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 THE TREATMENT OF CAVERNOUS AND 
 
 PLEXIFORM ANGIOMATA BY THE 
 
 INJECTION OF BOILING WATER 
 
 WYETH METHOD 
 
 REDER 
 
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THE TREATMENT OF CAVERNOUS AND PLEXI- 
 
 FORM ANGIOMATA BY THE INJECTION OF 
 
 BOILING WATER (WYETH METHOD) 
 
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Plate I. 
 A typical cavernous angioma of the left clieek and upper lip. 
 

 THE TREATMENT OF CAVERNOUS AND 
 
 PLEXIFORM ANGIOMATA BY THE 
 
 INJECTION OF BOILING WATER 
 
 (WYETH METHOD) 
 
 BY 
 FRANCIS REDER, M.D., F.A.C.S., 
 
 VISITING SURGEON TO CITY HOSPITAL; CONSULTING SURGEON TO 
 
 ST. JOHN'S HOSPITAL AND MISSOURI BAPTIST SANITARIUM, 
 
 ST. LOUIS. 
 
 ILLUSTRATED 
 
 ST. LOUIS 
 
 C. V. MOSBY COMPANY 
 1918 
 

 Copyright, 131S, by C. V. Mosby Company 
 
 Press of 
 
 C. V. Mosby Company 
 
 St. Louis 
 
TO MY WIFE 
 
 WHO HAS SHARED WITH ME 
 
 THE "MIDNIGHT OIL" 
 

 PREFACE 
 
 Perhaps no apology is necessary for the appear- 
 ance of this monograph in brochure form. 
 
 An excuse, however, may be offered on the 
 grounds that a liberal supply of reprints has been 
 exhausted, and though the original article ap- 
 peared in Surgery, Gynecology and Obstetrics 
 nearly three years ago, requests for reprints are 
 still being received. It is the best attestation 
 whereby the value of the procedure embodied in 
 this brochure is to be judged. Furthermore, it 
 conveys the conviction that physicians are alive 
 to appreciate what appears in medical journals of 
 high standard. A subject of special interest will 
 usually engender the wish for a reprint. For this 
 there is one good reason; viz., that a reprint is 
 filed away and becomes readily accessible in case 
 the physician wishes to refresh his mind on a 
 particular subject, whereas the journal in which 
 the desired article appeared is usually displaced 
 and frequently can not be found among the mass 
 of medical literature when it is most needed. 
 
 Dr. Stuart McQuire, of Richmond, Va., about 
 two years ago, embodied a number of his reprints 
 in one volume. It made a handy book. The idea 
 impressed me as a splendid one. There have been 
 occasions when it was my desire to obtain his 
 
tO PREFACE 
 
 opinion on some special subjects and it was a relief 
 to be able to do so without loss of time. 
 
 In presenting in brochure form my monograph 
 on the treatment of vascular tumors by the injec- 
 tion of boiling water it is the hope that it may 
 perhaps be of a similar service to the busy prac- 
 titioner. 
 
 To the thoughtful physician this subject pos- 
 sesses points of interest in which advantages can 
 readily be recognized. Would a physician remove 
 a vascular tumor from a baby's face, especially 
 if that baby be a girl, with the scalpel, when an- 
 other measure will completely obliterate the tu- 
 mor without any scar or disfigurement 1 If so, an 
 excision under such circumstances would be an 
 unjustifiable procedure. What excuse can the 
 physician offer for the cicatrix that has been left 
 in place of this tumor? None, except that he 
 was not familiar with, or did not know of the 
 existence of any other method whereby this could 
 have been accomplished with a happier result. 
 
 When Dr. John A. Wyeth advocated the injec- 
 tion of boiling water into these tumors as a cura- 
 tive agent, I doubt very much if he was aware of 
 the greatness of his beneficent advice. Many a 
 mother has remembered him in her prayers for the 
 good that has come to her child through his 
 method. When some fifteen years ago Dr. Wyeth 
 presented his idea of injecting vascular tumors 
 with water at a high temperature at the meeting 
 
PREFACE 11 
 
 of the American Medical Association, Dr. William 
 J. Mayo, in the course of his discussion, stated that 
 it was his belief that the procedure was one of the 
 advances in the treatment of tumors of the blood 
 vessels. 
 
 The farsightedness of this remark by this emi- 
 nent surgeon has been fully realized. Nothing can 
 be more convincing than to see a vascular tumor, 
 the size of a pigeon's egg 7 disappear about five 
 weeks after one or two injections of boiling water, 
 and leave the structures in a state bordering on 
 the normal. 
 
 For my successes I am deeply indebted to Dr. 
 Wyeth. It has been my good fortune to enjoy a 
 number of visits with this master surgeon where I 
 could hear from him in a most interesting man- 
 ner his views and ideas on the treatment of these 
 vascular tumors. During one of my visits when 
 the doctor enlightened me with most valuable sug- 
 gestions relative to this procedure, I asked him if 
 he would be kind enough to write a few lines about 
 the treatment of vascular tumors by the injection 
 of water at a high temperature in the way of an 
 introduction, should I decide to present the sub- 
 ject in brochure form. To this request he gave 
 me an affirmative reply, for which I am very 
 grateful. 
 
 Francis Reder. 
 
 St. Louis, Mo. 
 
ILLUSTRATIONS 
 
 PLATE PAGE 
 
 I. Cavernous angioma of left cheek and upper lip Frontispiece 
 
 II. Plexiform angioma Facing 28 
 
 FIG. 
 
 1. Angioma of right cheek complicated by nevus .... 2(1 
 
 2. Angioma of lower lip 21 
 
 3. Angioma of lower lip in left corner of mouth .... 22 
 
 4. Angioma of tip of nose and underneath upper lip . . 23 
 
 ."). Angioma of left upper eyelid 24 
 
 (>. Angioma of left frontoparietal region 25 
 
 7. Angioma of right middle finger near knuckle .... 26 
 
 „ s. Angioma of left gluteal region 27 
 
 !t. Angioma of tongue 34 
 
 Id. Cavernous angioma of right cheek of congenital nevoid 
 
 origin 37 
 
 11. Front view of case shown in Fig. 10 38 
 
 12. Showing result of Wyeth treatment and paquelinization . 39 
 1 .">. Front view of case shown in Fig. 12 40 
 
 14. All-glass syringe 42 
 
 15. Jacketed syringe and cork-protected needle 44 
 
 16. Operating room arrangement 46 
 
 1 7. Injection of boiling water 47 
 
 IS. Plexiform angioma 53 
 
 19. Showing the result of "Wveth treatment in case shown in 
 
 Fig. 18 . . . . ' 54 
 
 20. Angioma of left upper eyelid 56 
 
 21. Showing result of Wyeth treatment in case shown in Fig. 
 
 20, front view y 57 
 
 22. Showing result of Wyeth treatment in case shown in Fig. 
 
 20, lateral view 58 
 
 23. Cirsoid aneurysm 60 
 
 24. Showing result of Wyeth treatment in case shown in 
 
 Fig. 23 61 
 
 25. Cavernous angioma of left cheek and upper lip .... 65 
 
 26. Showing result of Wyeth treatment in case shown in 
 
 Fig. 25 67 
 
 13 
 
INTRODUCTION 
 By Dr. John A. Wyeth 
 
 While limited to a comparatively narrow field, 
 the value of water at a high temperature as a 
 therapeutic agent has been fully demonstrated. 
 
 It is more than seventeen years since I first em- 
 ployed this method to coagulate subdermally the 
 blood and lymph for the arrest of the circulation 
 in arterial, venous, capillary, and lymphatic angio- 
 mata. A certain proportion of these neoplasms are 
 at times inoperable, either by the ligature or by 
 excision, on account of noncontrollable hemor- 
 rhage ; and among the most gratifying experiences 
 of my career have been the cure of a very consider- 
 able number of cases, which, without this method 
 of treatment, must have been hopelessly aban- 
 doned to untimely death, or to lifelong disfigure- 
 ment. 
 
