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FACE AND FOOT
DEFORMITIES.

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FACE AND FOOT

DEFORMITIES

BY

FREDERICK CHURCHILL, CM.,

SURGEON TO THE VICTORIA HOSPITAL FOR CHILDREN.

(ttl; finit^trationg of ^thy Epplt'anccsf for tijc Cure of
I3tvtl>'^arfe, €luft;=droot, etc.

LONDON

J. & A. CHURCHILL

II, NEW BURLINGTON STREET.
1885

PREFACE.

It is needful at the outset that I should explain, and
if possible justify the selection of a title which to
some minds may appear rather indefinite.

There can be, of course, no hard and fast line
between that which is deep, and that which is super-
ficial.

I use the term deformities in its broadly generic
sense, as applicable to all surface lesions and sym-
metrical defects.

It is important to make this explanation because,
no doubt, we, as surgeons, have become too much
accustomed to such a restricted definition of deform-
ities as may be found in some text-books of ortho-
paedic surgery, the authors having limited themselves
to a description of alterations in the normal outlines
of the body from changes in the osseous and ligamen-
tous structures.

By deformities I understand any recognised altera-
tion in structure, whether temporary or permanent,
whether produced by disease, by congenital de-
ficiences or outgrowths, by want of symmetry in the
general configuration of the body, or by structural

vi PREFACE. '

and surface changes the result of injury or disease.
A deformity in fact, is anything that is manifestly
ugly or crooked.

As regards the foot, there can be no difficulty in
understanding what is meant by deformity of that
member of the body.

Limiting myself to surface deformities and modern
methods of treatment thereof, I do not undertake the
general surgery of the deep structures of the foot or
face. It would not only very much enlarge the scope
of my work to do so, but it would lead me to embark
upon a path which has been so ably and well trodden
by writers upon systematic surgery. For the same
reason, I do not enter upon a full consideration of the
etiology and pathology of skin diseases, but I give
a brief outline of skin eruptions as they appear on
the face. Moreover, in dealing only with those de-
formities which appear on the surface, I believe I am
more accurately discharging my duty when defining
my position in regard to the title of this work.

To introduce such subjects as cleft palate and
disease of the antrum into any work which is limited
to the surgery of the face, is, I think, to overstep
the natural limitations of the subject under considera-
tion. I have therefore omitted all reference to diseases
of the jaws, mouth, etc.

It may be asked, — why I should associate the face
with the foot, as these are the two extreme parts of
the body .■' Chiefly because deformities of these
members of the body being more manifest than

.PREFACE. ■ vii

deformities elsewhere, they constitute a greater hind-
rance to success in life. They not only deform but
deface, by reason of their great disfigurement, the
artistic proportions of those parts of the body upon
which the eye of the observer or critic most loves to
rest.

I may add that as Surgeon to the Victoria Hospital
for Children, these deformities of the body have oc-
cupied much of my thought and attention, with an
earnest desire to erase from the chapter of accidents
as many as possible of such unsightly disfigurements,
so that in the mevitable struggle for supremacy, in
after life, these poor children may stand a better
chance of competing for the prizes, and not be so
heavily handicapped in the race by their more for-
tunate competitors.

The litho illustrations are taken from cases that
were under my care while this book was passing
through the press.

The chromographs and monotones are taken from
photographs enlarged by the camera lucida process,
and are accurate representations of the before and
after effects. Mr. Burgess, the well-known anatomical
and pathological artist, has faithfully carried out my
instructions in every detail. I shall be happy to
show the photographs to any surgeons who may
desire to see them.

I am indebted to the publishers of Erichsen's,
Fergusson's, Pirrie's, and Bryant's Manuals of Sur-
gery for permission to copy some of their woodcuts

viii PRE FA CE.

Mr. Brodhurst has also kindly lent me two wood-
cuts to copy.'

I have made some selected quotations from Mr.
Adams' prize essay on Club-foot, because few, if any,
surgeons can have had such good opportunities as he
had of studying by dissection the osseous and liga-
mentous changes as they appear in the several varie-
ties of club-foot.

I regret that I have only been able to give a limited
space to the consideration of deformities upon col-
lateral subjects, such as skin eruptions, and surface
lesions of the eye.

There are an endless variety of congenital deficien-
cies, and our museums are full of strange examples of
developmental defects. Most of these being irreme-
diable, I have not allotted a section to such malforma-
tions.

I have omitted some of the rarer forms of deformity
of the face, as, for example, elephantiasis, anasarca,
and atrophies dependent upon neurovascular degener-
ation. But these are local manifestations of general
diseases, and are therefore passed over. Still I am
conscious of having failed to exhaust the repertory of
deformities within the range of my definitions, and
may consider the subject open for more elaborate
treatment hereafter.

Frederick Churchill.

4, Cranley Gardens, S.W.
April 1885.

GENERAL CONTENTS.

PART I.

THE FACE.

