Fig. 284.—Eckstein Method of Insulating Needle and Syringe.
Fig. 284.—Eckstein Method of Insulating Needle and Syringe.
Fig. 284.—Eckstein Method of Insulating Needle and Syringe.
Paget and Harmon Smith warm the needle in hot sterilized or even boiling water. Previous to this Smith cools the contents of the syringe drawn into it at a temperature of 120° F. by immersing the latter in a bath of sterilized water at a temperature of 80° F.
From the above it will be noted that Smith advocates using the injections in semisolid state being ejected in a thin, cylindrical thread. A syringe of special construction, as referred to later, is, of course, required for such work.
Quinlan has invented a so-called paraffin heater, as shown inFig. 285, in which the paraffin is kept in solution by the syringe being surrounded by a continuous flow of hot water. A plain and very objectionable syringe is shown in the illustration, and while the preparation in the syringe is thus kept ina liquid state the solidification in the needle is not overcome.
Fig. 285.—Quinlan Paraffin Heater.
Fig. 285.—Quinlan Paraffin Heater.
Fig. 285.—Quinlan Paraffin Heater.
Downie winds fine platinum wire about the needle through which he passes the current from a storage battery to keep the needle hot, yet such an arrangement is obviously difficult of manipulation, and when paraffins of high melting points are employed it is quite likely that a plug is formed in the exposed point of the needle.
Karewski has introduced a syringe having a jacket through which hot water is allowed to circulate, while similar instruments have been originated by Pflugh and De Cazeneuve. None of these overcome the difficulty in question.
Viollet went even further by inventing a syringe surrounded with a coil of resistance wire, heated by an electrical current, and Delangre, Ewald, and Moszkowicz use special thermophorm sleeves over the syringe proper; all, however, offering the same objection in the exposure of a part of the needle in which temperature of the liquid must necessarily be lowered, or be low enough to cause plugging, the very fault for which all these modifications have incidentally been urged, as the greater amount of paraffin in the syringe itself is as a rule large enough to retain sufficient heat to permit of its ejection, if the injection is made as expeditiously as possible.
The objection of the setting of the paraffin in the barrel of the syringe has never hampered any operator, the difficulty in these instances having been entirely due to the obstruction offered its ejection by the threadlike plug obstructing the metal cannula before it; the barrel, being glass, retains its temperature more readily than the thin metal needle, hence the difficulty.
That all prothetic preparation of the nature in hand should be placed in the barrel of the instrument in liquid form is essential, in that the syringe is thus filled to its required height evenly, and devoid of air spaces, yet in the light of the best and most successful resultsthe mass should be allowed to cool and be ejected in semisolid state from a specially constructed instrument, to be described later.
With such method it is impossible to have an occlusion of the needle at any time, and the objection of sudden outbursts of unknown and undesirable quantities of the mass is entirely overcome.
15. Absorption or Disintegration of the Paraffin.—The question of the ultimate disposition of paraffin, injected subcutaneously for any purpose, has been an extensive one in which many operators have taken part.
Gersuny at first claimed an encapsulation for the injected mass of vaselin, which he states was not taken up by the lymphatics, but remainedin situas an inert, nonirritating body. Shortly after it was shown that the encapsulated mass soon became ramified by newly formed, fine bands of connective tissue, which developed more and more in the part until the entire mass had become displaced by this tissue with an eventual consistency of cartilage.
Eckstein claims that at first a capsule of new connective tissue incloses the injected mass (Hart paraffin) a few days after the latter is injected, which can be easily stripped away from the encapsulated matter several weeks or months after, showing a smooth inner wall, the encysting capsule showing a decided lack of blood vessels, proving histologically its relation to the structure of cicatricial formation.
In this Eckstein is undoubtedly mistaken. He objects to the ultimate replacement with connective tissue for the vaselin process of Gersuny, when in reality we have begun to realize that such result will follow any hydrocarbon subcutaneous injection unless the latter be made in small quantity into parts of the body which are in constant motion.
The latter is shown with injections of paraffin made into or about the nasolabial fold. The tumor is so smallas to be hardly felt by the palpating finger, but soon takes on larger proportions, evidencing an encapsulation of some extent or less independent of the encysted mass. That this is true can be ascertained by incising these little hard tumors when the contents can be readily pressed out or evacuated, the mass appearing practically as injected months before.
The same result is shown by Harmon Smith, who made an injection of paraffin (110° F.) into the peritoneal cavity of a rabbit which was killed twenty-two days later. On examination no sign of inflammation of the peritoneum was found—a fact that seems to prove the nontoxic effect of paraffin—nor were there evidences of the formation of adhesions. The mass had become rounded, had traveled about the abdominal cavity, and was found lodged between the liver and the diaphragm.
