The Secrets of Specialists/Chapter 17

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Under the above caption we have the latest and one of the most profitable of office specialties; this specialty incorporates perhaps more of the apparently insignificant things in medicine than any other specialty; in fact, the cosmetic treatment of the body a few years ago, was considered a too trifling matter for the grave-faced physician, and this neglect on his part has had a serious reaction in actually forcing such patients to consult the "winning ways of the beauty specialists," who are, as a rule, absolutely devoid of any true knowledge of cosmetic therapeutics, other than the use of massage creams and manicuring the finger nails, and it certainly is time that the physician should awaken to the fact that any information or assistance he can give his patients will be greatly appreciated, and, in many instances he will receive more praise for his skill in this special sphere of practice than any other. Always bear in mind that the face is the most conspicuous part of the body, and your work is constantly before the eyes of the public; select some person in your vicinity, who has a broken nose or birthmark, successfully remove or correct this blemish or deformity, and you will then realize the influence it will have in establishing an office practice in cosmetic therapeutics.

There are thousand of dollars waiting, in every vicinity, which would be gratefully paid for skill in this special field of medicine and surgery, as the territory is fertile in clinical material. Visit any public place, and observe the people about you who have some blemish or deformity of the face, which should be removed or corrected, and if we figure from the simple mole to the more noticeable birthmarks, scars and other deformities, you will find that ninety per cent. of the people are thus afflicted.

​It has always seemed to be a trait or perhaps an instinct in the nature of the human family to cultivate as perfect a degree of beauty as possible, and if we would visit the deepest jungles of Africa, we would find the Congo belle taking the same pride in endeavoring to outclass her sisters in beauty lines, as the strutting princesses of the fashionable thoroughfares of cities. It is a duty, however, which each individual owes himself to appear at his very best, and no one except the afflicted can realize the disadvantage under which they are laboring, who possess an unsightly sear, birthmark or other deformities of the face. It is only in rare instances that we find people thus afflicted employed in public places; their faces are so repulsive that it is often difficult to find employment at all. It is, therefore, the physician's duty to correct and remove these disfigurements, and thus place these unfortunate people on an equal footing with the rest of the world.

There is an old saying that "beauty is only skin deep"; that saying is a monstrous error, for true beauty is heart-deep, lung deep, stomach deep and liver deep. In fact, to be beautiful will depend upon the healthy and harmonious functions of all the organs of the body, and often how quickly the physician can identify, by a bad complexion, a "lazy liver"; inactivity of the kidneys by puffiness under the eyes, and constipation by a muddy complexion. In cultivating true beauty these are the things which should first occupy our attention. There are many different things that have a tendency to make people attractive, other than complexion, and form; the quick wit and sparkling eye, the vivacity of manner, and sprightliness of carriage have a world to do with personal attractiveness; yet these attainments do not go hand in hand with a torpid liver, dyspepsia and other inharmonious conditions of the body. Therefore, to obtain the translucency of the skin that we may almost look through the outer layers, and observe the blood circulating in the deeper tissues, which gives the rosy cheeks and lips of the ideal complexion of pink and white, the integument cannot be clogged with waste matter, which should be eliminated by other organs. We, therefore, find that cos​metic therapeutics not only embodies the local application of massage creams, to cover up defects, as is practiced by the "beauty specialist," but often requires eliminative measures to force these toxic influences, which ruin many complexions, through their natural channels; although the kin proper will necessarily require its due attention.

From a theoretical standpoint, it would seem that no other class of diseases furnishes such favorable conditions for an easy and accurate diagnosis and treatment as do the diseases and cosmetic defects of the skin. The morbid phenomena, instead of being concealed in organs remote and hidden from view, are spread out upon the surface, and brought directly under examination of the senses of sight and touch. They actually obtrude themselves upon observation, and the disfigurement they occasion is, oftentimes, the sole reason for consulting a physician; yet, notwithstanding these circumstances, there is no branch in the practice of medicine so little understood by the general practitioner as the discases and cosmetic defects of the skin.

In the treatment of these diseases and defects, the average physician very frequently experiences uncertainty, vexation and failure; yet in no other class of conditions can a physician earn better fees, or become the recipient of more gratitude, commendation and fame, than to successfully master this branch of his art. In order that I may revive his "forgettory" in the anatomy of this important organ, the skin, I have inserted the accompanying diagrammatic illustration, to assist in a correct understanding of the integument, as the different structures will be frequently referred to in discussing the different diseases and conditions.

There is one principal point which is always to be remembered in treating the skin from a cosmetic point of view, viz.: We can destroy and remove the four outer layers of the epidermis as often as we wish, but as soon as our treatment interferes with the true skin, or arrests its development, we are treading upon forbidden ground, and our treatment will ac​

complish just the opposite of what is desired in the form of cicatricial tissue and resultant scars.

The face, as a rule, is always in close proximity to the hands during all forms of labor: it is, therefore, the second part of our body which is the most susceptible to deformities ​and injury from accidents. We therefore find broken and deformed nose cuts, wounds, burns, etc., appearing upon the face nearly as frequently as we do upon the hand. If similar accidents would happen to other parts of the body they would not react to such a disadvantage, as they would be covered from observation by the clothing and not be noticed. The face also seems to be a favorite and unfortunate seat for many destructive diseases, which mutilate the integument. Thus we find the face the "play grounds" for the ravages of smallpox and acne, with their unsightly pittings, while ninety per cent. of all birthmarks are upon the face and neck, where they will appear the most conspicuous and repulsive, and react to a disadvantage in both a social and business way. No one realizes this more than the unfortunate possessor, who is continually subjected to the embarrassing stare of the ignorant, and inquisitive glances from the more refined people they meet on the street and elsewhere. As a lady stated, who had a slight deformity of the nose, "the way people stare at me one would think I was some dime museum curiosity." Other patients have made similar statements, whose faces contained several moles, superfluous hair, etc.; one of the most amusing cases was a young man, nineteen years old, who wished to have his nose reduced in size. Ile stated that ever since he could remember he had been called "beaky," on account of the length of his nose, and, judging from the size of the organ, he was legitimately entitled to the name.

We have at our disposal many methods of treatment, whereby these conditions can be painlessly and permanently corrected, removed and cured, without leaving any trace, mark or sear, to indicate their former existence. By giving the benefit of your skill in this special field of practice, you will not only receive the everlasting gratitude of your patients, but will be amply remunerated for your services.

Before discussing the different diseases, deformities and blemishes of the face, which require treatment or correction, ​we will outline some of the popular methods of treatment used in this class of conditions, as they will be referred to from time to time, in the following pages.

This treatment originated at the St. Louis Hospital, Paris, where cosmetic improvements are treated on an equal basis with disease. Some speculative "Yankee physician managed to secure the process, and brought it to this country, where he disposed of it, in several cities, to beauty specialists for several thousand dollars. It is estimated that in one year he made over thirty thousand dollars by the sale of these formulas in different cities. The French gave it the name Ecorchement," but on this side of the water it is often referred to as the rejuvenating treatment, derna vita, desqua dermia and other coined names, bearing upon new life to the skin, and is the banner treatment in all beauty culture establishments. This treatment consists of two parts, one in which the outer skin is killed, and the other where it is sloughed off en mass. The following is the original formula, although it has many variations, without any improvement:

Resorcine	80	parts
Zinc oxide	20	parts
Salicylic acid	4	parts
Lard	40	parts
Olive oil	16	parts

White gelatine	8	oz.
Zinc oxide	4	dr.
Glycerine	½	dr.
Boiling water	q. s.

