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 Fig. 77 Fig. 78

Osteoma of frontal sinus. (Neisser.) Recurring sarcoma of parotid. (Original.)

A. Round-cell Sarcoma.—This is simple in construction, and consists

of round cells containing very little intercellular substance. The nuclei
of the tumor cells stain easily, the cells themselves varying in size in
different cases. Bloodvessels lead up to the tumor, but in the interior
appear rather as channels. These tumors have no lymphatics: they
grow rapidly, infiltrate easily, recur quickly, and give rise to numerous
metastatic or secondary deposits. They may affect any part of the
human body. The size of the cells is supposed to be in some
measure an index of their malignancy—the smaller the cell the more
malignant the tumor. They appear at all periods of life. They are
perhaps the most commonly seen of malignant tumors in animals.
(See Plate XVII.)
Lymphosarcoma.
—This tumor is composed of cells similar to the previous form, but
enclosed in a delicate meshwork resembling that of lymph nodes,
hence the term lymphosarcoma. Lymphosarcomas are not to be
confounded with enlargements nor with the specific granulomas
involving these lymphatic structures.
B. Spindle-cell Sarcoma.—In this form the cells have a spindle shape
and run in all directions, so that sections will show them in various
shapes and sizes. In some cases the cells are small and slender, in
others large. The size of the cell is a measure of the malignancy of
the tumor. (See Plate XVII.)
The largest of these spindle cells are frequently striated
transversely like voluntary muscle fiber, and tumors composed of this
form have been considered as tumors of striped muscle tissue, and
are generally called rhabdomyoma. There is no tumor of striped
muscle fiber, and the rhabdomyomas of writers generally should be
considered as spindle-cell sarcoma, or may be dignified by the name
myosarcoma. (See Rhabdomyoma, under Myoma.)
Alveolar Sarcoma.—This is a rare form, in which the cells, contrary
to the general rule of sarcomas, assume an alveolar arrangement
strongly imitating that of epithelial cells in carcinoma. Almost
invariably, however, on close examination it will be possible to
distinguish a delicate reticulum between individual cells, which is
never met with in cancer.
C. Myeloid, or Giant-cell Sarcoma.—In this form the tissue resembles
histologically the red marrow of young and growing bone, containing
large numbers of multinuclear cells embedded in a matrix of spindle
or round cells. These tumors usually occur in the long bones, and
when freshly cut look like a piece of liver. They constitute most of the
epulides or cases of epulis—i. e., spongy tumors springing from the
gums. (See Plate XVIII., Fig. 2.)
 Fig. 79

Sarcoma of femur following fracture—i. e., developing in callus. (Original.)

Giant or multinuclear cells should be present in considerable

numbers to entitle a tumor to classification in this group. When round
cells, spindle cells, or giant cells mingle in nearly equal proportion
the tumor should be called a mixed-cell sarcoma.
D. Osteosarcoma.—Osteosarcoma is something more than sarcoma
of bone, which latter may spring from the fibrous or medullary
elements. It is sarcoma of the specific bone-forming connective
tissue, including the osteoblasts and osteoclasts; in other words, of
the stroma of the bone. Under these circumstances real bone
develops throughout the tumor, and it is essentially a bony
neoplasm. In like manner there may be true osteofibroma. These
tumors are to be distinguished, even clinically, from the medullary
sarcomas, which develop within the bone and expand it, even to
enormous proportions, the bony covering then being a mere shell.
 E. Chondrosarcoma.—Chondrosarcoma resembles osteosarcoma in
that it is sarcoma of the stroma of cartilage, or of the specific tissue
which produces cartilage. In it true cartilage (white fibrous) also is
found throughout the tumor. Chondrofibroma is also possible. (See
Plate XIX.)
F. Endothelioma.—Endothelioma has been called various names,
and its true character has been only lately determined. It is
composed particularly of the endothelial cells which line the lymph
spaces, and which have no peculiar secretion. It is met with most
often in the skin (especially of the face), in the parotid region, in the
genital glands, the bones, the lymph nodes, and dura.
 PLATE XVIII
FIG. 1

Angiosarcoma. (Low power.)

FIG. 2
Giant-cell Sarcoma. (High power.)
 PLATE XIX
FIG. 1

Chondrosarcoma. (Low power.)

FIG. 2
Osteosarcoma. (Low power.)
 PLATE XX

Melanosarcoma of Skin. (Dry high power.)

The microscopic picture of these tumors varies greatly, the

endothelial cells often shaping and grouping themselves so as to
imitate epithelioma. In doubtful cases the primary location or origin of
the growth should be ascertained.
Endotheliomas are mainly of rapid growth, and often show a high
degree of malignancy. If thoroughly extirpated before metastasis has
occurred, prognosis is fair; but metastases happen early because of
the direct connection of the tumor with the lymph current.
Fig. 80
 Endothelioma of the soft palate: a, dilated lymph space; b, endothelial
cells with beginning cystic formation; c, completely formed cyst.
(Volkmann.)