Comstock, with his experiences of injections of paraffins at high melting points, found that the harder paraffins do not become encysted, but become a part of the new tissue, which belief is corroborated by Downie, who introduced paraffin into a carcinomatous breast. Upon subsequent amputation and microscopic examination there was shown an intimate connection between the ramified site of the injection and the surrounding tissue. The same results have been noted by Jukuff.
Smith found that, in trying to remove an injected mass of paraffin several months after introduction, the greater part of the mass had become so thoroughly imbedded in the meshes of the newly formed connective tissue that it was practically impossible to remove it without including a considerable portion of the connective tissue as well.
Stein claims also that the paraffin is absorbed, little by little, as it is replaced by the new connective tissue, no matter what the melting point of the introduced paraffin might have been. The mass grows smaller to a degree, according to the amount injected; finally, at theend of a month or more, the entire mass is replaced by a tissue perceptibly analogous to cartilage.
Freeman, like Eckstein, claims that encystment of the paraffin occurs soon after the injection, much like that following a bullet or other foreign body in the tissues, but, unlike the latter author, that a limited amount of the connective tissue also penetrates the mass, which is speedily converted into a solid cartilagelike body.
Wendel believes entirely in the encystment theory, while Hertel, in specimens removed twelve to fifteen months after injection of paraffin with a melting point of 100° F., found a wall of round cells under various states of inflammation surrounding the masses with fibers of connective tissue traversing the latter. In the various histological findings he argues that the greater the tissue surface exposed to the injected foreign body the greater the irritation, and the larger the smooth paraffin mass the less the reaction; in other words, small masses of the injected mass cause a higher rate of tissue formation, while the larger masses have a tendency to encystment merely. He also believes that the harder paraffins require a greater length of time to become absorbed, and that during such time of resorption new connective-tissue growth is established, continuing to the time of its complete disappearance.
Comstock, after thorough and extensive investigation with the injection of paraffins of various melting points made at varying times after the injection of such procedures, concludes definitely that, “In paraffin we have a substance that will fill in spaces of lost tissue, and not remain entirely a capsulated foreign body, but become a bridgework, and, in fact, a part of the new tissue.”
Wenzel, after an unsuccessful attempt to overcome a laparocele by the injection of paraffin, a year later performed a radical operation of the parts. The excised tissue at the site of the injection showed deposits of thebroken-up mass of paraffin, each being enveloped by a capsule of connective tissue without any signs of ramifying bands, and hence decided against the belief of the resultant tissue formation.
Eschweiler, the latest authority on the above question, after examining microscopically a portion of paraffin-injected tissue that had been carried “in situ” on the bridge of the nose for about one year, concurs absolutely with the connective-tissue replacement belief.
From the foregoing it may be definitely accepted that while there may be an encapsulation or encystment of the injected mass, be it what it may so long as it belongs to the paraffin group, there is always a ramification of the mass by the formation of the strands of new connective tissue which eventually in a month or more, according to the amount of the mass, develops to a size corresponding to the latter or even beyond the size of the latter, as will be mentioned later, and that in all cases the paraffin is ultimately and almost, if not completely, crowded out of the area occupied by the injection, and that its disappearance is accountable to absorption.
This absorption, following such an injection, is productive of no harm to the human economy, and the new tissue caused to be formed by such injection truly enhances the cosmetic and surgical value of the method inasmuch as an encapsulated mass of paraffin is liable to displacement, spreading, and irregularities, should it be subjected at any time to external violence.
Such violence, again, would lead to the irritation and inflammation of such cyst wall, causing an undue crowding upon the parts injected and possible gangrene of that part of the wall upon which such pressure was brought to bear, leading to unsightly attachment and ultimate contraction of the skin where bound down by the inflammation, or even evacuation by the absorption of gangrenous material and resultant abscess.
That this absorption or disintegration of paraffin isof no consequence may be proven by all the early cases in which such injections were used. Gersuny’s first case, having been done May, 1899, shows no diminution of the prothetic site at the end of two years. The same may be said of the hundreds of cases done by other operators.
The greater question in the mind of the author is what will be the ultimate behavior of this new connective tissue.
That the development of this new connective tissue is gradual has been mentioned, some authors claiming a complete replacement of the mass at the end of a month, others from two or three months. Morton says that four months’ time is required before the mass is, more or less, completely removed and replaced by organized tissue. The author believes, however, that the length of time necessary for this replacement not only varies, proportionately with the amount of paraffin injected, but that it differs in each case, and markedly with some patients in which the growth or developments of the new tissue did not cease for months and even a year after such injection. This corresponds truly to a hyperplasia, and will be considered later.