 It is essentially applicable to the arrest and cure 
 by ultimate absorption of that form of arterial 
 angioma (cirsoid aneurysm) which most fre- 
 quently affects the arteries of the scalp, and to the 
 large, venous angiomata with rich anastomoses, 
 which, while in the majority of instances are found 
 above the level of the clavicles, may be met with 
 in any part of the body. So far, all of these cases 
 have been successfully treated, and, to my sur- 
 prise, without disaster, even from embolism. 
 
 15 
 
k; 
 
 INTRODUCTION 
 
 I am confident the author of this monograph 
 will deal with the technic in detail. The fact will 
 ever be present in the operator's mind that water, 
 at or above, 212° F. is instantly destructive of the 
 skin in the presence of the atmosphere. Even sub- 
 dermally a too intense heat should not be used 
 near the skin or a vessel, or a vitally important 
 nerve. 
 
THE TREATMENT OF CAVERNOUS AND 
 
 PLEXIFORM ANGIOMATA BY THE 
 
 INJECTION OF BOILING WATER 
 
 (WYETH METHOD) 
 
 An angioma is a vascular tumor, nonmalignant 
 in character. On an anatomic basis, angiomata 
 can be classified as venous, which are rather 
 frequently observed; then arterial, or plexiform 
 angioma, otherwise known as a cirsoid aneurysm, 
 the "angioma arteriale racemosum" of Yirchow, 
 a vascular neoplasm rarely observed, and, lastly, 
 the capillary form, the so-called "port-wine stain" 
 or "mother's mark," which is quite common. 
 
 The theory that these neoplasms are caused by 
 a dilatation of the capillaries, the walls of which 
 have become absorbed, resulting in the formation 
 of spores, has been favorably received. Of the 
 cavernous angioma, it can be said that it is a 
 large, blood-filled nonpulsating cavity, of variable 
 size, with a thin covering of skin, usually bluish 
 in color. 
 
 The walls of these spaces possess an endothelial 
 lining similar to that of veins. Numerous tortuous 
 vessels supply the blood which fills these cavities 
 and circulates with varying degrees of rapidity. 
 The arteries open directly into the cavities. 
 
 17 
 
18 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 The connective tissue enmeshing the vessels of 
 an angioma is sometimes scanty and sometimes 
 plentiful, thus causing irregularities about the 
 vascular tumor that often give it a lobulated 
 appearance. 
 
 A venous angioma may be diffuse, or may form 
 a distinctly circumscribed tumor. A circum- 
 scribed cavernous angioma possesses its distinct 
 efferent artery and afferent veins and does not 
 communicate with the neighboring capillaries; i. e., 
 there exists no anastomosis with the capillaries in 
 the surrounding tissue. The angioma shows a cir- 
 culation wholly within itself, there being only a 
 connection with the neighboring arteries and 
 veins. 
 
 Their growth is slow. They increase, how- 
 ever, progressively in size with the growth of the 
 patient; viz., a baby which at three months shows 
 an angioma upon its lip that has the appearance 
 of a fleabite, will exhibit the same lesion the size 
 of a hazelnut nine months later. 
 
 These vascular neoplasms are congenital in their 
 origin. They are benignant in character and al- 
 though their histologic formation closely resem- 
 bles certain types of malignancy, yet clinically 
 angiomata are considered nonmalignant. 
 
 One of the principal characteristics of a heman- 
 gioma is that the entire tumor can be caused to 
 disappear upon pressure, with a prompt return to 
 its original size as soon as the pressure is removed. 
 
TREATMENT WITH BOILING WATER 19 
 
 Another characteristic is the prompt response 
 in reflecting the temperament of its possessor, ex- 
 citable influences causing the tumor to swell, be- 
 come tense, and more deeply discolored. This is 
 accomplished through elastic fibers, closely resem- 
 bling the normal erectile tissues of the body, which 
 are contained in the connective tissue stroma. 
 
 From statistics it must be inferred that the face 
 is the favorable locality for an angioma, two- 
 thirds of these growths being located there. 
 
 The brow and the cheeks seem to be selective 
 regions. Next in frequency come the lips, the nose, 
 the ears, and the eyelids. Strange as it may ap- 
 pear, the feminine sex is more prone to this affec- 
 tion than the male, two-thirds of all cases occur- 
 ring in females. 
 
 Cavernous angiomata may occur in the orbit, 
 muscle, liver, spleen, kidneys, and the alimentary 
 tract. These vascular tumors have also been found 
 in bone, the ''myelogenous angioma" of Virchow, 
 an extremely rare condition. Its resemblance to 
 osteosarcoma is very great, making an intra vitam 
 diagnosis almost impossible. 
 
 Inasmuch as there is no pain jn connection with 
 a cavernous angioma, except when the tumor is 
 so located as to cause pressure upon a nerve, the 
 discomfort experienced must be ascribed to its 
 size and, of course, its location. For instance, a 
 vascular tumor situated upon the upper eyelid can 
 become very annoying on account of visual inter- 
 
20 CAVERNOUS AND PLEX1FORM ANGTOMATA 
 
 Fig. 1. — Baby G., age eighteen months. Angioma of right 
 cheek, complicated with a nevus. Four injections obliterated 
 the angioma. First injection, September 10, 1913, 3 ounces; 
 second injection, October 12, 1913, 3 ounces; third injection, 
 December 6, 1913, 2 ounces; fourth injection, February 18, 
 1914, 2 ounces. The tumor had entirely disappeared by June 
 1, 1914. The nevus was destroyed with two applications of the 
 Paquelin cautery. 
 
TREATMENT WITH BOILING WATER 
 
 21 
 
 Fig. 2. — Baby M v age seven months. Angioma of lower lip. 
 One injection of boiling water obliterated the angioma. The 
 angioma was injected with 1.5 ounces January 5, 1914. There 
 was complete disappearance of the tumor by April 1, 1911. 
 
22 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 Fig. 3. — Baby C, age two years. Angioma of lower lip in left 
 corner of mouth. When baby laughed this tumor would roll 
 out of the corner of the mouth and appear as large as a Cali- 
 fornia grape, dark purple in color. Three injections obliterated 
 the tumor. First injection, April 6, 1914, 0.5 ounce. Second 
 injection, June 3, 1914, 0.5 ounce. Third injection, October 
 11, 1914, 0.5 ounce. 
 
TREATMENT WITH BOILING WATER 
 
 23 
 
 Fig. 4. — Peter E., age nineteen years. Angioma on tip of 
 nose and underneath upper lip. Two injections required for 
 tumor underneath the upper lip, and three injections for angioma 
 on tip of nose. Owing to the cartilaginous structure of the tip 
 of the nose, much difficulty was experienced in making these 
 injections. First injection, June 2, 1911; nose, 0.5 ounce, lip, 
 1 ounce. Second injection, July 8, 1911; nose, 0.5 ounce, lip, 1 
 ounce. Third injection, September 2, 1911; nose, 0.5 ounce. 
 Complete disappearance by October 1, 1911. 
 
24 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 Fig. 5. — Baby E., age three years. Angioma involving left 
 upper eyelid. This tumor grew rapidly during the last four 
 months and interfered with vision. Two injections obliterated 
 angioma. First injection, January 3, 1912, 2 ounces. Second 
 injection, March 1, 1912, 1 ounce. Disappearance of tumor by 
 July 1, 1912. 
 
TREATMENT WITH BOILING WATER 
 
 25 
 
 Fig. (3. — Baby K., age eighteen months. Angioma in left 
 frontoparietal region. Two injections obliterated the angioma. 
 First injection. May 2, 1914, about 2.5 ounces. Second injection, 
 May 28, 1914, about 1.5 ounces. Disappearance of the tumor by 
 August 1, 1914. 
 
2(3 
 
 CAYHUNOUS AND PLEXIFORM ANGTOMATA 
 
 Fig. 7. — John F., are thirty-two years. Angioma of right 
 middle finger near knuckle. One injection of 2 ounces caused 
 the tumor to disappear in six weeks. 
 
TREATMENT WITH BOILIXU WATER 
 
 L'< 
 
 Fig. 8. — Frank L., age forty years. Angioma of left gluteal 
 region. Five injections required to obliterate this tumor. First 
 injection, February 4, 1910, about 5 ounces. Second injection, 
 March <i, 1910, about 5 ounces. Third injection, May 2, 1910, 
 about 3 ounces. Fourth injection, June 18, 1910, about 3 ounces. 
 Fifth injection, August 2, 1910, about 2 ounces. Complete dis- 
 appearance of tumor by November 1, 1910. 
 
