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1941

Injection treatment for hernia : its inefficacy

Burton B. Wilt
University of Nebraska Medical Center

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Wilt, Burton B., "Injection treatment for hernia : its inefficacy" (1941). MD Theses. 898.
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 THE INJECTION TREATlv1ENT FOR HERNIA:
ITS INEFFICACY

by
B. SINCLAIR WILT

Senior Thesis Presented to the Uollege of Medicine,

University of Nebraska, Omaha
1941
 UONTENTS

1. Hi story ................................... . 1.

2. The Anatomy of the Inguinal Region •••••••••• 10.

3. Etiology .............. ...................... . 16.
4. The Importance of Technic •• • • • • • • • • • • • • • • • • • 21.

5. The Role of the Solutiun ••••••••••• . . . .. . . . . 25.

6. Results of Experimental Studies •••• ......... 29.

7. Gomplications. . ...... . . . . .. .... . ... . . . . . . . .

, 34.
8. End-results .•• . .... ....... . . ... ....... . .. ... 38.
9. Present Status ••• ... . .. .. . . ..... .. . . ..... . .. 45.
10. conclP.sions ••• . . .. ........ ..... .......... .. . 49.
11. Bibliography •.•.•..•..••.•..•••••.•.......•• 51.
 1.

HISTORY

The injection treatment for hernia is not at all

new. Before the days of antiseptic surgery there was
a definite need of some such treatment, which would
eliminate the dangers of infection. Gauterization
f'or the nurpose of forming an eschar in the treatment
of hernia was used from the earliest times. Paulus
(34) has a nice description of the method of cauter-
ization used in his time. But still this did not
get away from the possiblity of infection.
Velpeau (43) was the first man to publish vmrk
on the injection treatment for hernia. 0auterization
and velpeau's method had the same end result in mind,
which was the formation of sufficient eschar formation
to prevent the hernia from reappearing. In most cases
at that time cauterization was not quite as radical
as done by the ancients.
Some surgeons laid bare the hernia and cauter-
ized the ring to a great denth; others just touched
the neck with a button cautry. A number of chemical
caustics were employed at the same time. Some of these
were sulphuric acid, muriate of antimony and· potash.
These were applied to the skin over the hernia, as well
as in the sac itselr or to the coats of the sac.
 2.

velpeau criticised direct application to the skin

on the grounds that if the inflarmnation extended to
the peritoneum it would cause the death of the patient.
However, he believed were the caustic applied to the
sac it would lessen the danger of peritonitis, and, as
a matter of fact, he believed this was the only chance
of a cure by this method.
Velpeau's own method was purely an injection
method. It is inferred by his writing that he was
the first to employ this mode of treatment, but that
he developed the idea from the results obtained from
the treatment of hydrocele. At that time wine was
used to inject hydroceles, but it was being demon-
strated that tincture of iodine was superior to this.
Therefore in 1835 Velpeau conceived the idea of using
iodine in the injection of inguinal hernias.
It wasn't until 183? that he had his first op-
portunity for employing his idea; this was after he
had employed it successfully in the treatment of hy-
drocele. In this instance he made an incision about
an inch long through the tissues of the scrotum to
the external surfa~ of the sac. He introduced a troc-
har into the sac and secured the opening of the sac on
the canula by means of forceps. One assistant com-
 3.

pressed the inguinal canal to prevent the solution

from running into the peritoneal cavity, while another
injected the solution. The solution was six "gros" of
tincture of iodine to three ounces of water. After
all points of the sac were covered with iodine the
solution was allowed to run out of the sac through the
canula. After the canula was removed the wound was
closed "by means of three points of twisted suture."
He makes no mention of after treatment or care,
but states that after three months there had been no
recurrence of the hernia.
From reading the work of Velpeau one comes to
the conclusion that although the anatomy was under-
stood and the nature of the defect known, none of this
was utilized in the treatment. The efficacy of all the
treatments depended on the forrnation of a cicatrix
which would plug the passage. This was even true in
the operative treatment. Velpeau stated:
The operation for hernia almost of necessity
produces a wound which will suppurate, and the
whole surface of which will become covered with
cellular granulations as high up as into the ring.
By this means a new tissue is formed which is the
base of the cicatrix, and which by its great
elasticity and the adhesions it contracts with
the surrounding tissues, is certainly calculated
to close up, by a firm consolidation, the tract
of the hernia.
 4.

At the same time in this country Pancoast was (33)

doing similar work, using a trocar rnd canula fitted
with a syringe, canable of holding a drachm of fluid.
His technic was to place the patient on his back,
press on the external ring with a finger to displace
the cord inwards and t1bring the pulpy end of the
finger on the snine of the pubis." The trocar was
then pushed into the area at the outside of the
finger until it came against the "horizontal portion
of the pubis 11 just to the inner side of the spine of
that bone. The trocar was then retracted slightly
and then turned upward, when the point was in the sac
it was then run into the inguinal canal and the sac
scarified freely. This was done to the inner surface
of the upper part of the sac as well as that just be-
low the internal ring. The trocar was then withdrawn
from the canula and half a drachm of either Lugol's
solution or tincture of cantharides injected into the
sac. vVhen the canula was removed the operation was
completed.
As after care a compress was pressed down over
the external ring and a truss slipped down over this.
The patient was kept in bed for ten days.
Pancoast stated he did thirteen of these opera-
 5.

tions, but could not state how permanent the cure was,
due to the inablity to follow up the cases afterward.
Pancoast didn't directly claim the origination
of this oethod., but he does state:
Very recently M. Velpeau has published a
process almost precisely the same as that just
described.
I believe he infers they were co-oilsinators of the
method, working independently of each other.
Marcy (28) quoting Warren states the credit of
the origination of the method belongs to Pancoast.
From reading the literature it would seem the credit
belongs to both of them.
In 1892 (24) the method of widest repute was that
of Dr. George Heaton, of Boston, who published his
work in 1843. He used the fluid extract of oak-bark.
His first work was done in 1832, although he wasn't
successful until several years later in getting cures.
This was before Velpeau's first work, but since the
work wasn't published until 1843, six years after
Velpeau did his first wor~, there could be no claim
for his having originated the method. However,
Heaton was the first one to use the true hypodermic
injection v1i thout any preliminary incision.
His operation created much discussion in Boston,
 6.

and was generally adversely criticised, a.nd his methods

were claimed by some to be unprofessional. There was
no doubt of his enthusiasm. He had good results, but
not always an entire cure.
Dr. Joseph H. Warren (44) was the most famous of
Heaton's followers. He modified and improve~ the
needles and syringe used by Heaton, and also the med-
ication. Warren modified the operation by not inject-
ing into the sac; he injected into the rings and
around the sac.
Warren, in his writing, gives a clear insight
into the reason for the enthusiasm over the injection
method. The surgical treatments at that time were
severeand "likely to be attended with a great danger
of life, if not absolute loss of it." This was in
1880.

