A Primary Polymorphous-Cell 
Sarcoma of the Nose, 
With Universal Metastasis and Forma- 
tion of a Free Sarcomatous Mass in 
the Right Ventricular Cavity. 
BY 
ALDRED SCOTT WARTHIN, M.D., Ph. D., 
Instructor in Pathology, University of Michigan, 
Ann Arbor, Mich. 
"Meto "STorfe ftSeMcal journal 
REPRINTED PROM THE 
for June 1899. Reprinted from the New TorTc Medical Journal 
for June 2J 1899. 
A PRIMARY POLYMORPHOUS-CELL SARCOMA 
OF THE NOSE, 
WITH UNIVERSAL METASTASIS 
AND FORMATION OP A FREE SARCOMATOUS MASS 
IN THE RIGHT VENTRICULAR CAVITY. 
By ALDRED SOOTT WARTHIF, M. D., Ph. D., 
INSTRUCTOR IN PATHOLOGY, UNIVERSITY OF MICHIGAN, ANN ARBOR, MICH. 
The reports of sarcoma of the nasal passages have 
multiplied to so great an extent during the last several 
years that the condition can no longer be looked upon 
as one of very rare occurrence. Bosworth, in 1889, had 
collected from the literature previous to that year re- 
ports of forty-one cases. In 1896 twenty-one eases were 
added to this list hy Boylan, and I have been able to 
find in the literature since the latter’s paper reports of 
twenty-seven additional cases. It is evident from this 
rapid increase of reported cases that sarcoma of the 
nose must occur with some degree of frequency. 
The sarcomatous tumors described as being found in 
the nose present a wide variety in kind. Small and 
large round-cell, spindle-cell, lymphosarcoma, fibrosar- 
coma, myxosarcoma, osteosarcoma, osteoid sarcoma, an- 
geiosarcoma, myxosarcoma, alveolar sarcoma, and mela- 
COPYRIGHT, 1899, BY D. APPLETON AND COMPANY.  POLYMORPHOUS-CELL SARCOMA OF THE NOSE. 
2 
notic sarcoma have been reported as occurring in this 
region. The site of the tumor presents also a wide 
range. The turbinated and nasal bones, the periosteum 
of these bones, the nasal cartilages, the sseptum, the 
muscles of the nose, the blood-vessels and connective 
tissue of the mucosa of the nose and nasopharynx have 
all given rise to sarcomata. In a number of cases an 
attempt has been made to prove their origin from non- 
malignant polypi. The evidence upon this point, how- 
ever, is very slight, and there is no proof of any close 
relation between a benign polyp and sarcoma. From the 
cases reported they would seem to be of independent 
origin. The nasal sarcoma, because of its location and 
the conditions of its growth, often presents a polypoid 
form, and in those cases in which a myxoma was 
thought to have become sarcomatous it is more probable 
that the so-called polyp was malignant from the begin- 
ning. The possibility of the development of a sarcoma 
in a benign polyp need not be denied, but in those cases 
where this change was thought to have taken place the 
microscopic evidence is either entirely wanting or in- 
sufficient. 
The opinion is quite generally held in the older lit- 
erature that sarcoma of the nasal passages is not so ma- 
lignant as sarcoma occurring in other regions of the 
body. Bosworth concludes from the result of his study 
of forty-two cases that “ sarcoma of the nose does not 
apparently present the same malignant tendencies as it 
does when found in other locations.” Warren, in his 
Surgical Pathology, says: “ The disease does not appear 
to show the same malignant tendencies in the nasal 
passages that it does in other localities.” And Boylan, 
from the study of his twenty-one cases, is inclined to POLYMORPHOUS-CELL SARCOMA OF THE NOSE. 
3 
favor this opinion, since rapid recurrence took place 
after operation in the minority of cases, and in others 
there was a prolonged or permanent cure. From these 
points he concludes that the prognosis in nasal sarcoma 
is relatively favorable. 
A study of the literature since Boylan’s paper, how- 
ever, leads to the conclusion that there is no justifica- 
tion for the assumption that sarcoma of the nasal pas- 
sages is less malignant than in other regions. It is less 
malignant only in so far as it is in a situation where 
it may possibly be thoroughly removed. While many of 
the nasal sarcomata described have been of slow growth 
and slow recurrence, this is also true of sarcomata in 
other parts of the body. The slow growth of a sarcoma 
or carcinoma should never deceive us as to its possibili- 
ties of malignancy or lead us to delay in operative meas- 
ures. Slow-growing sarcomata of the nose have some- 
times taken on an extraordinarily rapid growth just as 
in other parts of the body. The possibility of a favor- 
able prognosis in nasal sarcomata is based, therefore, 
purely upon the operative conditions, and not upon the 
character of the tumor. 
