Appreciating the earnest efforts of various authors and members of committees to educate the laity and impress on the profession the methods which should be adopted to improve results in the treatment of cancer, the author feels that he can best introduce the surgery of cancer of the lips by calling attention to certain facts which seem of special moment in cancer occurring in this situation.

Precancerous Lesions

The surgical importance of any abnormality appearing at the mucocutaneous junction of the lips, especially the lower lip, at middle life or later, cannot be too much emphasized. If the lesion persists for a few weeks or over a month, although it may be only a slight scab (Figs. 75, 76), wart, induration, or little ulceration, it may be of the gravest significance, for this is exactly the way that cancer of the lip starts. There is always a precancerous stage, and this is the ideal time for interference. Bloodgood reports cases which show that a wart situated on the lower lip may become malignant within two months after its appearance. Cancer may develop in a pipe burn within two months, and a fully developed cancer with metastases to the glands of the neck is possible three months after the initial lesion is noted. The greatest risk is in the cases where there has been a delay of more than six months before operation. Hence these early persistent lesions should be excised with a margin of healthy tissue; generally a small wedge-shaped excision will suffice. This slight operation can be easily done under local anesthesia, and with little or no resulting disfigurement. The portion removed should be examined by a pathologist accustomed to differentiate epithelial growths. It is important not to curette, burn, freeze, x-ray, or treat with radium these early lesions because, should one have already taken on malignant changes, it coidd not be recognized until the patient returned with glandular involvement. When the latter, are involved, the operation is a serious one, and the percentage of cures is very much lower than in the early eases. If the tissue prove, on microscopical examination, to be cancerous, the cervical lymph glands should lie at once excised.

Fig. 75.-This patient Is suffering from a seborrheic keratosis of the lip. It would probably have become malignant had it not been removed. (Sutton's collection).

In early cases, before the lymph glands are involved, we can hope to cure about 95 percent of our cases, but after involvement of them has taken place the statistics show about 50 percent of cures. Oui methods are improving, but two very vital factors in future success are early diagnosis and early operation.

Incidence

Cancer of the lips is comparatively common in men and very rare in women, and usually occurs upon the lower lip. Steiner* reports 140 cases of cancer of the lower lip and 12 of the upper, Judd" has had 153 of the lower and only three of the upper, while Rowntree* gives the ratio as 234 to 7, and also states that six times as many cancers arc found upon the side of the lip as upon the center. Bloodgood's* statistics show 161 epithelial tumors of the lower lip and 21 of the upper lip. Cancer of the lip appears about or after middle life in the vast majority of instances (Fig. 77), but may occasionally develop in the young. Hertzler shows a marked example in a boy of 16, and the author illustrates a case in a man of 27 (Fig. 78). Cancer of the lip is much more common than benign affections of these organs.

Fig. 76.-This man has a very extensive seborrheic keratosis of the lower Up. (Sutton's collection).

Etiology

Irritation of the lips seems to be the most potent factor in the etiology. A smoker's burn of the lower lip is the commonest cause of irritation, but ragged teeth, or the habit of biting or picking the lips may cause sufficient irritation. Cigarette smoking, where l ho paper stuck to the lips and left irritation when removed, was apparently the cause of one cancer under the writer's observation. The early abnormality may be a slight ulcer or loss of epithelium, or there may be an epithelial hypertrophy and a resuiting wart. Some lesions may persist as benign lesions for several years, and then degenerate, but generally the change is early and often very rapid, as has already been stated.

*Judd: Old Dominion Jour. Med. and Surg., 1008. vli. 399.

*Rowntree: Arch. Middlesex Hosp., 1908, vll. 119.

*Bloodgood: Jour. Amer. Med. Assn.. 1910. Iv, 1537, 1616.

*Surg. apilM. and Obst., April. 1914. 404.