SUBCUTANEOUS HYDROCARBON PROTHESES
Although the subcutaneous employment of oil and liquefied paraffin has
been known for some years, particularly by Corning, who refers to his
use of solidifying oils in surgery in an article published in 1891, no
actual application for prothetic purposes was made until 1900, when
Gersuny first advocated the method. In his published report he says that,
“if vaselin, which at the temperature of the body has the consistency
of ointment, be liquefied by heat and by the means of a Pravaz syringe
is injected into dilatable tissue of the human body, there is produced,
at the site where the injection is made, a tumefaction whose volume
corresponds to the quantity of vaselin injected. The reaction which
results from the procedure is insignificant and the mass appears to rest
without change where injected.”
This subcutaneous method of vaselin injection he employed in the case of
a young girl to correct a saddle or depressed nose. The operation was
purely a cosmetic one, and was performed on May 8, 1900, with a very
satisfactory result.
From the time of the appearance of Gersuny’s paper, “Ueber eine Subcutane
Prothese,” a number of operators, such as Halban, von Frisch, Kapsammer,
Delangre, Rohmer, Stein, and others, began to follow the method with
gratifying results.
Pfannenstiel, shortly after, claimed that the injection of vaselin was
not wholly without danger, and that pulmonary embolism had been observed
by him subsequent to its use. Moszkowicz denied the possibilities of
such danger, although at this date it is quite evident that there are
many objections to the sole use of sterile vaselin for all subcutaneous
cosmetic purposes where such protheses might be indicated.
Eckstein, on July 24, 1901, rehearses these objections and advocates the
use of “Hart paraffin,” or paraffin with a melting point of 57-60° C.
(140° F.). His method was taken up by Brœckært, Baratoux, Brindel, Watson
Cheyne, Walker Downie, Leonard Hill, Lake, Scanes Spicer, Karewski, and
other prominent surgeons abroad, and by Parker, Harmon Smith, Hamilton,
Quinlan, Connell, and others in the United States.
Drs. Lynch and Heath were the first American physicians to place
themselves on record in the employment of the method of Gersuny for the
correction of nasal deformities.
Each of the operators employing the now so-called Gersuny method
advanced their individual ideas and improvements in the art, and those
of distinctive merit will be considered later by the author, who has
employed both methods from the time of their incipiency.
The method of procedure in the injection of vaselin or paraffin is
practically similar, except for the various ways in which the paraffin of
different melting points is rendered liquid.
INDICATIONS
The indications for the protheses of either method are the same,
except where the author advocates the use of either one or the other
or a combination of the two from an experience with over five hundred
personally conducted cases.
The advantages of the Gersuny method is that the operation is practically
painless, causes no scar if properly performed, and corrects a deformity
that could not be overcome otherwise in some cases, while in others it
would entail not only difficult surgical interferences, but subsequently
unsightly cicatrices that would render them more objectional than the
very defects which were intended to be corrected.
This is particularly true in the cosmetic correction of depressions about
the forehead resulting from direct violence or frontal sinus operations,
for obliterating habit furrows, or frowns, between the eyebrows;
also to restore the symmetry of the face in hollows of the cheek due
to the removal of malignant growths, the maxillæ, or when caused by
facial hemiatrophy or a congenital or long-acquired sinking in of the
cheeks; while it may also be employed with excellent result to prevent
post-operative adhesions about the face after mastoid operations and even
to restore the form of the breast after operation for malignant disease
and the raising of smallpox pits.
Numerous other uses may be mentioned, such as elevating an undue
depression at the root of the nose, raising sunken furrows below the
eyes, obliterating nasolabial folds, angular droops about the chin,
rebuilding weak or pronounced oval or peaked chins, filling hollows about
the neck and shoulders, and in fact anywhere about the body to restore
the contour.
In correcting the deformities of the nose, whether congenital or
acquired, this method has met an urgent and most useful demand, so much
so that many rhinoplastic operations of extensive delicacy have been
thrown aside for this simpler, rapid, and gratifying means of surgery.
Not only has it been employed to restore the nasal line in saddle noses,
but also in many other deformities of that organ which do not require the
removal of superabundant tissue.
According to the appended classification of nasal deformities, given by
Roe, it will be seen that many faults of that organ may be overcome by
the method.
{ Concave.
{ { Vertical { Convex.
{ Bony Portion {
{ { Lateral { Spatulated.
{ { Defected.
Deformities {
of the nose { { Excessive or Deficient Tissue.
{ { Tip { Deviation from Median Line.
{ Cartilaginous {
{ Portion { Wings { Collapsed.
{ { Expanded.
From the above arrangement, and taking each division separately, the
author enumerates the applicability of the subcutaneous prothesis, adding
such as are not included in the above.
1. Vertical concavity. An overmarked depression at the site of
the bony structure and about the root of the nose.
2. Lateral deficiency of form about the root of the nose
extending downward as far as the inferior borders of the nasal
bones.
3. Median anterior vertical concavity or saddle nose involving
the middle third, otherwise the inferior and superior sections.
4. Deviations of the cartilaginous structure about the middle
third of the nose, either unilateral or bilateral.
5. Deviation of the lobule.
6. Deficiency of the lobule.
7. Lobular cleft.
8. Subseptal cleft.
9. Collapsed alæ, unilateral or bilateral.
10. Retraction of subseptum.
In these ten subdivisions much can be done to bring about a normal
appearance of the nose.
PRECAUTIONS
In selecting a case for subcutaneous injection the operator must well
consider the methods to be employed, his successes with such methods,
the importance and gravity of the operation, the condition of the
patient, the extent of the deformity, the peculiarity of the patient and,
particularly, the state of mind of the patient.
While at this date of the use of this method of beautifying parts of
the human face we may feel certain of the happy outcome of an operation
undertaken by the operator, he must not lose sight of the hypercritical
person upon whom the work is to be done; even with an outcome gratifying
in the extreme from a surgical standpoint, the patient will insist, and
that in eighty per cent of all cases, to still further improve them in
spite of the fact that a normal appearance has been attained, often
leading the operator into doing what he should not do, and eventually
undoing his own excellent efforts.
The author does not mean to imply this as a weakness on the part of the
surgeon, but cannot impress too deeply upon him the unreasonable demands
of a person insanely bent upon having the alabaster cheek ideal of the
poets, the nose of a Venus, the chin of an Apollo, the neck of swanlike
form, etc.
The patient believes it lies in the power of the cosmetic surgeon to
do with their malformations as a sculptor would model in clay and will
insist upon gaining their ideal beyond all reason.
Let the author warn the operator against the “beauty cranks,” especially
of those who are just about to engage in great theatrical ventures,
circus performances, or “acts,” and very desirable marriages. These are
patients who are not only difficult to deal with, but the first to harm
the hard-earned, well-deserved reputation of the surgeon and to drag
him into courts for reimbursement for all kinds of damages, especially
backed up by events, losses, and sufferings largely imaginable and
untrue, and ofttimes entirely impossible.