The case which I present in this report is of value, 
first, in that it adds a new variety to the list of sarcom- 
ata found in this region; secondly, because of its great 
malignancy; thirdly, because of the great extent and in- 
teresting character of the metastases and the occurrence 
of a free sarcomatous mass in the right ventricular cav- 
ity. The history of the case is as follows: 
Mr. P. E., aged thirty-nine years, was admitted to 
the University Hospital on the Ist of April, 1897. He 
was a lumberman, single, and gave a negative family 
history. Previous to the beginning of the present con- 4 
POLYMORPHOUS-CELL SARCOMA OF THE NOSE. 
dition his health had been good. A year and a half be- 
fore admission his right nostril became partially oc- 
cluded. By blowing his nose with some violence he could 
force out large “ scabby, flaky masses/’ This condition 
lasted for a year, when a vesicular eruption becoming 
pustular gradually spread over the right side of the 
nose, extending to the left. Three months before admis- 
sion he had had a number of “ polypoids ” removed from 
his right nostril. The patient did not know whether a 
microscopical examination of these had been made, but 
was told that they were ordinary nasal polypi. From the 
treatment of the ease it is evident that the operator had 
regarded them as benign growths, as when the patient 
entered the hospital no suspicion had been raised as to 
the malignant nature of his disease. 
He had been under treatment with a number of 
physicians who had diagnosticated his condition as ec- 
zema, syphilis, and lupus. He had no history of acquired 
syphilis, and under specific treatment his condition had 
grown steadily worse. 
A month before admission he had noticed numbness 
over the left side of the nose, left cheek, upper lip, and 
forehead to the median line. Diplopia, left-sided ptosis, 
and dilatation of the left pupil soon followed. 
On admission the general condition of the patient 
appeared fair. He complained of weakness, nervous- 
ness, insomnia, and of dull pain in his forehead. His 
appetite was poor, and bowels were constipated. He 
passed about one litre of urine daily, very highly colored, 
and with specific gravity of 1.024. His nostrils were 
completely occluded, his breathing being entirely by the 
mouth and very shallow in character. His nose was sym- 
metrically enlarged; the skin covered with yellowish, 
opaque crusts, with scattered pustules. Around this and 
extending slightly into the skin of each cheek there was 
redness with firm induration. The nostrils were filled 
with grayish-red masses. There was no odor. 
The sense of smell was entirely lost. There was com- 
plete anaesthesia over the distribution of the supraorbital POLYMORPHOUS-CELL SARCOMA OF THE NOSE. 
5 
and infraorbital branches of the fifth nerve. There was 
some atrophy of the muscles in this area. Ptosis of the 
left lid was present, wfith complete paralysis of the mus- 
cles of the left eyeball. Sight was diminished in the left 
eye. The retinal examination showed a marked degree of 
choked disk. The patient’s mind was clear. 
A clinical diagnosis was made of malignant tumor of 
the nose with secondaries at the base of the brain, involv- 
ing the first, second, third, fourth, the first and second 
branches of the fifth motor fibres of the fifth and the 
sixth cranial nerves. The condition of the patient grad- 
ually became worse. No operation was attempted. 
On the 11th of May he had attacks of nausea and vomit- 
ing, followed by great disturbance of respiration and cir- 
culation. The extremities became oedematous, the pa- 
tient sank into coma and died on the 17th of May. The 
necropsy was performed by me in the university labora- 
tory of pathology four hours after the patient’s death. 
The gross findings were as follows; 
Section-protocol.—Body of medium height and slen- 
der build. The musculature good, slightly flabby. Fair 
amount of panniculus. No oedema. Skin sallow, nutri- 
tion fair. Marked hypostasis, amounting to cyanosis 
over the upper part of thorax, head, and back. Rigor 
mortis present in all muscles. Body heat present. 