Time alone will show the ultimate behavior of this new tissue, and while it is reasonable to argue that this newly organized tissue could cause no untoward results, it must be determined whether this tissue will not undergo atrophy and contract, or become susceptible to other changes in time. It is a new tissue practically, and as yet we know nothing of its idiosyncrasies, although its histological nature is determined.
We do not know that irritations, such as surgical interference, will cause it to take on new growth, as evidenced by the attempts of extirpation of unaccountable overcorrections obtained with injections made early in the time of the employment of the Gersuny method, in which the parts practically grew back to their former size or became even larger. This may be accounted forby the fact that most, if not all, of the connective tissue was not removed or points to an active nucleus or several such centers which were not destroyed.
That the growth is not limited by the size of the mass injected is the author’s belief; in other words, the replacement of the new tissue is not proportionate to the injection, but that other forces, such as adjacent tissue pressure and presence and outer influences, as, for instance, the daily massage of the parts with the hands, have much to do with the final amount of tissue caused to be developed by the initial stimulus of the injection. Nothing further or definite, however, has been written on this supposition.
16. The Difficulty of Procuring Paraffin with the Proper Melting Point.—This should not prove an objection to the method, since operators can procure pure and sterilized paraffins of the various melting points from any reliable chemical house.
What the operator should determine first of all is the kind of paraffin he intends to use for subcutaneous injection.
The selection of paraffin of a certain melting point should be influenced by what he has read on the subject, as given by authorities of wide experience.
A few cases do not suffice from which to draw conclusions; it is only from a great number of similar operations that a definite form or preparation of paraffin can be decided on.
From the following authorities is shown a variance in the melting points of the preparations used, but by a glance it may be noted that the first division of men, from numbers 1 to 10 inclusive, use paraffins of melting points very near to each other; the latter group, from 11 to 13 inclusive, employ those of the higher melting points.
The former group may, therefore, be said to utilize the paraffins of lower melting points.
From a glance of the first group the variance of the temperature of melting points is not a great one, practically lying between 102° and 115° approximately. When we consider the actual difference in the employing practicability and the effect upon the tissue there is practically little, if any, difference. The only difference between these authorities is that some employ their preparation in liquefied form, through the application of heat, while the others employ it in the cold or semisolid form. The choice of such method, from what has already been said, should unreservedly be the employment of a paraffin in the cold or semisolid form at a mean temperature of about 110° F.
This choice would fall upon any one of the paraffins used by the authorities given in Group I.
The objections to the “Hart paraffins” of melting points given in Group II have been sufficiently shown in preceding paragraphs, although a few pointed objections from the various surgeons may not be out of place here to offset the claims and advocacies of those employingthe preparation in liquid form at higher temperatures than 110° F.
Paget says: “I am absolutely sure now that Eckstein’s paraffin is without any real advantage. It is very difficult to handle; it sets very rapidly; it causes a great deal of swelling and some inflammation, and may even produce some discoloration of the skin, and it yields no better results than does Pfannenstiel’s paraffin, which melts at 110° F.”
Again he says: “The best paraffin is that which has a melting point somewhere between 108° and 115° F. When the paraffin has to stand heavy and immediate pressure, the higher melting point is preferable.”
He had up to the date of the latter extract operated upon forty-three cases of deformed noses and “in no case was there embolism, sloughing of the skin, or wandering of paraffin.”
Paget, however, employs the paraffin in liquefied form, and allows cold water to trickle over the nose while the injection is molded into form. Of this later.
Comstock says, “Paraffin must be used where it will be at all time above the body temperature,” and further that, “in selecting the melting temperature for surgical uses, it should be that from 106° to 107° F., the best for use in subcutaneous injections, for the reason that it gives a substance firm enough to hold very well its form, especially when confined by the surrounding tissue, and at the same time with a melting point out of the reach of the system at all times.”
From this we are given to understand that he uses his preparation in cold form entirely when injecting, but of the melting point mentioned.
The author can see no advantage in using any paraffins of low temperature melting points in liquid form. Here is the very factor of causing embolism reintroduced. Surely a liquid of any kind injected into a blood vessel will give cause for trouble, even if the temperature ofthe setting of such a paraffin be high or low. The employment of the paraffins of a melting point above 120° F. in cold form is difficult, if not impossible, even with the latest pattern of screw syringe which is quite true, but there is no need of using such paraffin nor any liquefied paraffin, since any such preparation of about the melting point of 110° F. will serve every purpose overcoming all the objections of the advocates of those using any other.