In all cosmetic surgery this branch is the most dangerous from that
point of view; therefore the operator should take his case well in
hand, proceed with an unshakable determination and give the patient to
understand his position, even to explaining what disappointments there
might be and what dangers, if any, he might look forward to. The author
believes it no unjust demand to have an agreement made with the one to be
treated in which these matters are fully considered. Such an arrangement
will save him much worry and will tend in the majority of cases to keep
his patient satisfied.
On the other hand, the operator should not undertake to do an operation
of a cosmetic nature unless he has a fundamental and practical experience
of long standing in this branch of surgery, and is ready at all times to
cope with such post-operative conditions as are likely to arise, which
will be described later.
The author has on various occasions been asked to correct the most
hideous malformations of parts of the face, particularly the nose, in
which surgeons of high standing, both here and abroad, had injected
paraffin in liquid form, usually under a general anesthetic, the most
remarkable being that of a hospital orderly in the United States service,
who had been subjected to not only one of such injections to correct
a saddle nose under chloroform anesthesia, but to three distinctive
operations, with the result of a permanent disfigurement, bettered only
by a succession of excisions at different parts of the nose.
Apropos of such cases it may be timely to state that a general
anesthetic for the performance of a prothetic injection operation is
never justifiable and should be considered a lack of knowledge on the
part of the operator, unless its use be advised by another surgeon in
consultation.
The greatest mistake made with this so-called “filling method” has been a
desire on the part of the patient or the operator, or both, to complete
the work too quickly. Unscrupulous operators have restored a saddle nose
or the contour of the cheeks in a few minutes, when it is an established
fact that the work should be done slowly, giving time for the injections
to accommodate themselves and to organize before others are attempted.
This is not only true of fillings about the cheeks and shoulders, but
also of injections about the nose and forehead.
Eschweiler particularly emphasizes the advocacy of oft-repeated
injections, and the author recommends such rule without reserve or
deviation.
THE ADVANTAGE OF THE METHOD
As has been said, the advantage of the Gersuny method over other
procedures is that it can be undertaken practically without pain, that it
is quick, bloodless, leaves no scar, and is harmless except under such
conditions as will be referred to under a separate heading.
While the method entails only the pain of a pin prick a local anesthesia
may be employed to overcome this, but never a general anesthetic. The
ethyl-chloride spray, except at very small points of the skin, is not
to be recommended because it freezes and consequently hardens the
very tissue which should be flexible, the operation being undertaken
the moment the needle is inserted and lasting only a few seconds. The
hypodermic use of a two-per-cent solution of cocain, or better Eucain β,
can be employed, but the author sees no advantage in it, as the hyperemic
engorgement following its use obliterates, to a certain degree, the
actual extent of the deformity.
It is desirable to obtain the best result to have the skin above the
part as free as possible. When closely adherent it should be freed by
the careful use of a delicate tenotome, inserted at the point where the
injection is to be made, the same opening being used for the introduction
of the needle of the syringe. If this opening has been made too large
a fine suture of silk should be employed to bring the lips of the
wound together before the injection is made; the needle point, being
knife-edged, will not disturb the apposition and will tend to retain the
filling if no undue pressure is used, as in the case of hyperinjection.
UNTOWARD RESULTS
Connell has tabulated the difficulties and dangers met with in this work
as follows:
1. Toxic absorption.
2. Marked inflammatory reaction.
3. Loss of tissue, due to infection and abscess formation.
4. Pressure necrosis, caused by hyperinjection.
5. Sloughing of tissue as a result of the heat of paraffin.
6. Injection into very dense or inelastic structures, or where
scar tissue is firmly attached to the underlying and adjacent
parts.
7. Subinjection of too small an amount of paraffin with an
insufficient correction of the deformity.
8. Hyperinjection with overcorrection of deformity.
9. Air embolism.
10. Paraffin embolism.
11. Primary diffusion or extension of paraffin (when first
introduced) into adjacent normal structures.
12. Interference with muscular action of the nose.
13. Escape of paraffin after the withdrawal of the needle or
primary elimination.
14. Solidification of the paraffin in the needle, which renders
the injection difficult and causes injudicious expedition on
the part of the operator.
15. Absorption or disintegration of the paraffin.
16. The difficulty of procuring paraffin at the proper melting
point.
17. Hypersensitiveness of the skin over the injected area.
18. Redness of the skin over the injected area.
To those the author would add:
19. Secondary diffusion of the injected mass.
20. Hyperplasia of the connective tissue following the
organization of the injected matter.
21. A yellow appearance and thickening of the skin after
organization of the injected mass.
22. The breaking down of tissue and the resulting abscess due
to the pressure of the injected mass upon the adjacent tissue
after the injection has become organized.
Each of the above subdivisions may be advantageously considered
individually, to wit:
=1. Intoxication.=—The danger of intoxication may truly be said to be
more so due to the unclean or unsterilized matter injected than to
the absorption following its employment, although Meyer has claimed
untoward symptoms found in his experiments from absorption of injections
of vaselin in the animal. Taddie and Delain, Stubenrath, Straume,
Sobieranski, and Dunbar have corroborated this claim. They injected
paraffin of various melting points in the lower animals and observed
results therefrom, among which were loss of hair, a reduction of eighteen
per cent in the body weight in two months and death.
Stein and Harmon Smith refute these conditions and remarked neither
systemic nor local untoward results from such injections when paraffin of
higher melting points were used.
Jukuff claims that no toxic symptoms resulting from the absorption of
paraffin injected into tissues are shown, unless the amount be equal to
ten per cent of the weight of the animal. To have this apply to the human
as much as ten to fifteen pounds would have to be injected—an amount
never required in operations of this nature.
While it cannot be denied that the injected mass becomes more or less
absorbed in from two to three months and is replaced by connective
tissue, it may be definitely stated that no toxic symptoms are caused
directly thereby, except by the employment of an impure product.
=2. Reaction.=—The reaction following a properly made injection is of a
mild inflammatory character. Considerable inflammation points to some
fault in the technique or impurity of the injection. More or less edema
of the site and its adjacent area may be noted, associated with slight
or marked discoloration and pain of variable degree. The normal reaction
following the injection is temporary and does not necessitate treatment
or confinement of the patient, who can resume the duties of life fifteen
hours after the operation.
=3. Infection.=—The cause of infection cannot be said to be due to
anything but surgical uncleanliness, as it is with any surgical
undertaking, and can be overcome by the same means.
The material injected should be thoroughly sterilized by boiling before
using. Brœckært suggests combining an antiseptic with the paraffin and
has used guiaform, a combination of formic aldehyde and guiacol in a
proportion of five to ten per cent; yet this is of little value when we
consider how readily these hydrocarbons can be rendered sterile at high
temperatures.
=4. Necrosis.=—Death of tissue may follow an injection of paraffin when
too much pressure has been applied, or when too much has been injected
into the tissue, cutting off the blood supply, or when the injection has
been made into the skin instead of beneath it. Again, constitutional
disease, such as diabetes or Bright’s disease, may superinduce the
breaking down of the tissue.
