DISEASES OF THE TONGUE, MOUTH, AND LIPS.

What is glossitis?

This is inflammation of the tongue. Of its varieties, the nonspecific are comparatively rare, and should be treated as are similar inflammations elsewhere-suppuration incised, etc. Of the specific varieties, tubercular and syphilitic glossitis are important. As a rule, these inflammations are circumscribed, rather than diffused throughout the tongue, and those which are tubercular are usually superficial; syphilitic inflammation when deep-seated really constitutes a gumma. Both varieties sooner or later form ulcers.

What other causes are there for ulcers of the tongue ?

Epithelioma, chancre, the "secondary" lesions of syphilis, and traumatism. The last two will not be further considered. (For an approximate differential diagnosis between ulcers of the tongue due respectively to tubercular and syphilitic glossitis, epithelioma, and chancre, see following table.)

What is ranula ?

It is a cyst occurring in the floor of the mouth. It may be due to dilatation of one of the mucous glands or of the lingual gland, or more rarely of Fleischman's duct. This is obliterated, as a rule, but may persist. It is a foetal remnant, and extends from the foramen cæcum of the tongue to the thyroid gland.

What affections of the lips are of surgical importance?
Ulcers and hare-lip.

Describe the ulcers.

They are practically the same as occur in the tongue, except that epithelioma is much more frequent than the other varieties. A diagnosis between these ulcers may be made, based on the same points already given for similar ulcers of the tongue. Epithelioma should be removed by a V-shaped incision.

What is hare-lip?

line

It is a defect in the upper lip. It may be single or double. It consists of a cleft or fissure of a depth varying from a mere indentation up to a complete severance of the lip. It is always in corresponding to that separating the lateral incisor from the canine tooth. It is congenital, and is due to a failure to unite on the part

Gumma.

of the foetal folds from which respectively are to be developed the central and lateral portions of the upper lip. It may occur without cleft palate.

What is the treatment?

A plastic operation of freshening the edges and bringing them together by sutures, or by either of the methods represented by Figs. 108 and 109. The latter is to be preferred in cases where there is a bridge of tissue at the upper part of the cleft.

Hare-lip may be operated upon within a few weeks after birth, but, as a rule, it is best to wait for six months. It all depends on the physical condition of the child and its ability to take nourish

ment.

What is cleft palate?

This is a condition of the hard palate which corresponds exactly to "hare-lip" in the lip, and is of similar origin.

The foetal folds from which are developed each half of the upper jaw do not unite with one another in the middle line anteriorly, but with a middle fold coming down from the nose, and from which the so-called "intermaxillary bone" (containing the four incisor teeth) is formed. Hence cleft palate is never in the median line anteriorly, but occupies a position exactly on a line with that of hare-lip. Posteriorly, or behind the alveolar margin, the cleft is in the middle line. Cleft palate may be single or double, and in either case may coexist with a hare-lip. It may or may not involve the soft palate as well. What is the treatment?

Freshen the edges of the cleft. The approximation is effected by bending down the bone on each side and by suturing the mucous membrane. These procedures are facilitated as follows: Make a

longitudinal incision through the mucous membrane to the bone on each side of the cleft, midway between it and the alveolar margin. Then loosen the mucous membrane on each side between the incision and the cleft. This aids the suturing. A series of small holes are now drilled through the bone along the line of each incision. This helps the bending down of the bone. The operation, as a rule, ought not to be performed until the fifth or sixth year. How may the tongue be removed?

Removal of the tongue is indicated for epithelioma and advanced tuberculosis. There are various methods, of which probably the most practical is Whitehead's, as follows: Insert a mouth-gag, and then deliberately cut out the entire tongue with scissors, beginning at the frænum and keeping close to the floor of the mouth. The lingual arteries may be clamped first at the base of the anterior pillars of the fauces, or not until they are cut. The hemorrhage is easily controlled.

What may be said as to malignant tumors of the jaw?

Upper Jaw.-Carcinoma seems to be the most common of the malignant growths. It starts in one of the mucous glands of the mucous membrane lining the nasal cavity or that of the antrum of Highmore. Diagnosis is made by observing the condition of the eye and of the nasal fossa on the side affected, and by palpating the mouth and pharynx.

Treatment.-Removal of the upper jaw.

Lower Jaw.-Sarcoma of the lower jaw is either subperiosteal or central. The latter is of quicker growth, and on palpation gives a crackling feeling. The former is slow in growth, quite hard to the touch, and in developing seems to embrace the angle and ramus. This condition is ascertained by palpating the jaw both from without and within.

What is salivary fistula ?

It is an opening into Stenson's duct, either externally or from within the mouth. It is due to traumatism or to obstruction of the duct from calculus or inflammation. A plastic operation is necessary for restoration.

What is epulis?

This means, literally, "on the gum." Hence it is applied to a tumor on the gum. Epulis is either a fibroma or a sarcoma or a fibro-sarcoma.