Monsters are born with almost complete absence of the face, which is called aprosopia. They have also been observed with double faces. Again a condition of congenital hypertrophy is known involving one or both sides. On the other hand congenital atrophy is also occasionally noted, affecting one or both sides. The former is likely to be of syphilitic origin (hereditary), in which case it will be accompanied by other indications such as corneal opacity, irregularity of teeth, or other evidences of its luetic origin.

Among the most interesting congenital defects are those connected with imperfectly closed branchial fistulas and the various outgrowths therefrom. These may lead to fissures extending from the ear to the mouth. Fibrocartilaginous growths occur along the regions of the original branchial clefts, either as tags of skin upon the face or so-called supernumerary auricles or auricular appendages. While these are covered with skin they usually contain a cartilaginous nucleus. They are most common in front of or on the tragus. They may be single, multiple, or symmetrical. They sometimes increase in size and at others remain stationary.

Fissures are seen more often upon the central portions of the face, especially in the nose or between it and the cheek. About the root of the nose and the orbit dermoids are somewhat common. They may be connected with fissures or fistulas, and extend upward and involve the dura.

Absence of the mouth is known as astomia, and of the lips as acheilia. These malformations are exceedingly rare. Atresia, or narrowing of the mouth, is more common. While the lips and mouth may be apparently well formed there may be imperfections. These conditions of narrowing call for division on each side and union of skin to mucous membrane. Fistulas of the lip are extremely rare, but are found occasionally, especially opening upon the lower lip. Branchial fistulas opening upon the lips have also been observed.

A condition of arrest of development of one or both jaws leads to unnatural smallness of the mouth known as microstoma. The opposite condition, macrostoma, is produced usually by fissure of the cheek on one or both sides, extending upward and backward from the labial junction and due to incomplete closure of a branchial cleft. The most common congenital defect of the lip known as hare-lip is a median fissure involving the upper lip. This occurs in all degrees, from a trifling notch at the vermilion border to a hideous defect, in which, through a wide cleft, projects a relatively overdeveloped intermaxillary bone, with a small downward projection of skin, known surgically as the philtrum. This defect may involve much more than the lip alone, for there may be failure to unite, along the median line between the lip and the uvula, of those portions of the superior maxillary which should develop symmetrically, and coalesce as they are formed from the rudimentary maxillary processes. Any portion, then, of the hard or soft tissues may show failure to unite in the middle line.

Hypertrophy of a lip is known as macrocheilia. It is not uncommon in strumous subjects. Another form is known as mucous ectropion. (See p. 373.)

The chin may be malformed in the direction either of atrophy or the reverse, as in the so-called double chin. A deviation forward, known as galoche chin, is also recognized. A peculiar malformation, consisting of the implantation of a supernumerary inferior maxilla by its own symphysis upon that of the subject, is known as hypognathy. Such a tumor will occasionally develop to considerable size, with cystic degeneration or other irregular changes.

Aside from the common forms of hare-lip most of the congenital defects that occur about the face are to be explained through incomplete closure of the branchial clefts or the development of dermoid cysts and tumors therefrom. Deviations rather than defects appear more commonly about the nose than anywhere else. They produce disfigurements known as pug-nose, saddle-nose, parrot-nose, etc. Again, double noses exist, each being more or less well formed. In such a case the surgeon should endeavor to remove a part of each and unite the remaining portions in one, unless one of them be placed away from the middle line, in which case it may be extirpated.

ACQUIRED MALFORMATIONS OF THE FACE.