Hyperinjection should and can be avoided by the use of the proper
instrument with which the required amount is graduated to a nicety. At no
time should an injection be crowded into a dense tissue or where the skin
is closely adherent, nor carried so far as to create a blanching of the
skin. By carefully injecting the mass this danger should be overcome.
Dense or bound-down areas of skin should be loosened and freed, as has
already been mentioned.
If care be exercised and small amounts be injected, in preference to
overcoming the defect in one sitting, pressure effects are entirely
overcome.
The circulation in the skin over the site of injection should be normal
immediately after the operation has been performed, determined by
observing the reaction in the color of the skin after delicate digital
pressure.
=5. Sloughing.=—That sloughing of the skin should be occasioned by
the high temperature of the paraffin injected is a condition entirely
inexcusable. Paraffin of high melting points 58° to 65° C., or the
so-called “Hart paraffin” employed by Wolff, liquefying at from 57°
to 60° C., are to be used with caution. The author doubts whether the
temperature of the paraffin at the time of injection, even in the latter
method, is ever beyond 54° C. even if the thermometer registers 60° C. in
the liquefying, hot-water bath.
By the time it has been drawn into the syringe, which has been heated
by dipping into hot water, and the moment it is injected it has lost
several degrees in heat.
It would not be permissible to inject a molten mass of a temperature
so high as to scar or burn the tissues, and the best results of most
operators have been obtained with such of the paraffin group that become
liquefied at a temperature of not over 45° C. (112° F.).
The claim of Eckstein, that paraffins of low melting points are more
likely to be absorbed, has not been substantiated in actual practice,
since we now know that any and all of these injections, irrespective of
their melting points, are absorbed in time, giving place to connective
tissue, and that rarely, if ever, is there a true and complete
encapsulation or encystment of the mass thus introduced. Even the hard
paraffins are split up in time into minute pearllike particles which
are displaced by the growth of tissue arising from the presence of the
foreign substance. This is true even in those cases in which the author
has introduced by surgical means solid paraffin plates in the cold state.
=6. Sloughing Due to Pressure.=—When an injection is forced into a dense
or firmly bound-down tissue, as into the body of a thickened cicatrix, or
about the point of the nose or the subseptum of the nose without first
dissecting off the skin above the subcutaneous layers, an acute anemia is
at once marked, followed by inflammation and gangrene.
By injecting sterile water into the area thus loosened with the knife a
good idea of the thoroughness of the dissection and the possibility of
building up the part to be corrected is obtained, yet in these cases the
author has always found more or less difficulty in keeping the injected
mass in place for the reason that the divided surfaces tend to unite
at their peripheral borders, crowding the mass upward or to one side
or diffusing it in such a way that the result has been anything but
satisfactory.
To overcome this it is advisable to inject a smaller quantity than
necessary to entirely correct the defect, to mold it out flat and to
allow it to organize before more is introduced.
=7. Subinjection.=—Insufficient injection leading to an undercorrection
of the defect is a far more desirable condition than hyperinjection,
and is easily corrected by a repetition of the treatment, even to a
third sitting, until the desired result is obtained. Following this rule
will give far better results, as has been said, than to be compelled to
remove a part of the filling and some of the connective tissue which has
resulted therefrom.
=8. Hyperinjection.=—The injection of too much vaselin or paraffin is one
of the most common faults found with operators. In the first instance a
tumefaction of the site results which with the production of the tissue
which takes the place of part of the filling makes the result very
unsatisfactory and requires one or more cutting operations to reduce it.
A peculiar fact with these hyperplastic growths is that even though they
may be reduced with the knife to a normal size they seem to redevelop
again and again, giving both surgeon and patient great concern.
This, in the opinion of the author, is due to the binding down of the
marginal borders, which, in the event of partial extirpation, are not
injured sufficiently to displace them and that they unite again in their
former position. To overcome this it is found best to excise the entire
filling much beyond the margins and to apply pressure over the area until
perfect union has taken place.
This is best accomplished with a disk of aluminium, bent to conform to
the shape of the part operated, lined with sterilized lint and fixed over
the site by strips of Z. O. plaster.
While the hyperinjection of vaselin is not as objectionable as that of
paraffin, because of the more ready accommodation and absorption of
the mass, it nevertheless leads to diffusion of the material, owing to
its softer consistency and consequent greater facility in seeking fine
avenues of escape, paraffin having the advantage of cooling upon itself
_en masse_, leaving little to escape into undesirable channels after it
has once been molded and set.
Vasserman cites a case in which gangrene of the bridge of the nose
resulted after an injection of 2.05 c.c. of vaselin.
However, when these faults occur they are errors of technique, and should
be avoided, as has been mentioned heretofore.
The removal of such hyperinjected masses by the aid of paraffin solvents,
such as benzine, ether, chloroform, or xycol, applied to the skin above
the filling, has proved a failure, nor will heat used externally in the
same manner remedy evil.
What is left to the operator is to open the skin and, with a small, sharp
spoon curette, remove the mass early, before it has become organized,
or to excise the new connective tissue and the broken-down filling, as
mentioned.
When, however, the tumefaction resulting from such hyperinjection is not
extensive, as is often found about the chin and at the root of the nose,
the secondary deformity can be materially, if not entirely, remedied by
electrolysis. A needle or brooch of certain hardness is to be employed,
connected with the negative pole of a continuous current apparatus. From
twelve to twenty milliampères are required. The process is similar to
that used with the destruction of hair, nævi, or moles on the face. The
needle should puncture the entire tumor or penetrate its maximum diameter
and be charged with the current for two or three minutes. Several of such
punctures should be made at each sitting, the latter being repeated as
often as is deemed necessary by the operator. The reaction which follows
this procedure is of little moment, and these sittings can be undertaken
every three or four days.
While this method is liable to leave little punctuate scars at the sites
where the needle is introduced, it is nevertheless more satisfactory than
the linear scar made with the knife, to the use of which the patient
may, on the other hand, object, not to speak of the difficulty and
unsatisfactory results usually obtained therewith.
=9. Air Embolism.=—The fault of introducing air under the skin with the
syringe at the time of injection can only be the result of flagrant
negligence. Every physician should know enough to hold the syringe in an
erect or vertical position, and to expel the air above the solution in
his syringe, as is done with any hypodermic injection.
Air embolisms are also occasioned by a careless filling of the syringe
with the hydrocarbon in a cold state, as the material is now generally
used, and while the dangers of such emboli are very much exaggerated they
should not be permitted, when by the pouring in of the liquefied material
the syringe can be filled evenly.
Practically there is no harm done by the injection of air under the
skin, yet it elevates the skin at the site of the defect and hinders the
surgeon in accomplishing the best results.
These emboli cause a bulging up of the skin for the time being and may
occasion more or less pain to the patient, which passes away in ten or
twelve hours, leaving the parts as injected except for such reactionary
symptoms or edema, already referred to.