28 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 ference. Again, an angioma of the cheek may in- 
 volve the buccal tissue to such an extent as to make 
 mastication difficult and even dangerous. This 
 was exemplified in one of my cases in which the 
 patient accidentally bit the inner side of her cheek, 
 causing an alarming hemorrhage. 
 
 Now, let us consider briefly the plexiform an- 
 gioma. This is usually a distinctly outlined tumor 
 occurring in definite arterial regions. According 
 to Fischer, 12 per cent are of traumatic origin, the 
 remaining 88 per cent being derived from simple 
 congenital angioma. 
 
 The tumor is composed of arteries and veins, the 
 tortuous vessels giving this tumor mass a most 
 characteristic appearance. 
 
 A favored site is upon the forehead, scalp, and 
 face. It is not infrequent, however, to find the 
 hand, fingers, and forearm affected. 
 
 In its clinical characteristics a plexiform an- 
 gioma differs markedly from the cavernous type. 
 The former usually forms a flattened tumor, grad- 
 ually spreading into the surrounding tissues. The 
 skin covering the tumor is very thin, usually more 
 of a reddish than a bluish color, and is locally 
 adherent. Pressure upon the mass will not cause 
 it to be completely evacuated, as is the case in a 
 cavernous angioma. This must be attributed to 
 the large number of anastomoses. 
 
 Another characteristic phenomenon found in the 
 plexiform angioma and not present in the cav- 
 
Plate II. 
 
 A typical cirsoid aneurysm (plexiform angioma) of the forehead, a favorite 
 site for these vascular tumors. 
 
TREATMENT WITH BOILING WATER 29 
 
 ernous variety is the well-marked pulsation and 
 bruit. For instance, the hand flatly applied to a 
 plexiform angioma will distinctly perceive the pul- 
 sation and bruit in the tumor. Such an angioma 
 located on the scalp or forehead will often cause 
 a partial destruction of the underlying bone by 
 attrition. This defect can be readily discovered 
 by making gentle, but firm pressure upon the thin- 
 ned-out skin of the tumor, at the same time sweep- 
 ing the finger over the affected area. 
 
 A plexiform angioma is not free from clinical 
 symptoms ; it usually causes dizziness, vertigo, and 
 a dull pain in the head. Such disturbances are not 
 associated with a cavernous angioma. 
 
 The capillary form of angioma has very little 
 of clinical significance, and exclusive of the un- 
 sightly appearance, causes no discomfort. It is 
 not often that the possessor of a port-wine stain 
 seeks advice as to the possibility of having it re- 
 moved. Even so, should the angioma involve a 
 large area, which they not infrequently do, noth- 
 ing of an encouraging nature as to its total or even 
 partial removal could be promised. 
 
 An interesting fact in connection with capillary 
 angioma is that their distribution often corre- 
 sponds to the area of distribution of the three 
 branches of the fifth cranial nerve; viz., angioma 
 of the frontal germinal area, and angioma of the 
 superior and inferior maxillary areas. Baren- 
 sprung was the first to call attention to this. Cush- 
 
30 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 Lng and others later confirmed his observations. 
 Simon entertained a theory that nutritive dis- 
 turbances in the region of the trigeminus were 
 causal in producing such a condition.* 
 
 Virchow advanced a theory that angiomata 
 find their origin in the embryonic relations when 
 slight irritative conditions about the margins and 
 the circumference of the fetal clefts, which are 
 always copiously supplied with blood vessels, may 
 cause an abnormal development about these parts, 
 with the possibility of a nevus formation. Such 
 a condition may remain latent for a time and later 
 manifest itself as a cavernous angioma. Virchow 
 lias applied to them the name of "angioma fissu- 
 raux. ' ' 
 
 According to Ribbert, the genesis of angiomata 
 rests with two questions: Is the tumor a sim- 
 ple dilatation of the vessels in a circumscribed 
 area! or, is the tumor the result of a new growth? 
 To this may be added Stangl's argument as to 
 whether or not these vascular tumors are of 
 epithelial or connective tissue extraction. Ribbert 
 advocates the view that they are the result of a 
 new growth. From the exhaustive researches that 
 this interesting vascular lesion has been sub- 
 jected to, the inference must be made that the 
 genesis of angiomata is not clearly understood. 
 
 *%arry in his interesting exposition of this lesion adheres to a theory 
 that angiomata are congenital vascular productions caused by modifica- 
 tions occurring during embryonal development. 
 
TREATMENT WITH BOILING WATER 31 
 
 A cavernous or plexiform angioma, especially 
 of large size, is one of the most difficult lesions 
 with which the surgeon has to contend. In fact, 
 some of these lesions are looked upon as inoper- 
 able and have been abandoned to an ever- 
 increasing deformity and discomfort. 
 
 The most radical intervention for the "cure" 
 of an angioma is excision. However, before hav- 
 ing recourse to this measure, it is well to consider 
 several salient points. One, a point of much im- 
 port, is the size and location of the angioma, and 
 the risk to life from hemorrhage. Another point, 
 and one that commands recognition, especially 
 when the angioma is located on the face, is the 
 liability to deformity from mutilation and cica- 
 trization. 
 
 These two points can be fused into one consid- 
 eration for the surgeon who attempts to cure an 
 angioma by excision; viz., that this radical measure 
 is only permissible when the vascular tumor is of 
 limited extent, well-circumscribed, and situated in 
 parts which can be sacrificed without the danger 
 of great hemorrhage or the loss of important 
 structures. » 
 
 In an angioma of the face, the effect of a muti- 
 lating or disfiguring operation must be seriously 
 considered, especially in the female sex. 
 
 That many of these tumors are inoperable; i. e., 
 not amenable to extirpation, has been demon- 
 
32 CAVERNOUS AND PLEXIFOTIM ANGTOMATA 
 
 strated repeatedly by an attempted operative 
 measure which had to be abandoned. 
 
 Other surgical measures, such as peripheral li- 
 gation, ligature of the afferent arteries, and tissue 
 strangulation by the buried ligature, have been 
 considered when a surgical extirpation seemed too 
 hazardous. However, the results have at best been 
 only palliative and disappointing. 
 
 The severity of the surgical intervention in deal- 
 ing with an angioma caused other methods to be 
 promulgated. Efforts were made to destroy the 
 growth with all its constituent elements by the in- 
 terstitial action of irritating caustics or other 
 agents applied externally or introduced into the 
 afflicted tissues. Some of these methods have been 
 used by me, but have proved disappointing. 
 
 For instance, the injection of alcohol (Schwalbe) 
 and ferric sesquichloride are very prone to cause 
 suppuration, and are not to be recommended. In- 
 jection of hydrogen peroxide (Mosetig-Moorhof) 
 is a dangerous agent to use. Its introduction may 
 be followed by a fatal gas embolism in the lungs. 
 Payr's method, consisting of the introduction into 
 the tumor of darts or rods of magnesium, a pro- 
 cedure that does not involve the danger of throm- 
 bosis or embolism, is not familiar to me, neither 
 have I had any experience with radium. 
 
 The injection of water at the boiling point as 
 recommended by Dr. John A. Wyeth has given me 
 the most satisfactory results. The method must 
 
TREATMENT WITH BOILING WATER 33 
 
 be looked upon as one of the advances in the 
 treatment of vascular tumors. Of 104 cases sub- 
 jected to this method, 1 have had no failures to 
 record. The results were certain, and the pro- 
 cedure was free from accident. There are two 
 cases, however, of which I wish to briefly speak. 
 
 In the first case, a child of sixteen months, with 
 an angioma on the lower lip to the left of the 
 midline, in size as large as a filbert, had received 
 two injections in the course of six weeks. The 
 tumor was reduced to slightly less than half its 
 size. It was then quite hard and its color, which 
 before the injection, was purple, was that of the 
 normal lip. 
 
 The mother became dissatisfied that the tumor 
 had not entirely disappeared. At the advice of 
 her friends, she saw a physician who removed it 
 by excision. The removal was a success, and 
 were it not for the scar on the lip the result would 
 have been ideal. 
 
 I was informed by the physician that the re- 
 moval was attended with but little bleeding. This 
 must be explained on the assumption that the 
 blood in the tumor, coagulated by the boiling 
 water, had become well organized. The mouths 
 of the vessels opening into the vascular tumor had 
 been well sealed. It was noticed during the sec- 
 ond injection that the boiling water did not enter 
 the vascular growth so easily as during the first. 
 More piston pressure was necessary, and the dif- 
 
34 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 Fig. 9. — Albert H., a<je forty years. Angioma of tongue. 
 Tumor was size of an ordinary pecan and was located midway 
 nn the right marginal side. A little less than an ounce of boil- 
 ing water was injected. The resultant edema spread to the 
 epiglottis and so embarrassed breathing that six hours after 
 the injection it became advisable to perform laryngotomy. 
 Thirty-six hours later the edema had subsided and breathing 
 became normal. The tube was then removed. Patient made a 
 prompt recovery. Angioma had entirely disappeared eight 
 weeks later. 
 
 This distressing condition could have been avoided if a 
 smaller dosage of boiling water had been injected and repeated 
 to meet conditions later as they presented themselves. This 
 was demonstrated in two subsequent cases when an extensive 
 edema was anticipated by resorting to small quantities of boil- 
 ing water and repeating the injection. 
 
TREATMENT WITH BOILING WATER 35 
 
 ficulty was plainly apparent. This was noticeable 
 in every angioma of the lip that required subse- 
 quent boiling-water injection. 
 
 The structure of the lip is peculiar in its make- 
 up, and it is advisable to use extra precautions 
 while introducing boiling water into these struc- 
 tures. It is far better to subject the tumor to a 
 subsequent injection, rather than have an overdis- 
 tention during the first injection that may be the 
 cause of a slough. The greatest success in a lip 
 angioma, however, can be obtained by introduc- 
 ing the proper quantity of boiling water at the 
 first injection. Otherwise, conditions may arise, 
 as those just cited, which may invite excision. 
 
 It is gratifying, however, to know that an an- 
 gioma of the lip which had not been entirely 
 obliterated by the injection of boiling water can 
 be excised with very little loss of blood. 
 
 The other case was that of a young man who had 
 an angioma midway on the right margin of his 
 tongue. The growth was as large as a pecan nut 
 and deep purple. Xot quite an ounce of boiling- 
 water was introduced into it. Within six hours 
 the edema had involved the epiglottis to such an 
 extent that breathing was seriously embarrassed. 
 It was necessary to perform a laryngotomy. In 
 thirty-six hours the edema had subsided and 
 breathing again became normal. The angioma dis- 
 appeared entirely in eight weeks. 
 
 In this case too much boiling water had been 
 
36 CAVERNOUS AND PLEXIFOKM ANGIOMATA 
 
 injected at once, it would have been safer to have 
 given a smaller amount, repeating the injection in 
 three or four weeks, if necessary. 
 
 The question, whether or not a cavernous or a 
 plexiform angioma is a lesion that endangers life, 
 must be answered in a guarded manner. These 
 vascular tumors possess an element of danger in 
 proportion to their size and location. When there 
 is noninterference, their growth may eventually 
 produce a secondary lesion by spreading indefi- 
 nitely, which may cause death. When there is 
 operative intervention, that is, excision, the great 
 danger is hemorrhage. 
 
 The injection of boiling water is not entirely 
 free from danger. However, of all the procedures 
 it is unquestionably the safest. The danger of an 
 embolism must be reckoned with, and in all injec- 
 tions peripheral compression while the boiling- 
 water is being introduced into the tumor must be 
 made. 
 
 There is always a possibility that boiling water 
 injected into a plexiform (cirsoid aneurysm), lo- 
 cated upon the head, might be productive of a 
 meningeal trouble. Furthermore, it may be read- 
 ily seen how a slough can result from boiling 
 water when injected into a cavity filled with 
 blood. It is not a simple matter to judge a boil- 
 ing water injection. 
 
 Before speaking of the technic of the boiling- 
 water injection, I wish to say something about a 
 
TREATMENT WITH BOILING WATER 
 
 ;;< 
 
 Fig. 10. — Xeoma K., age five years. Cavernous angioma of 
 lace of congenital nevoid origin. Two injections of 2 ounces 
 and iy 2 ounces respectively covering a period of six weeks 
 completely obliterated the angioma. The nevus was destroyed 
 with the pointed Paquelin cautery. Three applications at inter- 
 vals of four weeks were necessary to efface this obstinate vas- 
 cular growth. 
 
38 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 Fig. 11. — Xeoma K., age five years. Front view of case 
 shown in Fie.'. 10. 
 
TREATMENT WITH BOILING WATER 
 
 39 
 
 Fig. 12. — Neoma K., age five years. The slight shading 
 about the malar region depicts the site of the nevus and the 
 result of paquelinization. 
 
41) 
 
 CAVERNOUS AND PLKXIKORM ANGIOMATA 
 
 Fig. 13. — Neoma K., age five years, 
 of ease shown in Figs. 10, 11, and 12. 
 
 Result after treatment 
 
TREATMENT WITH BOILING WATEE 41 
 
 type of nevus which is elevated above the skin, 
 and has been of interest to me. It is not infre- 
 quent that a nevus complicates an angioma. The 
 treatment of a nevus has proved more or less un- 
 satisfactory to me, no matter what method I em- 
 ployed. The Paquelin cautery with round point 
 has given the best results, yet that was not satis- 
 factory because recurrences were numerous, re- 
 quiring frequent applications of the cautery. This 
 procedure usually resulted in a well-defined scar, 
 which was very undesirable. 
 
 By using the boiling-water injection in conjunc- 
 tion with the cautery, I found that usually with 
 one application of the cautery a satisfactory ob- 
 literation of the nevus could be accomplished. 
 This is to be explained on the ground that the 
 nevus is feci by deeper lying vessels, even in the 
 absence of an angioma. The injection of boiling- 
 water introduced underneath the skin in the con- 
 nective tissue in the immediate vicinity of the 
 nevus will obliterate these vessels, thus depriving 
 the nevus of further nourishment. The cautery, 
 with the aid of this starvation, will usually prove 
 successful with one application. 
 
 In making the injection of boiling water into an 
 angioma certain conveniences will expedite this 
 measure. A suitable syringe is essential. I have 
 found that an all-glass syringe with a good shoul- 
 der, a large ring on the piston, and an asbestos 
 
42 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 Fig. 14. — All-glass syringe, small size, for injecting boiling 
 wilier into an angioma. Note the asbestos plunger, the large 
 ring at the end of the piston, the shoulder of the barrel, and 
 the point of the barrel which is ground to receive the "slip" 
 needle. A syringe with a capacity of one or two ounces is the 
 preferable syringe for boiling water injections. 
 
TREATMENT WITH BOILIXG WATER 43 
 
 plunger, has answered the purpose better than 
 any of the many I have tried. 
 
 A syringe with an all-glass plunger has its draw- 
 backs, as the steam generated within the barrel 
 will find its way between it and the glass plunger, 
 thus inhibiting the free and easy movement of the 
 piston, so essential to this procedure. 
 
 The slip needle (small caliber, Xo. 20) is the 
 preferable one. With it no time is being lost in 
 the transference of the boiling water. It should 
 always be borne in mind that the water must be 
 injected at a boiling temperature and time is an 
 important factor. It can be stated that those cases 
 of angiomata subjected to the boiling-water treat- 
 ment which did not respond properly, did not re- 
 ceive the "water" hot enough. 
 
 To protect the hands, at the same time making- 
 it possible to handle the boiling water, a pair of 
 easy-fitting chamoisette gloves of good thickness 
 have served me well. That portion of the glove 
 intended for the little finger is cut off, so that the 
 degree of heat in the tissues can be judged by 
 occasional contact with the exposed end of the 
 finger. * 
 
 Another protection for the hands of the opera- 
 tor, while transferring the boiling water, and one 
 which has been found very valuable because it 
 does not require the wearing of gloves, was con- 
 trived by jacketing the barrel of the syringe with 
 a heavy piece of white rubber tubing. The tubing 
 
44 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 Fig. 15. — Showing how the barrel of the syringe is jacketed 
 with a piece of white rubber tubing. The "window" in the 
 jacket is placed so that, should the boiling water be drawn be- 
 yond the edge of the tube, it can be seen and its expulsion con- 
 trolled. Note the "shoulder" of the needle imbedded in a 
 cork, so that the transmitted heat from the boiling water will 
 not burn the unprotected finger steadying the needle. 
 
TREATMENT WITH BOILING WATER 45 
 
 does not cover the barrel to its full length, as 
 this is not necessary with the syringe that is gen- 
 erally used. It permits the exposure of the lower 
 half, and inasmuch as the syringe is never drawn 
 full of boiling water when an injection is made, it 
 is an advantage in being able to watch the amount 
 of water that is being forced out. 
 
 To furthermore facilitate observation in case 
 the boiling water is drawn beyond the edge of the 
 rubber jacket, a "window" is cut into the lower 
 half of the tube. 
 
 To protect the fingers of the hand engaged in 
 steadying the needle from the heat that will be 
 transmitted to the needle, a cork placed about the 
 "shoulder" of the needle has been found very 
 efficacious. 
 
 This method of protection has the advantage 
 of having the hands unincumbered with gloves. 
 
 The arrangement in the operating room should 
 be such that the surgeon stands between the ves- 
 sel containing the boiling water (the water being- 
 kept constantly at the boiling point over a flame), 
 and the patient, at a distance that will not neces- 
 sitate a step on the part of the surgeon for the 
 transference of the boiling water into the tumor. 
 
 The parts not involved should be protected with 
 moist cloths, lest a scalding of these tissues result 
 from the hot water in the syringe being forced out 
 at the needle junction by the generated steam. 
 
 The introduction of the needle and the force 
 
46 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 Fig. 16. — Showing position of surgeon and patient for an 
 injection of boiling water. Note the distance between surgeon 
 and patient and the open vessel containing the water at boiling 
 point over a flame. The movement on the part of the surgeon 
 in transferring the boiling water is barely a quarter of a circle. 
 The canula is previously introduced into the region where the 
 injection is to be made. It requires only a second to make 
 connection with the syringe. 
 
TREATMENT WITH BOILING WATER 
 
 47 
 
 Fig. 17. — Showing how the boiling water is being injected 
 into an angioma. 
 
48 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 applied in injecting' the hot water is of much im- 
 portance. Inasmuch as the tissues of the new 
 growth do not offer the resistance of normal skin, 
 the hot water injected without great care may 
 cause these tissues to break down. Injections 
 made directly into the soft vascular mass are in- 
 variably followed by a necrosis. 
 
 For this reason, it is well to make the initial 
 injections by introducing the needle- through the 
 sound skin about one-sixteenth or one-eighth inch 
 from the edge of the angioma well into the base of 
 the vascular tumor, thus assuring coagulation of 
 the deeper parent vessels. This is also a wise 
 precaution against the dangers of embolism. 
 
 If the arteries leading into the tumor can be 
 demonstrated, it is well to enter the needle along 
 their course and inject a sufficient amount of boil- 
 ing water to cause coagulation in these vessels. 
 
 Judgment should be exercised in introducing the 
 needle to prevent the point from resting too near 
 the opposite wall of the tumor. To properly esti- 
 mate this procedure, it is well to first introduce 
 the needle without the syringe, pushing it through 
 the mass till it can be felt on the opposite side, 
 then withdraw to the extent of half an inch. This 
 will give a reasonable assurance that the boiling 
 water can be injected into the tumor without the 
 likelihood of getting a slough. When the skin be- 
 gins to show signs of becoming blanched and turns 
 grayish in color, the injection into that area is to 
 
TREATMENT WITH BOILING WATER 49 
 
 be discontinued. Hyperdistention must be care- 
 fully guarded against. The amount of hot water 
 necessary to cause this bleaching rests wholly 
 with the amount of tissue under treatment. After 
 coagulation of this particular area has been satis- 
 factorily accomplished, the point of the needle is 
 made to penetrate into another area of the tumor 
 and the hot water injected. 
 
 In this manner the needle is introduced into the 
 tumor in different places, and at various angles, 
 (ill the whole mass gives evidence of coagulation. 
 
 The quantity of hot water which may be in- 
 jected at one sitting can amount to three or four 
 ounces in a tumor the size of a lien's egg, the time 
 consumed in making the injection being about 
 three minutes. 
 
 However, if the new growth is of unusual size, it 
 would be advisable to inject only a portion of the 
 tumor at one time, making a subsequent injection 
 two or three weeks later. 
 
 It may be stated here that safeguarding not only 
 becomes an imperative measure when tumors of an 
 unusual size are to be injected. Even tumors of 
 small size when located upon the tip of the nose, 
 upon the eyelid, or upon the tongue, must be ap- 
 proached with great caution. A boiling water in- 
 jection of an angioma involving the tip of the 
 nose, if injudiciously given, might cause a necrosis 
 of the nasal cartilages, a very distressing acci- 
 dent, should it occur. An injection into an angi- 
 
")() CAVERNOUS AND PLEXIFORM ANGTOMATA 
 
 oma upon the upper eyelid must be administered 
 most cautiously on account of the damage which 
 might be inflicted upon the eye; while an angioma 
 of the tongue, when injected with too copiously a 
 dose of boiling water, may cause the edema to 
 involve the epiglottis and seriously embarrass 
 respiration. It was my misfortune to meet with 
 such a mishap (see case history). 
 
 Boiling water injections into an angioma situ- 
 ated in these regions must be given with good 
 judgment plus great care. 
 
 It is interesting to observe the characteristics 
 presented by an angioma subjected to the hot 
 water treatment. The independence of the blood 
 spaces from the blood vessels of the surrounding 
 tissue can be demonstrated by the fact that the 
 neighboring tissue is not affected; i. e., none of the 
 hot water finds its way into the adjacent struc- 
 tures while the injection is being made. However, 
 shortly after the injection an edema of the im- 
 mediate parts begins to manifest itself. This 
 edema may be very extensive, according to the 
 amount of hot water injected. Frequently, when 
 the lesion is on the face, the swelling may become 
 so extensive as to close the eyes. 
 
 Although the condition looks alarming, there is 
 little ground for actual fear, except when an in- 
 jection is made for an angioma on the tongue. 
 The patient suffers no pain, the condition is an 
 
TREATMENT WITH BOILING WATER ol 
 
 afebrile one, and the edema usually subsides within 
 the first week. 
 
 It is a wise precaution to apply ice or cold com- 
 presses to the tumor and surrounding tissues im- 
 mediately after the injection for the first four to 
 six hours, thereby lessening the severity of the 
 edema. 
 
 At the end of the first week the tumor, but 
 slightly diminished, has almost fully lost its patho- 
 logic color and the tissues are beginning to as- 
 sume a normal appearance. 
 
 To the touch, the mass is hard. If it remains 
 bard, the metamorphic process is active and no 
 further injection will be necessary. Should the 
 tumor, however, begin to show evidence of soften- 
 ing with visible formation of a new blood supply, 
 an immediate injection is indicated.* 
 • The course of an angioma successfully injected 
 is one of gradual diminution, the greatest progress 
 being made from the second to the third week. A 
 tumor the size of a hen's egg will usually require 
 six to eight weeks for its disappearance. If the 
 injection has been a fortunate one, i. e., free from 
 accident, such as cicatrization* following slough- 
 ing, the site that once harbored the angioma will 
 appear healthy and quite normal. 
 
 It is advisable that a general anesthetic be ad- 
 
 *A successful obliteration can only be accomplished by granular 
 metamorphosis, made possible by the coagulation of the blood and albu- 
 minoids; i. e., the effect of the boiling water in the tissues is to speedily 
 bring about' vascular blockade, lymph infiltration, and cell retrograde, 
 followed by restoration to healthy conditions. 
 
52 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 ministered. The assurance of greater accuracy in 
 administering the injection is thereby given. 
 Sometimes, however, a general anesthetic may 
 carry with it elements of danger, as has been the 
 case in a cirsoid aneurysm, when the anesthetic 
 had to be discontinued for fear of bursting the 
 tumor. I have repeatedly given the injection 
 without an anesthetic and was astonished that the 
 pain was not more severe. 
 
 A Case of Plexiform Angioma 
 (Cirsoid Aneurysm) 
 
 (See Figs. 18 and 19.) 
 
 J. W., age forty-three, a carpenter, struck the 
 frontal portion of his head against a joist six 
 years ago. Two years later he noticed a swelling 
 in his forehead which gradually became larger, 
 spreading beyond the hair margin onto the scalp. 
 During the last six months, he suffered much with 
 dizziness and noises in his head. 
 
 Examination revealed a tumor mass involving 
 the frontal region back to the coronal suture. 
 Laterally the swelling extended to the temporal 
 ridge. The tumor mass was evenly distributed. A 
 hand placed flat upon the forehead would give a 
 good idea of its size. 
 
 The tumor was bluish in color and the undula- 
 tions of its surface gave it a convoluted appear- 
 ance. All vessels leading to it were tortuous and 
 
TREATMENT WITH BOILING WATER Od 
 
 filled to such an extent as to make them appear 
 abnormally large. Distinct pulsations in the vas- 
 cular tumor were perceptible and a marked 
 aneurysmal bruit and fremitus were present. 
 
 There was considerable destruction by attrition 
 of the outer table of the skull. 
 
 Pig. 18. — J. W., age forty-three years. Plexiform angioma 
 (cirsoid aneurysm) of forehead. Injected with five ounces of 
 boiling water at one sitting. Seven weeks later the tumor had 
 disappeared. 
 
 On August 10, 1917, under a general anesthetic, 
 this tumor mass was injected with five ounces of 
 boiling water. As soon as the water was intro- 
 
54 
 
 CAVERXOIS AXI) PLEXIFOIt.M AXGIOMATA 
 
 duced into the cavity of the tumor, pulsation 
 ceased. The doughy feeling of the mass gave evi- 
 dence of thorough coagulation of the blood. 
 
 An edema began to develop immediately. In 
 two days it had reached its height. It involved 
 
 Fig. 19. — J. W. Plexiform angioma (cirsoid aneurysm). 
 Appearance of patient shown in Fig. 18, two months after 
 injection. 
 
 the upper half of the face, closing both eyes. After 
 the third day, the edema subsided rapidly, and 
 the patient was able to leave the hospital on the 
 fifth day. 
 
TREATMENT WITH BOILING WATER 00 
 
 Seven weeks later, all evidence of the cirsoid 
 aneurysm had disappeared. There was only a 
 slight thickening- discernible at its former site 
 and that was undoubtedly due to an infiltrated 
 periosteum. The dizziness and noises in the head 
 had disappeared. 
 
 A Case of Cavernous Angioma 
 
 (See Figs. 20, 21, and 22.) 
 
 Miss G., age thirty-three years. Left upper eye- 
 lid harbors an angioma as large as a lien's egg. 
 A picture of the patient taken when two years old 
 shows the left eye closed by a tumor mass in the 
 upper eyelid. The sight in the left eye, though 
 weak, is normal, the tumor, however, robbing the 
 patient of its usefulness. 
 
 At the age of fifteen years, an operation, by a 
 skillful surgeon, was performed. The operative 
 measure consisted in the ligation of vessels leading 
 to the angioma. There was a slight improvement, 
 but not enough to open the eye. 
 
 A year later, the condition getting worse, i. e., 
 the vascular tumor enlarging, another operation 
 of a similar nature to the previous one was per- 
 formed. No improvement. 
 
 In October, 1914, the patient went to a New 
 York surgeon to subject herself to the radium 
 treatment. This treatment was refused, injury to 
 the eye being feared. An operation at St. Luke's 
 
56 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 Fig. 20. — Miss G. A typical angioma of the left upper eyelid 
 since babyhood. Three extensive operative measures were un- 
 successful. The condition of the cicatricial tissue resulting from 
 these operations inhibited to some extent the action of the boil- 
 ing water. However, three injections covering a period of seven 
 months brought about a most gratifying result. (See detailed 
 history.) 
 
TREATMENT WITH BOILING WATER 
 
 .)< 
 
 Hospital was performed instead. This operation 
 gave considerable improvement. Patient was able 
 to slightly elevate the upper eyelid. 
 
 Fig. 21.— Miss G. Full view of ease shown in Fig. 20. The 
 result after three injections of boiling water covering a period 
 of seven months. 
 
 This improvement lasted four months, when the 
 blood tumor again began to show evidence of 
 enlarging. 
 
58 
 
 CAVERNOUS AND FLEX I FORM ANGIOMATA 
 
 Iii July, when I saw the patient, a bluish mass, 
 very soft to the touch and about as large as a 
 hen's egg, appropriated the upper eyelid. 
 
 fig. 22. — Miss G. Lateral view of case shown in Figs. 20 
 and 21. The result after three injections of boiling water cover- 
 ing a period of seven months. 
 
 There were numerous scars in the immediate 
 vicinity of the eye, evidences of former opera- 
 tions. There was a very conspicuous cicatrix 
 
TREATMENT WITH BOILING WATER 59 
 
 along the orbital ridge, evidently the remains of 
 an attack on the supraorbital artery. 
 
 The location of the angioma made the boiling- 
 water treatment a rather hazardous undertaking. 
 Under extraordinary precautions, three injections 
 were given, covering a period of seven months 
 (the first injection was given July, 1915, the last 
 February 1, 1916). Owing to the great amount of 
 cicatricial tissue about the angiomatous area, the 
 influence of the boiling water was to some extent 
 interfered with. Nevertheless, the angioma was 
 made to disappear. The patient is now able to 
 open her eye to two-thirds normal. The color of 
 the skin is almost normal. 
 
 The sight of the eye, which at first was very 
 weak, is being gradually restored with the aid of 
 a proper lens. 
 
 Case History of Mr. F. in Detail 
 
 (See Figs. 23 and 24.) 
 
 A carriage painter, never seriously sick, was 
 referred to me by Dr. C, Quincy, Illinois. 
 
 As far back as fifteen years^ he had experienced 
 attacks of dizziness. During the last two years he 
 had been unable to follow his trade as carriage 
 painter on account of the severity of these at- 
 tacks. Has had a small swelling behind his ear as 
 long as he could remember. Four years ago the 
 swelling had grown to such a size that it crowded 
 
GO 
 
 CAVERNOUS AND FLEX I FORM ANGIOMATA 
 
 Fig. 2'.i. — Mr. F., age thirty-two years. Cirsoid aneurysm be- 
 hind rijiht ear extending well down on neck. This patient had 
 been subjected to a surgical measure with almost fatal results. 
 Two injections were sufficient to cause obliteration of the an- 
 gioma. First injection, March 14, 1909, 6 ounces. Second in- 
 jection, April 18, 1909, -4 ounces. Tumor mass disappeared by 
 June 1, 1909. (See detailed history.) 
 
TREATMENT WITH BOILING WATER 
 
 61 
 
 Fig. 24.— Mr. 
 June 1, 1909. 
 
 F. Appearance of patient shown in Fig. 23, 
 
62 CAVERNOUS AND PLEXTFORM ANGIOMATA 
 
 his right ear forward and extended into his scalp 
 and down upon his neck. 
 
 The condition of the tumor mass when he 
 consulted me, March, 1900, presented these char- 
 acteristics: Extending from the midparietal re- 
 gion near the center of ossification on the right 
 side down to the clavicular region, the tumor oc- 
 cupied the entire right half of the occipital region, 
 crowding the right ear markedly forward. The 
 contour of the tumor was clearly defined. The 
 mass proper was elevated to a level with the helix 
 of the ear. That portion of the tumor involving 
 the neck was of a bluish discoloration. Upon pal- 
 pation a distinct pulsation and a bruit were readily 
 detected. 
 
 With the application of pressure the contents 
 of the swelling could be forced out easily. Upon 
 releasing the pressure the tumor promptly reap- 
 peared. With touch the roughened bone margins 
 and many irregularities of the skull underlying the 
 tumor could be distinctly discerned. This destruc- 
 tion of bone was caused by attrition of the pulsat- 
 ing mass. 
 
 About the lower pole of the tumor were a num- 
 ber of cicatrices, the result of an attempted opera- 
 tion. The patient informed me that he almost 
 perished from loss of blood when the operation 
 was undertaken. 
 
 The condition of this patient was one of extreme 
 distress. The ringing and noises in his right ear 
 
TREATMENT WITH B01LIXG WATEK 0O 
 
 were incessant. He was unable to be on his feet on 
 account of vertigo and was compelled to sleep in 
 a sitting posture. 
 
 An attempt was made to administer an anes- 
 thetic preparatory to the injection of boiling water. 
 This, however, was found to be too hazardous a 
 procedure, the influence upon the tumor mass be- 
 ing such that it appeared as though it would 
 burst. 
 
 The injection of hot water was made without an 
 anesthetic, and about six ounces were introduced. 
 In making the injection, all factors of safety were 
 considered: the scalp had been shaved and 
 cleaned, and during the injection peripheral com- 
 pression was diligently exercised. 
 
 The needle was first introduced at the lower 
 pole in the neighborhood of the vessels that led 
 .into the tumor. As soon as there was evidence of 
 coagulation, following the injection, the needle 
 was withdrawn and reinserted into the tumor ;it 
 a different site. The needle was introduced about 
 one-eighth inch from the mass. In this manner 
 the whole of the tumor base was injected. After 
 six ounces of hot water had l^een introduced into 
 the mass it ceased to pulsate. While the injec- 
 tions were being given, cloths wrung out in ice 
 water were frequently applied to the mass, which 
 had become quite hot. 
 
 The condition of the patient following the first 
 injection, exclusive of the enormous swelling that 
 
()4 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 followed (the edema involved the right side of the 
 face, closing the right eye, and encroached upon 
 the neck, throat, and chest), was very encourag- 
 ing. He appeared more comfortable, the ringing 
 in his ear had ceased, and he was able to lie in 
 bed. At the end of four weeks the growth had 
 diminished to less than half its size. The patient 
 could sleep well and was able to walk about with- 
 out experiencing dizziness. A second injection of 
 about four ounces of hot water was given at that 
 time. Six weeks later the tumor mass had 
 practically disappeared, excepting a small mass 
 the size of a pigeon's egg at the angle of the man- 
 dible which had the appearance of an enlarged 
 gland. An attempt was made to inject it, but the 
 substance was found to be too resistant. 
 
 Case History of Miss S. in Detail 
 
 (See Figs. 25 and 26.) 
 
 Always in good health, with splendid physical 
 proportions, suffered much from periods of 
 marked depression. Since childhood had a small 
 bluish spot on her upper lip and immediately be- 
 low left eye upon malar prominence. Seven years 
 ago the bluish spot on the lip began to enlarge. 
 It continued to grow very gradually and was the 
 size of a tangerine when she presented herself 
 to me June 6, 1906. 
 
 This was the condition of her face. The right 
 
TREATMENT WITH BOILING WATER 
 
 65 
 
 Fig. 2."). — Miss S., age twenty-four years. Angioma of left 
 cheek and upper lip. Ligation method with loops of silk tried 
 and failed. Five injections of boiling* water and one injection 
 of alcohol obliterated the tumor mass. First injection, June 25, 
 1906, 4 ounces. Second injection, August 2, 1906, 3 ounces. 
 Third injection, August 18, 1906, 2 ounces. Fourth injection, 
 August 30, l!?06, 1 ounce. Fifth injection, September 25, 1906, 
 I ounce. Sixth injection, October 8, 1906, 1 ounce. Alcohol 
 was substituted for boiling water on account of fear of too 
 great a contraction with a possible deformity about the lip. 
 (See detailed history.) 
 
66 CAVERNOUS AND PLEXIFORM AX(i K ).M ATA 
 
 side, excepting two-thirds of the portion of the 
 upper lip, was normal. The left side showed a 
 marked swelling of the cheek which pushed up the 
 lower eyelid and encroached upon the left ala of 
 the nose. About the malar prominence was an 
 elevated bluish spot as large as a pea. The left 
 nostril was considerably flattened, about one-half 
 normal. Two-thirds of the cheek showed involve- 
 ment in a tumor mass that hung down over the 
 under lip within one-quarter inch of the margin 
 of the lower jaw. The tumor mass was of a 
 dark blue discoloration and was convoluted. Upon 
 stooping, this mass would increase in size very per- 
 ceptibly. The swelling was soft, the skin covering 
 it appearing very thin to the touch. Upon ] pres- 
 sure it could readily be made smaller by forcing 
 the blood out of it. The evidence that there were 
 cavities filled with fluid was unmistakable to the 
 touch. The protrusion of the tumor was such that 
 it was on a level with a line drawn from the tip of 
 the nose across the cheek and down to the chin. 
 The lower lip and the chin showed atrophic 
 changes corresponding to the shape and contour 
 of the tumor, caused by pressure of the overhang- 
 ing mass. The incisor and canine teeth of the up- 
 per jaw had long been destroyed by the constant 
 attrition of the tumor. Within the mouth there 
 could be seen large bluish masses of mucous mem- 
 brane lying between the molar teeth and filling 
 about one-third of the cavity of the mouth, caus- 
 
TREATMENT WITH BOILING WATER 67 
 
 Fig. 26. — Miss S. Appearance of patient shown in Fig. 25, 
 December 1, 1906. A slight scarring of upper lip occurred, the 
 result of a superficial slough. The scar was excised a year later. 
 
68 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 ing an impediment of speech. Fear of biting this 
 mass during mastication and causing free bleed- 
 ing was a constant source of danger. It was a 
 great discomfort to the patient because of the dif- 
 ficulty in eating. The patient carried the tumor 
 in a sling partly because it relieved the weight 
 and partly because it hid from view the unsightly 
 mass. 
 
 Having had no previous experience with the 
 hot-water injection, I spoke very discouragingly 
 to her because I did not know how much good or 
 how much harm I might be able to do her should 
 I undertake to interest myself in her behalf. She 
 had consulted a number of physicians, good and 
 bad, during the past six years, seeking relief, but 
 invariably returned home downhearted and dis- 
 couraged. 
 
 The idea that occurred to me at first was to re- 
 duce the pendulous part of the tumor with the pro- 
 cedure that incurred the least amount of risk. I 
 thought this to be the ligation method — strangula- 
 tion by introducing loops of silk subcutaneously 
 along the mucocutaneous margin of the lip. With 
 a very small cambric needle I ligated the lower 
 third of the tumor. Small as the punctures were, 
 the bleeding was most obstinate, continuing for 
 sixteen hours. With the aid of ice and pressure it 
 was checked. The experiment demonstrated that 
 it was not the procedure to be followed. The 
 threads became infected and were removed on the 
 
TREATMENT WITH BOILING WATER 69 
 
 fifth day. After nine days the infection had sub- 
 sided. The condition remained the same, except- 
 ing that about one-half inch of the lip on the right 
 of the median line had contracted; furthermore, 
 hard nodules could be felt throughout the por- 
 tion that had been ligated. 
 
 The condition as it presented itself after two 
 weeks gave me considerable encouragement, and 
 I concluded to resort to the treatment of injecting 
 boiling wafer. The risks seemed to increase while 
 I was debating with myself as to the advisability 
 of using this method, and I spoke very frankly to 
 the patient of what might happen. This case 
 seemed to me to be one particularly prone to risks, 
 inasmuch as so much mucous membrane had to be 
 dealt with. To inject boiling water into spaces 
 filled with blood seemed to me an operation not 
 .free from danger. 
 
 The first injection, under aseptic precautions, 
 was made on June 25, 1906. Under ether narcosis, 
 four ounces of boiling water were injected into 
 the tumor. A small aspirating needle, three inches 
 in length, was inserted into the swelling through 
 healthy skin on the right cheek, about one-eighth 
 of an inch distant from the tumor margin and 
 about one-half inch below the nose. In making 
 these injections, the advice of Dr. Wyeth was 
 closely followed. All of the tumor was injected 
 excepting the portion on the inside of the cheek. 
 About ten minutes were required to inject the 
 
70 CAVERNOUS AND PLEXIFORM ANdlo.MATA 
 
 four ounces of boiling water. Time was lost by 
 not having been able to obtain a Wyeth syringe. 
 An ordinary glass syringe holding two ounces was 
 used, the aspirating needle being attached to the 
 syringe with rubber tubing. It was a clumsy way 
 of doing this work, but it answered the purpose 
 satisfactorily. The handling of boiling water is a 
 rather delicate task. 
 
 While the injection was being made, the pa- 
 tient's face was protected in the immediate vicin- 
 ity of the needle so that the boiling water which 
 was being forced out at the needle junction by the 
 confined steam would not scald the skin. The 
 hands of the operator were protected by a folded 
 towel. It did not serve the purpose well, and to 
 those who have occasion to handle boiling water I 
 would suggest the use of heavy duck gloves. 
 
 To anticipate as far as possible any danger 
 from embolism, peripheral compression was 
 made. In introducing the needle, it was carried 
 through the mass till the point could be distinctly 
 felt through the skin. The withdrawing of the 
 needle about one-half inch gave a reasonable 
 amount of assurance that the boiling water could 
 be forced gently into the affected area with 
 little danger of provoking sloughing. The 
 needle was introduced in four different places at 
 various angles. In some places the integument 
 turned pale, in others an ashen gray, while the 
 water was being injected into the tumor. The 
 
TREATMENT WITH BOILING WATER ( L 
 
 beat of the water could be very distinctly felt 
 through the tissues — they were hot. 
 
 After the operation the patient was put to bed. 
 The following day the left side of the face was 
 very much swollen, but not painful. The left eye 
 was partially closed. A large blister had formed 
 along the mucous border of the lip. The tumor 
 felt hard to the touch. There was a slight rise in 
 i em] icrature (99.6° ) . Two days later the tempera- 
 ture returned to normal. The patient left the hos- 
 pital on the fifth day. On July 26 a large scab 
 which had formed on the lip margin was removed. 
 The whole tumor was hard, excepting about two- 
 thirds of the tumor mass inside of the cheek. 
 Diminution by granular metamorphosis had re- 
 duced the tumor to one-half its original size. I 
 wish to state here that a linear sloughing of the 
 skin occurred which extended from the ala of the 
 Left nostril to the margin of the lip. It resulted in 
 a cicatrix that was but slightly disfiguring. This 
 scar was removed subsequently. 
 
 On August 2, under ether anesthesia, the buccal 
 mucous membrane was injected with three ounces 
 of boiling water. The outcome was most favor- 
 able, only a small slough resulting. 
 
 On August 18, under ether anesthesia, two 
 ounces of hot water were injected into the lip. 
 Some difficulty was encountered in introducing 
 the needle on account of the hardened condition 
 of the tissues. 
 
72 CAVERNOUS AND PLEXIFORM ANGIOMATA 
 
 On August 30, without anesthesia, one ounce of 
 boiling water was injected into the buccal mass. 
 
 On September 15 conditions began to take on a 
 normal appearance. 
 
 On September 25, without anesthesia, one ounce 
 of boiling water was injected into the outer por- 
 tion of the lip, which still appeared quite large. 
 Ten days later the lip was almost normal. 
 
 On October 8 an injection of one ounce of alco- 
 hol* caused the lip to assume so nearly a normal 
 condition that further intervention was deemed 
 unnecessary and the patient was discharged. 
 
 *In substituting alcohol for boiling water, I wish to state that I feared 
 too much contraction might take place with the use of boiling water and 
 cause a deformity of the lip. In this assumption a more extensive experience 
 now convinces me that I was in error. The alcohol injection was not nec- 
 essary, and did not influence the condition. It was the time given to 
 metamorphosis that brought about the result. 
 
INDEX 
 
 Advisability of giving an anes- 
 thetic, 51 
 Aneurysm, cirsoid, 52 
 Angioma, nevus complicating, 
 41 
 
 time required to disappear 
 after an injection, 50 
 Angiomata, behavior of, after 
 injection of hot water, 
 50, 51 
 
 capillary, 29 
 
 cavernous, IS 
 
 classification of, 17 
 
 location of, 19 
 
 pain in connection with, 19 
 
 of the tongue, dangers of in- 
 jecting, 35 
 
 plexiform, clinical character- 
 istics of, 28 
 
 theory of, 17 
 
 various methods other than 
 surgical used to destroy, 
 32 
 Arrangement of operating 
 mom, 45 
 
 B 
 
 Barensprung's view, 29 
 Behavior of an angioma after 
 
 hot-water injection, 50, 
 
 51 
 
 Boiling water used in conjunc- 
 tion with Pacpielin cau- 
 tery, 41 
 
 Boiling water, Wyeth method of 
 injecting, 32 
 
 Capillary form of angioma, 29 
 
 Care in injecting an angioma of 
 the lip, 35 
 
 Care in injecting tip of the 
 nose, 49 
 
 Characteristics of cavernous an- 
 giomata, 18 
 
 Characteristics of plexiform 
 angiomata, 19 
 
 Cicatricial tissue, a serious ob- 
 stacle to the injection of 
 hot water, 59 
 
 Cirsoid aneurysm, 52 
 
 Classification of angiomata, 17 
 
 Clinical characteristics of a cav- 
 ernous angioma, 18 
 
 Cork-protected needle, 45 
 
 D 
 
 Danger of injecting angioma on 
 
 the tongue, 35 
 Dangers of injecting boiling 
 
 water into an angioma, 
 
 36 * 
 
 73 
 
74 
 
 INDEX 
 
 Edema of adjacent tissues fol- 
 lowing injection, 50 
 
 Pace, protection of, 45 
 Force used in injecting hot wa- 
 ter, 45-48 
 
 H 
 
 Hands, protection of, while 
 making injection, 43 
 
 injection of boiling water, dan- 
 gers of, 36 
 syringe for, 41 
 technic for, 41 
 Wyeth method, 32 
 Injection of hot water, edema 
 of adjacent tissues fol- 
 lowing, 50 
 force used in, 45-48 
 quantity to be used at one 
 
 time, 49 
 time consumed in making the, 
 49 
 Injections of hot water, subse- 
 quent, when indicated, 
 49 
 Introduction of the needle and 
 force used in injecting 
 hot water, 45-48 
 
 Jacketed syringe, 4J 
 
 Lip, care in injecting angioma 
 
 on the, 35 
 Location of angiomata, 19 
 Larry's theory, 30 
 
 N 
 
 Needle, cork-protected, 45 
 introduction of, 45-48 
 size and character of, 43 
 Nevus complicating an an- 
 gioma, 41 
 Nose, care in injecting tip of 
 the, 49 
 
 O 
 
 Operating room, arrangement 
 of, 45 
 
 Pain in connection with an- 
 giomata, 19 
 
 Paquelin cautery, boiling water 
 used in conjunction with, 
 41 
 
 Plexiform angiomata, clinical 
 characteristics of, 28 
 
 Protection of hands while mak- 
 ing injection, 43 
 
 Protection of patient's face, 45 
 
 Quantity of hot water to lie in- 
 jected at one time, 49 
 
INDEX 
 
 75 
 
 R 
 
 Ribbert on the genesis of an- 
 giomata, 30 
 
 S 
 
 Salient points to be considered 
 in the treatment of an- 
 giomata, 31 
 
 Simon's theory, 30 
 
 Size and character of needle, 
 13 
 
 Strangl's argument, 30 
 
 Subsequent injections, when in- 
 dicated, 49 
 
 Syringe for injecting boiling 
 water, 41 
 
 Syringe, jacketed, 43 
 
 T 
 
 The ny of angiomata, 17 
 
 Time consumed in making in- 
 jection, 49 
 
 Time required for an angioma 
 to disappear after injec- 
 tion, 51 
 
 Tongue, danger of injecting an 
 angioma of the, 35 
 
 V 
 
 Various methods other than 
 surgical used to destroy 
 an angioma, 32 
 
 Virehow's theory of the origin 
 of angiomata, 30 
 
 W 
 
 Teehnic of injecting boiling Wyeth method of injecting boil- 
 water, 41 ing water, 32 
 
6 It 
 
 
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