G. Angiosarcoma.—Angiosarcoma is a sarcoma arising from the

adventitia of the bloodvessels. It is characterized by its extraordinary
vascularity, the ease with which hemorrhages into the structure of
the tumor take place, and the frequency of pigmentation.
Peritheliomas constitute a subvariety, met with especially in the
kidneys, the bones, and the skin, and originate in the perithelial cells
between the capillaries and the perivascular lymph spaces. They are
more vascular than the angiosarcomas. The latter are common in
the liver. In many cases the cells of these tumors simulate the
columnar epithelium of adenocarcinoma. (See Plate XVIII, Fig. 1.)
H. Cylindroma.—This is a term applied to tumors of the
angiosarcomatous type in which hyaline changes have occurred, so
that along the vessels appear cylindrical masses of altered cells.
Similar appearances are noted in certain endotheliomas and are due
to the same hyaline degeneration.
I. Melanosarcoma (better known as Melanoma).—This refers to the
deposition of pigment, rather than to type or shape of cell, the
distinguishing feature of these growths being the presence both in
the cells and in the intercellular substance of a variable quantity of
blackish pigment. Of all the forms the melanotic growths are
considered the most malignant. They invariably recur after removal,
lead to secondary deposits at long distances, and present the most
intractable and incurable forms of cancer. Deposition of pigment in
carcinomas is most rare, if ever met with, and the growths of
melanotic type should be relegated entirely to the class under
consideration. The tumors most often develop from pigmented nevi
of the skin, though primary melanoma of the deeper parts of the
body is known. These will be treated more fully in the chapter on the
Skin. (See Plate XX.)
This name has been variously applied by different writers to
different growths. In order to avoid confusion it would be well, in
using it, to be definite.
General Characteristics of Sarcomas and Endotheliomas.—The vascular
supply of sarcomas varies within wide limits. In nearly all instances it
is of capillary character, the blood circulating rather through vessels
without well-marked walls. While large vessels may be found about
and in the periphery of these tumors, distinct vascular structure is
usually absent from the more internal portions, which will explain the
frequency of hemorrhage, its persistency after operation, and the
ease with which large extravasations occur. True hematocele may
thus take place within sarcomatous tumors, with the usual later
cystic alterations, and thus in one way we have the condition known
as cystosarcoma.
In attacking these growths the vascular and bloody area may be
met just about their margins, the bloodvessels expanding as they
arrive at the tumor, and sometimes bleeding extensively. Under most
circumstances, however, this hemorrhage can be controlled by
packing or by operating at a greater distance from the circumference
of the growth.
Metastasis in sarcoma is common, dissemination occurring mainly
along the veins, as these growths connect with the venous channels
and permit of easy detachment of fragments, which are then carried
along as emboli. These emboli pass naturally to the right side of the
heart, and thence to the lungs, where it is most common to find
secondary growths, except in areas emptying into the portal veins, in
which case the liver will be the most common site. Sarcomas are
destitute of lymphatics, and dissemination does not occur through
these channels.
Infiltration is also a common phenomenon with these growths. This
is generally seen in muscular tissue, particularly with growths
proceeding from the periosteum and projecting into it.
Sarcomas, like other tumors, tend to grow along the lines of least
resistance. Hence processes of these tumors will insinuate
themselves into fissures and interspaces, and penetrate perhaps
even into the cavities, from which it is hazardous or impossible to
remove them. Thus, sarcomas springing from the head of a rib have
been known to extend through an intervertebral foramen and give
rise to an intraspinal tumor, causing fatal pressure.
 Secondary changes are usually seen in sarcomas, the most
frequent being hemorrhage. Myxomatous degeneration is also
frequent, and gives rise to cystic conditions. Calcification is common,
particularly in the slowly growing tumors which arise from bone.
Upon the other hand, necrosis (i. e., ulceration) is common in
growths which project upon the surface or into any of the open
cavities of the body. Ulceration here is growth at a rate faster than
nutrition will justify, and gangrene is to be regarded as a failure to
supply sufficient blood. It may also mean infection, of which it is a
usual expression.
Tumors of this character, which luxuriate upon reaching the
surface, and bleed easily upon the slightest touch, were formerly
known as fungus hematodes. The name may be preserved for the
sake of convenience, but should be held to mean, in almost every
instance, a rapidly growing round-cell sarcoma.
Sarcoma is common in the lower animals, particularly so in horses
—most common in those of gray color. It is met with also in cows
and various other domestic and undomesticated animals.
Myxoma.—The myxomas are composed of mucous tissue, whose
best-known normal representative is the Whartonian jelly
of the umbilical cord. True myxoma should be distinguished from
myxomatous degeneration, which occurs frequently in cartilage,
fibrous tissue, and sarcoma, and which brings about a similar
condition of affairs, though of essentially different origin. Myxomas
appear under the following forms:
1. Polypi.—These include many of those which grow in the nose.
The pure form of nasal myoma proceeds from the mucous
membrane of the nasal passages or sometimes from the accessory
sinuses. But most of the so-called nasal polypi are due to edematous
hypertrophies of the submucosa. The polypi usually hang as
gelatinous tumors of grayish-yellow tint, being present sometimes
singly, sometimes in clusters or in large numbers. Their principal
effect is to produce nasal obstruction, with, perhaps, subsequent
serious disorder, due to decomposition or to extension into the
pharynx or other cavities. Similar growths also occur from the
mucous membrane of the tympanum, and constitute the common
variety of aural polypi.
 2. Cutaneous Myxoma.—Cutaneous myoma is not common. It
presents usually as a sessile tumor, although about the perineum
and labia the tumors may become pedunculated. It is often difficult to
distinguish between a myoma of the skin and a sarcoma of the same
which has undergone myxomatous degeneration, and which then
should be called sarcoma myxomatodes. The latter tend to recur
after removal; hence the importance of exact diagnosis.
3. Neuromyxoma. Neuromyxoma is a similar condition involving the
