Onlayn kitobni bepul oʻqing: ta muallif  The Cure of Rupture by Paraffin Injections

Charles Miller

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 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.