These are usually the result either of mutilation or of some ulcerative morbid process. Injuries of the face, unless extremely carefully and promptly attended to, are commonly followed by scars, which may cause great disfigurement. This is invariably true of severe burns, which, by subsequent contraction, draw features badly out of shape, and sometimes close the mouth or pull the lower jaw down upon the neck and the chin upon the chest. Serious contused wounds are frequently accompanied by fracture of parts beneath, and should be treated as a compound fracture. Considerable portions of the facial mask are sometimes torn away, producing hideous appearances. By punctured wounds the maxillary sinus, orbit, or brain cavity may be perforated and foreign bodies carried in. A wound may be so placed as to sever Stenson’s duct. All of these injuries may be accompanied by serious brain disturbance, as the result of the contusion. Gunshot wounds will present either punctures or extensive lacerations, according to the proximity and the weapon. In no part of the body are gunpowder stains more observable or more deplored than upon the face. In order to prevent them each grain of powder must be picked out with a small spud or needle, after a careful scrubbing of the face. Every grain of gunpowder allowed to remain will produce a minute area of staining.

Injuries to the nose may require plastic reconstruction or the formation of a new nose by one of the rhinoplastic methods later described, or an artificial nose, carried by spectacles, may be worn. The cartilages of the nose are frequently dislocated, thus producing deformity, and the same result may follow fractures. As already indicated in the chapter on Fractures, prompt and complete replacement with support are usually sufficient to give a satisfactory result.

Deviations of the nose, and especially cosmetic defects which result from injuries or disease, producing the so-called saddle-nose, when not extreme, may often be remedied by the injection of paraffin, the patient being either under cocaine or general anesthesia.

Burns, injuries, and serious ulcerations about the cheeks and lips produce conspicuous disfigurement (perhaps none more so than a serious form of cancrum oris) with a considerable loss of substance. In this way may be produced an acquired microstoma, or adhesion of cheek to jaw, which is known as syncheilia. More superficial lesions may produce ectropion or eversion of the lips, or acquired macrostoma. Cretins, idiots, and patients with facial paralysis acquire gradually a chronic swelling of the lower lip with drooling of saliva. The lip may enlarge to such an extent as to ulcerate as the result of exposure. Frostbite also produces serious deformity by ulceration of the skin. When a puncture of the cheek occurs at the opening of Stenson’s duct, i. e., opposite the second upper molar tooth, there may occur a salivary fistula. In a recent clean wound the duct ends may be stitched together. In old wounds Souchon recommends to introduce catgut into the distal end, and then by pressure on the parotid to discover the proximal end and stitch it with the catgut in the divided portion; or the wound may be enlarged and the proximal end turned into the mouth and there retained.

Considerable emphysema may follow contusions of the face, especially those causing fracture of the nose. In this way a face may be so distended as to produce almost a caricature of its former appearance; this, however, will subside within a few hours.

By virtue of its extreme vascularity wounds and injuries of the face heal with a surprising degree of promptitude and certainty. This affords the reason for the satisfactory results of extensive plastic operations. For the same reason secondary hemorrhages may easily occur and additional precautions should be taken. Exact hemostasis, before closure of wounds, will afford protection as against this event. Wound edges should be neatly trimmed and subcutaneous sutures may often be used to advantage to minimize the resulting scars. A lesson “how not to do it” may be learned from the faces of German university students who have indulged in the common but senseless sport of duelling, and who are said to rub salt and alum into their cuts in order to make the scars as conspicuous as possible.

NEUROSES AND CONSEQUENCES OF INJURIES OF NERVES OF THE FACE.

Anesthesia of parts supplied by the trifacial necessarily follows division of its various portions. It may also occur as the result of a deep-seated or central lesion. In course of time more or less sensibility will return, apparently due to an anastomotic process. Facial paralysis, so-called Bell’s palsy, may be of central origin, or be due to the effects of a “cold” following exposure, apparently with inflammation of and an exudate around the trunk of the facial nerve as it passes through its bony canal in the temporal bone. It is also the result of a division of the nerve trunk either outside of the bone or in the bony canal, where it is occasionally wounded in operations upon the mastoid or in removal of the parotid for malignant tumor. Facial neuralgia is an affection of one or more of the branches of the fifth nerve, and, when assuming a spasmodic and intermittent type, is often spoken of as tic douloureux. Its exciting cause may be a carious tooth, even though it give no pain, while other causes are lesions in the neighborhood, such as callus, foreign bodies, tumors, bone disease, and the like. Its special treatment has already been indicated in the chapter dealing with the Cranial Nerves. Many of these cases of neuralgia gradually diminish the patient’s strength.

