CHAPTER XIX

THE FACE, ORBIT, AND LIPS

FACE--Congenital malformations: _Hare-lip and cleft palate_; _Macrostoma_; _Microstoma_; _Facial cleft_; _Mandibular cleft_--Injuries of soft parts: _Wounds_; _Burns_--Bacterial diseases: _Boils_; _Anthrax_; _Glanders, etc._; _Lupus_; _Syphilis_. Tumours: _Epithelioma_. ORBIT--Injuries: _Contusion_; _Wounds_; _Fractures_--Injuries of eyeball--Orbital cellulitis--Tumours. LIPS--_Cracks_; _Chronic induration_; _Tuberculous ulcers_; _Syphilitic lesions_--Tumours: _Naevi_; _Lymphangioma_; _Cysts_; _Epithelioma_.

THE FACE

CONGENITAL MALFORMATIONS.--The description of the various congenital malformations of the face will be simplified by a brief consideration of its development.

_Development._--About the middle of the first month of intra-uterine life the prosencephalon bends acutely forward over the end of the notochord and sends out from its base a series of processes, which ultimately blend to form the face (Fig. 231). These processes surround a stellate depression, the primitive buccal cavity or stomatodaeum, from which the mouth and nasal cavities are developed. The buccal cavity is bounded above by the fronto-nasal process, which is divided by a fissure--the nasal cleft or olfactory pit--into a lateral nasal process, and a mesial nasal process, at the outer angle of which a spheroidal elevation appears--the globular process.

From the mesial nasal and globular processes the septum of the nose, the mesial segment of the premaxillary bone, and the middle portion of the upper lip are developed; while the lateral nasal process forms the roof of the nasal cavity, the ala nasi and adjacent portion of the cheek, and the lateral segment of the os incisivum or premaxillary bone. Each segment of the os incisivum carries one of the incisor teeth, and each of the mesial segments may contain in addition an accessory tooth. The nasal cleft ultimately becomes the anterior nares.

The primitive buccal cavity is bounded below by the mandibular arch, which contains Meckel's cartilage, and from which are developed the mandible, the lower lip, and the floor of the mouth.

From the lateral and back part of the mandibular arch springs the maxillary process, which grows upwards and blends with the lateral nasal process across the naso-orbital cleft--the deeper portion of which persists as the nasal duct. From the maxillary process are developed the cheeks, certain of the facial bones, the lateral portions of the upper lip, the soft and hard palate (with the exception of the os incisivum). The development of the face is completed about the end of the second month of intra-uterine life.

HARE-LIP AND CLEFT PALATE

Hare-lip is a congenital notch or fissure in the substance of the upper lip, and cleft palate a congenital defect in the roof of the mouth. Either of these conditions may exist alone, but they occur so frequently in combination that it is convenient to consider them together.

In hare-lip the cleft may be median or lateral, and it may or may not be associated with a cleft in the palate. The resemblance to the Y-shaped cleft in the upper lip of the hare, suggested by the name, is in most cases only superficial.

#Median hare-lip# is extremely rare. It occurs in two forms: one in which there is a simple cleft in the middle of the lip, the result of non-union of the two globular processes; another in which there is a wide gap due to entire absence of the parts developed from the mesial nasal process--the central portion of the lip, the mesial segment of the os incisivum, and the septum of the nose. The second form is usually associated with cleft palate.

#Lateral hare-lip# is much more common. It is due to imperfect fusion of the globular process with the labial plates of the maxillary process. There may be a cleft only on one side of the lip, or the condition may be bilateral. In some cases the cleft merely extends into the soft parts of the lip--_simple hare-lip_ (Fig. 232) forming a notch with rounded margins on which the red edge of the lip shows almost to the apex. In other cases the cleft passes into the alveolus of the jaw--_alveolar hare-lip_--partly or completely separating the mesial and lateral segments of the premaxillary bone (Fig. 233). These cases are usually combined with cleft palate (Fig. 236).

