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                        The Cure of Rupture

                                 BY

                        Paraffin Injections

                                 BY

                      CHARLES C. MILLER, M. D.

     _Comprising a description of a method of treatment destined
          to occupy an important place as a cure for rupture
            owing to the extreme simplicity of the technic
                and its advantages from an economic
                            standpoint_




                              CHICAGO
                  Oak Printing Co., 9 Wendell St.
                                1908




                           Copyright 1908
                        By Charles C. Miller




                             FOREWORD.


In taking up the description of the injection of paraffin for the cure
of hernia a number of remarks of a prefatory nature are called for, as
it is necessary to justify a treatment which has come in for a
considerable censure from surgeons who have had no experience with the
method and who have judged solely from a few mishaps which came to
their attention and which in no way permit of an accurate estimate of
the treatment.

Paraffin injections have been in use only a few years. When first
introduced their value for the closing of hernial openings was
mentioned. At the time the factors which made injections valuable for
such treatment were not appreciated. Paraffin was merely looked upon
as an agent which might be used to plug a hernial opening and such
plugging of a hernial opening is impracticable without histologic
changes in the tissues to cause permanent closure of the hernial
passage.


            The need which Paraffin fulfills in Hernia.

Paraffin has a tendency to promote the formation of connective tissue
and in hernial cases there is invariably a state of the parts which
will be benefitted by the throwing out of connective tissue in the
neighborhood of the deficiency which gives passage to the hernial
contents. Besides this production of connective tissue, the occlusion
of the hernial sac and glueing together of the walls of the hernial
canal, the plugging and supportive action of a material like paraffin
is likely to be in a measure useful as the paraffin does not lie in
the tissues as a single mass, but it is traversed by trabeculae of
connective tissue.




          OPERATION WITHOUT ANESTHESIA A GREAT ADVANTAGE.


Injections of paraffin are accomplished with such ease without
anesthesia that the mere fact that a hernia is curable without the
taking of an anesthetic is an advantage on the part of the paraffin
method which will be highly appreciated by a very large percentage of
patients suffering from rupture.

It is safe to say that for every patient suffering from rupture who is
willing to submit to the cutting operation four or five patients will
be met who are afraid to submit to such operation because a general
anesthetic is to be taken.


               Applicable in the Physician's Office.

Paraffin injections may be made in the physician's office and there is
no condition produced which renders it difficult for the patient after
injection to go to his home, if he must not travel more than a
moderate distance. The reaction may be such as to make it advisable for
the patient to remain quiet for a week or even two weeks, though this
is exceptional, yet such avoidance of exertion is not looked upon in
the same light by patients as two weeks strict confinement to bed.

The probability of escaping confinement is a great incentive to a
patient to submit to an injection, when he would refuse operation.

Injections are not necessarily unphysiologic as the sufferer from a
hernia has a physiologic deficiency which the paraffin accurately
fills with normal connective tissue.

The dangers of injection can be eliminated. The technic is not
difficult even when all precautions are taken.

There is less likelihood of suppuration following the injection
treatment than following the cutting operation.

The consequences of suppuration are less. If suppuration occur after
the open operation failure is likely, not to mention the danger of
peritonitis. Such is not the case following injection, and while
consequences are less serious suppuration is avoided much more readily
than following the open operation.

Only the operator thoroughly acquainted with the manner of disposition
of paraffin should attempt the injection of hernia.


                            Simplicity.

To the skilled operator the injection treatment is exceedingly simple
and the injection method must always be far more simple than the open
operation can ever become.

A hernia can be injected without haste in from two to four minutes.

An assistant is of no use.

The open operation cannot be performed without the aid of several
trained assistants, and without elaborate and expensive preparations,
it is not feasable as anything but a hospital operation.

Hospital surgeons may be expected to condemn the injection treatment
of hernia, as it will open to thousands of the profession a field
which has hitherto been monopolized by the surgeons with hospital
facilities.


         Experimental injections before human injections.