=10. Paraffin Embolism.=—The creation of an embolism is invariably due to
an injection of the foreign substance directly into a blood vessel. This
condition is one of the most objectionable, if not the most dangerous,
factor associated with the subcutaneous injection of any foreign matter,
be it a liquid substance, as, for instance, an oil; many cases have been
placed on record where they have been observed after the introduction of
even paraffin of high melting points, when introduced under the skin in
hot liquid state. Consequently the use of vaselin liquefied by the aid of
heat is especially liable to give rise to such condition.
Pfannenstiel cites a case wherein he injected paraffin in which the
patient was at once attacked with violent coughing, and for three days
exhibited symptoms of grave nature, such as pain in side, intense
dyspnea, acceleration of the pulse, hyperthermia, cyanosis of the
face, hemoptysis, violent cephalalgia, and vomiting—all indications of
pulmonary and cerebral embolism. The injection in this case was one of
30 c.c. of paraffin, with a melting point of 45° C. The symptoms as
mentioned continued for about one week, gradually subsiding, and followed
by recovery.
Kapsammer has also noticed such symptoms. Leiser, after injecting vaselin
to correct a saddle nose, noted an immediate collapse of the patient,
which was obviated only by the hypodermic use of ether and the resort
to artificial respiration. When the patient returned to consciousness,
he was found to be entirely blind in the right eye, the eye before the
operation having been known to show only a pronounced astigmatism.
Kofman cites the loss of a patient from the injection of 10 c.c. of
paraffin for vaginal prolapsis. Moskowicz observed two cases of pulmonary
embolism treated in the same manner, stating that an alarming dyspnea
continued for several hours.
Especially have cases in which the injections of paraffin were made
submucously for the correction of atrophic coryza shown embolic
tendencies. This is especially true when paraffins of high melting points
have been employed, as in the case of Pfannenstiel, in which instance
the condition of the mass permitted of freer absorption or the high
temperature caused a coagulation of the blood in the veins, leading to
thrombosis and embolism, and when the amount of such an injection is so
large as to prevent cooling and hardening in the normal space of time
added to the quantity and associated at the same time with consequent
pressure, predisposing to absorption or dissemination, especially if the
injection be made into the parenchymatous instead of the subcutaneous
tissue.
Comstock, in his experience on animals, states that “in all cases in
which paraffin was used at 102° F. the animals died within two weeks’
time, hence the specimens at that temperature are limited (death being by
thrombosis). In all other cases with the higher melting point, 110° F.,
no unpleasant results were experienced.”
Hurd and Holden have observed a patient who had previously undergone two
injections of paraffin for the correction of a depression in the upper
part of the nose. A third injection was advised and made under the same
conditions as the first, except that no cocain anesthesia was employed,
the paraffin being at same temperature as before.
The moment the injection was made complete blindness in the right eye
resulted, while a small ecchymotic spot appeared at the site of the
needle insertion in the skin. Half an hour later an examination of
the eye showed the right pupil dilated and inactive light stimulus,
the patient being unable to distinguish light from darkness.
Ophthalmoscopically the lower branch of the central retinal artery and
its subdivisions were found to be empty and in a state of collapse,
evidenced by their pale appearance. The upper branch of the same vessel
was found to be poorly filled.
The authors endeavored to remove the embolism to a collateral branch of
the artery by the use of amyl nitrate, digitalis, and pressure on the
globe of the eye, with no effect. Some hours later edema of the retina
appeared, followed by permanent loss of sight. The same authors have
observed several cases of pulmonary embolism result from the injection of
paraffin.
It is also a fact that injections of the nature being considered, while
not causing immediate embolism, may do so as a result of phlebitis,
caused by a direct injection into the vein or over or upon it in such a
way as to cause irritation.
Mintz reports a third case of amaurosis following a paraffin injection.
The latter was made to correct a saddle deformity caused by syphilis.
Three minutes after the injection the patient complained of pain in the
left eye, which was followed by total blindness, vomiting, and a pulse
of 48. Several days later there appeared symptoms of venous congestion
in the orbit, paralysis of the ocular muscles, corneal cloudiness,
and exophthalmos, a small gangrenous spot appeared at the site of the
injection.
Brœckært observed a case of facial phlebitis, followed by pulmonary
infarction. Brindel cites a case in which he observed a hard line of
considerable extent and painful to the touch, extending from the inner
angle of the eye to the angle of the eye, where it deviated toward the
root of the nose and terminated at the origin of the eyebrow.
De Cazeneuve made an injection, and on the following day noted that the
right cheek had increased considerably in size with an elevation of
temperature in the part. Two days after, under the right eye and to the
right of the nose, the whole cheek was red, hot, and much distended,
giving the skin a glazed appearance. Palpation was extremely painful. A
hard line could be made out, extending from the inner angle of the eye
outward and downward under the lower eyelid and terminating in the center
of the edematous cheek. The phlebitis in this case resulted without the
development of an embolism.
After a careful study of the causes of such embolisms we come to the
conclusion:
1. That the injected mass should not be heated above a certain melting
point.
2. That hyperinjection should at all times be avoided, particularly with
paraffins of high melting points.
3. That the injection should be made subcutaneously not into
parenchymatous tissues, and
4. That a puncture of a vein or the introduction of the injected mass
into a vein should be avoided.
In the consideration of the first two causes the author advocates using
injections of low melting points only at all times; in fact, from his
experience with over two thousand subcutaneous injections, he relies
entirely upon such paraffins or hydrocarbon mixtures as are semisolid at
70° F., appearing as a white cylindrical thread from the needle of the
syringe as pressure is applied.
With such a preparation and a careful introduction of the needle, as
described later, and with the injection of an amount much less than that
needed to correct the deformity and proper digital compression on the
blood vessels and about the site of the injection embolism is practically
impossible.
The avoidance in the third instance is self-evident, and it is to the
fourth fault and cause that we must pay particular attention.
Stein says that all that is necessary to avoid puncturing a vein is to
first introduce the needle alone under the skin and to attach the syringe
only when it is found no flow of blood results from the puncture thus
made.
Freeman and the author add to this by advocating the use of a somewhat
blunt-pointed needle instead of the extremely sharply pointed knife-edged
needles usually furnished with syringes intended for this purpose.
=11. Primary Diffusion or Extension of Paraffin.=—The spreading of
paraffin into normal tissues about the site to be corrected by prothetic
injection is a fault due principally to a careless use of the syringe.
The employments of an improper syringe in which the amount to be injected
cannot be graduated or controlled will be considered later—the result
with such being hyperinjection. In this event, when the anterior line
of the nose is to be restored, the mass is liable to find its way into
the loose areolar tissue of the infra-orbital region; in correcting
a nasolabial furrow the mass is pushed upward or is forced into the
tissue of the cheek above it, aggravating the trouble; in obliterating a
frown it travels upward toward the margin of the scalp, giving a median
prominence to the forehead that is found to be very difficult to correct;
in injections about the mouth the mass moves down upon the chin or
accumulates at the angle of the jaw; in correcting the creases beneath
the chin it seeks the sides of the neck, even traveling to the superior
border of the clavicle at its sternal third. Many other forms of such
diffusions can be mentioned directly due to primary diffusion the result
of hyperinjection.