When the hare-lip is _bilateral_, the two clefts may be unequal, one forming a simple notch in the lip, the other passing into the nostril. In most cases, however, both clefts are complete, and the mesial portion of the lip is entirely separated from the lateral portions. The central portion or prolabium is usually smaller than normal, and is closely adherent to the os incisivum. This bone may retain its normal position in line with the alveolar processes of the maxilla (Fig. 234), or it may be tilted forward so that the incisor teeth, when present, project beyond the level of the prolabium (Fig. 235). In aggravated cases, the os incisivum and prolabium are adherent to the end of the nose. In these cases there is a Y-shaped cleft in the palate.

#Cleft Palate.#--It has already been mentioned that the palate is formed by the blending of the two palatal plates of the maxillary processes with the four segments of the os incisivum, derived from the nasal processes. The foramen incisivum (anterior palatine foramen) marks the point at which these elements of the palate unite. The process of fusion begins in front and spreads backwards, the two halves of the uvula being the last part to unite.

As development may be arrested at any point, several varieties of cleft palate are met with. The uvula, for example, may be bifid, or the cleft may extend throughout the soft palate. In more severe cases, it extends into the hard palate as far forward as the foramen incisivum. In these varieties the whole cleft is mesial. In still more aggravated cases, the cleft passes farther forward, deviating to one or to both sides in the fissures between the mesial and lateral segments of the os incisivum or between the lateral segments and the maxillae. These cases are combined with double hare-lip.

The cleft varies considerably in width. It may be so wide that the imperfectly developed nasal septum is seen between its edges, and gives to the cleft the appearance of being double, or the septum is adherent to one edge of the palate--usually the right--and the cleft appears to be to the left of the middle line. In most cases the roof of the mouth is unduly arched, and is narrower than normal (Fig. 236).

_Clinical Features._--_Single hare-lip_ is about twice as common on the left as on the right side, and it occurs more frequently in boys than in girls. In a considerable proportion of cases there is a well-marked hereditary tendency to these deformities, and they frequently occur in several members of a family.

The nose is characteristically broad and flattened, the ala being bound down to the alveolar margin of the maxilla by fibrous tissue. The margins of the cleft in the lip are also attached to the alveolus by firm reflections of the mucous membrane. The orbicularis oris and other muscles of expression about the mouth being defective, the deformity is exaggerated when the child cries or laughs. In simple hare-lip the child may have difficulty in sucking, but this can usually be overcome by some mechanical contrivance to occlude the cleft.

When the _hare-lip is double and combined with cleft palate_, the child is unable to suck, and food introduced into the mouth tends to regurgitate through the nose. The nutrition can only be maintained by having recourse to spoon-feeding, and in feeding the child it is necessary to throw the head well back and to introduce the food directly into the back of the pharynx. Many of these infants are of such low vitality, however, that in spite of the most careful feeding they emaciate and die.

In those who survive, the voice has a peculiar nasal twang, as in phonation the air is expelled through the nose instead of through the mouth, and the articulation, especially of certain consonants, is very indistinct. Taste and smell are deficient. The constant exposure of the nasal and pharyngeal mucous membrane renders it liable to catarrhal inflammation and granular pharyngitis.

_Treatment._--The only means of correcting these deformities is by operation, and, speaking generally, it may be said that the earlier the operation is performed the better, provided the general condition of the child is equal to the strain. In simple hare-lip the best time is between the sixth and the twelfth weeks. When cleft palate coexists with hare-lip, the lip should be operated on first, as the closure of the lip often exerts a beneficial influence on the cleft in the palate, causing it to become narrower.

Considerable difference of opinion exists as to when the cleft in the palate should be dealt with. Some surgeons, notably Arbuthnot Lane, recommend that it should be done in early infancy, as soon as the viability of the child is assured. We agree with R. W. Murray, James Berry, and others in preferring to wait until the child is between two and a half and three years old. It should not be delayed longer, because, even if the cleft in the palate is repaired, the nasal character of the voice persists, as the patient cannot overcome the habit of expelling the air through the nose.

Before the operation is undertaken, the child must be got into the best possible condition; and arrangements must be made for its constant supervision by a competent nurse. Success depends largely on the avoidance of infective complications, and on absence of tension between the rawed surfaces that are brought into apposition. More than one operation is sometimes required to effect complete closure of the cleft.

_Voice Training._--The treatment of cleft palate does not cease with a successful operation; the importance of voice training must be explained to the parents. The child must be taught, in speaking, to send the stream of air through the mouth, instead of through the nose. If the soft palate is not sufficiently large and mobile to shut off the mouth from the nasal cavity, little improvement in speaking can be looked for.

