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R a d i u m 177
emanation tubes. The dosage given is about 9,000 millicurie hours, which
will produce a slight skin erythema. The lymphatic glands of the neck
are exposed in the same way. With such heavy filtrationonly the deeply
penetrating rays arc effective. When the available emanation was limited,
we have recently substituted X-radiation in the pre-operative phase
of treatment. Although theoretically not as efficient, it nevertheless
has a distinct field of usefulness, especially in clinics that are equipped
with only a small amount of radium.
Operative Treatment. Before the tumor area is touched, a 10 centimeter
skin incision is made under local anaesihesia along the anterior
border of the sternocleidomastoid muscle. 1 he lymph-bearing tissue
close to the internal jugular vein and in the posterior submaxillary space
is exposed and examined. If there is any suggestion of metastases, a
complete neck dissection is at once performed. If not, unfiltercd emanation
tubes arc inserted, and the external carotid, lingual, and facial
arteries are ligated. By tying the latter two vessels, the establishment
of a vigorous anastomotic circulation is much delayed. Although such
a careful observer as Bullin (11) did not approve of a preliminary ligalion,
we believe from experience thai 1: is a wise procedure for two reasons.
First, the danger of serious hemorrhage from the primary growth
is much reduced both during the second stage of the operation and at
a later date when the radium slough separates from the antrum; and
second, the starving effect on the tumor is a distinct aid to any method
of radiation treatment. We have performed the operation of ligation
in well over 400 cases of oral and associated cancers with no bad results.
Matas (quoted by Scudder, 1) refers to two fatalities from
cerebral embolism, but there seems to be no danger if the point of ligation
is well above the origin of the superior thyroid, and the lingual and
facial arteries are tied separately.
The antral operation is performed at the same sitting or postponed
a few days, depending on the patient's condition. It is essentially an
operation to expose the growth for radiation. The method of approach
varies with the local condition.
1. Many cases present signs of increased intra-orbital pressure
and a swollen cheek with the swelling most prominent adjacent to the
inferior rim of the orbit. The palate and alveolus indicate no evidence
of invasion. The cancer has. therefore, followed the orbital plate, and
not the antral floor. The logical operation is to make an opening closest
to the bulk of the growth, namely through the floor of the orbit. _ At
first wc hesitated to sacrifice a functioning eye. but we now believe
that in many instances our hesitancy was the cause of ultimate failure.
In a few patients with the eye remaining in situ, the severity of the radium
inflammation in adjacent tumor tissue forced us to remove it subsequently.
These patients would have been spared much suffering if
we had been less conservative at the outset.
2. In another group there are no orbital signs and symptoms, and
the external tumor is well below the eye. The alveolus and palate are
however swollen and perhaps destroyed. The cancer has therefore grown
downward, and is best reached through a large window made below.
3. A third and smaller group may require an opening through
both the orbit and the alveolus. These are very advanced cases, but we
feel that in selected patients, there is the possibility of clinical cure or
palliation.