Warren, as the others at that time, used just one

injection. The patients were treated as bed patients
and had to wear trusses and limit their activities.
He felt if the natient went for a year without return
of the hernia, it could be considered as a nermanent
cure. This belief is not justified at the present
time as will be brought out later in the paner.
The status of the injection treatment in the
 ?.

1890' s may be determined from the statement of 1>,arcy:

--the danger in competent hands is slight,
but the results are certainly not as satisfac-
tory as the profesion was led to expect.
Llanley ( 25) , in 1893 was the next author to pub-
lish work on the injection treatment for hernia. He
showed great enthusiasm and emphasized the proper
selection of' cases~~this type of therapy. He favored
operation in many of the individuals whom he saw.
In 1925 McDonald (38) reported on twenty-five
years experience with this method. He recommended
this 1'orm of therapy for hernia. He emphasized the
fact that antagonism and indifference had contributed
greatly to hinder the progress of this method. He
reported that 90 per cent of all hernias which came
to him could be treated by this method.
In 192'7 Ignatz Mayer (29) claimed twenty-eight
years or experience with the injection treatment for
hernia, using a complicated formula for the fluid.
Rice (38) states that the credit of modernizing this
mode of therapy should go to foayer. i.J.ayer claimed
98 per cent of his cases had permanent relief. At the
same tin1e he attacks the other men's percentages by
saying a Doctor never sees his own failures because
they go to other Doctors. It would be interesting to
 8.

know in what way he was different from the other men

that his statistics should be acceptable. However,
he finished his article by stating that the subcutan-
eous method is not a cureall, and just selected cases
could be used.
Hall (19) of New York was apparently the first to
approach the injection method in a truly scientific
manner. His work seems to have set off a flurry of
research. He stated there were two serious objections
to the old methods of injection treatment. Yirst the
solutions employed were decidedly irritating, painful
and had to be used over a period of months. Second it
was necessary to wear a truss during treatment and for
a long time afterward, which was not done in the old
methods.
He went caref'ully over the work of Pina Mestre,
a Spanish physician. He states that Mestre's solu-
tion was 1'ree rrom the above objections. Its active
principles were alcohol and tannic acid.
Then we find for the first time the publication
of histological work done to determine the actual
tissue reaction to the injection fluid. He definitely
showed that fibrous tissues were formed, but as we
shall see later he did not carry on this work long
 9.

enough.
Between 192.? and 1929 Hall treated thirty-three
patients with hernia and only one had recurred at the
time his work was published. Since this was done in
1929 he cannot claim permanent cures for the others,

nor have we any way of telling what the subsequent

course of these has been.
Wolfe {49) in 1931 worked out variations in the
constituents of the solution "hernial" by injecting
rats. Be worked out a solution considered satisfac-
tory, which was manufactured by the Fitch Company of
New York. He described the histological response as
a seroplastic exudation followed by the formation of
adhesions resulting in a connective tissue barrier
blocking the inguinal canal.
During the decade of 1930 to 1940 the literature
has been flooded with articles dealing with the in-
jection treat!!l.ent for hernia. ·rhese have all more
or less contributed to the history of this type of
treatment, but most of these will be covered in the
following chapters of this work.
 10.

THE .ANATOMY OF THE INGUINAL REGION

Ji'rom the forgoing history it should be apparent

that the early men who used the injection method of
therapy for hernia thought of the anatomy of the re-
gion only from the standpoint of what structures to
avoid. If there is a rationale for any surgical or
operative procedure it should be based on the exist-
ing anatomical conditions; each case should be in-
dividualized. This has become increasingly apparent
in the injection method of treatment for hernia.
f;;1ore and more men are expressing the necessity for
selection of cases for this method.
Watson (45) states:
A thorough knowledge of the anatomy of the
inguinal region is necessary in order to recog-
nise the variations from the nornal and to select
the hernia operation which will give the best
chance of permanent cure in each individual pa-
tient.
Since this is a discussion of the efficacy and
not the treatment per se, there would be little ad-
vantage in detailing the anatomy of the inguinal re-
gion. Therefore I shall just stress the important
structures as they would be concerned in the injec-
tion of this region.
The varieties of inguinal hernia are the indirect
 11.

and direct with an intermediate form, spoken of as

the saddle-bag type. The indirect is so nemed due to
the fact it passes through the internal inguinal ring,
down the inguinal canal and out the external ring.
'i'he direct, so named, since it takes the most direct
route through the abdominal wall structures. It
passes through the lower fifth of the inguinal canal.
'l'he internal ring is situated midway between
the anterior superior spine of the ilium and the pu-
bic tubercle. It lies i cm. above Poupart's liga-
ment. It lies immediately lateral to the inferior
epigastric artery. This structure is not actually a
ring, but it marks the site at which the spermatic
cord passes through the transversalis fascia as it
makes its exit from the abdominal cavity and the point
at which the hernial sac of the indirect hernia leaves
the peritoneal cavity.
The inguinal canal is not a canal in the usual
sense, but a chink or flatsided passage in the thick-
ness of the abdominal wall. In early life there is
no canal; one ring lies directly behind the other, so
as to facilitate the easy passage of the testis. In
the adult the canal measures approximately 4 cm. in
length. Its direction from the internal to the ex-
 12.

ternal ring is dO"wnward, forward and medial.