Great care should be exercised in compounding these formulas, and better results will be obtained if they are prepared ​fresh each time they are used, and do not attempt to substitute vaseline for lard, in the first formula, unless you wish to meet with failure.

The first formula is applied to the face twice a day, for about four or five days, until the skin becomes brown, dry

and commences to crack. Then the face is thoroughly washed with soap and water, to remove every particle of ointment, and after thoroughly drying the skin, the second application is used.

The ingredients of formula No. 2 are placed in a water bath, by first adding sufficient boiling water to dissolve the ​gelatine; then thoroughly stir in the other ingredients. This should be applied to the face with a small paint brush, and as you cover a surface, a piece of absorbent gauze, the size of the painted surface, should be immediately applied, while the gelatine is still hot; this adheres firmly to the skin, after the entire surface has been thoroughly covered. The same process should be repeated again, until you have several thicknesses of the gelatine and gauze, and a solid mask is formed.

At the end of three or four days, it will be noticed that this mask is breaking loose from the edges, and as soon as the

mask becomes loose, it can be removed, and the face will be found very much the same color as a newly born baby, and is often very sensitive to the touch and air. The face is dressed with any good cold cream, and in a few days, the shade of the skin resumes its normal color, only we have an absolutely new skin, which in many instances, is marvelously beautiful, for the ​treatment has removed every mark or discoloration, which the old skin had accumulated in past years, and is properly named "the rejuvenating treatment," as it will add the youthful appearance to any face. This treatment has a large sphere of usefulness, and owing to the large fees (usually one hundred dollars) obtained for this treatment by "Beauty Doctors," it is the backbone, from a financial point of view, of their establishments, and they encourage its use whenever opportunity presents itself; for the bane of a woman's existence

is growing old, and this is one of the few means we have of restoring her youthful appearance. It is not believed that physicians will use this treatment for a rejuvenating purpose, but its use in the treatment of many diseases places it within his domain. This treatment is used in acne, acne rosaca, eczema, chloasma, smallpox pits, and many other forms of facial blemishes, which will be pointed out under their respective classifications.

Another very valuable treatment in cosmetic therapeutics is the Cantharides blister; I usually prefer the "Canthos plaster," manufactured by Johnson & Johnson. These blisters ​have the same effect as the Ecorchement treatment, and occupy less time to accomplish the same results. The object of both treatments is to remove the outer cuticle, without interfering in any way with the true skin. We therefore find that this process of blistering will occupy only about four hours, while the former treatment requires that many days. Blistering is a more heroic measure, and where a large surface, as the entire face, is to be treated, the Ecorchement treatment is often advisable, but all small surfaces, up to four inches in diameter,

may be successfully treated by this means. If it is deemed advisable to treat the entire face, it should be done in sections according to the following technique: Apply one plaster, from two to four inches in diameter and allow the blister to form. As soon as this is accomplished, draw off the fluid and apply another blister; commencing at the edge of the already formed vesicle. These vesicles may be continued until the entire face is covered, if desired or required. After you have prepared the surfaces, in which you wish to remove the outer integu​ment, the fluid is all drawn off by puncturing the under surfaces, but avoiding any abrasion in the loosened skin; antiseptic absorbent gauze is now applied over the surface, and held in position, either with strips of adhesive plaster or the face mask. This is allowed to remain until it is desquamated by nature; if removed too soon the under skin is so sensitive that the patient will not be able to withstand the pain. The old skin forms a dense scab, which can be removed in a few days, leaving a beautiful, new, pink under skin. This process of scabbing is absolutely necessary to obtain the best results,

but the face has a horrible appearance of one continuous scab (see illustration) and unless the patient is advised beforehand, she will think her face is ruined; it is, therefore, often advisable not to allow the patient to see her face until the treatment is completed. I, therefore, keep the face mask in continuous use, until the last remnant of old skin is removed.

There is one more thing I wish to point out, viz.: wherever this treatment is applied and the skin removed, the final effects of the treatment are so perfect, and the new skin so clear and beautiful, that it makes the old, remaining skin look like "the breaking up of a hard winter"; it is, therefore, sometimes ​necessary to remove all the skin of the face and neck, with either this or the ecorchement treatment, to give the face a uniform appearance. I often follow this blistering process with the ecorchement or other bleaching treatments, in order to obtain a uniform complexion; this and the ecorchement treatment are among the most highly prized "tricks" of the beauty specialists, and by using these methods singly, or combining the two, we can eradicate many blemishes which were formerly rather puzzling to the physician. You can "lift" any form of discoloration, from cholasma to the more superficial birthmarks; while it is not as pleasing to the eye as the ecorchement treatment, it is more rapid and positive in action, and with due caution, no harm can be obtained from its use.

Another still more heroic measure of destroying the outer skin is to apply pure Carbolic Acid; this treatment is used with a small brush, on the surface of the skin, and allowed to penetrate the integument, when a second or third coat is given. After the skin has become dry, the entire surface is covered with adhesive strips (see illustration); this is allowed to remain for three or four days, until the outer skin sloughs, and suppuration takes place. The skin is allowed to remain, however, until nature desquamates the integument. This treatment is frequently resorted to in deep-seated smallpox pittings, and the most favorable reports have been obtained in many cases. Of late, I have been using the rubber adhesive strips, as illustrated above, with the ecorchement treatment, instead of the gelatine compound, as it is more convenient to apply.

This is an appliance which is very much used in beauty culture, and consists of a thin rubber mask, which is supplied in three different sizes, to fit over the face tightly. Its principal utilization is for the purpose of forcing medicine, bleach​ing agents, etc., into the skin, as by direct pressure over the entire surface, it compels medication to be absorbed, and bears an important part in many treatments the technique of which will be given later.

Vibratory massage is a very valuable adjunct for the treatment of many diseases of the face, and is used for the purpose of creating new activity to the circulation, acne, comedones, etc.; its stimulating effects forces out impacted secretions, and assists nature in many ways which are conducive to eliminating disease and restoring the florid complexion.

Face creams are extensively used by at least one-half of the female population of the civilized world, for the purpose of making the skin soft, pliable and smooth, and also for bleaching purposes, and to remove slight blemishes. Prepara​tions known as "cold creams" are mixtures of solid fats, like wax, spermaceti, petrolatum, lanolin, etc. Such preparations receive their name from the ingredients they contain, either for flavoring or some specific purpose; thus, we may have rose cold cream, when flavored with ottar of roses, cucumber cold cream, when the juice of cucumber is used, etc. These creams are rapidly absorbed by the skin, and have much to do in preserving and beautifying the integument, and also protect the skin from atmospheric and other conditions. A good cream will be rapidly absorbed by the skin without having the appearance of oiliness. The following formula is a well-selected variety for different purposes:

The above name is given this cream, because by rubbing the face with this mixture, it will, apparently, vanish without leaving the face oily.

Pure stearic acid	1 av.oz.	26 gr.
Cocoa butter		77 gr.
Sodium carbonate		308 gr.
Borax		77 gr.
Glycerine		405 min.
Water	13 fl.oz.	252 min.
Mucilage of tragacanth	3 fl.oz.	183 min.
Alcohol	1 fl.oz.	7 min.
Perfume	enough

Place all the ingredients, except the alcohol and perfume, in a capsule, over a water bath, and heat until effervescence ceases. Remove the mixture from the heat, and when it begins to stiffen, add the alcohol containing the perfume, and mix well. Permit the mass to harden, and re-apply heat; beat up vigorously until fluffy and creamy, and place it in tubes.