In _adolescents_ and _adults_, if the cleft is wide and the soft tissues of the palate are thin and atrophied, better physiological results may be obtained by the use of an artificial obturator or velum. With the aid of the dentist a plate of vulcanite or gold is fitted to the teeth and kept in position by suction.

#Other Congenital Deformities of the Face.#--_Macrostoma_ is an abnormal enlargement of the mouth in its transverse diameter, due to imperfect fusion of the maxillary and mandibular processes.

_Microstoma_ is due to excessive fusion of the maxillary and mandibular processes. In some cases the buccal orifice is so small as only to admit a probe.

_Facial cleft_ is due to non-closure of the fissure between the nasal and maxillary processes. It passes upwards through the lip and cheek to the lateral angular process of the frontal bone.

_Mandibular cleft_ occurs in the middle line of the lower lip, and may extend to, or even beyond, the chin; it is due to non-union of the two lateral halves of the mandibular arch.

These various deformities are treated by plastic operations carried out on the same principles as for hare-lip.

_Fistulae of the Lower Lip._--Two small openings, about the size of a pin's head, are occasionally met with on the free border of the lower lip, near the middle line. On passing a probe, each is found to lead into a narrow cul-de-sac, which runs for about an inch laterally and backwards under the mucous membrane. Watery, saliva-like fluid exudes through the openings. These fistulae frequently occur in several members of the same family, and are usually associated with hare-lip. The treatment consists in dissecting them out.

#Injuries of the Soft Parts of the Face.#--Owing to its free blood supply, the skin of the face has great vitality, and even when severely lacerated it not only survives, but shows such resistance to bacterial infection that primary union frequently takes place. In plastic operations, also, even extensive flaps seldom become infected, and they heal so rapidly that the sutures can be removed in two or three days.

In _incised_ wounds the bleeding is usually free at first, but unless one of the larger arteries, such as the external maxillary (facial) or temporal, is injured, it soon ceases. Paralysis of the muscles of expression may follow if the facial nerve is injured; and loss of sensation may result from injury to the supra-orbital or infra-orbital nerves. If the parotid gland is implicated, saliva may escape from the wound, but it usually ceases in a few days; if the duct is involved, a persistent salivary fistula may form.

_Punctured_ wounds may perforate the orbit, the cranial cavity, or the maxillary sinus, and be followed by infective complications, particularly if the point of the instrument breaks off and is left in the wound.

_Contused and lacerated_ wounds result from explosions and injuries by firearms, and foreign bodies, such as particles of stone or coal, or grains of gunpowder and small shot, may lodge in the tissues. Every effort should be made to remove such foreign bodies, as if left embedded they cause unsightly pigmentation of the skin. Ligatures are seldom necessary for the arrest of haemorrhage unless the larger branches are injured, as the bleeding from smaller twigs is arrested by the sutures. The edges of the wound are approximated by means of Michel's clips, or by a series of interrupted horse-hair stitches, and for this purpose a fine Hagedorn needle is to be preferred, as it leaves less mark than the ordinary bayonet-shaped needle. If the mucous membrane of the mouth or of the eyelid is implicated, its edges should be approximated by a separate row of catgut stitches.

_Cicatricial contraction_ after severe burns may lead to marked deformities of the eyelids (ectropion), mouth, and nose. When the burn has implicated the neck, the chin may be drawn towards the chest, and the movements of the lower jaw and head seriously impeded.

#Bacterial Disease.#--_Boils_, _carbuncles_, and _anthrax pustules_ frequently occur on the face, and when situated near the middle line, and particularly on the upper lip, are liable to give rise to general infection and to intra-cranial complications which may prove fatal. The primary infection of _glanders_ and of _actinomycosis_ may also occur on the face.

The various forms of _tuberculous lupus_ are met with more frequently on the face than in any other situation (Fig. 237). _Tuberculous disease of the facial bones_, particularly of the lateral half of the orbital margin at the junction of the zygomatic (malar) bone with the maxilla, is not uncommon in children.

The primary lesion of _syphilis_, and the various forms of secondary and tertiary syphilides, may simulate tuberculous lupus, cancer, and other ulcerative conditions.