The anterior surface of the canal is formed by
the fascia of the external oblique muscle. Poster-
iorly it is bounded by the transversalis fascia. The
suDerior surface is formed by the arching fibers of
the internal oblique muscle, and the inf'erior surface
is occupied by Poupart's ligament. The canal con-
tains the spermatic cord in the male and the round
ligament in the female.
The external ring is formed by the splitting of'
the fascia of the external oblique muscle into two
pillars. •rhe external fibers unite with Poupart' s
ligament, pass lateral to the cord, then beneath it
and insert into the spine of the pubis. The spermatic
cord in the male and the round ligament in the female
pass through this ring, after which they enter the
scrotum and the labia majora respectively.
The inferior epigastric artery crosses Poupart's
ligament perpendicularly, posterior to the inguinal
canal at its lateral extremity, at the midpoint of
Poupart's ligament. It lies at the medial border of
the internal inguinal ring and passes between the
planes of the transversalis fascia anteriorly, and the
peritoneum posteriorly. It forms the lateral boundry
 13.

of Hesselbach's triangle. This vessel may be displaced

by a distended ring or may be anomalous.
Hesselbach's triangle is bounded inferiorly by
Poupart's ligament, laterally by the inferior epigas-
tric artery and medially by the lateral border of the
abdominal rectus muscle. This triangle is essentially
bisected from its lateral apex to its medial border by
the arching conjoined tendon. The upper part of the
triangle is supported by all three muscle layers of
the abdomen, and this portion is therefore rarely a
factor in the development of hernia. Direct inguinal
hernias pass through the lower portion, where protec-
tion is served only by the weak transversalis fascia.
The conjoined tendon of the internal oblique and
transversalis is usually triangular in shape with its
base inserted into the crest of the pubis and the pec-
tineal line. It is situated immediately behind the
inguinal canal and the external ring. In the direct
inguinal hernia the tendon may form one of the cover-
ings of the sac.
It is generally believed that all indirect in-
guinal hernias are due to a preformed sac, which con-
sists of an unobliterated portion of the processus
vaginalis. The indirect hernia leaves the abdomen
 14.

through the internal ring, and is divided into three

varieties, according to the degree of descent of the
sac. They are incomplete, com~lete and scrotal.
In the incomplete (bubonocele) the sac remains
in the inguinal canal, in the complete the hernial sac
emerges from the inguinal canal at the external ring,
and in the scrotal the hernia passes down into the
scrotum..
Indirect hernias are also classified into con-
genital, infantile, and funicular varities, according
to the degree of patency of the processus vaginalis,
but since this distinction has no direct bearing on the
discussion, description of these will be omitted.
The direct inguinal hernia takes the most direct
route through the abdominal wall, passing through the
lower fifth of the inguinal canal. It is also called
the internal inguinal hernia and the straight inguinal
hernia. The direct hernia can only develop through
the lower part of Hesselbach's triangle. As a direct
hernia passes out of the external ring it encounters
the external spermatic fascia. This fascia is close-
ly attached to the cord and does not readily allow
dissection between it and the cord. For that reason
the direct hernia seldom descends into the scrotum.
 15.

The saddle-bag type of hernia is just a combina-

tion of the indirect and direct hernias, and may be
present in varying degrees.
 16.

ETIOLOGY

At the present time the saccular theory of for-

mation of hernia is generally the accepted one. This
was propounded by Russell (39), by which he explains
the etiology of hernia on the basis that the process-
us vaginalis fails to become normally obliterated,
wholly or in part. The numerous anatomical varieties
of indirect inguinal hernia are explained as divertic-
ular offshoots from the nrocessus vaginalis, which
occur during the descent of this structure during em-
bryonal lire. The properitoneal, interstitial and sub-
cutaneous hernias are varieties of this anomaly. This
then puts indirect hernias in the congenital class ex-
elusively.
Russell has described three groups of indirect
hernia:
A. The processus vaginalis being norraal in
shape resulting in two varieties of hernia: to-
tal hernia in which the processus vaginalis is
open throughout its entire length, and the nar-
tial hernia in which the processus vaginalis has
closed throughout only a portion of its lower
limit
B. The processus vaginalis having been dis-
torted in its funicular portion with lateral sac-
culations so as to result in properitoneal, in-
termuscular, and superficial inguinal hernia
c. The processus vaginalis having been dis-
 l?.

torted by implication of its testicular partion

in the abdominal wall with the result of a hernia
magma, encysted, or infantile hernia or a hydro-
cele.
In addition to this factor Watson (45) lists the
anatomic cause for indirect hernia. He sum.~arizes

them as follows:
(a) The descent of the testis which carries
with it a process of neritoneum, transversalis
fascia, and cremasteric muscle; (b) the weak spot
at the internal ring, which makes it um.able to re-
sist sudden increase in intraabdominRl pressure
caused by straining, coughing, whooping cough,
pregnancy, tight lacing, obesity, ascites and tu-
mors; (c) the hernia cannot break through outside
the internal ring because of the well developed
iliac and transversalis fascia; (d) the fact that
there is usually a weak point near the inner side
of the internal ring that is unnrotected by muscle
or tendon; {e) the existence of an unobliterated
processus vaginalis or a preformed sac.
It does not necessarily mean that because there
is an existing processus vaginalis, that a person will
develop an indirect inguinal hernia, but it is neces-
sary for the processus vaginalis to be nresent for
the formation of the hernia. In other words these
conditions listed by Watson must all be nresent to
some degree to allow the formation of the hernia.
Watson goes on to list the secondary factors in-
volved in the formation of indirect inguinal hernia.
One of these I consider exceedingly pertinent. Dur-
ing the first world war many of the recently called
 18.

men develoned hernias and this was early in their

training period. ~hese men were pulled from seden-
tary occupations and thrown into streneous unaccus-
tomed exercise. Watson states that added resistance
that comes from such training made later anpearance
of hernia infrequent.
Possibly those who were going to develop hernias
developed them early. The way to prove his statement
would be to take two groups of men; throw one group
into the streneous exercise immediately as done in
World War one and the other group gradually built up
to the streneous exercise over an extended period of
time. It would be interesting to note which group
had the higher incedence of hernia, or if they were
the Sfu~e would those in group one show up at once,
and those in group two come on over an extended period
. Of time.
Moorhead {31) stated that a single act of vio-
lence could not cause a hernia unless the overlying
tissues had been damaged, or unless the violence pro-
duced such severe intra-abdominal pressure that im-
mediate onset of symptoms would result. Repeated
acts of violence, however, can produce a hernia.
Rice ( 38) quoting '1'aylor states 16 per cent of
 19.