SECTION PAGE

I. — Structural Deformities — Birth-marks,

Congenital Growths, N^vi, etc i

II. — Face Eruptions— Abscesses, Ulcerations,
Parasitic Diseases, Surface Tumours,
Dental Abscess, etc 19

III.— Injuries of the Face — Incised Wounds,
Fractures and Dislocations, Burns and
Scalds 64

IV.— Plastic Surgery— Nose, Hare-lip, etc. .. 72

V. — Other Deformities of the Lips .. .. 90

VI. — Deformities of the Eyelid and Eyeball

— Diseases of Cornea, etc 95

VII. — Deformities of Neurotic Origin 114

■ PART II.
THE FOOT.

VIII.— Deformities induced by Injury or Disease
— Dislocations of the Ankle, Amputa-
tion Stumps, etc. ; Ingrowing Toe-nail ;
Simple Onychia, Onychia Maligna, etc, 117

GENERAL CONTENTS.

SECTION PAGE

IX. — Deformities induced by Bad Habits — Faulty
Boots, Bunions, Corns, Distorted Toes,
etc 127

X.— Congenital and Paralytic Deformities —
Contraction of Plantar Fascia ; Con-
traction of One Toe ; Weak Ankles ;
Club-foot ; Varieties of Talipes— their
Causes, Classification, and Treatment ;
Flat-Foot ; Choreic, Hysteric, and Spas-
tic Contraction of Groups of Muscles ;
Webbed Toes, Supernumerary Toes, etc. 138

APPENDIX OF CASES 185

CONTENTS OF SECTIONS.

THE FACE.

SECTION I.

Structural Deformities.

Introduction i

" Liver marks " 4

" Port-wine stains " .. .. 4

Birth-marks 5

treatment of, by

the stippling process, etc. 7

Aneurism by anastomosis . . 8

Mother's marks and nsevi .. 9

Nasvus araneus 12

Erectile tumours . . . . i

Warts I

Scars of burns i

Wens

Pigmentary changes ..

Moles

Bronzing of skin . .
Leucoderma

Freckles

Horny growths . .
Horns

SECTION II.

Eruptions, etc.

Erythema

E. simplex

E. marginatum .,

20
21
21

E. nodosum 22

Erysipelas 22

Traumatic erysipelas .. .. 23

Urticaria 24

Eczema 25

Impetigo 27

Lichen 27

L. strophulus 28

Herpes 28

Miliaria 28

Ecthyma 29

Pemphigus 29

Rupia 30

Pityriasis 30

Psoriasis 30

Facial Carbuncle .. .. 31

Anthrax 31

Malignant pustule .. .. 32

Keloid 33

Xanthelasma 33

Abscesses, simple .. .. 34

Fistulous tracks 35

Strumous abscesses ,. .. 35

Furuncles 35

Hordeolum 35

Ulcers, simple 36

syphilitic 36

Acne 36

Stearrhoea 38

Acne indurata , 38

CONTENTS OF SECTIONS.

PAGE

Acne rosacea 40

Molluscum 42

Lupus 43

exedens . . . . . . 44

devorans 45

non-exedens . . . . 46

erythematosus .. .. 47

Cancrum oris 48

Congenital syphilitic erup-

. tions 49

Parasitic Diseases.

Scabies 50

Pediculi 50

Tinea tonsurans 51

circinata . . . . . . 51

sycosis 52

favosa 53

Chloasma 54

Pityriasis versicolor ,. .. 54

Surface Growths.

Lipoma .. 54

Fatty tumours 55

Primary cancer 56

Rodent cancer 56

Epithelioma 57

Sebaceous cysts 59

Dental abscess 60

Salivary fistula .... . . 63

SECTION in.

Injuries.

Incised wounds

. 64

Fractures of bones

. 67

Dislocation of jaw

■ 67

Fracture of nasal bones

. 68

Burns and scalds

. 69

Cicatrices, removal of

• 71

PAGE

SECTION IV.

Plastic Surgery.

Primary union 72

Deformities of the nose . . 74

Dislocation „ „ .. 75

Atrophy „ „ .. 75

Taliacotian operation . . 76

Plastic surgery of the eyelid 78

Harelip 79

plastic operation for 82

Hainsby's truss .. 85

Double harehp 86

Plastic operations on lower

hp 90

SECTION V.
Other Deformities of the

Lips.

Excessive growth of hair . . 90

Simple cracked lip .. .. 91

Cracks at angle of mouth .. 92

Small nasvoid growths . . 92

Hypertrophy 93

Chancre 93

Cysts 94

Congenital cystic growths . . 94

Sub-mucous ulceration .. 95

SECTION VI.
The Eye.

Ecchymosis 95

Emphysema 96

Wounds 96

Injuries from corrosion .. 96

Sub-conjunctival ecchymosis 96

Penetrating wounds of cornea 97

Excavation of cornea .. 97

CONTENTS OF SECTIONS.