ULCERATIVE AND GANGRENOUS LESIONS OF THE FACE.

The serious ulcerative lesions of the face are usually due to tuberculosis, syphilis, or malignant disease. In all of these conditions there will be enlargement of the neighboring lymphatics. This is true also of the lesions of actinomycosis, which should not be forgotten as a possible cause. The free border of the lips is occasionally ulcerated in patients with pulmonary tuberculosis. Otherwise tuberculous lesions are uncommon upon the lower lip, while in the upper lip they show a tendency to invade and spread. Syphilitic ulcers may be either primary chancres, which are most common on the lower lip, or the results of mucous patches, or other secondary or tertiary lesions. Of the cancerous ulcerations, which tend always to break down and spread, without any tendency to healing in the centre, epithelioma is the most common form. It is a frequent disease in men, occurring much oftener on the lower than upon the upper lip. In women it is exceedingly rare at this point. The difference is explained by the liability to constant irritation incurred by those who smoke pipes or are particularly careless about their teeth. Of epithelioma there are, as is well known, various types, including the so-called rodent ulcer, which, however, is less frequent here. The location of the lesion subjects it to constant irritation, as well as maceration from the moisture of the mouth. Such a growth may be superficial and raw, or it may be covered by scale or crust. It will nearly always have an indurated and raised periphery. A papillary form, with non-indurated edges, is also known, as well as a diffuse form, where several minute lesions seem to coalesce, with elevation of the central portion. This is perhaps the most malignant of all, as it has no well-defined boundaries. In nearly every well-marked case involvement of the submaxillary lymphatics can be detected. All of these cancers of the lip and face should be removed, with plastic re-arrangement of the parts. Growths of this kind seen early, before much tissue is involved, can be removed with permanent success. Error is made on the side of not doing sufficient rather than doing too much. (See Chapter XXVI.)

Cancrum oris has already been described in the chapter on Gangrene. The extensive destruction which it may cause is also described there. The condition, when seen and recognized early, has been successfully treated by local applications of bromine and the actual cautery. It is, however, a destructive and unpromising condition with which to deal, as it rarely occurs in healthy children, but usually in those with a constitution already vitiated by heredity or environment. (See p. 75.)

TUMORS OF THE FACE.

The parts described in this chapter may be the site of almost every tumor which is met with in any other part of the body; in addition to which there are two which are peculiar to the nose and adjoining tissues. These are rhinophyma and rhinoscleroma. They have both been described briefly in the chapter on Tumors, and each is to be differentiated from the other, having a very different etiology.

Rhinophyma consists of vascular engorgement, with hypertrophy, especially of the glandular and connective-tissue elements of the skin, which begins about the tip and the alæ of the nose, and produces disfiguring deformity. It is, however, at first, quite innocent in its character. It occurs most often in hard drinkers, and is to be regarded as an overgrowth, coupled with a large amount of secretion, of the sebaceous glands of that portion of the skin. This secretion is often so great as to escape and lead to the formation of scabs, as it dries, until more or less ulceration takes place. The nasal enlargement is rarely symmetrical, and is nearly always lobular, so that the overgrowth may consist of a series of nodules whose escaping secretion becomes offensive. The parts are often discolored, even to a purplish color, in consequence of venous stasis. Frostbite frequently predisposes toward it.

Treatment in incipient cases may consist of a sort of massage, by which the overloaded glands are emptied. In more serious instances the diseased tissue should be extirpated, and either left to granulate or be covered by a plastic operation.

