Prognosis

Prognosis depends on the stage of the growth and the extent of the operation; even in fairly late cases the mortality should not be high if an extensive and thorough operation be done. The diagnosis must be made early if good results are to be obtained;

The cells themselves deserve study. They are large, more or less angular in outline, and stain intensely with the acid dyes, due to the presence of keratin. They retain none of their prickles, these being lost early in the course of the new growth. Especially have they undergone some of the types of hyaline degeneration already described. Where crowded closely together, the angular shape is lost and they appear as elongated spindle cells. Various types of atypical division can often be recognized.

There is usually considerable inflammatory exudate in the invaded tissue, an exudate that is greater than in most cases of basal-celled growths. This infiltration consists of small round cells, of fixed tissue cells, and occasionally of mast and plasma cells, an exudate that is comparable to that appearing in any chronic inflammatory disthis is especially true in growths originating upon the lips, tongue, or penis, for here any delay usually results in extensive glandular metastasis.

Treatment

In the opinion of the writer the treatment should be entirely surgical, leaving x-ray or radium for the so-called inoperable cases. It is true that Pusey* and others have obtained admirable results from the x-ray in many cases of this type of neoplasm, but the majority of other workers have not been so fortunate, presumably because they could not use their apparatus as efficiently as Pusey; hence it seems a form of treatment that is not suited for the majority of cases. Another objection is that it is difficult to determine when metastases to the neighboring glands have taken place, and, as Pusey himself admits, it is very unsafe to treat with the rays any tumor that has metastasized. Certainly no prickle-celled tumor arising from the mucous surfaces should ever be treated with the rays, unless the patient absolutely refuses operation, and, if such a treatment be attempted, the patient should sign a statement that he assumes all of the responsibility.

A complete excision of the tumor, of the underlying fat and fascia, of the lymphatic vessels and glands, all being removed in one piece, is the ideal operation. In a very early case, where the growth has existed but a week or two, complete local excision is sufficient if the growth be upon the skin, but not if it be upon mucous membrane. In small tumors a margin of at least half an inch should be given; in large tumors an inch or more, and the incision should always slope away from the tumor, so that a wide area of fat and underlying structure can be removed, and enough skin left for plastic work. In all of the late cases the neighboring glands should be removed, and it were better if the lymphatics connecting the site of the primary growth with the glands could be taken out in a block operation.

The problem in treating spino-celled cancers is to completely remove the local growth and also the draining glands. In a recent case under the care of Dr. H. H. Kerr and myself this problem was solved in an interesting way. The primary growth was situated over the junction of the parotid gland and Steno's duct, so that surgical removal would have necessitated dissecting out this gland and probably cutting the facial nerve. An attempt to dissect out the nerve in a cancerous field did not appeal as being good surgery. As a result Kerr did a block operation upon the glands of the neck, while the author subjected the primary lesion to deep radiation. The immediate results were excellent. Such a procedure probably has a rather wide field of usefulness.

*Pusey: Jour. Amer. Med. Assn., 1913, lxi, 552.

The use of caustic pastes is mentioned only to be condemned; they do not reach sufficiently deep to destroy the outlying cells unless a great quantity is used, and then leave a wound that is a thousand times worse than any incision; in addition, they are very painful while being applied.

Articles concerning these neoplasms have been written by Borst,* Bloodgood,* Franz,* Borrmann,* Von Brunn,* Steiner,* McGlannan,* Volkmann,* and myself.12

*Borst: Die Lehre von den Geschwttlsten, Wiesbaden, 1902. 'Bloodgood: Progressive Medicine, Dec, 1907, 1908, 1912; Jour. Amer. Med. Assn., 1906, xlvli, 1740; Amer. Jour. Med. Sc., 1914, cxlvii, 76. •Franz: Beitrage z. klin. Chir., 1902, xxxv, 171. T Borrmann: Deutsch. Zeitschr. f. Chir., 1906, lxxxii, 363.

*Von Brunn: Zentralbl. f. Chir., 1907, xxxiv, 550.

*Steiner: Deutsch. Zeitschr. f. Chir., 1906, lxxxii, 363.

*McGlannan: Maryland Med. Jour., July and August, 1908. "Volkmann: Samml. klin. Vortr. Chir., 1889, No. 102.

*Hazen: Jour. Amer. Med. Assn., 1915, lxiv, 658; Southern Med. Jour., 1915, viii, 577.