Deep ulcers are rare, and in the majority of them it is probable that the growth consists primarily of cuboidal rather than of basal cells. They usually arise upon the face, grow rapidly, and, owing to a lack of resistance of the tissues, grow downward rather than upward; in other words, the fungoid growth is reversed. At the start they may have acted like typical rodent ulcers, but because of injudicious treatment, which injured the surrounding tissue, they may have found it much easier to penetrate deeply. The cancerous tissue has sloughed out, leaving a deep hole. The base of the ulcer is usually very ragged and dirty, there is frequently much discharge, often of a foul odor due to putrefactive bacteria, and the patient may be toxic from absorption. Death takes place from hemorrhage or from secondary infection, meningitis sometimes resulting.
Histologically, the cancer cells are usually arranged in long cylinders.
In diagnosing basal-celled tumors from prickle-celled cancers, several factors must always be borne in mind. First, basal-celled tumors are common upon the face and fairly common upon the shoulders, but are very rare upon the limbs. Second, they usually originate from keratoses, and frequently from cutaneous abnormalities, frequently considered to be congenital. Third, their growth is usually comparatively slow. Fourth, their surface is rather smooth. Fifth, the induration is not as deep as in the squamous-celled neoplasms. Sixth, on section the infiltration is not so deep and the fine white lines of the cancerous alveoli are very fine. Seventh, on microscopical examination the cells are very different from the prickle cells, for they are smaller and stain more readily with the basic dyes, such as hematoxylin, while the prickle cells stain better with the acid dyes, such as eosin. The arrangement of cells is also different, there being no tendency for the basal.cells to form whorls or pearls.
*Sutton: Amer. Jour. Med. Scien., 1911, cxlil, 69. "Wile: Jour. Cutan. Dis., 1910, xxviii, 667.
These tumors, even in moderately advanced cases, can be cured by sufficiently radical operation, for they do not metastasize except in very exceptional cases, and then only if there be a mixture of cuboidal cells. As regards treatment, there are several schools. The surgeons advocate the knife, and certainly show a very high percentage of permanent recoveries when the operation has been thorough. Certainly the actual cautery is even better than the knife, and it would seem to the author that when the knife is used the edges should always be treated with some caustic agent to prevent the multiplication of any cancer cells that might have been deposited upon the cut surfaces. Some believe that a combination of the curette and caustic is the best, and many adhere to the use of various cancer pastes or caustics. The x-ray has many advocates, and certainly some beautiful results have been secured with it. In the vast majority of instances the dermatologists have not attempted to check up their cases, Pusey* and Sherwell* forming two notable exceptions to this rule. Hence all cases reported as cured should not be taken too literally; the cases must be followed for at least three years before a cure can be pronounced. Bloodgood emphatically states that at least 50 percent of his cases that were cured by operation had been subjected to various caustics.
To the author's mind the rules of treatment are simple. If the production of a scar makes no difference the actual cautery should be used. This is simpler and better than excision followed by the use of a caustic, such as the acid nitrate of mercury, for the operator is not troubled by hemorrhage. If the growth is freely accessible and a small scar is allowable the knife may be employed, the edges swabbed with alcohol or a fairly strong antiseptic that will not produce deep necrosis, and the wound closed so as to produce a linear sear. In small growths where they are not freely accessible, as in the naso-facial fold, or where it is important not to produce a scar, as upon the eyelid, the x-ray should be tried. It is important to give one or two heavy exposures of a measured dose, rather than to try many small doses, for recurrence follows many of the latter, and the growth is then resistant to further radiation. In absolutely inoperable growths either the x-ray or radium may be employed. However a small dose of radium should never be employed, or marked* stimulation of the neoplasm may occur. In the case of extensive growth x-ray is the best method, for radium seems not to be applicable except in small tumors. In some instances a combination of these measures is to be advocated. For instance it is probably well to radiate after every operation. In all instances it is highly important not to employ measures that are insufficient, for such treatment is almost sure to result in the rapid spread of the cancerous process. Simple curetting, cauterization with silver nitrate, carbolic acid or similar substances, and the use of carbon dioxide snow should not be employed, as they usually do much more harm than good.
*Pusey: Jour. Amer. Med. Assn., 1913, lxi, 552.
*Sherwell: Jour. Cutan. Dis., 1910, xxviii, 487.