The following account is from a recent article by the author.26

Because of the failure to distinguish between the various types of cutaneous cancer, many of the older articles on carcinoma of the extremities are practically worthless from a modern point of view. Howard Fox* has recently reported an interesting case of cancer of the hand which metastasized to the mediastinal glands, and has reviewed the literature. After studying various articles, notably those by Heimann,* Gurlt,* von Winiwarter,* Neumann,* Bulkley and Janeway,* von Brunn,* Volkmann,* and Franz* he comes to the conclusion that cancer of the limbs is comparatively a rare disease as compared with cutaneous cancer in other portions of the body. Fox, referring to cancer of the hand, further says: "In spite of the malignancy of these cases from a microscopical standpoint, there can be no doubt that clinically they are relatively benign, generally running a slow course, and only late, if at all, invading the lymphatic glands." On the other hand, in a discussion* of this paper, both Schalek and Corlett reported cases in which metastases had occurred, while Wile called attention to the fact that cancers originating in arsenical keratoses usually metastasized.

Bloodgood* has consistently contended that the lymphatic glands should be removed in all cases of prickle-celled cancer of the body, no matter where located, but especially on the limbs, for here is it always easy to remove the draining lymphatics. Steiner,* writing from the clinic of Dollinger, states that a routine practice is made of removing lymph glands in all cases of cancer of the extremities. A summary of the literature would seem to indicate that cutaneous cancers of the extremities are not especially common, that they are more common on the lower than on the upper limbs, that they always follow some precancerous conditions, that they are usually of the prickle-celled type, that they are rare on the palms of the hands, and that when occurring on the backs of the hands they are relatively benign. Regarding their tendency to form metastases, there is considerable diversity of opinion.

*Bloodgood: South. Med. Jour. 1914, vii, 542.

MHazen: Jour. Amer. Med. Assn., 1915, lxv, 837. 27 Fox: Jour. Cutan. Dis., 1915, xxxii, 22. MHeimarm: Arch. f. klin. Chir., 1898, lvii, 911. wGurlt: Arch. f. klin. Chir., 1880, xxv, 421.

*von Winiwarter: Beitrage zur Statistik der Carcinome, Stuttgart, 1878. "Neumann: Beitrag zur Kenntnis der Extremitaten-Krebse im Anschluss an zwei Falle der Freiburger Klinik, Inaug. Diss. Freiburg im Breisgau, 1911. 32 Bulkley and Janeway: Med. Record, New York, lxiii, 465. 88 Von Brunn: Beitr. z. klin. Chir., 1903, xxxvii, 227. "Volkmann: Samml. klin. Vortr., 1889, No. 102. "Franz: Beitr. z. klin. Chir., 1902, xxxv, 171. "Discussion: Jour. Cutan. Dis., 1915, xxxiii, 29. "Bloodgood: Progressive Medicine, Dec, 1904, 1907, 1908, 1912. 88 Steiner: Deutsch. Ztschr. f. Chir., 1906. lxxxii, 363.

With a view of clearing up the last point, which is of great practical importance, especially now that radium, the Rontgen rays, fulguration, desiccation, and similar nonoperative procedures are making great bids for the treatment of these conditions, the author presents the statistics shown in table 2, derived largely from Dr. Bloodgood Js surgical-pathologic laboratory of the Johns Hopkins Hospital, from the surgical wards of the Freedmen's Hospital, and from the writer's practice.

Table 1. Distribution On Upper And Lower Limbs Of The Various Types Of Cancer

Prickle Malignant Cuboidal Basal Malignant

There was a total of fifty-eight cases. It will be readily seen that the commonest tumor is the spino-celled one, and that the basal-celled one ranks next. Malignant warts are much commoner on the upper than on the lowrer extremity, while the reverse is true of the cuboidal-celled carcinomas. Cancer of the upper limb is just about as common as is cancer of the lower limb.

Prickle-celled growths originated in precancerous dermatoses, and metastasized as shown in table 2.

Table 2. Metastases Occurring In Prickle-Celled Growths

The observation that cancer originating from Rontgen ray dermatitis and from arsenic keratosis usually metastasizes is borne out here. Cancer springing from the scars of burns has given a rather high percentage of metastatic growths.

With respect to the influence that location of the primary growth has on the liability fo metastatic formation, table 3 is presented.

Table 3. Metastases With Reference To Location Of Primary Growth

Total Cases followed Metastatic cases three years cases

In such a small series of cases it is impossible to determine just what influence position has on the liability toward metastasis, but it would appear to have very little. The high percentage of metastases in the followed cases is notable. It will probably be objected that most of these cases were surgical ones, and that they were severe cases and of long duration. Now, as a matter of fact, in six of the metastatic cases the primary cancerous changes had been present for three months or less. In one notable case there was a cancer of the lower leg that had existed for two months. Under divided doses of the Rontgen rays the primary growth healed and stayed healed, but five years later metastases developed in the inguinal glands and the patient succumbed. In the other ten instances recurrence in the glands followed amputation in five cases and local surgical removal in five. The nine patients who stayed cured for more than three years were all subjected to local operation alone.