If a vessel be injected and filled with any paraffin preparation there is danger of phlebitis and thrombosis; the only possible way to overcome it is not to puncture the vessel.
While a preparation injected cold can be more easily governed from without by digital pressure or guidance, what can be said for a hot seething preparation introduced under great pressure?
Furthermore, when paraffin is injected in liquid form, especially when so rendered by a temperature necessarily even higher than the actual melting point, there is danger of searing the entire site intended for injection—a condition inducive to no good and a burning of the skin where the necessary superheated needle enters it, causing a punctate scar, more or less painful during the time required to heal the wound.
With the later knowledge that small amounts should be injected, and that such injections should be repeated, it being known that such method facilitates the production of new connective tissue, may we not draw the conclusion that the result obtained by the injection depends not upon the injectionper se, but the resultant of that injection—namely, tissue production, and that this tissue production is the outcome of a stimulus in the form of that injection?
There has not appeared an authority who has claimed otherwise for injections of paraffin hot or cold, while it is true that the use of liquefied paraffins at hightemperatures have caused all sorts of untoward results, while those of lower melting points in similar form have not escaped objections.
The author has used the cold-injection method in over three hundred nose cases without a single case of sloughing, embolism, or death, and in no case was there secondary diffusion or hyperinjection. The only fault has been the desire on the part of the patient to be finished too quickly, which usually leads to a result not as satisfactory as when the injections are made sufficiently far enough apart to allow the formation of organized tissue at the site of injection.
Gersuny’s preparation of paraffin, particularly useful for the cold-injection method, is made as follows: A certain amount of cold paraffin, melting at about 120° F., and white cosmolin or vaselin, melting at about 100° F., are mixed by being heated to liquefaction. The bulb of a clinical thermometer is then coated with the cooled mixture of paraffin, which is then placed into a hot-water bath, the temperature of which is gradually raised until the paraffin melts and floats upon the surface of the water. The water is then allowed to cool and its temperature noted just as the oil-like liquid paraffin begins to look opaque, which marks the melting-temperature point of the mixture.
Should this be found to be too high more vaselin is added, orvice versa, until the desired quantity of both is known.
This method of preparation is, however, a tedious and awkward one, and can be readily improved upon by mixing certain known quantities of the one with the other after the first experiment.
The author recommends the following formula for the preparation of a mixed paraffin, which he has found serviceable and satisfactory for use with cold-process injections and employed by him for the last four years.
The two are placed into a porcelain receptacle and melted in a hot-water bath to the boiling point, then thoroughly mixed by stirring with a glass rod and poured into test tubes of appropriate size and allowed to cool. Each tube is sealed properly with a close-fitting rubber cork, which may be coated with a liquid paraffin without, including the neck of the tube, and put away for later use.
Since 1905 the author has used an electrothermic heating device in which the paraffin mixture is prepared. The apparatus is made up of a metal pot set into a resistance coil, and is shown inFig. 286.
Fig. 286.—Author’s Electrothermic Paraffin Heater.
Fig. 286.—Author’s Electrothermic Paraffin Heater.
Fig. 286.—Author’s Electrothermic Paraffin Heater.
This instrument overcomes the complications of the water bath and burning or browning of the paraffin mixture, so commonly found with ordinary methods, the temperature of the resistance coil within the heating chamber being controlled by a small rheostat at will.
Before using, the contents of each test tube thus prepared are reheated to sterilization and poured into the barrel of the syringe to two thirds of its length, the piston introduced and screwed down into position; the syringe being placed to one side until its contents have been cooled, or the entire instrument is immersed in sterilized water at about 70° F. until the paraffin mixture has set or becomes uniform in consistency, which takes about five minutes.
Upon screwing down the piston the mass will be found to issue from the needle as a white, cylindrical thread, and is ready for use in this form.
Harmon Smith has had such a paraffin prepared which has a melting point of 110° F. This can be purchased in the market in sterile sealed tubes ready for use. The contents of these tubes should, however, be resterilized at the time of employment.
The same author prepares this paraffin of 110° F. melting point by mixing sufficient petroleum jelly (evidently white vaselin) with the commercial paraffin melting at about 120° F. to bring the melting point down to 110° F. He claims that making such a mixture is a difficult matter, since a plate of paraffin will have various melting points, one corner melting at 120° and the opposite as high as 140° F. He advises having the mixture accurately prepared in large quantities and dispensing it in test tubes of one-half ounce capacity, as now found on the market. The mixture is poured in hot liquid form into these test tubes, which are then sealed with wax and placed on a sand bath, whose temperature is raised to 300° F. to insure sterilization.