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Spermaceti	2	oz.
White wax	2	oz.
Sweet almond oil	14	oz.
Distilled water	7	oz.
Powdered borax	60	gr.
Coumarin	½	gr.
Oil of bergamot	24	min.
Oil of rose	6	min.
Oil of bitter almond	8	min.
Tincture of ambergris	5	min.

Melt the spermaceti and wax, add the oils, and incorporate the other ingredients; this, and the other creams may be called rose cold cream, by having the odor of rose predominate, and tinting a rose color by means of a solution of carmine.

are intended to remove discoloration of the skin, such as chloasma or liver spots, tan, freckles, etc., and depend upon bi-chloride of mercury for this purpose, which enters largely into most of the "patent" creams on the market, as in the following:

Saxoline	265	gr.
White wax	50	gr.
Spermaceti	30	gr.
Bismuth oxychloride	40	gr.
Mercuric chloride	½	gr.
Spirit of rose (4 dr. of oil to one pint)	20	min.
Oil of bitter almonds	⅛	min.

Warm the saxoline, white wax, and spermaceti together until melted; while cooling, incorporate the bismuth oxychlo​ride and mercuric chloride, this last previously dissolved in a little alcohol, and when nearly cold, stir in the perfume.

The above caption may seem misplaced, yet it is under this head that all diseases having a tendency to interfere with the cosmetic appearance of the face may be discussed. We find the face a particularly favorite seat for a certain class of diseases, from which other parts of the body seem nearly immune; thus we find acne, and acne rosacea, comedones, warts, moles, chloasma, freckles, milium, seborrhœa, etc., are in reality diseases of the integument of the face and scalp. We will not attempt to discuss the pathology of these diseases but will point out, as near as possible, a successful means of curing these conditions.

Acne is a chronic inflammation of the sebaceous glands, characterized by the development of papules, pustules or tubercles, or a combination of all these lesions, which may also include comedones. When this condition exists in combination, it is usually termed acne vulgaris. The cause of acne, although appearing in patients with apparently robust health, has been attributed to gastro-intestinal disorders, anæmia chlorosis, uterine disorders, etc., and is a frequent disease of puberty. The treatment of acne should consist of both local and constitutional measures. For a continual treatment, the following, in tablet form, has been of more service to me than any other medication. Each tablet contains:

Arsenie	1/40	gr.
Calcium sulphide	½	gr.
Hexamethylenamine	2	gr.
Ferrous carbonate	5	gr.

Sig. A tablet after each meal.

​In resuming the therapeutic value of the above formula, we find arsenic the oldest, and one of our most reliable remedies for arresting chronic eruptions of the skin. Calcium sulphide is the first remedy to be thought of, when pus is present, in any condition. Hexamethylenamine is given for its antiseptic influence upon the gastro-intestinal tract, to arrest autointoxication, to which cause a large per cent of acne is

due. Ferrous carbonate is added for its blood building and general tonic effect.

Constipation is present in a large percentage of acne cases, and a suitable treatment should be employed, to relieve this condition at the outset of treatment.

Local medication is also of the greatest importance, and sulphur, in combination with an astringent, in the old "stand​by" lotio alba, answers this purpose as well as any remedy, to my knowledge, which I have modified as follows:

Resorcine	½	dr.
Zinc sulphate	2	dr.
Potassium sulphuret	2	dr.
Aqua	4	oz.

This may be made stronger or weaker as desired, as the different strength is required for different cases.

Ichthyol internally, and locally, is a valuable remedy in many cases. I have also had the most brilliant results with the ecorchement treatment, and have frequently applied this medication to the entire afflicted areas, which has resulted in a rapid and complete disappearance of the acne lesions. Phototherapy is another indispensable treatment, a decided solar erythema should be produced, and when the outer skin is desquamated, the acne will be found greatly improved. Electricity and vibratory massage are also valuable for their stimulating influence upon the skin. In all acne cases the greatest attention should be given to the diet, and every effort exercised to avoid auto-intoxication by keeping the bowels regular, and all the functions of the body in a normal condition.

Acne rosacea is a chronic hyperæmia, or inflammatory affection, usually appearing upon the nose, cheeks or chin. This may appear as a simple hyperæmia, or discoloration of the skin in the milder types, to a congestion and enlargement of the blood vessels in the prolonged variety, which has been known to develop into a typical lipoma, as illustrated here. The cause of acne rosacea is the same as other forms of acne, but a large number of cases may be attributed to the excessive use of alcohol, (the tippler's nose) tea, coffee, etc.; whereby the stomach is kept in a continuous state of irritation.

​A red nose is generally associated with cold feet and hands, denoting poor circulation. This disease may first appear as a blood stasis in the vessels, producing an undue redness, which, if neglected, will cause the blood vessels to dilate and become hypertrophied, and as a result of the obstruction to circulation, the sebaceous glands become involved and form

papules and pustules. The treatment of acne rosacea has many things in common with other acne medications.

Special attention should be directed to relieve constipation and keep the gastro-intestinal track aseptic and open. The acne tablets given above, are, in most cases, very serviceable. Equal parts of ichthyol and glycerine painted on the affected surface, at night before going to bed, covered with oiled silk and the face mask. This may be thoroughly washed off in the morning, and lotio alba applied several times during the day will produce excellent results in mild cases.

If the blood vessels are enlarged they should be destroyed by the electric needle, and do not forget that the ecorchement treatment was originally instituted for the purpose of curing acne rosacea, and it is often surprising the rapidity ​the action of this treatment has in many cases, while there are total failures in others.

The solar rays may be used, as in other acne lesions, to a good advantage; vibratory massage is also indispensable, to stimulate the skin to new activity.

This is also a chronic affection of the sebaceous glands, characterized by a retention, in the excretory ducts, of an inspissated secretion, which is visible upon the surface, either as white or yellow, which develops into black pin head elevations, hence the name "black heads"; this coagulated sebum may distend, and obstruct the gland, until a papule or pustule is formed; the duct may contain small hairs, and the microscopic mite demodex folliculorum, which was, at one time, erroneously supposed to be the cause of the disorder.

Blackheads appear upon the face, nose, forehead, chin and neck. They occur exclusively in the ducts of the sebaceous glands—see accompanying figure, where SS represents the skin; K, the sebaceous gland with the duct opening on the skin; B, a blackhead plugging up the opening; C and E, are soft hairs growing in the duct. In old age, when hairs grow out on the face, there are no blackheads. Each blackhead consists of a whitish, fatty plug, formed by the secretion of the gland congealing, one end of the plug being visible at, and sometimes extending above, the surface of the skin. The exposed end of each blackhead becomes blackened by diffused pigment deposited within. Sometimes both ends of the plug are discolored by a deposit of pigment.

The predisposing causes of comedones are the same as acne, and the same rules observed regarding the diet, etc. The local treatment should be directed to stimulate the skin to new activity by vibratory massage, electricity, etc. The comedones should be thoroughly removed by pressure between the thumb nails or comedones extractor, see cut, a good astringent lotion should be applied several times a day, for ​which the lotio alba will answer the purpose, and the skin kept clean by the use of soap and water. The following ointment has rendered me good service:

Sulphur	1	dr.
Green soap	1	dr.
Precipitated chalk	90	gr.
Zinc ointment	1	oz.

