Meanwhile, especially in extrinsic varieties, the submaxillary and the cervical lymphatic glands become successively involved and tumefied. Squamous-celled carcinoma becomes pale, wrinkled, and nodulated, and sometimes dendritic. Large spheroidal-celled carcinoma becomes nodulated, dark, and irregularly vascular, and finally ulcerated, perhaps at a number of points. In the ulcerative stage of carcinoma of the epiglottis and of the interior of the larynx discrimination is requisite from syphilis and from tuberculosis. In all cases of doubt as to malignancy, laryngoscopic inspection should be supplemented by microscopic examination of fragments detached for the purpose. The early detection of sarcoma may lead to surgical measures competent to save life--a remark applicable, perhaps, in a far more limited degree to intrinsic carcinoma. [Footnote 10: Butlin, _op. cit._, p. 14.] PROGNOSIS.--The prognosis is usually good in benign growths submitted to proper surgical treatment. Left to themselves or treated medicinally, the prognosis is bad both as to function and to life. Such growths are occasionally expectorated after detachment during cough or emesis. Some {131} occasionally undergo spontaneous absorption. Some remain without change for years. Most of them enlarge and compromise life as well as function. Recurrence occasionally follows thorough removal, and this recurrence is occasionally malign in character. Repullulation frequently follows incomplete removal. The prognosis is favorable in sarcomata, provided thorough eradication can be accomplished by surgical procedure. Incomplete removal is followed by repullulation or recurrence. Unsubmitted to operation, sarcoma will destroy life either mechanically by apnoea or physiologically by asthenia. The prognosis is unfavorable in carcinoma. Recurrence takes place as the rule despite the best devised resources of surgery. Intrinsic carcinoma offers some hope of success to the surgeon; extrinsic carcinoma, little if any. Life is shortest in the large spheroidal-celled, and longest in the small spheroidal-celled variety, other conditions being equal. Death may take place by apnoea or asthenia, as in sarcoma, or by hemorrhage, collapse, or pyæmia. Submitted to tracheotomy at the proper moment in cases in which death is threatened by occlusive dyspnoea, life is prolonged and suffering mitigated. The fresh lease of life is longest in the squamous-celled variety.