The Secrets of Specialists/Chapter 15
The introduction of paraffin into the domain of surgery has added another term to the nomenclature of the science, under the name of "Neoplastic Surgery," which was, perhaps, to identify the use of paraffin for scientific purposes, and differentiate and mystify its purpose, from its more common use in candles and chewing gum.
Paraffin has quite an extensive field of surgical usefulness, and every physician should become familiar with the technique of manipulating this neutral substance.
Paraffin injections are used for two principal purposes: to make cosmetic improvements, and as a support for funetional derangements; therefore, we find its use indispensable in "saddle back" nose, and to fill out other hollow places, to add to the contour of organs and expressions; its supportive influence is used in hernia, insufficiency of vesicle and anal sphincters, prolapsus of the uterus, paralysis of the soft palate; it has also been used to prevent ankylosis, after resection and filling, in brain defects, and a variety of other conditions.
Paraffin was discovered by Reichenbach, in 1830, who derived its name from parum, too little affinis, or affined, because the product was not attacked in its cold state by concentrated sulphuric and nitric acids. The product may be obtained in large quantities from the dry distillation of peat, turf, coal, etc., rich in hydrogen. There are a large number of products which belong to the paraffin groups, many of which have been trade-marked under the names of vaselin, cosmolin, albolene, etc. These are all practically graduations of the same body in a different consistency. They are all absolutely non-irritants, and neutral as water, the alkalies and acids have no action upon them and therefore, when injected into living tissues, they have only slight, or perhaps, no reaction with the tissues of the body, and only act as a bland foreign substance. Therefore, it is particularly adapted for the special purpose it is used.
If we would study the different chemical products of the paraffin groups, from Hexadecane to Dimyricyl, we would find their melting points varying from 64 degrees F., in the former, to 215 degrees F. in the latter. Hard paraffin (paraffinum durum) has a melting point from 110 degrees F., up to 166 degrees F., and there is no possible way of identifying the melting point of any paraffin unless it is tested, and the only way to obtain the product at the melting point desired for any purpose, is to blend the hard paraffin with the liquid paraffin (paraffinum liquidum), frequently called liquid petroleum or albolene. By combining these two, we may obtain any degree of consistency we may desire. The melting point required for most operations upon the body will vary from 107 degrees F. to 115 degrees F., according to the resistance of the tissue, and several other conditions which may be presented.
It is, therefore, always well to have paraffin of several degrees of melting points on hand, for different operations.
I generally have paraffin prepared at two standard melting points: one at 107 degrees F., and one at 115 degrees F., and by mixing the two, in the right proportions, I can approximately determine the melting point I desire between the two. To obtain these two melting points, a small piece of hard paraffin is placed in a vessel of water containing a thermometer; this is very slowly heated and by watching the thermometer at the time we reach the melting point, we can determine the melting point of the hard paraffin, and by mixing this with the liquid paraffin we may obtain the exact melting point desired. This is rather a tedious process, and those who do not care to spend the time to prepare the paraffin, may obtain the preparation from surgical supply houses, but I have always deemed it a good policy to become familiar with the "tools of our profession," and prefer to make my own paraffin preparations.
The next important thing to be considered in paraffin operations, is a suitable syringe, with which to inject and place the paraffin. There have been several syringes devised for this purpose, but the one illustrated here, has given me the best service. Under no consideration attempt to use paraffine with the ordinary hypodermic syringe, where direct pressure upon the piston is required to force the paraffin through the needle, for such procedures are always followed by disappointment. Paraffin, in a semi-solid state, is a very treacherous substance to inject into subcutaneous tissues, as the needle will invariably become clogged with the solid paraffin before the contents of the barrel is used, and when sufficient pressure is applied to force the opening through the needle, it will take a sudden spurt, and the contents of the syringe will be placed in almost any part other than where it is desired; therefore, with the special syringe with a strong screw piston stem, we can force the paraffin into the tissues as slowly or rapidly as is desired, and always have the most accurate control of the distribution of the paraffin, and place it at exactly the points desired.
In ninety per cent of all paraffin operations the melting point of the paraffin has been from 110 to 115 degrees F. This, having been previously prepared, is now placed in a glass receptacle and boiled in a water bath for ten minutes; the syringe has also been sterilized by boiling, and the surface of the operation, and the hands of the operator, are prepared with the same care as for any other surgical procedure.
