Perforating Ulcer

PERFORATING ULCER, a trophic disorder affecting the skin, mucous membranes, and spreading in depth to underlying tissues. The most frequent localization is the sole, hence the name P. u. of the foot, s. malum perforans pedis, s. mal perforant du pied. P. u. of the foot usually develops on those parts of the sole that serve as support points [the metatarsophalangeal joint of the big (see illustration) or small toe, the heel], less frequently in other places; it can be bilateral and symmetrical. P. u. of the foot is considered a trophic disorder in diseases of the nervous system; it is most frequently observed in tabes (see), syringomyelia, spina bifida, in some diseases of the spinal cord accompanied by sensory disturbances; this disorder can also occur in traumatic neuritis of the ischiadic nerve, whereas in neuritis of other etiology P. u. is very rare. In addition to the primary nervous system disease, the development of P. u. requires some traumatization - rubbing of the sole by excessive walking, uncomfortable shoes, work associated with prolonged standing, etc. Alcoholism, diabetes, arteriosclerosis are predisposing factors for P. u. The pathogenesis of P. u., considered a trophic disorder, remains controversial. One of the most widespread opinions attributes the development of P. u. to damage to the vasomotor apparatus, as a result of which tissues are poorly supplied with blood, improperly nourished, and therefore cannot resist ordinary traumatization. Other authors explain trophic disorders by the existence of special trophic centers and fibers, the functions of which are impaired in the disease. P. u. of the foot begins with the appearance of a peculiar hardening, callus formation, in the serous bag of which inflammatory phenomena develop; then ulceration occurs, which goes in depth and width; gradually a larger or smaller deep ulcer with undermined, thickened edges forms, sluggantly granulating, with serous-purulent discharge. Later the ulcer can penetrate further in depth and involve joints, bones, leading to the formation of sequestra. Sensitivity in the vicinity of the ulcer is disturbed (analgesia) at a greater or lesser distance. The entire process of ulcer formation mostly proceeds without pain. As complications, erysipelas, lymphangitis, purulent osteoarthritis, gangrene are observed; ascending neuritis is possible. The course of P. u. of the foot is slow, progressive; at first improvement can be observed, but the formed ulcer very poorly responds to treatment; recurrences are very frequent. Treatment should be directed at the underlying disease (see Ulcers, Tabes, Syringomyelia, Neuritis).-Prevention. Persons suffering from the above-mentioned diseases should be forbidden work associated with prolonged standing, walking; comfortable footwear must be worn. The callus that appears should be protected from ulceration. In addition to the foot, P. u. is also observed in the mouth (malum perforans buccalis, s. mal perforant buccal), more frequently on the upper jaw, but it also occurs on the lower jaw, on the lateral walls near the alveolar edge of the molar teeth. This ulcer is observed in tabes, is also considered, like P. u. of the foot, a trophic disorder; it can be bilateral and symmetrical. Ulceration of the mucous membrane appears in the corresponding places, which quickly develops in width and depth and reaches the bone; it is accompanied by loss of teeth and formation of bone sequestra, due to which perforation occurs connecting the oral cavity with the nasal cavity and the sinuses. Loss of teeth occurs very quickly, in a few days: a tooth that was completely healthy begins to loosen and falls out; the process can involve one or several teeth on the lower and upper jaw; neighboring teeth remain completely healthy. There is complete anesthesia both around the ulcer itself and at some distance from it. Despite anesthesia, in the initial periods during tooth loss, severe shooting spontaneous pains are sometimes observed. The process can stop at various stages of development. P. u. in the mouth must be differentiated from the perforation of the palate of syphilitic origin, formed due to the disintegration of a gumma; the syphilitic ulcer is usually located on the median line. In the presence of anesthesia of the oral mucous membrane, hot drinks and very spicy foods should be avoided. Treatment--see above.-It should also be noted the possibility of localization of P. u. on the hand, on the palm (mal perforant palmaire), which is observed in the same diseases (tabes, syringomyelia, leprosy, severe lesions of the nerves of the hand). This localization is very rare and the clinical picture is insufficiently studied.