Mix direct to cover the skin well on retiring. Wash thoroughly the next morning with warm water and soap, and most

of the blackheads will disappear. The application may be repeated at intervals, until all are removed.

This disorder resembles comedones somewhat in appearance, only the sebaceous glands are distended, without an opening, and remain white, while the comedones turn black when exposed to the air. The milia are planted under the epidermis and cannot be removed by pressure unless the skin is punctured. When there are quite a number in one locality, as is often the case under the eye, I remove them en mass, by the use of the ecorchement treatment or blister. This entirely eradicates the difficulty, and leaves a nice, healthy skin underneath.

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Freckles and liver spots, in anatomical structures, are the same, and consist of an increased amount of normal pigment deposited in the mucous layer of the epidermis. Freckles are usually caused by the sun's rays and consist of small, pinheaded deposits, which often disappear during the winter months.

Chloasma or liver spots are of larger size, variously shaped, more or less defined, smooth patches, either yellow, brown or black in color. They may be associated with either pathological changes, as in Addison's disease, or physiological conditions, as during pregnancy, and the menstrual epoch.

The following lotion will generally remove these pigmentary deposits, if applied several times a day:

Corrosive sublimate	5 to 12	gr.
Dilute acetic acid	2	dr.
Sodium borate	40	gr.
Rose water enough to make	4	oz.

It is better to test the sensibility of the skin by the weaker solution, at first, increasing the strength as the point of toleration is learned. The idea is to induce a brany desquamation, and as soon as this appears, to suspend the application until the exfoliation ceases, when it is resumed.

If you should desire a complete and thorough removal, the ecorchement treatment is the process to pursue. Many of our female "Codfish aristocrats" will visit the sea shore, and other watering places, during the summer to obtain the rugged complexion,—tan and freckles,—and, upon returing home, will pay some beauty doctor one hundred dollars to make them a new face, by the use of ecorchement process. Thus we find that "for ways that are dark, and for tricks that are vain," the heathen Chinese is not the only one that is peculiar.

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Following each Fourth of July, and the opening of the hunting season, physicians are called upon to remove powder marks as the result of accidents. These patients either consult the physician immediately after the accident, or dress their own wounds, and detain the consultation when they find their faces are permanently disfigured by these unsightly black specks. If the patient is seen immediately after the accident, the process of permanently destroying these marks is rather an easy procedure, but if the skin is allowed to heal over the embedded powder, we have a more difficult condition to deal with. We will, therefore, outline the treatment used in the different stages.

If the patient is seen immediately after the accident, he will, generally, rebel against any interference, stating that the parts are too sore and painful, but by explaining to him that a "stitch in time saves nine," will consent to your advice, and it is usually best to give a general anæsthetic in nervous cases.

When powder is forced under the skin it has provided an open wound and we have direct access to each grain of powder. If the open surface is large, many of the deposits may be scraped out with the point of a knife, but the powder becomes soft when it comes in contact with the tissues, and is difficult to remove; therefore the best, quickest and easiest method to pursue is to thoroughly scrub the entire area involved, with a stiff antiseptic nail or tooth brush, dipped into a full strength solution of peroxide of hydrogen. The minute wounds are somewhat aggravated by the bristles, but in no way deter the process of healing, and to be sure you are removing every remnant possible the skin should be pinched up in folds, between the thumb and finger, that it will open the wounds, and reach the deeper seated particles. This will often by followed by "bubbling" at point of entry of the powder grains; after this has ceased, it will be found that nearly all the powder has been washed out by the bath and effervescent ​process. A saturated solution may now be applied to the face with absorbent gauze, and allowed to remain a few hours; the minute wound has, by this time, closed and all dressings may be removed.

As a rule, this procedure will thoroughly remove all powder marks. Should any remain, they may be treated later, by pricking an opening to the stain, and applying the peroxide of hydrogen.

The second class of cases are those which were neglected at the time of the accident, and consult you after the openings have healed, containing the embedded powder; here we have a more tedious condition to deal with. Each mark may be opened with the point of a knife, and removed with the peroxide of hydrogen treatment. They may also be removed with the electric needle, as is superfluous hair, or trephined out, with a small dermal punch, about the size of a watch key. A slight rotary motion will remove a "button" of skin, containing the discoloration which is snipped off with scissors. These are all very tiresome precedures and it is here that our ecorchement treatment, and canthos blister serves us once ​more. If the discoloration is deep-seated, I prefer the blister; if more superficial, the ecorchement treatment will suffice. Either treatment will, usually, completely eradicate every trace of the marks.

Tattoo marks are generally embedded deeper in the skin than powder stains, which makes them more difficult to remove. The first treatment used is the Canthos blister. This blister is applied to the entire surface, if not too large, and removed in about four hours. This will be followed by a large vesicle, which may be punctured at its base, and dressed with absorbent gauze, held in place by adhesive plasters. At the end of about a week, the scab will desquamate, taking with it a large proportion of the mark; if there is any remaining, another blister should be applied at once, and continue these treatments until you have "lifted" as much of the mark as possible, and in many cases you will entirely remove these disfigurements. Any remaining traces may be removed by the Ohmann-Dumesnil method, which consists of tattoing the design over again with a bundle of six or ten very fine cambric needles, tightly wound with silk thread, dipped in a glycerine solution of papoid. This is repeated over the entire stain; a local anæsthetic is previously used, to obtund the pain of the surfaces. If of quite large size, it may be treated at one sitting. The rationale of this method is based upon the following principles: the digestive principle of the papoid is disseminated about the deposit of pigment, thus liberating it, a portion is absorbed, in a finely divided state, by the lymphatics; another part, probably, finds it way into the upper layers of the epidermis, and thence to the surface. In this manner we obtain a disappearance of the pigment, by using either of these methods, or, combining the two, little difficulty is experienced in removing these otherwise indelible marks.

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Smallpox, acne-pustulosa and chickenpox are diseases which often leave the face in a terrible state of repulsive disfigurement, and the physician who can successfully eradicate these ravages of disease can always demand a liberal compensation for his services; it is these methods which are most secretly guarded by the advertising cosmetic specialists. In these conditions, we have cicatricial tissue to deal with; in fact each pit is the result of a minute abscess of the true skin, and connective tissue, and in order to be successful with our treatment, we must remove all the superficial tissue, and dissolve the remaining cicatricial tissue, as far as possible.

The epidermis may, therefore, be removed, either by the ecorchement, blister or phenol method, and as soon as the outer skin has been removed, which takes with it the greater number of pits, fibrolysin is placed over the entire surface, saturated with the solution, and held in place by rubber adhesive bandages and the face mask; or thiosinamine used by catophoric application, as described in treating scars.

Warts and moles are the most common of facial blemishes and are also the most easily removed. Of the numerous remedies and methods, the chemical ones should be the first to consider; before removing these growths by this means, the healthy skin, surrounding the growth, should be thoroughly painted with collodion, to protect the healthy skin. I generally do this at the office, and give the patient a small vial of glacial acetic acid, and instruct her to dip a wooden toothpick into the solution, and apply it to the wart or mole several times a day; at the end of this time, the wart or mole will form into a scab, and gradually disappear, leaving very little scar. This is the mildest way; sometimes this may fail, which is very seldom. I then use some of the stronger acids, trichloracetic ​acid or nitric acid; they may also be removed by electrolysis or carbon dioxide snow, etc.