#Tumours.#--The simple tumours met with on the face include sebaceous and dermoid cysts, naevus, plexiform neuroma and adenoma; the malignant forms include the squamous epithelioma, and rodent, paraffin, and melanotic cancers.

_Epithelioma_ occurs most frequently in men beyond the age of forty. The affection usually begins at the margin of the lip, the edge of the nostril, or the angle of the eye. There is generally a history of prolonged or repeated irritation, or the condition may develop in connection with a scar, a wart, a cutaneous horn, or an ulcerating sebaceous cyst. It may begin as a hard nodule, or as a papillary growth which breaks down on the surface, leaving a deep ulcer with a characteristically indurated base--the _crateriform ulcer_. The neighbouring lymph glands are infected early, but metastases to other organs are not common. The treatment consists in excising the growth and the associated lymph glands as early and as freely as possible. When excision is impracticable, benefit may be derived from the use of radium or of the X-rays.

The face is the commonest seat of _rodent cancer_ (Volume I., p. 395).

THE ORBIT

#Injuries.#--_Wounds of the eyelids_ are liable to be complicated by damage to the lachrymal apparatus, leading to stenosis of the canaliculus and persistent watering of the eye. If the wall of the lachrymal sac or nasal duct is torn, the patient should be warned not to blow his nose for some days lest air be forced into the tissues and produce emphysema. In suturing wounds of the lids care must be taken to secure accurate apposition at the free margins, and to avoid constricting the canaliculi.

_Contusion_ of the eyelids and circum-orbital region--the ordinary "black eye"--is associated with extravasation of blood into the loose cellular tissue of these parts, and is followed within a few hours of the injury by marked ecchymosis. The lids may swell to such an extent that the eye is completely closed. In some cases the impinging object lacerates the vessels of the conjunctiva and produces a sub-conjunctival ecchymosis, which may be situated under the palpebral conjunctiva of the lower lid, or close to the corneal margin on the front of the globe. The blood effused under the conjunctiva remains bright red as it is aerated from the atmospheric air. The characteristic play of colours which attends the disappearance of effused blood is observed within a week or ten days of the injury.

Firm pressure applied by means of a pad of cotton wadding and an elastic bandage, if employed early, may limit the effusion of blood; and massage is useful in hastening its absorption.

A black eye is to be distinguished from the effusion which sometimes follows such injuries as fracture of the anterior fossa of the skull, fracture of the orbital ridges, or a bruise of the frontal region of the scalp, chiefly by the facts that in the former the discoloration comes on within a very short time of the injury, the swelling appears simultaneously in both lids, and the sub-conjunctival ecchymosis, when present, is coeval with the ecchymosis of the lids. In fractures of the orbital plate and bruises of the forehead, on the other hand, the ecchymosis does not appear in the eyelids for several days, and that under the conjunctiva is usually disposed on the globe as a triangular patch towards the lateral canthus.

_Wounds_ of the orbit result from the introduction of pointed objects, such as knitting pins, pencils, or fencing foils, or from chips of stone or metal, or small shot. They are attended with considerable extravasation of blood, which may be diffused throughout the cellular tissue of the orbit, or may form a defined haematoma. In either case the eyeball is protruded, and the cornea is exposed to irritation and may become inflamed and ulcerated. The optic nerve may be lacerated, and complete and permanent loss of vision result. Sometimes the ocular muscles and nerves are damaged, and deviation of the eye or loss of motion in one or other direction results. The globe itself may be injured. Foreign bodies lodged in the orbit, so long as they are aseptic, may give rise to little or no disturbance, and are liable to be overlooked. The Roentgen rays are useful in determining the presence and position of a foreign body.

Infective complications are liable to follow injuries by bullets or fragments of shell, and they not only endanger the eyeball, but are liable to be associated with suppurative conditions in the adjacent air sinuses--frontal, maxillary, and ethmoidal--or in the cranial cavity. In purifying wounds of the orbit, and in extracting foreign bodies, great care is necessary to avoid injury of the eyeball or of its muscles or nerves.

