There are many ways of uniting the lip. The simplest, perhaps, consists in paring completely the central portion and then making two flaps from the lateral portions, bringing them down and uniting them to each other below the central portion, and also to it, so that they may fill up the gap left by the deficient length of the central portion (Figs. 143 and 144).

RODENT ULCER perhaps most often occurs on the cheek, especially near the outer and inner canthus of the eyelid, the ala of the nose, and the external auditory meatus; and is therefore conveniently described here. It is also met with on the scalp. Rodent ulcer is generally regarded as a form of carcinoma; it differs from ordinary carcinoma, however, in that it is much slower in its growth, and does not become disseminated, affect the lymphatics, or return after removal. Signs.-The disease is one of advanced life, and seldom occurs before fifty. It generally begins as a wart, which later becomes an ulcer; the ulcer is

FIG. 143.

FIG. 144.

Operations for Double Hare-lip.

generally single, its edges are irregular, sinuous, and a little raised, and but very slightly, if at all, indurated; its base is slightly depressed, void of granulations, generally of a pale pink color, and at times covered with a scab. The skin around is healthy, and although attempts at cicatrization are sometimes seen, the ulcer never quite heals, but slowly extends, destroying muscle, cartilage, and bone, and producing great deformity. Treatment. It should be early and widely extirpated with the knife; or if any part cannot be thus removed, what remains should be destroyed by caustic or the cautery.

STOMATITIS, or inflammation of the mouth, may be divided into the aphthous, the parasitic, the ulcerative, the syphilitic, the mercurial, and the gangrenous.

Aphthous stomatitis generally depends upon some digestive disturbance, and is common in young children. It is characterized by white patches of erosion on the mucous membrane of

the lips, cheek and tongue. Rhubarb and magnesia, and locally borax and honey, are the usual remedies.

Parasitic stomatitis, or thrush, resembles the preceding, but depends upon the presence of a parasite known as the oidium albicans. It is generally merely symptomatic of other diseases, to the alleviation and cure of which the treatment should be directed.

Ulcerative stomatitis is more serious, but is still, as a rule, superficial. It may depend upon digestive disturbance, local irritation of cutting teeth, or bad hygiene. The ulcers are covered with a gray slough, the gums are red and swollen, and the breath is foul. A stimulating plan of treatment is generally required, with attention to the digestive functions, hygienic surroundings, etc. Locally, the mouth should be rinsed out with a wash of chlorate of potash.

Syphilitic stomatitis is common during the secondary and tertiary stages of syphilis, and requires no further mention.

Mercurial stomatitis, depending upon an overdose of mercury, or some idiosyncrasy of the patient to the drug, is of less frequent occurrence in its severe forms than formerly. It is attended by foul breath, swollen tongue, spongy gums, profuse salivation, swelling of the parotid and submaxillary glands, and loosening of the teeth. It may terminate in gangrenous ulceration, with extensive destruction of the soft tissues, and sometimes necrosis of the bones. Chlorate of potash, both internally and as a mouth-wash, should be given; and the strength supported by fluid nourishment and, if indicated, by stimulants.

Gangrenous stomatitis, or cancrum oris, is a phagedenic ulceration, which begins on the inside of the cheek, and if not checked rapidly involves its whole thickness. It is very apt to terminate in blood poisoning. It appears to depend upon thrombosis of the capillaries, a condition recently shown to be induced by the presence of a specific micro-organism. It is most frequently met with in under-fed, debilitated children recovering from one of the exanthemata, or subjected to bad hygienic conditions. A dusky patch soon appears on the surface of the cheek, which becomes hard and brawny, and then black; and if the disease is not soon arrested, extensive sloughing occurs, typhoid symptoms set in, and the patient dies comatose of general blood poisoning, or of bronchitis or pneumonia. It appears to be of a similar nature to the gangrenous inflammation of the female genitals known as noma. The treatment must be energetic. The parts should be well dried, and thoroughly destroyed with fuming nitric acid; or boroglyceride may be applied in milder cases. The strength must be supported with strong beef-tea, brandy

and-egg mixture, and nutrient enemata; and recumbency should be insisted upon during convalescence, as there is a tendency to fatal syncope, which may remain for some time.

SALIVARY CALCULI are sometimes met with blocking the orifice of Wharton's duct, or, more rarely, one of the ducts of the other salivary glands. They are composed of animal matter, impregnated with phosphate and a trace of carbonate of lime. Generally they can be seen, or at any rate felt, in the interior of the mouth, as hard bodies in the course of the duct. They may give rise, by causing retention of the secretion of the gland, to swelling, pain, and tenderness in the obstructed gland, and sometimes to suppuration and salivary fistula. A slight incision over the calculus will allow of its removal with a scoop or forceps. Should stricture of the duct follow, it must be divided transversely.

RANULA is a bluish-white, semi-translucent, globular or ovoid swelling situated in the floor of the mouth beneath the tongue, and containing a glairy, mucoid fluid. It is probably produced by the enlargement of one of the mucous follicles so numerous in that situation. Mr. Morrant Baker has conclusively shown that it is not usually a dilatation of Wharton's duct, as was formerly taught. It is painless, but interferes to a greater or less extent, according to its size, with the movements of the tongue in speech and deglutition. Sometimes these cysts attain a large size and extend deeply in the neck, presenting below the jaw. Treatment.-After painting the parts with a twenty per cent. solution of cocaine, a portion of the cyst wall should be pinched up with nibbed forceps, and a good sized piece of it excised with curved scissors. A deep hold must be taken or the mucous membrane, which adheres but loosely to the cyst, will alone be caught up. The fluid should be squeezed out, and the lining membrane cauterized with a stick of nitrate of silver, and the opening kept free by the daily passage of a probe, so that healing may take place from the bottom. If a mere incision is made, the cyst is nearly sure to fill again. A seton will sometimes answer, but it is not always reliable.