If there is any one thing that a woman utterly despises it is a wrinkle, and as soon as she witnesses these landmarks of age developing she generally seeks the "beauty sharks" for creams, pastes and lotions, that she may maintain perpetual youth; as a rule, they do not seek the advice of the dignified physician; yet any advice the physician may impart will be gratefully received by most women, and the process of arresting the development, and removing these unwelcome visitors is equally divided between medical, mechanical, manual and surgical means. We will briefly discuss the subject before entering the surgical field of cosmetics.

Wrinkles are caused by a relaxed condition of the skin, due to the absorption of the subcutaneous tissues, in some cases, and lack of tonicity of the integument itself, in others. We therefore, find a demand for a variety of treatments, with a view of toning the skin to its youthful activity; manual and mechanical massage has always played an important role. Great care should be exercised with these treatments not to massage with too great a force, as such treatments will invariably do more harm than good; only the cushioned end of the fingers should be used, or the softest kind of rubber; with the bell vibratode, the gentle percussion stroke is preferable to the stroking movement.

One of the best means of applying massage to the face is with the vibro-hand apparatus, see illustration; with this, you can execute the delicate touch with the finger tips, and vibratory movements from this instrument, with little or no exertion from the operator. The effect from this treatment is very exhilarating. We are indebted to Zabludowski for the most scientific system of facial massage, which can be conducted by either manual or mechanical means, or a combina​tion of the two, as illustrated above. The doctor gives the following:

For a special massage of the face and neck, which must be continued for several weeks, or even months, to obtain a noticeable result, Zabludowski gives the following directions: "The massage is best performed in the morning, and should last for a quarter of an hour. The parts covered with hair, whether shaved or unshaved, are to be avoided by the fingers. The masseur stands at the side or behind the patient.

1. Stroking and kneading of the forehead.
   Kneading is done with the right hand, which moves zigzag-wise across the forehead, beginning at the bridge of the nose and traversing the forehead as far as the margin of the hair; whilst the left hand, with light stroking movement, beginning at the frontal eminences, travels lengthwise over the forehead to the mid-line of the occiput.
2. Kneading of the nose with the balls of the thumbs and index-finger of the right hand.
   The zigzag-like vibratile movement proceeds from the tip of the nose to its root, and extends laterally over the alæ nasi. The left hand of the masseur supports the occiput.
3. Kneading of the left cheek, double movement.
   The right hand, half closed, moves across the face from within outwards, and vice versa, and at the same times moves upwards, beginning from the lower jaw to the cheek-bone, below the lower eyelids.
4. Kneading the right cheek with both hands half closed in the vertical direction.
   Chiefly done by the thumb and index-finger; the latter bent at right angles. The movement extends outward from the lower jaw and right ear over the malar-bone to beneath the right lower lid.
5. Smoothing the lines of the forehead.
   Stroking with the index and middle fingers of both hands ​across the forehead from the middle line to the temporal region.
6. Vibration of the face.
   The digits of both hands, with the exception of the thumbs, are applied to the cheeks, between the malar eminences, and the ascending ramus of the mandible, and execute
   Image missing

   Vibratory facial massage.
   the shaking movements, whilst the tips of the fingers approach and move away from each other in the quickest possible time. After a number of vibrations on one part of the face, the vibrating fingers are transferred to another part. The thumbs hang free in the air. ​
7. Stroking the lines under the eyes with both thumbs.
   The movement begins on the bridge of the nose at the root, and is continued over the cheek-bones beneath the lower eyelids as far as the temporal region.
8. Stroking the lines between the chin and lower lip.
   The movement is executed with both thumbs, beginning close to the lower lip, and is continued to the ascending ramus of the lower jaw. The masseur stands on the right of the patient.
9. Kneading of the neck.
   The movement begins close beneath the chin, descending upon the throat, and following the direction of the neck as far as the upper extremity of the sternum.
   Image missing

   Vibro hand vibrator.
10. Stroking and kneading of the right shoulder.
    Whilst the right hand, beginning at the upper third of the right arm, makes kneading movements in a transverse direction over the shoulder-joint, the left hand travels with a stroking movement, following the right hand, over the region of the shoulder, upwards upon the neck as far as the level of the ear."

One of the simplest and best methods of facial massage is by means of Bier's suction glasses. These glasses will obtain sufficient suction to maintain the cup in position without support (see illustration). These can be moved about the face in any direction, and will retain the suction, and is one of the most invigorating treatments in our possession.

​Another very popular method to remove wrinkles is by the use of the face mask, before applying the mask, the entire skin of the face is stretched backwards and downwards and

the mask is adjusted as tightly to the skin of the entire face as possible. This smooths out the wrinkles, and by continuous ​use most excellent results may often be obtained. The mask may only be used at night.

Another similar treatment of pressing out wrinkles is known by the alluring name of "Wrinkle Eradicators and Frowners," and are sold in large quantities, by a company in Cleveland, Ohio. These plasters, however, are not to be compared with the common adhesive plaster, which has more body to retain the skin stretched after being applied. These plasters are used at points where wrinkles are found in profusion, as at the corner of the eye, for crow's feet, under the eye, etc. The method of application is illustrated in the accompanying drawings.

One of the most invigorating and effective home treatments for the removal of wrinkles and keeping the face young is by combining several of these methods as follows: the face is first massaged with the hand, with the vanishing face cream; this is followed by the Bier's cup, the adhesive plasters are applied to the deep-seated wrinkles around the eyes, forehead, etc., over which the face mask may be applied. The ​only time this treatment is used is just before retiring, as the face during the sleeping hours is placid. All these dressings are removed in the morning, and the face massaged for the day. By following this treatment for sometime, it is often surprising the youthfulness which can be restored to an old face. Many facial specialists precede this treatment with the

ecorchement treatment, which also adds to the beauty of the integument.

The surgical treatment of wrinkles consists, principally, of paraffin injections, to fill in deep crevices, and what is referred to as "wrinkle tucks." Paraffin may be injected under ​deep crevices of the face, as the naso-labial line, and the transverse furrows of the forehead, to raise the skin to a level with the rest of the face.

Wrinkle tucks are taken about one-quarter of an inch back from the hair margin in the scalp. The scalp is shaved and various sized pieces of skin are dissected away, and the edges of the wound united. This draws the skin of the face up and back; after this wound has healed the hair is combed back, which covers the wound. These tucks are also sometimes taken below the inferior maxillary bone, to draw the skin down and back. Such operative procedures may seem ridiculous to the conservative physician; yet it is these operations which fatten the purse of many unethical and ethical physicians.

The nose is the protruding organ of the face, and is, therefore, the most often injured or deformed by accident or otherwise; it was this part of my anatomy which always seemed to be in the way during pugilistic contests in college days. These deformities are extremely conspicuous, and have been classed as follows: (See cuts 1, 6 and 10) illustrating the different degree of concave, or what is referred to as the saddle back nose. These deformities are often found at birth, but are generally due to a severe blow, completely or partially, breaking the bony frame work or bridge, giving the nose a ​very unpleasing appearance. Cuts 2 and 7 represent the humped nose. This deformity is not what is generally called the Roman nose, as the bridge is much broader, and gives the nose a very clumsy and massive appearance, independent of its convex shape. Cut 3 is the broad nose as in found in the negro. Cut 4 represents the lateral tipped nose, which is generally

due to accidents of the cartilaginous portion of the nose. Nos. 5 and 8 are the receding nose, which is usually caused by syphilis, scrofula and other destructive diseases of the septum. Cut 9 is the narrow nose which not only gives the face a miserly appearance, but often interferes with respiration. We also have the bulbous nose, the hawk-billed nose, ​the split septum, etc. Each deformity representing different characteristic forms of unpleasing conformity which require our personal attention to adjust and restore to a natural and pleasing contour.