Enough has been said of the danger of hyperinjection, yet even with a
proper amount of the injected mass this distention may be observed. To
avoid this the operator, or his assistant, should compress the margins
of the site of the injection with his fingers firmly applied, as, for
instance, in the injection of the root of the nose pressure should be
made at both inner canthi and over the tissue just above the root of the
nose and beneath the finger tips.
Downie advocates the use of celloidin in the correction of a saddle nose
as follows: He paints a band of celloidin or collodion down each side of
the nose, limited by the line of junction with the cheeks, and another
band across the root of the nose. These painted on bands he allows to
dry and contract for fifteen minutes before undertaking the injection.
The contraction of these bands prevents to a certain extent the spreading
or extension of the liquid paraffin into the cellular tissue about the
eyes, yet experienced digital pressure is at all times to be preferred.
If a liquid paraffin or hydrocarbon mixture or vaselin is used, the
immediate use of ice cloths applied to the part as digital pressure is
removed, is advisable to aid in the rapid hardening or setting of the
injected mass before the tension of the tissues over and about it might
influence it. With semisolid injection this is not necessary, except
in the subsequent treatment, as will be considered later, because the
mass, unless of too soft a consistency, as, for instance, vaselin, will
practically remain as injected and molded.
Vaselin when injected into tissue where there is tension would naturally
be forced out of position and shape, and should not be used except in
combination with a paraffin of a melting power high enough to give the
proper consistency to the former.
=12. Interference with Muscular Action of the Wings of the Nose.=—That
nasal respiration may be encroached upon as a result of injecting
paraffin about the nose has been observed by Alter. He points out that
during nasal inspiration there is a tendency for the alæ to contract
upon themselves or to move inward, decreasing the lumen of the orifice,
and that in the normal state this movement is counteracted by the action
of dilator muscles of the alæ—that is, the dilator naris anterioris,
the pyramidalis nasi, and the levator labii superioris alæque nasi—and
that this muscular action is interfered with owing to the pressure of
the paraffin upon these delicate structures, and resulting in more or
less permanent collapse or indrawing of the alæ during inspiration. He
observed considerable interference with inspiration in a case cited in
which an injection of paraffin had been made.
To avoid undue pressure upon the structures referred to, it is advised to
have an assistant place a thumb into each nostril and the index fingers
without and above the alæ in such way that the tips of the fingers may
be enabled to exert the necessary pressure over the injected mass into
these structures, and to maintain this pressure until the mass has been
properly molded and set. Connell advises inserting the little fingers
into the nostril to prevent an encroachment on the lumen of the nasal
canal.
The above applies particularly to those cases where injections are made
into the anterior lower or lateral third of the nose, as, for instance,
in overcoming slight depressions in the anterior line, immediately above
the lobule or in a low unilateral deviation of the nose.
=13. Escape of Paraffin after Withdrawal of Needle.=—When the injected
mass employed is of a semisolid consistency, as heretofore advised, it is
hardly possible for the mass to be forced out through the opening of the
skin made by the introduction and withdrawal of the needle, unless there
be an unwarrantable immobility of the skin above the site to be injected.
The latter should be corrected before injection.
The mass after having been molded in the shape desired may be further
hardened and set by the application of ice cloths or spraying with
ether before the needle is withdrawn from the skin, yet this is hardly
necessary, and the author advises against the practice for the reason
that pressure of the needle prevents proper and free molding of the mass
and renders the tissue liable to further injury by scraping its point to
and fro subcutaneously, adding to the extent of the wound and the dangers
of infection and repair.
The skin immediately around the needle hole, after withdrawal of the
needle, may be gently smoothed out with the dull rounded metal handle end
of the bistoury to free the interdermal canal of any foreign matter.
The skin about the needle hole is then gently washed with a
fifty-per-cent solution of hydrogen peroxid, dried with a sterile cotton
sponge and the opening sealed with a drop of collodion. Subsequent
treatment of the parts will be considered later.
=14. Solidification of Paraffin in Needle.=—This occurs only when
paraffins of high melting points are employed in liquid form in the
syringe, and is due to the rapid cooling of the paraffin in the small
metallic cannulæ, or needle, wherein it sets more readily, since the
volume contained therein is very small, often not more than two or three
drops.
This cooling establishes a pluglike formation in the distal end of the
needle, which prevents a proper use of the syringe, often breakage, and
when suddenly liberated by an extra pressure on the piston rod causes a
rapid discharge of the contents of the syringe to an extent not desired
with the result of hyperinjection.
This fault was one of the most annoying in the early days of such
injections when syringes of ordinary pattern, such as the Pravaz, or
those built like the ordinary hypodermic, were used. It was not unusual
to have the paraffin cool in the needle so quickly between the latter
in the flame of an alcohol lamp that the syringe became unmanageable
and broke in the hands of the operator. Since that time new and more
useful syringes have been introduced by various operators which overcome
this difficulty, yet with them, too, come the employment of semisolid
paraffins or mixtures thereof. Yet, as some authors insist upon using
paraffins of high melting points, it may be well to rehearse their
methods of overcoming this annoying intraneedle solidification.
Eckstein surrounds the syringe and needle shaft, except the tip of
the needle, with a rubber tubing, as shown in Fig. 284, to act as an
insulator, and thus, for a time at least, keep the preparation liquid.
Before filling the syringe he heats it by several immersions in and
internal washings of hot sterile water. To prevent the paraffin from
setting in the exposed tip of the needle he draws into the filled syringe
a few drops of hot water, which are injected into the tissues, causing no
objection to the method.
[Illustration: 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 in Fig. 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 in a liquid state the solidification in the needle is not
overcome.
[Illustration: 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 results the
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 remained
_in situ_ as 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 small as 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 the end 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 the broken-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 is of 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 for by 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.
GROUP I
1. Gersuny 36-40° C. 97-104° F.
2. Moskowicz 36-40° C. 97-104° F.
3. Parker 102° F.
4. Freeman 40° C. 104° F.
5. A. E. Comstock 107° F.
6. Walker Downie 104-108° F.
7. A. W. Morton 109° F.
8. Harmon Smith 110° F.
9. Stephen Paget 108-115° F.
10. Pfannenstiel 115° F.
GROUP II
11. Brœckært 56° C. 133° F.
12. Eckstein 56-58° C. 133-136° F.
13. Karewski 57-60° C. 134-140° F.
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 employing the 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 of
the 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
injection _per 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 high temperatures 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, or _vice
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.
℞ Paraffin (plate, sterile) ʒij;
Vaselin alba (sterile) ℥ij.
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 in Fig. 286.
[Illustration: 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 in Fig. 287.