_Fracture of the margin_ of the orbit results from a direct blow, and is followed by circum-orbital and sub-conjunctival ecchymosis, and sometimes is associated with paralysis of the optic nerve, or of the other ocular nerves. Implication of the frontal sinus may be followed by emphysema of the orbit and lids, and if there is infection by suppurative complications.

The _roof_ of the orbit is implicated in many fractures of the anterior fossa of the skull produced by indirect violence. It is also liable to be fractured by pointed instruments thrust through the orbit, in which case intra-cranial complications are prone to ensue, and these in a large proportion of cases prove fatal. When the medial wall is fractured and the nasal fossa opened into, epistaxis and emphysema of the orbit are constant symptoms. Sub-conjunctival ecchymosis, and some degree of exophthalmos, are almost always present. Treatment is directed towards the complications. When the nasal fossae or the air sinuses are opened into, the patient should be warned against blowing his nose, as this is liable to induce or increase emphysema of the orbit or lids.

#Injuries of the Eyeball.#--These injuries may be divided into two groups--(1) those in which the globe is contused without its outer coat being ruptured, and (2) those in which the outer coat is ruptured.

In cases belonging to the first group, while the sclerotic coat and cornea remain intact, the iris may be partly torn from its ciliary origin, and the blood effused collects in the lower portion of the anterior chamber; or the pupillary margin of the iris may be ruptured at several points, causing apparent dilatation of the pupil. The lens may be partly or completely dislocated, and in the latter case it may pass forward into the anterior chamber or backward into the vitreous. Among other injuries resulting from contusion of the eye may be mentioned haemorrhage into the vitreous, rupture of the choroid, and detachment of the retina.

Injuries in which the outer coat of the eyeball is ruptured may be further subdivided into two groups according to whether or not a foreign body is lodged in the globe.

Rupture of the outer coat, especially when it results from a punctured wound, adds greatly to the risk of the injury, by opening up a path through which infective material may enter the globe, and this risk is materially increased when a foreign body is retained in the cavity of the eyeball.

When the globe is burst by a blow with a blunt object, the sclerotic usually gives way, and as the rupture takes place from within outward, there is less risk of infection than in punctured wounds. The lens may be extruded through the wound, and the iris prolapsed. If the rupture is large, the conjunctiva torn, and the globe collapsed from loss of vitreous, the eye should be removed without delay. If sight is not entirely lost and there is no marked collapse of the globe, an attempt should be made to save the eye.

Wounds produced by stabs or punctures are liable to be followed by infective complications ending in panophthalmitis. When this is threatened, removal of the eye is indicated, not only because the affected eye is destroyed beyond hope of recovery, but to avoid the risk of "sympathetic ophthalmia" affecting the other eye.

#Orbital Cellulitis.#--Infection of the cellular tissue of the orbit by pyogenic bacteria is specially liable to follow punctured wounds and compound fractures, if a foreign body has lodged in the orbital cavity. It may also result from the spread of a suppurative process from the globe of the eye, the conjunctiva, or the nasal fossae or their accessory air sinuses. Both orbits may be affected simultaneously.

_Clinical Features._--The disease is ushered in by rigors, high temperature, and severe pain, which radiates all over the affected side of the head. There is exophthalmos and fixation of the globe, with redness, swelling and tenderness of the eyelids, and congestion and ecchymosis of the conjunctiva. The pupil is usually dilated, the cornea becomes opaque and may ulcerate, and there is photophobia and sometimes diplopia. Suppuration usually ensues, and the pus burrows in every direction, and may ultimately point through the eyelids or conjunctiva. Sometimes the infection spreads to the meninges, and to the ophthalmic vein, and the phlebitis may then extend to the cavernous sinus. The eyeball may be infected and destructive panophthalmitis result. The prognosis therefore is always grave.

The _treatment_ consists in making one or more incisions into the cellular tissue for the purpose of removing the pus and establishing drainage. A narrow bistoury is passed in parallel to the wall of the orbit, care being taken to avoid injuring the globe. When possible, the incision should be made through the reflection of the conjunctiva, but in some cases efficient drainage can only be established by incising through the lid. When the eye is destroyed by panophthalmitis, the propriety of eviscerating or enucleating it will have to be considered.

