Pfili^'i'l" -;;'^^ G 000 005 431 2 ON THE SUEGERY OF THE EACE By the same Author, HARE-LIP AIJD CLEFT PALATE. With 66 Engravings, 8vo, 63. ON THE SUEGEEY OF THE FACE FRANCIS MASON, F.R.C.S., SUEGEON, AND LECTTIREE ON ANATOMY AT ST. THOMAS'S HOSPITAL I HON. FELLOW OF KING'S COLLEGE, LONDON, ETC. WITH ONE SUNDEED ILLUSTRATIONS LONDON J. & A. CHUECHILL, NEW BURLINGTON STREET 1878 /?7? TO THE PRESIDENT (GEORGE BUCHA.NAN, M.D.), COUNCIL, AND FELLOWS OF THE MEDICAL SOCIETY OF LONDON, f I]is JBfllttm^, COMFKISING THE LETTSOMIAN LECTURES DELIVEEED DUHING THE SESSION 1877-78, VERY RESPECTFULLY DEDICATED. PEEFACE. The three lectures contained in the accom- panying volume were delivered at the Medical Society of London in the early part of this year, and were subsequently published in the pages of the ' Lancet.' In obedience to the flattering re- quest of several Fellows of the Society and other friends I now venture to reproduce them collec- tively in the hope that they will receive the kindly judgment and favourable consideration of my pro- fessional brethren. In order to facilitate reference I have prepared a full index of contents, which will be found at the end of the work. FRANCIS MASON. 5, Brook Street, Grosvenor Square ; October, 1878. THE SUEGEEY OF THE FACE LECTURE I. DISEASES OF THE FACE. Mr. President and Gentlemen, — My first and most obvious duty is to express to the Council my sincere thanks for the honour they have conferred upon me by electing me as the Lettsomian lecturer for the current session. I must confess that whilst I am deeply sensible of the compliment that has been paid me, I am at the same time profoundly conscious of the respoDsibility that so distinguished a position involves. In contemplating how I might best occupy the time allotted to the three lectures that I shall have the honour of delivering, I remembered that for many years I had taken considerable interest in the surgery of the face, mouth, throat, and contiguous 1 2i THE SURGERY OF THE FACE. parts, and, as I bad collected several thousand references bearing on these regions^ — representing, as may be supposed, an immense amount of valuable information — I came to the conclusion that if I sifted some of these references, I might be enabled to submit to the Fellows of the Society many points of more than ordinary or passing interest. I ven- ture therefore to engage your attention by describings as far as my limited time will allow, the surgery of the face, and in bringing this subject before you, I must beg your kind indulgence, inasmuch as I shall necessarily have to refer to many topics with which I feel sure you are all more or less familiar ; and I wish to say, at starting, that my object is not to excite sensation, or to provoke controversy by placing before you novelties, but is rather to group toofether a number of cases I have culled from various sources, including many that have been under my own observation, and which have special reference to the surgery of a region which from its conspicuousness forms a very important part of the human body. My first lecture will be devoted to the diseases, the second to injuries, and the third to the deformi- ties of the face. In order to render my subject as complete as possible, it will be necessary for me to make a few observations on skin diseases, and these need not detain us long. the surgery of the face. 3 Erythema, Roseola, and Urticaria. These diseases are not unfrequently met with on the face, and resemble each other in many par- ticulars. Erythema. In erythema the face is covered more or less with blotches of either a bright red or bluish hue. The eruption depends upon various causes, into which I need not now enter, but I may make a passing reference to the peculiar erythematous blush that is occasionally noticed on the body after surgical operations even of the most trivial kind. The face often participates in the general eruption, which has almost a scarlatinal character. It is amenable to simple treatment, and is chiefly important from a diagnostic point of view. Erythema circinatum is particularly seen on the chin and lips, and appears as distinct circles, or segments of circles. Erythema nodosum is sometimes observed on the forehead, and very much resembles the same disease noticed on tbe front of the legs in delicate women. It has been mistaken for nodes, but with a little care a correct diagnosis may be arrived at. Roseola. In roseola there is less swelling of the skin. The eruption is first of a bright red, which gradually 4 THE SURCxERY OF THE FACE. subsides into a deep rosy hue. In this disorder there is more or less redness about the palate and fauces. Urticaria. Urticaria or nettle-rash is sometimes limited to the face, and seems to be an aggravated form of erythema or roseola, its characteristic point being the presence of a number of elevations or wheals of variable shape, which are produced by spasm of the muscular fibres of the skin, with a slight effusion of serum. Mr. Erasmus Wilson has pointed out that in the wheals of urticaria an alternate contraction and relaxation of the muscular fibres may be observed, which gives an appearance of pulsation, as of an ebb and flow of blood in the capillary vessels.* All these eruptions may, in most instances, be traced to some error in diet, and are prevalent at particular seasons of the year, especially if there be sudden alternations of temperature. I need not add that certain medicines produce similar erup- tions. As a rule these diseases require but little treatment beyond attention to diet, with the admin- istration of saline purgatives, alteratives, and suit- able tonics. Lichen. Lichen is often found on the face of infants and * ' Diseases of Skin,' p. 264. THE SURGERY OP THE FACE. 5 children, and seems to be due to tlie irritation caused by teething. The eruption is easily recog- nised, and if the finger be passed lightly over the skin of the part affected, the cutaneous surface feels like a delicate nutmeg grater. There is generally more or less erythema present. In simple cases the eruption undergoes desquamation, and thus a cure is effected, whereas in the more severe forms, as in lichen agrius, there is considerable inflam- matory action, inducing a copious serous discharge, almost amounting to eczema, and accompanied by much constitutional disturbance. Herpes. Herpes is commonly met with on the face, at- tacking chiefly the lips, eyebrows and ears. The vesicles, which are dome-shaped, appear in groups of patches, more or less circular in form. More- over, they are frequently found to coincide exactly with the cutaneous distribution of certain nerves. Thus, in one case reported,* the eruption was limited to the distribution of the left supra-orbital nerve, and throughout showed its distinctive nerve character. Five days before the eruption appeared there was constant neuralgia in the exact course of this nerve. The vesicles ran upwards over the forehead, and as far as the top of the head, in a * ' Brit. Med. Journ.,' May 5, 1866, p. 470. b THE SURGERY OF THE FACE. longitudinal direction. The eruption was markedly limited to the left side of the forehead and head, the side of the nose, and to the left upper eyelid. Sir James Paget has placed on record * an interest- ing example in which the parts supplied by the second division of the right fifth cerebral nerve were implicated. In this instance, as in the pre- vious one, extreme pain preceded the eruption. This case was, moreover, considered unique in having necrosis of the jaw as a consequence of the intense inflammation of the palate and gums. Twenty-six days from the commencement of the disease one of the bicuspid teeth of the right side of the upper jaw fell out, on the next another, and in a few days later the canine and both incisors. The herpetic eruption was also noticed on the roof of the mouth. Eczema. The eyebrows and ears are no uncommon situa- tions for eczema. In this eruption there is a con- stant serous exudation, hence its title " humid tetter." The vesicles have a pointed or acuminated form, and if the disease remain unchecked, it assumes a somewhat purulent character, bordering on impetigo, and known as eczema impetiginodes, * ' Brit. Med. Jouru.,' Oct. 13, 1866, p. 402. THE SUKGEBY OF THE FACK. 7 a disease frequently noticed on tlie alee of the nose and on the lips of ill-fed children. The eruptions of impetigo and ecthyma often co- exist, and I need hardly add that their main differ- ence is that in impetigo the eruption is generally confluent, whereas in ecthyma the pustules are soli- tary, and have an inflamed base. The constitutional treatment of these diseases must be conducted on general principles, but local applications are particularly suitable when there is much serous exudation. Ointments of a simple character, such as zinc ointment or compound sub- acetate of lead ointment, are especially serviceable, as they prevent evaporation, and thus obviate the production of scabs. Psoriasis and Lepra. These affections are occasionally met with on the face. They are characterised by their dryness, and in this respect difier essentially from eczema. Psoriasis that follows the infecting or true syphi- litic sore does not, I venture to believe, commonly afiect the face, and when this part is attacked, the inference is, as I think, that the patient has been rather severely poisoned by the disease. The severity of the attack is further indicated by the eruption appearing simultaneously on the palms of the hands and the soles of the feet. From some 8 THE SURGERY OP THE FACE. cause the face and the dorsum of the hands — parts exposed to atmospheric influences and exposed also to observation — seem, fortunately for the sufferer, to possess comparative immunity. I may add that I have at the present time under observation four well-marked instances which serve to illustrate this point remarkably well. All the patients have patches of psoriasis which have manifested them- selves on the abdominal wall and on the flexor side of the forearms at the usual period after the appear- ance of the primary sore, but the eruption stops short at the wrist. In other words, these patients when dressed could not be accused of being the subjects of syphilis. One patient, referring to his condition, said, " I can and do mix in society as usual, but should not hke to join my friends at the swimming-bath." The administration of arsenic, iron, iodide of potassium, and the perchloride or other preparations of mercury, generally efiects a cure. Locally the white precipitate ointment may be advantageously employed. Parasitic Diseases. Of the parasitic diseases we have the type of the animal parasite in scabies, which is said by some authorities never to attack the face, but I am sure that it is occasionally found in this region. When THE SURGERY OP THE FACE. 9 it occurs in this part, Dr. Tilbury Fox* lias noticed that it is occasionally accompanied by sympathetic eczema about the scalp, and in children by ecthy- matous pustules. The tinece or vegetable parasites are not unfre- quently seen on the face. Thus ti7iea circinata is occasionally observed on the chin and on the cheek, as shown in the woodcut (Fig. 1, taken from a Fig. 1. photograph). Tinea decalvans manifests itself as bald patches on the skin in the region of the whiskers or beard, and tinea sycosis especially attacks the chin. I may say briefly respecting the treatment, that ointments containing sulphur are invaluable in scabies, and slight mercurial prepara- tions are useful in the different forms of tineee. * ' Skin Diseases,' p. 305. 10 the surgery of the face. Acne, The only other affection to which I need now refer is acne, which is perhaps the most common of all diseases of the skin of the face. Acne punctata appears as small black spots, which are the orifices of the sebaceous follicles blocked up with sebaceous matter, dirt, and soap. Its most usual situations are those that escape the friction of the towel after washing. Thus the disease is particularly noticed on the cheeks, beneath the prominence of the malar bone, between the chin and lower lip, on the side of the nose, in the temporal region, and especially in the concha of the ear. In acne sinipJex there is peri-follicular inflammation, and very often the black spots of acne punctata may be observed at the summit of the small pustules. In acne indurata the inflammatory action is of subacute character. Here the black spot is seldom observable, but instead there is a hard, somewhat diffused lump, which is readily appreciable to the touch. These varieties of acne are essentially diseases of early adult life, and are met with, as a rule, from puberty to about the age of thirty. They are often rebellious to treatment, but may be kept in abey- ance by the patient attending strictly to diet and by irritating the parts as little as possible. It is best not to wash the face more frequently than is THE SURGERY OF THE FACE. 11 absolutely necessary, and warm water alone, with- out soap, should be used. The part should be dried with a soft towel. A more active plan of treatment is, however, required in inveterate cases of acne, and the vigorous application of soft soap is highly recommended by some writers. Dr. Robert Liveing * finds that the following method of treatment succeeds in a large number of obstinate and troublesome cases : — 1st. The face should be steamed every night by holding it over a basin of hot water for a few minutes. 2nd. The skin should then be well rubbed for five or ten minutes with soap and flannel, or a soft nail-brush may be used with advantage when the skin will bear it ; the soap should then be sponged off with warm water. 3rd. When the face has been dried, a lotion composed of half an ounce of precipitated sulphur, two drachms of glycerine, one ounce of spirits of wine, three ounces each of lime-water and rose- water should be thoroughly applied and allowed to dry, and to remain on all night. If the skin is greasy, the addition of some ether to the lotion is an advantage. Acne rosacea seldom appears before the age of forty, and thus differs from the other varieties * ' Lancet,' Jan. 19, 1878, p. 83. 12 THE SURGERY OF THE FACE. already described. The face is especially its local habitation. It is observed partly on the nose, and extends laterally to the cheeks as a reddish patch, on which a few pustules are here and there scattered. Although it is often attributed by the ignorant to high living, it is very frequently an indication of imperfect digestion, and occurs, as is very well known, in persons of the most abstemious habits. Boils and Carbuncles. Boils and carbuncles occasionally attack the lips, cheeks, and forehead. They cause great disfigure- ment, and are attended with more or less, but sometimes a considerable amount of, pain. The more circumscribed swelling in a boil gives it its distinctive character, and it comes, from time to time, in this, as in other parts of the body, in crops, whereas carbuncle is usually solitary, and there is a diffuse, brawny, and peculiar hardness due to the arrangement of the soft structures com- prising the lips, cheeks, and neighbouring parts. With regard to local treatment the question of making incisions seems still to be sub judice. I venture to think that in most instances boils and carbuncles are better left to nature, the surgeon merely assisting by advising the free application of warm-water dressings. By this mode of treatment the surrounding parts become thoroughly relaxed. THE SURGERY OF THE FACE. 13 and thus the inflammatory products are more readily carried off. It is not often that facial carbuncle is followed by a fatal termination, yet Dr. Cockle brought before the notice of our Society in 1874 an example of death from this disease, which was situated on the left side of the upper lip.* Mr. Caesar Hawkins also reports a fatal case of a carbuncle which attacked the chin, and was as large as a tennis ball.f Both these patients died of pyaemia. Again, Mr. Thomas Smith has directed attention to two deaths from facial carbuncle. He attributed the fatality of this form of carbuncle to the susceptibility of the face to erysipelas and oedema, and also to the pecu- liarities of the venous circulation shown by the sudden deaths that have been occasionally noticed after injecting nsevi of the face with strong styptics, such as the tincture of the perchloride of iron. I Abscesses. Abscesses of idiopathic origin are not very common, but they are occasionally seen on the face, and the usual variety is that which is known as strumous abscess. It is of slow growth, and exists as a collection of sero-purulent fluid, imme- diately under a reddened, thin, and generally oblong * 'Proceedings of Med. Soc.,' vol. i, p. 163. t ' The Lancet,' Nov. 17, 1860, p. 487. X ' Brit. Med. Jouru.,' Jan. 22,1870, p. 94. 14 THE SURGERY OF THE FACE. portion of skin, the cheek being a common situa- tion. A good plan of treating these abscesses is to make a small opening in a dependent position, which allows the contents to exude spontaneously If, in addition, a pad of lint of suitable size be applied over the abscess, a re-accumulation of the matter is obviated. These abscesses are compara- tively painless, their progress is slow, yet even with the greatest care and attention they are frequently followed by ugly cicatrices, which are well shown in Fig. 2, taken from a photograph. Fig. 2. Fistulous openings on various parts of the face are not unfrequently met with as the result of decayed teeth, or of necrosis of the subjacent bones, the lower jaw, for example, as shown in the accom- THE SUEGERY OF THE PACE. 15 panying woodcut (Fig. 3), taken from a photograph. Or they may depend upon the presence of other foreign bodies, as in a case that was under the care Fig. 3. of Mr. Henry Smith, which was sent to him in the behef that there was necrosis of the jaw. After a careful examination, Mr. Smith discovered and removed a piece of tobacco-pipe, about three inches long, which had been imbedded in the cheek for several years.* Sometimes the disease may be traced to the antrum, as in a case that Dr. Richardson kindly placed under my care about two years ago. In operating on the patient I thought it advisable to * ' Assoc. Med Journ.,' Nov. 10, 1854, p. 1017. 16 THE SURGERY OF THE FACE. divide the upper lip in tlie median line, and having separated the soft parts from the bone I freely opened the antral cavity. A large quantity of offensive cheesy material was evacuated, and the patient made an excellent recovery. Figs. 4 and 5, Fig. 4. Fig. 5. THE SURGERY OF THE FACE. 17 taken from photographs, are intended, to show the condition of the patient before and after the opera- tion. Abscesses connected simply with the soft parts may be compHcated with erysipelas, but they are rarely dangerous to life. Dr. Bacon, of the Ful- bourne Lunatic Asylum, has, however^ placed on record an interesting example to prove that even death may occasionally occur in such cases. His patient was a lunatic who had an abscess of the cheek caused by a decayed tooth. In three or four days from the commencement of the attack the patient died comatose from the extension of the inflammation into the brain.* Ulcers. Ulcers of infinite variety are met with on the face, and are frequently the result of injuries by which the soft parts have become more or less damaged ; or they may arise idiopathically, as in rodent ulcer and epithelioma, of which I shall speak presently. t The cachectic ulcer is frequently found on the face. It begins as one or more hard lumps of vari- able size in the subcutaneous tissue, in which at first there is but little pain. To these indurations the name of " gummata " has been applied, and * ' Medical Times and Gazette,' Nov. 21st, 1868, p. 584. t See Clinical Lectures by author on "Ulcers," 'The Lancet,' September 15th, 1877. ^ 18 THE SURGERY OF THE FACE. thej are said to be usually due to syphilitic taint. There are, however, many examples of this ulcer, in which the history of syphilis is entirely wanting. Thus, I here show you several photographs of patients having such ulcers, and in none of these instances was there, as far as I could make out, the slightest trace of syphilis. Fig. 6 affords a good illustration of one of these patients. Fig. 6. Whilst on the subject of ulcers, I must not omit to refer to the possible presence of the true infect- ing syphihtic sore which has been met with on various parts of the face. These sores are impor- tant chiefly from a diagnostic point of view, for they have not unfrequently been mistaken for cancer, and have been treated accordingly. In illustration of this point, I may say that in 1872 I THE SURGERY OF THE FACE. 19 saw a man at the hospital, who was twenty-six years of age, and had been operated upon three times within two months for, as he said, cancer of the lower lip. When I saw him he had about his body the clearest evidence of constitutional mis- chief. What remained of the lower lip presented an uneven, jagged, white patchy appearance, which seemed to me, as well as to those who examined him, to be markedly characteristic of syphilitic infection. He was placed on the solution of per- chloride of mercury, and he recovered. His object in applying at the hospital was to undergo a further operation.* By the kindness of Mr. Royes Bell I am enabled to show you a photograph of one of his patients, having a well-marked infecting sore on the upper lip. Cysts, Cysts, or cystic tumours, of various kinds are frequently found on the face. Perhaps the com- monest variety is the sebaceous tumour, well repre- sented in Fig. 7 (taken from a photograph). Such cysts are of slow growth, and often present at their summit a black spot, as was the case in the patient just referred to. They are, as a rule, dome-shaped, and their outline differs in this respect from fatty * See a paper, by the author, on " Infecting Sores on the Lips," ' St. Thomas's Hospital Reports,' 1873. 20 THE SURGERY OF THE FACE. tumours, which generally present a more flattened form, and are seldom met with in this region. This Fig. 7. rough diagram (Fig. 8) is introduced to show the comparative appearance, on section, between a sebaceous cyst and a fatty tumour. Fig. 8. Cystic tumours are usually subcutaneous. Occa- sionally, however, as in the frontal region, they are THE SURGERY OF THE FACE. 21 submuscular, or subaponeurotic. Sometimes tliey are met with in connection with the mouth, or even with the cavity of the nose, as in a remarkable instance reported by Mr. Mungo Park,* in which the tumour, being so situated, displaced the nasal bones considerably. Their contents vary in cha- racter ; thus they may either be of cheesy consist- ence, being principally composed of cholesterine, fat, and epithelial scales, or they may be of a more fluid nature. Hydatid cysts are occasionally met with on the lips and eyelids, and the dermoid cysts are gene- rally situated in the region of the eyebrow, and often contain hair, as in this example (specimen shown), which I removed from a patient aged twenty -two. I am indebted to Mr. Wagstaffe for enabling me to show two drawings which illustrate the mode of origin of such cysts ; one was from the inner angle of the orbit, and the other from the temporal region. The best mode, in my opinion, of removing cystic tumours is to transfix them, by which a free open- ing is at the same time made into the cyst cavity. After the contents of the sac have been squeezed out, the cyst itself becomes more evident, and is easily dissected from the surrounding parts, with- out much haemorrhage, provided care be taken to keep the knife close to the sac. * ' The Lancot; 1841—42, vol. i, p. 88fi. 22 THE SURCtERY of THE FACE. The removal of cysts situated in the region of the brow is often attended with troublesome heemor- rhage which hampers the operator. It is well, under such circumstences, to suspend the operation for a few minutes until the bleeding has ceased. Fine silk stitches may be employed to bring the edges of the skin-wound together, or really good adhesive plaster is frequently all that is required. Such plaster may be obtained of Messrs. Savory and Moore, of Bond Street, or of Mr. Martindale, of New Cavendish Street. In children it is of special importance to bring the edges accurately together, in order to obviate a subsequent scar. Blood-tumours, or heematomata, are occasionally seen on the ears (Fig. 9) and are said to be fre- quently met with in insane and idiotic persons. In Fig. 9. THE SURGERY OF THE FACE. 23 referring to such cysts, Dr. Grriiber observes that, inasmuch as he has noticed finger-marks, these tumours may often be traced to rough handling either by the patients or by others.