individuals presenting hernia on one side, subse-

quently develop a hernia on the other side. This
would lend weight to Watson's statement that heredi-
ty is a predisposing cause.
In conclusion then, we may say that the presence
of the preformed sac, no doubt, explains the underly-
ing etiologic factor of all indirect inguinal hernias.
Just as the etiology of indirect hernia is the
open processus vaginalis, so a poorly developed in-
guinal musculature is the etiologic factor in a direct
inguinal hernia. As a rule the entire region is in-
volved with all of the structures being effected in
some degree. Any variety of abnormalities may occur.
There may be an open funicular peritoneum with Derfect-
ly closed processus vaginalis, or we may find any com-
bination of abnormalities. Watson states that many
writers consider the direct inguinal hernia as a vari-
ety of hernia in the linea semilunaris, since the
weak spot in Hesselbach's triangle is the lowest nart
of the linea semilunaris.
·fvatson sites one case ·where he operated on an
indirect hernia by the Bassini method, only to bave
the patient return a year later with a direct hernia.
Bisgard (5) states that because of the frequency of
 20.

this occurence he always incorporates the strengthen-

ing of this area when he operates on indirect inguin-
al hernias.
Another fe.ctor in the development of direct her-
nias is the physiological atrophy of all tissues oc-
curing with increasing age. The tissues tend to lose
their ability to retain the contents of the abdomen.
The inguinal regions being the weakest points, this
weakness of tissues is first aDparent here. There is
usually a gradual bulging, which is first unnoticeable
and then discomfort finally brings it to the attention
of the individual. Then as the factors leading to in-
creased abdominal pressure, such as, hypertrophic
prostate with obstruction, constipation, coughing,
heavy lifting, etc., the hernia tends to become much
larger. It is possible to show the increase in the
aged can be traced and explained in this manner.
 21.

TIIB IMPORT.ANCE OF TECHNIC

This chanter is for the discussion of the role

of technic, rather than the actual technic of the
injection treatment. Technic is one of the linpor-
tant items in this treatment. Biegeleisen and
Tartakow (4) point out that a review of the litera-
ture shows a lack of interest in detailed standard-
ized technic. 'l'hey go so far as to state that those
authors who mention technic do so in a general way,
and favor angles of injection which they, Biegeleisen
and Tartakow consider essentially unsafe.
They state the aim is the adhesion between im-
portant structures as the result of fibrous tissue
grmvth, and not just the formation of a mass of fi-
brous tissue, which in itself will not prevent the
recurrence of the hernia. "It is, therefore, im-
portant to place the needle point in the proper fas-
c ial plane by a definite orderly and systematic plan.
at the completion of the case a line of adhesions
will be formed in much the same manner as after a
thorough surgical operation."
This is all very well v:here the layers are all
~resent and intact, but here we must keep in mind
 22.

the anatomy of the region and the etiology of hernias.

From this one perceives the necessity for selecting
the cases for injection, and it would seem that only
small indirect hernias could be successfully treated.
This will be borne out later in this paper.
Biegelseisen and Tartakow go on further to state
that before attempting to use the injection treatment
for hernia one should be thoroughly familiar with the
detailed anatomy of this region. This can only be
done by repeated cadaver injection and dissection.
When one considers the anatomy, it is realized that
important structures are only fractions of centimeters
from the needle point. They state that none of these
dangers were taken into consideration by any of the
previously published technics. The technic Biegeleisen
and Tartakow have worked out does, thus lessening the
dangers of complication from the injection treatment.
They bring out a further uoint in the treatment
that is interesting. As was pointed out in the first
chapter the original operation consisted of injecting
iodine directly into the sac. This was later drouped
in favor of injecting around the sac and into the ad-
jacent tissues. Now these men in their article state
it is necessary, not only to deposit irritating sol-
 23.

utions in the canal itself, but outside it. They make

no mention of injecting in the sac itself, but they
could not very well inject into the canal with out go-
ing into the sac a large nercentage of the time.
This swinging back and forth from one technic to the
other would lead one to believe none were too success-
ful.
Originally one injection was made, but it was
later found that numerous injections were necessary.
At present all of the authors agree on this point.
Biegeleisen and Tartakow state that the average num-
ber of injections with their method is fifteen, but
that this varies in the individual cases. Rice ad-
vocates eight to ten injections, 2nd then for the
natient to be seen at four, twelve, and twenty-eight
weeks and then each six months until assured there is
no recurrence. If an impulse is elicited at the end
of any of these periods, it is an indication for fur-
ther injections.
Dobson (14) lists sixteen injections as their
average, and states that many of their patients were
given two or even three courses of injections with a
month or six weeks between courses.
Then we come to the truss. All of the authors
 24.

agree a truss should be worn, but they don't agree

on the length of time. The time varies from wearing
the truss until after five or six injections have
been made to ten months after the injections are com-
pleted. Dobson states that in their successfully
treated cases the patient was allowed to remove the
truss at night arter one month from the time of the
last injection and that the successfully treated cases
wore their trusses for an everage of ten months.
 25.

THE ROLE OF THE SOLUTION

This chapter will discuss the trend of solutions

and their efficacy from the beginning. Velpeau•s or-
iginal solution was a diluted solution of tincture of
iodine, which was much too irritating and would cause
necrosis. Rice describes the ideal solution as one
which would ~reduce no pain from its injection, pro-
duce no systemic reaction, be relatively nondestruc-
tive to tissues, be non-toxic if injected inadvertent-
ly into the blood stream, and should not be irritating
enough to cause peritonitis if similarly injected into
the peritoneal cavity. It should induce growth of
fibrous tissue with a minimum of the exudative type
of reaction. The solution should be mildly irritating;
should not produce necrosis of the tissues and it
should produce the minimal amount of polymorphonuclear
infiltration.
Iodine does not rit in this classification at all.
Pancoast used Lugol's solution and tincture of canth-
arides, but this did not get a following. Heaton used
quercus albus, but this also proved too irritating.
Schwalbe used 70 per cent alcohol, but this is far
from meeting the requirements.
Then came Pina Mestre and his work; his solution
 26.