Rhinoscleroma is a serious and fatal lesion, consisting of a parasitic invasion by a peculiar bacillus. It begins as a painless induration, either at the edge of the nostril or upon the upper lip, grows slowly, the tissue affected becoming firm and dense. The growth is usually lobulated, with fissures or excavations between the lobules, which may crack and give rise to a yellowish discharge that dries into crusts. While the affection may begin in the deeper parts of the nasopharynx its occurrence there is usually the result of extension from the anterior growth. The disease may occur either in the young or in the adult. A case illustrated elsewhere (see p. 55), for which I am indebted to Dr. G. W. Wende, proved fatal after a couple of years. In this country it is rare, but occurs frequently in some portions of Russia.

For treatment there is but little encouragement, least of all for operative intervention. Growths nearly always recur after removal.

In the cheek cysts of Stenson’s duct and dermoid tumors and cysts have often been observed near the parotid region. The so-called “fatty ball of Bichat” is occasionally the site of an angioma, which may press upon Stenson’s duct and be accompanied by calculus in the parotid gland, the superficial veins being much dilated. (Souchon.)

Fatty tumors, as well as sarcoma in this same tissue, are prominent. The most frequent tumors of the face are the epitheliomas of the lip, nearly always of the lower lip, occurring oftener in men than in women. A growth of this character at this site is regarded as an expression of the result of irritation, which may be produced by a carious tooth or by constant friction of a pipe-stem, or from many other causes. It frequently develops at the site of an old chronic fissure. These growths spread from small beginnings, and if, when small, they were extirpated there would be fewer cases of cancer of the lip spreading to and involving the face and neck. Every ulcer of the lip whose base becomes indurated, and from which the syphilitic element can be excluded, should be excised, the ensuing defect being repaired by a plastic operation. (See above.)

OPERATIONS UPON THE FACE AS A WHOLE.

The tissues composing the face are extremely vascular, hence hemorrhage is profuse and hemostasis should be exact. By virtue of this same rich blood supply the process of repair is prompt and satisfactory, if sources of infection be avoided. Patients here, more than anywhere else, desire a minimum of scar. Incisions, then, should be so planned as to permit the utilization of the natural folds or grooves of the face. They should also be so made as to avoid injury to main trunks of vessels and nerves, as well as to Stenson’s duet. Sharp knives and the least possible bruising of the tissues help to ensure the desired result. When possible a subcutaneous suture should be employed. When this is not sufficient fine needles and fine suture material should be used. A reasonably short, clean wound upon the face, especially in the neighborhood of the mouth, should be protected from the air until it is dry, using a dusting powder and then covering with collodion. In extensive operations provisional or permanent ligation of the carotid may be necessary; usually the external branch will suffice. In every instance plastic repair should be made, as it will always be required after the excision of growths involving the surface.

Space does not permit of detailed or specific directions for all possible methods of plastic repair of facial defects, but Figs. 421 to 441 illustrate the principal methods which may be utilized in planning and sliding flaps which shall serve this purpose. These may be modified or combined to meet special indications.

It is often necessary to intermit the anesthetic because the operator must displace the mask in order to do his work. Souchon advises an apparatus by which most of this delay can be avoided. By means of a rubber bulb a current of air is passed through the bottle containing the anesthetic and then directed through a tip which is passed down in the pharynx through a nostril. This may be connected, if so desired, with a bag of nitrous oxide gas, which is illustrated in Fig. 442, and its use in Fig. 443.

Ligation with excision of a section of the external carotid has been suggested by Dawbarn as a means of cutting off the blood supply in cases of inoperable malignant tumors of the face, thus reducing their rate of growth. In tumors of the jaw, for instance, he would also tie the inferior dental artery, with its mylohyoid branch, just before it enters the inferior dental canal. He advises, also, the removal of one inch of the inferior dental nerve, thus avoiding pain and distress, occluding the artery on the less diseased side first, waiting for two or three weeks before attacking the more diseased side, for should there be noticeable benefit after operation on the more affected side many patients would be unwilling to be again subjected to the other operation. Other operations include those made upon the various nerves for relief of neuralgia or for nerve suture of divided trunks. These have been described in a previous chapter.

