nature of the ulcer is doubtful, it may be justifiable to apply radium freely. We have seen cases in which the disease has disappeared and no operation has been necessary after the application of 100-150 milligrammes of radium for twenty-four hours.

Removal of the glands.-The question of the removal of the lymphatic glands, which receive the lymph from the infected region (viz. the submaxillary and submental glands), arises here, as in all other cases of carcinoma. When the glands are enlarged there is no difference of opinion as to the necessity for removing them, the only questions in that case being, whether they should be removed at the same time as the primary disease or on another occasion, and whether all the

intervening tissue, likely to contain the lymphatic vessels, should be taken away, as is always done in the case of many other cancers, such as cancer of the breast. Further, if both are removed at the same operation, which should be done first?

As regards the question of infection of the lymphatic vessels it has been pointed out on p. 467 that it is unnecessary to take away the tissues intervening between the growth and the glands in many cases where cancer originates in the skin, and that it generally suffices to take away the primary growth and the affected glandular area. On the other hand, when the primary tumour is large or when it affects the mucous membrane, it is well to take away a large area, including the lymphatic vessels and the nearest lymphatic glands.

FIG. 207. INCISIONS FOR THE REMOVAL OF AN EPITHELIOMA OF THE LOWER LIP AND THE SUBMAXILLARY GLANDS. The ordinary incision for the removal of the tumour is prolonged downwards and backwards, and a submaxillary flap is thus raised.

The question as to the period at which the affected glands should be removed is governed largely by the risk of sepsis occurring in the planes of the neck. It is naturally best to complete the whole operation at one sitting, and when the incisions for the lip and the glands do not communicate, there is no objection to this course. In that case it is well to remove the glands first, and then to deal with the affected portion of the lip; there is thus less risk of soiling the wound in the neck. The submaxillary salivary gland should always be taken away if the submaxillary lymphatic glands are enlarged, as the latter lie close to it and may escape notice unless the salivary gland is removed as well.

The best incision for removing the submaxillary glands is a curved one commencing beneath the symphysis, passing downwards and back

wards towards the hyoid bone, and finally upwards to the angle of the jaw. This flap is dissected up, the deep fascia divided, and the glandular area exposed and removed. In removing the submaxillary gland the facial artery and vein will be divided, but care must be taken to push up the branch of the facial nerve going to the lower lip. Through this incision the submental glands can also be removed by retracting the wound well, but if necessary the incision may be prolonged along the lower border of the chin towards the opposite side.

Should the submental glands alone be enlarged, the best incision for their removal is a curved one beneath the chin parallel to the lower border of the jaw and somewhat nearer to the latter than to the hyoid bone (see Fig. 208). The enlarged glands are generally superficial to the genio-hyoid muscle, but they are sometimes found between and even beneath these muscles, so that a careful search must be made to see that all are removed before the operation is finished. If necessary, any enlarged glands can generally be made more prominent by having the floor of the mouth pushed well downwards by an assistant, so as to make the submental region project.

When the primary disease is more advanced and the incision for the disease in the lip would join that for the glands, and especially when the glands in the anterior triangle are also affected, it is often best to operate on separate occasions. In that case the glands should be removed, in the first place, unless the primary disease is advancing rapidly, and then the operation on the lip performed about a week later; the wound in the neck will then have practically healed before it is exposed to septic infection. When, however, the primary disease is so advanced that no time must be lost in dealing with it, the order of operating must be reversed.

When the disease is so extensive that a plastic operation is required after removal of the primary growth, it will be unnecessary to make special incisions for the removal of the enlarged glands, as those requisite for the plastic operation will generally be carried below the jaw and will permit free access to the glands.

When the glands are not noticeably enlarged, opinions differ as to the advisability of removing the glandular area at once, or of waiting to see if enlargement occurs. If the primary growth is quite small and begins in the skin, and if the patient is old, it is quite allowable to wait and see whether the glands enlarge, but if the growth is of fair size and spreading

on to the mucous membrane, and the patient is comparatively young, it is best to remove the whole of the fat and glands in the submaxillary and submental areas at the same time that the operation on the lip is performed.

Should the growth be adherent to the jaw, a portion of the bone must be removed; it is never advisable to be content with merely peeling off the periosteum. As soon as the growth becomes adherent to bone, the cancer cells penetrate along the Haversian canals and recurrence is certain, unless the affected portion of the bone is removed. At the same time it must be remembered that removal of portions of the jaw always leaves a troublesome deformity, and as much of the bone should be left as possible. When the jaw is affected, it is usually from a growth which has commenced on the mucous surface of the lip and spread downwards on to the gum, and a large portion of the lip will have to be removed as well as the affected portion of the jaw. An extensive plastic operation will usually be necessary.