was much more satisfactory and has been used exten-

sively. He claims 98 per cent cures, but it is dif-
ficult to accept this in the face of the work done by
others.
l'ilayer used a solution of zinc sulfate, -nhenol
end alcohol. His solution has had some acceptance.
In the l930's there were a great number of solutions
on the market. The formulas of many of these were
kept secret and it was difficult to determine the
nature of their ingredients. Many of these, it is
certain, contained alcohol and various acids, the
most common of which was tannic acid.
The three solutions used by Dobson in his work
were phenol-thuja (25 per cent phenol, 25 per cent
SDecific tincture of thuja and 50 per cent alcohol),
proliferol (Ulmer){tannic acid, alcohol, four botanic-
al tinctures, thymol and benzyl alcohol), and sodium
psylliate {Searle) (a mild soap of a fatty acid).
The reaction of the tissues to these solutions was
esse:ntially the same, except for more necrosis, which
was noted in the phenol preparation.
Rice believes it is nreferable to use a solution
which requires no preliminary anesthesia. An anes-

thetic would mask or would disguise important signs

 2?.

and symptoms which help in the avoidence of erroneous

injections. Where the injection is being made too
close to the cord or peritonetnn. the elicitation of
pain as the needle point encroaches upon these struc-
tures leads to a change of course of the needle.
With anesthesia this is impossible.
Biegeleisen (3) summarizes his article on sol-
utions by stating that poor solutions are responsible
for most of the complications following the injection
for "reducible" hernia. From reviewing the litera-
ture this statement seems a little too positive for
the present era, but there is no doubt this was true
to a certain extent when work first started on this
method.
Wernicke (46) states that the ideal solution has
not yet been developed, and that if the same progres-
sive scar tissue could be produced in the inguinal
region that is produced in the lungs of silicosis
cases, the success of the injection treatment of "se-
lected" hernias could probably be assured. He fur-
ther states an attempt is being made to produce such
a solution with the various silica preparations.
That was in 1939, but so far nothing more has
been mentioned in the literature concerning such a
 28.

solution. Therefore the situation now stands at this

point; there still is no truly satisfactory solution
available for the injection treatment of hernia.
 29.

RESULTS OF EXPERIMENTAL STUDIES

There is no argument 81Ilong the various men who

have done work with the injection treatment over the
formation of scar tissue. All of the work has been
about the same, and results comparable, but most of
the work has only been carried as far as three months.
Rice (3?) in 1935 did work which covered a uer-
iod of forty-two days. They had an ingenious method
for obtaining their material for microscopic sections.
They had patients who were not sure as to whether they
wanted injection or operation, these were gotten to
try an injection, if they didn't like it they could
have an oneration. Likewise they saw patients, who
after one or more injections, wanted operations. It
was arranged so these people could be admitted to the
hospital at intervals so sections could be obtained
at intervals from fifteen hours to forty-two days
after the injection of the irritating solution.
Rice states that no difficulties were encounter-
ed in the operations as a result of the previous in-
jections, and this has been confirmed by some of the
other authors. One case where ten injections had
been nade without a cure the scar tissue was similar
to that encountered at a second hernia operation.
 30.

His results from the histological sections were

as follows:
At the end of fifteen hours the section
showed an exudative reaction with polymoruho-
nuclear cells and round cells. There was also
some proliferation of the fixed connective tissue
cells and some evidence of cellular necrosis.
On the fifth day fibroblasts were seen with
large dark staining nuclei. Polymorphonuclear
cells were still present.
On the eighth day the fibroblasts were more
abundant and likewise appeared more mature. The
intercellular fibers were beginning to make their
appearance. Newly formed blood vessels were
seen. An occasional polyblast was found.
On the fourteenth day the fibrous tissue
was found to lie in dense bundles. Fibroblasts
seemed to have assumed more adult uro~ortions.
Their nuclei were smaller and the fibers more
abundant. No poly;norphonuclear cells could be
found.
On the eighteenth day most of the fibrous
tissue apneared to be mature.
At the end of the forty-second day the
tissue was dense and looked like adult fibrous
tissue. The fibroblast nuclei were small and
the fibers were abundant.
Two years later Fowler (16) in his article states
that a slow progressive resorption of repair tissue
had long been susnected, and suggests that studies
should be made along this line in hernial repair
tissues.
This is what Dobson did. His work confirmed the
 31.

work of Rice, but he did not stop there. He went on

and made sections up to ten months. At ten months
his sections showed, in place of the diffuse sheets
of fibrous tissue interlacing between muscle bundles,
as was seen in the first four months, that the fi-
brous tissue generally appeared as small irregular
scattered islands of compact adult fibrous tissue.
This work shows that the fibrous bands contract-
ed from each other and from adjoining muscle bundles
and fat. Ulinical reports of hernias breaking down
arter two or more years would lead us to believe that
resorption continues to take place over a ueriod of
years.
Jimenez (23) states that his solution is "liqui-
fied synthetic tendon" and claims that injection be-
comes organized as part of the living tissue and serves
as a base for the formation of a great amount of new
connective tissue. Then he gives his patients intra-
muscular injections of calcium which "gives the tissue
formed by the protein a stony hardness." He implies
that the area becomes calcified, but he has no exper-
imental work to show what really takes place.
Dobson did further work to show the reactions
within the important structures involved in the re-
 33.

compressed, it was not obliterated except in one in-

stance. The significance of this is realized when
the fate or the hernial sac is speculated on.
Most of the authors state that the sac is com-
pressed or obliterated, not being sure which takes
place. Rice, after operating on two previously in-
jected cases for appendicitis and examining the in-
ternal rings, states that he believes the sacs are
obliterated. The work of Dobson, however, seems to
discredit this belief.
Out of the four dogs injected, only one had an
obliterated processus vaginalis. From this we may
infer that in the majority of cases the hernial sac
is just compressed, rather than obliterated.
The explanation of the high recurrence rate re-
ported by most of the authors can be made on this
basis. As the connective tissue formed by the injec-
tions is absorbed, the pressure, which has been com-
pressing the sac, is gradually released. Thus allow-
ing the hernia to descend once more.
 34.

UOMPLIUATIONS

Every author lists complications in this method

of treatment. Harris and White (20) give a list of
complications which includes: excoriation of the skin
under the truss prior to the injections, swelling of
the cord, transient swelling of the penis, scrotum or
inguino-abdominal region, hydrocele of the cord, swell-
ing of the epididymis, fat nodules from superficial
injection, intra peritoneal injections, needle in the
vein, abscess, peritonitis, atrophy of the testicle,
impotence and death. They had none of the last five
of these complications in their series of cases, but
other authors have reported having had these among
their cases.
Harris and White found transient swelling of the
penis, scrotum, or inguino-abdominal region in 90.2
per cent of their cases. 'l'his alone in an ambulant
method of treatment, which extends over a period of
several months, would discourage a great many people
from going on with the treatment.
Fowler (16) does not believe impotence is really
a factor, being more of a psychological complication,
since it has been seen in cases where only unilateral
injections were ~ade.
 35.