* Tumours. It would be obviously impossible for me to enter into a full description of the different varieties of tumours that have been met with on the face. I can, therefore, only refer to a few which appear to possess more than ordinary interest. Fatty Tumours. These are rarely observed on the face, and the exemption in this region is remarkably illustrated in a case reported by M. Danez. At a post-mortem examination of a man no less than 215 fatty growths were found in different parts of the body. The only situation that was quite free from such tumours was the face.f I happen to know at the present time a gentleman who has at least sixty such tumours on the arms, legs, and trunk, but he has none on the face. The diagnosis of fatty tumours is not at all times * See Lennox Browne's paper on " Othcematoma, or the Insane Ear," in 'West Riding Lunatic Asylum Reports,' edited by Ci-icMon Browne, vol. v, 1875, p. 149. See also ' Brit. Med. Journ.,' May 4tli, 1861, p. 469. t ' Med. Times and Gaz.,' October 27tli, 1866, p. 464. 24 THE SUEGERY OF THE FACE. easy, but a method has been suggested of solving the difficulty, which consists in applying ether or ice to the part, in the case of a doubtful tumour. If the growth is felt to become harder, the pre- sumption is that the tumour is fatty.* Fatty tumours under the eyebrow have been mis- taken for n{Bvi,t and a growth of this kind in the temporal region was regarded as an aneurism, for which the carotid artery was tied. Subsequently the patient died, and at the post-mortem examina- tion the true nature of the tumour was revealed.:]: Fatty tumours are occasionally met with either in the substance of the cheek or lying immediately under the mucous membrane of the mouth. Four years ago I removed a small growth of this kind through the mouth. It was, singularly, non-ad- herent to the surrounding parts, and consisted of soft fat. A tumour thus situated has been mis- taken for a cyst in connection with Steno's duct, as in a case under Mr. Ward's care at the London Hospital. § Fig. 10 shows a glandular tumour in the upper lip which I removed from a patient at the West- minster Hospital in 1868. The woman was forty- five years old, and was struck on the lip when she was four years of age. Mr. Goodhart has reported * ' The Lancet; August 2nd, 1873, p. 157. t ' Med. Times,' vol. xxviii, 1853, p. 630. + ' The Lancet,' vol. i, 1835, p. 689. S ' Med. Tiuies,' vol. xx, 1849, p. 451. THE SUKGEFvY OF THE FACE. 25 three cases of a somewhat similar cliaracter in the ' Pathological Transactions,' vol. xxviii, p. 213. Fig. 11. Fig. 11 represents a tumour of a myxomatous character which I took from a patient thirty-five 26 THE SURGERY OF THE FACE, years of age. It had been growing for about ten years, and was scarcely observable before operation, as he managed to hide it very cleverly with his whiskers. Tumours invading the parotid region are of con- stant occurrence. Some of them are a mere tem- porary enlargement due to inflammatory effusion, as in this case, taken from a photograph (Fig. 12), in Fig. 12. which the swelling disappeared after the applica- tion of tincture of iodine and the adoption of an alterative constitutional treatment. The more important tumours in this region, how- THE SURGERY OF THE FACE. 27 ever, consist, as a rule, of mixed glandular and car- tilaginous tissues, with here and there cyst-forma- tions. Such a case is shown in Fig. 13. The Fig. 13. patient was under my care at the Westminster Hospital. The tumour commenced as a small nodule about forty years before he came under observation, and after removal weighed over four pounds. The probability of return after removal of course depends upon the character of the tumour : for example, in some soft sarcomata recurrence takes place very rapidly, as in a case that was under the care of Mr. Barnard Holt, in which he performed two operations within twelve months. In other examples the growth increases very slowly ; thus, Mr. S. Jones removed a pendulous growth from the parotid region of a patient, aged fifty-eight, who 28 THE SURGEEY OF THE FACE. stated ttat twenty-eight years previously a tumour had been removed from about the same situation.* Perhaps one of the most remarkable tumours of this kind was that of which I show you photographs, operated on by the late Sir William Fergusson.f I assisted at the operation, and the sterno-mastoid muscle was found to be spread over the tumour, which weighed 9J lbs. There was considerable haemorrhage. Apropos of haemorrhage, I may add parenthetically that in dealing with parotid tumours it is as well, as a last step before their final removal, for the sur- geon to place a ligature on the vessels supplying the growth at the bottom of the wound. Without this precaution, the vessels are apt to retract, and are not easily secured afterwards. Even tumours having apparently a distinct pedicle often bleed very freely. Thus Mr. Hussey, of Oxford, removed a pendulous growth connected with the face weigh- ing 3 lbs., from a patient aged seventy-three, and the operation was, according to the report, attended "with profuse and almost fatal haemorrhage." J It is alleged that complete extirpation of the parotid has been practised, but, considering the anatomical relations of this organ, it seems almost impossible to effect its entire removal without * 'Path. Soc. Trans.,' 1872. t ' Practical Surgery/ 1870, Sth ed., p. 578. + ' The Lancet,' January 13th, 1877, p. 52. THE SUEGEEY OF THE FACE. 29 serious risk to the patient. However, Dr. Valen- tine Mott states * that the operation has been fre- quently performed ; and M. Marzolo, an Italian sur- geon, gives an account of the case of a woman, aged fifty, " from whom he had removed the entire parotid without injuring the facial nerve or the external carotid artery. "f Sir William Fergusson,J in recording his experience on this point nearly forty years ago, stated " that in no instance had he seen a case in his own practice to which the de- scription of extirpation of the parotid gland was applicable;" and writing more recently, in 1870, he adds, " that when tumours near the parotid are small, that gland is slightly compressed, and when large most of it has disappeared." § Sarcomatous Tumours. Sarcomatous tumours, in their varied forms, are not unfrequently observed on the face. Fig. 14, taken from a photograph, illustrates a case that was under my care at St. Thomas's Hospital two years ago. After removal, Mr. Stewart, the curator of the museum, kindly examined the growth micro- scopically, and pronounced it to be a round-celled sarcoma. The tumour recurred within a year, and * ' The Lancet,' 1842—43. t ' Gaz. Med. de Paris,' Jauuary 5tb, 1861, p. 9. X ' The Lancet,' 1842—43, vol. ii, p. 217. § ' Practical Surgery/ p. 574, 5th ed., 1870. 30 THE SURGERY OP THE FACE. in a few montlis after the patient died. Another and perhaps rarer form of tumour is the melanotic Fig. 14, sarcoma, of which I show you photographs. The patient was a man aged sixty-four, who was under my care at St. Thomas's Hospital in 1872.* He had a con- genital mole, which gave no inconvenience whatever for over threescore years. The tumour commenced to grow from the skin quite close to the mole, if not from the mole itself. The chief point of interest in the case was the probability of its recurrence after operation, for there were several enlarged glands in the right submaxillary region, which I endea- voured to remove, but the surrounding parts were so implicated that I was compelled to leave some of the disease. Nevertheless, the patient made a rapid and excellent recovery, and was quite well about a month ago, as I ascertained from his wife, whose * 'Brit. Med. Journ.,' October 4th, 1873, p. 393. THE SURGERY OF THE FACE. 31 letter, dated Dec. 3rd, 1877, is appended to the photographs I send round. There has therefore been no return of the disease for a period of over five years. Figs. 15, 16, and 17, show the patient Fig. 15. Fig. 16. before and ten days after the operation with the microscopic appearance of the tumour. 32 THE SURGERY OF THE FACE. Sir James Paget, in a lecture on tumours in con- nection with moles,* refers to a case of a somewhat Fig. 17. similar character : The patient was sixty years old, healthy all his life, and very temperate, and in the site of the tumour there had been a mole as long as he could remember ; it never gave him any trouble until about nine months previously, when, with some tingling, it began to enlarge, and continued to do so up to the time of his admission. Liston refers to another case in a patient aged forty. f Hypertrophy. Hypertrophy of the integument of the nose — the hpoma of some writers — is not infrequently ob- served. The growth appears to be an excess of the fibro-areolar tissue with some enlargement of the sebaceous glands. Many cases of the kind are * ' Med. Times and Gaz.,' January 16tli, 1861. t ' The Lancet,' 1840, vol. ii, p. 794. THE SUEGBRY OF THE FACE. 33 on record, but one remarkable instance is reported by Mr. Pollock.* The patient was a woman aged seventy-three, and the growth was eight inches in circumference, being the shape of an ordinary pear. Another remarkable example is one that was under the care of Sir William Fergusson, of which I show you photographs before and after operation. The growths were cut away with a scalpel. M. Oilier is stated to remove such tumours by making an inci- sion in the middle line, and separating the excres- cence on each side, Hke taking oflf the green covering of a walnut. t In very rare cases the external ear or pinna under- goes hypertrophy, but generally the enlargement is only temporary, and is due to the inflammatory thickening of the part. Boyer, however, met with a genuine case of hypertrophy, in which the ear was so large that it covered a great part of the cheek. HOENY GeOWTHS. Horny growths occur on diff'erent parts of the face. They either consist of epithelium in various stages of dryness, or they may originate in the sebaceous follicles by a continuous prohferation of their epithelial contents. Mr. Canton describes a * ' The Lancet,' 1864, vol ii, p. 152. t ' Brit. Med. Journ.,' Nov. 22, 1873, p. 604. 3 34 THE SUEGERY OF THE FACE, good example on the upper eyelid,* and Mr. Cock, of Guy's Hospital, another instance on the lower lip.f And a third and still more interesting case is re- corded in the ' Pathological Transactions ' by Mr. Charles Roberts, of York. The growth was taken from the face of a woman, aged seveuty-five.l And, lastly, this specimen of a horny growth from the museum of St. Thomas's Hospital is of considerable interest. The growth measured ten inches in length, and was removed from the upper part of a man's forehead. Carcinomata. Epithelioma or the epithelial form of cancer is that most frequently observed on the face. It attacks the nose (as shown in Fig. 18) or the cheeks and lips, and relatively by far most frequently the lower lip (Fig. 19). Sir Astley Cooper stated that, of 200 cases that he had seen of this disease, in only one was the upper hp the seat of the affection. It is essentially a disease of adult hfe, for Lebert states that, of 17 persons upon whom he operated for this disease, 2 only were under the age of thirty-five ; § and M. Fleury, of Clermont, observes that between 1845 and 1855 he had operated on 86 patients, 71 being * Path. Soc, Oct. 21st, 1862. t ' Med. Times,' Nov. 8tb, 1856, p. 471. X ' Path. Soc. Trans.,' 1865, p. 267. § 'Med. Times and Gaz.,' Jan. 25th, 1873, p. 81. THE SURGE BY OP THE FACE. 35 men and 15 women, and not one of them was less than forty-three years of age. Fig. 18. Fig. 19. The comparative frequency of epithelial cancer may be gathered from the observations made by Mr. Erasmus Wilson, who remarks that, of 2000 36 THE SURGERY OF THE FACE. cases of cutaneous disease, epithelioma occurred 11 times ; in other words, about 1 in every 200. In 20 cases it was more than twice as frequent in males as in females. In two thirds of that number it occurred after the age of fifty, several of the patients being above sixty, and its general duration at the time of coming under treatment ranged between two and fifteen years. In all the 20 cases the disease mani- fested itself on the face or its immediate neighbour- hood ; in 9 it appeared on the cheek ; in 8 upon the nose ; while in one case it was developed on the eye- brow, near its outer extremity, in another on the temple, and in a third, upon the mastoid process.* Tobacco-smoking is alleged to be a common cause of epithelioma of the lip. Roux held this opinion, but Fleury noticed the remarkable fact that his patients came from a district where smoking was almost unpractised.! Colloid cancer of the face appears to be very rarely met with, but one example occurring in the upper lip is recorded by Mr. Curling. J The patient was a young man, and the growth had existed for five months. Dr. Andrew Clark examined the specimen microscopically. One of the specimens on the table is a section of a skull, projecting into the cavity of which is an * ' Diseases of the Skin,' p. 431. t ' Gaz. Medicale,' No. 35 ; ' Med. Times,' Oct. 29th, 1859, p. 439. X ' The Lancet,' July 7th, 1860, p. 8. THE SURGERY OF THE FACE. 37 encephaloid growth. It was taken from a patient from whom the parotid gland had been removed by Mr. Solly for encephaloid disease.* Diseases of the Jaws, &c. I regret that time will not allow me to speak fully of the different diseases of the jaws, although I fear that I can add but little to what Mr. Heath has published on the subject ; but the tumours connected with these and other bones of the face may, I ven- ture to think, be reduced to a very simple classifi- cation. Thus : 1st. "We have cysts in the upper and lower jaws, of which I show you specimens from St. Thomas's Hospital Museum; Figs. 20 and 21 illustrate such Fig. 20. /\ / * St. Thomas's Hospital Museum, c. 198. 38 THE SUEGERY OF THE FACE. diseases, the latter figure being taken from a patient who was under the care of Mr. Royes Bell. 2nd. There are the fibromata or fibrous tumours, which usually spring in the upper jaw from one of two situations, either the interior of the antrum, or Fig. 21. some portion of the alveolus. They are the com- monest form of growth in the lower jaw. Cysts may be superadded to the fibrous structure, as in this case, of which I show you a photograph, of fibro- cystic disease involving the palate bones and palatal processes of both superior maxilljB. Mr. MacCormac was kind enough to allow me to take charge of this patient. 3rd. There are the different forms of sarcomatous tumours. Here are photographs, taken before and after operation, of a patient from whom I THE SURGBEY OF THE FACE. 39 removed a spindle-celled sarcoma in April last. The tumour apparently commenced in the roof of the mouth, and subsequently implicated the antrum. An incision was made in the middle line of the upper lip, and the whole of the right superior maxilla, excepting the orbital surface, with a considerable portion of the soft palate, was removed. * [This patient was exhibited to the Fellows.] 4th. There are the enchondromata or cartilaginous tumours. 5th. The osteomata or bony tumours. t 6th. The carcinomata, of which the medullary or encephaloid cancer is the most common variety, although cases of scirrhus are recorded as involving both the upper and lower jaws. 7th. Lastly, there are the vascular tumours. By permission of the treasurer, I am enabled to show you several typical specimens from the museum of St. Thomas's Hospital, to illustrate most of these diseases. A brief reference may now be made to the pre- liminary skin incisions which are generally employed at the present day in removing tumours of the upper jaw. Sir William Fergusson seems to have perfected the planning of these incisions, and I imagine that few surgeons would now think of gashing the cheek * ' Med. Times and Gaz.,' Oct. 6th, 1877, p. 387. t See ' Ericlisen's Surgery,' vol, i, p. 756, for ivory exostosis occur- ring on face ; also ' Bryant's Surgery,' vol. ii, p. 500, fig. 506. 40 THE SURGERY OF THE FACE. from the angle of the mouth to the external ear. Before applying the knife to the skin of the face, the surgeon should be quite sure that an incision is absolutely required, for many growths of small size, and cysts connected with the upper and lower jaws, may be operated on through the open mouth, with- out cutting the lip. Assuming incisions to be neces- sary, a considerable and often sufficient amount of room is afforded by dividing the upper lip exactly in the median line, carrying the wound into one or both nostrils as shown in fig. 22. If more room is required, a second incision may be made upwards along the side of the nose, at the junction of the ala with the cheek; and a third may, if necessary, be employed, extending in a horizontal and somewhat curved manner under the lower eyelid towards the zygoma. After the diseased part has been removed the cut surfaces may be united by the ordinary inter- rupted suture made of silk, which seems to me to be preferable to silver wire. In closing the lip, some surgeons use hare-lip pins and the twisted suture. THE SURGERY OP THE FACE. 41 but I fail to perceive that this plan possesses any advantage over the ordinary interrupted suture. Dieffenbach seems to have been fully alive to the importance of not disfiguring the patient unneces- sarily. Thus, in a paper on " Resection of the Facial Bones," published in 1838,* he says : " I began the operation by dividing the face in the median line, commencing between the eyebrows, and extended this incision downwards to the nose and upper lip; I then made a transverse incision parallel with the aperture of the eyelid, and separated the soft parts — i.e., half the nose, the lower eyelid, the upper lip, and the cheek — from the tumour, and turned back the flap towards the ear." He adds that, by dividing the face along the median line " I have suggested a new method of operation, the effect of which is to prevent the paralysis of one side of the face, the infallible consequence of commencing our incisions on the posterior part of the cheek." Respecting operations on the lower jaw, I need only add that, if incisions are required in the skin, they should be so planned as to leave as little scar as possible. The removal of tumours involving the greater part of the upper and lower jaws by the subperiosteal method has been practised by Langenbeck, Oilier, von Pitha, and by surgeons in this country. Nearly forty years ago Signoroni practised a sub- * ' The Lancet,' 1838, vol. i, p. 692. 42 THE SURGERY OF TEE FACE. cutaneous extirpation of the lower jaw without making any external or skin incision. The patient was a young woman who had osteo-sarcoma. He di^dded the operation into three stages : — 1st. The isolation of the tumour ; 2nd. The division of the diseased bone ; 3rd. The extraction of the detached part.* More recently Mr. Maunder has performed a somewhat similar operation and has placed on record the notes of two cases which were under his treat- ment.! N^VL'S. Nsevus is not unfrequently found on the face, and, when of rapid growth, may cause great disfigure- ment. It is met with, first, either as the cutaneous variety, as in this instance, situated on the ear (Fig. 23). Secondly, it may be subcutaneous, and Fig. 23. Fig. 24. not involve the skin, when it is generally observed * ' Med. Times,' Sept. 10, 1842, vol. 6, p. 381. t 'British Medical Journal' for 1872, vol. i, p. 48, and for 1873, vol. i, p. 611. THE SURGERY OF THE FACE. 43 about the lips (Fig. 24), on the cheeks, and over the parotid region. Or, thirdly, it may be of the mixed kmd, as is shown in this sketch I show you, taken from a patient under the care of Mr. Croft. Nsevus seldom produces displacement of the neighbouring bones. Mr. Bryant, however, describes a case in which a nsevus of the lip flattened the teeth of both jaws.* It is not unusual to find two or more na9vi on the same patient. Mr. Croly, of Ireland, reports a case in which there were four distinct nsevi, one situated on the lower lip, a second in the right parotid region, a third at the back of the neck, and a fourth on the tongue, t A still more remarkable instance is recorded of symmetrical nsevi, the size of a sixpence, occurring in twins, male and female, eight years of age. I The question of operation is one of some import- ance, and before the surgeon proceeds to efiect a radical cure, and thus perhaps produce a permanent cicatrix, he should not forget that many naevi dis- appear without surgical interference. The cutaneous nsevus is especially the variety to which this remark applies. I do not think there can be a doubt that some ngevi do wither away spontaneously, for they are very rarely met with in the adult. * ' Practice of Surgery,' vol. i, p. 444. Brit. Med. Journ.,' April 2, 1870, p. 348. J ' Med. Times and Gaz.,' Feb. 3rd, 1872, p. 130. 44 THE SURGERY OF THE FACE. If the ngevns be situated on the lip it may be com- pressed with an instrument something like a pair of castanets as recommended by Dupuytren,* or it may be subcutaneously ruptured as in a case recorded by Dr. Mezger, of Amsterdam.! He rapidly squeezed the nsevus so as to rupture the vessels when quite full. The thermo-cautery is very useful in superficial nsevi, and so is a hot needle applied at a black heat. J The elastic ligature has its advocates, and in very severe cases it may be necessary to tie the common carotid artery. In the subcutaneous variety which are so fre- quently found on the hps and cheeks, I have for some years used the electrolytic treatment with excellent results. § Dr. Althaus and Mr. Knott, of St. Mary's Hospital, || Dr. Duncan, of Edinburgh,^ and Dr. Beard,** have contributed valuable papers on this subject to which I would refer you. I will only add that, from personal experience, I am enabled completely to corroborate their views as to the efficacy of this treatment in suitable cases. With regard to the cure of nssvi, I need not * * Lancet,' 1833, vol. 2, p. 169. f ' Archiv. fiir Klin. Chirurgie,' Band xiii (' Brit. Med. Joum.,' Dec. 23, 1871, p. 730). t ' Lancet,' Marcli 14, 1863, p. 294. § ' Brit. Med. Joum.,' 1867, vol. i, p. 539. il 'Lancet,' vol. i, 1875, p. 402. i ' Brit. Med. Joum.,' June 10, 1876. ** ' New York Med. Joum.,' Dec. 1877. THE SUEGEEY OF THE FACE. 45 occupy time by referring in detail to the various methods of treating such tumours, whether by the apphcation of continuous pressure, or by the actual or other form of cautery, or by obliterating the neighbouring vessels by acupressure, as in a case reported by Mr. Bellamy,* or by enucleation, as advocated by Mr. Teale, of Leeds,t or by the use of styptic injections, &c., but will conclude this lecture by alluding to some of the more complicated methods of applying the Hgature. Practically, these methods resolve themselves into two classes : 1st, those in which the skin is not included, a very important consideration when the nsevus is situated on a conspicuous part, such as the face; and, secondly, those in which the skin is included. The Hgature may be carried subcutaneously in a variety of ways which have been practised by Ricord, von Pitha (in 1847), Curling, | John Adams, § and others. Thus, the whole of the nasvus may be encircled without the skin being involved, in the following manner : — A surgical needle of suitable size (but not in a handle) is entered at the skin at a (Fig. 25), and is made to go half round the circum- ference of the naBvus (as indicated by the arrow), penetrating the skin at b. It is then re-entered at * ' Brit. Med. Journ.,' Dec. 9, 1871, p. 668. t Med. Chir. Soc, Feb. 26, 1867. X Curling, ' London Med. Gaz.,' vol. 10, 1850, p. 136. § Adams, ' Med. Times,' 1851, new series, vol. ii, p. 178. 46 THE SURGERY OF THE FACE. B and carried round the other half of the naevus, and made to emerge at the first point of puncture a. The two ends c, d, are then tied, and thus the skin Fig. 25. C^. is left intact. Or, the ngevus may be divided in halves subcutaneously thus : — (Fig. 26)An ordinary surgical Fig. 26. needle (without a handle) armed with a thread is carried under the naevus from a to b, and the two ends near the needle divided (g, h). The needle is then to be threaded with say g, and is passed round for a quarter of the circumference of the naevus sub- cutaneously, and is made to emerge at c (Fig. 27). THE SUEGERY OF THE FACE. 47 The corresponding end e (Fig. 26) is treated in like manner, and made to emerge at c (Fig. 27). The ends Ej G, are then tied. The ends h and f are dealt with in the same way, being made to emerge at D, as the woodcut indicates.