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).

[Illustration: FIG. 463

Mixed tumor of the parotid. (v. Bruns.)]

[Illustration: FIG. 464

Mixed tumor of the submaxillary gland. (v. Bruns.)]

Cancer of the parotid is especially serious and discouraging, because, while radical removal is necessary, it is impossible to effect this without destroying the facial nerve and producing consequent paralysis of the face on that side. Such an operation should not be made without explaining to the patient beforehand its inevitable result. Only when seen in their very early stages can these tumors be so effectually removed as to not leave the patient liable to secondary or metastatic affections. This also should be explained to them in order that the surgeon may protect himself from blame.

SALIVARY CALCULI.

Calculi which form either in the substance of the glands, or much more commonly in their ducts, by precipitation of those salts held in solution by the saliva, are of the same character as the accumulations of the so-called tartar upon the teeth. They are met with frequently in Wharton’s duct and occur more often in men than in women. They may vary in size from that of a rice-grain to a stone more than one inch long. They are always ovoid in shape and with a rough exterior. They are believed to grow much as do gallstones, as the result of some previous infection, a clump of bacteria perhaps affording the nidus on which calcareous material is deposited. The affection may be spoken of as _sialolithiasis_.

They usually give rise to pain and swelling, and lead occasionally to the formation of abscess and fistulous openings. They may be revealed by the _x_-rays, or the operator may search for them as for stone in the bladder, with a small probe passed through the duct opening. The discharge of mucopus or blood into the mouth would suggest infection of this kind. They may also be recognized by thrusting a needle through the overlying tissues in the direction of the swelling which they produce. Their removal through the smallest incision on the interior of the mouth which will suffice for the purpose is indicated. No attempt need be made to close the opening.

Operations on the parotid region are difficult and severe. In case of large tumors the external carotid and the common carotid may be ligated. By separating the patient’s jaws the parotid space is increased and deep dissection is more easily made. Caution should be taken not to open the maxillary joint. Souchon has called attention to the fact that the safest plan is to proceed so long as the surrounding tissues are easily removed _en masse_, and to stop when they become too resistant as the deep surface is approached. Then the portion of the tumor which has been cleared should be cut off. The stump thus left will, in growing again, become more superficial, and it is sometimes possible to effect a radical removal by a second operation.

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