Before injecting a hernia the operator should be thoroughly <a
acquainted with the manner of diffusion of paraffin in the tissues.
This experience can be gained by the making of numerous injections
into the carcass of a small animal and the subsequent careful
dissection of the animal. A dead cat, dog, rabbit, or chicken may be
used for experimental injections and many such injections should be
made.

Hyperinjection of a hernial canal should be religiously avoided.

Should the operation fail and the patient suffer from the presence of
the paraffin it can be removed by surgical means and at the same time
the open operation performed.

The presence of the paraffin will not interfere with the successful
performance of the open operation nor will it complicate the operation
so that the chances of a radical cure are not diminished from this
method, nor is the patient liable to a slower convalescence.

Vehement protests against the use of paraffin injections are to be
expected from surgeons doing the open operation, and unbiased readers
should not be misled by condemnatory remarks from inexperienced
sources.




                      PREPARATION OF THE SKIN.


The hair over the pubes and the groin of the affected side should be
cut rather close and then the parts scrubbed with a solution of green
soap. A small amount of a forty per cent. solution of formaldehyde may
be added to the soap solution as this agent is a very powerful
antiseptic.


                        Soap solution.

Formaldehyde solution, one dram (40%).

Green soap, four ounces.

Dilute alcohol to make one pint.

The dilute alcohol is made up of equal parts of ninety-five per cent
alcohol and water.

After the parts are thoroughly scrubbed with this solution the soap
should be removed with moist compresses and then the parts mopped with
a solution of seventy per cent alcohol. Finally the field of operation
should be flooded with ether as this agent is an effective antiseptic
and also acts as a solvent for any greasy matter not removed by the
soap.




             PREPARATION OF THE HANDS OF THE OPERATOR.


Antiseptics cannot be as freely used upon the hands of the operator as
upon the skin of the patient as the repeated application of the
stronger antiseptics cause a scaling of the epithelial cells and
finally the development of an irritated state which prevents cleansing
of the hands sufficiently to permit operating.

It is well to scrub the hands with the soap solution and then to
follow with the use of the seventy per cent alcohol. The alcohol
solution is the least irritating of effective antiseptics and it is
the solution in which needles and leather washers should be kept, so
that they are at all times ready for use.




                            THE SYRINGE.


The sterilized paraffin syringe should not be handled until the hands
have been scrubbed. The washers and needles, just before using, should
be removed from the alcohol solution. It is unnecessary to wash the
alcohol from the fingers, washers or needles, in fact, it is
preferable to leave it upon them.

Using an extra large syringe it is possible to operate upon several
patients without resterilizing the syringe. This instrument may be
soaked in the alcohol solution, the needle changed and the operator
may continue until the syringe is empty.

Even though one have a syringe capable of holding enough for several
operations it is well to have a second at hand ready for use as the
instruments sometimes break or spring a leak when least expected.
Never use a syringe which leaks, as one cannot tell how much is going
into the tissues and how much is escaping. Leaks invariably occur at
the side of the needle base or at the point of juncture of the barrel
of the instrument with its anterior portion. Paraffin in the solid
state will seldom if ever escape along the side of the plunger within
the barrel of the instrument when the all metal paraffin syringe is
used and the all metal syringe is the only instrument which should be
used for paraffin injections.

The screw piston is preferable to the sliding piston under all
circumstances as it gives the operator a better control over the
injection. Injections are made with the paraffin compounds cold so
that considerable pressure must be brought to bear to cause the harder
mixtures to flow through a long needle.




                    PREPARATION OF THE SYRINGE.


The plunger should be removed from the syringe and the instrument in
two parts should be thoroughly boiled before filling. It should be
scrubbed with soap and water if dirty or corroded before it is dropped
into the boiling water. After boiling for a half hour the barrel of
the syringe which is closed anteriorly, except for the needle opening,
is held up and the melted paraffin poured in until the instrument is
quite full, then the plunger is fitted in and pressed down until it is
possible to assemble the instrument ready for use.