* The operation devised by Mr. John Wood like the last divides the ngevus into two portions. f A needle in a handle is armed with a long stout thread, and made to pass from above downwards under the nsevus from a to b (Fig. 28). A loop is left at c. The needle is withdrawn, having still one of the free ends on it (say d). The needle carrying d is now introduced into the hole in the skin a, and is passed around the circumference of the tumour in the direc- tion of the arrow e, and made to emerge through the skin at b (Fig. 29). The thread is now taken away from the needle, and the latter unarmed * Birkett, * Guy's Hospital Reports,' 2nd series, vol. vii, part ii, 1851, p. 294. t 'Med. Times and Gaz.,' July 31, 1858, p. 113; Oct. 28, 1865, p. 468. 48 THE SURGEEY OF THE FACE. is witMrawn at a. The end f (Fig. 28) is now threaded and carried round the opposite side of the tumour in like manner in the direction of the arrow g (Fig. 29), and is made to emerge at b. The thread being removed the needle is withdrawn unarmed as before. In order to complete the operation the two ends d and f are passed through the loop 0, and having been drawn tightly are fastened in a bow (not in a knot) so that the ligature may be tightened from day to day, until it cuts its way out at the aperture b. It will thus be seen that the threads emerge from one small hole in a depending position which may be arranged in accordance with the position of the ngevus. More recently Mr. Jardine Murray has de- scribed another operation.* An ordinary surgical needle (not in a handle) armed with a thread is passed under the njBvus from a to b (Fig. 30). The C E loop is cut close to the needle, so that there remain * 'Lancet,' March 19, 1864, p. 321. THE SURGERY OF THE FACE. 49 four ends c, d, and e, f. The needle (or another with a blunt point as Mr. Murray suggests) is now threaded with one end, say e, and is made to pass subcutaneously around a quarter of the tumour from B to G, penetrating the skin at G (Fig. 31). It is then passed under the ngevus from G to h, emerging at H. It is again introduced at h, is passed from H to A, emerging through the skin at a. The needle being now released is threaded with the end r, which it carries subcutaneously first from f to h, > then from h to G, and, lastly, from g to a, and is then released. The ends c, e, and d, f, all emerging from the single aperture in the skin at a are tied respectively, and thus the nasvus is subcutaneously surrounded and cut into four parts. For the sake of clearness the course of one thread only c, e, is shown in the diagram. I will now speak of two methods of ligature in which the skin is included : Sir William Fergusson's knot was first published in the ' Edinburgh Monthly Journal of Medical Science ' for 1847. At that time Sir William used a needle in a handle, but latterly he preferred the common surgical needle. The operation may be performed thus : — A needle having a large eye, and threaded with a ligature of good length, is entered at A, and passed under the nsevus, emerging at b (Fig. 32). One side of the loop is to be cut (say e) (Fig. 33). The opposite end of the cut side (f) is then 4 50 THE SURGERY OF THE FACE. Fig. 32. Fig. 33. Fig. 34. threaded, and the needle carrying the two ends e and F is passed under the nsevus at right angles from D to H (Fig. 34). The needle is now to be Fig. 35. Fig. 36. released, and the corresponding ends e+, c , and f°, G° (Fig 34), respectively tied tightly. Thus, the tumour is encircled, and cut into four pieces. iinother knot devised by Mr. Wood, and which includes the skin, is applicable to large ngevi, and as it is secured with a single bow can be tightened from day to day. A needle in a handle is threaded I I THE SURGERY OF THE FACE. 61 and passed under tlie naevus from a to b (Fig. 35), a loop is left at b, and the needle withdrawn. The needle still armed with one end (say a), is now passed at right angles from c to D, and another loop left. The needle is withdrawn on the end f, and is then released. All that is necessary to complete the operation is to pass the two ends e and f through the loops B and d, and tie them in a bow (Fig. 36). By this method the na3vus may be tightened from day to day until it is cut through. Before tying the threads it is well in this as in Fergusson's knot to snip the healthy skin at the circumference of the nsevus with scissors. This procedure provides a groove in which the threads may conveniently lie, and obviates the pain incidental to the ulcerative pro- cess. In my next lecture I shall speak of injuries of the face. LECTURE II. INJURIES OF THE FACE. Me. President and Gentlemen, — You will re- member that in my last lecture I alluded to some of the principal diseases of the face, and now with your permission I will refer to a few of the injuries incidental to this part. Considering its exposed situation, the face has comparative immunity from accidents of all kinds, and this immunity may be thus explained : — First, because the head is extremely movable in all direc- tions; and, secondly, because the hands and arms intuitively protect the part. It is not within the scope of this lecture that I should speak of fatal injuries occasioned by gas ex- plosions, railway accidents, the bursting of shells and gunshot wounds received in warfare, which I think may be well left to the imagination. I shall therefore confine my observations to such injuries as are usually remediable, and which are therefore con- sistent with fife. Lacerated wounds of great extent are frequently occasioned by broken glass. Thus, not long ago, I THE SUROERY OP THE FACE. 63 saw a barmaid wliose face was terribly disfigured by the bursting of a soda-water bottle ; and also another patient, a plumber, who was rendered a pitiable object by falling head foremost for a dis- tance of twenty feet through a skylight. Again, I once had the opportunity of seeing a cabinet maker who had a very severe wound of the face occasioned by a circular saw. But perhaps the worst examples of such injuries were two, one in which the face was literally smashed by a cricket-bat coming in full contact with the face, and the other was the result of a direct blow on the part from a cricket ball, of which I show you photographs. Injuries of the face must be treated on the ordi- nary principles of surgery, but in this region it is of paramount consequence to procure, if possible, immediate union, and thus preserve the patient's personal appearance. Therefore, after the wound has been thoroughly cleansed from dirt, glass, or other foreign substances, the edges should be brought together accurately with good sticking plaster.* Sutures may be employed, but they should be dispensed with if possible inasmuchas they cause additional scars. If used the sutures should be of fine silk, which is, I think, preferable to silver wire, for the removal of the latter requires some little skill, and I am sure that if there be any tension, the * An excellent preparation known as india iiibber plaster may be obtained of Messrs. Savory and Moore, of New Bond Street. 54 THE SURGERY OF THE FACE. wire cuts its way through the cutaneous structures much more rapidly than silk does. In injuries of the lips, harelip-pins with the twisted suture are very commonly used to unite the parts, but I employ, by preference, the ordinary interrupted suture, made of silk. Even simple strapping, efficiently applied, answers the purpose completely. This woodcut (Fig. 37), taken from a Fig. 37. photograph, illustrates a case in which a portion of the lip had been bitten away by a woman, and in which the parts were successfully brought together with strapping only. In speaking of injuries of the face, Mr. Holmes Coote aptly remarks * " that wounds in this region caused by the violent action of blunt instruments have often the same appearance as if inflicted by the sharp cutting edge of a knife. For example, the sharp border of the superior maxillary and malar bones, or the edges of the teeth, will, when a blunt body presses against them, cut through the * ' Holmes' Surgery,' vol. ii, p. 428. THE SURGERY OP THE FACE. 55 skin and subjacent soft parts, and cause an injury closely resembling an ordinary incised wound." As an instance in point, Mr. Erichsen relates* the case of a man wbo was admitted into the hospital drunk and much bruised about the face. " Shortly after admission he vomited a large quantity of blood, which was at first supposed to proceed from some internal injury, but, on examining his lip, it was found that the haemorrhage was from the coronary artery of the lip, which was divided with the mucous membrane." In injuries of the face in children it is of great moment that the scar should be reduced to a minimum, and the same rule applies, as already referred to in my previous lecture, to wounds made by the surgeon in removing cysts or other tumours, ncevi, &c., at an early period of life. It is, I suppose, an accepted pathological axiom that all scars grow in proportion to the growth of the body, and the question of the probable disappearance of cicatrices is one of more than ordinary interest, especially from a medico-legal point of view. As bearing on this question, it will be in the recollection of the fellows that Mr. W. Adams read a paper on the subject at this Society in 1873, and alluded to four cases, amongst them one of a young lady who, when a baby a year old, was operated on for ngevus by excision in the region of the breast. The scar left * ' Science and Art of Surgery.' vol i, p. 597, seventh edition. 56 THE SURGERY OF THE FACE. at the time was less tliaii an inch and a half, but at nineteen years of age it was found to have increased enormously, measuring three inches in diameter. The case showed that when a portion of the skin has been destroyed, the cicatrix appears to be persistent through life, and grows pari passu with the rest of the body, or rather with the portion of the body over which it may be placed. The increased size of the vaccination scars observed in the adult seems to prove this. Sir James Paget puts the case well in saying that " the scar of a child, when once completely formed, grows as the body does, at the same rate and according to the same general rule, so that a scar which the child might have said was as long as his own forefinger will still be as long as his forefinger when he grows to be a man." Apropos of this part of the subject, you will perhaps remember that about two years ago I showed a patient, a girl aged fifteen [photograph shown] who had a cicatrix, about an inch and a quarter in diameter, situated over the left breast, which was the result of an operation for ngevus performed when she was three months old, the scar after the operation being about the size of a sixpence. As the breast developed, so the cicatrix became proportionately larger. I venture to cite this case, not as strictly relating to the part of which I am now treating, but because it illustrates in a remark- able manner the fact that cicatrices increase not THE SURGERY OP THE FACE. 57 only in proportion to the growth of the body, but that they grow in proportion to the development of the organ on which they are placed.* I am, however, glad to be able to adduce a more apposite example to illustrate the growth of such cicatrices (represented in Fig. 38). In November Fig. 38. last a young man consulted me with reference to a circular scar situated on his right cheek, and which was thought to be growing rapidly. He was eighteen years of age, and his mother informed me that when he was a baby he had a very small n^evus in the situation of the cicatrix, which was cured by ligature. His mother was assured at the time of the operation that as he grew up the scar would * ' Med. Soc. Proceedings,' vol. iii, p. 60. 58 THE SURGERY OF THE FACE. disappear, and she was therefore rather astonished, not to say disappointed, to find that it was now three times as large as it was in babyhood. The explanation of this enlargement lay in the fact that the young man was getting, as his mother remarked, unusually " fat in the face." Burns and Scalds. With regard to the management of burns and scalds in the region of the face (and I allude to such cases as are not beyond surgical aid), the popular treatment at the present day seems to be the appli- cation of carron oil. At St. Thomas's Hospital we frequently employ this remedy; but in the children's ward, into which these accidents are almost daily admitted, a mixture of whiting and acetic acid is used. It is prepared in the following manner : one part of acetic acid is mixed with twelve parts of water, and whiting is added until the fluid becomes of the consistence of cream. The mixture is applied lightly with a brush during effervescence, and in addition the part is usually covered with soft linen and cotton-wool.* The soothing effects of this preparation are so marked that I confidently recom- mend it for more general use. It is very clean, and * See a paper by the author on Burns and Scalds in ' St. Thomas's Hospital Reports,' vol. v, 1874. THE SURGERY OF THE FACE. 59 is especially useful in burns and scalds of the face and neighbouring parts. The deformities occasioned by burns and scalds are well illustrated in Figs. 39, 40, Fig. 39. '^C } Fig. 40. 41, and 42, taken from photographs; but of these, with their treatment, I shall speak in my next lecture. 60 THE SURGERY OF THE FACE. Fig. 41. Fig. 42. the surgery of the face. 61 Injuries of the Parotid Gland and its Duct. Cases are reported in which the duct of the parotid gland has been ruptured subcutaneously by a blow, and in which the salivary secretion has burrowed in all directions, giving the patient an emphysematous appearance, and causing much disfigurement of the face and neck. The duct has also been partially destroyed by ulceration in severe cases of lupus or cancrum oris; and it has been divided, either of necessity or unintentionally, by the surgeon in operating on the cheek, or in removing tumours from the jaw. Sabre wounds have in some instances been followed by salivary fistula. In a case of this kind of fistula which resulted from the patient falling on a red-hot poker I adopted a simple plan of treatment. A probe was passed through the mouth and made to emerge from the fistulous aperture in the cheek; then, having bent the instrument slightly, it was pushed along the duct as far as possible in the direction towards the gland. The probe thus fixed was retained for the remainder of the day (altogether about eight hours), and at night it was removed. Three days afterwards it was again introduced through the mouth, and passed readily towards the gland. After the first introduction the saliva ceased to flow from the opening in the cheek. Mr. 62 THE SURGEEY OP THE FACE. Pick, of St. George's Hospital, has treated a case much in the same manner in a patient aged twenty.* An attempt was made to pass a probe in order to ascertain if any opening existed into the mouth, but the instrument being too large, further attempt was abandoned until a smaller one could be procured. " The following morning the patient was surprised to find that her pillow, which had been previously saturated with moisture, was quite dry, and upon examination it was found that the opening was completely closed."! Fistulous openings in connection with the parotid gland itself are of very rare occurrence, yet they are known to have been produced by the opening of an abscess behind the jaw, and have even followed a pecuHar inflammation of the gland structure. I had the opportunity of watching a case of this kind occasioned by a burn which destroyed the ear and neighbouring parts. There were nine or ten minute spots over the parotid gland from which saliva exuded. The patient got quite well after a free use of the solid nitrate of silver and the firm appli- cation of a bandage. * The ' Lancet,' Feb. 19th, 1870. t See article " Surgery of the Mouth," by author, ' Monthly Keview of Dental Surgery,' Jan., 1873, p. 364. THE SURGERY OF THE FACE. 63 Sloughing of the Face. Owing to the extreme vascularity of the part, sloughing seldom occurs on the face, and, when met with generally depends upon the direct application of intense heat, such as red-hot iron, &c. Injuries even at a distance from the face, say in the neck, are sometimes followed by sloughing of the nose or ears — that is to say, parts to which the blood is with most difficulty sent. Sir James Paget* quotes several examples to show how portions of the body may mortify from the absence or deficient supply of fresh blood, and refers to a specimen in the Museum of the College of Surgeons, which is of especial interest in connection with the surgery of the face. The specimen was the larynx of a man who, while in low health, cut his throat, and suffered a great loss of blood. Before he died his nose sloughed. Treatment of detached Soft Parts. However mutilated the skin of the face may be, the surgeon should under all circumstances endea- vour to bring the edges of the wound accurately together, and even if a portion should be completely detached by accident or design, an attempt should * ' Lectures on Surgical Pathology,' p. 25, third edition, 1870- 64 THE SURGERY OF THE FACE. be made to restore the part to its pristine position. There are numerous instances on record in which the nose has been replaced, and an interesting ex- ample of this kind is reported by Dr. Malfatti.* A soldier had his nose cut off by a sabre. The piece was taken up from the ground on which it lay, was cleaned and reapplied, being secured in its place by sutures. The case did perfectly well. Again, Mr. Spencer Watson f relates the case of a gentleman who, when he was a child, cut off a por- tion of the end of his nose with a carving-knife. His mother, with great presence of mind, instantly replaced it, and kept it in position by means of a plaster composed of brown paper smeared with soap and sugar. The severed parts completely united, and only a trace of the original injury was left. A somewhat similar case in an adult came under my observation when I was house-surgeon at King's College Hospital. In this instance I reap- plied the greater part of the nose,:j: and Mr. Slayter, the then house-surgeon at the "Westminster Hos- pital, afterwards reported three cases, one in which the nose was readjusted, the second in which three teeth had been replaced, and a third in which a portion of the scalp had been knocked off with a quart pot, and had been sewn on successfully. * ' Brit. Med. Journ.,' Dec. 21st, 1872, p. 690. t ' Diseases of the Nose,' p. 296. X ' The Lancet,' Sept. 7tb, 1861. THE SURGERI OF THE FACE. 65 Injuries of Bones of Face. "With regard to injuries of the bones of the face, perhaps the nasal bones are those most frequently fractured or dislocated. In either case the parts should be brought into their normal position as soon as possible after the accident, and if once in their proper place, are little apt to shift, because, as is well known, there are no muscles directly at- tached to them. Mr. W. Adams who gave us a paper on this subject in 1875, observes that sucli cases may be divided into two classes — (1) those in which the injury is limited to the cartilaginous por- tions, and (2) those in which the nasal bones are fractured. The principle he advocates in all such instances is to straighten the bent cartilaginous sep- tum with a pair of strong forceps having flat parallel blades, and when the nasal bones are depressed, to raise them also with the same instrument.* Dief- fenbachf operated by a subcutaneous method in two cases in which the nose was thrown outwards on the cheek, one nostril being turned upwards and the other downwards. He introduced a narrow bistoury under the skin of the bridge, dividing the union of the cartilage with the bones, and separated * 'Med. Soc. Proceedings,' vol. ii., 1875, p. 99 t ' Prov. Med. Journal,' vol. iv, p. 141. 5 66 THE SURGERY OF THE FACE. the alae and septum, every part of the operation being subcutaneous. Whilst it is expedient in adults to bring the dis- placed parts in apposition as speedily as possible, it is even of greater importance to effect this in chil- dren, for Mr. Hilton has shown that the expansion of the sphenoid bone pushes forwards the vomer and the septum nasi, and subsequently also the nasal bones. Any injury therefore of the nasal bones attended with displacement to either side would necessarily result in a progressive deformity, since the bones would continue to grow in the abnormal direction.* In cases of severe burns, involving the eyelids or the nose, great care should be taken to retain the external apertures. Mr. Le Gros Clark has re- ported a case which he treated successfully by incis- ing the anterior nares and keeping the parts open with a trocar. t Blows inflicted on the nose are occasionally followed by abscess and exfoliation of the nasal bones, but such consequences may in many cases be averted by timely incisions, as in a case under the care of Mr. J. Hutchinson, in which there were two inflamed swellings of equal size symmetrically situated on either side of the bridge of the nose in such a manner as to extend its transverse measurement to about * ' Cooper Forster : ' Surgical Diseases of Children,' p. 13. t ' Med. Times and Gaz.,' Dec. 15th, 1860, p. 584. THE SURGERY OF THE FACE. 67 an inch and a half. The abscesses were laid open freely, and the patient did well. Injuries to the nose of even trivial character are occasionally followed by a fatal result. Thus, Dr. Keeling, of Sheffield, reports* the case of a patient who was struck with a piece of iron on the forehead and nose. There was a simple fracture of the nasal bones without much displacement. The patient died, and on opening the calvaria the dura mater was found much lacerated. Five ounces of pus escaped, and the crista galli, with the perpendicular plate of the ethmoid, was found to be separated from the cribri- form plate, quite loose, and imbedded in the sub- stance of the brain, Mr. Bryant also quotes a case in which a severe blow upon the jaw produced a fracture of the middle fossa of the base of the skull. Emphysema. Emphysema of the face and neck is not unfre- quently met with when the bones of the face or the frontal sinuses are damaged. Thus, I once saw a man who, whilst walking, received on the right side of his face the whole weight of a long rod of iron which was being carelessly carried by another person. There was a very superficial wound situated over the malar bone, and no apparent displacement of the * The * Lancet; March 13th, 1869, p. 362. 68 THE SURGERY OF THE FACE. bones. In two or three days, however, the patient's face on the injured side was very puffy and emphy- sematous, being nearly twice its normal size. The swelling entirely disappeared in ten days. The following case occurred in the practice of Mr. Prescott Hewett.* The patient was twenty-three years of age, and fell during a fit on the left upper jaw, which was displaced, but firmly fixed. The following day the emphysema had spread to the hyoid bone, and went as low down as the cricoid cartilage ; but it all disappeared within a week from the time of the accident, and the patient made a good recovery. Emphysema of the eyelids, result- ing from fracture of the os planum of the ethmoid, has been referred to by Dupuytren.f Dr. Keith, of Aberdeen, has most truly observed that " wounds of the face however ghastly to look at, are not dangerous to life," and some remarkable recoveries are on record after very extensive in- juries to the bones and soft parts in this region. The following may be taken as an example, the patient having been under the care of Baron Larrey. J The patient was a soldier aged twenty-three, who attempted suicide on March 4th, 1823, by shooting himself. " In the left ramus of the lower jaw there was a large irregular aperture by which the ball had * The 'Lancet; vol. i, 1875, p. 231. t The ' Lancet,' vol. ii. 1834. p. 109. + " Clin. Ohirurg.," ' The Lancet,' vol. ii, 1829, p. 186. THE SURGERY OF THE FACE. 69 entered. It made its way through the lower and upper jaw, the left nasal cavity and orbit, and had come out at the left side of the root of the nose. The jaw bones were crushed to fragments, part of the tongue was lacerated, the lower parietes of the orbit fractured, and the eye had burst the eyelids ; the nose and upper lip were torn into several flaps, and the lachrymal and frontal bones fractured." He made a good recovery. Another case is reported by Professor Longmore, of Netley,* which he believed to be unique, inas- much as it was followed by total dumbness without direct injury to the organ of voice. A soldier was struck just below the centre of the lower hp during a charge of his regiment on Sept. 21st, 1860, by a musket-ball. The two incisors, the canine, and one bicuspid on the left side were carried away, and the ball lodged in the soft tissues of the floor of the mouth behind the frgenum linguae. Immediately after the injury there was complete loss of the power of articulation. The ball was not removed till the twenty-third day after the injury, and was then extracted from within the mouth. The sequel of the case may be briefly told, for, about two years after (at the end of July, 1862) the man suddenly recovered his speech while in a state of excitement during an altercation at a public-house. Professor Longmore was inclined to attribute the dumbness to "nervous * ' Brit. Med. Journ.,' Dec. 19tb, 1863, p. 670. 