Part 2

In all cases precautions should be taken to avoid throwing of the paraffin mixture directly into the circulation. This is accomplished by passing the needle slowly into the tissues which are to be injected and while the needle is passing through the tissues it should have a strong vacuum suction upon it so that should it strike a vein the blood will immediately begin to flow into the needle. To illustrate how easily blood may be sucked from a vein a hypodermic with a glass barrel may be taken armed with a small needle. If the arm of a patient be allowed to hang down the veins will distend and the point of the needle may be slipped through the skin and into the vein. If the vein is punctured by the needle point the instant the piston of the syringe is drawn back a vacuum forms in the syringe and the blood will flow into the syringe. This same method is to be used in the passage of the larger paraffin needle or any paraffin needle only as the needle is passed along its course the suction should be constantly exerted. This constant suction is secured by simply attaching the half glass syringe to the needle and then as soon as the point of the needle is under the skin the piston is withdrawn and a vacuum formed. Then holding the piston of the syringe out, maintaining the vacuum, the needle is pushed slowly in as far as the operator desires to inject. Should blood begin to flow into the needle at any point the onward passage of the needle is stopped and is withdrawn and re-inserted in a somewhat different direction, particularly if during the withdrawal a point is found where the blood flows steadily into the syringe.

If at no point blood flows into the syringe it is plain that no vessel of dangerous size has been punctured by the needle. The veins of the cord are found rather closely around the cord and the cord usually lies below and behind the sac so that should the operator aim to carry his needle point along rather high in the canal he will be least likely to encounter these vessels. It is not to be forgotten that the veins of the cord are particularly likely to be somewhat dilated in these cases of hernia and the operator is taking more or less of a hazard in neglecting the suction technic outlined. It is not safe to trust to the fact that the paraffin is injected in a solid state as is asserted by some operators. It is true that paraffin in a liquid state is more likely to flow into an opened vein than the paraffin in the solid state, yet it is possible to throw a very small amount of solid paraffin into a vein if no precaution is taken to prevent it, and while a very small mass thrown directly into a vein would be harmless in nearly all instances it might do considerable damage should it be so unfortunate as to lodge in certain vessels.

FACTORS TO BE CONSIDERED IN DEALING WITH INGUINAL HERNIA.

The inguinal canal gives passage to the spermatic cord. It is an oblique canal extending from a point one-half an inch above the center of Poupart's ligament to the spine of the pubes. The cord emerging from the external ring continues into the scrotum, and the most definite manner of finding the external ring is by picking up the cord in the scrotum and following it with the index finger until the point of the index finger is pressed into the canal, the scrotum being invaginated at the same time. In scrotal hernia when the patient is placed in the recumbent posture the contents of the hernial sac may be pressed into the abdomen and the finger following the receding hernial contents will slip into the opening of the external ring.

OPERATOR MUST BE SURE HERNIA IS REDUCED.

A hernia should always be completely reduced before any operation is attempted and the size and situation of the external ring definitely determined. The larger and the longer a hernia has been allowed to go unreduced the shorter the inguinal canal will be, as the inner margin of the internal ring is gradually forced toward the median line of the body, and in very large hernia the external ring is stretched somewhat outward so that an opening exists directly through the abdominal wall. This character of hernia is such that three fingers may easily be pressed directly into the hernial interval and as a rule so much of the abdominal contents have been outside the abdomen for so long that the hernia cannot be overcome without decidedly increasing abdominal pressure. These cases in which hernial contents can be pressed into the abdomen by force and which markedly increase the intra-abdominal pressure when reduced are unsuited for any operative treatment which does not include excision of a quantity of omentum.

The average case.

In the average case the examination of the external ring will not show a canal so greatly dilated and it may be taken for granted that it has not been shortened to a considerable extent by the giving of the internal margin of the internal ring toward the median line. Under these circumstances the operator may decide that he has a canal of from two to three inches in length and lying parallel to Poupart's ligament and slightly above this structure.

The sac of the hernia usually lies above and in front of the cord.

Running closely connected with the cord are the veins which go to make up the pampiniform plexus. These veins being close to the cord and the cord itself quite susceptible to pressure it is advisable to pass the needle along near the roof of the inguinal canal and to attain this end it is well to locate definitely the external ring and to have a distinct knowledge of the exact situation of the upper margin of the ring.

Considerable cellular tissue is found in the inguinal canal so that in passing the needle through the canal should it meet with considerable resistance it has no doubt missed the canal and entered some of the more resistant tissues making up its walls.

The cellular tissue in the canal is to receive the injection of the operator and it will be his object to facilitate the diffusion of the various materials injected so that an extensive formation of connective tissue will be promoted. The plug action of the injection is not alone to be considered for the operator is then likely to throw too much into the canal and with the development of the connective tissue the canal is unduly crowded.

