[Extracted from The Medical News, September 20, 1884.] 
A CASE OF SARCOMA OF THE SKIN AND 
CELLULAR TISSUE ABOUT THE ANKLE, 
WITH REMARKS.1 
By FRANCIS J. SHEPHERD, M.D., C.M., 
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 
1 Read before the Montreal Medico-Chirurgical Society, June 
27, 1884. 2 
was dislocated, but after six weeks' rest the pain dis- 
appeared, and he could walk as well as ever ; the 
swelling about the joint due to the injury, however, 
never entirely disappeared. A year subsequent to 
the above-described accident the ankle again became 
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 only 
escaping from the incision ; this incision has never 
entirely healed, but ever since has remained open as 
a sinus, discharging a thin sanious pus. Three years 
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 appa- 
rently never been affected, and its movements have 
always been free and comparatively painless, but the 
swelling on the inner side has been slowly increasing 
in size, and at different points sinuses, which dis- 
charge a thin pus, have formed. 
When I first saw him, the parts about the inner side of 
the left ankle-joint were of a shiny, dusky-red color, 
and considerably swollen. The swelling extended 
from a point several inches above the tip of the in- 
ternal malleolus to below the tarsal joint, it also ex- 
tended laterally to the sole of the foot, half way across 
the instep, here the skin over the swelling was quite, 
normal. There was also fulness over the tendo 
Achillis and the parts behind the internal malleolus. 
Near the edge of the swelling were several reddish 3 
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 pain in 
the part, and patient only complained when his foot 
was bandied 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 4 
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 of 
round-cell sarcoma. 
On consultation with my colleagues, amputation of 
the leg was decided on. The lad and his friends, on 
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 groin 
were much enlarged, one, below Poupart's ligament, 
had increased to the size of a pigeon's egg. I looked 
upon this condition of the glands as purely inflam- 
matory, knowing the rarity with which sarcomatous 
tumors secondarily affect the glands, and also know- 
ing that they had been enlarged ever since the first 
accident. In the interval between the making of 
the exploratory incision and the amputation, the 
swelling had slowly increased in size and extent, and 
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 do 
in amputations, with iodoform and pads of sublimated 
jute. In this case I made use of decalcified bone 
drains, which, owing to their collapse, had to be re- 
placed on the second day by rubber tubes. From 
this time the case progressed favorably, the tempera- 5 
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 i> 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 suspect a new growth was 
the existence of apparent fluctuation with the presence 6 
of numerous sinuses, the freedom from pain on move- 
ment of the joint and the absence of any carious or 
necrosed bone. 
The long duration of the tumor, and the fact that 
it can be directly traced to traumatism as its cause, 
add further interest to the case. Cases have lately 
been reported by Mr. Barwell and others in which 
injury was followed by an acute and rapidly growing 
sarcoma; this is comparatively rare, but slowly grow- 
ing sarcomata not infrequently follow injuries, a fact 
which was pointed out by Billroth many year ago. 
It is of rare occurrence that the skin of the parts 
about the foot is affected with sarcoma; the more 
common forms of sarcoma of the lower extremity 
being connected with bone itself or the parts in con- 
nection with bone. When the skin is the seat of a 
sarcomatous tumor it is of the spindle-cell variety, as 
a rule, round-cell sarcoma being very rarely seen in 
connection with the skin. 
Prof. Markoe, in The Medical News of April 26, 
1884, reported a series of cases of what he calls 
"Sarcoma of the Sheaths of Tendons about the 
Foot." His cases closely resemble that which I have 
just narrated to this Society. The skin, however, 
was not involved in Dr. Markoe's cases, the disease 
being confined to the parts immediately beneath. It 
seems to me that Dr. Markoe's description of his 
cases hardly bears out the idea put forth by him that 7 
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.