OPERATIONS ON THE NOSE.

Plastic operations upon the nose appear to have been practised early in the history of surgery. The East Indians had a method by which the skin of the forehead was made to furnish a flap from which a new nose was created. This was known as the Indian method. It has been somewhat modified of late years by raising with the skin flap the periosteum, or, as suggested by König, the outer table of the frontal bone, with the intent and hope that something resembling the nasal bone might be secured. The so-called Italian method (named the Tagliacotian operation, after Tagliacozzi) consists in utilizing the skin of the arm, which is loosened according to a pattern previously made, leaving it connected only by a pedicle through which its blood supply is to be afforded. This flap is usually cut out and perfectly formed, then left loose upon the arm for about fifteen days until its viability has been thoroughly proved and its under surface is granulating. Then the edges of the defect in the nose are pared, as well as those of the flap, and the arm is brought into such position as to allow fitting the latter to the former, where it is held by stitches. The arm is held in proper position by cushions and by bandages of plaster of Paris until union has taken place, after which the pedicle is severed and the arm then released.

Lesser deformities of the nose may be remedied or repaired in various ways. Angular deformities may be excised, while a sunken bridge may be raised, as Weir has suggested, through a bevelled incision at the junction of the nasal and maxillary bones, they being held in place by a transfixion pin. One of the most common and objectionable deformities is the so-called saddle-nose, which may be treated by Weir’s method, or which has afforded satisfactory results after the injection of paraffin. Roe, of Rochester, New York, has succeeded in remedying many of the more trifling nasal deformities by operation from within the nose, as, for instance, in case of pug-nose, where he dissects from within superfluous fat and connective tissue (Fig. 444).

HARE-LIP AND OPERATIONS UPON THE LIPS.

Hare-lip, or coloboma of the upper lip, is due to a failure in coalescence of the developing maxillary processes, which should unite early in fetal life to form the lip, alveolar process and roof of the mouth. This failure may involve but a trifling part of this line of normal junction or may be complete. Thus anywhere along it defects may be noted, such, for instance, as a little notch in the lip, a small opening in the hard or soft palate, or a bifid uvula. The defect in the lip alone is known as hare-lip because of its normal occurrence in the hare, and occurs on either side of the median line, absolute median fissure being extremely rare. It may occur alone or in combination with deeper fissures which involve the gum or the alveolar process alone or the entire palate. In extensive fissures of this character development is rarely symmetrical, and one side is usually not developed sufficiently to match the other. This makes operative treatment the more difficult. The more complete and extensive fissures are often complicated by excessive development of the intermaxillary bone, apparently from lack of pressure. This permits a projection of the septum, and especially of the central portion of the alveolar process, with a small part of the skin and connective tissue, which should have been blended into the lip proper. It represents the original intermaxillary bone with the portion which should have been developed downward from the nasal process of the midfrontal region. This gives a snout-like appearance to the face, and nearly always necessitates doing an operation for closure of the lip in two sittings. In Figs. 445 and 446 will be seen wide clefts with projecting intermaxillaries, while Fig. 447 illustrates a much more complete coloboma of the face, with complete bilateral fissures. Figs. 448 and 449 show the double form with philtrum or snout. Figs. 450 and 451 give the palatal conditions of irregularity and projection of the intermaxillary bone. (See Cleft Palate.)

All forms of hare-lip call for operation not alone for cosmetic purposes, but so that patients can nurse, drink, eat, and talk to better advantage. Obviously the earlier such operations are done, other things being equal, the better the results. When the cleft does not include the deeper tissues it may be closed within the first week or two of infancy. When the roof of the mouth is involved the surgeon is perplexed in deciding which is the better of two courses—to operate or to wait. Unquestionably by early closure of a fissured lip a gentle but constant influence is maintained to press the divided upper edges together, or at least to influence their more rapid growth toward each other. For this reason it would be desirable to operate early. On the other hand with a bad palatal defect it is a difficult thing to operate until, with the increasing age of the child, the mouth has attained a size which will permit the manipulations required for the purpose. Nevertheless, unless there be some special reason for delay it would appear wise, at least as a general rule, to operate early. (See Cleft Palate.)

