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 A CASE OF SARCOMA OF THE ARM INVOLVING THE SKIN— AM- 
 PUTATION-RECuRRENCB IN THE STUMP A YEAR LATER,' 
 
 BT 
 
 ■ •:■' *• FRANCIS J. SHEPHERD, M. D., 
 
 '"'"' Surgeon to the Montreal General Hospital. 
 
 THE following case is of interest, chiefly on account of the 
 difficulty of diagnosis and the rather unusual course of 
 the affection which in a comparatively early stage rapidly 
 involved the lymphatic trunks of the arm, and the glands in 
 the axilla. The microscopic characters of the affection are also 
 somewhat unusual, and are fully described separately by Dr. 
 Wyatt Johnston, who kindly examined the various specimens 
 for me. 
 
 Case. — C, A. B., machinist, aet, 35, married, entered my 
 service at the Montreal General Hospital on May 28, 1890, 
 complaining of an ulcerated left forearm. 
 
 Patient lives in the country and has always been very 
 healthy. There is absolutely no history of syphilis. Has been 
 married two years, and his wife had a miscarriage in 1888, and 
 a healthy child now living born in 1889; never, that he knows of, 
 had any injury to the arm. 
 
 History. — About the middle of December 1888, he first 
 noticed three small nodules about the size of peas beneath the 
 skin, covering the back part of the middle third of the left ulna. 
 These nodules were painless, and moved freely beneath the 
 
 'Read before the meeting of the American Dermatological Association, Washington, 
 September 5, 1891. 
 
 L 
 
WPP" 
 
 2 
 
 Original Communication. 
 
 skin. They gradually increased in size, and became adherent 
 to the skin ; soon the skin became red and inflamed, and Anally 
 in August, 1889 (eight months after the commencement of the 
 disease), they ulcerated. The ulcers were poulticed freely, but 
 this treatment seemed only to hasten the rapidity with . which 
 they deepened and enlarged, and now, for the first time, they 
 became very painful, the pain being especially severe at night. 
 The three sores thus formed, soon became one large irregular 
 ulcer with sharp edges, and sloughy base. The discharge was 
 never great and was of rather a watery consistency. Later on other 
 lumps appeared in the neighborhood, which also became at- 
 tached to the skin, and breaking down subsequently resulted 
 in small ulcers. 
 
 Qondition on entering Hospital. — The patient is a well 
 nourished raij.n, having a healthy appearance and with a good 
 appetite. He says he has not lost flesh lately. Heart, lungs, 
 kidneys, etc., are found to be perfectly healthy. On examin- 
 ing the left forearm, three large ulcers are seen on the middle 
 third of its extensor surface. The largest is the size of a 25 cent 
 piece. They are deep, purulent with sharp indurated edges 
 and irregular in shape ; the bases are sloughy and have rather 
 a honeycomb appearance. The surrounding skin is red, swol- 
 len and eczematous. Near the elbow are several smaller ulcers 
 and between the two sets of ulcers are a number of small shot- 
 like nodules quite moveable beneath the skin. In addition to 
 this, on the inner side of the biceps from the bend of the elbow 
 to the axilla, can be felt a chain of nodules, large and small, 
 which feel very much like buckshot under the skin. They 
 seem to follow the course of blood vessels. They are painless, 
 and are covered by perfectly healthy skin. The arm Is com- 
 paratively useless, the hand being swollen and oedematous, and 
 the extensor muscles paretic, this causes the characteristic 
 wrist drop. A portion of one of the growths was excised and 
 submitted to Dr. Wyatt Johnston, pathologist to the hospital, 
 who p/onounced the case to be probably one of spindle celled 
 sarcoma, but he should like specimens for further examinations. 
 However, it was decided to try antisyphilitic treatment, and 
 the patient was put upon gr. xx pot. iod. three times a day, 
 largely diluted, at the same time black wash was applied to the 
 ulcers, the dose of iodide was increased to one drachm three 
 times a day, and there was for a time marked improvement, 
 but later this improvement ceased, and the patient's condition 
 remained much the same as it was previous to treatment. The 
 
 ■ 
 
■MM 
 
 itmrmmim 
 
 I 
 
 Sarcoma of the Arm Incolmng the Skin. 
 
