ON THE THALAMUS *

removal of that gland increases the severity of the operation, and there is a deep depression left under the jaw, which is slightly disfiguring; and in removing it some ot the fibres of the facial nerve which go up to the angle of -the mouth are sometimes cut, so that control of that angle of the mouth may be slightly affected. About three years ago it occurredtome that I might turn up the submaxillary salivary gland from below, and clear out the contents of the submaxillary triangle from beneath it, and the gland or glands which lie embedded in the salivary gland, then lay the salivary gland back in its place once more. I did that in three instances and those cases gave me the greatest anxiety. One of the patients is dead, and I think he died from having had his salivary gland eft, because, a year after the operation, he came back with a big mass, growing from the lower part of the gland almost into the pharynx. And although I made a very large operation for the.removal of it he died of recurrence of the disease a few months afterwards. In bath the other cases I have been disappointed at the result. from what may be termed a cosmetic point of view; the gland bulges a little, and there is a prominence instead. of a depression. I think the patients are safe, because it is some time since I operated on them. I do not recommend you to take this course, for the advantages are not nearly great enough to justify the risk. You will see that four of the first series of twenty-eight patients died of affection of the glands without recurrence in the mouth, which.seems a large number alter removal of the contents of the anterior triangle. But, in two of them, the glandular disease was so extensive that tbere was rapid recurrence in the neck itself. hl tbe other two unusual events occurred, and I direct your attention to these particularly. In one of the patients, although the primary disease was but a kind of button quite on the border of the tongue, and apparently not going far into the tongue, and although I removed it and the glands on that side successfully so that it never recurred in the tongue or in the glands on that side, he died of diseased glands on the other side of the neck. And that occurred about a year after the first operations. It grew very rapidly. I tried to remove the disease, but it was absolutely inoperable. You must take into account that in a certain number of cases-I cannot give you an idea of the proportion, but I think it must be small-the patient is liable, even with . disease limited to one border of the tongue, to affection of the glands on the other side of the neck. And this has led certain surgeons to recommend-though I do not think it has been done in this country-that the glands on both sides of the neck should be removed in every ease of cancer of the tongue. E. have not got to that stage yet. I doubt if I shall ever do so. I have removed the glands of the neck on both sides for cancer of the tongue, but not when the tongue cancer was limited to one side. I do not think at the present time circumstances warrant so large an operation as that, and I do not think the patients would submit to it. The remaining patient died of disease of the glands of the posterior triangle of the neck, and again the question arises, 's it necessary, or desirable, to remove the contents of the posterior triangle of the neck when the contents of the anterior triangle are removed ? I reply that experience has not taught me that this is necessary in the ordinary cases. That patient was the first person on whom I performed this operation of clearing out the anterior triangle. He had a bad cancer far back in his tongue, implicating the anterior half arch of the palate, and with that a great cancerous gland ander the mastoid muscle, in the parotid region; and I performed a large operation on the tongue and glands at one sitting; I fully expected that in a few months he would have recurrence of the disease. But to my great surprise he remained well for a year and a half, when he came to show me an enlargement of the glands in the posterior triangle, which he had recently discovered. I attempted to remove them, but they were matted in with nerves and vessels, and it was impossible. I made use of that experience in the case which I related at the beginning of the lecture. There was a large m2ass breaking down at the angle of the jaw beneath the sterno-mastoid muscle; I therefore cleared out the contents of the posterior triangle, where I found absolutely malignant glands. I think where the disease of the glands is only slight and not adherent, and where they are not badly diseasedin ,the parotid region you need not remove the contents of the posterior triangle; but if there is severe glandular disease in 'the parotid region, and beneath the sterno-mastoid, I feel sure you should not be content with removal of the contents of the anterior triangle, but should remove also the contents of the posterior triangle.down to the brachial plexus: b I have, naturally, been speaking of disease on only one side of the tongue. -lf the disease is in the middle line, as it sometimes is, or if it has spread from one side to the other, I am sorry to say you will have to take your courage into your hands, and remove the contents of the triangle on both sides of the.neck. I have done-so on several occasions, and the patients have made very good recoveries. That is an absolute necessity if you want to save your patient from recurrence and death from the disease. And now let me finally say that I am only giving you what I believe to be the beet advice, on my experience, up to this time. It is possible I may have to modify my opinions on some of these points, but I am not likely to modify them in the direction of makiDg a smaller operation than I have demonstrated to-day. I advise you, in every case of cancer of the tongue, even in the very earliest period, to recommend your patient most strongly to have not only the disease of the tongue removed, but if the disease is on one side to have the anterior triangle completely dissected out, and if the disease of the tongue is in the middle line to have thecontents of both triangles taken out.