286

Kurt

H. Thoma, Henry

D. Howe, and Martin

Wenig

betalin, and 500 cc. amigen, 1 C.C. liver concentrate intramuscularly, and 4 grains iron; this was repeated on September 14. On September 35 the patients condition changed for the worse; he had Cheyne-Stokes respiration; the temperature, pulse rate, and respirations were all elevated. The nonprotein nitrogen was 52 mg. per liter. He was given 2 cc. cedilanid intra.muscularly. In spite of all efforts, however? the patient died on September 16. Pathologic report, gross : a hemispherical mass of friable, moderately soft, gray-brown meaty tissue, measuring 12 cm. in diameter and 7 cm. high, was covered on the round surface with skin that was partially covered with hair, and in some areas was thin and irregular with many sessile and pedunculated nodules measuring up to 2 cm. in diameter. The flat amputation surface was red and covered with a thin layer of fascia. The tumor tissue extended everywhere to the amputation surface. On section the mass had a 2 cm. broad capsule of light gray meaty tissue within which was a yellow-pink mass of soft necrotic tumor tissue. Diagnosis: Carcinoma, type undetermined (Fig. 427).

Case DfZ Unilateral Parotid Swelling

D.M.D., M.D.
DAVID WEISBERGER,

H. S. (474528)) a 21-year-old woman, enfered the hospital on Jan. 9, 1945, with a swelling on the left side of the face. About two and one-half months ago the patient was delivered of her second child without complications. Five days later a swelling in the left preauricular area was noticed; this gradually enlarged and became tender. The whole side of the face was involved and the eye almost closed. The swollen area became painful, and the skin red and shiny. The face was numb and t,he patient could not move the left side; she had difficulty in opening the mouth to eat. Originally the pain had been limited to mealtime, and was present under the left mandible. About one and one-half months ago the swelling reached its maximum. During t.his time the patient had a fever for about ten days. She had been in another hospital for two weeks where sulfonamides and penicillin were given, and inAbout cision and drainage were performed twice at about a weeks interval. one month after the swelling on the left appeared, the right side started to swell. There was a small mass in the preauricular area, but this never enlarged over a few centimeters and was not painful and not tender. It disappeared while the patient was in the hospital. Shortly after the last incision and drainage, a small, red swelling appeared on the left side below the site of the drainage, and has persisted to the present time, although it has gradually decreased in size. The patients general health has been good, although she had headaches, dizzy spells, and tinnitus. Last summer she had a watery discharge from the nose when she bent over. Examination showed a small, 2 by 3 cm., oval, fluctuant swelling in the left preauricular area. The edges overlying the skin were inflamed, and the central area was yellow in the most fluctuant part. There was only slight tenderness. The parotid tissue seemed to extend several centimeters beyond the edges of There was a scar from the previous inthe raised mass, and felt indurated. cisions. The ducts in the mouth were normal ; no pus could be expressed.

Clinic

of Massachusetts

General Hospital

Fig.

428.-Sialogram

of parotid II, Parotid

gland duct;

showing several P, pocket Alled

dilated pockets with lipiodol.

filled

with

lipiodol.

Fig.

429.-Exaggerated

lipiodol.

Waters D,

position. Parotid duct;

Sialogram P, pocket

showing fllled with

dilated lipiodol.

pockets

fllled

with

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Kurt

H. Thoma, Henq

D. Howe, and Martin

Wenig

Impression : Bilateral parotid tumor. Sialograms were advised. A sialogram taken on January 10 showed the left parotid gland and duct to be of normal size. The lateral and anterior portion of the gland showed several dilated pockets consistent with sialectasis (Figs. 428 and 429). At this time the white cell count was 8,850 ; hemoglobin, 96 per cent ; prothrombin time, 17 seconds, normal 18 to 20 seconds; serum amylase, normal. On January 16, 4 cc. of grayish-yellow pus was aspirated from the abscess cavity through normal tissue. The culture showed Staphylococcus dbus. On the next day 4 CC. of grayish fluid was again aspirated, and the cavity collapsed. It was irrigated with 4 C.C. penicillin. The patient tasted a salty fluid in the mouth, and the fluid was reaspirated and a pressure dressing applied. X-ray examination showed that the lipiodol previously injected into the left parotid gland had ,entirely disappeared. On January 18 the patient was shown at grand rounds, and it was decided that a regime of multiple aspirations with penicillin therapy should be followed. Two days later after dinner the patient complained of severe headache on the right side and vomited once or twice. She had blurring of vision. She stated she had had similar attacks previously. Codeine brought relief. Impression : Migraine. On January 25 the patient was seen in dental consultation. Examination of the secretion of the left parotid gland revealed a scanty and viscid saliva which could lx seen oil17 aft:r s+::nl -to:l up31 chcwin:c a lemon. The duct was probed with various-sized lacrymal-duct probes, and it was found to be very narrow and constricted. An attempt was made to dilate the duct. Following this, stimulation with lemon juice produced a moderate increase in thin saliva. It was believed that the gland would never function normally. The patient was discharged on January 25 to be followed in the Outpatient Department for dilation of Stensens duct. On February 1 the patient said the left side of the face was better. The duct was probed, but very little saliva was present.