70 THE SURGERY OF THE FACE. sliock," in addition to the structural lesions, and to class the case with those of temporary aphonia which sometimes occurs from hysteria, fright, &c., and where the recovery of speech is often sudden. Dr. Aitken, however, who saw the case, thought that the loss of voice was due to injury of the muscles of the tongue and to the disturbance of the ninth nerve. A third interesting case is reported by Dr. M'Quillen, of Philadelphia,* of which I show you drawings. Dislocation of the Superior Maxilla. Simple disarticulation of the superior maxillary bones is a very rare accident, but Mr. John Salter, of Tolleshunt d'Arcy, reports such a case.f " The dislocation was," he says, "beyond doubt, inasmuch as the bones, in their wedge-shaped entirety, could be freely moved backwards and forwards, upwards and downwards, and from side to side. The separa- tion of the malar bones from their articulation was no less distinct. A gutta-percha splint was applied, but it was several months before the patient, aged thirty, could bite solid food." In this case, at the time of the accident, the face felt like a quantity of * ' Montlily Review of Dental Surgery,' voL iv, No. 5, for Oct. 1875. t ' Med. Times aud Gazette,' June 5th, 1869, p. 600. THE SURGERY OF THE FACE. 71 "loose bones." Mr. South, in speaking of a some- what similar accident, describes the bones as feeling like " beans in a bas:." A curious case of dislocation of the left superior maxilla was under my care in the summer of 1876. The patient, a woman, was thrown from a cart, and alighted on her left cheek on some prominent object (she believed a loose stone). On examination a dis- tinct depression of about half an inch was seen on the injured side, and on placing the finger behind the soft palate, there was an evident prominence. The patient was perfectly free from pain or annoyance, and left the hospital in about ten days, apparently as well as ever, with the exception of the depression above referred to. Mr. Houghton* reports a case of depression of the superior maxillae, in which the parts were so displaced that the patient could not protrude the tongue until the bones were readjusted. I am indebted to Mr. Walter T. Clegg for the following notes of an interesting case that was under the care of Mr. Bickersteth, of Liverpool. A gentleman on board a ferry steamer was standing near the hawser which was fastening the steamer to the Rock Ferry Landing Stage. A sudden strain snapped the iron hook attached to the rope, so that it shot up, stru.ck him on the face, and sent him reeling across the deck. When examined by Mr. Bickersteth immediately after the accident, the * • Brit. Med. Jom-n.,' Jan. 2nd, 1858, p. 15. 72 THE SURGERY OF THE FACE. mouth seemed to be filled by a piece of bloody meat, but on further investigation this proved to be the muscles attached to the upper jaw; the orbital plate of the superior maxilla of the injured side was found beneath the cheek, whilst the palate process with the alveolar ridge and teeth were, for the time, situated in the upper part of the pharynx, looking towards the bodies of the upper cervical vertebra3. The facial surface took the place of the roof of the mouth, jamming the jaws open. The soft palate was not, however, torn through, but considerably stretched. In fact the superior maxilla of one side was turned completely on its axis. The detached mass was carefully replaced by Mr. Bicker steth and fixed, the lower jaw was then closed and firmly bound up as a support. The whole rapidly united with scarcely any deformity. Dislocation of the Lower Jaw. The usual causes of dislocation of the lower jaw, such as yawning, the attempt to bite an apple or other substances, are too obvious to need reference at the present time. This luxation is known to occur occasionally, though very rarely, during the extraction of teeth, and Mr. James Salter, in a THE SURGEHY OP THE FACE. 73 series of papers* alludes to sucli cases, and with characteristic candour, speaks of this accident occurring in his own practice when he was taking a model of the lower jaw in a patient aged seventy. Mr. Salter took the upper model first, and then, having taken that of the lower jaw, he noticed that the patient did not shut her mouth ; it was fixed wide open. The reduction of the dislocation was easily effected, and the patient stated that she frequently " put out " her jaw in yawning and lauo-hinof. Mr. Merson also relates a similar case.f Such displacements have been known to occur during a laryngoscopic examination, and I know of one instance in which, in the operation for cleft palate, the gag had been so vigorously applied as to produce a similar deformity. Mr. Edwin Morris, of Spalding, refers to a case of dislocation of the jaw which he believed to be the result of tongue-sucking. :|: The patient was a young lady, aged fifteen, who was awakened from her sleep with pain under her ears, and inability to close the jaws, or to articulate plainly. The patient was addicted from infancy to tongue-sucking during sleep, and Mr. Morris thought that the continual action of the pterygoid muscles had so preter- naturally loosened the ligaments and muscular * ' Brit. Journal of Dental Science,' July, 1871, p. 311. t ' Monthly Review of Dental Surgery,' Aug., 1875. + ' Brit. Med. Journ.,' Aug. 31st, 1872, p. 242. 74 THE SURGERY OF THE FACE. structures supporting the joints as to render them unable to resist their violent action during sleep. Dr. Ballard speaks of a similar dislocation, the result of thumb-suckino;.* In reference to thumb- sucking I may add that Dr. Dobell has observed in patients who are given to this practice that there is a peculiar and rather common deformity of the chest, caused by the habit of sucking the thumb in infancy and early childhood. The weight of the arm on the thorax of the child during sleep pro- duces depression of the ribs in the line occupied by the arm when the thumb is placed in the mouth. I need not enter fully into the various theories as to the mechanism of dislocation of the lower jaw. Petit, Boyer, Astley Cooper, and others have pointed out that the condyle hes in front of the transverse root of the zygoma, and is there held either by muscular contraction or by the resistance of the zygoma. Malgaigne and Nelaton thought that the coronoid process came in contact with the malar bone, and believed that, in order to effect reduction, it was only necessary to place the two thumbs on the coronoid processes after the patient has opened his mouth, and, without taking hold of the jaw or making any fulcrum, to press the condyles back into their place s.f Mr. Barnard Holt, writing in 1840, J suggested a somewhat similar method, * ' Brit. Med. Journ.,' vol. ii, 1872, p. 327. t The ' Lancet,' 1850, vol. i, p. 663. + Ibid., 1840-41, vol. ii, p. 270. THE SUEGEEY OF THE FACE. 75 fl but depressed the angles of the jaw from the out- side. Thus, he says, " the surgeon stationing him- self behind and above the patient, places the thumb of either hand upon the angles of the jaw on a level with the insertion of the posterior fibres of the masseter muscles, and then presses downwards and backwards." Other observers, as Maisonneuve and Weber, believe that the coronoid process does not become fixed against the malar bone ; and Mr. Heath corroborates their view on this point, for, from experiments he himself made, he found that " in the macerated skull it is easy to dislocate the condyle so far in front of the articular eminence as to cause the coronoid process to be hooked against the malar bone, but this is by no means easy on the subject, even when the parts are dissected, and can only be accomplished by tearing the structures of the joint very considerably."* The relaxation of muscles appears to be the chief means of effecting the reduction, and thus it is in many instances sufficient to divert the patient's attention. M. Clement speaks of cases in which after very painful efforts at reduction the condyles suddenly returned to their cavities during an exami- nation of the mouth. t A remarkable case, illus- trating the spontaneous reduction of the lower jaw * ' Injuries of Jaws,' p. 83. t 'Lyon Medicale,' Sept. 11th. 'Med. Times and Gaz.,' Sept. 24th, 1870, p. 359. 7.6 THE SURGERY OF THE FACE. in dislocation, was under my observation at St. Thomas's Hospital two years ago. The patient was a middle-aged woman, who stated that for several years she had been subject to luxation of the lower jaw, which happened sometimes twice a week. At times the dislocation was easy of reduction, but she had got so accustomed to the condition that she was in the habit of going to bed with the parts unreduced, and she invariably found when she awoke that the jaw was in its proper position. Feacture of Lowee Jaw. Fracture of the lower jaw most usually occurs between the lateral incisor and the canine teeth, this situation being perhaps the weakest part of the bone. The inferior maxilla may, however, be broken in other situations — at the symphysis, the angle, or at the neck of the condyle. An interesting case, from a diagnostic point of view, in which the neck of the condyle was fractured, is recorded by Mr. T. Holmes.* In this example there was displacement of the lower fragment into the meatus auditorius externus, with serous discharge from the ear. The case was interesting, as showing the source from which a sero-sanguineous discharge may come, whether it may depend on a fracture at the base of * ' Path. Trans.,' 1861, p. 159. THE SUEGEET OF THE FACE. 11 the skull, or whether merely from a fracture of the external auditory meatus. Fracture of the neck of the jaw by contre-coKf is still more rare, yet such a case has been described by Dr. Cockburn, of the Royal Engineers.* The injury was caused by a blow of the fist, received at the left side of the face. The least attempt to open the mouth caused much pain at a point close to the tragus of the right ear. It was easy to guess the nature of the injury, and it required but little mani- pulation to detect a simple fracture of the condyloid process of the right side, at a point very close to the insertion of the external pterygoid muscle. The fracture was put up in the usual manner, with a splint of gutta-percha moulded to the lower jaw, the usual chin-sling bandage, with a piece of cork between the teeth. The case did perfectly well. Fractures of the lower jaw, as a rule, unite most perfectly, and however great the primary displace- ment may be, experience proves that the muscles resume their harmonious action, and in the end a most satisfactory result is obtained. In some instances, however, the bones unite very irregularly, thus, in a case of this kind, Mr. Bickersteth, of Liverpool, had to divide the bone with a saw, and then nailed the parts together with small brass pins.f * 'Brit. Med. Journ.,' Dec. 28th. 1867, p. 590. t ' Brit. Med. Journ.,' Nov. SOth, 1S61. p. 588. 78 THE SURGERY OF THE FACE. The plan of fastening the broken ends together with wire passed over the teeth is of ancient date, but the wire so placed is very apt to slip. Mr. Thomas, of Liverpool, speaks highly of a plan he has successfully adopted of boring a hole with a drill on each side about a quarter of an inch from the Fig. 43. fracture (Fig. 43). Through these holes a wire is passed, and twisted in the form of a coil. The immediate effect in one case was that from the first day the patient expressed himself as able to use the jaw.* Another plan is that practised by Mr. Wheelhouse, of Leeds, and represented in the accompanying diagram (Fig. 44). f Two holes are bored with a drill through the substance of the jaw-bone, one on either side of the fracture. Through these holes two pins, having flat, circular, and perforated heads, * The 'Lancet,' Jan. 19th, 1867, p. 79. t The ' Lancet,' Aug. 17th, 1867, p. 195. THE SURGERY OF THE FACE. 79 are passed from behind forwards, and their points bent in opposite directions. The perforated heads Fig. 44. are then threaded with good stout silk ligature, which is brought forward over the teeth, and a fiarure-of-S suture made round the reversed ends of the pins. And, lastly, although I have not yet had an oppor- tunity of testing it, I take the liberty of referring to a simple plan of uniting broken bones, which I successfully employed in 1871 in a case of ununited fracture of both bones of the forearm, an account of which is published in the ' Medico-Chirurgical Trans- actions.'* This method might, I venture to think, be advantageously used in suitable cases of fracture of the lower jaw. Its principle is well illustrated in the woodcut (Fig. 45), which represents it as applied to one of the bones of the forearm. It will be per- ceived that it is nothing more than the twisted suture, and that by withdrawing the needle the wire or thread is of course released. In adopting this * Vol. liv, 1871, p. 313. 80 THE SURGERY OF THE FACE. metliod I imagine that the risk of damaging the bone is very slight. Various other kinds of mechanical Fig. 45. apparatus for keeping the fragments together have been devised by Mr. James Salter,* Mr. Gunning, Mr. Berkeley Hill, t Mr. Moon,:{: and others. In those rare examples in which bony union fails to take place there is abundant scope for ingenuity on the part of surgeons practising dental surgery. Thus Mr.W. D. Napier has furnished me with the par- ticulars of a case of ununited fracture of the lower jaw which was sent to him by the late Sir William Fergusson, in August, 1867. The patient had been frightfully wounded during the siege of Lucknow, and besides having the lower jaw fractured in three places, had also a large portion of the superior maxilla carried away by a cannon ball. Exfoliation * The ' Lancet,' June 16tli, 1860. p. 593. t ' Essentials of Bandaging,' p. 32. X ' Guy's Hospital Reports,' vol. xix, 1874. THE SURGERY OF THE FACE. 81 to a considerable extent took place in the lower jaw, which, together with the loss of many teeth, caused an ugly and inconvenient contraction. There was no bony union whatever, but Mr. Napier so constructed an apparatus as to completely restore the power of mastication. Permanent Closure of the Jaws. In all cases of permanent closure of the jaws in which the lower jaw is fixed by cicatrices, whether caused by injury or by disease, the mere division of the cicatricial band is seldom sufficient to effect a complete cure, for the wound heals rapidly, and the cicatrix, as a rule, becomes even more dense than before. In operating on such cases, Mr. Callender suggests that after the free division of the cicatrix a portion of the alveolar border, together with the teeth, should be removed.* The division of the masseter muscles has been adopted in certain cases, both subcutaneously and by a submucous method through the mouth. f The operations that meet with most favour at the present day are (1) that proposed by Rizzoli, of Bologna, in which the bone is simply divided, and (2) that prac- tised by Esmarch, which consists in removing a * The ' Lancet,' Jnne 18th, 1870, p. 873. t ' Piov. Med. Journal,' vol. iii, 1841-2, p. 345. 6 82 THE SURGERY OF THE FACE. portion of bone. Esmarch's operation has been performed by Messrs. Mitchell Henry, Barnard Holt, Heath, Lawson, Mac Cormac, M. Eichet, by myself, and other surgeons. Most of these cases have been published, and I therefore need not detain you further than by saying that the operations were undertaken either on account of a dense cicatrix existing between the jaw and the cheek, the result of injury or disease, or for anchy- losis of the temporo-maxillary articulation. The case on which I operated belonged to the latter class, and the joint on one side only was affected. The patient was a woman aged twenty-nine, who thirteen years previously had scarlet fever. Abscesses formed in the temporo-maxillary region, and she recovered with fixed jaws. A horizontal incision was made, about two inches in length, in the soft parts under the body of the jaw on the right side ; the soft tissues were then separated from the bone, and an opening made into the mouth between the teeth and the cheek. A narrow saw was applied vertically in the space between the first and second bicuspid teeth, and the bone divided with the help of the cutting forceps. After this section the left side of the jaw was found to be freely movable, but the right side was firmly fixed. A piece of bone nearly an inch in length was then removed from the right or anchylosed side. There was no hasmor- rhage worthy of remark, and the wound was closed THE SURGERY OF THE FACE. 83 with silk sutures. She unfortunately had an attack of erysipelas which retarded her progress consider- ably, but the result was that when she left the hospital she could open her mouth for about three quarters of an inch.* Figs. 46 and 47, taken from Fig. 46. photographs, represent the patient before and after the operation. Dr. Maas relates! a case in which there was bilateral anchylosis of the jaw. The patient was a man aged twenty-seven, who had scarlet fever when he was seven years old, and since the age of ten he * ' Med. Times and Gaz.,' July ]st, 1876, p. 7. t ' Archiv. fiir Klin. Cliirurg.,' Band xiii, Heft 3. 84 THE SURGERY OF THE FACE. had not been able to move the jaw at all. The secondary dentition was attended with great diffi- culty in the removal of the milk teeth, and the new Fig. 47. teeth were for the most part displaced laterally. Herr Middledorpf operated on the right side, ac- cording to Esmarch's plan, with good result, and Dr. Fischer about four months after operated on the left side with great improvement.* It is seldom that an opportunity is afforded of examining the pathological condition of the parts after operation, but M. Boinet reports one such * ' Brit. Med. Jonrn..' June 1st, 1872, p. 585. THE SUKGERY OF THE FACE. 85 example.* The patient was a little girl who had immobility of the lower jaw following gangrene of the mouth. Rizzoli's operation was performed, and matters appeared at first to go on well, but at the end of three months the divided portions began to unite, and in eight months there was complete con- solidation. M. Boinet then performed Esmarch's operation, removing a wedge-shaped piece of bone, with the base at the lower border of the jaw and the apex at the alveolar ridge. The operation was performed in June, 1863, and six weeks or two months afterwards the patient could eat any kind of solid food. In the beginning of September, 1866, she died of phthisis, having up to the time of her death retained the mobility of the jaw. On examin- ing the bone, it was found that there was a false joint between the divided portions, and there was an arrest of development of the bone and atrophy of the muscles inserted into it. Foreign Bodies in the Nose and Ears. Foreign bodies, such as cherry-stones, locust- beans, brass rings, slate pencils, screws, buttons, pieces of wood, peas, &c., are not unfrequently met * ' Gazette Medicale de Lyon,' October 1st, 1866 ; ' Brit. Med. Journ.,' November 17tli, 1866, p. 552. 86 THE SUEGEEY OF THE FACE. with in the aural and nasal cavities of children, and even in adults. Such substances have been known to remain in one or other of these cavities for well- nigh a lifetime, causing little or no inconvenience. Thus a case is related of a lady from whose nostril a foreign body was dislodged during the act of sneezing ; it was found to be a button which had belonged to her little brother when they were both infants.* Another case is recorded f in which a piece of slate pencil was removed from a woman's ear, which had been put there when she was at school " forty years before." And a third instance, a patient of Mr. Winterbotham's, of Cheltenham, in which a cherry-stone had been in the ear for sixty years. I Mr. Hargood, of Eastbourne, also recently reported the case of a gentleman, aged forty-one, from whose ear a piece of cedar wood was removed by syringing. " The patient remembered distinctly the fact of its introduction when he was a boy at school at least thirty years before. No attempt had been made to extract it, and its presence had not troubled him until now."§ It occasionally happens, however, that a good deal of inflammatory action is set up by the foreign body. As a case in point, I may mention that of a * The ' Lancet,' July 2nd, 1859, p. 13. t Ibid., May 11th, 1867, p. 591. X ' Med. Times and Gaz.,' vol. ii, 1866, p. 497. § ' Brit. Med. Journ.,' Jan. 5th, 1878, p. 12. THE SURGERY OF THE FACE. 87 girl who was under my care at the hospital, and who was admitted on account of having a small stone in her ear. She subsequently had paralysis of the facial nerve. Mr. Jonathan Hutchinson alludes to the case of a child who not only had facial palsy, but died of meningitis caused by the presence of a locust-bean in the ear. There are various instruments employed for removing foreign bodies from the ear, each good in its way. A loop of wire, a scoop, or a needle with the point just slightly turned up, or a pair of forceps of suitable size may be used. It is not always easy to detect the exact character of the foreign body, and as bearing on this point I may incidentally refer to the case of the man who is here this evening in the adjoining room. About fifteen months ago he was accidentally shot behind the left ear. The patient was seen by my friend, Mr. Henry Jacobs, of Kensington, who has given me the opportunity of examining him with reference to the lodgment or not of the bullet, for the latter could not be discovered after the accident. There is a constant discharge from the ear, and, as you will observe, well-marked facial palsy. My colleague. Dr. Stone, has kindly constructed a clever electrical apparatus by which we are enabled to detect the unquestionable presence of the bullet. Dr. Stone has done us the honour to be present, and I think you will agree that the Society is much indebted to 88 THE SURGERY OF TEE FACE. him for the trouble he has taken in bringing the apparatus here, and of thus giving the Fellows the opportunity of witnessing so interesting an experi- ment. [The apparatus constructed by Dr. Stone con- sisted of two fine pieces of silver wire, covered with silk, which were wound together in a single strand to imitate a probe, about three inches in length. The whole was insulated and stiffened with shellac, the ends being left loose for connection with a battery and galvanometer. The joined ends at the opposite extremity were cut, so as to leave two little discs of clean silver. On placing these discs in contact with the foreign body in the ear, the galvanometer was visibly deflected, indicating the presence of a metallic substance, which was naturally assumed to be the bullet. The exposed surfaces of the discs were intentionally kept as small, and the insulation as perfect, as possible, to prevent the transmission of a perceptible current by the fluids of the sinus.] Living larvae have been found in the meatus of the ear. Dr. Routh publishes such a case : — The patient was a gentleman who three years before was tormented with a fly near his ear. Convulsions followed the presence of the larvae, but the patient recovered, although he remained deaf.* Dr. Blake, of Boston, has seen four such cases. f * The ' Laneet,' 1849, vol. i, p. 588. t The ' Lancet; 1872, vol. ii, p. 861. THE SURGERY OF THE FACE. 89 Dr. Kealy, of Gosport, reports a case to show the curious course taken by a pin that had been intro- duced into the external meatus. It passed through the middle ear, probably along the Eustachian tube, and was extracted by the patient from her throat by hooking it with her finger.* In dealing with foreign bodies situated in the external auditory meatus, syringing the passage will often suffice to effect removal. In many cases, how- ever, forceps and other instruments must be used, but then they should be employed with the greatest caution. As a rule, if left alone, the foreign body becomes loose, and falls out on the pillow as the patient lies in bed. In extracting foreign bodies from the ear M. Deboutf has recommended that the mouth of the patient should at the same time be kept open. It is sufficient, he remarks, to introduce the end of one's finger (and the Fellows may try it on their own person) into the external auditory canal, and to make the lower jaw move, in order to become con- vinced of the enlargement that the canal undergoes each time the condyle of the jaw is made to move. Dr. Voltilini offers some very sensible and practical remarks on this subject, which I venture to quote.:]: He says : " The first thing we have to do is to assure * ' Med Times, and Gaz.,' Dec. 17tli, 1859, p. 602. t 'Brit. Med. Journ.,' May 4th, 1865, p. 229. X ' Brit, and For. Med.