nerve trunks, and is dealt with under Neuroma.
Myxomas require complete removal, and, in the nose especially,
cauterization or destruction of the surface from which they spring.
When this is thoroughly done they do not recur; otherwise, they are
likely to require subsequent operation.
Myoma.—The true myoma is a tumor composed of unstriped or
involuntary muscle fiber. Until recently it has been
customary to divide the myomas into the leiomyomas in
contradistinction to the rhabdomyomas, the latter being supposed to
be tumors of voluntary muscle fiber. Myomas are met with only
where involuntary muscle fiber is found—namely, in the uterus and
adnexa, the vagina, the esophagus, alimentary canal, the prostate,
the bladder, and the skin. They form encapsulated tumors composed
of fusiform muscle cells with a rod-like nucleus, the size of the cells
varying greatly in different specimens. The bundles of muscle fibers
are much contorted, and it is often difficult in a single section to
decide to just what class of cells they belong.
These tumors are most common in and about the uterus, and are
referred to as intramural when developing in the true uterine tissue,
and submucous and subserous when situated just beneath one or
the other of the adjoining membranes. They differ in their rate of
growth, are firm in composition, and are moderately vascular,
sometimes containing areas of softening and becoming even cystic.
In rare instances they become enormously vascular, and are then
known as cavernous myomas. Aside from mucoid or colloid changes
they occasionally undergo fatty metamorphosis or calcareous
infiltration. The latter is possible to such an extent as to lead to a
condition of uterine calculi.
 Uterine myoma is liable to septic infection, which frequently follows
exploration of the uterus or the changes incident to pregnancy or
parturition. It then becomes a case for immediate operation. Uterine
myomas do not occur before puberty, rarely before the age of thirty-
five, and are most common between the thirty-fifth and forty-fifth
years of life. They produce disaster not alone by their size, but by
hemorrhage, by pressure on adjoining viscera (rectum, kidneys,
etc.), and occasionally by torsion of a long pedicle.
Myomas are found in the esophagus, in the walls of the stomach,
where they are frequently confounded with malignant tumors, in the
prostate and wall of the bladder, and in connection with the skin. As
soon as they give rise to inconvenience or to dangerous symptoms
they are to be dealt with surgically, as no other treatment has proved
of lasting benefit.
The rhabdomyomas deserve but brief description. The striated
muscle fibers of which these tumors are composed have been often
confused with spindle-shaped sarcoma cells. They are met with
almost exclusively in the mixed tumors of the kidney under
Teratomas.
Myoma or myofibroma is exceedingly likely to undergo sudden
conversion into a form of growth entitling it to be called malignant
myoma.
Angioma.—Angiomas are tumors composed of bloodvessels, and
group themselves under three headings, in accordance
with the structure of the vascular system:
1. Capillary Angioma, or Nevus.—Capillary angioma, or nevus, is the
most common form of all, and is frequently seen in the skin and
subcutaneous tissue. When the condition is spread over a relatively
large area it gives rise to a discoloration known as port-wine mark,
and called telangiectasis by the pathologists. The condition is often
congenital or begins soon after birth. The color of the affected area
determines whether the vessels belong to the venous or to the
arterial system. These tumors may be found in all parts of the body,
on the surface, on the submucous surfaces of the tongue, the inside
of the mouth, the conjunctiva, and the vulva. The tendency is toward
gradual increase in size; rarely, spontaneous contraction and
obliteration occur.
 2. Cavernous Tumors.—These are similar in structure to the corpus
cavernosum, and are called erectile tumors. They are common in
connection with the skin, and are exaggerated forms of the variety
first described, the vessels becoming not merely dilated but
cavernous in arrangement. They occur occasionally in the tongue, in
the voluntary muscles, and in the liver, and are noted very rarely in
the mammæ, in the larynx, and subperitoneally.
A similar condition is met with in the so-called cavernous tumors
which involve various organs, especially the thyroid and the liver. In
these instances a part or the whole of the organ may be involved,
and presents great increase in size and evidences of vascularity.
In cavernous growths of the thyroid are vessels, veins especially,
the size of the thumb, while with the ear not touching the body of the
patient a distinct venous murmur may be heard.
3. Arterial or Plexiform Angiomas.—Arterial or plexiform angiomas,
when of any particular size, are called cirsoid aneurysm or aneurysm
by anastomosis. This form consists of arteries abnormal both in
number, length, and diameter, tortuous in arrangement, occurring
often in the scalp, but rarely in the perineum or genitalia, and seldom
in other parts of the body. (See Aneurysm, Chapter XXIX.) These
tumors are liable to rupture from external injury, and necessitate
ligation of the main arterial trunks, with perhaps extirpation of the
tumor mass.
Recognition of angiomas is not difficult unless they are deeply
concealed. The effect of intermitting pressure, the emptying and
refilling, and the distinction between arterial and venous growths by
the result of alternating pressure and relaxation, either above or
below the growth, with discoloration of the skin, and, in the larger
growths, audible murmur, leave little doubt of the character of the
growth.
When such growths are small they may be dealt with by
electrolysis, the needles from both poles being introduced, or that
from the negative, the positive being applied upon some neighboring
portion of the body. The effect of the electric current is to determine
coagulation of the blood in the tissues acted upon, and this is
followed by organization of thrombus, conversion of vascular into
cicatricial tissue, shrinkage, and possible eventual disappearance of
the mass. Radical excision under an anesthetic should be made,
dissecting out the mass, securing bleeding vessels, and reuniting the
parts by sutures, with the expectation of securing primary union. This
is the quickest and in many cases the least disfiguring method. Old
methods of ligation of surrounding vessels or the subcutaneous
ligature are now practically discarded. The injection methods as
formerly practised, especially the use of iron salts in solution, are
severely condemned, as death is liable to occur. With electrolysis
and excision the surgeon has nearly all the measures which he will
need to practise for the medical treatment of angiomas.
 Fig. 81