Of all the deformities of the nose, the concave or saddle back nose (Figs. 1, 6 and 10) is the most frequently met with and is also the easiest to restore to its normal shape, by the use of paraffin injections as follows: the paraffin is prepared at a melting point, between 110 and 115 degrees F. The nose and instruments are treated antiseptically, the needle of the syringe, containing the paraffin in a semi-solid or half cooled

state, is inserted to a point of the greatest depression in the convexity, and while the assistant is making pressure on both sides of the nose to avoid having the paraffin spurt in some open channel, where it is not desired, the screw on the piston stem is gently turned, and after sufficient paraffin has been injected to raise the surface, it is molded into shape either by the assistant or surgeon. Great care should be exercised not to inject too much paraffin, as these injections are followed by inflammation and infiltration, which subsides, leaving the tissues somewhat thickened, and if care is not exercised in this point, we may convert a concave nose into a convex one. ​The opening should be sealed with collodion and the nose treated with aseptic dressings.

This deformity (Figs. 2 and 7) is restored to its normal shape by an oblique incision, to prevent scar tissue. The incision

is made along the median line. The opening is enlarged sufficiently to admit the instruments required, which consist ​of bone scissors, rongier forceps, and a slender saw, and such other instruments as may be necessary. After the skin is elevated from the deformed surface, the nasal bone is sawed off, and the edges trimmed smoothly, with a pair of slender bone-clipping forceps, so as to give the nose the exact contour desired. After the parts are thoroughly cleansed and rendered aseptic, the skin is replaced and united in as close apposition as possible, to avoid scar tissue. What scar tissue remains may be removed later by the usual way of removing this tissue.

This deformity, (Fig. 3) which resembles the negro nose, is corrected by overcoming the elasticity of the wings, by incisions through the shield cartilages, subcutaneously, with a slender knife, in several places and then holding them in place by an external form until they are firmly fixed in the desired position. In some cases the cartilage is so redundant as to require the excision of a portion of the same.

This deformity (Fig. 9) is corrected by incising the cartilage at its base, and forcing the cartilaginous wings outward from the septum and holding it thereby sutures and mechanical means; by inserting antiseptic "plugs" into each nostril and retaining them there until the cartilaginous tissues are firmly fixed.

​

This deformity (Figs. 5 and 8) is often one of the most difficult derangements we have to correct, as the septum is often destroyed, either by accident or disease, of which syphilis and scrofula bear their destructive influence. We may build out many of these receding tips with paraffin as is illustrated here, but if the septum is so destroyed that it will not bear

support by artificial means, as is the case with all deformities of the nose, there are no two cases exactly alike, and it will depend upon the surgeon's judgment and mechanical genius to find a way of properly adjusting these deformities of the nose. In this class of deformities we may be required to supply a silver or other metallic support, embedded in the tissues, or force support from some other source. The same rule applies to surgery of the nose, as in other parts of the body and if a patient has an abundance of tissue he wishes to dispose of, cut it out, or fill in the deficiencies by any of the means offered in modern surgery.

​

To correct this deformity (Fig. 4) a narrow bladed knife is inserted at the margin of the skin and mucous membrane at the middle of the septum, and the point of the knife is directed upwards to the point of bone and septum, or the angle of the tilt. The septum is divided, and the tip of the nose is forced to the opposite side, and a little beyond, and held in this position by mechanical means, with "plugs" within the nostrils, and rubber adhesive strips, passing over the nose, and attached to the cheek, after the septum has been reunited, the dressings may be removed, but if the tip has a tendency to go beyond the median line the adhesive strips should again be applied until the tip of the nose is trained to its normal position.

Protruding ears may be either hereditary or acquired. The latter condition is frequently the result of wearing a stocking cap by children. I have had two very interesting cases traced to this cause, which came from Upper Canada. The boys were exposed to the cold much of the time during the winter and would pull their caps over their ears, which trained them to protrude. The same treatment may be used to force them back to their normal position, by the use of the ear truss (as is illustrated here) or a slight operation will rapidly return them to their natural condition. The technique is as follows: The line of incision is marked off, behind the ear, on both the mastoid process and ear, so that the apposition of the skin at the border of the surfaces will meet perfectly; the integument is now removed and the borders of the skin united with sutures and dressed antiseptically. To hold the ear in contact with the mastoid surface, a cloth bandage is placed around the forehead and back of the head and one over the head and under the chin. These bandages are held in place by reinforcing them with adhesive strips; this is the ​most popular way of "resetting ears," as it is frequently referred to. Other operations consist of removing parts of the cartilage.

It is these operations in which the use of paraffin reaches its greatest degree of usefulness, and can serve for the noble purpose of restoring contour to unsightly depressions and defects, which cannot be reached by any other means, and in this capacity its usefulness is almost unlimited, grading in degrees of magnitude, from elevating a small pox pit to the complete filling in of cavities, after resection of bone, from the upper and lower jaws, and other parts of the face. The writer had one case of congenital malformation, hemiatrophia ​facialis, in which nearly five ounces of paraffin was injected to restore contour to the face, and the result was almost perfect.

The receding chin, small pox pits, depressions from abscesses, the eradication of the naso-labial line, hollow cheeks, and many other deficiencies may be restored to perfect contour by the use of paraffin.

It was formerly believed that liquid paraffin would answer the purpose for elevating surfaces upon the face, and leave the tissues soft and pliable but these operations were failures, as the paraffin would become absorbed in a few months' time. There is a great deal of tension when paraffin is injected over bone and the melting point should never be lower than 110 degrees F., and it is still better to use a higher melting point for receding chin.

The technique for the use of paraffin is given elsewhere, which applies, in general, to all paraffin operations; we therefore refer you to the preceding chapter.

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The removal of cicatricial tissue, as the result from cuts, burns, bruises, abscesses, etc., is one of the most frequent blemishes the physician is requested to remove and the treatment required and the degree of success obtained will depend upon the length and breadth of the scar. In order that I may implant firmly in the reader's memory, I wish to repeat what has already been said in a preceding page, "we may mutilate, cut, bruise or destroy the first four layers of the skin as much as we like, without leaving any cicatricial tissue, but when we go below the epidermis into the true skin, our operations are always marked by the formation of cicatricial tissue.

We may desquamate the outer skin, and draw to the surface cicatricial tissue, from the true skin, by a process of blending and absorption, by continually removing the outer skin. In order that I may demonstrate this process I will cite the following case:

Mr. H. was kicked by a horse when nine years old, resulting in a depressed scar, about three inches long and three-quarters of an inch wide; the wound was united at the time, which was followed with septic infection, with considerable sloughing of tissue, which left a deep depression. The first step to be considered was to dissect away all the cicatricial tissue, and unite the edges of the integument in as close apposition as possible (see scarless surgery); we now have left a slight line of cicatricial tissue, and a deep depression to deal with. The next step was to elevate the depression by an injection of paraffin to a level with the face; this was allowed several weeks, for the reaction to subside and thoroughly heal, and the only trace left was a fine lineal scar where the skin was united. The patient was so well pleased that he wished it to remain as it was, but I encouraged him to completely eradicate every mark possible. I therefore, proceeded to apply a thin strip of Canthos blister plaster, along the entire line of incision; this was applied at five different times, which still reduced the cicatricial tissue, so that it could ​not be noticed at six feet distance. The patient was then given a ten per cent. thiosinamine ointment which was applied for some weeks; today it will almost require a magnifying glass to find any trace of scar tissue and the operation may be considered perfect.