#Tumours of the Orbit.#--Tumours may originate in the orbit or may invade it by spreading from adjacent cavities. Those which originate in the orbit may be solid or cystic. Of the solid tumours the glioma and the sarcoma are the most common, and when they originate in the pigmented structures of the globe they present the characters of melanotic growths. Primary carcinoma begins in the lachrymal gland. Osteoma--usually the ivory variety--may originate in the wall of the orbit, or may spread from the adjacent sinuses.

_Clinical Features._--In children, the tumour is usually a glioma, and it is frequently bilateral. It generally occurs before the age of four, is associated with increased intra-ocular tension, protrusion of the eyeball, and dilatation of the pupil, and soon produces blindness. The tumour fungates and bleeds, and rapidly invades adjacent structures and spreads along the optic nerve to the brain. It is highly malignant, and recurrence usually takes place, even when the tumour is removed early.

In adults melanotic sarcoma is most common. It occurs between the ages of forty and sixty, and is almost always unilateral; and while it shows little tendency to invade the brain, the adjacent lymph glands are early infected, and death usually results from dissemination.

In all varieties of intra-orbital tumour exophthalmos is a prominent feature (Figs. 238, 239), and when the protrusion of the eyeball is marked the lids become swollen, oedematous, and dusky. The eye is seldom pushed directly forward except when the tumour is growing in the optic nerve or its sheath. When the tumour is solid, the eye cannot be pressed back into the orbit, but in cystic tumours it may to some extent. The movements of the eyeball are restricted in a varying degree, and ptosis often results from paralysis of the levator palpebrae superioris. In almost all cases there is also more or less visual disturbance. The cornea being unduly exposed is liable to become inflamed, or even ulcerated. Pain is a variable symptom; when present, it usually radiates along the branches of the first and second divisions of the trigeminal nerve. Tenderness on pressure is not always present. It is comparatively uncommon for a tumour of the orbit to invade the globe directly.

_Treatment._--When practicable, removal of the tumour is the only method of treatment, and in malignant tumours it is often necessary to sacrifice the eye to ensure complete removal. When the tumour has invaded the orbit secondarily, its removal may be impossible, but it may be necessary to remove the eye for the relief of pain.

The _orbital dermoid_ usually occurs at the lateral end of the supra-orbital ridge (Fig. 240). A less common situation is the anterior part of the orbit, near the nasal wall, and this variety, from its position and from the fact that it is usually met with in children, is liable to be confused with orbital meningocele or encephalocele. Treatment consists in its removal by careful dissection, and this can usually be done under local anaesthesia.

_Orbital aneurysms_ have already been described, Volume I., p. 317.

THE LIPS

_Herpes_ of the lips, due to a mild staphylococcal infection, is common in delicate children and in the early stages of pneumonia. A crop of vesicles forms and, after bursting, these leave dry scabs.

A more severe staphylococcal infection may give rise to a carbuncular swelling with great oedema, and lead to infective phlebitis of the facial vein and general septicaemia. Excision of the focus is indicated.

The lip is sometimes the seat of the malignant pustule of anthrax.

Painful _cracks and fissures_ are frequently met with in the middle line of the lip and at the angle of the mouth in young subjects. They usually develop during frosty weather, and as they are constantly being torn open by the movements of the mouth, they are difficult to heal. If local applications fail, it may be necessary to cocainise the fissure and scrape it with a sharp spoon.

_Chronic Induration of the Lips (Strumous Lip)._--A chronic oedematous infiltration, probably of the nature of a lymphangitis, sometimes affects the submucous tissue of the lips of delicate children. It is most common on the upper lip, and may be associated with a fissure or with chronic coryza. The lip is everted, and its mucous membrane unduly prominent. The cervical glands are frequently enlarged.

The _treatment_ consists in removing the cause and in improving the general condition. In cases of long standing it may be necessary to remove from the inner aspect of the lip a horizontal strip of tissue having the shape of a segment of an orange.

The term "_double lip_" is applied to a condition occasionally met with in young men, in which there is a hypertrophy of the labial glands in the mucous membrane of the upper lip. It is of slow growth, and forms an elongated swelling on each side of the frenum, covering the teeth, and projecting the lip. It is shotty to the feel, and the only complaint is of disfigurement. The treatment consists in excising the redundant fold of mucous membrane, including the enlarged mucous glands.