Rice states that local abscesses have formed in

two of their cases. These were directly attributed
to errors in technic.
Rice also states they had six cases of chemical
peritonitis after the injection of tannic acid-alco-
hol solutions. This was due to intraperitoneal in-
jection. This condition he states will clear up spon-
taneously if there has been no damage to the bowel.
He reports one case of gangrene of the bowel. It was
thought the injection was made too near the mesenteric
vessels of the ileum. The mesentery must have been
lodged within the hernial sac. He reports the patient
recovered after resection and anastomosis of the af-
fected gut.
Hydrocele complicated the treatment in 1.5 per
cent of the cases treated by Rice; this has been borne
out by the other authors.
While Harris and White stated they had no deaths
in their series, others have not been so fortunate.
Berne (2) has reported on two deaths. He submitted
these cases to refute the impression created by most
of the writers. He states that many individuals are
treating hernias by injection ·who ordinarily treat
few hernias, inferring that this would lead to more
 36.

and worse complications. He goes further to state

that the factors surrounding cases of this type are
such as to lessen the chances of their deaths being
reported, consequently he feels this suggests a
higher incidence of this complication than the liter-
ature would indicate.
Rice, reporting on systemic reactions, makes the
statement that occasionally, after the injection of
tannic acid-alcohol solutions, the patient develops a
systemic reaction manifested by rhinitis, generalized
muscle aches and soreness. He reports there is no
doubt it is due to these solutions. Sodium psylliate
less often will produce a systemic reaction consist-
ing of muscle aches and a sensation of feverishness,
but these reactions are remarkedly infrequent and
never disabling.
Where inadvertently the tannic acid-alcohol sol-
ution has been injected into a vein a shock-like re-
action may result, but when sodium psylliate solution
is injected no systemic reaction results, other than
the taste of soap in the mouth and a tingling sensa-
tion throughout the body.
On e:xperimental animals where the solutions were
injected into the veins the animals staggered around
 3?.

for about ten minutes and then appeared to be perfect-

ly normal.
Slater (40) writing on the inadequacy of the in-
jection form of treatment reports that they had few
complications. Two patients were in shock for sever-
al hours after treatment, requiring morphine and emer-
gency ward care. Five had painful cords, lasting
three to five weeks. Nearly every patient had some
local pain; in two cases the patients could not re
sume work for several days. Two patients had to have
emergency treatment for strangulated hernia. Here we
find he disagrees with Rice. Rice stated that no dif-
ficulties were encountered on operating on cases after
injections had been given, but Slater found repair was
more difficult because of the fibrosis and inflamma-
tory reaction. This seems the more logical finding.
Manoil (26) reports his complications were com-
paritively few during the last eighteen months of his
study, due to improvement of his technic. This alone
should make one realize this form of treatment is one
which cannot be done as simply and without consider-
able knowledge as can be done in the injection treat-
ment of varicose veins.
 38.

END-RESULTS

At this point we reach the greatest divergence

of opinion on the whole subject of the injection
treatment for hernia. Fowler may have had the answer
to this when he stated:
Significant studies of end-results, however,
take years of the most careful and thorough fol-
low-up of a multitude of cases. Unlike surgery,
the injection treatment is not essentially nor
primarily a hospital procedure. But the office
practitioner usually lacks the follow-up facil-
ities and organization, for which reason rela-
tively little has been done in this particular
study.
This leads us back to Mayer, who claimed 98 per
cent cures over a period of twenty-eight years of ex-
perience with over two thousand cases. As was stated
earlier he attacks the surgeons on the grounds that
when they have failures their patients go elsewhere,
so they don't learn of their failures. He offers no
proof or details to establish the reliability of his
figure.
Fowler says the German workers, with better au-
thenticated data, claim an end success of 94 per cent
in several thousand cases over a o'
neriod~forty years.
This was even with a "very ineffective injectant."
It is difficult to credit these results in the face
of the latest reports of this method of treatment.
 39.

All of the early reports were enthusiastic, and

all claimed high percentages of cures. .Most of these
were reports of cases, which had been finished with
their treatments less than two years. As time has
gone on reports have become less enthusiastic, and re-
sults have been less encouraging. Bratrud (6) renort-
ed ?O? cases, 2nd only nine in which final closure
could not be obtained. He expected a considerable
recurrence rate, however, due to the fact a substan-
tial part of his series was composed of large sized
hernias, with many contraindications for surgery.
This also made the injection treatment difficult.
McKinney following up these cases, found 83 per
cent cured after six months to three and a half years.
The preponderance of recurrences was among older pa-
tients, end among those with the fewest average num-
ber of treatments. At that time it was considered
that age and insufficient treatment were the major
factors in causing failure. In the light of later
reports, it may be regarded that these were just the
first to break down, since there was not as much con-
nective tissue to be absorbed.
Fowler claimed experience with some 800 cases,
over a neriod of nearly seven years. He did not give
 40.

his percentage of cures, but he states he is convinced

that Bratrud's irmnediate results are generally to be
maintained in the end-results by the persistent fol-
low-up reenforcement in the more difficult cases.
This would mean most of these patients would have to
come back for treatment about every six months, and
then take treatments over a period of several weeks.
Then to turn to the other side, we find ~oley (9)
reporting on the results obtained at Rupture and Crip-
pled in New York, stated:
First results seemed satisfactory, but by
the end 01' six months there were so many recur-
rences that the method was definitely abandoned.
Slater gives a clear picture of this method and
possibly indirectly the public reaction to this meth-
od. He started treatment on approximately fifty
patients, but only twenty continued through a full
course. The others were forced to stop treatment for
several reasons. .Among these were pain on injection,
annoyance of weRring a . . ~russ continously day and
night, and occasional untoward reactions. The full
course of treatment for the remaining twenty consisted
of an average of twenty injections a week or more apart
depending on the oase.
In the cases of the twenty who finished, ten were
 41.

direct hernias and ten were indirect. The patients'

ages varied from twenty-eight to seventy-five years.
The solutions used were: Mayer's in eleven cases,
Sylasol in five cases, and Tropli suspension in four.
All of the natients were discharged as cured at one
to two years after treatment was started. The follow-
up observation began two years after the first injec-
tion in all cases. The results were as follows:

Follow-up ueriod Hernia present Absent

2 yrs. and 3 mo.
2 yrs. and 6 mo.
.............
. . . . . . . .... .. 4
0 20
16
2
3
yrs. and 9 mo.
yrs. ....................................... 1286 14
12
3 yrs. and 3 mo.
............. 17
8
3 yrs. and 6 mo.
4 yrs. ............. 18 3
2

Slater sunnnarized his report:

Twenty patients with hernias v:ere treated
by the injection method and carefully followed.
At the end of four years two patients were cured.
We believe that the injection treatment of
hernias is not satisfactory and should be used
only when the yiatient must not be operated on,
and then only after the method of treatment and
its potentialities for cure have been fully ex-
plained to the pe tient.