Needles should be boiled. Leather washers when not in use should be
kept in solutions of alcohol.

Preparations for operation, such as sterilizing syringe and needles
should be done hours before operation. If the sterilized loaded
syringe is placed in a sterile towel it may be kept for days and then
before use to insure sterilization it should be soaked in a seventy
per cent solution of alcohol. If a needle is attached to the syringe
when it is thrown in the alcohol solution it will be found that the
paraffin in the syringe will not be affected by the alcohol. The
instrument may be used from the alcohol without even drying it.

Before inserting the needle for the injection of the paraffin start
its flow and observe that the paraffin is escaping from the needle in
a perfectly smooth string.

The same words as to preparation apply when the white vaseline is
used. This agent should always be sterilized by heat before placing it
in the syringe and when syringe and vaseline are sterile the exterior
of the instrument may be re-sterilized at the time of using by alcohol
soaking.

Paraffin in the liquid state may be drawn from a large container
directly into the syringe when the needle has been removed. The needle
may then be screwed in place and the instrument held with the point of
the needle directly upward and pressure made upon the piston until all
air escapes and the liquid paraffin begins to flow. Then the
instrument may be allowed to cool and its contents to consolidate.


               Material injected at room temperature.

All these injections are made with the material in the syringe at room
temperature. The syringe may be left filled for days and not heated at
all when the injections are finally made. In mid-winter if the syringe
has been kept in a cold room its temperature may be so low that it may
be advisable to warm it somewhat, but at an average temperature of
seventy degrees Fahrenheit the mixture first described should flow
freely through an ordinary hypodermic needle.




               PREPARATION OF THE PARAFFIN.


Some operators have said a good deal about the paraffin and the proper
place to secure it. As nearly as can be learned the compounds used in
this country are products of the Standard Oil Company. The paraffin
used in the formulae of this book has an average melting point of 130.

For reducing the melting point of the paraffin mix the paraffin with
the white vaseline of the Chesborough company. If an agent is sold in
a tin stamped white vaseline it should have the name on the tin of the
Chesborough company as this is the only firm having the right to use
this name. Petrolatum albi or white petrolatum is a few cents cheaper
than the vaseline but the difference is of so small an amount that it
is better to use the vaseline rather than packages which may vary more
than the Chesborough product.




FORMULA NUMBER ONE.

White vaseline, one-half pound.

Paraffin, one-half pound.

Melt together.

This should be sterilized by having the mixture stand in a covered
container in a vessel of water which is also covered and the water
should be kept boiling for a half hour.


                Containers for sterilized compounds.

With the paraffin may be boiled a number of test tubes. These after
boiling one-half hour may be lifted from the boiling water with
forceps. As they will be quite hot if they are held with opening
downward the water will drain from them and their own heat will
evaporate the few drops in the interior and they will be left dry.
Into each test tube sufficient paraffin may be poured to fill a
syringe and then they should be plugged with sterile cotton or corks
which have been boiled. The test tubes containing the paraffin
mixture may then be put away and when taken out at a later time for
filling the syringe the paraffin may be melted by heat and poured into
the sterile syringe or the paraffin may be boiled by holding the test
tube over a Bunsen burner, or other heater. When paraffin boils the
temperature of the boiling mixture is higher than that of boiling
water but the boiling causes dense black smoke to be given off and
this is objectionable in a closed room. Repeated boiling of paraffin
causes it to discolor but this does not occur when the vessel
containing the paraffin is placed in a water bath and the water around
the paraffin container boiled. No smoking of the paraffin occurs when
it is heated in a water bath and this means of sterilization is the
most satisfactory though the first time the paraffin is sterilized it
should be kept in the boiling water for a half hour.

A softer mixture of paraffin, which may be used when in fear of the
effects of the injection of the harder mixture, is made as follows:




                        FORMULA NUMBER TWO.


Paraffin, two ounces.

White vaseline, eight ounces.

Melt together and sterilize.

