Part 4

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The infiltration of skin or canal being complete the needle must be withdrawn and the syringe emptied and the plunger pressed down so that the empty syringe is attached to the needle through which the paraffin injection is to be made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.