Part 6

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.