In some cases the disease affects only the alveolar portion of the bone, the lower margin of the jaw being healthy; in this case the lower margin of the jaw should be left intact so as to maintain the continuity of the bone and prevent deformity. This is done as follows: The teeth on either side of the growth are extracted and a vertical saw-cut is made through the upper two-thirds of the bone on each side about threequarters of an inch beyond the disease. These cuts are then connected by an horizontal one, which is most easily made by a Gigli's saw. The periosteum must be removed with the bone.

When the bone has been removed, the flaps are brought together so as to restore the lip, and in doing so it is most important to stitch the edges of the mucous membrane accurately together, otherwise the mobility of the lip may be greatly interfered with, owing to adhesion of the lip to the jaw. In bringing up the flaps to form a fresh lip, a raw surface may be left below. If this is so, it is a good plan to cover it with a Thiersch's skin-graft, otherwise the contraction of the scar may pull down the new lip. Later on, a dentist will probably be able to supply the patient with a bar carrying artificial teeth, which will give support to the lip.

In many cases the growth involves the whole depth of the jaw, and it is impossible to save any portion of it. The various operations for removal of parts of the jaw will be found in Vol. IV.

CHAPTER XL.

TRIGEMINAL NEURALGIA.

NEURALGIA of one or more of the branches of the fifth nerve is not uncommon. The disease may be confined to a single branch, or all the main trunks may be affected; it often commences in one branch and extends thence to the whole nerve. The pain is generally intermittent and is frequently accompanied by spasmodic contractions of the facial muscles the condition known as 'spasmodic tic.' In other cases the pain is practically constant and so severe that the patient's life is almost unbearable; indeed, many ultimately become insane or commit suicide.

In the primary or idiopathic cases the affection is a true neuritis, spreading from the terminal branches to the main trunks, and leading in severe cases to changes in the Gasserian ganglion or even in the nuclei of the trigeminal nerve. In the secondary cases, dental caries is a common cause, although the pain may not be referred to the particular tooth that is diseased. The nerve may also be pressed upon by a cicatrix, a foreign body, callus or a tumour, while sometimes the affection may result from a simple osteitis of the wall of the canal in which one of the branches runs. Intra-nasal conditions may also give rise to the affection; more rarely, it may depend upon caries of the petrous portion of the temporal bone or upon the presence of an intra-cranial tumour.

TREATMENT.-The treatment differs according as the case is primary or secondary.

In the secondary cases it is generally sufficient-in earlier stages, at any rate-to remove the cause; the affection then subsides and the patient gets well. Should the cause be inaccessible, as it is in disease of the petrous bone, the treatment of the case will be more difficult.

In the primary cases, when no exciting cause can be discovered and the case is one of simple neuritis, the treatment for that

condition must be adopted first (see Vol. II. p. 127). The face should be wrapped up and kept from exposure to cold or draughts, while quinine (in five-grain doses four times a day) or liquor arsenicalis (in doses of three to five minims cautiously increased up to twelve or more) should be administered. Antipyrin (in ten- to twenty-grain doses) is useful during the severe paroxysms; in some instances methylene blue (in three-grain pills) seems to exercise a specific action. Among the various other drugs employed are gelsemium and butyl chloral hydrate. As local applications, menthol or linimentum terebinth. aceticum sometimes gives relief. The diet should be light but nourishing. This part of the treatment, however, is within the province of the physician, and for further details a treatise on medicine should be consulted.

Should no improvement take place after a prolonged trial of these or similar remedies, and should the patient's condition become unbearable, the propriety of undertaking some surgical measure for the relief of the pain must be considered.

Operative Methods.-The surgical measures employed for this affection fall into three categories:

(1) Injection of substances into the nerves; that most commonly used is alcohol. (2) Neurectomy of the individual nerves. (3) Removal of the Gasserian ganglion.

Of these, extirpation of the Gasserian ganglion is the most certain method, and, if the patient's condition permits, it should certainly be undertaken, whenever more than one branch of the nerve is involved; in these cases the ganglion is diseased, and it is only waste of time to adopt any minor operation. Even when the disease is limited to one branch, the Gasserian ganglion should be removed if other methods fail. The operation is, however, a severe one, though much less dangerous now than when it was first introduced and, apart from its severity, it has considerable disadvantages. In the first place, the motor root of the trigeminal nerve is usually divided in the course of the operation, and, as a consequence, paralysis of the muscles of mastication on the affected side occurs. In the second place, there is considerable risk of trophic changes in the cornea which may lead to complete destruction of the eye.

On account of these disadvantages of the radical operation, it is well to resort to one of the other two methods in the first instance, especially when the pain is limited to one branch, and to reserve the operation on the Gasserian ganglion until their failure is certain. Division and removal of portions of the various branches was frequently performed at one time, but, of late, these operations have been replaced to a considerable extent by injections of alcohol, either into the large nerve trunks as they emerge from the base of the skull, or into their peripheral portions as they pass out of the foramina on the face. Recently, the Gasserian ganglion itself has been successfully injected with alcohol through the foramen