[Illustration: 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
surface on 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 fullness over 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 held in 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 to be 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 a saddle 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 was found 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 develops after 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 mixture of 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 lower region 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 connective tissue, 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, especially noted 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 paraffin _in 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 in
Figs. 288_a_ and 288_b_:
“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. 288_a_, 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 in Fig. 288_b_.
[Illustration: FIG. 288_a_.—MICROPHOTOGRAPH SHOWING FIBROMATOSIS. × 40.]
[Illustration: FIG. 288_b_.—MICROPHOTOGRAPH SHOWING FIBROMATOSIS. × 40.]
“SUMMARY.—_Histological Diagnosis._—Diffuse fibromatories with fatty
infiltration and giant-cell formation in a vacuolated area produced by
paraffin injection.”
Once the hyperplasia is established the surgeon must simply wait until he
believes the activity of the abnormal growth has subsided and then remove
the superabundant tissue with the knife.
With another case, in which the patient was operated on by another
surgeon, the author was called upon to remove the growth. A part of the
coarse, yellowish pale and cartilagelike tissue was excised, sufficient
to restore the parts to a normal contour. After an uneventful recovery
the patient went away, greatly pleased, only to return in six months,
presenting a similar condition as before the extirpation.
A second operation was done, this time more extensively, the entire
yellowish connective tissue being removed by the aid of a long median
incision on the anterior aspect of the nose.
The wound healed readily and showed very little scar, and the patient was
discharged. One year after the last operation the nose was still normal
in appearance and the growth had not reappeared.
From this it is deemed absolutely necessary to remove practically all of
the newly formed tissue to warrant a nonrecurrence of the fibromatosis.
=21. A Yellow Appearance and Thickening of the Skin after Organization
of the Injected Mass Has Taken Place.=—This condition of the skin is
evidenced some time after the injected mass has become organized,
beginning about the sixth month after the time of injection. It has been
especially noticed with the hard paraffin fillings of the nose, but also
with other injections, even of the lowest melting points, about the
sternoclavicular regions of the neck.
The skin becomes at first streaked with a superficial and irregularly
defined patch of red, the forerunning indication of the size of the
ultimate pathological change. The red color subsides slowly, leaving the
area pale, which thereafter gradually thickens, taking on the appearance
of a light yellow stain in the skin.
Practically opposite to the condition in xanthalasma, where the yellow
area is slightly elevated and occurs in the loose tissue of the eyelids.
The cause seems to be a degenerative change in the skin dependent on
pressure upon its underlying tissues. Evidently the pressure of an
overproduction of the connective tissue which has sprung up to replace
the injected mass.
Seemingly the cause is due to an injection being made too close to the
derma where the latter is bound down to the subcutaneous tissue, or a
desire on the part of the surgeon to prevent an injection into the deeper
areolar tissue, especially when the injection is made in the vicinity of
the larger blood vessels, for fear of causing embolisms or phlebitis.
Excluding the use of hard paraffin for such injection, the operator
should be sufficiently experienced to use these injections properly and
without fear, and at all times avoid injecting into the skin instead of
subcutaneously.
Making the puncture first and observing if blood flows freely or
trickles from the detached needle will assure the operator into what
tissues he has thrust his needle.
Should active bleeding follow the puncture, he should withdraw the
needle and wait to inject the site at a later sitting, using the same
precaution; at no time should he be in doubt as to the absolute placing
of the injected mass.
When the injections are done about the lower neck or shoulders great
care must be exercised to avoid the blood vessels, and small quantities
be only injected to prevent reactions that may cause phlebitis of these
vessels; furthermore, the injected mass must be carefully molded to
prevent the formation of uneven elevations or lumps. Without doubt an
injection into one of the blood vessels of the neck would mean certain
death.
Kofman lost a patient by pulmonary embolism twenty-four hours after an
injection of 10 c.c. of paraffin. How many punctures he made to inject
this amount is not stated, but certain it must be that he introduced part
of the mass directly into some blood vessel.
The author advises, when injecting about the neck, to use a stout,
dull-pointed needle introduced under local ethyl chloride anesthesia and
to elevate the tissue with the needle as the injection is made. In this
way the operator can observe the behavior or placing of the injected
mass, at the same time stretching the skin to permit of the injection
without encroaching upon the blood vessels. The mass is immediately
molded after each injection. The further question of the practical method
of making these injections will be fully considered later.
If, however, the pigmentation under consideration has taken place,
electrolysis with a fine needle may be resorted to, with the object of
whitening the discoloration by producing scar tissue, in the form of
punctations, in the discolored area.
While the numerous white spots so caused are objectionable, they are
better borne by patients than the pigmented appearance. A thorough
needling of the spot in this way eventually brings about an improvement,
and if, for æsthetic reasons, the patient objects to the unsightliness of
the result thus obtained, the white area may be carefully tattooed with
an appropriate color to match the rest of the skin of the face or neck.
If the pigmented area is not too large, it can be excised with the knife
and the healthy skin be brought together with a fine silk suture, thus
leaving a thin linear scar which can be dealt with as the punctate scar
area, if desired; the electrolysis being a painful procedure at all
times, since sufficient milliampères must be used to cause scar-tissue
formation, which is between 20 to 30 milliampères in such cases.
=22. The Breaking Down of Tissue and Resultant Abscess Due to the
Pressure of the Injected Mass upon the Adjacent Tissue after the
Injection Has Become Organized.=—The above result is particularly
noticeable when the injections have been made into the cheek or the
breast. It is understood that the suppurative changes under consideration
herein are not attributable to imperfect sterilization of the injected
matter, although it is possible, and perhaps is the cause in fifty per
cent of the suppurative elimination of the infected mass from the cheek,
that a nucleus of infection is carried into the tissues and is held in
suspense for a time, because of its imbedment in a neutral media that
does not readily permit of bacteriological propagation, but eventually
this nucleus must come in contact with tissue which it can affect, and
only then may its infection be taken up.
The author believes that such secondary affections are accountable to
pressure effects upon the blood vessels or glandular structure, as in the
case of breast injections, the new connective tissue causing a lack of
nourishment in the part or gland, and a resultant breaking down of the
tissue, directly influenced in some instances by external violence.
Tuffier reports the elimination of paraffin injected into the breast
several weeks after the injection. If this elimination had been caused
by primary infection an acute reaction would have taken place at least
within forty-eight hours, ending in abscess shortly after.
A case which came to the author’s attention was that of a lady who had
been operated upon for the correction of a saddle nose three months
before. The result had been satisfactory. The day previous to consulting
the author she had injured her nose in an automobile accident. The nose
was much swollen, very painful, and red over the entire upper and middle
third. The use of external cold did not relieve the condition much, and
on the fourth day the skin broke open at one point, allowing pieces of
the paraffin to escape. Immediate relief followed, the wound healed with
a marked sinking of the middle third of the nose. After three weeks the
nose was again injected with no further untoward symptoms, the result
being satisfactory for two years past.