The underlying principle of these operations is easily and briefly stated. The edges of the defect should be freshened and brought together by sutures. Extreme care should be taken that the vermilion border of the lip be maintained. A little particle of mucous membrane in the lip of an infant, dislocated to a level higher than that where it belongs, will appear later in life as a reddish patch upon the skin, which will prove quite a disfigurement. Simple fissure of the lip is easily managed by Nélaton’s procedure (Figs. 452 to 457). The deeper and more extensive the fissure the more plastic reconstruction is required.

Incision, when necessary, may be extended around the angle of the nose on one side or both, and the lip should be dissected away from the bone sufficiently to make it movable. Operations by which a certain dovetailing of the little flaps is performed afford more security than a perfectly straight incision, but the resulting scar is rather more marked. The more perfectly the mucous membrane can be preserved upon the under side of the lip the better will be the result.

Hare-lip pins have been abandoned. Sutures only are used, which may be of thread or horse-hair, catgut absorbing too rapidly. It is my custom to pass a retaining suture of stout silk through the cheek on either side, at a distance of one inch or so from the wound margin, to bring this forward in front of the alveolar process, and, by using a plate and shot on either end, to prevent tension upon the line of junction. This is very important, for children will fret and cry in a manner to tear out many a stitch not thus fortified. After operation young children should be snugly enclosed in a protective bandage around the chest, by which it shall be made impossible for them to get their hands to their mouths. It is vitally necessary to maintain absolute rest of the face and protection from any possible source of harm.

Fissures of the lower lip are surgical curiosities. Should one be met it may be treated on the same general principles.

The other cheiloplastic operations upon the lips are those made necessary by excisions of malignant growths, or by deforming cicatrices such as follow burns, syphilitic lesions, and the like.

Fig. 460 illustrates one method of filling a defect of the lower lip, while Figs. 461 and 462 indicate a method of bringing down a flap from the upper lip for the same purpose.

THE SALIVARY APPARATUS.

FOREIGN BODIES IN THE SALIVARY DUCTS.

Foreign bodies occasionally enter the salivary ducts, especially Stenson’s and Wharton’s, where they may set up an inflammation known as sialoductilitis. These may consist of bristles, fish-bones, and the like. Abscess, in consequence, may form in the gland or between it and the foreign body. Calculi also lodge in the ducts, where they remain as foreign bodies, producing sometimes a disproportionate amount of irritation.

FISTULAS OF THE SALIVARY DUCTS.

Fistulas of the salivary ducts involve Stenson’s duct. They open on the inside of the buccinator muscle, back of the orifice of the duct, which is opposite the second upper molar tooth. These fistulas of the parotid gland may be recognized by the passage of a probe from within the mouth. When they open externally they result nearly always from injury, and it is only the external forms which are troublesome. One may resort to the mildest measures first, and experiment with cauterization of the orifice or compression by occlusion. These measures will be ineffective if there be no opening upon the inside of the mouth, in which case one must be made by reëstablishing the original canal or forming a substitute. For this purpose a suture may be passed around the duct, back of the fistula, using a curved needle, and making it come out near the point of entrance. It should hold the duct in its loop. This suture may then be tightened and the distended duct punctured on the inside of the cheek. When once the flow of saliva is diverted to the mouth the edges of an external fistula may be pared and closed. In obstinate cases which have resisted all other methods it has been suggested to remove or destroy the gland which connects with the duct at fault. Even this is not an easy matter, but it can be done in the case of the parotid by careful dissection, with separation of the branches of the facial nerve and removal of the greater portion of the gland itself.

