The Secrets of Specialists/Chapter 23

The treatment of hernia, up to the sixteenth century, constitutes the darkest pages in medical history. These unfortunate sufferers were objects of scorn and ridicule, denied access to society, and shut out from positions of honor and rank, while the strangulated were all abandoned to themselves to die. In the latter part of the seventeenth century the spring truss was invented and from that advent, the mechanical and surgical treatment of hernia has gradually progressed, until we have at our command several successful means of curing this condition.

Hernia is another condition which has offered the physician an inviting field in which to specialize, owing to the freqency in which rupture is found. Several years ago Bryant gathered the statistics, and recorded 93,355 hernia cases, with a view of finding the relative percentage of the different forms of hernia; out of this number of cases there were 46,551 simple inguinal, to 7,452 femoral, without distinction of sex; of 30,575 double hernia there were 28,503 inguinal and 1,972 femoral. The sum of his figures were 75,054 simple and double inguinal to 10,425 simple and double femoral, being one femoral to 7.10 inguinal. Malgaigue also gives statistics regarding the frequency of hernia in relation to population, and he estimates the proportion of the whole population of France that is ruptured, to be one out of every thirteen males, and one out of every fifty-two females, or taking both sexes together, one out of every 20.5 individuals. The accompanying illustration shows the different forms of hernia and their location; some of these are so rare, however, that they are considered curiosities when presented.

​Judging from these statistics, we can readily see why the treatment of rupture makes a remunerative specialty. There have never been any cutting in fees with rupture specialists. The price for such treatment is usually $100.00 for single and $150.00 to $200.00 for double hernia.

The treatment of rupture is divided into palliation of rupture or supportive measures and those which have a tendency to permanently close the canal. The former will depend upon a suitable truss, while the latter involves many different surgical procedures. We will only discuss, however, the three operations which are the most suitable and practical for the office specialist.

It was the latter part of the seventeenth century that the first spring truss made its appearance, and although a very crude affair, compared with the modern truss, it offered great relief and improvement to the only means previously used of carrying and supporting their hernias in cloth bags.

The modern apparatus employed for the retention of hernia have been brought to great perfection in the past few years, and when it is considered how great is the number of ruptured persons in the community, together with the essential relief they receive from these appliances, they must be regarded as one of the most useful productions of modern surgical appliances. The ingenuity of American truss-makers has enabled them to produce apparatus far superior to those made in other parts of the world. The object to be obtained by the application of a truss is to close the opening through which the protrusion has taken place, by means of external pressure ​and thereby, after reduction has been effected, to prevent a second descent. A well-made instrument should exert sufficient and uniform pressure to keep the hernia in place without being easily displaced or causing undue discomfort. When the opening is not exactly closed by a properly fitting truss the omentum or intestine easily slips out and the patient who wears such an apparatus is in a state of constant insecurity and danger, especially if he be engaged in laborious work. There are, unfortunately, many trusses in the market which do not

fill these requisites and expose the patient to the risk of strangulation, by allowing a portion of the intestine to escape. It would indeed be better for the patient that no truss should be worn than such a makeshift. In the words of an eminent specialist, it may be stated that by early mechanical treatment a large percentage of hernias occurring under middle age can be cured. This is brought about by a slow process of thickening and gluing together of the sides of the opening through which the rupture occurred. It is advisable, however, that a truss be worn for at least one year after a cure has been effected.

​In ordering, especial attention should be given to the following points: 1. The pad should be sufficiently large to covtr the hernial opening and extend at least half an inch over the surrounding parts. It should be made of material which will not readily absorb moisture and thus become foul and irritating to the skin. It should also have the proper shape, according to the variety of hernia, and press uniformly upon the parts. 2. The spring should have sufficient elasiticity to maintain the pad in position, without undue pressure or chafing.

The fitting of trusses is a much neglected art with physicians, and the safety and comfort of patients will greatly depend upon a perfect fitting appliance. This is doubly essential where this support is depended upon to make pressure during the Neoplastic process of the injection treatments. To have a well fitted truss, the following points should be observed: The patient should be able to place his body in any position which is usual, or may be unusual, in his vocation of life. He should lie on his back and raise his body from the floor by having some one support his feet, cough violently and persistently, bend his body forward, and try to touch the floor; in fact, go through various bodily contortions, to be sure the truss holds firmly, and when you are satisfied of this, you are ready for operative procedures to effect a permanent cure. The truss should be worn continuously during this treatment, however, only removing the appliance during the sleeping hours and in many cases it is well to continue its use during the night.

