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SURGERY WITH SPECIAL REFERENCE TO PODIATRY
BY MAXIMILIAN STERN, M.D.
AND EDWARD ADAMS, M.D.
_Professors of Surgery at the School of Chiropody of New York_
EDITED BY MAURICE J. LEWI, M.D.
_President of the School of Chiropody of New York_
THE SCHOOL OF CHIROPODY OF NEW YORK 213-217 WEST 125TH STREET NEW
YORK
_It is intended to publish a series of books which will constitute a
complete SYSTEM OF PODIATRY, comprising the entire range of subjects
essential to a comprehensive knowledge of the theory and practice of
Chiropody and all that is or should be known by the practising
chiropodist, or that should be taught to the student of Chiropody._
_The present volume, “Surgery,” is the first of this series and will
be followed by “Practical Chiropody,” “Chiropodial Orthopedics” and
other volumes on subjects of major interest and of vital importance to
all interested in Podiatry._
CONTENTS
CHAPTER PAGE
PREFACE ix
I INTRODUCTION 1
II SURGICAL BACTERIOLOGY 6
III ASEPSIS AND ANTISEPSIS 18
IV INFLAMMATION 28
V WOUNDS AND CONTUSIONS 39
VI HEMORRHAGE 51
VII BURNS, FROST BITE, ETC. 56
VIII FISTULAE; FISSURES; SINUSES; ABSCESSES; FURUNCLES; ULCERS 64
IX DISEASES OF JOINTS—THE SEROUS AND SYNOVIAL MEMBRANES 82
X DISEASES OF THE BONES 99
XI DISEASES AND INJURIES OF THE ARTERIES AND GANGRENE 118
XII DISEASES OF VEINS 125
XIII SPECIAL FORMS OF INFLAMMATION 130
XIV VERRUCA (WART), CALLOSITY, HELOMA (CORN OR CLAVUS),
DISEASES OF THE NAILS—INGROWN NAIL 139
PREFACE
This volume is intended to serve as a guide to the diagnosis and to
the treatment of the diseases and conditions of the body in general,
in their relation to the foot, as well as to those conditions which
primarily affect this member.
Much of the matter herein contained might be regarded as beyond the
scope of Chiropody; this, however, is a fallacy not more applicable to
Chiropody than to any other specialized branch of Surgery requiring a
knowledge of the physiologic and pathologic processes at work in the
production of disease.
The advances made in this branch of Surgery have long since translated
it from the realm of empiricism to the field of rationalism. Treatment
based primarily on the results of experience or observation must give
place to a system based upon a knowledge of abnormal conditions and
the resultant changes in the tissues. Such knowledge elicits treatment
directed definitely against these processes. It is obvious that this
can be accomplished only through the agency of certain definite manual
and therapeutic measures, the physiologic actions of which are well
understood and known to be reliable.
Much stress has been laid upon the subject of asepsis and antisepsis.
The foot is peculiar in that conditions surrounding it are especially
congenial to the development and multiplication of bacteria. Modern
surgery has been built upon the recognition of the rôle of bacteria in
the behaviour of wounds, and the greatest hazard to successful surgery
lies in the ever-present possibility of bacterial invasion. Surgical
safety, however, can be secured by the employment of a perfect technic
for asepsis. Once the precept is established that the operative field
must be asepticized and thereafter protected from contact with any
septic object, the status of Podiatry will be secure for all time.
Should we accomplish this, these pages will have served a purpose.
Two notable features of the present volume are a comprehensive
glossary and an exhaustive index which greatly enhance its
usefulness, enabling the reader to find references to the subject
before him, and with very little inconvenience to learn the meanings
of unfamiliar words, thus obviating the necessity for a medical
dictionary.
We avail ourselves of this opportunity to acknowledge our gratitude to
Dr. Maurice J. Lewi for his assistance in editing and in publishing
our work in keeping with his estimate of its possible field of
usefulness.
M. S.
E. A.
CHAPTER I
+INTRODUCTION+
Surgery, in contradistinction to medicine, as a separate branch of the
healing art, includes all manual procedures and is not limited to
cutting operations exclusively. It is that branch which deals with the
treatment of morbid conditions by means of manual or instrumental
agencies.
Morbid conditions include three distinct classes: those due to
1. Injuries
2. Infections
3. Diseases
+Injuries.+ To this class belong all the processes due to physical
agencies and it includes besides traumatism, the effects of heat and
cold, of chemicals, of light and of electricity.
+Infections.+ These may be either local or general. The reaction might
occur at the point of entrance of the bacteria, or constitutional
symptoms may evidence their invasion into the blood, or the absorption
of their toxic products.
Many conditions in this class are linked closely with those in the
following class:
+Diseases.+ Here are classified (_a_) new growths, both benign and
malignant; (_b_) changes due to age and environment, and (_c_)
diseases not belonging in either of the above classes. These latter
are generally known as _idiopathic_ or _spontaneous_ in their
etiology. These terms, however, often indicate only a limit of
knowledge as to their true etiology.
+The Tissues.+ The tissues of the body, though apparently so different
and varying so decidedly in their functions, are in many respects
similar.
Every tissue is composed of two parts: the _cellular elements_ and the
_intercellular substance_. These are called _cells_ and _stroma_. Upon
the first of these depends the vitality and function of the part,
while its density, shape and general physical properties are
determined by the second. Likewise along the same lines of reason, all
of our organs have two separate areas of tissue: the _parenchymatous_
and the _interstitial_. The first contains the functioning and the
second the supporting elements.
The physical conditions of the interstitial tissue or the
intercellular substance vary greatly in density. _Blood_ is a tissue,
the intercellular constituent of which is fluid, and as we consider
more dense tissues, we encounter all degrees of density of the
framework or intercellular substance, until with the additional
presence of calcareous elements, we conceive the hardness of bone and
dentine. Tissues as a whole, however, are not solid; there are spaces
in the supporting structure to admit of the passage of arteries,
veins, nerves, and lymphatics.
Abnormal conditions arise in the various parts of the tissues. Certain
diseases affect the parenchymatous tissue in an organ more than the
interstitial tissue and again others affect the blood vessels
particularly.
There may be _hypertrophy_, in which the entire organ or part becomes
larger as a whole, the active cells and stroma sharing alike in the
process, or there may be an _hyperplasia_, in which the active cells
of the part proliferate abnormally. When the interstitial tissue alone
develops excessively it is known as an _infiltration_. Under such
circumstances the parenchymatous cells often undergo what is termed
_pressure atrophy_; they are diminished by squeezing.
_Atrophy_ of the part or organ, from whatever source, signifies its
diminution in size; its function is, of course, either impaired or
suspended as the process goes on.
The efforts on the part of the organism as a whole to combat or repair
injury, bacterial invasion and disease are directed along definite
lines. The study of these functions does not rightly come within the
scope of these pages, belonging to physiology, but must be considered
here, if only in brief for the purpose of a good understanding of the
processes at work in surgical conditions.
As surgeons, the functions which concern us most are the
1. Nervous
2. Circulatory
3. Lymphatic
+THE NERVOUS SYSTEM+
The nerves operate in harmony with each other and with the organs to
maintain health. The nervous system comprises the brain, the spinal
cord, the nerves, and the ganglia. Aside from presiding over the
special senses, this system controls and directs the processes of
defense and repair. In doing so, the force and frequency of the heart
beat, the calibre of the vessels and the chemistry and composition of
the blood are all altered.
These phenomena are the ones which concern us in our present subject,
acting as they do upon the blood and the organs which contain it. They
will be considered more fully in the following:
+THE CIRCULATORY SYSTEM+
In health and disease the force and frequency of the heart beat and
the calibre of the arteries undergo momentary alterations to meet
changes surrounding us.
Dilatation and constriction of the arteries, and arterioles through
the activity of the vasomotor nerves, permit of increasing and
diminishing amounts of blood reaching the various organs and regions
of the body. In this way the peripheral circulation, through the
activity of the heat centre in the brain, acting upon the superficial
capillaries, maintains the normal temperature of the body during the
changes of season. In winter, heat conservation is effected by
vaso-constriction of the superficial capillaries, while in summer,
heat radiation is accomplished by vaso-dilatation together with the
evaporation of moisture so abundantly supplied by the active sweat
glands. Other phenomena demonstrating the vasomotor function are
blushing, going pale, and the redness and swelling following injury or
infection. Of the latter we will treat under the heading
“Inflammation.”
Certain changes also occur in the blood in order that it may perform
its functions. These changes are found both in the chemistry of its
fluid content and in the number and kind of its solid elements: the
corpuscles. The blood is a tissue; its corpuscles are the functioning
cells and its fluid content the basement substance.
In the fluid content of the blood or _plasma_, as it is called,
certain chemical changes occur in its fibrin-forming capacity. Clot
formation, an effort on the part of the economy to arrest hemorrhage,
is thus facilitated when there is active bleeding, also during labor
and certain diseases.
The number and kind of white blood cells also undergo changes, as we
shall see, under circumstances in which the defences of the organism
are called into operation, for it is the function of the white blood
corpuscles to combat bacterial invasion.
It is the preponderance of these white cells which imparts the
peculiar milky color to pus.
Nourishment and oxygen are carried to the tissues by the red blood
corpuscles. Under circumstances which we shall see later, these are
also altered both in number and in size, and also in their arrangement
in the vessels. (See Chapter IV, “_Inflammation_.”)
+THE LYMPHATIC SYSTEM+
Waste material in the tissues is carried off by the return blood in
the veins and also by the lymphatics. These are in reality the
scavengers of the body, both the lymphatic vessels and glands,
performing important functions for the good of the economy. They are
found beneath the skin and in the subcutaneous tissue, also along the
course of the great veins.
The lymphatics far exceed the veins in number and perform a function
similar to the veins, gathering waste material from the tissues, also
the digested food called _chyle_, from the stomach and intestines. The
lymphatic vessels, also the lacteals which absorb the chyle, all pass
through glands, which are extremely numerous, where certain
deleterious substances are extracted from the lymph before it is
emptied into the blood stream.
The lymphatic glands in performing their function as filters often
become inflamed and when large numbers of pathogenic bacteria, or very
virulent ones are contained in a gland, abscess formation results just
as it would in any tissue so invaded.