This second paraffin compound is advisable when the operator is
anxious to secure a plugging action with a mixture which will always
be fairly soft, and which is less likely to be absorbed than plain
sterilized white vaseline.


                             Vaseline.

The third compound is the sterilized white vaseline. It is probable
that this agent is frequently absorbed in a comparatively short time
but it has the valuable property of diffusing freely through the
tissues so that it produces a more extensive reaction and when it is
used in connection with the harder mixtures the operator may be more
certain of securing an occlusive inflammation of the sac of the hernia
and the more extensive production of connective tissues so that the
parts separated to make way for the passage of the hernial sac are
more certainly bound together.

None of these mixtures are hard. If a portion of the mixture first
described is secured under the arm for a half hour or held in the
mouth for that length of time and it is raised to body temperature it
will be found that it is comparatively soft. It is not a liquid and it
is not likely to be absorbed, yet it is not a hard waxy mass.

The great danger of the untrained operator is to inject too much at
one point and should the operator do this and get it in the canal it
will make a lump at one point and press unnecessarily upon the tissues
and in time will be displaced and will drag involved tissues with it,
producing discomfort by the distortion.




                 POSTURE OF PATIENT FOR INJECTION.


The patient for injection should be placed upon the back. When the
thigh is slightly flexed the wall of the abdomen is relaxed and should
the external ring be not dilated by the protrusion of a large hernia
the relaxation obtained by the flexing of the thigh and allowing the
flexed leg to rest against the other will relax and dilate the
external ring somewhat so that it may facilitate the free passage of
the needle and it will also permit of the more free moving of the
point of the needle in the loose cellular tissues as the needle is
gradually withdrawn.


                     Pelvis high and head low.

If the head is dropped low and the pelvis is high, a position easily
possible with some surgical chairs, the veins of the cord are depleted
and the likelihood of opening or entering a vein is diminished. This
posture should only be used where there is a well marked varicocele
and the suction method of inserting the needle should always be used.
When the veins are dilated the elevation and their depletion may
prevent the operator making several efforts to pass the needle without
striking them, a thing which is easily possible in the presence of a
canal full of dilated vessels.

Should there be a well marked varicocele the blunted needle should be
used so that it will not be possible to cut a vein by the moving of
the needle and at the same time the operator should move the point of
the needle slowly from side to side as it is withdrawn.




       SKIN INFILTRATION TO PERMIT OF INSERTION OF LONG NEEDLE
                        WITHOUT UNDUE PAIN.


It may be well to infiltrate the skin slightly at the site of the
puncturing of the skin with the larger needle. To do this a weak
cocain or alypin solution should be used. This solution is made by the
addition of the cocain or alypin tablets to one or two drams of boiled
water.

A tablet containing six tenths of a grain of alypin or cocain is
sufficient for a dram solution. A few drops of this injected over the
external ring will permit of the passage of the needle through the
tough skin without pain. The pressing of the needle along the roof of
the canal is not usually sufficiently painful to call for much
complaint from the patient.

If the patients are nervous a preliminary injection of a one per cent
solution of cocain or alypin into the inguinal canal is not
contraindicated. To accomplish this the larger needle should be
screwed upon the infiltrating syringe and as the needle is pressed
into the canal the solution is slowly forced in front of the needle
point. If sufficient solution is thrown ahead of the needle the
passage of the needle along the inguinal canal is entirely painless.

The infiltration of skin or canal being complete the needle must be
withdrawn and the syringe emptied and the plunger pressed down so that
the empty syringe is attached to the needle through which the paraffin
injection is to be made when the operator has assured himself that the
needle has been passed as far as desired without traversing or
puncturing a vein.




         THE EFFECT OF PARAFFIN COMPOUNDS UPON THE TISSUES.


No matter what precautions are taken, paraffin deposited in the
tissues causes an increased flow of blood to the parts. The reaction
is in the nature of a distinct active hyperemic state and it is
sufficient to cause the proliferation of connective tissue. Even if
pure white vaseline alone is injected there will be such connective
tissue proliferation and if the paraffin is deposited close along the
peritoneal surfaces of the sac sufficient of a circulatory disturbance
will be produced to result in the sticking together of the serous
surfaces of the sac and such sticking together of the walls will mean
an elimination of the patency of the sac, one of the essential
features of a radical cure.