Congenital anomalies of the salivary glands are rare and of small import. Any one of them may be displaced, or either of them may connect with an accessory gland separated from it by an appreciable interval. Abnormal duct openings have also been noted.

INFLAMMATION OF THE SALIVARY GLANDS.

Inflammatory affections of the salivary glands give rise to sialoadenitis. Among these by all means the most common is parotitis (mumps), which often occurs in epidemic form. It is an infectious and probably contagious disease, usually attacking the young, though no age is exempt. The period of incubation is about fourteen days. The condition begins with a stomatitis and with swelling of the affected parotid, with edema of the overlying tissues. It is accompanied by moderate fever. Swelling may be extensive and involve the entire neck region. The parotid on the other side becomes affected within a few days, although usually not to a similar extent. The other salivary glands occasionally participate. The febrile stage lasts for about a week, after which the swelling recedes and is gone within from two to four weeks. Occasionally the affected glands suppurate, in which case the condition may be very serious, since it may simulate Ludwig’s angina, or may be followed by sloughing and gangrene.

Save when abscess threatens the treatment should consist of warm antiseptic mouth-washes and the external application of an ichthyol-mercurial ointment or of Credé’s silver ointment. When suppuration threatens early incision should be made for the relief of tension and prevention of destruction.

A frequent and important complication of parotitis is orchitis, or swelling of the testicle. This is an unexplained feature of these cases, and occurs mainly in sexually mature individuals. It is the testis proper which suffers and not the epididymis. Suppuration here is rare. More or less atrophy is a remote consequence in many cases, estimated at about one-third. When both testicles are affected to a marked degree impotency may follow. Treatment of this orchitis consists in absolute rest in bed, with elevation of the parts affected, often with the application of an ice-bag. Painting the scrotal skin with guaiacol in small amount will often relieve pain. A similar complication occurs in the female, the ovary being involved. Aside from this, other complications may occur in the breast, the vulvovaginal glands, the prostate, the heart, the eye, and the ear.

Apart from this somewhat specific affection the parotid and the other salivary glands may become involved in swelling and inflammation on account of surrounding local infections, or the presence of foreign bodies, stones in the ducts, etc. Metastatic abscesses, especially in the parotid, are not uncommon. Considering the open pathways offered it is surprising that these glands are not oftener involved in septic conditions of the mouth.

MIKULICZ’S DISEASE.

Mikulicz has described a not very infrequent simultaneous affection of two or more of the salivary glands, occurring in middle age, characterized by uniform swelling which may involve even the palatine, labial, and buccal glands. It is spoken of in German literature as Mikulicz’s disease. The swelling progresses slowly, so that the glands reach a varying size in the course of years. Thus the parotid glands may attain the size of the fist, and other glands a corresponding increase. Sometimes the adjoining lymphatics are also involved. The enlargements are not tender, but may interfere with movements of the tongue and jaw. These tumors have been known to recede after an intercurrent acute disease. Nothing is as yet known of the cause or nature of the affection. In its treatment arsenic and potassium iodide have given perhaps the most favorable results.

The salivary glands, especially the parotid, are as likely to be involved in the manifestations of tuberculosis, actinomycosis, and syphilis as are the other structures of the body. Lesions of these various natures will be appreciated without further description.

TUMORS OF THE SALIVARY GLANDS.

Tumors of the salivary glands are not uncommon. The parotid is more frequently affected than either of the others. These tumors may be of cystic character, either large from obstruction of the excretory duct, or small and numerous. Almost all the tumors described in Chapter XXVI may be found in this region. Simple adenomas are common and the parotid especially is often the site of tumors of mixed character, in which the various mesoblastic elements mingle in a confusing manner. Cartilaginous tumors here are frequent. The presence of cartilage is to be explained on Cohnheim’s hypothesis. Endothelioma, sarcoma, and carcinoma are also common, especially as primary tumors in the parotid. Any or all of the glands may also suffer by extension of malignant disease from primary foci in their neighborhood (Figs. 463 and 464).