Head: Face cyanotic. There is a subcutaneous growth 
extending over the entire nose and a short distance into 
each cheek. The skin over this is thickened, rough, scaly, 
with numerous minute vesicles. The nostrils are com- 
pletely closed by masses of soft, grayish-red tissue. The 
growth does not extend into the mouth. Over the bridge 
of the nose there is a small ulcer covered with surgical 
dressings. The nasal bones and cartilage seem complete- 
ly replaced by the growth. 
Brain: A small, soft growth, of the size of a cherry, 
is found on the inner surface of the dura near the longi- 
tudinal sinus. The pi ais congested; all of the sinuses 
are distended with fluid blood. The brain substance is 
hypercemic and oedematous. There is a large amount of  POLYMORPHOUS-CELL SARCOMA OP THE NOSE. 
clear fluid in the lateral ventricles, which are somewhat 
distended. The pineal body is replaced by a tumor nod- 
ule, of the size of a large cherry. Otherwise the brain 
seems normal. The hypophysis is replaced by a tumor 
growth. The left third nerve is surrounded by a thick 
mass of new growth which is partly colloid in appear- 
ance. The left Gasserian ganglion is greatly enlarged 
and completely surrounded by new growth. The nasal 
fossa is completely filled with a soft tumor mass, showing 
extensive mucous degeneration. This mass is directly 
continuous with tumor masses filling up the frontal 
sinus, the sphenomaxillary fossa, and with the mass in 
the nostrils. The left cavernous sinus is also filled with 
tumor tissue. All of these masses are very soft, homo- 
geneous, and show myxomatous change. The right third 
nerve and Gasserian ganglion are normal. 
The examination of mouth, larjmx, and trachea is 
negative. 
Thyreoid enlarged, and shows colloid degenera- 
tion. 
The main incision shows marked venous congestion 
everywhere. The tissues bleed freely. The muscles are 
red, moist, and soft. There is a moderate amount of ab- 
dominal fat. The position of the abdominal organs is 
normal. There is no fluid in the peritoneal cavity. 
Diaphragm extends to the fourth intercostal space 
on the right, to the fifth interspace on the left. 
No remains of the thymus are present. The medias- 
tinal tissue contains a number of enlarged lymph glands. 
Pericardium: The pericardium contains about one 
hundred cubic centimetres of cloudy fluid in which there 
are small flakes of fibrin. The surface of the pericar- 
dium is dull and clouded. There are no new growths in 
the pericardial layers. 
Heart: Of about twice the normal size, and very ir- 
regular in shape. The surface is irregularly nodular, the 
nodules appearing yellowish as seen through the epicar- 
dium. They are elevated, firm, and do not show any 
umbilication. A thick ring of new growth extends POLYMORPHOUS-CELL SARCOMA OF THE NOSE. 
around the auriculo-ventricular groove. On section the 
heart muscle is almost entirely replaced by homoge- 
neous yellowish-white areas, contrasting strongly with 
the deep red of the remaining heart muscle. These areas 
project as rounded nodules into the cavities of the heart, 
and form the nodules seen on the surface beneath the 
epicardium. 
Many of these areas are surrounded by a zone of hy- 
peraemia or haemorrhage. The centre of some of the 
nodules is soft, in others there is a colloid appearance. 
The endocardium appears unchanged, and in no place 
does it give any evidence of a breaking-through of the 
tumor. In the left ventricular cavity there is a large 
jelly clot with some fluid blood, and in the auricles and 
great vessels are large white clots. The right ventricle 
contains some fluid blood and a large firm mass, about 
the size and shape of a large English walnut. It is gray- 
ish-red in color, and has a ribbed and furrowed surface 
suggesting the appearance of brain coral. Its surface 
presents no appearance of any previous union with the 
heart wall, nor can any evidence of such connection be 
found in the endocardium of the right heart. 
Lungs: There are about five hundred cubic centime- 
tres of turbid fluid in each pleural sac. The surfaces of 
the pleurae are cloudy and are covered with numerous 
flakes of fibrin. All over the surfaces of both parietal 
and visceral pleurae are scattered numerous small 
growths, varying in size,but for the most part of the size 
of a small pea. In the parietal pleura they are arranged 
in rows corresponding to the direction of the ribs. The 
right lung shows extreme congestion and oedema. There 
is a moderate anthracosis. Throughout its substance 
there are many small growths, most abundant about the 
bronchi and under the pleura. These tumors are soft, 
white, and perfectly homogeneous. The left lung pre- 
sents a similar appearance, but shows fewer of the 
growths. There are several small deep-red areas in the 
lower lobe just under the pleura. These are triangular 
in shape, with their bases beneath the pleura. 8 
POLYMORPHOUS-CELL SARCOMA OF THE NOSE. 