The paraffin compound number one is of such consistency that it is
unlikely to be absorbed and properly placed with discretion it will
favor the retention of the hernia by acting as a plug. This plugging
action is not likely to be successful if the paraffin is simply thrown
in as a mass, as it will be displaced, and when displaced it will make
undue traction upon parts with which it is intimately connected so
that should the paraffin be thrown in in the form of an irregular mass
closing only a small part of the canal and such displacement occur the
patient may suffer considerable discomfort.

The corking action of the paraffin is not to be disregarded, yet at
the same time it must be remembered that the injection must be so
diffused that the supporting mass has quite a universal support from
all the tissues from the internal ring clear out to the external ring.

It must also be remembered that the paraffin thrown into the tissues
causes a thickening of the tissues and should the canal be filled with
paraffin with the thickening which so rapidly develops the canal will
be unduly crowded.

If the canal is plugged up tightly and marked pressure is made upon
the nerves of the cord at one point it is likely that discomfort will
be produced which will last for some time.


                        Object of operator.

The object of the operator is to secure a diffusion of the injection
through the loose cellular tissues by the directing of the needle in
all directions as it is withdrawn. This diffusion is facilitated by
the nature of the paraffin. It is not to be forgotten that the
vaseline diffuses very readily and extensively and if the operator is
fearful of overinjecting the parts it is best to use it in excess
rather than the harder mixture.

If the needle is simply withdrawn the paraffin is not thrown into the
canal in a regular pencil-like plug but it lumps irregularly with
small diverticula projecting from each irregular mass.

The free moving of the needle point in all directions as the needle is
withdrawn favors the diffusion and avoids the unsatisfactory lumping
of the injection.




       THE IMMEDIATE AFTER EFFECTS OF THE PARAFFIN INJECTIONS.


Within twelve hours after the operation the tissues are almost certain
to become quite sensitive to pressure. The reaction may be followed by
considerable pressure pain for a day or two. Should the patient not be
comfortable while at rest, that is sitting about or lying down; then
something should be given to relieve the pain. Codeine is the most
satisfactory agent for preventing the patient from feeling pain during
the most acute stage of the reaction. Codeine does not put the patient
to sleep as does morphine, nor does codeine constipate or make the
skin itch. Codeine is only about one-third or one-fourth as toxic as
morphine and consequently it may be given in a proportionately larger
dose. It may be given in tablet form or in solution by the mouth. The
best way to administer it is in doses of one-half grain every hour
while the patient is suffering actual pain. Tell the patient that it
will relieve him of unpleasant symptoms during the reaction and that
it is undesirable that he should suffer from the reaction. In this way
the patient will be kept quite comfortable during the time that the
reaction is sufficient to cause pain. It is impossible to tell whether
the reaction will be such as to cause any pain or not. In case it does
not develop no internal treatment is necessary. Other agents may be
used to relieve pain, though none offer the advantages of codeine
without disadvantages. It is not advisable to let these patients
suffer from a severe reaction. It is better to meet the first
indications of pain with the free administration of codeine. The
patient should not know the nature of the drug, and as it produces
none of the peculiar effects of morphine it is not really a drug at
all dangerous from the habit forming standpoint.

Local applications of heat or cold may be used if the reaction is well
marked.




        THE PRECAUTION USED TO PREVENT THROWING OF PARAFFIN
                       INTO THE CIRCULATION.


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.

Case 9--Italian section worker wearing spring truss for holding of
inguinal hernia. Strong pressure of truss making marked depression at
site of internal ring. Patient injected with dram and half of paraffin
of melting point 115. May 20, 1906. Agent deposited along canal and at
internal ring. One week later no pain, no tenderness to moderate
pressure. Cord somewhat larger than normal and epididimus thickened
but not tender. Shreds in urine. Through interpreter information
gleaned that epididimus had been somewhat tender following operation.
History of acute epididimitis some months before.