Within the last two years I have used the thiosinamine by cataphoresis as suggested by Dr. Nieswanger.

Thiosinamine and its double salt fibrolysin, is used to such an extent in the treatment of many diseases given in this publication that it is well to have a clear conception of the therapeutic value of these two products.

Thiosinamine is a synthetic preparation made from the artificial oil of mustard and appears in clear crystals of faint garlic odor, and bitter taste, and is only slightly soluble in water, but can be made more soluble by the addition of glycerine and aqueous solution. It is very soluble in alcohol and ether but, owing to the pain caused by the hypodermic injection of alcohol, it has been superseded under the coined name of "Fibrolysin," which is a double compound of thiosinamine and sodium salicylate. It was first prepared by Dr. F. Mendel, of Essen-Ruhr, who, by combining two molecules of thiosinamine with one molecule of sodium salicylate produced a white crystalline powder, soluble in both hot and cold water. This he found unirritating when injected.

Fibrolysin has the same indications as thiosinamine; it is a cicatricial and glandular resolvent; but it has the advantage of quicker absorption, and freedom from pain or irritation, upon injection, on account of its solubility and aqueous vehicle.

Most authors agree that thiosinamine alone is ineffectual when given by mouth, while subcutaneous application is unsatisfactory, owing to its slight solubility in water, and the pain which always follows when given in alcoholic solution. On the other hand, when combined with sodium salicylate, in ​the form of Fibrolysin, if the usual antiseptic and other precautions are observed injections are painless and irritation at the site of an injection rarely occurs.

We therefore find that the therapeutic application of thiosinamine and fibrolysin may be utilized either internally, in one-half grain doses; by inunction, in a ten to twenty-five per cent. ointment; by hypodermic medication (fibrolysin), and by cataphoric application. With these four methods of medication at our disposal, we are not only able to dissolve cicatricial tissue, as found in scars, structures corneal opacites, etc., but also to reduce hypertrophied glands and superfluous tissues, thiosinamine being preferred for cataphoric purposes in the following formula:

Thiosinamine	½	dr.
Glycerine	1	dr.
Aqua dis.	1	dr.
Sodium chlor.	3	gr.

A piece of absorbent lint is cut to cover the surface of the scar tissue, if not too large, and saturated with the above solution. This is placed in a special electrode (see cut) and applied firmly against the scar, using the positive pole of the galvanic battery; the negative pole is placed at any convenient place, and the current turned on, in strength from four to twenty milliamperes. Each sitting should be continued about ten minutes; in three or four days the skin over the ​scar will become dead and peel off, when another treatment may be used until the scar tissue entirely disappears.

This same procedure is also used for fibrous degeneration of the thyroid gland, with marked success; the positive electrode being packed with absorbent gauze, and saturated with the thiosinamine solution, can be applied to sections of the goitre, until the entire enlarged surface is treated in different areas. The best place to apply the negative pole for the treatment of this affection, is upon the abdomen; the amount of current tolerated by most patients is from twelve to twenty milliamperes to obtain success. Patients should receive three treatments each week and the duration of each treatment should be about ten minutes. Solutions of iodide of potassium have also been used to a good advantage by cataphoric applications.

Puffiness under the eyes has always been associated with Bright's disease and other kidney disorders; although the condition may be a symptom of kidney disorders, we often find that it presents itself spontaneously in perfectly healthy people, and is one of the most damaging disfigurements to the facial appearance, as it produces an expression of sadness, melancholy or ugliness and many faces which otherwise have a fine complexion and contour are ruined by this "bloating" under the eyes.

The double or baggy chin, which consists of a superfluous amount of flesh hanging from the chin, reacts to a disadvantage in many ways; it not only mars the general contour and expression of the face, but also draws deep lines elsewhere on the face, and it is surprising to note the wonderful improvement which takes place after removing this superfluous flesh. The skin of the face proper becomes more tense and trans​parent, the deep lines disappear, and the general expression assumes a more youthful appearance. In both of these conditions we have a superfluous amount of flesh to deal with, and it has been the custom of featural surgeons, in the past, to deal with these conditions purely upon a surgical basis, and dissect away this over-amount of redundant tissue. More satisfactory results have been obtained by making compresses of the thiosinamine solution, as used for goitre and scars; to obtain results, a pad of absorbent gauze is saturated with the solution, and applied over the area of superfluous tissue. This

is held in place, so as to make heavy pressure, during the sleeping hours and held in position with adhesive strips under the chin and over the head for a baggy chin and the face mask is used for both the chin and puffy eyelids. This preparation is also used by cataphoresis, as in goitre, and for removing scar tissue.

Chief among facial blemishes which constitute a sad disfigurement, that renders the possessor a recluse from society, are birthmarks (pigmentary nævi). These marks are generally noticed at birth, hence their name, and come under the classification of tumors by the name of angioma to which you ​are referred; these tumors consist of a net-work of dilated blood vessels, either arterial or veinous. Until within recent years these marks were not considered removable and their unfortunate possessors were doomed to exist with these "princes of disfigurement," and obstacles, throughout their lives, which were a constant annoyance in both a social and business way.

Modern therapeutics offer many methods in which these marks may be removed. The point aimed at is to destroy or contract these anastomosing dilated vessels. Very superficial marks may often be removed by the blister treatment, but the

deeper seated lesions will require a more distructive influence, for which carbon dioxide snow perhaps offers the greatest advantage; the technique for using this, for birthmarks, is the same as for other neoplasms, given elsewhere. It will, therefore. not be necessary to repeat the details here; the accompanying illustration shows the results which may be obtained from this indispensable element and if due caution is exercised not to freeze too deeply, the cosmetic effect is the best at our disposal. Most excellent results have been obtained by the use of trichloracetic acid for this purpose.

Electrolysis offers us a means of cauterizing these minute blood vessels, and obliterating the discoloration and disfigurement they produce. The area is anesthetized, either by hypo​dermic injections of quinine and urea hydrochloride or by the cataphoric application of cocaine. A sharp pointed needle attached to the negative pole is entered at the border of the mark, to transfix the growth beneath the skin, in lines of about one-twelfth inch apart; this is followed by the same process in a transverse direction until the growth has been blocked, like a checker-board (see illustration). This thoroughly cauterizes the small blood vessels, and in a few hours the mark will assume a brown appearance, which forms an eschar that desquamates in a few days, taking the mark with it. If any remnant should remain, it may be followed with other treatments until it entirely disappears. Caution should be exercised not to cauterize too long or too deeply, lest an unsightly scar my result. It is the practice, nowadays, to use

several needles (see illustration) on one electrode instead of the single needle as it saves time. This process is referred to as multiple electrolysis.

Dr. Nieswanger highly recommends the following where the mark is not elevated:

Antim. tart	1	dr.
Soap plaster	3	dr.
Green soap	1	dr.