Mancil is one of the last authors to still hang

on to this method, although he does advocate its use
only in old peonle whose ages prohibit operation, and
 42.

only where the hernia is reducible. The first part of

this statement is against what most of the men believe.
ttis results showed a total of 19.6 per cent of fail-
ures. In spite of this, and the fact that as the age
increased the incidence of cure lessened, he stated:

The injection treatment is the method of

choice for older patients provided the hernia
is reducible and can be comfortably maintained
with a truss. It should be the alternative meth-
od of treatment for younger patients who refuse
operation.

Dobson's work has been one of the last published

and the picture his work paints is anything but favor-
able for the injection treatment. They treated 101
hernias in ?4 patients between September 1935 and June
1938. All patients were first offered operetion, but
this was refused. At'ter one and one-half years it was
found the recurrence rate was so high for direct and
postoperative recurrent hernias that therafter they
only accepted indirect inguinal hernias for injection.
The technic of treatment and the solutions used
were essentially the same as those used by the other
authors. Dobson's exceptionally low percentage of
complications indicates a definite familiarity with
the work. Only patients who had been without their
 43.

trusses for six months or more after the last injec-

tion were considered in this estimate of the end-re-
sults. Follow-un studies for from six months to two
and one-half years irmre obtained on 53 indirect in-
guinal hernias, 19 direct and 6 postoperative recur-
rent inguinal hernias. Recurrences were noted in
3?.73 per cent of the indirect, 68.42 per cent of the
direct and 100 per cent in the postoperative hernias.
Interesting here is the fact that all of the post-
operative recurrent hernias had direct defects.
Dobson also found the results of the first six
months of the injection treatment very promising.
He stated that it seemed as if they were curing all
of the hernias, and the patients seemed well satisfied.
His description will give a good idea of what a pa-
tient goes through when he is being treated by this
method:

In the indirect inguinal hernias after four

or five injections the tissues behind and above
the external ring were firm and the external ring
seemed tighter. The patients usually commented
at that time that they were no longer aware of a
hernia; they no longer felt the impact of the sac
against the truss pad when they coughed or strain-
ed. After twelve to fifteen injections the en-
tire region about the inguinal canal was firm and
the abdominal wall in that area was almost as
firm as sole leather. The outline of the extern-
al ring could be palpated, but the finger could
 44.

not be introduced into the canal. On introduc-

ing the needle for the injections, it was passed
with difficulty through the layer of fibrous tis-
sue ·which was 1 cm. or more in thickness. Usu-
ally the patient was then given a rest period of
one month or six weeks during which time he wore
the truss day and night. At the end of the rest
period it was noted that the external ring had
loosened up and much of the firm mass in and a-
bout the inguinal canal had disappeared. The
patient was then given six to ei0ht morcinjec-
tions. Following these injections, the external
ring again became tight and the firm mass was
again present in the inguinal canal. The patient
continued to wear his truss day and night for an-
other month and was then allowed to leave it off
while in bed and while bathing. If any definite
weakness was noted at that stage, many of the
patients were given a third course of injections
in the hopes of finally closing a smell defect.
The patient by that time had been wearing his
truss eight to twelve months, had made thirty to
forty office visits, and had received twenty to
thirty injections. Most of the direct inguinal
hernias recurred within three to four months
af'ter the last injection. All of the cases show-
ed signs of disappearance of the scar tissue
within two to three months following the last in-
jection.

This gives an idea of what can be expected of

the injection treatment in the hands of competent men,
who have spent years on developing technic. One should
speculate on what the results and complications would
be were this method employed by the general practitioner,
who does relatively little hernia repairing. One
should also realize the results obtained by most of
these men ·were on carefully selected cases.
 45.

PRESENT STATUS

One should, after reading the preceding chapter,

have a fairly good idea as to the present status of
the injection treatment for hernia, but in the light
of the report by the Council on Pharmacy and Chem-
istry (11) o:f the American Medical Association I feel
its :findings should be included in this work.
In September 1936 the council published a report
based on questionnaires which were sent to a selected
list of hospitals throughout the country. The essence
of the report resulting from this was that although
there were cases in which this treatment was applica-
ble and effective, nevertheless it was to be borne in
mind that the attempted cure of hernia by this method
was not new; that it had failed to establish itself
as a routine method for such treatment and was still
in an early experimental stage; further, physicians
who used this method should realize the dangers from
an ethical, a legal and a financial point of view.
Then in 1940 the Council again sent out the same
questionnaire to those hospitals which formerly re-
plied. From these they found the same hospitals us-
ing the method as before except for one which had a-
 46.

bandoned its use. The number of hospitals stating

they did not use the method remained the sarne; more
hospitals seemed to think the method safe than unsafe;
and more considered it ineffective than effective. In
most cases the reply was "effective only in selected
cases. 11
To give the best idea of the results obtained
from the questionnaires is to quote directly from the
August 17, 1940 report of the Council:

The consensus expressed by comments in re-

ply to the last question indicate that one hoSJ>i-
tal has abandoned the injection treatment of
hernia since the first questionnaire was renort-
ed, and others have narrowed its anplication to
a smaller number of cases. Many hospitals con-
cur in the opinion that this method is suitable
only for small reducible indirect inguinal her-
nias. In general the importance of using care-
ful technic, relatively nonirritating solutions
o.nd adequate truss support is indicated. Other
hospitals indicate that surgical repair is the
method of choice, 'rhe injection treatment being
reserved for those cases suited to this method
in which the patients could not or would not un-
dergo surgical operation. In some instances e-
valuation of the injection method is withheld be-
cause of inadequate follow-up or insufficient
lapse of time. Cooperation of the patient in
the matter of truss wearing is considered an im-
portant factor in success. In those hospitals
not employing the injection method for hernia
(about 65 per cent of those consulted) various
reasons are given: Its original use has fallen
into disrepute over a neriod of years and aban-
donment of its employment as a regular procedure
is evidence that the method has no permanent val-
ue; it was previously abandoned because it failed
 47.

to give useful results; scar tissue, whatever.

the origin, is R weak tissue, nonresistant to
tension; the method is unestablished and opens
the field of hernia treatment to incomnetents,
and the method is considered unsafe or unsatis-
factory.