Bronchial glands: These contain large masses of 
new growth. On section they are soft, white, and ho- 
mogeneous, and show a colloid appearance in their cen- 
tral portions. 
The examination of the thoracic vessels and oesoph- 
agus is negative. 
Spleen enlarged, very soft, cyanotic. On its anterior 
margin near the deepest fissure are two cavernous tu- 
mors about the size of small hickory nuts. On section the 
pulp is deep red, very soft, flows readily. The follicles 
are not visible and the stroma is unchanged. There are 
a number of depressed areas, grayish-red in color, with 
deep-red borders, and of firm consistence. 
JL 7 
Adrenals show no change. 
Kidneys: Both enlarged and cyanotic. The fat cap- 
sule is rather thick. The fibrous capsule is not adherent, 
except in areas corresponding to small white nodules in 
the capsule. On section both kidneys present practically 
the same appearances. The cortex is increased in thick- 
ness, deep bluish-red, of increased consistence. The cut 
surface bleeds very freely. The glomeruli can not be 
made out. The pelvis is filled with large tumor masses 
extending up between the pyramids into the kidney sub- 
stance, and also into the pyramids themselves. The new 
growth is very soft, white, homogeneous, and in many 
places myxomatous. The chief portion of the new 
growth seems to be in the cavity of the pelvis, which is 
greatly dilated. It is not adherent to the mucosa of the 
pelvis, as it can he easily separated from this, leaving the 
surface free and apparently unchanged. The growths 
extend out around the renal vessels into the retroperito- 
neal tissues. The retroperitoneal glands are replaced by 
large masses of new growth of the same character as de- 
scribed above. The ureters are dilated, the mucosa 
is thickened. 
Bladder: The walls are thickened, and there is a 
small area of hyperaemia with fibrinous exudate on the 
posterior wall. 
Genitals: The external genitals are apparently un- POLYMORPHOUS-CELL SARCOMA OP THE NOSE. 
9 
changed. The right testis is slightly enlarged. The 
body of the testis is replaced by tumor growth of the 
same nature as that described above. The left testis con- 
tains a growth of the size of a walnut. It is of the same 
character as that described above. The prostate is en- 
larged, but appears normal. 
Intestines: Appendix normal. The mucosa of the 
small and large intestine is injected. In the serous coat 
are several small nodules of new growth. The mesen- 
teric glands contain also tumor nodules. 
Stomach: On the floor of stomach about the middle 
of the greater curvature there is a round ulcer, of about 
the size of a dollar, with sharp clean edges, extending to 
the muscular coat. Near this are two irregular areas of 
i nfiltration of new growth in the mucosa and sub mucosa. 
They are flat and do not extend into the muscularis. On 
section they present the same appearance seen in all of 
the other tumor masses, and show a beginning central 
degeneration. In other parts of the mucosa there are 
small erosions with thickened bases and indurated edges. 
Pancreas: The head of the pancreas is replaced by a 
large tumor mass. On section this shows the same ap- 
pearance as seen elsewhere. 
Liver: The size is about normal; the left lobe is very 
long and thin. On section, the surface is dark-red and 
cyanotic, and bleeds freely. In some areas there is a 
distinct nutmeg appearance; the connective tissue is 
somewhat increased. No growths can be perceived by 
the naked eye. The examination of the gall bladder and 
biliary passages is negative. 
Lymph glands: The cervical glands on the left side 
contain large tumor masses. 
Microscopical Examination.—An abundance of ma- 
terial was taken from all parts of the body and fixed in 
alcohol, mercuric bichloride, and M tiller’s fluid. Both 
paraffin and celloidin imbedding methods were employed, 
and the sections were stained with various stains, hsema- 
toxylin and eosin and Van Gieson’s method being most 
commonly used. The microscopical examination of the 10 
POLYMORPHOUS-CELL SARCOMA OF THE NOSE. 
sections taken from the primary tnmor and from the 
metastases revealed such a variety of pictures that at first 
sight it seemed impossible that the different growths 
could be of the same origin. A careful study of these, 
however, made plain the fact that the differences in ap- 
pearance were due to differences in the age of the 
growths and to the conditions in the tissues where they 
were located. 