To fill the syringe, the cap is removed, and the barrel filled from a medicine dropper, by taking the paraffin from the center of the boiling solution. This avoids the scum and other floating particles, which are sure to be found upon the surface of boiling paraffin. After filling the barrel of the syringe, the cap is screwed on tightly, and the needle is pointed upwards, and sufficient pressure made upon the piston to force the paraffin through the needle. The paraffin is now encased in a hermetically sealed receptacle, and is ready for use at the present, or may be used several days afterwards, by simply placing the syringe in warm water, to partially melt the paraffin, so that it may be ejected through the needle.
I always prefer to use paraffin when it has cooled to a semi-solid state, as I have always found it more easy to manipulate and mould when placed within the subcutaneous tissues; it also avoids the danger of using the paraffin when too hot, and thus creating damage to the tissues, a mistake which has been made by many operators. "There is never a day so bright that it may not be marred by clouds of darkness," and this is true with the use of paraffin, which, if properly used, will give the most excellent results; but, if used injudiciously, will be the means of doing much damage.
It is, therefore, well to become familiar with some of the detrimental influences which may take place by the use of this preparation.
Injections of paraffin of too high temperature may create inflammation which would result in sloughing; likewise, sloughing may be induced from infection, or by creating tool much pressure upon a given part, and interfering with the blood supply by an over amount of the paraffin.
Wassermann reported a sad experience of necrosis, due to this cause, in a case of saddle back nose, which was only restored by skin grafting.
Deformities from over injections have frequently been reported, and it is always well to bear in mind that after the injection of paraffin there is more or less swelling and when the reaction subsides, it will leave the tissues somewhat thickened; this should always be allowed for, and just sufficient paraffin used to not quite fill the cavity or depression and the formation of the post-operative tissue allowed for. It is, therefore better to complete the operation with another injection than to dissect the paraffin away after it has been placed.
Embolus and Thrombosis are also conditions which may follow the injection of paraffin. While there have been quite a number of cases reported, the percentage is very low, considering the extensive use of this preparation, and in almost all cases, the cause was attributed to using the paraffin at a too low melting point.
When paraffin is injected into living tissue, the question naturally arises: in what way is this foreign substance treated, and what changes take place? There has been much controversy regarding this point. Gersury states: "A few hours after injection the conditions are entirely changed; a small celled infiltration sets in, and the paraffin, like any foreign body, is encapsulated, and new tissue fibers grow through the mass, so that a specimen, taken from the injected area, resembles an inflammed lipoma." Jakuff says: "The paraffin globules are grown through like a sponge, and are formed into a mesh-work."
Morton states: "New connective tissue and new blood vessels permeate the mass of paraffin. The fact is, these physicians were, no doubt, honest in their convictions, but erroneous in their conclusions, for when paraffin is injected into the tissues it is not left in one mass to be intersected later by any form of tissue, but the force of the syringe will cause the paraffin to follow the channels which offer the least resistance; in this way it is dispersed in such a manner that specimens examined some days later gives it the appearance as though the paraffin has been intersected by tissue, with an attempt to reorganize; but specimens removed a few minutes after being injected will have the same appearance, which proves conclusively, that the intersection takes place at once; therefore, we find the paraffin deposited in minute channels, and also globules, of greater and lesser size, where tissue has been ruptured in mass and allowed such deposits. Nature takes care of this, as it would any inert, foreign substance; but during the process of reorganizing, there is some inflammation, which, upon subsiding, will cause the tissues to hypertrophy (which should always be allowed for) and the greatest caution should always be exercised in injecting paraffin as stated above. It will follow the course which offers the least resistance, and in this way will often start in exactly the opposite direction in which you are aiming. It is for this reason, which will require in most instances, the services of a reliable assistant, to make pressure with his two hands upon surfaces you are trying to protect.
There will be much said regarding the use and technique of manipulating paraffin, in the following chapters, when the details will be more fully explained, but the foregoing are the fundamental principles upon which the therapeutics of paraffin are based, and by carefully observing them any physician will be able to use this valuable agent in surgical procedures, where it is indicated.