                              Case 10.

Case 10 A. J.--Patient first consulted at Harvey dispensary. Treated
for urethral stricture by internal urethrotomy. Subsequently
referred to A. C. C. Disp. for treatment. Developed acute appendicitis
and operation for removal after development of abscess. Abscess
drained and healing of abdominal incision imperfect leaving hernial
protrusion internally and near superior angle of scar. Injected with
seventy minims of paraffin, 115 melting point, on Aug. 2, 1906. No
pain following injection, no discoloration, and no recurrence over a
year and a half after operation.




                            CONCLUSION.


These cases represent the ten first which were seen subsequent to
injection. Cases which were injected and which did not return
subsequent to injection have not been included as they would be of no
value in estimating as to the usefulness of this method. In no
instance has an ill consequence been suffered which would cause the
patient to seek surgical aid elsewhere, or at least no case has come
to the knowledge of the author directly or indirectly.

Large hernia which have gone unreduced for years have not been treated
by injection and discretion demands that for some time, or until
injection treatments have been practiced upon many patients, that
large ruptures which have been outside the abdomen for long periods be
left to the surgeon or be injected only by practitioners capable of
doing the cutting operation in the advent of the failure of the
injection treatment.

The author for his own part has felt no hesitancy in injecting cases
which promised a fair degree of success, realizing full well that
untoward symptoms of a local character may be overcome by free
dissection, removal of the paraffin and restoration of the inguinal
canal by the usual surgical means.




                              CONTENTS


                                                            PAGE
     Foreword                                                  3
     Preparation of the skin                                  10
     Preparation of the hands of the operator                 12
     Preparation of the syringe                               15
     Preparation of the paraffin                              18
     Posture of patient for injection                         23
     Skin infiltration to permit of insertion of long needle
       without undue pain                                     25
     The effect of paraffin compounds upon the tissues        27
     The immediate after effects of the paraffin injections   30
     The precaution used to prevent throwing of paraffin
       into the circulation                                   32
     Factors to be considered in dealing with inguinal
       hernia                                                 35
     Where the injection should be placed                     39
     The amount of paraffin to be introduced in a given
       case                                                   42
     Technic to be used in injecting inguinal hernia          44
     The injection of femoral hernia                          51
     Injection of umbilical hernia                            53
     Case reports                                             69




                          Cosmetic Surgery

              The Correction of Featural Imperfections

                                 BY

                      CHARLES C. MILLER, M. D.


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                                       _Cleveland Medical Journal._

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                                                 _Southern Clinic._

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                                                   _Ophthalmology._

  Has gone far beyond the limits of surgery as understood and
  practiced in this country.
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  work upon the subject.
                                            _Yale Medical Journal._

  The book furnishes in an extremely convenient and accessible form
  much information concerning a branch of surgery which is daily
  growing in importance and interest.
                                                _Military Surgeon._

  Dr. Miller has made out a good case as to why the regular surgeon
  should give this question some considerable attention rather than
  leave such things to the charlatan and quack.
                        _Canadian Journal of Medicine and Surgery._


  160 Pages.              98 Illustrations.             Price $1.50.




                        Transcriber's Notes:

Words and phrases in italics are surrounded by underscores, _like this_.

Spelling changes:

  acqainted to acquainted, ... thoroughly acquainted with ...
  patrolatum to petrolatum, ... white petrolatum is a few cents ...
  PRACAUTION to PRECAUTION, ... THE PRECAUTION USED TO PREVENT ...
  pertoneal to peritoneal, ... into the peritoneal cavity ...
  urtehrotomy to urethrotomy, ... by internal urethrotomy ...
  protrusian to protrusion, ... leaving hernial protrusion,...
  Opthalmology to Ophthalmology, advertisement at end of book

Added missing period at end of chapter, ... reaction is well marked.