In this case undoubtedly the exciting cause was directly due to violence,
which may be the forerunner in many of such cases, but there is a number
of such eliminations directly due to a breaking down of the tissue from
internal pressure alone.
There is no way to overcome this difficulty, except to await the definite
formation of the abscess and then to puncture the skin directly over the
soft fluctuating area and to drain the cavity.
Once relieved, the condition quickly subsides, leaving a certain amount
of loss of contour, which can, however, be corrected several weeks after
by a secondary injection.
When the abscess occurs in the cheek it is not advisable to open
interiorly, but to make the puncture through the skin, on account of
the danger of infection from the buccal cavity and of the imperfect
evacuation thus attained.
A trocar and cannula of proper size will be found to be the most
suitable, the parts being gently manipulated to evacuate the contents of
the abscess.
Aspiration can also be resorted to, but for the breast a small linear
incision, made under local anesthesia at the most dependent point, best
answers the purpose.
A small gauze strip drain may be employed for a few days to insure of
perfect drainage in the latter case, the wound being brought together
eventually by a delicate cosmetic operation if desirable.
THE PROPER INSTRUMENTS FOR THE SUBCUTANEOUS INJECTION OF HYDROCARBON
PROTHESES
Although Gersuny advocated the use of a Pravaz syringe for injecting the
liquefied vaselin mixture for prothetic purposes, it was soon found that
such an instrument was practically useless, especially when the parts to
be injected offered more or less resistance to the introduction of the
foreign matter.
Other operators, following the advice of Eckstein, who advised the
employment of “Hart paraffin” of high melting point liquefied by heat,
raised the objection that the metal needle became so easily obstructed by
the rapid setting of the paraffin in its distal end that the great force
necessary to eject the contents of the syringe usually resulted in a
breakage of the glass barrel in the hands of the operator, or, as in some
types of the syringe, a separation of needle and syringe at the point
where the former was slipped upon the ground point of the latter, with
the annoyance of the paraffin squirting over the faces of both patient
and operator.
Eckstein tells us how to overcome the first difficulty with this same
style of syringe as used by him. He covers the syringe with a rubber
insulating sleeve and draws several drops of hot, sterilized water into
the needle to overcome the plugging up of the latter; an illustration of
his syringe has been shown on page 232. Mention has also been made of the
various methods used to overcome this difficulty by other operators.
It was presently found that such an instrument was not only impractical,
but also a detriment to procuring desirable results, the paraffin
solution shooting out suddenly, in some instances causing hyperinjection,
and at other times emerging so slowly that it required unusual force on
the part of the operator—a painful procedure for delicate hands, inasmuch
as the fingers only can be applied to operate the instrument.
With the object of overcoming this uncertainty of the amount of the
injection and the unnecessary exertion to inject any given quantity, as
well as to establish enough _vice à tergo_ to keep the needle free from
plugging up with cooling paraffin, various operators devised instruments,
all having practically similar points of mechanical merit and usefulness.
The required necessities being to invent a syringe which would have a
known capacity, a piston under control of the operator at all times, and
metallic needles of proper lumen, to prevent the solidification of the
liquid paraffin, screwed to the syringe to prevent loosening.
With the object of overcoming these difficulties the author devised a
syringe which was made for him by Tiemann & Co., early in 1902. He begs
to introduce the same here, as a type similar to which most operators
have built their special instrument.
The syringe at that time consisted of a glass barrel, of a size to hold
6 c.c. of liquefied paraffin. At either end of the barrel tube were
placed metal ends, the distal one containing a cap with a screw thread to
receive the needle, the upper cap being threaded to receive a check nut
through its center and on its outer surface, on opposite sides to each
other, two metallic rings to accommodate the thumb and forefinger. The
center of the check nut was double threaded to receive the piston rod,
the piston or plunger being held in place by two, upper and lower, washer
nuts, the lower being threaded to receive a small rod passing through the
bored-out center of the piston rod, and which ended in a check nut, in
the handle, threaded upon the outer or manual end of the piston rod, in
such a way that the fiber or asbestos piston washer could be tightened
and loosened at will.
The syringe permitted of being used as an ordinary syringe by unscrewing
the cap check nut or be made into a screw drop syringe by screwing the
same nut into place. By turning the handle end of the piston rod the
contents of the syringe were forced out smoothly and evenly in any
quantity desired.
With the later employment of the cold, semisolid preparation of vaselin
and paraffin, as heretofore considered, it was found necessary to
reënforce this syringe, so that the greater pressure necessary to
eliminate the wormlike thread of hydrocarbon would not force off the
lower cap or break the barrel of the syringe at its needle end.
This was done for the author by the Kny-Scheerer Company, December 6,
1902, when metallic strips were added to opposite sides of the glass
barrel connecting the lower with the upper cap.
The instrument as then made is shown in Fig. 289.
[Illustration: FIG. 289.—AUTHOR’S DROP SYRINGE.]
At the same time the same firm made the author a syringe entirely of
metal, similar in construction, except that the barrel was made larger in
diameter and shorter in proportion to bring the instrument near to the
seat of operation. The regulating washer rod was not needed, since in
this instrument no washers were required, the piston head being made of
solid metal throughout and the rod being soldered to the plunger, thus
overcoming any objectionable fault in sterilization.
This type of syringe was found to be most suitable for the cold,
semisolid injections, and is of the type now universally used except for
the slight modifications of the various operators. It is illustrated in
Fig. 290.
[Illustration: FIG. 290.—AUTHOR’S ALL-METAL DROP SYRINGE.]
Since there were no objections to making the barrel large enough to
permit of injections, such as are required for restoring the contour
of the cheek and the neck and shoulder, it was made to contain 10 c.c.
working capacity, overcoming the necessity of constant refilling, when
comparatively large injections had to be made—a fact worth remembering
from a practical standpoint, although two or three of these syringes,
specially prepared for each patient, might be found desirable by some
operators. Yet the simplicity and ready facility with which this
instrument can be used and refilled renders it useful and sufficient for
performing operations of this nature to any judicious extent.
Syringes holding small quantities of the paraffin mixture are found to be
a nuisance.
The following operators employ syringes of the capacity given:
Brœckært 3 c.c. 50 mm.
Eckstein 5 c.c. 80 mm.
Freeman 5.6 c.c. 90 mm.
Downie 10 c.c. 150 mm.
The instrument employed by Brœckært, holding less than one dram, would be
of little use except to correct very slight deformities about the brow or
nose, or dressing up or completing the contour of parts previously filled
by larger injections.
Another syringe similar in type to the author’s, but of a capacity of 5.6
c.c., was introduced by Harmon Smith.
The principles of the syringe are alike, but the style of handles, two
flat metal bars at opposite sides, offers no objection when comparatively
hard mixtures of paraffin and vaselin are used.
While operating the syringe the narrow blades are brought in contact with
the soft flexor sides of the thumb and forefinger, indenting the flesh
deeply, and with the least unexpected move on the part of the patient
permitting it to slip out of the grasp of the surgeon. Its incapacity for
large injections also offers some objection, but for correcting smaller
defects it is both practical and compact. It is illustrated in Fig. 291.