The injection treatment of hernia is purely an American operation, and the credit of its discovery has been divided between Drs. Valpeau, Pancoast and Heaton. Dr. Warren, who has done much to perfect this method, gives this honor, however, to Dr. George Heaton of Boston, who referred to his method as "tendonous irritation"; although Dr. Heaton's treatment ​created much inquiry in medical circles, he was inclined to keep it a secret; it was, therefore, used by only a few physicians, for a number of years. About fifteen years ago this method was revised and adopted by many physicians, who are today using it with splendid success, in all parts of the country. The fees attached to the operation have induced many physicians to commercialize the specialty by advertising.

The injection treatment for hernia is, without a doubt, as successful as other operations for hernia, and is the most practical and convenient for the office specialist, as well as the patient, for it does not detain the patient from the daily duties of life and the treatments may be given in the office, with little inconvenience. The two irritant methods and the paraffin operation are the only treatments which we will consider for office specialties.

If there is any one thing the medical profession has been "stung" in securing the "right to use" it has been hernia fluids. Every promoter of a secret hernia cure has some special hernia fluid, which the attempt to extol as "superior to all others," the "only one which will stand the test," etc. These silver-tongued medicine venders have reaped a rich harvest in fleecing money from the less worldly physician by selling some simple fluid, with the right to use in certain localities, for a fancy price. The fact remains that these fluids are simple mixtures which every physician has in his laboratory and there is a large variety of medicines which will cure hernia if properly injected. Valpeau and Pancoast used tinct. of iodine. Roberts of Alabama, used oil of cloves. Dr. Mason Warren used sulphuric ether. Heaton's injected fluid was a solution of quercus alba, etc.

The therapeutic mission of any hernia fluid is to create a mild irritation, without inflammation or abscess and cause nature to throw out an abundance of sero-plastic lymph, which ​will create adhesions in the ruptured muscles, with complete occlusion of the hernial rings, if possible. Theoretically, there are many remedies which may be used for this purpose. Elaterium and cantharides would be the most active, but would require very minute quantities.

Alcohol alone has been advocated by many; the following solution has been a favorite in my hands which I call:

Dissolve the quinine and urea hydrochloride, the resorcine and zinc sulphate in two drachms of water; add the other ingredients and sufficient water to make one ounce. This should stand a few days, and be shaken frequently; before using, filter through absorbent cotton until absolutely clear.

In resuming the above formula the quinine and urea hydrochloride is added for its prolonged anæsthetic effect and to obtund pain, during the irritant period. This is, also, greatly reinforced by guaiacol, with its irritant and antiseptic properties. Resorcine gives us all the advantages of carbolic acid, in a better form to use; zinc sulphate, quercus alba and thuja are incorporated for their mild irritant and astringent effects. The amount of this solution injected is from two to ten minims.

Before any injections are made, you must be satisfied that the patient has a well fitting truss and one that will support the hernia, under all circumstances; otherwise, you may be disappointed in the results, for this is the one essential thing in assuring success, for after the treatment is commenced, the rupture should never be allowed to protrude, even if the patient is required to wear the truss night and day.

After observing surgical cleanliness of both instruments and operating area, the patient is placed upon his back, on a surgical table or chair, with legs flexed and it is well to place a pillow under his hips in order to elevate them, that the gravity of the intestines will be away from the canal, and not come

in contact with the operation. Having previously filled the syringe and regulated the set screw on the piston stem for the amount of medicine desired for the treatment, the operator, if right handed, should take a position at the left side of the patient, the forefinger of the left hand should be inserted in the canal of the rupture invaginating the scrotum to the point of the internal opening; with the forefinger in the canal, and the thumb of the same hand, the tissues are lifted up so as to draw the issues away from the cord and thus avoid puncturing ​the contents. The needle is now inserted on an angle of about forty-five degrees until the point of the needle reaches the finger; if the needle pricks the finger, it should be withdrawn back, until it avoids the scrotal walls; pressure should now be gently made upon the piston head to force part of the contents of the syringe into the tissues, then the point of the needle moved to another place ir order that we may deposit the fluid at several minute areas in the canal. One of the principal things to be remembered is to try and deposit the fluid as high up in the canal as possible, for if you should close the canal too far down it would prevent further treatments, and not allow you to close the openings at the point desired; after

the injection is made, and the needle withdrawn, the parts should be gently massaged in order to scatter the medicine and cover as large an area as possible. The truss is now replaced, so that it will make constant pressure over the injected area, and the patient allowed to resume his daily vocations.

