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.
CHAPTER XL.
THE MOUTH, THE TONGUE, THE TEETH, AND THE JAWS.
CONGENITAL DEFECTS.
Aside from anomalies due to incomplete closure or erratic development from the branchial clefts, the principal congenital defects of the regions included in this chapter are as follows: The mouth is essentially a coalescence of the upper end of the foregut and a recess known as the stomodeum, which are at first separated by membrane, the latter disappearing early in fetal life. Some remains of it, however, may produce a narrowing of the oral fissure and cause one form of microstoma. Some of these facial defects are due to formation of amniotic bands and adhesions, which restrain or interfere with the normal development from the branchial fissures. Malformations of the tongue may accompany other anomalies. A median cleft, called also a bifid tongue, and defective development and undue adhesions to the floor of the mouth, are known, whose most trifling expression may be seen in the so-called tongue-tie, where the frenum is too short and needs to be divided in order to release the tip and more movable part of the organ. Adhesive bands may also attach the tongue laterally to the cheek, bands between the cheek and the gums being also occasionally seen. An extreme type of tongue-tie is known as ankyloglossum. Abnormally long tongues are also met, and cause an actual menace from danger of the tip being swallowed, as children have suffocated from this cause. Congenital macroglossia has been described; it is usually due to lymphangioma of the tongue. A condition known as lingua plicata is characterized by moderate enlargement of a number of either longitudinal or transverse folds or rugæ. The covering mucosa, however, is normal. Complete absence of the tongue has been noted.