[Illustration: FIG. 291.—SMITH ALL-METAL DROP SYRINGE.]
It is obvious that with the screw drop type of syringe the cold semisolid
paraffin mixture contained in its barrel is always under the full command
of the operator, nor can there be a plugging of the needle, since the
great force that can be exerted with a turn of the piston handle would
free it, even if the mixture were of a comparatively high melting point,
although the force to be applied would naturally increase in proportion
to the hardness of the mass within the syringe.
The turning of the screw piston forces out the contents of the syringe
in the form of a white thread of a diameter equal to the diameter of the
lumen of the needle.
To facilitate this ejection, the needles should be of ample diameter, not
over one inch long and having knife-edged points. Longer needles are not
necessary, and only add to the force required to turn the screw handle.
Curved needles, used by some operators, are never needed, and the author
does not see how they could be applied at any time in preference to the
straight.
As much of the paraffin mixture can be forced out of the syringe as may
be desired by screwing the piston down into the barrel.
The piston rod may be graduated in five- or ten-drop divisions, but the
operator rarely ever refers to the scale. He judges the amount required
by the elevation of the tissues brought about by the presence of the
paraffin thus forced under the tissue. Experience soon teaches him the
amounts necessary or judicious in each case, always remembering that it
is better to do a second and later injection than to hyperinject.
The entire instrument being of metal permits it to be sterilized as
readily and in the same manner as any other metallic instrument.
It is understood that the syringe must be taken apart for sterilization
at all times.
Lubrication, to facilitate operation, is never required, since the nature
of the mixture used in the syringe answers this purpose in every way.
Owing to the greater amount of metal in the solid piston itself, the
latter is very likely to expand under dry heat sterilization or boiling,
so much so that for a moment it cannot be introduced within the barrel.
This can be quickly overcome by dipping it into cold sterile water or
absolute alcohol, which brings about its contraction.
After using, the syringe should be emptied entirely, unscrewed and
sterilized, and placed in the metal case furnished for it. A screw cap is
furnished to take the place of the needle when not in use.
The method of filling and using the syringe will be considered later.
PREPARATION OF THE SITE OF OPERATION
The same surgical precautions should be observed when a paraffin
injection is to be undertaken, as with a minor surgical operation.
It is hardly found necessary to prepare the site of operation the day
before, nor need the patient be detained for such time for the purpose of
making him ready.
With careful observance of ordinary surgical technique, both as to
surgeon and patient, all of this class of operations can be performed in
any physician’s office, providing that both instruments and the mass to
be injected have been rendered sterile.
Especial care should be given to the operator’s hands, for with these he
not only handles the instruments, but must also mold the mass injected,
thus frequently coming in contact with the needle opening or openings
made in the skin.
When injections are to be made in the cheeks of the patient, the mouth
should be prepared by cleansing the teeth thoroughly and washing out the
buccal cavity with warm boric acid or hydrogen peroxid solution, or any
of the preparations of the Listerine composition.
This rinsing should be continued every few minutes for at least ten
minutes before the operation is undertaken.
This is necessary, as the surgeon must introduce his finger into the
mouth and behind the cheek to mold out the mass injected subcutaneously,
and infection could easily be introduced by his fingers during this
procedure.
Externally a generous field of the operation is scrubbed with a brush
dipped into green soap and water.
The skin is then thoroughly washed with gauze sponges steeped in absolute
alcohol, followed with spongings with a 1-5,000 solution of bichlorid
of mercury. The whole surface is then wiped off with a sponge dipped in
ether and covered for the time being with a pad of sterilized gauze until
the operator is ready to proceed with the operation.
PREPARATION OF THE INSTRUMENTS FOR OPERATION
The manner of preparing the necessary mixture of paraffin has been
described on page 244. After such preparation, the mixture, still hot,
may be poured into test tubes, which are sealed and put away for further
use, each tube holding just enough to fill the syringe two thirds full.
When a syringe is to be filled, one of the tubes is opened and the
contents are again boiled over a spirit flame, or simply liquefied and
poured into one of the types of heaters already described for the same
purpose of resterilization.
From the test tubes or the heater, the boiling mixture may be drawn up
into the sterilized syringe to the required amount or it may be poured
into the opened piston screw cap end.
In the latter event the ready cooling of the mixture as it enters the
needle will permit it to be retained in the barrel, or the needle may be
immersed in sterile water as the paraffin is poured into the syringe, yet
even if a few drops escape from the needle in the former method, no harm
is done, as such loss amounts to nothing and helps to eventually fill the
syringe evenly and free of air.
If the mixture is drawn up into the barrel to the required height, more
or less air enters, which must be removed by turning the syringe, needle
up, and screwing up the piston rod until either the liquid or cylindrical
thread of the cooled mixture appears.
If the mixture is poured into the syringe the piston is slowly pressed
into the barrel, thus allowing the air to escape along its sides if
the mixture is set, or if warm the syringe is turned up and the piston
screwed into place. As this is done the few drops of cooled paraffin
will be forced from the needle before the air is exhausted. The screw is
turned until the paraffin emerges evenly from the needle.
The syringe must now be laid aside, or placed in sterile water of the
temperature of the room, to allow the liquid within to set evenly and
become uniform in consistency.
The operator will follow what method he pleases in filling his syringe,
but at no time should he fill it with the cooled product with a spatula,
or other such means, as he is sure to fill it unevenly in this way,
incorporating a number of air spaces. The air issues from time to time
during an operation with sudden sputtering outbursts, that not only tend
to annoy the patient, but also to frighten him—the shock being unusual
and unexpected, while the air thus forced into the subcutaneous tissues
puffs out the parts and interferes with a perception of the proper amount
to be injected and adds to the danger of air embolisms.
Slipshod methods are inexcusable, and should not be tolerated. The
best results possible should be given the patient, and only from the
best results obtained with the best care can the most reliable data be
attained, all helping to fix the reliability, efficacy, and exactitude of
this branch of cosmetic surgery.
THE PRACTICAL TECHNIQUE
The field of operation and the instruments having been properly prepared,
as described, the _modus operandi_ must next be considered.
Since the various parts of the face to be injected demand specific
procedure, they will be considered somewhat individually hereafter,
whereas the general technique, applicable in as far as the method of
injection is concerned and applying similarly in all cases, may tersely
be first taken up.
Various and noted surgeons point out that these subcutaneous injections
should be made under general anesthesia, i. e., ether, while others
consider the hypodermic use of cocaine or Eucain β solution in one to
four per cent necessary to accomplish good results.
The author considers the method in the first case objectionable both as
to patient and operator, entailing much discomfort to the one operated
on and demanding an unnecessary waste of time for the etherizing and
recovery. Likewise is the employment of a local anesthetic not indicated
or demanded, since the operation to be undertaken necessitates only the
pain associated with the prick of the needle through the skin.