M. This is applied on adhesive plaster, about one-twelfth inch thick over the entire surface. The healthy border should be painted freely with collodion to protect the normal skin: at the end of from three to five days the full escharotic effects are evident and the plaster removed and the surface dressed with

​

Zinc oxide	20	gr.
Cold cream	4	dr.

This treatment will produce excellent results in many cases.

These two deformities come within the scope of the featural surgeon and it is well to consider the best means for their correction. Dr. D. La Ferte, in a recent article, gives the following technique for the correction of harelip, which will leave only a slight trace of the operative procedure:

In the treatment of harelip the efforts of surgeons for the most part have been directed toward closing the fissure in such a manner as to make the lip of uniform thickness and to avoid leaving a dimple in the vermillion border of the lip at the junction of the two flaps.

Little effort has been made, in planning the different operations, to so plan the trimming of the edges that in the male child when he grows up and desires to wear a mustache the part in the mustache may be in the median line and not to one side of the column of the nostril. I venture the asssertion that many grown-up individuals whose mustaches part to one side on account of a previous operation for harelip would willingly submit to an operation for remedying that defect if they were cognizant of the fact that such an opera ​tion was practical. Another point that has been sadly neglected is the flattened and depressed nostril that is generally found on one side of the nose.

The late Dr. A. M. Phelps was the first, I believe, to call attention to the desirability of throwing the scar in the median line of the lip. The drawings in this article are largely copied from an article from his pen.

The object of the operator should be to make as artistic a lip as possible and not only to close the fissure in as easy a manner as possible. He should try to have a lip that shows a graceful curve from each corner of the mouth to the median line, where it should terminate in a slight prominence, as seen in Fig. 3. That should be our aim, but it is not always possible to be as successful as we desire.

Describing the different steps of the operation should aid in its understanding. First take a loop of silk through each angle of the lip, at 4 right side and at 4 left side (Fig. 1). These are made tant by traction with the left index-finger, which aids to steady the parts, and thereby facilitates the other steps of the operation. By means of scissors or knife the lip, together with the depressed ala of the nose, are dissected from the bone, and if deemed advisable the ala of the ​nose may be slightly detached also upon the other side. The upper lip must be sufficiently detached so that it can move freely over the bone. With a tenotomy knife puncture the lip at aa, Fig. 1, the parts being put upon the stretch by making slight traction on the silk loops. The incision should describe a curve, following the dotted line to 2, and from there to 3 (see Fig. 1); then cut from 3 to 4 through the entire thickness of the lip (Fig. 1). The pieces B and B are now turned downward, leaving the V-shaped piece seen in Fig. 2. Now sew the raw edges together (I prefer fine silk for that purpose), when the result will appear as shown in Fig. 3; raise the lip and sew the mucous membrane as high as possible.

We should always allow for a certain amount of retraction. Therefore care must be taken that the pieces B and B shall be longer than is actually necessary. If there is too much redundant tissue, that can be trimmed off at the last stage of the operation. This operation is practicable in all cases of single harelip where one-quarter of the length of the lip remains between the fissure and the corner of the mouth. The punctures at 2, Fig. 1, should be at equal distance from each corner of the mouth and both nostrils should be entered at the same point on each side (3, Fig. 1). The V should be about one-half the normal width of the lip. If the V should be cut too short, the defect can be remedied by making a transverse cut through the whole thickness of the lip around the ala of the nostrils. If the V is left too long, it will cause the middle of the vermillion border of the lip to drop too far down at the median line. These same incisions can be made in cases of double harelip, saving the center from which the Vis made (Fig. 4). This figure gives a good illustration of the manner in which the incisions are made in cases of double harelip.

I had occasion lately to put this operation in practice at the Children's Free Hospital for single harelip in a boy fourteen years of age, who said he had been operated on twice for his defect since birth, and whose lip when he came to me was in the condition represented in the accompanying illustration. ​My incisions were planned as indicated in Fig. 1, and the flaps brought together as shown in Fig. 3; the result shows an artistic lip with the scar directly under the column of the nostrils (Fig. 6).

This method of operating I have followed for some time, and I feel pleased with the results.

Where one nostril is depressed and the ala of the nose upon one side spread out upon the face, 1 dissect the ala of that side from the bone and put in a button suture, penetrating from the depressed and loosened ala through to the fixed ala of the opposite side. In about five days the suture is removed, when the lip will be found to have become attached to the raw surface of the bone underneath and the wing of the nose to have become elevated.

Dr. Dean Smith's operation for cleft palate is performed as follows; The flaps are made in the usual way, cutting the muscles that would interfere with the easy bringing together of the margins. The edges being pared, the mattress sutures are introduced and tied. These are of silkworm gut. In placing them, the needle enters the flap near the end, about midway between the margin and the lateral incision. It passes obliquely through the tissues, and emerges on the under (upper, according to the position of the child) side near the free edge. The needles enter the other flap on the under side, near the margin, and opposite to the point of emergence from the first flap. It passes obliquely upwards, through the tissues, coming out on the free surface, at the same relative position that it entered the first flap. It now retraces its course through the flaps, parallel to the first part of the stitch, and about a quarter of an inch from it. This thread makes the mattress suture and when it is tied it will bring the margins together. Rather, it will bring the lower edges of the margins together, rolling the outer edge out. This will give us the broadest possible coating surface, when the marginal sutures are placed. Two or three mattress sutures will be required to control the whole length of the flap. It is evident that if these stitches are properly placed they will take all ​tension off the coapting or marginal sutures. I have seen it stated by one surgeon that he uses silk, instead of silkworm gut, because the latter irritates the tongue. Another surgeon uses the silkworm gut, because it will irritate the tongue, so that the child will keep it away from the flaps. The silkworm gut serves a good purpose. Unless the gut is very fine and pliable, silk should be used in the uvula. I have discussed the treatment of the cleft, involving the palate bones. The mattress stitch is just as important when the cleft is only through the soft palate.

The cleft or clefts, through the maxillary bones, require an entirely independent operation. This operation is done at the same time as the palate operation, or soon after. The proper management of the pre-maxillary bone will help materially in closing the space in the palate that could not be closed with the flaps. It is my practice to break this bone

loose, if the cleft is wide, and push it back, or downward into apposition with the edge of the maxilla. If the cleft is unilateral and the pre-maxilla cannot be broken and reduced, I cut through the alveolar juncture of the opposite side with bone shears so as to partially free the portion we wish to displace. When the lip is repaired it tends to hold the fragment back so the opening in the palate may entirely close in a year or two.

Before using the mattress suture, it was the exception to have a case hold throughout the entire length of the cleft. We often had to make two and sometimes three operations. ​before we were satisfied with the result. I may have been less skillful than other operators. 1 do not wish to boast of inefficiency, but state these facts for the sake of comparison. I know that since using the mattress suture, I expect and usually get complete union the first time.

Of the cases treated with the mattress stitch, one was a failure. The patient was a tiny delicate baby, with an exceedingly wide cleft of both palate and lip. Because of the frail appearance of the child 1 hurried the operation. The haste was unnecessary for, when the work on the palate was completed, the pulse and respiration were about as good as when we began. We then repaired the lip. The child suffered but little from shock.

The mattress suture will not cause the parts to heal unless the balance of the work is properly done.

In one other case the uvula did not hold. It was this case that led to the suggestion regarding silk sutures in this part of the palate.

All the other cases held throughout the entire length of the cleft.