Part 5

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.