The latter author has devised a neat paraffin heater, shown inFig. 287.
Fig. 287.—Smith Paraffin Heater.
Fig. 287.—Smith Paraffin Heater.
Fig. 287.—Smith Paraffin Heater.
Of this he says: “To insure still further the sterilization of the paraffin, I have devised a tin (nickle-plated) receptacle supported on an attached tripod, which raises the bottom an inch from any plane surfaceon which it is placed, and is closed with a detachable lid. This arrangement prevents the paraffin from burning or browning. Into this I pour the paraffin from the test tube, after melting, and place this receptacle into a sterilizer, or any ordinary boiler—surround it almost entirely with water and then boil. After I have boiled it for a few minutes I remove the receptacle and permit it to cool until the paraffin therein is about 120° F. I then draw it up into the syringe, which has been sterilized in the same boiler with the paraffin. When sufficient is withdrawn, I evacuate the air bubbles from the syringe by pressing the piston upward and run my set screw into place. Some two or three minutes are now allowed for the paraffin to assume equal consistency throughout and to cool down to a semisolid state. When the paraffin reaches this consistency it may be kept many hours ready for use, at the temperature of the room, if only the precaution to warm the needle is taken each time before attempting the injection.”
17. Hypersensitiveness of the Skin.—A permanent hypersensitiveness of the skin over the site of a subcutaneous paraffin injection has never been definitely shown. While it is true there is some pain and feeling of stress and fullnessover and about such area, immediately after the operation, this has subsided in about twenty-four hours in the average case, except in those where a very hot liquid paraffin and of large amount has been injected, when several days are required to overcome these symptoms.
Smith claims a numbness over the site of the injected area which soon passes away, but this is perhaps more a feeling of fullness rather than one of anesthesia.
The author has observed, however, in several cases a period of extreme discomfort, fullness and cephalalgia in cases of subcutaneous injections about the root of the nose. Peculiarly these attacks appear only after the filling has become organized; that is, after the connective tissue has displaced the paraffin. The secondary tumor in such cases appears to be slightly larger superiorly than the original size at the time of injection.
The irregularity of these attacks, with edema of the forehead and slight puffing of the upper eyelids, points to a disturbance of the circulation and is undoubtedly due to pressure on the angular vessels, and the venous arch across the root of the nose. The symptoms usually appear in the early morning and moderate toward night, reappearing again the next morning or not again until the next attack, which may be expected at any time.
This condition of affairs is an unfortunate one, since we cannot look to the avoidance of the trouble nor foresee it at the time of operation. In one case the symptoms did not develop until nearly two years after the injection was made and became so troublesome that the only relief had was by opening the skin of the nose laterally and excising as much as seemed necessary of the newly formed connective tissue with a fine pair of curved scissors. None of the injected matter was discovered except two fine scalelike disks of glistening paraffin of a diameter of one sixteenth inch. These were evidently all that remained of the injected mass, and were undoubtedly heldin the innermost meshes of the new tissue. Immediate relief followed the operation, but no appreciable difference in the size of the tumor could be noticed.
Cold applications or ice cloths relieve the temporary pain following an injection of paraffin, but in most cases this is rarely necessary except in extremely nervous and expectant patients.
On the whole the author believes the secondary neuroses and circulatory difficulties are now practically overcome by the more conservative use of the matter to be injected, coupled with a repetition of the injection of smaller amounts at each sitting and not repeating the same until the first has become organized.
18. Redness of the Skin.—Redness of the skin following an injection of the nature under consideration was one of the early objections made by various operators.
That redness, more or less permanent, has been found in many cases in which these injections were made is true, but such redness was found particularly when the injections were those of liquid paraffin of high melting points and in which the operator was overzealous in bringing about an absolute correction of a deformity, with the result that when the paraffin had been molded and set, it was generally pinched or shaped up or outward, thus causing a great deal of pressure upon the circulatory vessels of the skin.
The redness in such cases did not appear until several days after the operation, becoming worse gradually instead of better even in spite of the efforts to reduce it by external applications. Not unusually, in the permanent cases, distended capillaries can be seen in the skin resembling the condition in acne rosacea chronica, especially when the injection had been made to correct a saddle nose.
Smith says: “Redness is present in a good many cases. I have seen a case in which the redness lasted over a year, but it gradually disappeared. There seems tobe a tendency on the part of nature to take care of a foreign body, and I think the reënforcement of connective tissue that grows into this mass requires an increased blood supply, and later, when the blood supply is no longer necessary, the redness will disappear.”
