Treatment. In all cases, thorough cleansing of the ulcer with antiseptic lotions, as previously described, is of great benefit. Complete extirpation of the ulcerative lesions has been successful, but curetting does not always prevent their recurrence. Potassium or sodium iodide in large doses (totaling from 100 to 400 grains per day) and radiotherapy seem to be the most efficacious forum of treatment. Copper sulphate in a 1 per cent. solution as a wash for external use and also in one quarter of a grain doses internally, has in some cases given good results.
Epitheliomatous Ulcer. In none of the more common ulcerative skin lesions would the conditions for the development of cancer seem to be more favorable than in chronic dermatitis with ulceration; the despised and neglected varicose ulcers of the leg. The extreme chronicity of the inflammatory process, often lasting for many years; the age of the patient, which is usually advanced; the almost inconceivable neglect of the lesion in many cases, so that the persistent presence of foul and decomposing secretion and of the products of tissue necrosis is common: the frequent absence of even an attempt at cure; the fact that most of these patients are compelled to be on their feet all day and thus keep up and increase the unfavorable conditions; and, finally the circumstance that in many of them the added history of alcoholism, of renal or cardiac disabilities, or of other chronic affections is also present; all of these factors would lead to the presumption that in this ulcerative lesion, above all others, carcinomatous degeneration would be the most common.
While so few instances of cancer secondary to varicose ulceration are seen, it rarely appears before the age of forty. It is usually seen where varicose ulcers as well as the scars they produce are found. The base of the characteristic ulcer is hard, nodular and irregular, made up of firm warty granulations, and often covered with sloughs. It bleeds easily and has a foul discharge. The edges are hard and everted. The borders and base present a peculiar and striking thickness and hardness, as though the ulcer were imbedded in cartilage, while the granulations feel firm and appear red and warty. The amount of pain, the involvement of neighboring lymphatic glands and the rate of growth vary. Epitheliomata which have developed from congenital warts, moles, or nevi are apt to be very malignant. When epitheliomatous degeneration occurs in a chronic ulcer, it first begins to get hard about the edges, which become everted and gradually bound down to the deeper tissues. The granulations about the margins become large, red, nodular, hard and bleed very readily. This condition spreads over the entire ulcer, which assumes a sloughing and foul character. The diagnosis is confirmed by the microscopic examination of a section cut from the edge of the ulcer.
Treatment. Malignant ulcer can be cured only by the destruction or removal of the new growth. For its treatment, caustics with or without curetting, excision or radiotherapy may be employed. The best caustics are arsenic, chloride of zinc, caustic potash and formalin.
The objections to this method are the extreme pain; the lack of certainty as to the removal of all of the neoplasm; the fact that the lymphatics and glands are not dealt with, as well as the fact that unless the treatment is thorough, the growth is stimulated rather than retarded. The scar is also apt to be unsightly. Without doubt excision forms the best method of treatment. The incision should be wide of the ulcer, and all indurated tissues and any lymphatics or glands that are involved must be removed.
In some cases it may be necessary even to amputate the leg in order to effect a cure. The X-rays from the Coolidge tube are to be recommended, as the cross fire effect of these rays in some cases is of great benefit. Recently radium has been used in these ulcers of the leg with good results. The gamma rays are to be preferred as they are more penetrating and should be applied two or three hours a day for a number of days. At least from 50 to 200 milligrams of radium bromide must be used in order to obtain any effect. Recently beta rays have been found to be as effective as the gamma rays. In order to prevent a radium burn the rays have to be filtered before they are applied.