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sary, to return again three months later, under the following circumstances : Some two or three weeks prior to her second return to the dispensary, she had evidently found some one who had carried out her plan of treatment for the removal of the tumor and birth-mark. I shall not repeat the history of the operation as given to me by the mother, as I might do injustice to some surgeon or institution. Suffice it to say, the child was brought back to me, simply an object of pity, suffering intensely from the effects of some kind of operation. The whole side of the child's face was swollen to an extreme degree, the swelling completely closing one eye and extending over the side of the forehead into the scalp. The wine-mark had disappeared, and instead, there was a darkgrayish ulcer, with thick bands of gangrenous connective tissue covering the tumor, which had increased to the size of an English walnut. The carotids were throbbing, the respiration was hurried, the pulse was not easily counted and was irregular, with a temperature of 103°, Fahr. (axillary), frequent attacks of vomiting, and a tendency to stupor. I carefully syringed out the ulcer with a solution of bichloride of mercury, 1 to 2,000, and, with a pair of scissors, cut away a number of gangrenous connective tissue bands, which brought into view several pockets of pus. Thoroughly syringing these out, I carried my dissection a little farther, when a mulberry-like mass, containing a number of large blood-vessels distended with venous-colored blood, rolled up, and there was a rather profuse hæmorrhage. Passing a double ligature with an aneurism needle beneath the tumor, I crossed the ligatures and firmly tied them on either side, completely controlling the hæmorrhage. The greater portion of the mass above the ligature was cut away, and the wound was thoroughly cleansed with the bichloride - of - mercury solution. Twenty-four hours after the operation, the patient had very much improved. The tendency to vomit had disappeared. The temperature had fallen to 100.5°; the respiration was nearly normal; and the pulse was 110 and regular. A few drops of whisky in a little lime-water were given for a few days after each nursing. From this time on, the patient did well. The wound was thoroughly cleansed twice a day with the bichloride-of-mercury solution and was dressed with vaseline. At the end of the seventh day, the ligatures, with the remainder of the tumor, came away, leaving a healthy, granulating wound,

which healed kindly and left no vestige of the tumor to be seen

or felt.

Case II. - A Large Angiomatous Nævus of the Upper Lip of a Child Three Months Old, successfully removed with the Knife. -Florence P., aged three months, born of healthy parents, was brought by its mother to the dispensary, April 1, 1884, for advice with regard to a small tumor of the lip, accompanied by a winemark. The mother informed me that, when the child was born, she noticed that the lip was stained with the wine-mark, and that, five or six days later, she found a small, hard lump on the lip. This tumor, although small at first, increased rapidly in size until, at six weeks old, when the child was brought to the dispensary, it was about as large as a common marble. Examination showed that the tumor involved all the tissues of the lip. It was compressible and doughy to the touch, and it increased in size whenever the child cried. It was not pulsatile in character, and the wine-mark discolored the mucous membrane as well as the skin over the lip.

I recommended to the mother, removal of the tumor by an operation with the knife. This she refused to permit, and she took the child away without further counsel. On April 29th, she returned to the dispensary with the child, asking advice concerning a hæmorrhage which had developed in the tumor and which was the result of an operation made elsewhere. She could not give me a correct account of what had been done to the child since its previous visit to the dispensary, but said that it had been taken to a clinic somewhere in the city, where an operation with hot needles or similar appliances had been performed. Since this operation, the child had refused to nurse and had become very feverish. Ulceration had set in, followed by excessive hæmorrhage, and this so alarmed the mother that she decided to come again to the Demilt Dispensary. The appearance of the child was very bad. The respiration was rapid, the temperature 102° (axillary), and the child was subject to frequent attacks of vomiting. In examining the tumor, I discovered a small pocket of pus beneath the skin, which seemed pent up and was covered with a thick scab. I removed the scab, thoroughly cleansed the cavity with a solution of bichloride of mercury, 1 to 2,000, and then applied a light compress saturated in a strong solution of tannic

acid. This controlled the hæmorrhage. I informed the mother that, if the child recovered from its present fever, I should operate by removing the tumor entire. The lip seemed so unsightly to her that she said she would rather that the child should die under an operation than live in its present condition. I therefore gave preparatory treatment, and, in the course of five or six days, the child

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Fig. 1. -APPEARANCE OF THE LIP IN CASE 2. (From a Photograph taken on the

Day before the Operation.)

had so far recovered that I decided to operate on the following Sunday at my office. A cast of the tumor, and this photograph, which I here show you, were taken on the Saturday before the operation. The tumor was then enlarged to the size of an English walnut.

The child was in fair condition. The fever had abated, and she was able to retain food, although she was very anæmic from the loss of blood resulting from the former operation. On June 8th, in the presence of Professor J. W. Wright and my assistants, Dr. Segur and Dr. Carpenter, I placed the little patient under ether and proceeded to operate. I cut away about four fifths of the entire

[graphic]

Fig. 2.—APPEARANCE OF THE LIP IN CASE 2. (From a Photograph taken ten Days

after the Operation.)

lip, leaving as much of the vermilion border and of the orbicularis oris muscle as I could, in order to assist in the formation of a new lip. During the operation, the coronary arteries were held by my assistants, so that there was no great loss of blood. After removing the tumor, I dissected up the edges of the integument

on either side and brought the parts together, using one hare-lip pin and uniting the edges of the wound by fine catgut sutures. The after-dressing consisted simply of a piece of lint laid over the wound and kept moistened night and day, by the aid of a drop-glass, with a solution of bichloride of mercury, 1 to 2,000, for the first forty-eight hours.

On June 10th, I removed the hare lip pin without disturbing the dressing. On June 15th, I removed the dressing and found the wound united by first intention. On the same day, I allowed the babe to nurse its mother, which it did readily and well. This photograph, which I now present for your inspection, was taken ten days after the operation.

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