find less use for drugs. It is in the unknown and complicated cases that we prescribe shot-gun remedies, which a better diagnosis often reduces to a single ingredient.

The action of drugs in the human body will always be more or less obscure. The therapy of iron is still as uncertain as ever and in specifics we are mostly concerned with results. Until medicine then becomes more scientific and more of an exact science let us devote more time to painstaking inquiry into the etiology and pathology, more care in diagnosis, and, unless scientific and specific treatment can be applied, depend more upon the inherent power of resistance and repair of the body, hygienic measures, and nature's true handmaid, the trained nurse; and we shall find, in the words of the venerable Dr. Holmes, that, "If the entire pharmacopeia were thrown into the sea, it would be infinitely better for humanity, but all the worse for the fishes."

THE SURGICAL TREATMENT OF EPITHELIOMA OF THE LIP

J. CLARK STEWART, M. D.

Minneapolis

It is an unfortunate fact that the usual small size and slow course of this lesion when seen early has seemed to justify a large amount of incomplete and poor surgery. All medical men will admit that after a time in all cases the cervical lymph nodes become involved, and that after such involvement surgical interference is not only vastly more difficult, but is followed by results vastly more unsatisfactory. Also, few would claim to be able by any physical examination to determine just when the lymphatic infection has begun.

Why then does the large mass of the profession, including many very eminent surgeons, adhere to the old V operation without attacking the lymphatics? An eminent surgeon, well known to you all, answered this question lately by saying that he had never done anything but the old V operation, and that he did not believe that he had had thirty per cent of recurrences. How about his duty towards that thirty per cent? Had they no right to an operation more likely to prevent recurrence?

Any operation for so grave a disease as cancer, even in this its more benign form, should be the most perfect that can be devised to prevent recurrence in all cases. The ideal operation for carcinoma consists of the excision of the new growth, including a sufficient amount of healthy tissue on all sides, with the lymphatics and the first chain of lymph nodes, in one piece without any incision of the removed tissue, and the closure of the wound by a plastic

operation or skin-grafting so as to obtain union by first intention and not by granulation.

All these ideals can be attained in the early operation for epithelioma of the lip without seriously increasing the operative risk, and with great diminution of the recurrence percentage. The same can be attempted in later cases involving the lower jaw and floor of the mouth, and while these cases have sometimes infection beyond the field of operation, many can be relieved.

The point which I wish to bring before the society is that any one suffering from an epithelioma of the lip, however small, may have beginning lymphatic infection, and that anything short of a complete operation is therefore gross injustice to such a patient. Still worse than insufficient operation is the treatment by caustics and x-ray. By neither of these can a case with beginning lymphatic involvement be cured, and the delay may render all operative interference useless. It must be admitted that cures do result from the use of caustics and probably from x-ray treatment, but this can only be in purely localized growths, and here the knife properly used would give surer results. It is my opinion that the exploitation of the x-ray cure for cancer of all kinds has been a great damage to sufferers from cancer, as it has resulted in the wasting of the time when cure is possible by operation, in seeking after new gods, and finding failure in the immense majority of cases treated.

The operation to which I wish to call your attention has been proposed in various forms by several surgeons, but has never secured the acceptance accorded to its prototype in breast surgery, the Halsted operation, which is to be regretted, as its statistical results are far better, owing to the lesser malignancy of the growth attacked.

The essential parts of the operation are, making incisions at least one-quarter of an inch from the epithelioma through the whole lip to the jaw, and carrying both down to the lower line of the jaw and then curving backward along the jaw line to the submaxillary glands on each side. These two transverse incisions are next joined by a transverse cut

of the skin only, and then the skin flap is dissected down to the hyoid bone in the middle line and to a line joining this point with the lateral incisions on each side. The fascia, fat, and loose connective tissue are then incised at the lowest point reached, and dissected free from the muscles, thus raising a wide flap containing all the superficial lymphatics of the neck. At each outer corner the submaxillary glands are exposed, and removed with the lymph node behind (this being one of the most commonly infected of the cervical glands), and the whole taken away in one piece with the original mass enclosed by the incisions circumscribing the epithelioma. This perfectly fulfills the conditions of the ideal operation as to the removal of the tumor and connections, and nothing remains but closure of the wound, and the formation, if needed, of a sufficiently long lower lip.

In early cases where little lip need be removed, direct suture is satisfactory, but when over three-fourths of an inch of the vermillion is removed a plastic operation must be done to restore the lower lip to comfortable length. Various procedures aiming at this are figured in the textbooks, but are more or less unsatisfactory in not furnishing a mucous membrane to the new part of the lip.

I wish to describe a method not figured in the ordinary text-books, which has proved very satisfactory in my hands in a number of cases.

The mouth is extended outward by a straight cut through everything but the mucous membrane, the length of incision depending upon the amount of new lip needed. The mucous membrane is then dissected loose from the inside of the cheek far enough to amply cover the new lip and, then is incised and sutured to the skin edge. Before completing this suture the extra length of the upper lip must be adjusted, either by folding of the corner or by excising a triangle of skin only whose base is as long as the outward incision. By either method you can obtain good cosmetic results with little trouble.

I append histories of two recent cases of which I have photos.

CASE

Capt. P, aged 77, was referred to me by Dr. T. S. Roberts for r-ray treatment. He has had an indurated ulcer of the lower lip for the past year which has been growing worse. He has had no treatment except that from a magnetic healer.

Case 1.

Showing new mouth with thick angles, due to the deep extension into the cheek.

Examination shows an indurated ulcer extending along about one inch of the free border of the lip near its center. There is a nodule about one-half inch below this ulcer in the lip, and there are two palpable glands below the jaw. His general condition seems to be fair, though he is decidedly senile.

Operation, May 16, 1903, at Northwestern Hospital. Morphine hypodermically, and a very little chloroform.