CONGENITAL, DERMOID, OR DEEP SEBACEOUS CYSTS.-These cysts, which contain a grumous, sebaceous material, project both under the tongue and in the neck below the jaw. Fluctuation may be obtained by one finger in the mouth and another on the cyst in the neck. As they increase in size, they send prolongations in various directions, and are sometimes connected with the hyoid bone, or with the carotid sheath. In the latter instance the pulsation of the carotid may be communicated to the cyst. Treatment-When not too large, and apparently movable, an

attempt should be made to remove them through the mouth to prevent scarring. When too large for this, they must be dissected out through an incision in the neck.

DISEASES OF THE TONGUE.

TONGUE-TIE is due to the tongue being more or less tightly bound down to the floor of the mouth by the shortness of the frænum. It is apt, when well marked, to interfere with sucking, and, later, with distinct speech. It is easily remedied by dividing the frænum with probe-pointed scissors, taking care to direct the points downward and backward, and merely to notch the free border lest the ranine artery be wounded, an accident which, in infants, has been attended by severe, and in some cases fatal, hemorrhage. If the division of the frænum is too free the tongue may loll backward, pressing the epiglottis over the entrance of the larynx, and produce severe dyspnoea or even fatal asphyxia—“swallowing the tongue," as it has been called. On drawing the tongue forward the symptoms will at once cease, but a ligature should be passed through its tip and secured to the cheek, with instructions to draw the tongue forward with the ligature, should the symptoms recur.

NON-DIFFERENTIATION of the tongue from the surrounding tissues gives rise to the rare malformation in which the tongue appears bound down to the floor of the mouth. This condition must not be mistaken for that called ankyloglossia, in which the tongue, in consequence of cicatricial adhesions, presents a similar appearance. Divisions of the adhesions in the latter case will do much to remedy the affection.

MACROGLOSSIA, or HYPERTROPHY of the tongue, may be congenital or acquired. In either case it is rare. The whole tongue is uniformly enlarged, and sometimes so much so that it presses forward the alveolar process of the jaw and the incisor teeth, and protrudes from the mouth, hanging downward as low as the chin. When thus exposed the mucous membrane becomes cracked, spongy, and bluish-red, and is subject to repeated attacks of subacute glossitis. It appears to be due to blocking up of the lymphatics at the base of the tongue; at any rate, the lymphatics are found enlarged and distended with lymph, and the connective tissue is increased in amount and infiltrated with lymphoid corpuscles. It appears related, therefore, with elephantiasis-a condition sometimes found coexisting in the neck and other parts of the body. The only treatment of much avail is excision of part of the organ. The removal of a V-shaped piece has been attended with excellent results. It should be done before the teeth and jaw have been deformed by the pressure.

ACUTE PARENCHYMATOUS GLOSSITIS, or deep inflammation of the tongue, may be due to mercury, fever, iodism, injury, and stings of insects; sometimes there is no apparent cause. In severe cases the whole tongue is swollen, and protrudes from the mouth, interfering with speech and deglutition, and sometimes threatening suffocation. It frequently ends in abscess. It is often attended with high fever and salivation, and may be quite sudden in its onset. Treatment. Should the milder means applicable to acute inflammations fail, free longitudinal incisions, which need not be deep, should be made along the dorsum of the tongue, and the swelling will usually subside in a few hours.

SUPPURATION or ABSCESS sometimes follows an attack of acute glossitis; but the preceding inflammation may be so slight as to be overlooked. The abscess, which then forms a firm, tense, elastic swelling in the substance of the tongue, may be mistaken for a gumma or carcinoma; but the diagnosis is readily made by an exploratory puncture. A free incision is the proper treatment, the cavity filling up in a few days.

CHRONIC SUPERFICIAL GLOSSITIS, also known as psoriasis, ichthyosis, or leucoplakia of the tongue, is a chronic inflammation of the mucous membrane, and may be induced by syphilis, excessive smoking, some forms of dyspepsia, the abuse of spirits, jagged teeth, etc. It begins as a hyperemia of the papillary layer, and presents at this stage slightly raised red patches, better seen if the tongue be dried. This is followed by excessive growth of epithelium, the cells of which assume a horny character, and the patches, which were previously red, become bluish white, and, later, opaque white. Several of the patches may now coalesce, covering in severe cases the whole or greater part of the dorsum of the tongue. It is this condition to which the term psoriasis has been applied from its superficial resemblance to psoriasis of the skin. Still later, from excessive heaping up of the epithelium, the surface of the organ becomes cracked and nodular, simulating ichthyosis, a name by which it has also been called. As the pathology of the affection, however, is distinct. from that of the above-named affections of the skin, it would be better to drop these terms, and to call the affection either leucoplakia (white patches) or chronic glossitis. After variable periods, the hypertrophied papillæ may atrophy, or ulceration may occur; or the epithelium may grow into the substance of the tongue and the disease become epitheliomatous. At times the inflammation does not give rise to an increase of epithelium, the tongue then appearing smooth, glazed, and red. The disease, except when ulceration occurs, causes little or no pain,