 
with a new growth, 
 
 en from the pockets 
 
 :roscopical examina- 
 
 ;ry good example of 
 
 agues, amputation of 
 d and his friends, on 
 the disease and the 
 ited to the amputa- 
 
 e glands in the groin 
 Poupart's ligament, 
 eon's egg. I looked 
 ids as purely inflam- 
 h which sarcomatous 
 ands, and also know- 
 d ever since the first 
 :ween the making of 
 the amputation, the 
 I size and extent, and 
 p with coarse granula- 
 
 1 7th at some distance 
 stump, as I usually do 
 nd pads of sublimated 
 i of decalcified bone 
 ollapse, had to be re- 
 rubber tubes. From 
 vorably, the tempera- 
 
 ture after the third day never reaching 99°, and in 
 less than three weeks' time, with three dressings, the 
 wound was practically healed. The enlarged glands 
 below Poupart's ligament gradually diminished in size ; 
 and when last seen a few days ago, the lad was in 
 good condition, felt well and strong, and the 
 enlarged glands had almost entirely disappeared. 
 Whether or not he will have a return of the tumor in 
 some other part remains for time to show. Owing to 
 the long duration of the growth and its being of the 
 most malignant variety of the sarcomata, it is possible 
 that infection may have been conveyed to other 
 parts. 
 
 This case is instructive chiefly on account of the 
 difficulties it presented for diagnosis. In the first 
 place, the situation was an unusual one for a sarcoma ; 
 again, it resembled more some chronic form of in- 
 flammation connected with periosteal or bone 
 disease than a sarcomatous tumor and it was only 
 after a careful exploratory incision and a microscopical 
 examination that its true nature was made out. I 
 need not dwell upon the importance to the patient of 
 a correct diagnosis in these cases, for sarcoma, and 
 especially the round-cell variety, unless removed, is a 
 fatal malady. The patient before coming under my 
 care had been treated for some months on the sup- 
 position that his affection was of an inflammatory 
 nature. What led me to suspe^l a new growth was 
 the existence of apparent fluciuaLu-ri with the presence 
 
of numerous sinuses, the freedom from pain on mo^ 
 ment of the joint and the absence of any carious^ 
 necrosed bone. 
 
 The long duration of the tumor, and the fact th 
 it can be directly traced to traumatism as its cau; 
 add further interest to the case. Cases have lat( 
 been reported by Mr. Barwell and others in whi 
 injury was followed by an acute and rapidly growi 
 sarcoma; this is comparatively rare, but slowly gro 
 ing sarcomata not infrequently follow injuries, a d 
 which was pointed out by Billroth many year ago. 
 
 It is of rare occurrence that the skin of the pa 
 about the foot is affected with sarcoma ; the m( 
 common forms of sarcoma of the lower extrem 
 being connected with bone itself or the parts in cc 
 nection with bone. When the skin is the seat ol 
 sarcomatous tumor it is of the spindle-cell variety, 
 a rule, round-cell sarcoma being very rarely seen 
 connection with the skin. 
 
 Prof. Markoe, in The Medical News of April : 
 1884, reported a series of cases of what he c£ 
 "Sarcoma of the Sheaths of Tendons about 
 Foot. ' * His cases closely resemble that which I hi 
 just narrated to this Society. The skin, howev 
 was not involved in Dr. Markoe's cases, the dise 
 being confined to the parts immediately beneath, 
 seems to me that Br. Markoe's description of 
 cases hardly bears out the idea put forth by him t| 
 
m from pain on move- 
 ence of any carious or 
 
 mor, and the fact that 
 lumatism as its cause, 
 ;e. Cases have lately 
 I and others in which 
 :e and rapidly growing 
 
 rare, but slowly grow- 
 \f follow injuries, a fact 
 roth many year ago. 
 X the skin of the parts 
 :h sarcoma; the more 
 )f the lower extremity 
 elf or the parts in con- 
 le skin is the seat of a 
 
 spindle-cell variety, as 
 ling very rarely seen in 
 
 ncAL News of April 26, 
 ;ases of what he calls 
 of Tendons about the 
 emble that which I have 
 y. The skin, however, 
 rkoe's cases, the disease 
 nmediately beneath. It 
 :oe's description of his 
 ;a put forth by him that 
 
 the tumors were connected with the sheaths of the 
 tendons. 
 
 One thing is certain, that these sarcomatous tumors 
 about the foot are of rare occurrence, and if their 
 true nature is not ascertained in time the life of the 
 patient will be endangered, for though at first 
 apparently innocent, sooner or later they develop the 
 greatest malignity. 
 
 <'