The latter is true where the hyperemia is either acute or subacute, but in chronic cases where the capillaries have become distended and show plainly there is little to be hoped through the effort of nature.
Eckstein, the advocate of “Hart-paraffin” method of high melting point, states that a redness of the parts develops a few days after the injection that disappears after a time, but that this redness is more marked and of longer duration when the injections are made intracutaneous instead of subcutaneous.
These injections should be made subcutaneous in all cases, and there is no excuse for deviating from this method.
With the use of semisolid and cold paraffin mixtures, as heretofore advocated, redness rarely if ever follows the injection unless undue pressure has been made, in which case necrosis is more liable to follow unless the adjacent tissue will gradually allow the mass to become relieved by a change in form and position.
Such subsequent hyperemias are not now as common as when the injections were at first attempted, and the author may say freely that they never occur when the proper method and material is used.
Paget says: “In a few cases—but only in a few—some reddening of the skin has followed the injection, and in a few this has been very slow to fade.
“The few referred to are of a record of twenty-two nasal cases, but no data is given whether the operator used paraffin of high or low melting points. F. Connell found that redness in that case continued for a year, diminishing very little in that time. It appeared on the second time after the operation for a correction of asaddle nose, and remained stationary for about one month. Twenty drops of paraffin were injected. It very gradually increased, so gradually, in fact, that there is still a distinct reddened area over the bridge of the nose. On pressure this redness will disappear, but returns immediately after the removal of the pressure. A few dilated and tortuous capillaries course their way over the area. The condition is still present fourteen months after the injection.
“There has been practically no change or decrease in the redness during the last six or seven months, it is not as marked as it was during the first few months, but still requires the profuse application of face powder in order to prevent her nose from being conspicuously red.”
The above case has been cited because it is typical of such condition, and while the amount as stated was quite small, one is almost nonplussed for an explanation of the result, yet it undoubtedly must have been due to a close attachment of the skin to the underlying structures, necessitating pressure, which is known to cause it.
However, it is possible to have such redness develop weeks or months after the injections are made. In such cases it is not due to the primary pressure of the injection, but to that of the newly developed tissue which has taken its place, but which is slightly overdeveloped for the same unaccountable reason already referred to.
Almost every surgeon who has used this method of restoring the contour of parts of the face has observed redness, more or less permanent, follow the method used, but in most cases liquid paraffin of high melting points had been forced into the tissues at great pressure.
In one case, that of a southern operator, the entire tip of the nose had become injected by primary diffusion or direct filling.
It became inflamed immediately after, and some weeks later, when the swelling had subsided, the lobule wasfound to be very hard, tense, and extremely red. Two years after the author saw this case, and the tip of the nose still appeared like a red cherry with numerous capillaries showing over its area, while the rest of the nose, although much broadened by secondary displacement of the paraffin, was natural in color.
This proves that as the pressure was relieved by absorption and displacement, the tissue took on a normal appearance, whereas in the lobule of the nose, where there was no relief from the pressure, nature could do nothing to relieve the inevitable result.
In cases where the redness is suspected it may not be too late, a day or two after the injection, to remold the mass into such form as to relieve the acute tension.
If the redness develops early, cold applications of an antiseptic nature or ice cloths can be used to advantage. Antiphlogistin or other similar preparations applied externally give good results.
Later ichthyol, twenty-five-per-cent solution, may be applied; acetate of alumen in saturated solution seems to do well. Some operators apply hydrogen peroxid, but it gives only temporary benefit. When the capillaries have become distended and the redness is practically chronic the vessels should be destroyed with a fine electric needle, using about 20 milliampères—direct current.
Sometimes when the redness is acute and seems to persist depletion of the part does some good. This is done by nicking the skin here and there with a fine bistoury and allowing the part to bleed freely. Care should be taken not to puncture the skin too deeply, so as not to allow the injected mass to escape.
In some cases it is allowable to open the filled cavity early and remove enough of the filling to overcome the difficulty, injecting later, after the filling has become organized, to make up the deficiency.
When the redness is secondary—that is, when it developsafter the connective tissue has replaced the paraffin—it is best to open up the part and excise enough of the tissue to overcome the pressure.
In a case where the author injected for a deep furrow in the forehead with a cold semisolid paraffin mixture, a secondary redness developed three months after the injection had been made, no redness having been noticed in the meantime. There was more or less swelling for two or three weeks, undoubtedly due to pressure phlebitis, which eventually subsided.
The redness in this case was only reduced by an excision of the tissue causing the trouble. The result was satisfactory.
