Definition And Description

Sarcoma of the skin is a disease characterized by the development of one or more softish tumors of a malignant character. The tumors may be pigmented or non-pigmented. The literature of the subject is exceedingly scanty, due either to the intrinsic rarity of the affection, as asserted by Kobner (111, '69, 369), or to the fact that cases have not been diagnosticated and recorded as such. Personally, I have met with two cases of multiple pigmented sarcoma, both of which terminated fatally, and have examined, microscopically, specimens from a third fatal case of the same, which I had not an opportunity of seeing during life; one case of solitary pigment-sarcoma (referred to on page 229) and three cases of solitary non-pigmented examples of the disease, two of which, examined after excision, proved to be of the small round-celled variety of the 'histologists. The location first occupied by this growth varies in different cases. Of the four eases of multiple sarcomata, in one the first lesion appeared on the foot,* in another on the face, and in the other two the history is defective on this point. The solitary pigment sarcoma was on the left forearm, and of the solitary non-pigmented sarcomata, two were at the nape of the neck, and one on the left temporal region.

In all these cases the tumors were softish, in this respect presenting a striking contrast to carcinomatous growths, and in the solitary forms were characterized by a decided tendency to hemorrhage on the slightest provocation. "If you look at it, it will bleed," as one patient remarked.

The growths increase in size with varying rapidity, and, after a time, ulcerate - spontaneous hemorrhages (in the solitary forms at least) be-ing of frequent occurrence.+ In the multiple pigmented form, the disease may extend to internal organs, and has always, so far as I am aware, terminated fatally.

A single pigmented tumor, however, may exist for along time - years, perhaps, before the disease becomes generalized. The age at which the disease occurs varies from childhood to advanced life.

Diagnosis

The consistence of the growth and its tendency to hemorrhage suffice to distinguish it from epithelioma, the only affection with which it is likely to be confounded, and which it resembles only in the single feature of malignancy and liability to return after removal.

Prognosis

The prognosis is always grave, both in consequence of the tendency to relapse in situ, and to secondary developments elsewhere, not only on the skin, but in the deeper organs.

* Kaposi states (97, 2: 478) that they always occur first in this region, which is on a par with his many other dogmatic statements (see p. 170 of this book). Wigglesworth reports (110, '76, 98) a case in which the first lesions were on the abdomen.

+ In the cases that I examined microscopically, the growth consisted mainly of small cells and large blood-vessels.

Etiology

The causes that give rise to Sarcoma are unknown.

Treatment

In multiple Sarcomata treatment is of little avail, excision of all the tumors being probably impracticable. Attention to the general health, etc., may tend to delay the fatal issue. In cases of solitary sarcoma, free excision should be practised as early as possible. Before operating, preparation should be made for the control of hemorrhage which may be excessive. In the solitary pigment-sarcoma of the forearm, already referred to, a wide margin of surrounding skin was removed and the hem-orrhage was not great. In a small, cherry-sized Sarcoma at the back of the neck of a child the hemorrhage promised to be free, but the growth was rapidly removed, and the actual cautery instantly applied and kept in contact for about fifteen seconds. In a solitary Sarcoma at the nape of the neck of a young man, the oval wound, after excision, measured about three-fourths of an inch in its long diameter, and required nine ligatures and firm pressure to control the bleeding. In the Sarcoma of the temporal region the tumor measured 75 mm. (three inches) in both its horizontal and vertical diameters, and its circumference was 170 mm. (nearly seven inches), the tumor being of irregular shape and more pointed below than above. In the operation I was assisted by my friend Dr. Fox and others. In this case the hemorrhage was frightful, but finally controlled by ligature, the actual cautery, chloride of zinc and pressure. I mention these particulars to warn the physician not to meddle with sarcomata of any size, unless due preparation has been made against hemorrhage. On the first of these cases I operated at my office, on the second at my clinic at the University, on the third at the Charity Hospital, and on the fourth at the clinic. Besides these strictly skin-sarcomata, I have encountered two quite large tumors, one on the left thigh, and fifteen inches in circumference, pronounced by a microscopist to be osteo-sarcoma, and one on the right breast, twenty-one inches around, pronounced a myxosarcoma. These cases were in the surgical wards at Bellevue Hospital, and under the care of Prof. Stephen Smith, at whose request I removed them with the galvano-cautery loop, with the loss of but very little blood, although both tumors were highly vascular. The galvano-cautery then affords us a means of removing these tumors, where their form or position will permit, without risk of much hemorrhage. With reference to these two cases it may be stated that the operations were not undertaken with the expectation of permanent benefit, as that was believed to be out of question by any procedure whatever, but, simply with the view of affording temporary relief.