 8 
 
 pain returning and the ulcers, which at one time, showed .a ten- 
 dency to heal, increasing slowly in size. The iodide treatment 
 was continued for a month, and had the effect of disordering 
 the patient's digestion. Dr. Johnston wishing to have speci- 
 mens for further examination, I placed the patient under ether 
 and excised some o^ the deeper nodules which extended up the 
 inner side of the biceps, these I found to follow the course of 
 the lymphatic trunks and to be intimately associated with the 
 veins, and they were, in consequence, difficult to excise. In 
 appearance these lumps or growths were grayish in color, ir- 
 regular and beady in outline and not encapsuled. On sections 
 they were firm and the cut surface showed numerous opaque 
 white spots, the size of pin heads with translucent tissue be- 
 tween. The wound caused by this small operation healed by 
 first intention, and from these facts this part of the arm was 
 much less painful. The specimens thus removed were ex- 
 amined almost immediately by Dr. Johnston, who gave a more 
 positive opinion that the case was one of spindle eel' 1 sarcoma, 
 and advised removal of the arm. 
 
 The patient went home to settle his affairs ana returned a 
 month later, the 24th of July, and the reporter notes "that 
 several new nodules have appeared about the elbow and up the 
 inner side of the arm, also, that the first three ulcers on the 
 forearm have coalesced forming one huge ulcer, with irregular, 
 deeply excavated but firm edges and a sloughy face discharging 
 a watery fluid." 
 
 The pain was so great that amputation of the arm at the 
 shoulder joint was readily consented to. The operation was 
 performed on the 26th of July, 1890. After removal of the arm 
 it was seen that the axilla was filled with enlarged and infiltrated 
 glands of the same character as the nodules removed from 
 above the elbow, and that the affected glands reached even 
 above the clavicle. They were all carefully dissected away, and 
 this took time as they closely embraced the axillary vessels. 
 The posterior flat was also studded with small nodules of the 
 same character and a considerable portion of it had to be re- 
 moved. 
 
 In two weeks the patient returned home with the wound 
 completely healed by first intention, and feeling much pleased 
 with the result of the operation, as it had entirely relieved the 
 severe pain previously complained of. 
 
 I heard from him occasionally and the report was that he 
 had rapidly gained flesh and was feeling perfectly well. How- 
 
 "I 
 
OKKirxAL Communication. 
 
 ever, by the beginning of May, 18S)1, about ten montlis after tlie 
 operation, the stump became acutely i)ainful, he could not 
 sleep, and had recourse to opiates, he soon lost appetite and 
 flesh and came again to the hospital in the middle oi June, 1891, 
 looking ill and miserable. Upon examining the stump I found 
 that there was fulness in it wliicli was not natural, and in 
 cutting down in it I came on a large mass of new growth which 
 did not involve the skin, but extended up into the axilla. I ex- 
 cised this very freely, and closed the wound, which healed in a 
 few days. The pain was relieved, though not removed by this 
 operation, but he returned home much better. He re-entered 
 hospital on July 1st, saying that the pain had returned and 
 was worse than ever, and that I must do something for him. 
 At the previous operation I had removed the enlarged nerve 
 ends of the brachial plexus, but now I determined to dissect the 
 plexus above the clavicle. This was done the next day, an inch 
 from each cord being excised. I dissected freely, but could 
 find no trace of the new growth above the clavicle, the glands 
 not being involved. This operation completely relieved the 
 pain. He returned home in a week feeling very well. I have 
 since heard from him, and he says, with the excviption of slight 
 pain occasionally felt in the armpit, he was very comfortable. 
 Dr. Wyatt Johnston's Report on the Character of the Tumors. 
 — On May 31, 1890, examined a portion of growth from arm of 
 C. A. B. Sections made after hardening in absolute alcohol 
 show epidermis normal, cutis thick and dense ; immediately be- 
 neath the cutis are a large number of flattened cells, resembling 
 those seen in a large spindle-celled sarcoma, and arranged 
 in loose clumps apparently within the subcutaneous lymph 
 spaces. No lepra or tubercle bacilli. On June 27, 1890, exam- 
 ined an elliptical piece of skin, removed, with nodule attached, 
 from the inner side of arm below elbow. It contained a small 
 reddish papule the size of a split pea and situated deeply. In 
 addition to the skin a large mass of infiltrated tissue was exam- 
 ined. On lightly scraping this a whitish juice was readily 
 obtained, and was found to be composed of fatty detritus and 
 large flattened cells of very variable outline. The diameter of 
 these cells ranged from 0.015 to 0.050 m.m. Many of these 
 cells were pear or anvil shaped, with a long tapering pole. 
 Ovoid forms were very common ; they lie close together, with- 
 out any intervening inter cellular substance. A small propor- 
 tion were flattened and thin with folded edges. The nuclei were 
 usually multiple, and a few of the cells showed highly refract- 
 