19. Secondary Diffusion of the Injected Mass.—This is a condition that no operator can foretell, although it might be caused by a primary diffusion due to hyperinjection of so small an extent that it escaped the surgeon’s attention at the time.
Again, a site injected may at the time of operation present all the indications of a satisfactory result—that is, the tissues at the place of operation and its immediate vicinity appear perfectly loose and elastic; the injection being made easily and the contour of the defect being remedied either partially or entirely as the operator may desire; there being no mechanical anemia post-operatio, and no decided effort on the part of the tissues to cause primary elimination after the withdrawal of the needle; yet it is possible that, by such an injection, sufficient pressure may be caused upon some of the blood vessels within the limitations of the injection as to cause a decided reaction a few hours after the operation, as evidenced by a swelling, too great for the disturbance occasioned, and associated with all the signs of a fairly active inflammation.
It is possible that such a reaction may cause a displacement or diffusion, post-primary, of the mass injected, especially if the mass be merely vaselin or a mixtureof vaselin and paraffin at a melting point too low for the purpose. Nevertheless, it is practically impossible to foresee such result and the operator can only use the same care as with any or all such injections.
It is possible, when the reaction is too marked, to mitigate, to a great extent, this diffusion of the injected mass, by using such methods as reduce the inflammatory symptoms.
As a rule, these cases exhibit considerable ecchymosis after this active reaction has subsided, lasting from one to two weeks.
Secondary diffusion, as the author uses the term, signifies an extension of the injected mass beyond the intended area. This may occur in two or three weeks or be proportionate to the activity of the production of fibrous connective tissue that is supplanting the mass.
Leonard Hill has reported a case in which he injected vaselin to correct a saddle nose for æsthetic or cosmetic reasons. The result was very satisfactory to both operator and patient, and continued so for nearly twelve months, when secondary diffusion of the mass began to be noticeable. Eventually the diffusion became so great in the upper eyelids as to close both eyes completely.
The worst case of such secondary diffusion the author has ever heard of or seen came to his attention early this year. The patient had been subjected to a subcutaneous injection of oils for the cosmetic correction of an abnormal deepening of the inner clavicular notch. The injected mixture, as far as the author could learn, was made up of sweet almond, peanut, and olive oils with two others that had been forgotten. Her physician had made two injections several days apart with a satisfactory result. The reaction was trifling and the parts returned to the normal in two weeks.
Five months later the part injected became tender to the touch and began to enlarge daily. With the increase in size a gradual inflammation involved the whole lowerregion of the anterior region about the root of the neck. Various applications were made to the part to reduce the inflammation, but at the end of ten days a region of skin that had indicated the pointing of an abscess burst, allowing the escape of about eight ounces of pus. Under the most careful surgical attention this discharge continued for about three months, until under the influence of gauze packing the wound was made to heal from the bottom, leaving an ugly irregular scar at the site of the opening. With the healing of this fistular wound, however, the size of the tumor did not diminish whatever, but continued to grow until, at the present time, one and one half years after the injections had been made, the size of this peculiar hyperplastic growth of ovate form measures nearly five inches across its horizontal diameter and three and one half inches through the vertical. It is closely adherent to the overlying thickened skin, which has undergone a yellow pigmentary change to be considered in the next text subdivision. The tumor is hard, painless, and freely movable beyond the limitation of its skin attachment and rests upon the sternal thirds of the clavicles, extending upward and forward with evidences of traction on the whole anterior skin of the neck. Laryngoscopy discloses nothing abnormal. The deformity is hideous, and necessitates a mode of dress to conceal it. The patient has not as yet been operated on for the extirpation of the growth, owing to her present physical condition, the result of melancholia.
Scanes-Spicer injected some vaselin to correct a saddle nose with satisfactory immediate result, but after several days the upper lids became slightly edematous, and soon after a small hard lump, the size of a grain of shot, was felt in the left upper lid.
Harmon Smith observed a secondary diffusion in two cases in which the abnormality in one occurred on the side of the nose and in the other at the inner canthus following the course of the angular vein.
While in the foregoing cases the difficulty may have been overcome by using the cold, semisolid paraffin mixture and reducing the amount injected, it is questionable if the diffusion could thus have been entirely overcome.
The author points to the fact that undoubtedly this fault is observed more when the tissues at the side of the nose, or about the alæ, are injected, and that the cause here is one of an unequal pressure of the parts—the skin more or less bound down above and the ungiving cartilage below.