This treatment will cause the patient but little inconvenience; he may complain of a slight stinging or burning sensation, due to the mild inflammatory action. This will subside in a few days and at the end of four or five days, or a week, the operation should be repeated.

The amount of medicine used and the length of time required to effect a cure will depend upon the extent of the hernia. It is always well to commence with the minimum amount of the fluid and increase the quantity of each injection, according to the way the treatment agrees with the patient. I generally use only two or three minims, to commence with, and if it is borne well by the patient, increase the amount at subsequent treatments, always allowing sufficient time between each treatment for all inflammatory action to subside.

The length of time required to establish the desired results, from this treatment, will depend upon the condition and age of the patient and the extent of the hernia. The young and vigorous will respond to the treatment more rapidly than the feeble and aged. We can also obliterate a small opening with less difficulty than a large one.

In order that you may observe the progress of the treatment after the patient has received several injections, a test should be made to learn how the treatment is progressing. The first test should be made while the patient is upon the operating table. Place your hands over the hernia and request the patient to cough gently; if the hernia has a tendency to protrude the treatment should be continued until you are satisfied that the tissues have been thoroughly united, and the patient can go through the different manoeuvres in your presence, as was done to test the truss or are incident to his daily work. It is always well to have the patient wear the truss for some little time after you have discontinued the injections. This is especially so if the patient is doing heavy lifting. The truss may be entirely abandoned, however, in due time.

Dr. Langdon has devised a new method of accomplishing the same results as previously described, using a different means and "route" to reach the inguinal canal; instead of ​inserting the needle through the abdominal tissues, he has ingeniously arranged a needle and canula which fits over the little finger and by invaginating the scrotum with the little finger, with this attachment the needle is forced through the thin scrotal walls and thus deposits the medicine within the

inguinal canal at a point nearest the internal opening. The advantages offered by this operation are as follows:

1st. It avoids any possible danger of puncturing the cord, as the needle is inserted longitudinal, instead of transverse to the cord. 2nd. You are more certain of access to the canal, as you only have to penetrate the thin scrotal walls. 3rd. By ​gently rotating the little finger, after the needle has passed through the scrotal walls, you produce a slight scarification, which also has a tendency to reinforce the adhesions; (although the latter is not advised by Dr. Langdon, the writer has found this procedure quite an advantage in both operations).

The technique of this operation is very simple; the little finger containing the canula which adheres to the finger by two clasps is inserted up the canal's invaginating the scrotum; the needle, which has a blunt point with openings on each side, is inserted through the canula up to, and through, the scrotal walls and the medicine deposited at different points by

rotating the finger. The after treatment is the same as is given in the former injection method. Dr. Langdon states that he has used at least one hundred different ingredients and combinations in hernia fluids and prefers fluid extract of quercus alba to other injection fluids. For a child, up to nine years of age, he reduces the fluid extract by heat, in a test ​tube, to one half and injects from two to ten minims, using the minimum amount to commence with and increasing the quantity. From the age of nine to twenty, he reduces the F. E. quercus alba, by heat, to about four-tenths and adds one-tenth grain of zinc sulphate to each minim used. In patients from twenty-five to seventy-five years of age, he uses the same solution as is used for children, and adds one-half minim of beeehwood creosote to each three minims of quercus alba.

In conclusion the doctor says: "I have no doubt that others have just as good results with other formulæ, but assuredly in later years my record is almost perfect, so that today I feel confident to cure nearly every case."

Dr. Olstrum who has devoted several years of his life to the rupture specialty and although a very enthusiastic advocate of the injection method, says he can cure fully fifty per cent of all cases which are curable with other methods by scarifying the surface of the canal or ring. He uses for this purpose the ordinary large hemorrhoidal needle and endeavors to scarify the opening so thoroughly at one treatment that he will get immediate union. After the surfaces of the opening have been thoroughly scarified the abraided surfaces are kept together by the pressure of the truss, union takes place immediately and one operation is often all that is necessary. This operation, skillfully and painlessly performed by the use of a local anæsthetic, certainly deserves to be recognized as an advanced treatment to other radical cutting operations. It accomplishes the same results by the same process of inviting union of two abraided surfaces and has the advantage of overcoming the fear of the knife. The patient should be kept in bed for a few days until all soreness has disappeared; he is also instructed to wear a truss for a few months afterwards. ​This method of treatment illustrates what one of the simplest operations in the category of surgery can accomplish in curing a condition which is attended with a certain amount of danger to life, if not interfered with, and also avoiding the dangers of the radical cutting operations.