Sarcoma of the \r7n, Involving the Bkln, 
 
 I 
 
 \ 
 
 ing hyaline bodies beside the nuclei ^^phiHniosonintn), but tliere 
 was iio appearance of parasitic phisniodia (jr bacteria. Cultures 
 in f?lycerine agar remained sterile. The sections ^^llich were 
 made after fixation in various fluids (absolute alcoliol, diluted 
 alcohol, Muller's fluid, 1 percent, sublimate and Fleming's solu- 
 tion) showed the arrangement of the cells to be somewhat dif- 
 ferent to what had been anti(!ipated from the appearance of the 
 cells in the juice obtained from scraping the (!ut surface ; now a 
 delicate inter-cellular substance seemed to lie between each cell, 
 and the appearance of the cells themselves in section suggest 
 endothelium rather than epithelium. The nuclei were large and 
 rich in chromatin, and mitotic ftgiires were frequent, the diaster 
 form being most common. The growth appeared to arise in the 
 cutis and to be unconnected with the epidermis or rete; it did 
 not appear to proceed from the sebaceous glands, or from the 
 sweat glands when it was seen in the earliest stages in the 
 very small nodules, but the lymphatics seem to be the structures 
 earliest involved After amputation of the arm some portions 
 of skin and gland tissue from the axilla were examined. Sec- 
 tions made through the skin showed to the naked eye a diffuse 
 thickening. Under the microscope the epidermis is not thicker 
 than normal and the fibrous tissue in the cutis is not increased, 
 but a very considerable overgrowth of the several glands exists, 
 together with a much less marked overgrowth of the sebaceous 
 glands. This overgrowth, though extensive and ill defined at 
 the borders, has more the appearance of adenoma than cancer 
 and contrasts sharply with the tumor mass lying immediately 
 beneath it. These tumor masses have precisely the same ap- 
 pearance as those first examined, and consist of large closely-set 
 cells, flattened or of irregular spindle shape, and extremely rich 
 in chromatin. A few dilated thin walled vessels are seen and 
 also some minute hemorrhages. In the deeper parts of the sub- 
 cutaneous tissue a number of enlarged lymph glands are seen, 
 which show areas of spindle cell infiltration. 
 
 From a secondary operation performed in June, 1891, por- 
 tions of infiltrated tissue were obtained which show the cutis 
 and sub-cutis to be infiltrated by cells similar in appearance and 
 arrangement to those seen in previous examinations. The 
 spindle cell infiltration has involved the scar of the amputation 
 wound. The tumor above described is certainly a rare one and 
 presents many features of interest. From an anatomical point 
 of view the most interesting fact is the co-existence of tubular 
 adenoma in the sweat glands, distinct from the sarcoma. The 
 
6 OlMOINAL CoMMlfNICATIOX. 
 
 structure of tlu; luinor itself is also !inoiiiiilou8, at 8ome spots 
 resembling car(!inoiiiaiu the iiiitine and arrangement uf its cells. 
 
 The early involvement of the lymphatics in this case made it 
 one of unusual interest. Though the future prospects in the case 
 are not bright, still the man by the amputation has gained at 
 least a year if not more of comparative comfort. In his Archives 
 of Surgery^ Vol. II, p. 12;?, Mr. J. Hutchinson relates a case of 
 a sarcomatous eruption imitating syphilis in which there was 
 very general involvement of the lymphatic glands. In this case 
 the nodules showed no tendency to ulcerate. Melanotic sarcoma, 
 it is well known, has a tendency to spread by the lymphatics. 
 
 P. 8. — Oct. 24, 1891. — Since reading the above paper I have 
 heard from the patient, who s ys that an ulcerating growth, 
 has appeared on the riglit cheek and is growing rapidly. 
 
 i