The ill consequences of hyperinjection should not be forgotten. It is the error to which the beginner is most liable.

WHERE THE INJECTION SHOULD BE PLACED.

Some operators have been content to insert a needle over the approximate site of the internal ring and then to force it downward until it lies as close to the internal ring as they can approximate and then to throw in a mass of paraffin sufficient to occlude the canal at this point.

If the needle is inserted about half an inch above the middle of Poupart's ligament it will be over the site of the normal internal ring. After the needle passes through the subcutaneous fat it will be felt to strike the firm fibrinous layers of the external wall of the inguinal canal. After the needle has passed through this firm layer it will enter the loose cellular tissue in the neighborhood of the internal ring. If the injection is diffused over an area of an inch or an inch and a half in circumference the internal ring is likely to be plugged for the time by the injection.

The larger Hernia.

Should the hernia be large the injection should be made closer to the pubes, but injection at the internal ring is not sufficient, the canal should also be injected with a certain amount of the paraffin and vaseline.

The canal may be injected by passing the needle directly through the outer wall of the inguinal canal, remembering its course about one-half inch above the line of Poupart's ligament.

The most satisfactory plan of injecting where the operator can successfully follow the technic is to find the external ring and then insert the needle directly into the external ring close to its upper margin and to carry the needle along for at least two inches. The suction technic should be followed and the needle should be moved in all directions as it is withdrawn and the deposit diffused as much as possible.

About the external ring itself and directly between the pillars of the external ring a certain amount of the injection should be placed.

THE AMOUNT OF PARAFFIN TO BE INTRODUCED IN A GIVEN CASE.

The tendency is to overinject a case. One must not forget that the tissues will probably thicken to twice the size of the mass injected. The operator must estimate as nearly as possible the size of the tract to be filled and then aim to throw in enough to about half fill it. The diffusion of the paraffin will usually safely hold the hernia when the patient rises from the table.

Should the operator throw in mixtures one and two until the parts are fairly distended and the hernia be not held it is better to use only the plain sterile vaseline for a subsequent injection at the site of the internal ring. If a half dram of vaseline at this point does not hold the hernia a small amount of vaseline may then be thrown in the central portion of the canal.

At first the vaseline injections should be used whenever in doubt as to the amount needed above a certain point. As the operator becomes acquainted with the needs of cases by experience the vaseline can be largely substituted by the paraffin mixture number one.

TECHNIC TO BE USED IN INJECTING INGUINAL HERNIA.

Have a syringe loaded with paraffin mixture number one and another loaded with sterile vaseline. See that the paraffin flows smoothly from the syringe without leaks. See also that the vaseline syringe is working smoothly.

Have needles intended for injection of paraffin free from this agent. Place patient on back, thighs flexed slightly or straight if the external ring is easily accessible. Follow the spermatic cord and locate definitely the external ring.

Attach empty syringe to needle. Pass needle point through skin. As soon as needle point is through skin exhaust syringe. That is draw piston out to form vacuum in syringe and obtain suction. Pass the needle slowly through external ring and along close to the roof of inguinal canal.

When needle is in full length, if no vein has been struck and blood aspirated into the syringe, detach syringe and screw the paraffin syringe tightly to needle.

Inject a few drops of paraffin by screwing down syringe. As paraffin is flowing move the point of the needle about in the loose cellular tissue and continuing the injection slowly withdraw the needle. Continue moving the point of the needle in all directions as the needle is withdrawn so that the paraffin will be diffused as much as possible. As the point of the needle emerges between the pillars of the external ring discontinue the injection.

Test the effectiveness of the injection.

Allow patient to stand on feet. If the hernia reappears have the patient lie down again and reinsert the needle as before described and inject sterile vaseline rather than the paraffin mixture.

Not more than enough paraffin to half fill the canal should be injected. If such quantity does not hold hernia sterile vaseline should be used discreetly until hernia is held.

The surgeon must estimate the approximate size of the inguinal canal by the size of the external ring.

If a vein is struck the needle should be withdrawn and the syringe emptied of blood; then the needle should be reinserted, using the syringe for suction. If a vein is struck a second time it will be well to insert the needle through the abdominal wall at the site of the internal ring and if no vein is struck at this point an injection may be made. If this holds the hernia it may be well to make no injection of canal for two weeks. During the interval even if the hernia does not recur it will be well for patient to wear web bandage truss or a spica bandage with a pad pressure over the inguinal canal. At the end of two weeks inject canal moderately with paraffin or vaseline to promote formation of connective tissue.

If the injection of the canal at the site of the internal ring does not hold the hernia, reduce the same and make a puncture with a small needle through the external wall of the canal just above the external ring. If no vein is struck inject moderately and see if such injection holds hernia. In such a case place pad of moderate size over the canal and put on firm spica and have the patient stay off of feet as much as possible for ten days or two weeks. In this case the permanence of the cure will depend upon the amount of connective tissue formed.

Injection at Internal ring.

To inject through the abdominal wall at the internal ring select a point midway between the anterior superior spine of the ilium and the pubes and one-half an inch above the line of Poupart's ligament. This represents the site of the internal ring. The needle should be pressed through the fibrinous wall of the canal at this point and should be directed towards the pubes. If the hernia is at all large remember that the canal is shortened and select a point one-half or three-quarters of an inch nearer the pubes as the site of the ring. When through the outer wall of the inguinal canal the needle point will have a considerable freedom in the loose cellular tissue and the injection should be diffused in a circle of an inch or an inch and a half in diameter. Before taking off the suction syringe after the passage of the needle sweep the point slowly in a circle to make sure that no vein has been opened or is likely to be opened as the needle is swept about.

The hypodermic needle for injection.

A hypodermic needle may be used for an internal ring injection or an injection through the anterior wall of the canal, but in moving it about the operator should watch carefully and not break such needle. If a needle breaks it will be at the shoulder formed by the point of attachment of the shaft of the needle with the butt.

The advantage of the small hypodermic needle is that it may be passed with very little discomfort to the patient and it throws a finer string of paraffin and favors diffusion of the agent.

A hypodermic needle is lacking in length to inject the canal when passed through the external ring along the canal.

Should the surgeon attempt injection along the canal and find the patient too nervous or the technic too difficult the hypodermic may be used and an injection made through the anterior wall of the canal at the internal ring, at about the center of the canal and about one-half an inch from the external ring.

The hypodermic needle injections are simple and should be accomplished even on a very nervous patient without troubling to infiltrate with cocain or alypin.

BE DISCREET IF INJECTION IS PAINFUL.

Should a patient complain that the injection is painful inject very discreetly or better check the injection there, move the point of the needle and again try slowly. If the cold injection causes pain try at another point. Put in a drop or two and should the patient still complain discontinue and put on a spica or truss for a few days. Observe the reaction and then if it is not severe inject again.

Remember that several injections may be made upon a patient but hyperinjection, that is the injection of too much, will cause no little distress and that it is impossible to remove all the paraffin mixture or the vaseline without an open operation, if they are not absorbed.

Needle punctures should be sealed with collodion. No other dressings are required.

Begin codeine early and use freely when a painful reaction develops.

THE INJECTION OF FEMORAL HERNIA.

The femoral ring is below Poupart's ligament. When the femoral hernia protrudes through the crural canal it is directed upward over Poupart's ligament. To reduce it press the mass toward the feet of the patient and then upward toward the abdominal cavity. The saphenous opening may then be felt. On the outer side of the opening is the large vein of the thigh. The needle should be inserted at the inner extremity of the opening, that is toward the median line. Aspirating of blood may mean the puncture of this large vein and it may not be advisable to inject carelessly when this vein has been wounded owing to its size. The crural canal is only about a half inch in length. The injection of it may be accomplished with a hypodermic needle. It is not well to sweep the point of the needle externally with too great freedom as the vein may be wounded. Inject slowly and move the point of the syringe carefully so that the injection may be diffused in the canal.

INJECTION OF UMBILICAL HERNIA.

Reduce the hernia and examine the margins of the hernial ring with care so as to be thoroughly acquainted with the character and situation of these margins. Remember that the tissues are often very thin and that an injection in the center of the hernia may simply go through the peritoneum and thus be placed directly in the abdomen. Injections of paraffin into the peritoneal cavity of animals have not proven to be dangerous, the agent not causing irritation of the surface of the peritoneum when sterile.

Umbilical hernia may be injected with a hypodermic needle building out from the margins of the hernial opening, but it is well not to inject with too great freedom. After diffusing the tissues of the canal or ring a pad and binder should be applied and the patient given two weeks interval to see if sufficient of the connective tissue has developed to close the canal. If the hernia is not overcome and recurs injections may be repeated.

Case Reports

Case 1.

Case 1 A. G.--Italian child, age twenty-eight months, female. (Ass. Civ. Char. Disp.) Umbilical hernia protruding about one-half inch and with an opening which may be filled by tip of index finger.

Parts thoroughly sterilized, hernia reduced and contents held in abdominal cavity by pressure of index finger of assistant. The margins of ring and the skin covering hernial opening injected with paraffin of melting point 108. In effort to avoid puncturing of hernial sac and throwing paraffin into the peritoneal cavity the skin of sac injected with the paraffin. About half dram amount used. Operation Jan. 17, 1905. Jan. 18, 1905. Temp. normal. Parts sensitive. Cries and struggles when parts touched. May 13, 1905. Last examination. Skin somewhat red. Paraffin mass easily palpable. Skin red but not sensitive.

Case 2.

Case 2 A. C. C.--Disp. W. P. Swedish boy, age 2 years and 9 months. Injected Feb. 3, 1905. Hernia as large as walnut. Reduced. Finger of assistant holding in contents. Injection made into tissue surrounding the hernial opening with view of crowding margins together. Half dram injected. Child crying forced contents into sac. Reduced and injection under skin of sac and around margins of opening to plug. Nearly dram paraffin used, melting point 108.

Parts moderately sensitive at end of week. No redness though paraffin mass palpable close under skin and intimately connected with it. April 11, 1905. Last examination. No redness, no tenderness, no recurrence.

Case 3.

Case 3 T. F.--Teamster. Irish parentage. Age 20. A. C. C. Disp. Bubonocele, left side. First noted four weeks previously. Operation May 14, 1905. Area sterilized. Small area of skin infiltrated with a one percent solution of cocain. Paraffin melting point 108, injected over area of prominence of bubonocele and into upper portion of canal. Two punctures made a dram and a half of paraffin injected. Parts sensitive for three days so that patient walked without bending thigh at hip joint. No temperature. Local applications. Codeine given in quarter grain doses every two hours. Fourth day parts much less sensitive, can bend leg freely in sitting or walking. Area prominent from swelling but no impulse. Examination June 25, 1905. No pain, no tenderness, no impulse, prominence in region of internal ring slightly greater than on opposite side.

Case 4.

Case 4 A. P.--Sicilian. Worker in shoe factory. Age 24. Hernia four months duration. Never retained by truss. Sac extends half way to bottom of scrotum. Pubes shaved, skin sterilized. Operation Aug. 26, 1905. Skin infiltrated to allow passage of large needle without pain. Injection at internal ring of forty minims. Injections into canal of about thirty minims. In attempting to inject paraffin in cold state screw piston syringe broken. All metal syringe used for infiltrating, warmed and filled with melted paraffin. In using syringe to inject the canal near the external ring the needle plugged. Using all force possible the plug forced from needle and over a dram of melted paraffin thrown between the pillars of the external ring. Patient complained of considerable pain. Codeine used one-fourth grain every hour. On the third day after injection skin over the external ring infiltrated and with sharp spoon about a half dram of paraffin removed. Operation painless. Formaldehyde solutions one to five thousand used as moist dressings. Codeine continued for two days longer. Patient lost one week from work. Sept. 24, 1905. No recurrence, no pain or tenderness. Area at former site of hernia slightly more prominent than opposite side, no redness of skin.

Case 5.

Case 5 F. C.--American born, age 18. Private patient. Hernia about size of average marble midway between ensiform cartilage and umbilicus. Spontaneous origin. Injected at office with half dram of paraffin, melting point 115. Operation Dec. 2, 1905. About half dram total quantity used. No reaction when adhesive strip removed on fourth day. Slightly tender on pressure. Examination Feb. 7, 1906. No recurrence, no redness, no pain.

Case 6.

Case 6 J. C.--Italian barber. A. C. C. Disp. Inguinal hernia on right side. Noted three weeks before. Sac protruding through external ring. Injection after infiltration. Forty minims injected about internal ring. Twenty minims in canal. Twelve or fifteen minims thrown between the pillars of external ring. Codeine prescribed but not taken. Parts quite sensitive on third day. No fever. Sleeps well with two pillows under thigh of affected side. Fifth day, no pain, tenderness very much less, able to bend leg almost as freely as ever. Twelfth day impulse at internal ring? (Questionable.) Injection of twenty minims at internal ring, ten into canal and ten between pillars, melting point 104. March 4, 1906. Last examination. No recurrence, no pain or tenderness.

Case 7.

Case 7 A. Y.--Femoral hernia. Female, age 35, A. C. C. Disp. Worker in tailor shop. History of case indefinite as to length of time present. Never been treated in any way. Operation March 21, 1906. Injection of forty minims of paraffin through saphenous opening and about ten minims through Poupart's ligament. Codeine discontinued at end of fourth night. Tenderness slight. No recurrence at end of twenty days. Patient not seen subsequently.

Case 8.

Case 8 E. H.--Marshalltown, Iowa. Private patient. American born. Varicocele on left side and oblique inguinal hernia. Operation April 16, 1906. Infiltration and removal of dilated veins in scrotum. Wound closed and inguinal canal followed by large needle. No blood aspirated and cold paraffin mixture with melting point 115 injected along canal. About forty minims thrown along canal and then puncture made at site of internal ring and half dram diffused at this point.

Personal communication one year later making final payment for operation. Patient cured and grateful.

Case 9.