I once asked the doctor if he could devise a special knife or instrument which would be better suited for the operation than the point of a hypodermic needle to scarify the surface. He remarked: "I am used to a hypodermic needle and have no desire to change it for other instruments." While there are many cases in which this treatment cannot be applied, it will often close the doors of the canal more quickly and with greater certainty than injecting fluids and cutting operations.

Paraffin has been used in the treatment of hernia with marked success by many operators and is often referred to as the "supportive treatment." The object of the use of paraffin is to obliterate the opening and canal with this neutral substance and thus prevent the escape of the intestine. It also supplements the truss, by making pressure between the abdominal walls. Paraffin, used in hernia, should have a melting point of about 120 degrees F., and the technique of the operation is the same as in other injection treatments. The paraffin syringe is filled with the paraffin at the right melting point and when cooled to a semi-solid state, the finger of the left hand is inserted up the inguinal canal for a guide and the needle is forced through the tissues to the point where the deposit is desired; the assistant operating the paraffin syringe, while the operator directs the deposit of paraffin with the index finger of the left hand in the canal and the right hand attempts to mold it into place. Of course, we cannot mold and manipulate the paraffin, in hernia operations, as we can in saddle back nose, and other operations, as we do not have as free access to the deposit. We can do much, however, in directing the deposit.

​The effect of the paraffin in this operation has a double action; it not only acts as a support to prevent the protrusion of the intestine but also as a mild irritant, for while the paraffin is becoming incapsulated, there is an exudation of plastic material which creates adhesions and strengthens the resistance of the abdominal walls. Many operators do not advise the use of the truss after the operation, but the best success has been obtained where the truss is worn, after the operation, until all trace of inflammatory reaction has subsided; then the results of the operation are tested, the same as with the irritant injection treatment.

The paraffin treatment for hernia is slow in becoming popular as a general operative measure and at present is only advocated and used by a few, who are maintaining equal results with other hernia operators, and fattening their purses through their exclusive field, and secretive methods, but we feel safe to say that this operation in the near future will receive the credit it justly deserves from the regular practitioner.

By adopting any one of the foregoing methods the general practitioner will once more stay the hand of the surgeon and prevent his hernia patients from drifting into the hands of the advertising hernia specialists and retain both the glory and fees connected with the operation.

To refute the charges made against the injection treatment for hernia, Dr. C. F. Souder of Philadelphia, states: "I can only speak from personal experience; I have given nearly 16,000 such treatments without a death, abscess, septic infection or atrophy of the testicle. The treatment can be given from birth to old age."

Such assurance from a man with as wide experience as Dr. Souder, should convince any physician regarding the reliability of the injection treatment and although it is not indicated in all hernias, when it can be used it is thoroughly reliable, scientific and successful as any method in present use. ​When an astringent as well as an irritant is needed, Dr. Souder uses the following in all forms of hernia:

Inject two or three minims when reaction disappears.

The local and itinerant hernia specialists have always attempted to guard their fluids with great secrecy, or if they sold their fluids with the supposed formula, they would coin some name of an ingredient which would confuse the physician who secured it. I therefore publish the following formulæ as examples of this class.

The Ideal Hernia Cure Company of St. Paul, Minn., formerly used large space in Medical Journals, offering to sell a formula for the cure of hernia, and a hypodermic syringe for $10.00. The syringe was of the regular $1.50 variety and this places the value of the formula at $8.50. The following is the formula they sold:

Mix. Sig. Five to fifteen drops should be injected at each treatment. The patient must remain in bed at absolute rest for two days after each treatment.

Mix. Inject from five to ten drops at each operation.

Mix. Reduce from ten to fifty per cent. with alcohol, and inject four or five drops which can gradually be increased as the case requires.

Mix. Inject two to four minims.

This fluid is sold at $2.50 for a two-drachm vial. He publishes the following formula, which is so complicated that it would require further instructions to properly prepare it:

The above formula is a fair example of many of the so-called non-secret remedies (?) which are offered physicians with every intention to deceive them.

The following formula has been published as the exact formula of the fluid used by this company:

This company used both the hypodermic method of treatment and an external astringent. The injection fluid was the same as that proposed by Dr. Heaton. The external astringent, which was to be applied by the patient, was as follows: