[Reprinted from The Medical News, Aug. 14, 1897.] ARTERIAL VARIX OF THE LOWER LIP, INI/OLIY- IIV G THE CORONARY ARTERIES: EX- TIRPATION UNDER COCAIN ANESTHESI A. RUDOLPH MATAS, M.D., PROFESSOR OF SURGERY IN THE MEDICAL DEPARTMENT OF TU- OF NEW ORLEANS, LA.; Acquired aneurismal disease or varix of the coronary arteries must be a very rare condition when we consider the ample provision made by nature to prevent undue stretch- ing of the arteries in this particular area. The arteries of the face, as we know, are normally tortuous and wavy, in order to allow for the continuous mobility of the face and the almost incessant exercise of the muscles which are brought into play in the formation of expression, in mas- tication and in vocalization. The lips, in addition to being highly valuable prehensile organs, are indispensable in the exercise of many musical and other vocations. Of those that require the mastery of special instruments there are few which more seriously tax the muscular and circula- tory apparatus of the lips, especially the more mobile lower hp, than cornet playing. In performing upon this instru- ment not only is a certain configuration and thickness of the oral orifice very desirable but almost necessary. The lips must adapt themselves to the mouthpiece of the instrument and not the mouthpiece to the lips. While playing, the lips are firmly compressed by the circular edge of the mouthpiece, and in this way the mucous membrane is gradually forced and prolapsed into the nar- row funnel. By the combined pressure of the metallic rim and protracted constriction of the circular sphincter a condition of corrugation and puckering, followed often by slight edema of the projecting mucous membrane con- LANE UNIVERSITY. tained in the mouthpiece takes place, which is very stri- king to any one who will remember the appearance of the mouth of a cornet-player immediately after a long per- formance. This puffy and edematous condition is, in fact, necessary for effectual playing in some cases, and, if I am not mistaken in my information, it is cultivated by professional musicians, who often practice with the sole view of adapting their mouths to their work when- ever any especially difficult performance is expected of them. Nevertheless, arterial disease of the lips as the result of cornet-playing is certainly a rare condition: at least I know of no instances similar to the one which I report herewith. I have made no special inquiry upon the subject, but numerous systematic writers whom I have consulted fail to mention arterial varix of the lip as a sequel to this or any other mode of labial exercise or traumatism. During the summer of 1895 I was consulted by Mr. J. W., forty-two years of age, a professional cornet-player in one of our local theaters, on account of a peculiar pul- sating swelling which affected his lower lip. About seven months before consulting me he noticed that his lower lip “ throbbed ” considerably after any long performance upon his instrument, and that the lip remained slightly swollen for some time after he had ceased playing. He did not pay much attention to this at first, but the throb- bing became so persistent that it annoyed him. It was scarcely perceptible after a few hours’ rest, but it always recurred immediately after playing. As there was no pain or positive evidence of inflammation he did not seek advice until he realized that the condition ultimately would disable him. When he consulted me his lip presented, externally, a perfectly normal appearance. Upon stretching the lip and examining its inner surface I recognized a slight eleva- tion in front of the frenum labii, which pulsated very dis- tinctly. By pressing the lip between the thumb and index- 3 finger the existence of pulsation was confirmed and its area of distribution distinctly traced out toward the com- missures. The cause of the trouble evidently was an en- larged coronary artery which was especially dilated at the usual point of anastomotic communication in the middle line. The enlargement at this point caused the usually small and invisible coronaries to feel as large as the facial artery itself. The course of the dilated vessel could be distinctly traced in the submucous tissue by sim- ply stretching the lip and passing the pulp of the finger gently over the surface. It was evident that it was the inferior coronary circle which was enlarged and that a few other collateral vessels participated in the dilatation. I decided to cocainize the lip and extirpate the dilated arteries. A i -per-cent, cocain hydrochlorate solution (at that time the use of Schleich’s weak solutions had not been introduced) was injected at the commissure of the lip and along the line of the pulsating vessels. Ice was applied and the infiltration edema allowed to subside. The lips were kept very tense by an assistant, who also controlled the blood supply. With a fine and very sharp scalpel the mucous surface was carefully incised on one side of the dilated vessel and the edges of the incisions raised with dissecting-forceps. In this way a tortuous and rather thick vessel was brought into view. A blunt hook was then inserted under it and the vessel was soon detached from its loose connective-tissue surroundings. By pulling on the artery its course was easily traced to each commissure and the overlying parts were cut with sharp-pointed scissors. Two collateral ramifications, also dilated, were followed on each side of the frenum and ligated. After removal, the chief artery curled up and contracted to about iYt cm., or one-half its original size. The vessel walls were unusually thick and were undoubtedly in a state of endarteritis. The incision required for the extirpation was readily closed by a few 4 interrupted catgut stitches. The use of a mild antiseptic mouth wash and a weak peroxid of hydrogen spray was the only after treatment. The wound healed readily and the patient was advised not to play for at least two months. He has since resumed his regular occupation and has played during two winters in succession without experi- encing the least inconvenience. The interest in the case centers in the fact that this was an acquired or pathologic varix, not nevoid,—simply a dilatation of a distinct arterial trunk and a few collat- eral branches. It probably was associated with the special exercise to which the lip was subjected, and in this way differed essentially from the nevoid and other forms of congenital or acquired angioma which are so fre- quent in this region.