PERFORATING ULCER OF THE FOOT

Synonyms.—Malum perforans pedis; Fr., Mal perforant du pied; Ger., Perforirendes
Fussgeschwür.

Definition.—Perforating ulcer of the foot is a trophoneurotic
disease beginning primarily as a degenerative, circumscribed, more
or less calloused formation, and developing into an indolent, and usually
painless, sinus, leading down through the deeper tissues to the bone.

This malady is rare, and comes more frequently under the notice of
the surgeon, although occasionally also under dermatologic observation.
It has long been known, especially among the French surgeons. The
most elaborate study of the disease, both from a clinical and pathologic
standpoint, was that by Savory and Butlin,¹ although others, both
before and since, among whom Michaud,² Duplay,³ Lagrange,⁴ Schwim-
mer,⁵ Gasquel,⁶ have also described and discussed the malady, that of
the last named being especially complete.

Symptoms.—It begins with the formation of a localized callosity
or epidermic thickening, sometimes essentially the nature of a corn,
on the plantar surface, and most usually situated over the articulation
of the metatarsal bone with the phalanx of the first or last toe, the
regions which are subjected to more or less pressure. Exceptionally,
however, it has also been observed on the palm of the hand, as in Ter-
rillon's case,⁷ over the metacarpophalangeal articulation of the ring-
finger. Beneath this callous plate suppuration and necrosis take place,
and the overlying horny covering, or the central part of it, is generally
soon cast off, disclosing a shallow ulcer or sinus, which gradually ex­
tends more and more deeply, and finally exposes the bone, which soon,
as a rule, also shares, to a variable degree, in the necrotic process. The
orifice is sometimes surrounded by granulations, beyond which the adja­
cent epidermis is usually much thickened. This latter is often a con­
spicuous feature, the sinus apparently having its opening through a
callous mass or large, flattened-out, clavus-like formation. The external
opening is generally of less diameter than the deeper part of the sinus.
There is very little discharge. The formation is extremely indolent and
usually painless, and, moreover, shows but little, if any, tenderness on

¹ Savory and Butlin, London Medico-Chirurg. Soc'y Trans., 1879, vol. lxii., P. 373
(with colored plate, histologic cuts, and bibliography).

² Michaud, “Sur l‘état des nerfs dans l‘ulcére perforant," Lyon Médicate, 1876, p. 5.

³ Duplay, Arch. gén. de méd., 1876, vol. xxvii, p. 346 (hospital service reported by
Marot), and Jour, de méd. et chirurg. prat., 1875, vol. xlvi, p. 13.

⁴ Lagrange, “De l‘étiologie multiple des mal perforant plantaire,” La Semaine
Méd., 1886, vol. vi, p. 485.

⁵ Schwimmer, Ziemssen‘s Handbuch der spec. Pathol., 1883-84, vol. xiv., p. 80.
⁶ Gasquel, These de Paris, July, 1890.

⁷Terrillon, Bull, de la soc. de chirurg., de Paris, 1885, vol. ii, p. 155 (case demon­
stration).

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ATROPHIES

pressure, although walking itself is sometimes painful. The affected
part is, especially in places, commonly more or less anesthetic and of
subnormal temperature, although occasionally hyperesthesia has been
noted. The foot frequently, sooner or later, becomes the seat of other
symptoms or changes pointing toward nerve impairment, such as in­
creased hair-growth, hyperidrosis, usually of a fetid character (bromi-
drosis), pigmentation, and alterations in the nails. The plantar surface
may also exhibit more or less diffused epidermic thickening or several
or more scattered callosities or clavus-like lesions. The ulcer is usually
single, but in some cases several have been present; in the latter event
they may be on the sole of one foot, or both feet may be the seat of the
disease. As already stated, exceptionally a similar formation has been
observed on the palm.

The course of the malady is slow. Sometimes, but more especially
when the patient is kept at rest, the sinus heals up, to break down again
usually as soon as the patient becomes active. The destructive process
may bring about complete disorganization of the involved joint.

Etiology and Pathology.—The malady occurs principally in
association with those diseases in which there are nerve involvement
and loss of tissue resisting power, such as locomotor ataxia, anesthetic
leprosy, syphilis, peripheral neuritis, diabetes,¹ etc It is, in fact, ac­
cepted .that the malady is a trophoneurosis, and dependent upon impair­
ment or degeneration of the central, truncal, or peripheral nerves. This
is shown in Gasquel‘s analytic study of 91 cases: 69 had central, and 8
peripheral, nerve-lesion. Of the number, 32 were subjects of locomotor
ataxia, and 17 of general paralysis, while 8 were alcoholics and 14 dia­
betics, and 12 had varied diseases or lesions of the cord, of which 4 were of
traumatic origin. While, therefore, there is underlying nerve degenera­
tion, there is but little doubt, too, that local pressure and traumatism
are also important factors. As regards sex and age liability, of Gasquel's
91 cases 84 were males and 53 occurred between the ages of thirty and
fifty, 19 over fifty, and 7 under thirty, 3 of which were under twenty.

According to Savory and Butlin, there is degeneration of the sen­
sory and nutrient fibrillæ of the affected nerves, resulting from pressure
upon them by the thickened endoneurium; the motor fibrils, owing to
their thicker medullary sheath and larger size, escape damage. In some
cases there is arterial disease, the coats of the vessels being found under­
going calcareous or other degeneration, and this has led to the view that
there is a causal relation between such and the perforating ulcer; but
this is contradicted by the fact that in other instances the vessels have
been in normal condition.

Diagnosis.—When the associated general nervous disease and
phenomena are taken into consideration with the local development
and behavior of the lesions, a mistake could rarely occur. There may
be possible confusion in the beginning with a circumscribed callosity;
later with a simple suppurating corn, and still later with a tuberculous
or syphilitic ulcer.

¹ Wessinger, Jour. Cutan. Dis., 1889, p. 178, reports a case occurring in a diabetic,
a woman of advancing years, first developing in one foot and then in the other.

MORVAN‘S DISEASE

631

Prognosis and Treatment.—Treatment is, as a rule, unsatis­
factory, the affection being persistent and exceedingly rebellious, and
permanent betterment or cure scarcely possible. Nor have the results
in those cases which have been operated upon, either by thorough cur­
etting, excision, or partial or complete amputation, been, except in some
instances, under favoring circumstances, permanent, as the malady is
apt to recur, even sometimes in the stump of the amputated limb. If
curetting is employed, the surrounding hardened horny plate should
first be softened and removed by a 25 per cent, salicylic acid plaster.
Treves¹ accomplishes this by continuous poulticing with linseed meal,
shaving away the softened part from day to day; finally, after its removal
has been attained, requiring ten to fourteen days, the poultices are dis­
continued, and a paste composed of salicylic acid and glycerin, of the
consistence of thick cream, with the addition of 10 grains (0.65) of
carbolic acid to the ounce (32.), is applied to the sore. Under this plan
complete healing often takes place, especially if the bone is not diseased.
Success is only temporary, however, unless the pressure can be kept from
the part, and for this purpose Savory and Butlin advise an artificial leg
applied to the bent knee. For pure surgical methods, excision, ampu­
tation, etc, the reader is referred to works on surgery, to the domain of
which the management of the malady properly belongs.

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