Primary growth; Section taken from the periphery 
of the primary tumor in the nasal fossa and from the 
infiltration of the skin and subcutaneous tissue of the 
nose present the appearance of a small round-cell sar- 
coma. The mass of the structure is composed of small 
round, deeply staining cells; there is a very scanty reticu- 
lum, with numerous large and thin-walled blood-vessels 
lying in intimate contact with the cells. The deeper 
parts of the nasal tumor give varied pictures. There the 
cells for the greater part are not of the small, round-cell 
type, but are much larger and very irregular in shape. 
Division figures are very numerous, and many of the 
cells have large and very irregularly shaped nuclei pos- 
sessing a great excess of chromatin. “ Grape-cluster ” 
nuclei are very common, and many giant cells are found. 
In these older parts of the growth there is a greater 
amount of intercellular substance than in the peripheral 
portions. The cells are separated by a clear, slightly 
refractive substance, which does not stain with eosin or 
acid fuchsine, but gives the reactions for mucin. In the 
fresh tumor the intercellular substance must have been 
fluid. As in these older parts of the growth the number 
of cells is not nearly so great as in the areas of more re- 
cent development, it is probable that the intercellular 
substance has arisen from the degeneration or solution 
of part of the cells. Support is given to this view by the 
fact that the central part of all the larger masses is filled 
with a similar mucoid substance, the cells having entire- 
ly disappeared. In the fresh tumor these areas present- 
ed a colloid appearance, sometimes firm in consistence, 
at other times more watery. The posterior part of the POLYMORPHOUS-CELL SARCOMA OP THE NOSE. 
nasal fossa was completely filled with this jellylike mu- 
cin. In many places these eystlike spaces are surround- 
ed by a capsule of granulation tissue. It would seem 
that the tumor in its growth had reached a certain 
height in these areas, the cells had completely degener- 
ated, and there had been an attempt at encapsulation. 
No typical mucous tissue was found in any part of the 
original tumor or in any of the metastases. 
Dura: The small growth taken from the dura pre- 
sents the appearance of a small round-cell sarcoma. 
Pineal body: The growth here is polymorphous- 
celled and shows myxomatous degeneration in the cen- 
tral part. The peripheral portion has the appearance 
of a small round-cell sarcoma. 
Hypophysis: This is almost entirely replaced by a 
central tumor mass which is of the type of a polymor- 
phous-cell alveolar sarcoma. The central part shows a 
marked myxomatous change. Many giant cells are pres- 
ent here, and the irregularity in the size of the nuclei is 
very marked. In the periphery are nodules of small 
round cells. 
Gasserian ganglion: The sections of the mass taken 
from the region of the left Gasserian ganglion show a 
beautiful picture of the infiltration of large nerve trunks 
and ganglion by sarcoma cells. There are many of the 
ganglion cells preserved, surrounded by small, round 
cells, from which they stand out in sharp contrast. They 
are swollen and granular, but their nuclei and nucleoli 
can be distinctly made out, and their nucleated capsules 
appear unchanged. The nerve fibres of the large nerve 
trunks are widely separated by tumor cells and in many 
places have a knotted, swollen appearance. In the sec- 
tions stained by Yan Gieson’s method these knotted 
fibres have a greenish color. The tumor cells here, like 
those in the central portions of the primary growth, are 
very irregular in size and shape. There are many giant 
cells with large nuclei showing marked hyperchromato- 
sis. Many of the nuclei are star-shaped, others are 
ragged in outline. Caryomitotic and amitotic division 12 
POLYMORPHOUS-CELL SARCOMA OF THE NOSE. 
forms are abundant. There are many ectatic blood-ves- 
sels. The central portion of the growth shows also a 
myxomatous change. Throughout the trunk of the left 
third nerve there is an infiltration of sarcoma cells. The 
colloid mass into which the third nerve passed is a cavity 
filled with a colloidlike mucin surrounded by a capsule of 
granulation tissue. Outside of this capsule the tumor 
cells are of more uniform size and there are not so many 
giant cells. The blood-vessels are very numerous and 
large. 
Heart: The entire heart wall is infiltrated with tumor 
cells. The muscle in many areas is wholly replaced by 
nodules of polymorphous cells. The larger nodules show 
myxomatous change and in every way present an appear- 
ance similar to that of the original growth. The remain- 
ing muscle cells are greatly atrophied and are widely 
separated by small round cells. Many of the muscle 
fibres show simple and waxy necrosis. The entire endo- 
cardium is infiltrated with small round cells, and in one 
area in the right ventricular wall the tumor cells have 
broken through the endothelium and form a small flat- 
tened growth on the wall of the ventricular cavity. This 
could not be seen in the naked-eye examination. 