-Chir. Review ;' ' Brit. Med. Journ.,' March. 19th, 1864, p. 315. 90 THE SURGERY OF THE FACE. ourselves that a foreign body is really in the ear, for it by no means rarely happens that persons apply to the surgfeon under the belief that an insect or other substance is present, but which a more exact inspec- tion fails to discover," He adds we should never employ force, and in saying this he did not wish to convey the idea that foreign bodies should always be left in the ear, but that matters should not be made worse by violent manipulations. Still more recently, Mr. Dalby* has laid down a very practical law that no attempt should be made to remove a foreign body from the ear unless the auditory canal be thoroughly illuminated. Where this rule is broken the tym- panic membrane will most probably be ruptured, and thus the life of the patient placed in imminent peril. Foreign Bodies in the Orbit and Face. The limits of my time prevent me from entering into the different injuries of the orbit and its con- tents, and I regret this the more inasmuch as wounds in the neighbourhood of the eye frequently give rise to various anomalous sjanptoms. In fencing, the foil has occasionally passed straight through the orbit, and has penetrated the brain, in some cases, even without injuring the globe of the eye. * ' Brit. Med. Journ.,' Dec. 15tli, 1877, p. 847. THE SUEGERY OF THE FACE. 91 The specimen on the table, from the museum of St. Thomas's Hospital, is one of great interest, as illustrating the curious course taken by a portion of a table-knife, which entered the cavity of the skull through the orbit. A girl was mixing some deto- nating powder with a large table knife. An explo- sion took place, and she was severely burnt about the face, for which she was admitted into St. Thomas's Hospital. A part of the knife could not be discovered in the room in which the accident occurred. The girl died about a week after admis- sion, and at the post-mortem examination the miss- ing portion was found in the position you now see it, that is, vertically between the vertex and base of the cranial cavity. Mr. George Lawson* refers to a case reported by Mr. B. Carter in No. 4 of the ' Ophthalmic Eeview,' p. 337, in which a piece of iron hat-peg about three inches long, and weighing twenty-five scruples, was impacted in the orbit, and remained there for a number of days without the patient being aware of its presence. It was then extracted by the late Mr. Clarke, of Gloucester, and the man made a rapid recovery without any impairment of the sight of the eye. Another case to which the same author alludes is one that occurred in the practice of Nelaton. The patient, aged 26, had a lachrymal fistula, the result of a blow received three years previously * " Injuries of the Eye, Orbit, and Eyelids," 1867. 92 THE SURGERY OF THE FACE. from tlie handle of an umbrella. Nelaton believed there was some foreign body present, and after having made an incision, withdrew a piece of ivory handle, such as is often affixed to umbrellas, about an inch and a half in length. After a few days the patient left the hospital with his vision improved and with the fistula nearly healed. My friend, Mr. Jeaffreson, of Newcastle-on-Tyne, informs me that a case came under his observation in which a large portion of a spectacle frame en- tered the orbit and was found, after death, imbedded in the substance of the brain. The patient had few symptoms to indicate the presence of the foreign body, and remained fairly well for a few months after the accident, when he died in an epileptic fit. Mr. Lawson * has placed on record an interest- ing account of the lodgment of a large piece of stick in the orbit itself, accompanied with paralysis of all the muscles of the orbit. I may also refer to a somewhat remarkable case that was under the observation of Mr. Furneaux Jordan :t "A man, who was employed in threshing, became the subject of severe ophthalmia. At the expiration of several weeks the patient, whilst pressing his finger on the lower eyelid, suddenly ejected from a comfortable bed of warm pus a grain of wheat, which had shot forth a vigorous green sprout." Foreign bodies * The ' Lancet,' Sept. 15th, 1877, p. 390. t ' Med. Times and Gaz.,' Feb. 22nd, 1862, p. 203. THE SURGERY OF THE FACE. 93 will remain imbedded in the face for days, months, or even years without giving rise to any discomfort. Thus I not long ago removed from a gentleman's face eight or ten shots, which had caused no incon- venience whatever for twelve years. Substances of different kinds are occasionally found lodged in various parts of the face without the patient being at all aware of their presence. In 1868 I saw a man, aged forty-two, at the West- minster Hospital, who had a swelling on the lower lip on the left side. He had been told he had cancer, and sought advice on that account. It appeared that he had fallen from a scaffolding two or three months previously, and had sustained con- siderable injury to his scalp and face, and his lower jaw was fractured. He had been a patient else- where, and stated that when he was under treat- ment he had fits. On examining the part, the lip was found a good deal swollen, and rather tender to the touch. I made a puncture, when the knife impinged on a hard substance, which proved to be a portion of the crown of the left lateral incisor of the lower jaw, which the patient said he missed after the accident. It was decayed at the neck, and had sharp edges. The patient made a good recovery. Another instance is recorded * in which a canine tooth was lodged in the thickness of the lower lip * The ' Lancet,' May 17th, 1862. 94 THE SURGERY OF THE FACE. simulating a cancerous tumour. The patient was a lady forty years of age, wlio had always suffered with her teeth, and had but few incisors left, the rest of the jaws presenting roots more or less firmly wedged, and the alveoli more or less decayed. To- wards the end of the year 1854 she felt a small tumour forming in the lower lip of the left side. Pain was subsequently experienced, and a few months afterwards the patient could hardly eat. She sent for her medical attendant, who made a crucial incision, and discovered a long root of the canine tooth which had been imbedded in the sub- stance of the lip. Another case is related by Mr. W. H. Folker,* of the North Staffordshire Infirmary. The patient was sixteen years of age, a joiner, and was admitted August 29th, 1867, on account of a tumour existing in the substance of the upper lip. The swelling was on the right side of the mesial line correspond- ing to the right central incisor tooth (which was noticed to be wanting), and it seemed to be formed by hypertrophied lip. It caused a good deal of deformity, as the patient was unable accurately to close his lips. The tumour felt hard, but was not painful. On carefully examining the swelling, a small aperture was perceived at its base ; and on passing a fine probe a hard substance was felt, which was diagnosed to be a tooth. On August * The ' Lancet; October, 1868. THE SURGE EY OF THE FACE. 95 31st, an incision having been made througli tlie tumour, a tooth was found at its base. After its removal the swelhng disappeared, and the patient was discharged the following day. Mr. Haynes Walton has reported a case* of a patient, aged thirty-five, who, three years and a half before, had a fall, and lost his right upper lateral incisor. He had much pain, and a few weeks later an abscess formed, which discharged through a small opening in the cheek as well as through the alveolus of a lost tooth. Then another abscess formed, leaving a sinus open in the right cheek. On probing this, a hard substance was found. The wound was opened up, and a perfect incisor tooth, lying loose in the antrum, was removed. I need scarcely add that carious teeth, which may be almost regarded as foreign bodies, give rise, as all surgeons practising dental surgery are aware, to an endless variety of anomalous symptoms, such as neuralgia, squint, wry-neck, closure of jaws, epilepsy, &c. Mr. Hancock t has reported several such cases. One was a patient whose jaw had been closed for twelve months ; a second, a girl affected with wry- neck ; a third, a case of supposed tumour of the cheek ; a fourth, a case of amaurosis lasting for a month; a fifth, a man who was totally blind in the right eye for eight months ; and a sixth, a patient * ' Medical Times,' November, 1869. t The ' Lancet,' 1859. 96 THE SURGERY OF THE FACE. with strabismus and ptosis. Mr. Adams Parker* and Mr. Samuel Smith f have contributed similar examples. In conclusion, I will refer to an interesting case that was under the care of Dr. George Johnson, J in which tetanus, with facial neuralgia and palsy, and a recurrence of epilepsy, were excited by a foreign body imbedded in the cheek. The patient was a wheelwright, aged forty-four, who, on July 4th, 1872, was cut on the cheek by a blow from an iron axle that fell upon his face. The wound was strapped up by a chemist, and healed, but remained very painful. On the 12th he had an epileptic fit. In early life he had been subject to epilepsy, but until the occasion mentioned had been free from fits for twelve years. On the morning of the 13th — that is, about ten days after the accident — he had difficulty in opening his mouth. The left masseter muscle felt prominently hard and rigid. There was a scar, about three fourths of an inch long, an inch below the left eye, the cicatrix being hard and very tender to the touch. Dr. Johnson, believing that there was a foreign body present, directed the house- surgeon to cut through the cicatrix, when a sharp, angular piece of flint, nearly as large as a grain of wheat, was discovered and removed. With this the * The ' Lancet,' vol. i, 1862. t The ' Lancet,' vol. i, 1857. X ' Clinical Society,' Nov. 8th, 1872. THE SURGERY OF THE FACE. 97 symptoms gradually passed away. The chief interest of the case, as Dr. Johnson remarked, consisted in the fact that formidable nervous symptoms were excited by the presence of a foreign body of small size beneath the cicatrix of a recently healed wound. In my next, and concluding lecture I hope to speak of the "Deformities of the face with their treatment." LECTURE III. DEFORMITIES OF THE FACE. Mr. Peesidbnt and Gentlemen. — Having briefly disposed of the diseases and injuries of the face, I purpose, with your permission, in this, my con- cluding lecture, to describe some of the principal deformities that are met with in this region, with their appropriate treatment. I shall pass over such consrenital malformations as do not come within the scope of the surgeon's art ; those I mean that would be generally classified as monstrosities. In a paper " On the Relation of the Teeth and Mouth to Mental Development "* Dr. Langdon Down lays stress on the characteristic features of the lips in congenital idiots. The lips, he says, are in such persons usually thick, the thickness being greatly more marked in the lower than in the upper one. In addition to the thickening they are often striated and marked by transverse fissures. They are frequently deficient in muscular power, and the * ' Trans. Odontological Soc.,' vols, iii and iv, 1871—72, p. 14. THE SURGERY OF THE FACE. 99 want of muscular action interferes with their prehensile function, and also induces a tendency for the saliva to run over the chin. The mucous membrane is extremely liable to chronic inflam- mation, and ulceration is induced by the slightest pressure against prominent or uneven teeth. The glands of the mucous membrane of the mouth generally, as well as the salivary glands, are usually hypertrophied. Again,* the same writer alludes to certain semilunar folds of skin at the inner canthus of the eye — folds which, he believes, are more frequently present in feeble-minded children than in others, and which he describes as epicanthic folds. They are, according to his experience, marks of developmental degeneracy, and should always be looked for in doubtful cases. Then he remarks that the seat of implantation of the ear in idiots is usually placed further back in relation to the head and face than in normal children. The mouth is arched or gothic-shaped. The tongue is increased in size ; it is rugous, fissm^ed, and its papillse are enlarged. Again, the angle of the jaw is more obtuse than usual. Harelip. Perhaps one of the commonest congenital de- formities of the face is harelip, of which various * ' Trans. Obstet. Soc- of London,' vol. xviii, 1876. 100 THE SURGERY OF THE rA(!E. examples are sliown in figs. 48, 49, 50,51, and 52. Having written so recently on this subject,* I have little to add to what has been already published ; but I may be permitted to dwell for a moment on one or two points in connexion with this deformity. Fig. 48. Fig. 49. Fig. 50. Fig. 51. Fig. 52. 1st. Kespecting the intermaxillary or premaxillary bones. I think there can be no doubt that when * See author ' On Harelip and Cleft Palate,' Churchill, 1877. I THE SURGERY OF THE FACE. 101 harelip is associated with a fissure of the hard palate, the fissure takes the place of the lateral incisor tooth of one or both sides, as the case may be. In other words, the lateral incisor is usually wanting. Figures 53 and 54 indicate these points, but the actual specimens, which I hand round, as Fig. 53. Fig. 54. well as the photographs, put the matter, I think, beyond doubt. This specimen especially, from the collection of the late Sir William Fergusson, is of more than ordinary interest, for it shows one of the results of pushing back the intermaxillary bones, a plan of treatment adopted by some surgeons. It will be observed, first, that the central incisors alone are present; and, secondly, that they are situated horizontally backwards ; indeed, before removal they really occupied the anterior part of the roof of the mouth.* It is extremely rare to find a case of double hare- lip with no fissure of the palate whatever, but I have seen one case, and another is now under the care of my colleague, Mr. Croft, at St. Thomas's Hospital. 2nd. The hereditary character of harelip is in * ' Brit. Med. Journ.,' Dec. 25, 1875, p. 772. 102 THE SURGERY OF THE FACE. very many instances, I find, conspicuous by its absence, but occasionally it is very striking. Thus, Dr. Buck* gives an account of a family in which there was a very remarkable hereditary history : — " Mrs. M — and her three children (all girls) came under his notice in January, 1871. The mother her- self bore the marks of a successful operation for harelip performed in childhood. She had a brother and sister with harelip ; and besides the three living children above referred to, she had had four others, who had all died in early infancy ; three of these had harelip, and the fourth one only was a perfect child. In other words, there were nine instances of the deformity in two generations of a single family. 3rd. I may perhaps be allowed to make one or two practical remarks respecting the method of operating. The harelip pin with the twisted suture is very commonly employed to bring the edges together, but, without entirely discarding this method of approximating the parts, I feel sure that the usual interrupted suture of silk may in most cases be employed with great advantage, and, I believe, with certain precautions, it is in many instances preferable ; but whether the twisted or interrupted suture be used, the success of the operation mainly depends, first, on the soft parts being thoroughly freed from the subjacent bone; secondly, on the edges of the fissure being so pared that a good * ' Reparative Surgery,' 1877, p. 130. THE SURGERY OP THE FACE. 103 broad raw surface is left; and thirdly, on the patient being incessantly watched for three or four days by a skilled nurse, who should support the newly united surfaces by making continuous but gentle pressure on each cheek. I have little confi- dence in the use of mechanical appliances after the operation ; for, in nursing the child, they are apt to shift their place, and often do more harm than good. They are, however, invaluable as aids in bringing the two superior maxillae together if worn before operative procedure is undertaken. Again, strapping is of especial service before the operation, but afterwards it cannot be with safety solely relied on. Besides the ordinary forms of harelip, fissures of the lips extend in other directions : thus, Mr. Ward describes a case* in which the fissure ex- tended into the right cheek. Another more remark- able example is recordedf in which a boy was born with a *' very large mouth." At seventeen years of age his mouth was six and a half inches in diameter, extending from one ear to the other, so that the tongue always hung between the teeth. Langenbeck operated on the lips and brought the parts together. Again, a remarkable instance is reported by M. Guersant, in which the fissure on each side extended towards the eyelids. (Fig. 55.) * The ' Lancet,' May 28, 1859, p. 536. t Ibid., vol. xiii, 1827-28, p. 462. 104 THE SURGERY OF THE FACE. Fig. 55. Cleft Palate. The mention of harelip almost necessitates a few words on fissure of the palate, of which several varieties are exhibited in the diagrams I here show you. (Figs. 56, 57, 58, 59, 60, 61, 62.) It is extremely rare to meet with a case of fissure of the soft palate in which there is an entire absence of the uvula, but such a case I have the opportunity of showing you to-night. You will observe that there is not a vestige of uvula, the fissured palate being directly continuous with the pharynx on each side. Respecting cleft palate I have little to add to what I have already laid before the profession. I may, however, say that in the majority of cases in which THE SURGERY OF THE FACE. Fig. 56. Fig. 57. 105 Fig. 58. Fig. 60. Fig. til. / 106 THE SURGERY OP THE FACE. the hard palate is involved I perform the rauco- periosteal or Langenbeck's operation shown in Fig. 62. Fig. 63, in preference to Dieffenbach's method of procedure. Dieffenbach's plan of dividing the / entire bony palate with a chisel, and which was] introduced into this country by the late Sir \V. THE SUEGERY OF THE FACE. 107 Fergusson, has the disadvantage that it is some- times followed by exfoliation of bone. This unto- ward result, however, may to some extent be obvia- ted by boring a few holes with an ordinary bradawl in the line in which the chisel is to be applied, a plan I suggested in the ' Lancet ' of October 24th, 1874, p. 578, and which is indicated in Figs. 64, 65. Again, the closure of the hard palate is often attended with troublesome haemorrhage, but the bleeding may be instantly arrested by plugging the wounds on each side with dry lint, after which the operation may be completed without difficulty. I referred to this practice in the ' Lancet,' of July Fig. 64. Fig. 65. A A 29th, 1876, p. 170. Severe bleeding of an inter- mediary or secondary character occasionally, but very rarely, occurs. Such a case has, however, been recently reported by Mr. Marsh.* * The ' Lancet,' Jan. 19, 1878. 108 THE SURGERY OF THE FACE. The chief object of the operations for cleft palate is, of course, the improvement of the voice. I need not refer to my views on the subject further than to say that a cleft in the soft palate is not a mere rent or sHt in the parts, but is an actual deficiency or want of tissue. Hence, after the edges of the soft palate are brought together, the part remains as a tight curtain, stretched between the mouth and posterior nares. The result is that, in speaking, the air, instead of passing into the mouth, gains access to the nostril, and thus the peculiar nasal twang is maintained. I therefore venture again to recommend the performance of a very slight opera- tion, an account of which I published in 1869.* It Fig. 66. A must be understood that this procedure is an entirely independent operation, and should be per- * The ' Lancet,' vol. ii, 1869, p. 198. THE SURGERY OF THE FACE. 109 formed only when the surgeon is perfectly satisfied that firm union between the previously fissured parts has taken place. The sides are divided in the line from a to b (Fig. 66). These incisions release the part on each side and the palate is, so to speak, converted into a huge uvula. Congenital Deficiencies of Bones of Face, &c. Besides congenital defects of the superior maxillae and the palate bones, there are cases recorded of deficiency in other bones about the face. Thus Delpech * gives a description of a patient who had a congenital absence of the right nasal and lach- rymal bones, the nasal process of the superior maxillary, and of the soft parts. Again, Dr. Samelson exhibited at the Manchester Medical Society a patient, aged twenty-three, who had a congenital defect of the frontal bone. There was a somewhat thickened integument extending over a cavity produced by the absence of the bone. Within the gap the cerebral pulsation was very plainly visible, f Mr. Gay has favoured me with the notes of a case in which there was congenital absence of the nasal bones. The rough sketch I send round will afford * The ' Lancet; 1829-30, p. 260. t ' Brit. Med. Jouru.,' Feb. 3, 1872, p. 137. 110 THE SURGERY OF THE FACE. some idea of the condition of the parts. Further, Mr. Bryant, in his work on Surgery, refers to a case of Mr. Poland's of meningocele, which caused a considerable prominence over the nasal bones. Dr. Lichtenberg also reports a remarkable in- stance of a congenital tumour which protruded through the mouth of a newly born babe. The growth overlapped the chin, and rested with its base on the sternum. From the appearance. Dr. Lichtenberg believed the case to be one of polypus, and after putting on a ligature as tightly as possible, cut off the tumour. Three or four days after, the patient died of convulsions. At the post-mortem examination the pedicle of the tumour was found to perforate the sella turcica, and was there attached to an oval tumour which was connected with the brain.* Such a case as this should make us re- member that it is not always easy to pronounce a decided opinion as to the exact nature of a con- genital tumour. Whilst I am on this subject, I may allude to an instance that was under the care of my former colleague, Mr. Henry Arnott, which showed the difficulty of arriving at a correct dia- gnosis. There was a round sessile swelling, the size of a large walnut, situated just in front of the anterior fontanelle, in a child eight months old. The history of the case pointed very decidedly to the tumour being a meningocele. No operative * 'Path. Trans.,' vol. xviii, 1867, p. 251. THE SUHGERY OF THE FACE. Ill treatment was adopted, and the patient died of bronclio-pneunionia. At the post-mortem exami- nation the swelling proved to be a cyst of a dermoid character, and was quite unconnected with the in- terior of the skull. The mistake (adds Mr. Arnott) in this instance mattered little ; but fatal errors have been committed by surgeons mistaking menin- gocele for simple dermoid cysts, and undertaking their removal.* Again, Mr. Gay tells me he now has under obser- vation a case in which there was a swelling, the size of a small walnut, situated at the front part of the left temporal fossa. The patient was seventeen years of age, and the swelling had become promi- nent for the last ten years. Mr. Gay believes he had discovered the true nature of the tumour by cutting down, but not into it, for rather severe symptoms followed the operation. No pressure on it, or other efforts to detect the real nature of the swelling, answered before exploration. The tumour was thought to be a meningocele. Congenital Malformation of Ears, Jaws, &c. Congenital malformation of the ears of a slight kind is not uncommon, and we occasionally meet * ' Path. Trans.,' vol. xxv, 1874, p. 230. 112 THE SURGERY OF THE FACE. with supernumerary auricles. Mr. Birkett has pubhshed a case of this nature in which the extra auricular appendages were situated rather lower than the angles of the jaw on each side of the neck.* A supernumerary eyelid has also been ob- served by M. DuboiSjt but it proved to be nothing more than a fold of conjunctiva. Sir James Paget has given increased stimulus to the study of the subject of congenital malformation of the ears in an admirable paper lately read at the Royal Medical and Chirurgical Society on branchial fistula in the external ears.