The question of the closing of the wound is a serious one. The writer has noticed that when a basal-celled cancer recurred, this recurrence almost invariably took place at the edge of the scar and not in the depths of the wound. This means one of two things-either that the incision was not wide enough or that implantation took place on the edge. In practically all of his more recent operations he has cauterized the edges of the cut with either pure carbolic acid or with the acid nitrate of mercury, and since that time has had very much better results, although the appearance of the scar has not been nearly so good. If it be determined to close the wound by first intention, silk sutures are usually used, and a sufficient number employed to accurately approximate the edges throughout their entire length. This is especially necessary if there be much tension. The needle should be sufficiently strong, for at times the skin is remarkably thick and leathery, and prone to break needles unless they are carefully handled. The stitches should usually be removed on the second day, although in cases of tension this may not be possible. At first the wound may be dressed with silver foil, over which a piece of sterile gauze is placed, and sealed with either collodion or adhesive. Or the wound may be painted with iodine, smeared with a little sterile ointment to prevent the adhesion of the gauze that is placed next to it. After the stitches have been removed, a little more iodine may be added, and the wound dressed with cotton and collodion. In the case of a small growth the wound should be entirely healed by the end of the tenth day, although it is well to leave collodion on for a few days longer in order to remove strain and prevent the possibility of the edges separating.
For many years some surgeons have felt that, when they employed the actual cautery rather than the knife, there was less danger of cancer recurrence in the edges of the scar. Halsted, as well as many others, has noted this in cancer of the breast. Were it not that the electric cautery is liable to get out of order in the ordinary operating room, it would be the ideal one, but, as it is, the actual cautery is the more reliable. Excision can be managed by the cautery as well as by the knife, although in the removed tissue it is impossible to determine the limits of the neoplasm. As a consequence, some surgeons prefer to excise with the knife and then immediately employ the cautery. It is generally considered somewhat dangerous to employ the actual cautery in the presence of ether fumes. The cautery has the one great advantage over the knife of thoroughly searing the edges of the wound, so that no cancer cells can escape into the vessels or become implanted along the line of incision. In extensive cases of cancer upon the limbs or body the cautery is excellent, although it cannot, for example, be used near the eye. The cautery should always be used when it is not possible to give a wide margin, as in lesions of the tongue.
The use of the curette without following it by a caustic of some kind is mentioned only to be condemned. An occasional case may be cured by the vigorous use of this instrument, but a brief recollection of the pathology of a cancer will show that it cannot reach the cells that are progressing into the still healthy tissue.
If a wound is, however, thoroughly curetted and then efficiently cauterized, the results are often excellent. Sherwell* has elaborated a method in which he employs the acid nitrate of mercury as the cauterizing agent, and has had excellent results. Other dermatologists, including the author,* have likewise obtained good results from its employment. The following account is taken from the writer's own article on the subject.
*Sherwell: Jour. Cutan. Dis., 1910, xxviii, 487.
The acid nitrate of mercury, or the liquor hydrargyri nitratis of the Pharmacopoeia, is made by dissolving 40 grams of the red oxide of mercury in 45 grams chemically pure nitric acid and 15 grams of distilled water.
The method is applicable to basal-celled cancers, endothelioma, moles, warts, and certain chronic infections, such as lupus vulgaris. Growths of the eyelid can be treated with very good results. It is possible to benefit, if not cure, rodent ulcers of very considerable size. In my judgment this method should not be employed in spinocelled cancers, as this variety of growth usually metastasizes rapidly.
Either local or general anesthesia may be employed. In small superficial growths thorough infiltration with a Schleich's solution will amply suffice. If the growth to be removed be about the face, it is better to give a preliminary injection of morphine and atropine, so as to lessen the secretions.
The apparatus needed is simple. Two or three curettes of various sizes (at least one of which must be sharp), a scalpel in case hard fibrous tissue is encountered, forceps, clamps, and especially a good actual cautery with which to stop bleeding, comprise the instruments. Four glass vessels should be provided, in one of which the acid nitrate is placed, another contains powdered bicarbonate of soda, the third a solution of sodium bicarbonate, and the fourth a 1 to 1,000 solution of adrenalin. In operations around the face the solution of the soda is essential for the protection of the eyes, or of the mouth or nose. In addition, there should be plenty of cotton swabs.
The operation is straight forward. Once the patient is anesthetized, all diseased tissue is rapidly and thoroughly curetted away, the small curette being necessary to reach into the various ramifications of the growth. The sense of touch will tell when one is dealing with sound or diseased tissue. All diseased tissue must be removed; one must not consider what the scar will look like, for the permanent removal of a malignant growth is far more important than speculation as to the cosmetic result. Curettage being completed, the bleeding is stopped by pressure, by the use of the adrenalin, or by the actual cautery, or, if necessary with clamps. After the field is entirely dry, the acid is applied with a cotton swab; this is allowed to act for from fifteen to twenty minutes, several applications being made. Dr. Sherwell considers that the acid has a specific action upon cancer cells, but it seems to the author that it is simply a powerful and deeply acting caustic, which may readily be controlled. The dry soda is then applied with a gauze sponge until it has formed a crust over the entire area cauterized. In cases of congenital moles it is first necessary to blister the skin with carbon dioxide snow or with cantharides, and then apply the acid, neutralizing as has been described.
*Hazen: Washington Med. Annals, 1912, xi, 246.
The after-treatment consists in keeping the lesion dry; the thick black crust that forms after neutralization is a sufficient protection for the wound. Dr. Sherwell considers that in epithelioma, and more especially in sarcoma, it is wise to administer Fowler's solution, alternating with Donovan's solution, for several months. There is always considerable edema and inflammation following the operation, but this needs no treatment, and is undoubtedly a good thing, as the inflammation may suffice to kill cancer cells that may have escaped.
The results, both immediate and permanent, are excellent. The scar is soft and white, and to be approached only by the x-ray scar; in the author's hands the scar resulting from the deep application of the carbon dioxide has been more noticeable. Sherwell reports that he has had about 10 percent of recurrences, most of which have been cured by a second operation.
Of course, other caustics may be used after the growth has been curetted away; one may use silver nitrate, taking care to obtain the pure silver nitrate, and not the ordinary lunar caustic stick. Some men prefer to apply a caustic paste and allow it to act for several hours or days, as the case may be, but the author prefers the immediate cauterization as being less painful and more efficient.
An operation of this kind is especially useful in the basal-celled growths that originate upon the nose, or in the naso-facial groove, upon the eyelids or upon the ears. A modification of the operation that has yielded excellent results in the hands of the author, at least in early cases, is the excision of the growth and the thorough cauterization with the acid nitrate. This has the advantage of giving a specimen that is suitable for microscopic study, and the scar is surprisingly good. Even in very extensive cases it is sometimes possible to hold the disease in check for a number of years and render the patient much more comfortable, and occasionally a cure may result in an apparently hopeless case. Sherwell reports a number of cures in instances where the orbit is invaded, although the eye is, of course, lost.