The sections of the free mass in the right ventricular 
cavity show it to be of sarcomatous structure. There are 
many cells larger than leucocytes and possessing large 
vacuolated nuclei. A few giant cells are found, and 
many cells with large, irregular, deeply-staining nuclei. 
The majority of the cells are of the small round varietyj 
At one side of the mass there is a collection of red blood- 
cells and fibrin. A very scanty reticulum can be made 
out and a few small blood-vessels can be seen. The ori- 
gin of the mass seems very evident after the microscopi- 
cal study of the endocardium of the right ventricle. It 
is undoubtedly a polypoid nodule that, projecting from 
the endocardium, grew until it was too large to pass out 
of the ventricle, and then breaking loose continued to 
grow as a free body. The mass shows no necrosis or de- 
generation. POLYMORPHOUS-CELL SARCOMA OF THE NOSE. 
13 
Lung and pleura: The small growths in the pleura 
are of the type of a small round-cell sarcoma. The 
larger ones show a polymorphous variety of cells and 
myxomatous degeneration. The small nodules through- 
out the lung consist of small round cells, the larger ones 
of polymorphous cells. There is hardly a blood-vessel 
throughout the lung that has not a cireumvascular 
growth of sarcoma cells. Numerous emboli of sarcoma 
cells are found in the capillaries. In many of the small- 
est growths the cells are irregular in size and shape and 
show great excess of chromatin. The lung shows ex- 
treme oedema and congestion, and there are several haem- 
orrhagic infarcts and small areas of broncho-pneumonia. 
Many of the larger tumor nodules show a healing process 
and the formation of scar tissue in the central part of the 
nodule. This can be seen in all stages, from a beginning 
formation of granulation tissue around the myxomatous 
portion of the tumor to nodules made up of scar tissue 
alone. 
Spleen: Small nodules of tumor cells are found 
throughout this organ. There are also a number of 
anaemic infarcts. 
Liver: A number of small nodules of small round 
cells are found in the periportal connective tissue. 
Kidneys: There is an acute degenerative nephritis 
present, and the greater part of both kidneys is replaced 
by masses of sarcomatous tissue of the same structure as 
described above. Many of the smaller nodules are made 
up of the polymorphous cell type. 
Pancreas: The head of the pancreas is almost en- 
tirely replaced by a sarcomatous mass, which is made up 
chiefly of small round cells, but contains also many poly- 
morphous cells. 
Stomach; The base of the round ulcer and the flat 
infiltrations of the mucosa consist of nodules of sarcoma. 
The ulcer is apparently caused by the mucous degenera- 
tion of a large nodule projecting through the mucosa. 
The structure of these nodules in the wall of the stomach 
is the same as that found in the other tumors. 14 
POLYMORPHOUS-CELL SARCOMA OP THE NOSE. 
Intestine: The small nodules in the serosa are of the 
same type of sarcoma as that described above. 
Testis: The tumors here present the appearance of 
a small round-cell sarcoma. Areas of mucous degenera- 
tion are abundant, and the blood-vessels are very numer- 
ous and ectatic. 
Prostate: The prostate contains localized areas of 
small round cells. 
Lymph glands: The cervical, peribronchial, mesen- 
teric, and retroperitoneal lymph glands contain large 
nodules of polymorphous or small round-cell sarcoma. 
The majority of these show mucous degeneration. 
Summary.—All of the growths are of the nature of 
sarcoma. The majority of the smaller nodules and the 
periphery of all the larger ones are made up of small, 
round, deeply-staining cells having but little intercellu- 
lar substance and lying in intimate contact with the 
blood-vessels. In the central part of all the larger nod- 
ules, and in some of the small ones, the cells are larger, 
polymorphous, and there is an increase in the intercel- 
lular substance, which is myxomatous in character. In 
many of the nodules the entire central part of the growth 
has undergone a mucous degeneration, and early stages 
of this degeneration are seen in all of the growths. The 
tumors are further characterized throughout by the num- 
ber and size of the blood-vessels. From the structure of 
the growth the diagnosis of the tumor as a myxomatous 
polymorphous-celled sarcoma would seem most appro- 
priate. 