| The cases he de- scribed showed a remarkable hereditary tendency, and occurred in the family of a gentleman perfectly well formed in other respects, who had himself a branchial fistula on the right side of the neck. His father and a sister, as well as four of his own children, had similar malformations ; the fistula in two of the latter being on the left side, and in the other two symmetrically disposed on each side of the neck. But, in addition to these cervical fistulge, the gentleman himself, his sister, and five of his children, each had fistulas in the helix of one or both ears. The aural fistulse were minute, their orifices small, and their canal half an inch in length, passing from below forwards and downwards, being * ' Path. Trans.,' vol. ix, p. 448. t ' Med. Times and Gaz.,' Jan. 16, 1864, p. 78. + 'Lancet,' Dec. 1, 1877, p. 804. THE SURGERY OP THE FACE. 113 less soft and flexible than the cervical fistulse, pro- ducing no secretion, and giving no distress. In 1870 a remarkable case of this kind was exhibited at the Pathological Society of Reading, by Dr. Moxhay, of deformities of the ears and face, Tig. 67. shown in Fig. 67 (taken from a photograph for which I am indebted to Dr. Moxhay) . He says : " In addition to the proper complement of two perfect ears, there were on the right side three rudimentary auricles, one rather a perfect specimen. On the left side there were two of these abnormal growths, one representing a fleshy lump, with car- tilage in and beneath its substance, just below and in front of the proper ear ; the second being a mere projecting tubercle, but exhibiting, when removed, a cartilaginous meatus dipping deeply. A con- genital deficiency of the right ramus of the lower jaw also existed, which gave a singularly strange 8 114 THE SUEGEM OF THE FACE. expression to the face, resembling somewhat the drawing down of the chin by the cicatrices of burns. Dr. Moxhay stated that a curious reason was given by the mother of the child for these abnormalities. It seems that, when pregnant, the woman was suddenly frightened by a boy who was the subject of contraction in the neck which drew down the chin and lips in a manner very similar to the deformities described above. Upon receiving the fright the poor woman immediately put up her hands to her ears." At my request Dr. Moxhay kindly examined this patient in November last — that is, seven years after she first came under observation — and in reply to my inquiry stated that the jaw was absent from the first molar on the right side, and he could put his finger into the glenoid cavity from the inside of the mouth. There was no condyle, but there was a band of slightly firm tissue where the jaw ought to be. The girl was intelligent, and could speak well. I here show you, through the courtesy of Mr. Royes Bell, photographs of the ears of another patient with a somewhat similar deformity, the right ear being represented in Fig. 68. The appendages were merely small pieces of loose skin containing no cartilage. The fistulee in this case were not well- marked, and there was no family history to indicate its hereditary nature. The characteristic shortening of the lower jaw is also well shown. THE SURGERY OF THE FACE. 115 Whilst on the subject of malformation of the ears, I may briefly refer to one or two examples of cervical fistula, for I think some of these cases are overlooked. Heusinger reports two ex- amples. One occurred in a girl aged fifteen, and in this instance the cutaneous orifice of Fig. 68. the fistula, having a diameter of about one fifth of an inch, was situated at the upper edge of the sternum, near the sterno-clavicular articu- lation and the inner edge of the sterno-mastoid muscle. The canal of the fistula was nearly an inch long, and directed vertically upwards, ending in a cul-de-sac having a diameter of two fifths of an inch. In another case, occurring in a girl seven 116 THE SUEGERY OF THE FACE. years of age, the external ears, especially the right, were slightly malformed. On the left side of the neck, a little above the thyroid cartilage, was a small orifice, surmounted by a projecting crest of skin, in which there appeared to be a particle of bone or cartilage. The orifice led into a canal which proceeded towards the pharynx above the hyoid bone, but no internal opening could be found.* Dr. F. Mayer has also reported a similar case. Two examples of this congenital malformation in the neck have come under my observation — one at the hospital about six years ago, and a second in private practice in the autumn of 1876 ; in the latter case I had the advantage of Sir James Paget' s opinion. The patient was a young lady, aged nineteen, who had two minute orifices at the inner side of each sterno-mastoid muscle, just above the sterno- clavicular articulation, which occa- sionally discharged a mucous secretion. A small probe could be introduced for several inches in the upward direction, almost to the angles of the jaw. The patient was under the impression that the fistulee opened internally, but I could not satisfy myself, after careful examination, that such was the case. Dr. Munro, of Radstock, has publishedf a case in which there was a complete absence of the meatus * ' Virchow's Archiv,' and ' Gaz. Med. de Paris,' June IGtli, 1866. t The ' Lancet,' July lOth, 1869, p. 41. THE SURGERY OF THE FACE. 117 auditorius externus of the right side, although the pinna, or external ear, was perfectly normal; and Dr. Fleischmann, of Cheltenham, gives an account of a similar instance* occurring in a little girl, and on whom he endeavoured to establish a permanent aperture by means of the galvanic battery with very fine needles ; but the parts healed up soon after, notwithstanding every effort was made to keep them open. Mr. Hinton, however, is stated to have cured such cases by dividing the false membrane and introducing tents into the aperture. f Maternal Impressions. Congenital malformations are often traced to maternal impressions. Dr. E,. J. Lee, who gave us an interesting and instructive paper on the subject in November last, expressed a decided opinion that maternal impressions may be divided into two classes — viz., those producing lesions of the surface of the body, and those which were the effect of changes in the nervous and arterial system. | I may mention one or two instances which appear to have characteristic significance. The first is re- ported by Mr. Curgenven, as follows : — " A woman during pregnancy was horrified at seeing a man * ' Lancet,' July 24tli, 1869, p. 151. f Holmes' ' System o£ Surgery,' vol. iii, p. 135. + ' The Lancet,' Nov. 3rd, 1877, p. 651. 118 THE SURGERY OF THE FACE. whose ear had been mutilated. Her child, a girl, was born with her right ear presenting a similar appearance. This child grew up, and her sister, whilst pregnant, and during a fit of anger, called her ' old one ear.' She retorted by saying that one day she would be sorry for speaking of her defor- mity in that manner. The result was that the sister's child, a boy, was born with his right ear deformed like his aunt's." Another remarkable case came under my own observation. About a year after the burning of Covent Garden Theatre after a series of performances terminating in a lal masque^ a child was brought to King's College Hospital the half of whose body, including the face, closely resembled a piece of charred wood. It appeared that the mother during pregnancy resided opposite the theatre at the time of the fire, and attributed the condition of the child to the fright that the fire occasioned. Mr. Morrant Baker (to whom I am indebted for the photographs I hand round) has published an interesting case of a hairy mole of congenital origin on which he had successfully operated. The sup- posed cause of the deformity in this case was that the mother during pregnancy was frightened by a monkey in a travelling menagerie. A somewhat similar case, shown in this woodcut (Fig. 69), taken from a photograph, came under my notice about three years ago. The mother attributed the deformity to THE SURGEEY OP THE FACE. 119 a fright occasioned by seeing a rat. I proposed to attempt a partial destruction of the deformity, but the patient objected to any surgical interference. Dr. Buck* reports a case of abnormal growth of hair on the forehead (congenital). The patient, aged thirteen, had a hairy mole over the left eye, Fig. 69. looking like mouse-skin. The growth was removed partially by the actual cautery, but chiefly by caustic potash. Congenital Htperteophy op Face, Lips, &c. Valentine Mottf describes a peculiar form of tumour of the skin occurring in a boy aged fourteen, * ' Reparative Surgery,' p. 165. t ' Med.-Chir. Trans.,' vol. xxxvii (1854), p. 158. J 20 THE SURGERY OF TUE FACE. who had a deformity of the entire half of the left side of his head and face. It consisted of three layers of tumours from the crown of the head to some distance below the base of the lower jaw. It commenced as a pimple soon after birth. The mass involved the scalp of one side of the head, one-half of the nose, the upper and lower lips, and the whole side of the face. The growth was removed, but recurred. A second operation was performed, but with no permanent benefit, as the tumour continued to increase in size. Another case related by the same author was that of a boy aged twelve, who had the same thing, but of less extent, on the right side. The growth was removed, and six years after the patient was well. The specimen, according to Dr. Lovett, who ex- amined it microscopically, appeared to consist of hypertrophy of the skin and subcutaneous areolar tissue. Mr. Jardine Murray has described a very unusual congenital malformation of the lower lip, in which two sacculi existed.* The deformity occurred in four members of the same family. Mr. Murray thus describes the condition : — " About a quarter of an inch from the external edge of the pink mucous membrane of the prolabium are two crescentic openings, exactly similar in appearance and sym- metrical in position, one placed on either side of the * 'Brit, and For. Med.-Cliir. Rev.,' vol. xxvi (1860), p. 502. THE SURGERY OF THE FACE. 121 mesial line. The horns of the crescent are directed forwards, and a little outwards. A probe inserted into one of these openings passes downwards on the inner side of the lip under a considerable thickness of mucous membrane, to the depth of half an inch. Into each pouch a split pea might readily be intro- duced. The pouches do not communicate with each other; they secrete glairy mucus, and their presence does not occasion any inconvenience. Sacculi in every respect precisely similar to these are present in the under-lip of the father of this family and of his third and eighth children, all of whom were born with the additional malformation of harelip." By the kindness of Mr. Jardine Murray I am enabled to show you photographs, before and after operation, of a case of congenital hypertrophy of the upper lip which was cured by the removal of an elliptical portion. Mr. T. Holmes * refers to a somewhat similar example occurring in a child, two and a half years old, who had considerable enlarge- ment of the upper lip. An elliptical piece was removed, which, on examination, presented the appearance of "ordinary rather condensed cellular tissue." The mother stated that she was sure that the condition of the lip was congenital, and attributed it to her having been struck on her lip by her husband during her pregnancy. * ' Surgical Treatment of Cliildren's Diseases,' 1868, p. 27. 122 THE SURGERY OF THE FACE. Dr. Buck* relates the case of a man, aged twenty- five, who was admitted into St. Luke's Hospital, America, with a congenital ngevoid growth of the lower lip. The lower lip was more than double the thickness of the upper, and proportionately increased in all directions. A Y-shaped piece was removed with good result. Congenital absence of the nose is very rare. Of course the floor of the nostrils is more or less want- ing in cases of cleft palate. Lateral displacements of congenital origin are sometimes met with, and may be dealt with according to circumstances. I alluded to the treatment of such cases in my last lecture. Imjjerforate nostrils of congenital origin are very rarely brought under the notice of the surgeon. I saw one case at King's College Hospital in a newly born baby, but the child died almost im- mediately after birth, so that there was no oppor- tunity of attempting a cure. Mr. Thomas Smith, however, refers to an instancef which was under his care in a child, aged five, who suffered from "insuflBcient nasal aperture." Great improvement followed an operation, which consisted in passing a narrow bistoury into the nostril and retaining a piece of gum-elastic catheter. * ' Reparative Surgery,' p. 159. t ' Med. Times and Gazette,' Marcli 28th, 1863, p. 320. THE SURGERY OP THE FACE. 123 Non-congenital Deformities of the Face. Having disposed of the congenital malformations, I now pass on to consider the deformities of the face occasioned by accident or disease. A very rare case of unilateral atrophy of the face, caused by pressure of a thin cicatrix on the left side of the face and neck, is reported by Dr. Hering in Langenbeck's ' Surgery' (1867) ; and an interesting example of hypertrophy of the lower part of the face has been published by Mr. Barwell,* by whose kindness I am enabled to show you these photo- graphs. The patient was 20 years of age, and about five years previously went to bed one night perfectly well. On the following morning, on waking, he found that his face was distended and swollen, and the mouth drawn to one side. The swelling was unaccompanied by heat, pain, or red- ness, and the cheeks were much thickened, the greatest swelling being in the lower part of the face, extending upwards to the malar bone. The lips were greatly thickened, everted, and almost pendu- lous, and there were no cracks or indurations of the lips. The tongue, soft palate, and jaws were un- afi'ected. Erom the situation of the swelling it was evident that it lay in the region supplied by the facial arteries, which were obviously enlarged. Mr. * ' Clinical Society,' March 12th, 1875. 124 THE SURGERY OF THE FACE. Barwell placed a ligature on both facial arteries but with very little improvement. He thought that the only further treatment that could be adopted was to excise some of the mucous mem- brane of the .lips, but the patient was averse to further measures. Mr. Barwell informs me that when he last saw the patient, that is ten months after operation, there was but slight diminution of the part. Tumours of the lips of course produce more or less deformity, and to these I referred in my first lecture on the diseases of the face. Plastic Operations on the Face. The infinite variety of the deformities occasioned by accirlent or disease at once renders the subject of plastic surgery of the face one of more than ordinary interest. Moreover, as no fixed rule can be laid down as to treatment the surgeon has, in many instances, to exercise some ingenuity in designing and carrying out such operative measures as he may think expedient. With regard to operations, it will be well to consider them as two distinct classes — (1) Those that are undertaken for disease, and to remedy de- formities necessarily occasioned by the surgeon in removing epitheliomatous or other growths ; and (2) THE SURGERY OF TUE FACE. 125 those that are undertaken to improve deformities occasioned by accident, such as burns, gunshot injuries, &c. Respecting the upper and lower lips much may be done without resorting to the transplantation of skin. The soft parts of the face are so mobile that with proper precautions they may be stretched to almost any extent, the one point necessary being that the soft structures should be thoroughly sepa- rated from the subjacent bone; hence some sur- geons, Mr. Furneaux Jordan* amongst the number, speak confidently of making a mouth with one lip, either upper or lower. The Formation op a New Upper Lip. Various plans have been suggested and practised to form a new upper lip. Thus Berardf made two parallel and almost vertical incisions, so as to in- clude a portion of the skin of the cheek on each side of the nose, and, bringing the flaps downwards, united them in the middle line. Mr. Morgan prac- tised a similar plan in 1829.| Sedillot§ dissected a square portion of skin from each cheek, and united * ' Surgical Injuries,' p. 18. t Follin et Duplay, ' Traite Elementaire de Patliologie externe, vol. iv, 1875, p. 657. + ' Lancet,' 1829-30, vol. i, p. 357. § ' Prov. Journal,' 1848, vol. xii, p. 90. 126 THE SUEGEEY OF THE FACE. the parts in the centre, as shown in Fig. 70, repre- senting the operation as applied to double harelip. Dieffenbach* made an S-shaped incision on each side of the alas of the nose, and, detaching the flaps, brought them down to the median line (Figs. 71 and 72). The late Mr. Teale, of Leeds, in operating Fig. 70. Fig. 71. Fig. 72. for the restoration of the upper lip after burns, made a crucial incision, having its point of inter- * Follin et Duplay, op. cit., p. 657. THE SURGERY OF THE FACE. 127 section immediately below tlie septum of the nose (Fig. 73). " Each limb of this incision," lie says, " is about one and a liaK inch in length. The two limbs on each side diverge moderately as they pass outwards to the cheek, and enclose between them an acutely angular flap of skin and other tissues. The crucial incision is extended deeply through the entire substance of the imperfect lip and the cheeks. The parts implicated in the incision are then freely looeed from their attachments to the superior maxil- lary bone by the knife being passed upwards be- tween the bone and the remnant of lip. The parts being thus detached, the two lateral angular flaps are drawn across the median line, dovetailing with each other and thereby increasing the depth of the lip at the expense of its breadth. In this position the flaps are retained by one pin and twisted suture."* In a case of severe burn of the face which was recently under my care, and in which there was great eversion of the upper lip, I made a V-shaped incision through the whole thickness of the part, leaving the prolabium ; the edges were then brought down, and when the raw surfaces were united, the incision assumed the form of a Y- I referred to this patient in my last lecture (see Fig. 40, p. 59). * ■ On Plastic Operations,' 1857. 128 THE SURGERY OF THE FACE. Eestoration op Lower Lip. In remedying deformities of tlie lower lip after removal of disease, Buchanan's operation, which was first performed by that surgeon for cancer on May 20th, 1835, is well worthy of imitation in suitable cases. It is thus described by Mr. Buchanan* : — " The line a a (Fig. 74) represents the commissure of the mouth, and the semi- FiG. 74. a a elliptical line aha the incision by which the carcinomatous mass was removed. The new lip was formed by means of two flaps taken from the sides of the chin, each, however, by a curvilinear inci- sion, b c, and a straight one, d c. These flaps were raised and brought together in the mesial line " (Fig. 75). * ' Lond. Med. Gazette,' vol. i, 1842, p. 79. THE SURGERY OF THE FACE. Fig. 75. 129 Cliopart operated thus (Fig. 76) : — He made a vertical cut from the free edge of the lip on each Fig. 76. side of the disease, and carried the incisions under the chin. A quadrilateral flap was then dissected off from above downwards, and after the disease was removed by a transverse incision the remaining healthy portion of skin was brought up and fixed to the angles of the upper lip. Roux removed the disease by a semicircular incision, and after thoroughly separating the margins from the max- illary bone kept the raw surfaces in contact with a bandage. In suitable cases a flap of skin may be taken from each side and the parts brought together in the median line* as shown in the accompanying woodcuts (Figs. 77 and 78). * FoUin et Duplay, vol. iv, p. 655, 1875. 9 130 THE SURGERY OF THE FACE. Fig. 77. Fig. 78. Syme's operation may be described in his own words : — " Two incisions are made from the angle of the mouth so as to meet at the chin, and thus the morbid part is removed in a triangular form. The lines a, b and b, o (Fig. 79), being supposed to Fig. 79. represent these incisions, I cut from the point b outwards and downwards on each side to d and e in a straight direction, and then, with a slight curve outwards and upwards, to f and G. The flaps a, b, D, F, and G, B, E, G, are next detached from their subjacent connections and raised upwards, so that the edges a, b, and c, b, come into a horizontal line, while those represented by b, d, and b, e, meet together in a vertical direction, and the lateral extensions to f and G allow sufficient freedom to THE SURGERY OF THE FACE. 131 prevent any puckering or overstraining."* (Fig. 80). Mr. Tyrrell performed a similar operation at Fig. 80. St. Thomas's Hospital in 1829, and the case is re- ported with a woodcut in the ' Lancet 'f of that year. For extreme deformities of the lower lip from burns, I believe the best kind of operation is that designed by the late Mr. Teale, which he thus describes (see Figs. 81 and 82) : Fig. 81+ Fig. 82 + " Two vertical incisions, about three quarters of an inch in extent, are made through the everted lip down to the bone ; these incisions are so placed as to divide the upper portion of the everted lip into three parts, the middle being equal to one * Miller's ' Practice of Surgery,' 1856, p. 163. t The ' Lancet,' 1829-30, vol. i, p. 548. X A. A. Lateral flaps formed of everted lower lip and cheek; and B. Central portion of everted lower lip. 132 THE SURGERY OF THE FACE. half of the natural breadth of the lip, while the two lateral portions are each equal to one fourth. From the lower end of each vertical incision the knife is carried in a curving direction outwards and upwards to a point situated about one inch from the angle of the mouth opposite to the second molar tooth of the upper jaw ; the two flaps thus marked out and deeply incised are then separated from the bone, the mucous membrane uniting them to the alveoli being freely divided ; lastly, a bare surface is made along the alveolar border of the middle portion of the everted lip. The incisions being now com- pleted, the lateral flaps are drawn upwards and united by twisted sutures to each otber in the median line and to the middle portion of the everted lip at their inferior border. In this way a new lip is, as it were, built upon the middle portion of the old one." In relation to this subject I may be permitted to refer to a case under my observation, in which there was great deformity of the face, neck, and chest, with a gradual and daily increasing dragg- ing down of the lower lip. In this instance I per- formed an operation known as autojplastie jpar glisse- ment. The cicatrix was divided at the centre from side to side, the incision reaching to healthy skin at each extremity. The two halves were then tho- roughly separated from the subjacent textures in the upward and downward direction, and the tough THE SURGERY OF THE FACE. 133 areolar tissue in the wound notclied with the knife as deeply as the important neighbouring vessels would safely permit, thus leaving an open wound as shown in Fig. 83 a. An incision was then made on each side, from b to c, and the respective flaps (d d) dissected towards the wound in the direction of the arrows. Thus, two bridges were formed which were raised and without difficulty carried to the centre of the wound, their concavities meeting as convexities in the middle line as shown in Fig. 84. In this way the wound caused by the division of the cicatrix was almost completely filled by the two bridges of healthy skin, two raw surfaces of healthy tissue being left in the sites from which the bridges had been taken. It will be observed that by this method two im- portant indications are fulfilled. In the first place, 134 THE SURGERY OF THE FACE. the wound is occupied by healthy elastic and exten- sible skin, and, again, the skin being taken in the form of a bridge is necessarily attached at each extremity so that its vascularity is almost to a certainty maintained, at least the chance of its sloughing is reduced to a minimum. Moreover, Fig. 84. its vitality is still further insured by its adaptation to the subjacent raw surface. Figs. 85 and 86 (taken from photographs) show the patient before and after the operation. I take the opportunity of presenting to your notice two diagrams (Figs. 87 and 88, taken from photo- graphs) which illustrate a plan I adopted in the case of a cicatrix which was rapidly producing great deformity. The cicatrix was divided and dissected THE SURGEEY OP THE PACE. 135 Fig. 85. Fig. 86. 