The renort then goes on to state that the injec-

tion method of treating hernia may not be recognised
f'or general use and should be employed only by those
with special experience and with full cognizance of
the dangers involved in the use of such solutions.
The Council now concurs in the opinion that the meth-
od involves less danger of serious complications than
surgery when employed in selected cases by those skill-
ed in the injection or suitable standardized solutions
of known composition and action. The report also
states that the Council is not willing to recognise
any such solution for New and Nonofficial Remedies and
that present evidence indicates that better types of
solution are to be desired. They go further to say
they must condemn the exploitation of the injection
.,.
treatment of hernia by manufactu~es of solutions.
A clue to i:.vhat may develop from the injection
treatment is expressed in a recent article by Vv'ilmouth
(47). In connection with operative treatment of hernia
he reports that it is believed that many recurrences
 48.

are due to lack of sufficient fibrous tissue union

between the muscle and fascia which are satisfactor-
ily sutured. Believing that an added stimulus to
"fibroplasia 11 was necessary to secure firmer and last-
ing union, he injected irritating fluids during and
after oneration. He states his result was a strength-
ening of the line of suture, and that in this way the
number of recurrences may be reduced.
 49.

CONCLUSIONS

After reading most of the present and past lit-

erature on the subject of the injection treatment for
hernia, and a certain amount of speculation, I have
come to some very definite conclusions. First of all
it has been brought out by most of the authors that
it is not safe for anyone to use this method unless
equiped with the proper technic and training. Next,
the solutions at nresent in use are not truly satis-
factory. The method is not without complications,
even to the extent of death.
Further the method is not effective except in
carefully selected cases, such as thin young adults
with good musculature with recent, small, reducible
indirect inguinal hernias. It is necessary for these
cases to wear trusses for an extended period of time,
and is also necessary for them to remain under obser-
vation for at least three years, possibly longer.
Exp€rimental studies have shown that the process
of absorbtion of the scar tissue formed by the injec-
tions of sclerosing fluids continues over a period of
years, making retreatment necessary. These studies
have also shown that this method of treatment does not
 50.

fulfill the requirements of adequate hernia repair,

mainly, obliteration of the sac as advocated by
Bassini, and the reenforcing by overlaping or living
fascia technic of operation is not obtainable. The
tissue which is formed is finally absorbed.
The end-results as shown by the various authors,
even in selected cases, hardly make this treatment
worth while.
 51.

BIBLIOGRAPHY

1. Anson, B.J. and Mcvay, c.B., Inguinal Hernia 1.

The Anatomy of the Region. Surg. Gynec. and Obst.
6: 186-191. 1938.

2. Berne, C. J., J;,atali ties :trollowing Injection Treat-

ment of Hernias. J.A.M.A. 110: 1812-13. 1938.
3. Biegeleisen, H.I., Two Fatty Acid Solutions for
the treatment 01· Hernia. Am. J. Surg. 3?: 413-1?, '3?
4. Biegeleisen, H.I. and Tartakow, I.J., Technique of
the Injection Treatment for Inguinal Hernia. Surg.
5: 202-216. 1939.

5. Bisgard, J.D., The Use of Living Sutures of the

External Oblique Aponeurosis in the Repair of In-
guinal Hernias in Adults, Surg. Gynec and Obst.
68: 113-117, 1939.

6. Bratrud, A.F., The .Ambulent Treatment of Hernia,

Minnesota Iv1ed. 18: 623-62?, 1935.
7. Burdick, u.G. and uoley, B.L., Injection Method of
Treating Hernia, Am. surg. 106: 322-333, 193?.
s. Butler, P.I., Injection Treatment Of Hernia,.Am.
J. surg. N.s. 37: 256, 1937.
9. uoley, Vl .B., Review of Radical uure of Hernia Dur-
ing the Last Half Century, Am. J. Surg. N.S. 31:
397-402, (March) 1936.

10. Cooper, A., The Anatomy and Surgical Treatment of

Abdominal Hernia, Edit. t, Philadelphia, 1844.
11. uouncil on Pharmacy and Chemistry, Present Status
of the.Injection Treatment.of Hernia, J.A.M.A.
115: 533-434, Aug. l?, 1940.

12. Gowel, E .M. , Hernia and Hernioplasty, New York,

Paul B. Haeber, Inc., 192?.
13. urohn, N.N., The Injection Treatment of Hernia,
J.A.M.A. 108: ?, 193?.
 52.

14. Dobson, L., The Late Results of the Injection

Treatment of Hernia, :=:urg. '7: 836-84?, 1940.
15. Earl,G., The Comparitive values of Injection and
Surgical Treatment of Hernia, 111inn. l,'led, 21:250, '38
s.w., The Status of Research on the Injec-
16. )!'owler,
tion treatment of Hernia, Am.J.Surg. 3?: 403, 193?
1?. Garrison, Jf .H., History of 1,Iedicine, W. B. Saunders
co. 1929.
18. Gordon, B. and Gordon, E., Hernioplasty in Patients
Previously Treated by Injection Ii~ethod, J .li.~.M.A.
10'7: 14, 1936.
19. Hall, J.S.K., The Eradication of Hernia by Injec-
tion, hled. J. and Rec. 130: 61-63, 1929.
20. Harris, lf'.I. and Vv'hite, A.S., The Injection Treat-
ment of Hernia: A Critical Analysis of J_railures,
Recurrences and Complications, Am.J.Surg. 3'7: 263, '3'7
21. Harris, F.I., White, A.s., and Biskind, G.R.,
Observations on Solutions Used for Injection Treat-
ment of hernia, lrm. J. Surg. 39: 112. Jan 1938.
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