Lymphangioma of lip; macrocheilia. (Neisser.)

 Lymphangioma.—Lymphangiomas are tumors composed of
lymph vessels and bear resemblance to the
tumors above considered. They may be divided into three varieties:
1. The Lymphatic Nevus.—The lymphatic nevus is composed mostly
of lymphatics nearly normal in size, and occasionally colored red by
the presence of bloodvessels. When pricked, pure lymph or blood-
stained lymph, will flow. They are usually small, and are noticed
during childhood. They may occur anywhere upon the surface of the
body or in the mouth, generally in connection with the tongue, where
they may appear as large papillæ involving a portion or all of the
dorsum. When the lymphatic structures of the tongue are thus
enlarged and involved the condition is known as macroglossia, and
consists of enlargement of the organ, sometimes to a degree not
permitting its retention in the mouth, but leading to its constant
protrusion (Fig. 81).
2. Cavernous Lymphangioma.—Cavernous lymphangioma
corresponds to cavernous angioma, and is a condition in which the
lymph vessels become positively cavernous and sacculated.
3. Lymph Cysts.—Lymph cysts are the still more aggravated form
which lymphatic dilatation may attain, and are usually encapsulated,
complicated with more or less tense tissue, and produce a condition
of the parts, especially about the scrotum and labia, to which the
term elephantiasis is often applied (Fig. 83).
The question of congenital occlusion or dilatation of lymph
channels is one which has been made the subject of large separate
monographs (especially by Busey). Numerous tumors, essentially of
lymph-vascular origin, are found upon the lips, in the neck, and
elsewhere, which grow slowly, are more or less elastic and spongy
upon pressure, are frequently covered with skin, from which hair
grows most luxuriantly, and in which pigment or papillomatous
structures are dispersed. These tumors are called cavernous tumors,
are of slow growth, and undergo spontaneous involution, but usually
require surgical relief. They are often confounded with branchiogenic
and other congenital cysts of the neck.
Treatment.—The treatment for the smaller lymphatic tumors is
simple, but here electricity is less to be relied upon and excision is
more urgently demanded. Electrolysis will cause coagulation of