That the growth in the nasal fossa is the primary 
one there can be no reasonable doubt. The history of 
the ease, the development of the symptoms, the size 
and structure of the nasal growth all support this view. 
The exact site of origin can not be determined. The 
patient affirmed that it appeared first in the right nostril 
upon the right side of the saeptum. Moreover, the rela- 
tion of the sarcoma to the polyps stated to have been 
removed can not be settled in the absence of any definite 
microscopical evidence concerning their structure. The POLYMORPHOUS-CELL SARCOMA OF THE NOSE. 
fact that the tumor everywhere shows a marked tendency 
to a mucous degeneration of its cells and the formation 
of a myxomatous intercellular substance might be taken 
as an evidence of an inherited tendency on the part of its 
cells tending to show a descent from a myxomatous 
polyp. This, unfortunately, will not admit of further 
confirmation. 
The points of special interest in this case are the 
widespread metastases and the intracardiac growth. 
Secondaries were found in the dura, pineal body, hy- 
pophysis, cavernous sinus, lungs, pleura, heart, liver, 
spleen, kidneys, pancreas, stomach, intestines, perito- 
naeum, testicles, prostate, and the cervical, bronchial, 
retroperitoneal, and mesenteric lymph glands. The 
richness of the growth in cellular elements, the scanty 
stroma, the numerous large thin-walled blood-vessels, 
the smallness and shape of the cells, all contributed to 
the facility of the rapid dissemination of the tumor. 
The numerous metastases throughout both venous and 
arterial systems are easily explained by the above-men- 
tioned factors. 
The free sarcomatous body in the right ventricular 
cavity forms the most important feature of the case. 
Intracardiac and intravenous growths are very rare both 
in carcinoma and sarcoma, but have been described in 
both, more frequently in the case of the latter, Kan- 
thack * has described a case of carcinoma of the testis in 
which there was a metastatic mass upon the tricuspid 
valve extending through the auricle into the inferior 
vena cava and through the tricuspid orifice into the 
cavity of the right ventricle. The origin of this seemed 
to have been from an intravenous growth in the inferior 
* Jovr. of Path, and Bad January, 1898.  POLYMORPHOUS-CELL SARCOMA OF THE NOSE. 
vena cava, a fragment of which must have become sepa- 
rated and grafted upon the tricuspid valve, where it con- 
tinued to grow. 
The probable origin in my case is that suggested 
above—namely, the breaking loose of a polypoid nodule 
from the endocardium, its retention in the ventricle, and 
its subsequent growth. Microscopically the endocardi- 
um was infiltrated with sarcoma cells, and in one place 
there was found the thin, flattened growth on the sur- 
face of the endocardium. This may have been the ori- 
gin of the mass, or, on the other hand, it may have arisen 
from a primary embolus of tumor cells retained in the 
heart cavity. The numerous emboli of tumor cells 
found in the lung vessels and the haemorrhagic infarcts 
of the lung may have resulted from the breaking loose 
of portions of this intracardiac growth. The anaemic 
infarcts in the spleen were also probably caused by 
emboli of sarcoma cells, as masses of these cells could 
be seen growing in dilated blood-spaces of this organ. 
Another point of interest in the growth of this 
tumor is its tendency to self-healing. As mentioned 
above, this could be seen in all stages, from the begin- 
ning of the formation of a granulation-tissue capsule 
around the area of degeneration to completely formed 
nodules of scar tissue completely replacing the tumor. 
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17 
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p. 81. 18 
POLYMORPHOUS-CELL SARCOMA OF THE NOSE. 
Hengst. Laryngoscope, 1898, p. 43. 
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Clark. New York Medical Journal, January 7, 1899, 
p. 14. A Text=Book of General Surgery. 
By Dr. HERMANN TILLMANNS, 
Profeseor in the University of Leipsic. 
Vol. I. The Principles of Surgery and Surgical Pathology. 800 pages. 
Vols. II and 111. Regional Surgery. 833 and 929 pages. 
TRANSLATED BY 
JOHN ROGERS, M. D., and BENJAMIN T. TILTON, M. D. 
EDITED BY 
LEWIS A. STIMSON, M. D., 
Professor of Surgery in the New York University. 
Bvo. With many Illustrations. Cloth, $5.00) sheep, $6.00 each volume. 
SOLD ONLY BY SUBSCRIPTION. 
Practitioner: 
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