At times it is difficult to decide which is the best form of treatment for a special case. The patient usually dreads the knife, and likewise dreads an extensive operation for a small growth, and the physician must first gain the confidence of such a patient, and then point out the dangers incurred by doing an incomplete operation. But, in addition to the personality of the patient, the personality of the neoplasm must also be considered, and this the writer has endeavored to do in the chapters devoted to the special varieties of tumors. The author feels that excision with the knife is usually the preferable way in which to treat a tumor, for in this way a clean operation can be done with very little scarring, and it is possible to obtain a section of the tumor for microscopic study. This last should always be done, for in no other way have we a check as to what we are doing. The treatment of cancer without microscopical study is about as satisfactory as trying to read without eyes. This is because epithelial tumors vary markedly in their malignancy according to the type of cell from which they spring, and it is not always possible to make a diagnosis from a naked eye appearance alone, at least not until it has been many times confirmed by the histological study of similar conditions. Next to the use of the x-ray, the knife is the least painful of all modes of attack. And lastly, the results are the best, so far as one can judge by the study of statistics. So far as the writer knows, no dermatologist has kept an accurate list of statistics of the cases of cancer that he has treated by the curette or the caustic, and but few have checked up their x-ray results. So at the present time we can say that, so far as statistics go, the results with the knife are infinitely superior to the results obtained in any other way. Furthermore, in all surgical clinics it is noted that nearly one-half of all patients who apply for treatment because of skin cancer give the history of having been treated by a caustic paste, or by the curette, and often by the x-ray or radium. At the same time, it is difficult to use the knife upon tumors that are situated upon the nose, eyelids or ears, and here some other form of treatment must usually be devised. In the cases of the prickle-celled cancers the knife is the only proper instrument, and this probably applies to the cuboidal-celled neoplasms as well. Sarcomata, endotheliomata, and the tumors arising from the glands of the skin should be treated by no other method.
Having once decided that the lesion is to be excised, the form of anesthesia must next be determined. In the smaller tumors it is usually possible to operate under local anesthesia, and for this purpose there is no better substance than the well-known Schleich's solution, made without the addition of morphine. Schleich's solution is essentially a one-tenth of one percent solution of cocaine in normal salt solution. There is not the slightest necessity for using a stronger solution of cocaine, providing that the surgeon properly infiltrates the tissues. In fact, the use of more than one-third of a grain of cocaine at one sitting may be dangerous,* the patient showing either excitement or depression. It is very convenient to add a few drops of a 1 to 1,000 adrenalin solution to the cocaine mixture, for this will markedly lessen the amount of the bleeding. A fine needle should always be used, so that the solution will not escape through the needle track. The needle is inserted at a slight distance from the growth, usually about half an inch, and superficially just beneath the skin, so that the infiltration can be noted; if the injection be made deep into the corium, satisfactory infiltration will not ensue. It should always be remembered that it is very difficult to infiltrate scar tissue, and at times impossible, so cases showing much scarring are not suitable for local anesthesia. The injection of the anesthetic mixture must be kept up, through several punctures, until not only the tissue in and beneath the tumor is thoroughly infiltrated, but also an area at least one-half an inch beyond its margins. Anesthesia will be complete at the end of two minutes, if not earlier. Before using a local anesthetic, it is well to make one or two little scratches of the skin to indicate the intended line of incision, for when the growth and surrounding tissues are filled with fluid the original boundaries are often lost.
In extensive cases it is usually necessary to employ general anesthesia, and in growths around the mouth or nose there is great need for an expert anesthetist. Ether is usually employed for long operations, while nitrous oxide and oxygen may suffice for a short one.
In the majority of cases it is best to disinfect the skin with iodine about ten minutes before beginning the operation, remembering that the iodine must always be applied to a thoroughly dry surface in order to be efficient.
*Cushny: Pharmocology and Therapeutics, New York, 1911, 313.
It is usual to take out an elliptical-shaped piece of tissue, the line of incision extending never less than one-fourth and preferably one-half inch beyond the margins of the growth if it be small, and several inches beyond if it be large or rapidly spreading. The direction of the long axis of the incision must be carefully determined, so as to put as little tension as possible upon the healing scar, and also so as to make the line of the healed scar coincide as nearly as possible with the normal lines of the skin. Upon the face the axis of the oval incision should also run in the same direction as the lines of the face in that particular spot or region.
It is unnecessary to say that only a very sharp knife should be employed, and that the knife should never touch the cancerous tissue proper, for fear of implanting some of the cancer cells upon the edges of the wound. If any of the instruments touch the diseased tissue, they must be immediately discarded and fresh ones employed. The incision should be made with as few strokes as possible, usually in small growths one to each side will suffice, although it may be necessary to make one or two more in the depths of the wound in order to entirely free the excised mass of tissue, which should at once be removed and laid aside. After the bleeding has been checked, the surgeon should examine the growth with his 'naked eye, but should not handle it. An assistant should section it and hold it for the operator in order that he may run no risk of contaminating his hands. The tissue should then be preserved for microscopical examination.