136 THE SURGERY OF THE FACE. Fig. 87. Fig. THE SURGERY OF THE FACE. 137 up under the jaw, after whicli a flap was taken from the chest and turned on its pedicle. The details of the operation are fully described in the ' St. Thomas's Hospital Reports' for 1872. Contracted Lips from Injuries. The steady and intractable contraction that in some cases follows injuries, especially burns in the regions of the mouth, produces the greatest possible discomfort to the patient. In order to obviate this inconvenience, M. Serre, of Montpellier, practised an operation which seems to be of value in suitable cases.* It consisted in carrying the knife from the angles of the mouth into the cheek to a sufficient distance, and afterwards stitching together the skin and mucous membrane of the now newly formed upper and lower lips. (Figs. 89 and 90.) Fia. 89. Fig. 90. \ ■ ' ^tdV Some years ago I operated on a girl who had an extremely contracted mouth, consequent on a burn, in the following manner : — I passed a wire through the cheek about half an inch from each * ' Traite suv FArt de Restaurer les Eiflformitcs de la Face,' 1842. 138 THE SURGERY OF THE FACE. angle of the mouth, and allowed the wu^es to remain until a permanent hole was estabUshed. When the hole had quite healed, I introduced a knife through the aperture and divided the soft structures into the mouth, and stitched the mucous and cutaneous surfaces together. Mr. Husband, of York, refers to a case of much the same kind that was under his care. The patient was a young man, aged nineteen, who was severely burnt when he was six months old. The mouth in this instance was all but closed before operative procedure was adopted.* Restoration of the Nose. In a lecture delivered at the College of Surgeons in 1834, Sir Charles Bell aptly remarked that " the nose is the organ that chiefly distinguishes the face of man from brutes. "f Wlien the whole or greater part of the nose has to be restored, the surgeon may select one of three methods — 1st, he may adopt the French plan of taking a flap or flaps of skin from the face ; 2nd, he may employ the Indian method, which consists in taking a flap of skin from the forehead ; or 3rd, he may choose the Italian or Taliacotian operation. The history of rhinoplastic surgery is of very * ' Med. Times,' Jan. 3rd, 1857, p. 91. t The ' Lancet,' 1834, vol. ii, p. 829. THE SUKGERy OF THE FACE. 139 ancient date. The operation was known and prac- tised at a very early period of surgery in India by the Brahmins. Gralen recommends " the sur- geon, when a wound or ulcer shall have destroyed the whole or a part of the nose, to make a new one at the expense of the integuments of the face." From India the Sicilian surgeons in all probability received tkeir ideas on the art of re- storing noses, and the earliest record we possess on this subject is the report of a Neapolitan bishop in 1442, on an operation of rhinoplasty, performed by Branca.* I will now speak of these methods categorically : — 1st. With regard to restoring deformities of the nose by the French method (la methode par deplace- ment) M. Serref recommends that the skin should be freely separated on either side, and each portion lifted towards the median line (Figs. 91, 92) ; or again the incision may be extended laterally into Fig. 91. Fig. 92. * The Lancet, 1835, vol. i, p. 386. X Op. cit. 140 THE SURGERY OF THK FACE. the cheek, as recommended by M. Labat (Figs. 93, 94). Perhaps the peculiar advantage of the Fig. 93. Fig. 94 French method is that it may be employed in those cases in which the Indian operation has failed ; thus in a case reported by Mr. John Wood, of King's College Hospital,* which had been pre- viously unsuccessfully operated on by the Indian method, two large leaf-shaped flaps were taken from the integument of the face on either side of the central chasm, the pedicles of which were directed towards the corresponding internal canthus, and made broad in order to permit a full vascular supply to the bodies of the flaps. After this stage of the operation had been completed the upper lip was divided from above downwards, on either side of the median line, and an oblong flap formed, which was still more elongated by a slit having been made between the mucous and cutaneous surfaces, as far as the free borders of the lip which was not cut through. The long and thin flap thus formed was turned upwards, and fastened by a suture to the upper edge of the nasal chasm, and the external flaps * The ' Lancet,' Feb. 2Gth, 1870. TUB SUEGERY OF THE FACE. 141 were then carried inwards from the cheeks, and appHed over its anterior raw and bleeding surface. The wound in the upper hp was then closed by pins and the twisted suture. The soft tissues of the cheeks were previously detached over a great extent from the bone beneath, in order to facilitate the inward ghding of the integument over the raw surfaces, and also to prevent the zygomatic muscles from acting on the new nose. 2nd. The Indian or Kooman operation is stated to have been introduced to the notice of European surgeons by our countryman, a Mr. Lucas, since which it has been employed by Carpue, Travers, Liston, and other surgeons. Mr. Travers performed this operation with partial success on a patient thirty-four years of age, at St. Thomas's Hospital, in November, 1822. The edges of the nose having been first pared, a piece of skin was taken from the forehead, and after adjustment dossils of lint were placed in the nostrils to support the newly made nasal organ. In this case the lower two thirds of the frontal flap sloughed, but at the upper part of the nose a small piece of new skin remained. Dieffenbach, who was a master in rhinoplastic, as, indeed, he was in every other department of surgery, gives several practical hints as to the performance of the operation, which are embodied in a paper which appeared in the ' Lancet,' vol. i, 1835, p. 388. His method may be thus briefly described : — The patient 142 THE SURGERY OP THE FACE. being seated on a chair, the operation was begun by- raising the cicatrised skin to the extent of about three lines in width from the remnants of the carti- lages of the nose. Dieffenbach, you will observe, was not content with simply removing the edges of the cartilages because under these circumstances there was less chance of union. After having revivi- fied the edge of the imperfect septum, he proceeded to make the incisions on the forehead. From the lowest point of the two diverging incisions a cut was extended downwards on each side. The incision of the left side was not carried beyond the level of the angle of the eye, but that on the right side was pro- longed for some distance on the nose (see Fig. 96). The flap was then detached from the forehead, with due precaution against including the pericranium and the parts brought into careful apposition. Lan- genbeck advised that the pericranium sliovM he included in the skin flap, in order that by the after development of osseous tissue a finer and better nasal organ might be left.* I may briefly refer to one or two other minor points ; thus, in order to bring the edges of the frontal wound more readily together, Dieff'enbach made lateral incisions in the regions of the temples by which the cutaneous structures are relieved. In- cisions so placed do not affect the patient's personal appearance because they are afterwards concealed * Erichsen's ' Surgery,' 7tli edition, vol. ii, p. 499. THE SUKGERl' OE THE FACE. 143 by the hair. In forming the frontal flaps Dieffenbach, as already stated, employed a somewhat diamond- shaped incision, thus : — (Fig. 96) ; Delpech made three small slips of equal size (Fig. 97), and Carpue preferred an incision something like an inverted ace of clubs (Fig. 98).* Again, M. Bonnet,t of Lyons, Fig. 96. Fig. 97. Fig. 98. believed that in many cases a new nose might be made from the upper lip alone, but this operation is most useful when one ala only has to be repaired. Dieffenbach and Serre utilized the sJdn of the upper lip to form a new coiumna, and Blandin proposed to cut out a piece of the lip in its entire thickness to replace the lost septum. Dr. Lichtenberg and our honorary secretary, Mr. Astiey Bloxam, have shown themselves assiduous workers in this department of surgical science and art, and the photographs I hand round illustrate remarkably well the success which has attended their efforts. Whilst on this subject I may perhaps be per- mitted to refer to a case that was under my * The ' Lancet,' 1832, vol. i, p. 700. t The ' Lancet,' 1847, vol. ii, p. 261. ]44 THE SUEGERY OF THE FACE. own care at the Westminster Hospital in 1871, in which I performed what may be termed a mixed method, and which I had never previously seen practised. Three flaps were taken, two from the cheek and one from over the nasal bones (Fig. 95, A, A, b). These flaps were raised and turned inwards Fig. 95. and downwards respectively, as shown by the dotted lines. A portion of skin was then taken from the forehead, and being twisted at its pedicle, its raw surface was applied and fixed with sutures to the other three raw surfaces.* I may add that in this case, when the wound of the forehead was granu- * ' The Lancet,' June 10th, 1871, p. 780. THE SURGERY OF THE PACE. 145 lating, I took a piece of skin the size of a shilling from the patient's arm and transferred it to the granulating surface with marked benefit to his per- sonal appearance. The patient made a very good recovery, and both he and I were well satisfied with what had been done. My only regret now is that, from circumstances beyond my control, I cannot show you his photograph after the operation, but the case when under treatment was sufficiently well known both at the Westminster and at St. Thomas's Hospital. 3rd. Respecting the Italian or Taliacotian opera- tion, Alexander Benedictus, a Veronese, of Padua, appears to have been the first to write on the sub- ject in 1495, and gives the following description of the operation, which was really much the same as that practised afterwards by Taliacotius. The ope- rator dissected the upper skin of the arm with a razor, and then, paring oS the remaining edges of the nostrils, or if necessary cutting the latter away, he bound the arm to the head, in order that wound might adhere to wound. After this, the wounds having conglutinated, he separated from the arm with the knife as much as was wanted for the re- storation of the nose. He adds, however, that these artificial noses badly endure a severe winter, and he recommends his patients to use them gently, lest they be torn from the trunk.* Apropos of this, I * ' Lancet,' 1823-24, vols, i and ii, p. 169. 10 146 THE SUKGERY OF THE FACE. may remind you of the superstitious stories to which Butler refers in his well-known lines in Hudibras,* and you know the legend of the nobleman in Italy who lost a great part of his nose in a duel, and prevailed on one of his slaves to suffer a piece of the flesh of his arm to be cut out, which was so managed by a skilful surgeon as to serve in the place of a natural nose. The slave being re- warded and set free, went to Naples, where he fell sick and died, immediately on which gangrene appeared on the nobleman's nose. Gabriel Fallopio, who died in 1562, alludes to the same method of operation ; and Ambrose Pare, whose work was printed in 1561, also refers to this subject. Vesalius, too, printed an account in 1569 of the restoration of the nose by supplying the deficient parts from the arm. Again, Stephen Grourmelen in 1580, states in print, that the nose might be formed or refitted either from the arm of the patient, or from the nose of a slave. In Serre's work there is an illustration to show that a new nose may be formed from the skin of the palm of the hand. The method adopted by Taliacotius was, first, to make a paper model of the proposed end of the nose, and this, when flattened, served as a pattern for shaping the graft or flap of skin which was to be taken from the patient's arm. The portion of integument was then raised and twisted, and brought * ' The Lancet,' vols, i and ii, 1823-4, pp. 169, 171. THE SURGERY OF THE FACE. 147 in contact with the face. He then proceeded to dissect away the edge of the deficient nasal organ, and bringing up the graft to the nose, by lifting the arm, to which it at one end still adhered, fastened it in its place by ligatures. The graft or flap of skin having been thus applied to the defective nose, the patient was bound, so that he could not stir in any direction. At the end of twelve days the patient's arm was released from his face, the septum was modelled, plasters and bandages applied, and great care was taken for some time to defend the new nose from accidental injury. The Taliacotian operation seems almost to have died with its supposed author, for in the medical journals I do not remember to have met with a single instance (with one exception, and this was to restore the lip) in which this operation has been pubhshed. In speaking thus I am willing to con- cede that some examples of the genuine Taliacotian operation may be on record ; if so, they have, escaped my observation. I have, however, certainly met with several cases which have been described as such, but which I have found, on reading the history, to be instances illustrating the Indian method of treatment. My colleague, Mr. Mac Cormac, has performed the Taliacotian operation on two occasions. Once on a girl, aged sixteen, on February 12th, 1877, whose case has been fully reported in the Transactions of 148 THE SURGERY OF THE FACE. the Clinical Society. The deformity was occasioned by sloughing after injecting a naevus at the root of the nose with the pernitrate of iron. In this instance a flap was taken from the inner aspect of the left upper arm, more than double the size of the esti- mated deficiency of the nose, and the flap included the subcutaneous fat down to the muscular sheath. The portion of skin from the arm was separated after an interval of twenty-one days. Dr. James Hardie, of Manchester, has placed on record a novel rhinoplastic operation, by which additional solidity may be given to the newly formed nose by trans- planting, as a preliminary step, the first phalanx of the forefinger of the patient's left hand to the stump of the nose, which thus serves as an osseous basis of support for the cutaneous covering.* I may add that those Fellows of the Society who take interest in rhinoplastic surgery may be glad to know that we are fortunate enough to have in our library a copy of Taliacotius's work which was published in 1597. As to the result of these operations, there is one point to which I may refer, and it is the peculiar bloodless appearance of the newly-formed nose. Perhaps this may to some extent be remedied by tattooing the part, as practised by Professor Schuh, of Vienna. He employed it in the case of a young * 'Brit. Med. Journ.,' 1875, vol. ii, p. 393, and ditto, 1877, vol. ii, p. 300. THE SURGERY OF THE FACE. 149 girl wliose upper lip was formed from the skin of her arm, and which in eighteen months had not gained the normal redness of the lips.* The opera- tion consisted of taking from ten to twenty needles, each surrounded with silk, and united into a bundle. They were dipped into a liquid of vermilion, and pricked into the lip until it took a natural colour. Eestoration of Eyelids. I need say little respecting the plastic surgery of the eyelids, for the deformities occasioned either by disease or injury in this region must be treated on their respective merits, and most of the operations are described in works on ophthalmology. I may, however, refer to a case of epithelioma involving Fig. 99. Fig. 100. the lower eyelid in which I removed the disease by a Y-shaped incision. A lateral flap of healthy skin was then detached and twisted on its pedicle, which * ' Med. Times,' Feb. 5th, 1859, p. 150. 150 THE SURGERY OF THE FACE. became a very good substitute for the part taken away. The operation will be best understood by the accompanying figures (Figs. 99, 100) taken from Serre's work. Again, in another case of severe ectropium after a burn, occurring in a woman who was recently under my care at St. Thomas's Hospital, I performed the following operation (Fig. 101). A Y-shaped incision Fig. 101. was made under the eye, and the soft parts thoroughly dissected upwards towards the orbit. A flap of skin was then taken from the cheek, and this was twisted on its pedicle and inserted into the wound. I per- formed a somewhat similar operation to improve the less marked ectropium in the upper lid, but a portion of the flap which I took from the forehead sloughed. There was, nevertheless, some slight improvement. The case was not a favourable one for operation, THE SURGERY OF THE FACE. 151 inasmuch as the whole of the face was a mass of cicatrix. In bringing these lectures to a close I am willing to admit that the preparation of them has caused me no slight amount of labour and anxiety, but let me assure you that I am richly rewarded by the warm support and encouragement you have so generously accorded me. My object has been to deal with the surgery of the face from a practical point of view, and I have done my best to render the subject as attractive and interesting as possible. In conclusion, I venture to ask you to accept my most sincere thanks for your kind and considerate attention, and I earnestly hope you will not deem me unworthy of the distinguished position in which I have been placed. INDEX. A. Abscess, 13 death from, 17 strumous, 13 treatment of, 14 Absence, congenital, of nose, 122 of uvula, 104 Acetic acid and whiting, treatment of burns by, 58 scalds by, 58 Acne, 10 indurata, 10 punctata, 10 rosacea, 11 simplex, 10 Acupressure, treatment of nsevus by, 45 Adams, W., on cicatrices, 55 Anchylosis, bilateral, of lower jaw, 83 of lower jaw, pathology of, 84 Antrum, disease of, 15 loose tooth in, 95 Apparatus for detecting bullet in ear, W. B. Stone's, 87 Atrophy of face, unilateral, 123 Author's case of bullet in ear, 87 closure of jaws, 82 fibro-cystic disease of upper jaw, 38 formation of new nose, 144] formation of new upper lip, 126 spontaneous reduction of lower jaw, 75 cases of cervical fistula, 116 growth of cicatrix, 56 11 154 INDEX. Author's cases of restoration of eyelids, 149 method of dividing bone in cleft palate, 107 operation for cleft palate, lOG operation for improving voice after staphyloraphy, 108 plan of removing cystic tumours, 2 1 proposed treatment of fracture of inferior maxilla, 80 lower jaw, 80 B. Barwell on unilateral atrophy of face, 123 Battery, electric, to detect a bullet in ear, 87 Bickersteth's plan of treating fracture of lower jaw, 77 Bilateral anchylosis of lower jaw, 83 Blood tumours, 22 Blows on nose, 66 Bodies, foreign, in face, 90 orbit, 90 Boils, 12 Bones of face, congenital deficiency of, 109 injuries of, 65 intermaxillary in harelip, 100 nasal, congenital absence of, 109 Branchial fistula, 112 Paget on, 112 Buchanan's operation for restoring lower lip, 128 Bullet in ear, author's case of, 87 Burns and scalds, deformities from, 58 lips contracted from, 137 their treatment, 5 8 by acetic acid and whiting, 58 Cachectic ulcer, 17. Callender on permanent closure of jaws, 81 Cancer, colloid, efface, 36 encephaloid, 37 epithelial, 34 I INDEX. Carbuncle, 12 facial, death from, 13 treatment of, 12 Carcinomatous tumours of jaws, 39 Carcinoma, 34 Cartilaginous tumours of jaws, 39 Case, author's, of formation of new nose, 144 Cervical fistula, 115 author's cases of, 116 Cheek, fatty tumours of, 24 foreign body in, tetanus from, 96 tobacco-pipe removed from, 15 Chopart's operation for forming new lower lip, 129 Cicatrices, Adams, W., on, 55 Paget on growth of, 56 Cicatrix, author's cases of growth of, 56 its growth in proportion to growth of part, 56 its persistence, 5 5 Circular saw, wound of face from, 53 Classification of diseases of jaws, 37 Cleft palate, 104 DiefFenbach's operation for, 106 Langenbeck's operation for, 106 operation for, 104 varieties of, 104 Closure of jaws, author's case of, 82 Esmarch's operation for, 81 permanent, 81 Rizzoli's operation for, 81 Colloid cancer of face, 36 Congenital absence of nose, 123 deficiency of bones of face, 109 deformities of ears, 113 hypertrophy of face, 1 19 lower lip, 122 upper lip, 121 idiots, lips in, 98 malformation of lower lip, 1 20 Contracted lips from burns, 137 neck, operations for, 133 Cricket ball, wound of face from, 53 155 156 INDEX. Cutaneous nsevus, 42 Cystic tumours, 19 diagnosis of, 20 of nose, 21 sub-aponeurotic, 21 sub-muscular, 21 their removal, 21 treatment of, 21 Cysts, 19 hydatid, of eyelids, 21 lips, 21 of lower and upper jaws, 37 D. Death from abscess, ] 7 facial carbuncle, 13 foreign body in ear, 87 Deficiency, congenital, of bones of face, 109 Deformities, congenital, of ears, 113 of face, 98— 150 from burns and scalds, 58 nou -congenital efface, 123 Detached portions of face, treatment of, 63 nose, treatment of, 63 Diagnosis of fatty tumours of cheek, 24 infecting sore, 119 Dieffenbach on rhinoplastic surgery, 141 DiefFenbach's plan of removing tumours of upper jaw, 41 Disease of antrum, 15 fibro-cystic, of upper jaw, 38 Diseases of face, 1 — 51 jaws, 37 classification, 37 parasitic, 8 Dislocation of inferior maxilla, 72 treatment of, 74 lower jaw, 72 from tongue sucking, 72 from thumb sucking, 74 i INDEX. 157 Dislocation of lower jaw, its mechanism, 74 spontaneous reduction of, 76 treatment of, 74 superior maxilla, 70 upper jaw, 70 Down, Langdon, on epicaathic folds, 99 Duct of parotid gland, injuries of, 61 E. Ear, external, hypertrophy of, 33 larvae in, 88 pin in, passing down Eustachian tube, 89 Ears, blood tumours of, 22 congenital deformities of, 113 foreign bodies in, 85 hsematoma of, 22 Ecthyma, 7 Ectropium, treatment of, 150 Eczema, 6 impetiginodes, 6 Electric battery to detect a bullet in ear, 87 Electrolytic treatment of nsevus, 44 Emphysema of eyelids, 68 face, 66 Encephaloid cancer, 37 tumours of jaws, 39 Euchondromatous tumours of jaws, 39 Enucleation, treatment of ntevus by, 45 Epicanthic folds, Langdon Down on, 99 Epithelioma, 34 of lip, 34 of nose, 34 Eruptions on face, 3 scarlatinal, after operations, 3 Erythema, 3 circinatum, 3 nodosum, 3 Esmarch's operation for closure of jaws, 81 Ether, its use in detecting fatty tumours, 24 158 INDEX. External ear, hypertrophy of, 33 Extirpation of lower jaw, 42 Eyelid, horny growth of upper, 34 Eyelids, author's cases of restoration of, 149 emphysema of, 68 hydatid cysts of, 21 restoration of, 1 49 F. Eace, colloid cancer of, 35 congenital deficiency of bones of, 109 hypertrophy of, 119 deformities of, 98— 150 from burns and scalds, 58 detached portions, treatment of, 63 diseases of, 1 — 51 emphysema of, 66 eruptions on, 3 fatty tumours of, 23 rare in face, 23 foreign bodies in, 90 gunshot wounds of, 69 hairy mole on, 118 infecting sores on, 18 injuries of, 52 — 97 non-congeuital deformities of, 123 plastic operations on, 124 scars of, their persistence through life, 55 slougliing of, 63 unilateral atrophy of, 123 wound of, from bursting of soda-water bottle, 53 , circular saw, 53 cricket ball, 53 Facial carbuncle, death from, 13 Fatty tumours, 23 comparatively rare in face, 23 diagnosis of, 20 method of arriving at diagnosis, 24 of cheek, 24 INDEX. 159 Fatty tumours of cheek, their diagnosis, 24 their diagnosis from nsevi, 24 Tergusson's case, hypertrophy of nose, 33 knot for nsevus, including skin, 49 Fibro-cystic disease of upper jaw, 38 Fibrous tumours of jaws, 38 Fistula, cervical, 115 author's cases of, 116 Fistulse, branchial, 112 Fistulous openings on face, 14 of parotid gland, 62 Foreign bodies from ear, instruments for removing, 87 body in face, 90 nose and ears, 85 orbit, 90 cheek, tetanus from, 96 ear, death from, 87 Formation of new lower lip, 128 Fox, Tilbury, on scabies, 9 Fracture of inferior maxilla, 76 author's proposed treatment of, 80 Thomas's plan of treatment, 71 treatment, 77—80 Wheelhouse's plan of treatment, 78 lower jaw, 76 author's proposed treatment, 80 Bickersteth's plan of treatment, 77 mechanical appliance in, 80 treatment, 77— 80 Wheelhouse's plan of treatment, 78 neck of inferior maxilla by contreconp, 17 un-united, of inferior maxilla, 80 French method of restoring nose, 139 Frontal flaps, different kinds, to form new nose, 143 G. Gland, parotid, fistulous opening of, 62 injuries of, 61 Glandular tumours, 24 160 INDEX. Growth of cicatrix, author's cases of, 56 Growths, horny, 33 on lower lip, 34 on uj)per eyelid, 34 Gummata, 17 Gunshot wounds of face, 69 H. Hsematoma, 22 of ears, 22 Hsemorrhage in removing parotid tumours, 27 Hairy mole on face, 118 Harelip, 99 hereditary character of, 101 intermaxillary bones in, 100 operation for, 102 Heath, observation on dislocation of lower jaw, 74 Hereditary character of harelip, 101 Herpes, 5 in course of certain nerves, 5 Holt, on dislocation of lower jaw, 74 Horny growth on lower lip, 34 on upper eyelid, 34 Horny growths, 33 Humid tetter, 6 Hydatid cysts of eyelids, 21 lips, 21 Hypertrophy, 32 congenital, efface, 119 lower lip, 122 upper lip, 121 of external ear, 33 nose, 32 Fergusson's case, 33 Pollock's case, 33 I. Idiots, congenital lips in, 98 Imperforate nostrils, 122 INDEX. 