_Tuberculous disease_ may occur in the form of lupus or of ulcers. The _ulcers_ generally occur in patients suffering from advanced pulmonary or laryngeal phthisis. They are usually superficial, may be single or multiple, and are exceedingly painful.

_Syphilitic Lesions._--The upper lip is the most frequent seat of extra-genital chancre. The _chancre of the lip_ begins on the mucous surface as a small crack or blister, which becomes the seat of a rounded, indurated swelling, about a quarter of an inch in diameter. The surface is smooth, of a greyish colour, and exudes a small quantity of sero-purulent fluid. The lip is swollen and everted, and there is a considerable area of induration around. The submental and submaxillary lymph glands on one or on both sides soon become enlarged, and may reach the size of a pigeon's egg. At first they are firm, but they may subsequently soften and become painful. In some cases the sore is much less characteristic, resembling an ordinary crack or fissure, and its true nature is only revealed when the secondary manifestations of syphilis appear.

_Mucous patches_ and _superficial ulcers_ are frequently met with on the mucous surface of the lips and at the angles of the mouth during the secondary stage of syphilis. In the inherited form of the disease deep cracks and fissures form, and often leave characteristic scars which radiate from the angles of the mouth.

Gummatous lesions occur on the lips, and are liable to be mistaken for epithelioma.

_Tumours._--_Naevi_ are not uncommon on the lips. When confined to the mucous surface they may be dissected out, but when they invade the skin they are best treated by electrolysis.

_Lymphangioma._--The term _macrocheilia_ is applied to a congenital hypertrophy of the lip (Fig. 241), which is probably of the nature of a lymphangioma (Middeldorpf). One or both lips may be affected. The lip is protruded, the mucous membrane everted, and, when the lower lip is implicated, it becomes pendulous and is liable to ulcerate. The substance of the lip is uniformly firm and rigid, so that it moves in one piece, and sucking, mastication, and phonation are interfered with.

The _treatment_ consists in removing a wedge-shaped portion of the swelling on the same lines as for "strumous lip," or in employing electrolysis.

_Mucous cysts_ occur as small rounded tumours, projecting from the inner surface of the lip. They are of a bluish colour, and contain a glairy fluid. They are treated by removal of the cyst wall, together with the overlying portion of mucous membrane.

#Epithelioma of the lip# is of the squamous-celled variety, and is met with either as a fungating wart-like projection, or as an indurated ulcer. It almost exclusively occurs on the lower lip of men over forty years of age. The growth begins about midway between the middle line and the angle of the mouth, either as a horny epidermal thickening, or as a warty excrescence, which bleeds readily and soon ulcerates. The affection is said to be especially common in those who smoke short clay pipes, and it is a suggestive fact that, while epithelioma of the lip is rare in women, the majority of those who do suffer are smokers.

The ulceration spreads along the lip, chiefly towards the angle of the mouth, and downwards towards the chin, and the substance of the lip becomes swollen and indurated (Figs. 242, 243). The edges are characteristically raised and hard, and the raw surface is extremely painful, especially when irritated by hot food or fluids. The growth is liable to spread to the mucous membrane and gum, and to invade the mandible. The disease spreads early to the submental and submaxillary glands, which are best felt with one finger inside the mouth, under the tongue, and another outside, behind the mandible. The infected glands tend to become fixed to the bone, and while at first extremely hard, so much so that they simulate a bony tumour of the jaw, they later soften, liquefy, and fungate (Fig. 244). Metastasis to internal organs is rare. Unless removed by operation, the disease usually proves fatal in from three to three and a half years.

The _treatment_ consists in early and free removal of the affected portion of lip and of all the lymphatic connections in the submaxillary region and neck. Recurrence in the scar is rare; it is nearly always located in the glands.

The operation of cleaning out the glands below the mandible on both sides in men who are advanced in years is not free from risk to life, especially from respiratory complications which may or may not be traceable to the anaesthetic.

In inoperable cases benefit may follow the use of the X-rays, or of radium.

_Epithelioma of the upper lip_ is less common. It occurs with equal frequency in the two sexes, progresses more slowly, and is, on the whole, less malignant. It sometimes appears to be due to contact infection from the lower lip. It is treated on the same lines as cancer of the lower lip.