In such cases great care should be exercised in the amount injected, and if, after introducing the needle, the tissue be found to be unduly adherent and inelastic, to withdraw the needle and with a fine tenotome divide or dissect up the skin before the mass is injected. At no time would an operator be justified to inject more than ten drops of the mass, at a single operation, into the parts referred to.
As already mentioned, there is not only danger of diffusion of the mass in such region of the nose, including the lobule and the subseptum, but there is a special danger of gangrene from pressure where the tissues are less supportative than where muscular tissue or greater mobility of the skin is found.
After the immediate attempts to reduce a reactive inflammation, nothing can be done to overcome secondary diffusion except excision of the amount not wanted. This should not be undertaken until at least three months after the time of injection.
The mass of connective tissue must be entirely excised as thoroughly as possible, and slightly beyond the border of the abnormal elevation. A sharp curette is practically of no use for this purpose, and only wounds the skin, and by reason of retentive shreds of tissue may cause infective inflammation.
The opening into the skin should be made with a fine bistoury, the skin be dissected off from the elevated connectivetissue, and the latter extirpated by dipping cuts of a fine small, sharp-pointed, half-rounded scissors. The operation can be done neatly and painlessly under eucain anesthesia.
The wound may be sutured with fine silk or be allowed to unite of its own accord.
It is advisable to supply a small pressure dressing, made of a circular gauze pad, over the site to assure of the best union between the dissected or undersurface of the skin and the floor of the wound.
Dry dressings are to be preferred, since moisture would tend to soften the skin and permit it to crawl, which would not improve the ultimate result.
20. Hyperplasia of the Connective Tissue following the Organization of the Injected Matter.—The overproduction of connective tissue replacing the injected mass is rarely observed, yet a few cases have been noted.
Sebileau has reported a true case of diffuse fibromatosis following an injection of paraffin. This not only included the site of the injection, but extended to the surrounding or adjacent tissue, making the secondary defect much more disfiguring than the first.
The author has observed in one case of hyperplasia following the correction of a saddle nose, that the area injected presented no unusual appearance for six months, when the nose at its middle third began to enlarge slowly until it resembled a marked Roman shape, the enlargement extending laterally and as far down as the nasogenian furrows at the end of nine months.
The injection used was a cold, semisolid paraffin mixture, and only sufficient to barely correct the defect was injected, the skin being thoroughly flexible at the time of operation.
No reason can, therefore, be given for this unusual result, except, perhaps, a peculiar idiosyncrasy of the tissues, that may be compared, somewhat, with the external tissue changes in hypertrophic or keloidal scars, especiallynoted in the wounds of negroes—a condition for which we have, as yet, found no attributable cause.
While we cannot definitely prevent such a result, following an injection of a hydrocarbon, we may at least be sure that hyperinjection is not the cause.
The hyperplasia as exhibited in these cases is one of true fibromatosis. The microscopical examination may show the retention of paraffin in small, round, pearllike masses lying in cells of varying size, but with specimens of such tissue removed after a number of years’ standing does not show the paraffinin situ.
In a specimen taken from a chin five years after the injection of paraffin the Lederle Laboratory makes the following report accompanied by microphotographs of sections taken from the fibromatous area as shown inFigs. 288aand 288b:
“Anatomic Diagnosis.—The specimen consists of several pale, tough masses of tissue removed from the chin covered on the outside by normal skin.
“Histologic Diagnosis.—The various layers of the epidermis—i. e., the strata corneum, lucidum, and granulosum—are unthickened and practically normal. In the corium the papillary and reticular layers are apparently normal, showing no thickening nor round-cell infiltration.
“The glandular elements in this area and the hair follicles appear normal.
“Toward the deeper layers and the subcutaneous connective tissues appear isolated areas of round-cell infiltration separated by masses of fibrous connective tissue, much of which is of new formation, as indicated by the nucleated character of the elongated cells. There are areas of diffuse round-cell infiltration.
“In this portion of the corium there is also to be found a large number of vacuolated areas varying very greatly in size, and which are surrounded by membranous fibrous-tissue elements, much of which is likewise of new formation, as indicated by the character of its cells.
“These vacuoles doubtless represent the areas containing the masses of paraffin which have been split up by the new formation of fibrous tissue. Between the vacuolated areas can be seen actual infiltration by true fat cells.
“In many spots the fibrous-tissue formation has proceeded to the point of thick bands containing but few nucleated cells.Fig. 288a, which is a photomicrograph of this portion of the section, shows these changes.
“In one of the foci of round-cell infiltration which have been surrounded and invaded by bands of new fibrous tissue there are numerous giant cells of the so-called ‘foreign-body’ type. This is shown inFig. 288b.