161 Impetiginodes, eczema, 6 Impetigo, 7 Impressions, maternal, 117 Iricisioa ia skin for removing tumours of jaws, 39 Infecting sores on face, 18 Inferior maxilla, dislocation of, 72 fracture of, 76 Thomas's plan of treatment, 77 treatment, 77—80 WheelLouse's plan of treatment, 78 Holt's plan of reducing dislocated,. 74 un-united fractures of, 80 Iodine, treatment of parotid tumours by, 26 Indian operation for restoring nose, 141 Intermaxillary bones in harelip, 100 Injuries of face, 52 — 97 bones of face, 65 parotid gland, 61 Italian operation for forming new nose, 145 Jaw, fibro-cystic disease of upper, 38 lower, dislocation of, 72 from thumb sucking, 74 tongue sucking, 72 Holt's plan of reducing, 74 treatment, 74 fracture of, 76 treatment, 77—80 removal of, 41 un-united fracture of, Napier's case, SO necrosis of, 15 upper, Dieffenbach's plan of removing, 41 dislocation of, 70 Jaws, carcinomatous tumours of, 39 cartilaginous tumours of, 39 classification of diseases of, 37 closure of, author's case, 82 cysts of, 37 162 INDEX. Jaws, diseases of, 37 encephaloid tumours of, 39 enchoudromatous tumours of, 39 fibrous tumours of, 38 medullary tumours of, 39 osteomatous tumours of, 39 permanent closure of, 81 sarcomatous tumours of, 38 scirrhus tumours of, 39 tumours of, their removal, 39 vascular tumours of, 39 K. Knots, various, for tying nsevus, 43 — 48 Lacerated wounds of face, 52 LarvEB in ear, 88 Lee, E,. J., on maternal impressions, 117 Lepra, 7 Lichen, 4 Lip, epithelioma of, 34 horny growth on lower, 34 lower, Chopart's operation for forming new, 129 congenital liypertrophy of, 122 formation of new, 128 hypertrophy of, 122 Roux's operation for forming new, 129 Syme's operation for forming new, 130 Teale's operation for forming new, 131 tooth imbedded in, 93 wounds of mucous membrane of, 55 upper, formation of new, 125 tooth imbedded in, 94 Lips contracted from burns, 137 hydatid cysts of, 21 in congenital idiots, 98 INDEX. 163 Liveing, R., on the treatment of acne, 11 Lower jaw, bilateral anchylosis of, 83 dislocation of, 72 from thumb-sucking, 74 tongue sucking, 72 Heath on, 74 Holt's method of reducing, 74 its mechanism, 74 treatment, 74 fracture of, 76 Bickersteth's plan of treatment, 1(7 , mechanical appliance in, 80 treatment, 77—80 Wheelhouse's plan of treatment, 78 Napier's case of un-united, 80 necrosis of, 15 pathology of anchylosed, 84 removal of, 41 spontaneous reduction of dislocated, 76 un-united fracture of, 80 lip, Chopart's operation for forming new, 129 congenital malformation of, 120 Roux's operation for forming new, 129 Syme's operation for forming new, 130 Teale's operation for forming new, 131 M. Malformation, congenital, of lower lip, 120 Maternal impressions, 117 R. J. Lee on, 117 Maunder, on subcutaneous extirpation of lower jaw, 42 Maxilla, inferior, dislocation of, 72 treatment, 74 fracture of, 76 Wheeelhouse's plan of treatment, 78 treatment of, 77-80 un-united fracture of, 80 superior, dislocation of, 70 Mechanical appliances in fracture of lower jaw, 80 164 INDEX. Mechanism of dislocation of lower jaw, 74 Medullary tumours of jaws, 39 Melanotic sarcoma, 30 Meningocele, 110 Mixed nsevus, 42 Mole, hairy, on face, 118 Mouth, cystic tumours in, 21 Moxhay on congenital deformities of ears, 113 Mucous membrane of lip, wounds of, 55 Multiple nsevi, 43 Murray's, Jardine, plan of subcutaneous ligature of usevus, 48 Myx.omatous tumours, 25 N. Naevl, their diagnosis from fatty tumours, 24 multiple, 43 symmetrical, 43 Nsevus, 42 cutaneous, 42 effect on neighbouring bones, 43 electrolytic treatment of, 44 Fergusson's knot for, including skin, 49 mixed, 42 Murray's subcutaneous knot for, 48 operations for, 43-48 subcutaneous, 42 ligature of, 45 Wood's plan, 47 treatment by acupressure, 45 enucleation, 45 subcutaneous rupture, 44 with thermo-cautery, 44 Wood's knot including skin, 50 subcutaneous knot for nsevus, 47 Napier, on un-united fracture of lower jaw, 80 Nasal bones, congenital absence of, 109 Neck, contracted, operations for, 133 Necrosis of jaw, 15 New nose, author's case of formation of, 144 1 INDEX. 165 New upper lip, to form, 125 Non-congenital deformities of face, 133 Nose, blows on, 66 congenital absence of, 122 cystic tumours of, 21 detached portions, treatment of, 63 epithelioma of, 34 foreign bodies in, 85 French method of restoring, 139 hypertrophy of, 32 Indian method of restoring, 141 new, author's case of formation of, 144 Italian operation for forming, 145 Taliacotian operation for forming, 145 restoration of, 138 Nostrils, imperforate, 122 0. Openings, fistulous, 14 Operation, Buchanan's for forming new lower lip, 128 I for cleft palate, author's views, 106 harelip, author's views, 102 Chopart's, for forming new lower lip, 129 Esmarch's, for closure of jaws, 81 French method of restoring nose, 13 1 Indian, for restoring nose, 141 Italian, for forming new nose, 145 Rizzoli's, for closure of jaws, 81 Roux's for forming new lower lip, 129 Syme's, for forming new lower lip, 130 Taliacotian, for forming new nose, 145 Teale's, for forming new lower lip, 131 Operations for contracted neck, 132 nsevus, 43—48 plastic, on face, 124 Orbit, foreign bodies in, 90 Osteomatous tumours of jaws, 39 166 INDEX. P. Paget, on branchial fistulge, 112 growth of cicatrices, 56 scars, 56 Palate, cleft, 104 fissure of, with absence of uvula, 1 i Parasitic diseases, 8 Parotid gland, duct of, injuries, 61 fistulous opening of, 62 injuries of, 61 tumours, 26 chance of return, 27 hsemorrhage in removing, 27 treatment by iodine, 37 Pathology of anchylosis of lower jaw, 84 Permanent closure of jaws, 81 Persistence of scars of face through life, 55 Pin in ear passing down Eustachian tube, 89 Plastic operations on face, 124 Pollock's case, hypertrophy of nose, 33 Psoriasis, 7 syphilitic, 7 R. Removal of cystic tumours, 21 lower jaw, 41 by subperiosteal method, 42 tumours of jaws, 39 by subperiosteal method, 41, 42 Restoration of eyelids, 149 Restoring nose by French method, 139 Indian method, 141 Italian method, 145 lower lip, 128 nose, 138 Rizzoli's operation for closure of jaws, 81 Rhinoplastic surgery, Dieffenbaeh on, 141 Roseola, 3 Roux's operation for forming new lower lip, 129 INDEX. 167 s. Sarcoma, melanotic, 30 Sarcomatous tumours, 29 of jaws, 38 Scabies, 8 Tilbury Fox on, 9 Scalds and burns, deformities from, 58 their treatment, 5 8 by acetic acid and whiting, 58 Scarlatinal eruption after operations, 3 Scars of face, their persistence through life, 55 Paget on growth of, 56 Scirrhous tumours of jaws, 39 Sebaceous tumours, 19 Signoroni's plan of subcutaneous extirpation of lower jaw, 13 Silk sutures preferable to silver, 53 Silver sutures objected to, 53 Sloughing of face, 63 Smoking tobacco, a supposed cause of epithelioma of lip, 36 Soda-water bottle, severe wounds from bursting of, 53 Sores, infecting, on face, 18 Spontaneous reduction of dislocated lower jaw, 76 Staphyloraphy, author on improving voice after, 108 Stone's, W. H., apparatus for detecting bullet in ear, 87 Strapping to bring wounded parts together, 54 Strumous abscess, 13 Sub-aponeurotic cystic tumours, 21 Subcutaneous ligature of naevus, 45 Murray's plan, 48 Wood's plan, 57 rupture of nsevus, 44 nsevus, 42 Sub-muscular cystic tumours, 21 Subperiosteal method of removing lower jaw, 42 plan of removing tumours of jaws, 41, 42 Siguoriiii's, of, extirpation of lower jaw, 42 Superior maxilla, dislocation of, 33 Sutures, silk preferable to silver, 53 Symmetrical nsevi, 43 Syme's operation for forming new lower lip, 130 168 INDEX. T. Taliacotian operation for forming new nose, 145 Teale on formation of new lower lip, 131 upper lip, 126 Tetanus from foreign body in clieek, 96 Thermo-cautery in treatment of najvus, 44 Tetter, humid, 6 Thumb-sucking, dislocation of lower jaw from, 74 Tinea circinata, 9 decalvans, 9 Tinese, 9 Treatment of abscess, 14 acne, 10 indurata, 10 Liveing on the, 1 1 punctata, 10 rosacea, 11 simplex, 10 author's proposed, of fracture of lower jaw, of burns, 58 by acetic acid and whiting, 58 carbuncle, 12 cystic tumours, 21 detached portion of face, 63 portions of nose, 63 dislocation of lower jaw, 94 ecthyma, 7 ectropium, 150 eczema, 7 impetiginodes, 7 fracture of inferior maxilla, 17 injuries of face, 53 lepra, 7 of nsevus by acupressure, 45 enucleation, 45 subcutaneous rupture, 44 of scabies, 9 scalds, 58 by acetic acid and whiting, 5 8 sebaceous tumours, 21 INDEX. 169 Treatment of syphilitic psoriasis, 8 psoriasis, 7 tinea circinata, 9 decalvans, 9 sycosis, 9 Tinea sycosis, 9 Tobacco-pipe, portion of, removed from cheek, 15 smoking a supposed cause of epithelioma of lip, 36 Tongue sucking, dislocation of lower jaw from, 74 Tooth imbedded in lower lip, 93 upper lip, 94 loose in antrum, 95 Tumours, 23 blood, 22 cartilaginous, of jaws, 39 cystic, their removal, 21 of nose, 21 sub -aponeurotic, 21 sub-muscular, 21 enchondromatous, of jaws, 39 , fatty, of cheek, their diagnosis, 24 their diagnosis from nsevi, 24 fibrous, of jaws, 38 glandular, 24 medullary of jaws, 39 myxomatous, 25 osteomatous, of jaws, 39 parotid, 26 hsemorrhage in removing, 27 sarcomatous, 29 of jaws, 38 scirrhous, of jaws, 39 vascular, of jaws, 39 U. Ulcer, cachectic, 17 Ulcers, 17 Unilateral atrophy of face, 123 Un-united fractures of lower jaw. 170 INDEX. Upper jaw, DieiFenbacli's plan of removing, 41 dislocation of, 70 lip, congenital hypertrophy of, 121 formation of new, 125 "Urticaria, 4 cause of wheals in, 4 Uvula, absence of, 104 V. Vascular tumours of jaws, 39 Voice, author on improving, after staphyloraphy, 108 W. Wilson, Erasmus, on urticaria. Wood's knot for naevus, including skin, 50 plan of subcutaneous ligature of nsevus, 47 Wound of face from bursting of soda-water bottle, 53 circular saw, 53 cricket ball, 53 Wounds of face, 52 gunshot, 69 mucous membrane of lip, 55 FEINTED BY J. E. ADLARD, BAKTHOLOMEW CLOSE. Catalogue B] London, 1 1 , Ne-w Burling/o/i Street November, 1884 S E L E C T I O N FROM J. k A. 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By Edward J. Domville, Surgeon to the Exeter Lying-in Charity. Fourth Edition. Crown 8vo, 2s. 6d. i. Manual of Nursing, Medical and Surgical. By Charles J. Cul- lIjNgworth, M.D., PhysiciantoSt. Mary's Hospital, Manchester. Fcap. 8vo, 3s. 6d. By the same Author. ^ Short Manual for Monthly Nurses. Fcap. 8vo, is. 6d. ■Jotes on Fever Nursing. ByJ. W. Allan, M.B., Superintendent and Physician, Clasgow Fever Hospital. Crown 8vo, with Engravings, 2s. 6d. /lanual of Botany : Including the Structure, Functions, Clas- sification, Properties, and Uses of Plants. By RoKERT Bentley, Professor of Bo- tany in King's College and to the Phar- maceutical Society. Fourth Edition. Crown 8vo, with 1,185 Engravings, 15s. By the same Author. The Student's Guide to Struc- tural, Morphological, and Phy- siological Botany. With 660 En- gravings. Fcap. 8vo, 7s. 6d. Also. The Student's Guide to Syste- matic Botany, including the Classi- fication of Plants and Descriptive Botany. 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Bazaar Medicines of India, And Common Medical Plants : With Full Index of Diseases, indicating their Treat- ment by these and other Agents procur- able throughout India, &c. By E. f- Waring, C. I. E.,M.D., F.R.C.P. Fourth Edition. Fcap. 8vo, 5s. Tropical Dysentery and Chronic Diarrhoea — Liver Abscess — • Malarial Cachexia — Insolation — with other forms of Tropical Diseases, &c. By Sir Joseph Fayrer, K.C.S.I., M.D. 8vo, 15s. By the same Author. Climate and Fevers of India, with a series of Cases (Croonian Lec- tures, 1882). 8vo, with 17 Temperature Charts, 12s. Family Medicine for India. A Manual. By William J. MooRE, M.D. , CLE., Honorary Surgeon to the Viceroy of India. Published under the Authority of the Government of India. Fourth Edition. Post 8vo, with 64 Engravings, I2s. By the same Author. Health- Resorts for Tropical Invalids, in India, at Home, and Abroad. Post 8vo, 5s. 8 .7. .S- A. CHURCHILL'S RECENT WORKS. 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Sixth Edition. By Walter J. Cotjlson, Surgeon to the Lock Hospital and to St. Peter's Hospital for Stone. Svo, i6s. On Rupture of the Urinary Blad- der. Based on the Records of more than 300 Cases of the Affection. By Walter Rivington, F.R.C.S., Presi- dent of the Hunterian Society ; Surgeon to the London Hospital. Svo, 5s. 6d. The Reproductive Organs In Childhood, Vouth, Adult Age, and Ad- vanced Life, considered in their Physio- logical, Social, and Moral Relations. By \yiLLiAM Acton, M.R.C.S. Sixth Edition. Svo, 12s. The Medical Adviser in Life Assurance. By E. H. Sievekixg, M.D., F.R.C.P. Second Edition. Crown Svo, 6s. A Medical Vocabulary : An Explanation of all Terms and Phrases used in the various Departments of Medical Science and Practice, their Derivation, Meaning, Application, and Pronunciation. By R. G. Mayne, M.D., LL.D. Fifth Edition. Fcap. Svo, los. 6d. A Dictionary of Medical Science: Containing a concise Explanation of the various Subjects and Terms of Medicine, &c. By Robley Dunglison, M.D., LL.D. New Edition. Royal Svo, 28s. Abridged Medical Account Books. The "Expedite" Method. By J. Macnab, L.R.C.S.E. Index Ledger. Royal 4to., 15s. ]'i siting List. Cloth, 2s. 6d. ; Leather, 3s. 6d. Medical Education And Practice in all parts of the World. By H. J. Hardwicke, M.D., M.R.C.P. Svo, I OS. INDEX. Acton's Reproductive Organs, 14 Adams (W.) on Clubfoot, 11 on Contraction of the Fingers, 11 on Curvature of the Spine, 11 Alexander's Displacements of the Uterus, 6 Allan on Fever Nursing, 7 Allbutt's Visceral Neuroses, 9 Allingham on Diseases of the Rectum, 14 Anatomical Remembrancer, 3 Anderson (McC.) on Eczema, 13 Aveling on the Chamberlens and Midwifery Forceps, 6 on the Influence of Posture on Women, 6 Balfour's Diseases of the Heart and Aorta, 8 Balkwill's Mechanical Dentistry, 12 Barnes (E. G.) How to Arrest Infectious Diseases, 4 Barnes (R.) on Obstetric Operations, 5 on Diseases of Women, 5 Beale's Microscope in Medicine, 8 Slight Ailments, 8 Bellamy's Surgical Anatomy, 3 Bennet (J. H.) on the Mediterranean, 10 on Pulmonarj- Consumption, 10 on Nutrition, 10 Bentley and Trimen's Medicinal Plants, 7 Bentley's Manual of Botany, 7 Structural Botany, 7 Systematic Botany, 7 Bigg (R. H.) on the Orthopragms of Spine, 1 1 Binz's Elements of Therapeutics, 7 Black on the Urinary Organs, 14 Braune's Topographical Anatomy, 3 Brodhurst's Anchylosis, 1 1 Curvatures, &c., of the Spine, 11 Orthopaedic Surgery, 11 Bryant's Practice of Surgery, 1 1 Bucknill and Tuke's Psychological Medicine, 5 Bulkley's Eczema, 13 Burdett's Cottage Hospitals, 5 Pay Hospitals, 5 Burnett on the Ear, 12 Burton's Midwifery for Midwives, 5 Butlin's Malignant Disease of the Larynx, 13 Sarcoma and Carcinoma, 13 Buzzard's Diseases of the Nervous System, 9 Carpenter's Human Physiology, 4 Carter (H. V.) on Spirillum Fever, 8 Carter (W.) on Renal and Urinary Diseases, 14 Cayley's Typhoid Fever, 8 Charteris' Practice of Medicine, 8 Clark's Outlines of Surgery, 10 Clay's (C.) Obstetric Surgery, 6 Clouston's Lectures on Mental Diseases, 5 Cobbold on Parasites, 13 Coles' Dental Mechanics, 12 •— Deformities of the Mouth, 12 Cooper's Syphilis and Pseudo-Syphilis, 14 Coulson on Diseases of the Bladder, 14 Courty's Diseases of the Uterus, Ovaries, &c., 6 Cripps' Cancer of the Rectum, 14 Diseases of the Rectum and Anus, 14 Cullingworth's Manual of Nursing, 7 Short Manual for Monthly Nurses, 7 Curling's Diseases of the Testis, 13 Dalby's Diseases and Injuries of the Ear, 12 Dalton's Human Physiology, 4 Day on Diseases of Children, 7 on Headaches, g Dobell's Lectures on Winter Cough, 8 Loss of Weight, &c., S Mont Dori5 Cure, 8 Domville's Manual for Nurses, 7 Druitt's Surgeon's Vade-Mecum, 11 Duncan on Diseases of Women, 5 • on Sterility in Woman, 5 Dunglison's Medical Dictionary, 14 Eade on Diphtheria, 12 Ellis's Manual for Mothers, 6 of the Diseases of Children, 6 Emmet's Gynaecology, 6 Fayrer's Climate and Fevers of India, 7 Tropical Dysentery and Diarrhoea, 7 Fenwick's Chronic Atrophy of the .Stomach, 8 Medical Diagnosis, 8 Outlines of Medical Treatment, 8 Fergusson's Practical Surgery, 10 Flint on Clinical Medicine, S on Phthisis, 8 Flower's Diagrams of the Nerves, 4 Foster's Clinical Medicine, 8 Fox's (C. B.) Examinations of Water, Air, and Food. 4 Fox's (T,) Atlas of Skin Diseases, 13 Frey's Histology and Histo-Chemistry, 4 Galabin's Diseases of Women, 6 Gamgee's Treatment of Wounds and Fractures, 11 Gay on Hajmorrhoidal Disorder, 14 Godlee's Atlas of Human Anatomy, 3 ^ Gorgas' Dental Medicine, 13 Gowers' Diseases of the Spinal Cord, 9 Epilepsy, 9 Medical Ophthalmoscopy, 9 Pseudo-Hypertrophic Muscular Paralysis, 9 Granville on Nerve Vibration and Excitation, 9 Habershon's Diseases of the Abdomen, 9 ■ Stomach, 9 Pneumogastric Nerve, 9 Hamilton's Nervous Diseases, 9 Hardwicke's Medical Education, 14 Harley on Diseases of the Liver, 9 Harris on Lithotomy, 14 Harrison's Lithotomy, Lithotrity, &c., 14 ■ Surgical Disorders of the Urinary Organs, 14 Hartridge's Refraction of the Eye, 12 Heath's Injuries and Diseases of the Jaws, 10 • Minor Surgery and Bandaging, 10 ■ Operative .Surgery, 10 Practical Anatomy, 3 Surgical Diagnosis, 10 Higgens' Ophthalmic Out-patient Practice, 11 Hillis' Leprosy in British Guiana, 13 Holden's Dissections, 3 Human Osteology", 3 Landmarks, 3 Holmes' (G.) Guide to Use of Laryngoscope, 12 Vocal Physiologj- and Hygiene, 12 Hood on Gout, Rheumatism, &c,, 9 Hooper's Physician's Vade-Mecum, 8 Horton's Tropical Diseases, 8 Hutchinson's Clinical Surgery, 11 Pedigree of Disease, 11 Rare Diseases of the .Skin, 13 Huth's Marriage of Near Kin. 4 Hyde's Diseases of the .Skin, 13 Ireland's Idiocy and Imbecility, 5 James (P.) on .Sore Throat, 12 Jones' (C. H.) Functional Nervous Disorders, 9 Jones (C. H.) and .Sieveking's Pathological Anatomy, 4 Jones' (H. i\IcN.) Aural Surgery, 12 Atlas of Diseases of Membrana Tympani, 12 Spinal Curvatures, 11 Jones' (T. W.) Ophthalmic INIedicine and .Surgery, 12 Jordan's .Surgical Enquiries, 10 Lancereaux's Atlas of Pathological Anatomy, 4 Lee (H.) on Syphilis, 14 Leared on Imperfect Digestion, 9 Lewis (Bevan) on the Human Brain, 4 Liveing's Megrim, .Sick Headache, &c., 10 Macdonald's (A.) Chronic Disease of the Heart, 6 Macdonald's (J. D.) Examination of Water and Air, 4 Mackenzie on Diphtheria, 12 on Diseases of the Throat and Nose, 12 Maclise's Dislocations and Fractures, 10 Surgical Anatomy, 3 MacMunn's .Spectroscope in Medicine, 8 Macnab's Medical Account Books, 14 Madden's Principal Health-Resorts, 10 Mann's Manual of Psychological Medicine, 5 Marcet's Southern and .Swiss Health-Resorts, 10 Marsden's Certain Forms of Cancer, 13 Mason on Hare-Lip and Cleft Palate, 12 on Surgery of the Face, 12 Mayne's Medical Vocabulary, 14 Notes on Poisons, 7 Therapeutical Remembrancer, 7 Moore's Family Medicine for India, 7 Health-Resorts for Tropical Invalids, 7 Morris' (H.) Anatomy of the Joints, 3 Mouat and Snell on Hospitals, 5 Nettleship's Diseases of the Eye, 12 Nunn's Cancer of the Breast, 13 Ogston's Medical Jurisprudence, 4 Oppert's Hospitals, Infirmaries, Dispensaries, &c., 5 Osborn on Diseases of the Testis, 14 on Hydrocele, 14 {Coiitiiiiied 0)1 the next pag^c Owen's Materia Medica, 7 Page's Injuries of the Spine, 11 Parkcs' Practical Hygiene, 5 Pavy on Diabetes, 9 on Food and Dietetics, 9 Pharmacopoeia of the London Hospital, 7 Phillips' Materia Medica and Therapeutics, 7 Pollock on Rheumatism, 9 Porritt's Intra-Thoracic Effusion, 8 Pridham on Asthma, 9 Purcell on Cancer, 13 Quinby's Notes on Dental Practice, 13 Ralfe's Morbid Conditions of the Urine, 14 Ramsbotham's Obstetrics, 6 Raye's Ambulance Handbook, 10 Reynolds' (J. J.) Diseases of Women, 6 Notes on Midwifery, 5 Rivington's Rupture of the Urinary Ijladder, 14 Roberts' (C.) Manual of Anthropometr>-, 5 Detection of Colour-Blindness, 5 Roberts' (D. Lloyd) Practice of Midwifery, 5 Ross's Diseases of the Nervous System, 9 Roth on Dress : Its Sanitary Aspect, 4 Routh's Infant Feeding, 7 Royle and Harley's Materia Medica, 7 Sanderson's Physiological Handbook, 4 Sansom's Diseases of the Heart, 9 Savage on the Female Pelvic Organs, 6 Sayre's Orthopaedic Surgery, 11 Schroeder's Manual of Midwiferj-, 6 Sewill's Dental Anatomy, 12 Sheppard on Madness, 5 Sibson's Medical Anatomy, 3 Sieveking's Life Assurance, 14 Smith's (E.) Clinical Studies, 6 Disease in Children, 6 Wasting Diseases of Infants and Children, 6 Smith's (Henry) Surgerj^ of the Rectum, 14 Smith's (Heywood) Dysmenorrhoea, 6 Smith (Priestley) on Glaucoma, 12 Snell's Electro-Magnet in Ophthalmic Surgerj-, 11 Snow's Clinical Notes on Cancer, 13 Southam's Regional Surgerj', 10 Sparks on the Riviera, 10 Squire's Companion to the Pharmacopoeia, 7 Pharmacopoeias of London Hospitals, 7 Starkweather on the Law of Sex, 4 StilM and Maisch's National Dispensatory, 7 Stimson on Fractures, 11 Stocken's Dental Materia Medica and Therapeutics, 13 Swain's Surgical Emergencies, 10 I NDEX — continued. Swayne's Obstetric Aphorisms, 6 Taylor's Medical Jurisprudence, 4 Poisons in relation to Medical Jurisprudence, Teale's Dangers to Health, 4 Thompson's (Sir H.) Calculous Disease, 13 Diseases of the Prostate, 13 Diseases of the Urinary Organs, 1 3 Lithotomy and Lithotrity, 13 Surgery of the Urinarj- Organs, 13 Tumours of the Bladder, 13 Thompson's (Dr. H.) Clinical Lectures, 8 Thorowgood on Asthma, 9 on Materia 5ledica and Therapeutics, 7 Thudichum's Pathology of the Urine, 14 Tibbits' Medical and Surgical Electricity, lo Map of Motor Points, 10 Tidy and Woodman's Forensic Medicine, 4 Tilt's Change of Life, 6 Uterine Therapeutics, 6 Tomes' (C. S.) Dental Anatomy, 12 Tomes' (J. and C. S.) Dental Surgerj-, 12 Tosswill's Diseases and Injuries of the Eye, ii Tuke's Influence of the Mind upon the Body, 5 Sleep-Walking and Hypnotism, 5 Van Buren on the Genilo-Urinary Organs, 14 Vintras on the Mineral Waters, &c., of France, 10 Virchow's Post-mortem Examinations, 4 Wagstaffe's Human Osteologj', 3 Walker's Ophthalmology', 11 Waring's Indian Bazaar ^Iedicines, 7 Warner's Guide to Medical Case-Taking, 8 Warren's Hernia and Rupture, 11 Waters' (A. T. H.) Diseases of the Chest, 8 Waters (J. H.) on Fits, 9 Wells (Spencer) on Ovarian and Uterine Tumours, 6 West and Duncan's Diseases of Women, 6 West (S.) How to Examine the Chest, 8 Whistler's Sj-philis of the Lar>-nx, 12 Whittaker's Primer on the Urine, 14 Wilks' Diseases of the Nervous System, 9 Wilks and Moxon's Pathological Anatomy, 4 Wilson's (Sir E.) Anatomists' Vade-Mecum, 3 Lectures on Dermatology, 13 Wilson's (G.) Handbook of Hygiene, 5 Healthy Life and Dwellings, 5 Wilson's Qff. S.) Ocean as a Health-Resort, 10 Wolfe's Diseases and Injuries of the Eye, 11 Yeo's (G. F.) Manual of Physiolog>% 4 Yeo's (J. B.) Contagiousness of Pulmonary Consump- tion, 8 Zander Institute Mechanical Exercises, 10 The following Catalogues issued by J. & A. Churchill will be forwarded post free on application : — A. J. H) A. Churchill's General List of about 650 works on Anatomy, Physiology, Hygiene, Midwifery, Materia Medica, Medicine, Siirge?y, Chemistry, Botany, ^x., 8fc., with a complete Index to their Subjects, for easy reference. N.B. — This List ificludes B, C, & D. B. Selection from J. ^- A. ChirchilPs General List, comprising all recent Works published by them 07i the Art and Science of Medicine. C. ./. Sf A. ClmrchilPs Catalogue of Text Books specially arra?tged for Students. D. A selected and descriptive List of J. Sf A. ChurchilVs Works on Chemistry, Materia Medica, Pharmacy, Botany^ Photography, Zoology, the Microscope, and otiier branches of Scietice. E. The Half-yearly List of New Wo7-ks and New Editions published by J. S,- A. Churchill during the previous six months, together with particulars of the Periodicals issued froin their House. [Sent in January and July of each year to every Medical Practitioner in the United Kingdom whose name and address can be ascertained. A large number are also sent to the United States of America, Continental Europe, India, and the Colonies.] America. — /. ^ A. Churchill being in constant comnuinication with various piiblisJiing houses in Boston, Nezv York, and Philadelphia, are able, notivitJistanding the absence of international copyright, to conduct negotiations favourable to English Aiithors. LONDON: NEW BURLINGTON STREET. ^ Pardon & Sons, Printers,] vl [Paternoster Row, and limine Office Court. ate thej i UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. SiOMED OCT 20 79 "Hcir'lSf - - NOVllREci nouED mzym Wm APR 02 '66 mm ApR05'86i Form L9-40)«-5,'67(H2161s8)4939 :::::;!'^yiai«f