Charles Conrad Miller

“ 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. ”

“ 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. ”

“ 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 [Pg 70] in the advent of the failure of the injection treatment. ”

“ 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. ”

“ 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. ”

“ 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 [Pg 52] 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. ”

“ 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.
[Pg 13] 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. ”

“ The veins of [Pg 34] 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. ”

“ 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 [Pg 14] needle base or at the point of juncture of the barrel of the instrument with its anterior portion. ”

“ 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 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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.
[Pg 66] 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. ”