The lip was removed, getting nearly one-half inch outside of the ulcer on each side and taking out a broad V to the chin, where the incisions were extended along the line of the jaw to the region of the carotid artery. The skin between these two incisions was dissected down to the larynx, and then all soft parts between the carotids laterally were dissected up to the jaw, and removed with the lip. On both sides the submaxillary gland was removed and with it a suspicious looking lymph node. The wound was sutured with silk-worm gut and horse hair. The mouth was narrowed by the operation so that the lower lip was about three-quarters of an inch in length, consequently incisions were made at each angle outwards three-quarters of an inch, incision being made only to the mucous membrane of the cheek, and this being dissected up to form a flap, which, turned and sutured, furnished mucous membrane to the new lip. On the right side the upper lip was turned upon itself and sutured so as to form an angle. There was no reaction after operation. Union was primary throughout, and the cosmetic result is very good indeed except that the patient's smile is now somewhat sardonic. Patient left the hospital May 29th apparently well.

Microscopic examination of the removed parts shows an ordinary epithelioma of the lip with considerable tendency to infiltration. The lymph nodes were carefully examined without finding any involvement.

The patient is well and free from recurrence one year later.

CASE II

Mr. T, aged 59, referred to me for r-ray treatment. Patient has always been healthy; no specific history. Eight years ago he had a sore on lower lip which was quite obstinate and recurred from time to time. Five years ago it was burned off with nitrate of silver, and remained away after this for four years. One year ago it recurred and has remained as an open ulcer since that time.

Examination shows a small indurated ulcer of the ver

million edge of the lower lip, about one-half inch long, to the right side of the middle line. There is a scabbing and excoriation of the muco-cutaneous junction, running from the ulcer over to the left angle of the mouth, but there is no induration. Two moderate-sized lymph nodes can be palpated under the jaw.

Operation, June 6, 1903, at the Northwestern Hospital. Chloroform with three-eighths grain morphine, hypodermically, was administered.

Case 2. Photograph taken immediately after union was complete, and before the scars had at all smoothed down.

A complete operation was done, removing the epithelioma with all the subcutaneous tissues in connection with the contents of both submaxillary triangles of the neck. A number of small glands were observed, and one was removed from behind the field of operation on the left side. Both submaxillary glands were removed, and enlarged lymphatics were found in connection with each. As only three-quarters of an inch of the lip was removed, it was possible to

unite it without extending the angle of the mouth. The wound was sutured with silkworm gut and horse hair. Patient re-acted well, but had an extremely sore mouth with bad salivary discharge. About the fifth day there was a profuse brown salivary discharge from the lower angle of the wound and neck. This continued, then gradually lessened, but became very offensive throughout the two weeks of his hospital stay. In spite of this his temperature was normal, and the cutaneous wound healed by first intention. He left the hospital June 19th with a small, slightly offensive, purulent discharge from the lower angle of the wound and neck. Mouth is now well, and the excessive flow of saliva has ceased.

It was impossible to explain the salivary discharge from the neck. Two theories were considered: one that the fluid came from the mouth through the gaping between the jaw and clinging tissues, but it was impossible to prove any such connection by examination; the other more probable explanation was, that it came from an accessory submaxillary gland whose duct was opened by the operation, and that this continued to discharge until healing took place.

Microscopic examination showed a typical epithelioma in the lip, and no involvement of the lymph nodes or submaxillary glands.

May 1904, patient returned well with no recurrence. He has had no further trouble with the saliva, and his sublingual glands seem normal.

DISCUSSION

DR. C. H. MAYO (Rochester): The question the doctor has brought up in his paper is a timely one at this particular time. We find few pages devoted to the old anatomy of the lymphatic system in old text-books, but there are areas of lymphatic glands tributary to nearly all cancerous deposits, and when a patient comes with a cancer we must study the lymphatic area which is involved. In Halstead's operation he removes the lymphatic glands from the armpit to the neck. In cases of a malignant type, removal of the lymphatic glands does not always give the results hoped for, because in some cases we are already too late, and metastasis has occurred that otherwise would not have reached the circulation.

Cancer of the lip rarely recurs, locally, and that is why cancer-paste quacks have flourished. It so rarely occurs that they call it cured, but they may have cancer of the cervical glands, the liver, or an intestinal cancer. There is a metastasis, and so cancer of the uterus does not kill. They die from kidney trouble, secondary to blocking the ureters. In cancer of the rectum the new operation has entirely superseded the old. If you are not in time to remove the glands involved, no operation is going to be successful, unless it is the total removal of the rectum and of the lymphatic glands involved. I made the point, some time ago, that the lymphatic system, where the metabolism is so great, is the richest up to puberty, but after that it disappears gradually, and in old age it is quite deficient, so the younger the patient is with cancer, the surer he is to die. You never see him until his lymphatic system is involved. An old man comes in with cancer of the lip-a man sixty to seventy years of age he shows you a cancer that he has had for two years, and yet not a gland is involved. You cannot say that of a man under 45. He will usually develop trouble in the cervical glands, so we make a removal of the cancer of the lip, and he comes back with cancer of the neck, and it is the cause of his death ultimately, although he may have had several operations on one side of the neck. Such cases may live for some time; but they do not leave the hands of the surgeon, and finally die. A woman comes to you with cancer of the breast at 70, and says she has had it two or three years. How many women are there of 38 that will show that same condition? They will have recurrence within a year or two, and if a man has a history of successful cancer operations you will find that every decade of life has added to his success, but it has not come from young people. (Applause.)

DR. L. F. SCH MAUSS (Mankato): I would like to say a few words in support of what Dr. Stewart said about forming a new mouth. I had a case five years ago in which the entire lower lip and part of the chin had to be removed. After bringing the flaps together, we had a protruding upper lip. I cut this off, but it still left what the doctor called a "sucker mouth." It was too short. To widen the mouth I made an incision an inch long on each side, united the mucous membrane to the skin, and the results (the size and shape of the mouth) were very satisfactory.

DR. J. C. STEWART (Essayist): I am very sorry this paper could not have been discussed more. I believe the great bulk of surgeons are doing the little V operation in the cases that come into their hands, and they have no right to do so. Any patient is entitled to the removal of the whole associated lymphatic system. No man has a right to temporize with epithelioma of the lip, because when epithelioma involves the lymphatics of the neck the case is practically hopeless. Sometimes we can relieve these cases by dissec

tion, but they almost always recur. I do not think that age is a bar to the early dissemination of cancer cells, and, as I said in the paper, I do not believe we have any criterion to judge when the cancer has become disseminated. The extreme danger lies in making the small operation, and not adopting the more ràdical treatment for epithelioma. The patient comes back with a recurrence in only a small percentage of cases, but that small percentage has the same right to life as the rest, and epithelioma of the lip should be treated early and with the best of our present knowledge, to give this small percentage the best possible chance for recovery.