PAGE

Ptosis 97

Spasmodic irritation ,. .. 98

Epicanthus 99

Entropion 99

Trichiasis 99

Ectropion 100

Encysted steatomes ., .. loi

Chalazion loi

Strabismus 102

Abscesses and cellulitis .. 103

Ophthalmia tarsi .. .. 103

Blepharitis 104

Symblepharon 104

Obstructed lachrymal ducts 105

sac . 105

Acute inflammation of sac . 105

Fistula lachrymalis .. .. 106

Catarrhal ophthalmia .. 106

Purulent ophthalmia . . .. 107

Gonorrhoeal ophthalmia .. 109

Phlyctenular ophthalmia .. 109

Pterygium no

PAGE

Pinguecula no

Keratitis in

Opacity of cornea .. .. in

Ulcers Ill

Staphyloma in

Conical cornea 112

Arcus senihs 112

Syphilitic keratitis .. .. 113

Suppurative keratitis .. .. 113

SECTION VII.

Deformities of Neurotic

Origin,

Choreic spasms 113

Hysteria 114

Nerve irritation 114

Hemiplegia 114

Paralysis of the insane .. 115

Tetanus 115

Facial paralysis .. .. .. 116

THE FOOT.

SECTION VIII.

Injuries and Surface
Diseases.

Contusion 117

Partial displacement of astra-
galus 117

Separation of the tarsus . . 118
Dislocation of ankle, varie-
ties of 118

Compound dislocation . . 1 20

Dislocation of other tarsal

bones
Hypertrophy of foot
Cellulitis

Amputation stumps
Excisions
Chilblains ..
Diseased toe-nails
Ingrowing toe-nail
Simple onychia . .
Onychia maligna
Horny growths .,

121
121
121
122
122
122
124
124
125
126
126

CONTENTS OF SECTIONS.

Exostoses 126

Perforating ulcers .. .. 126
Tumours, etc 127

SECTION IX.

Deformities from Badly

Fitting Boots.
Partial dislocation of meta-
tarsal bone 1 30

Bunions 133

Inflamed bunions .. .. 134

Hard corns i35

Soft corns 136

Distorted toes 137

SECTION X.

Congenital and Paralytic
Deformities.

Infantile paralysis
Congenital deficiencies
Contraction of plantar fasci

of one toe

Weak ankles
Club-foot .. ..
Varieties of talipes
Causes of talipes
Pathology of talipes
Relative positions of
bones and ligaments
Intra-uterine compression .

Spinal irritation

Treatment

Little's shoe

Deformity of bones . .
Osteotomy for talipes

the

139
139
139
140
140
140
140
142
143

144
151
151
154
154
155
i?5

PAGE

Tenotomy 157

Scarpa's shoe 158

Moulding of bones .. .. 158

Reunion of divided tendon 159

Resistance of ligaments .. 160
Talipes varus, congenital

and acquired 161

Uselessness of irons .. .. 163

Fixation apparatus .. .. 165

Method of applying it .. 166

Talipes equino-varus .. .. 168
Talipes valgus, congenital

and acquired 168

Tenotomy in talipes valgus 169

Causation of talipes valgus 170

As in disease of hip or knee 170

Flat-foot 171

Causation 171

Treatment 172

Talipes equinus, congenital

and acquired 173

Relative frequency of talipes 174

Cause of talipes equinus .. 175

Treatment of talipes equinus 175

Talipes calcaneus .. .. 176

Causation 176

Treatment 176

Spastic contractions of

muscles 178

Choreic spasms 178

Partial paralysis 180

Congenital displacement of

toes 182

Webbed toes 182

Supernumerary toes .. .. 183

APPENDIX 185

ILLUSTRATIONS.

C H R O M O S.

PAGE

NiEVUS OF Nose to face \o

Extensive N^evoid Growth \

("Port-wine Mark") .. I ,. between 184 & 185

Ditto, after Operation .. )

MONOTONES.

Papillomata of Chin, Neck, and Buccal

Mucous Membrane to face 14

Necrosis of Superior Maxilla ; Eversion

OF Eyelid: Plastic Operation ,. ,, „ 62

Talipes varus .. .. .. .. „ 162

Acquired Talipes valgus and Pulpy Dis-
ease of Knee-joint „ 170

Two Cases of Flat-foot : {a) after Ex-
cision of Hip-joint, with a Shortened
Limb; {b) after Excision of {c) the Os
Calcis „ 194

Note. — All these plates show the condition of the patient before
and after operation, except the last plate, which gives the after effect
in two cases.

ILLUSTRATIONS.

WOODCUTS.
THE FACE.

PAGE

Cancrum oris 48

Removal of Cicatrices .. 71

Plastic Surgery of the Nose ^^

Incisions for Harelip 82

Hainsby's Truss 85

THE FOOT.

Little's Shoe To face 154

Deformity of Bones in Talipes 156

Three Grades of Talipes varus ,. .. To face 162

Talipes equino-varus To face 162

Moulding Process in Talipes 165

Fixation Apparatus i66

Talipes valgus To face 168

Talipes equinus (Four Varieties) .. .. To face 174

Talipes calcaneus To face 176

FACE AND FOOT DEFORMITIES.

PART I.
THE FACE.

SECTION I.

STRUCTURAL DEFORMITIES — BIRTH-MARKS,
CONGENITAL GROWTHS, N^VI, ETC.

It is impossible to drive or walk through the streets
of London without meeting almost daily with cases
presenting hideous deformities and blotches about
the face. These unfortunate people, many of them
in the upper ranks of society, have probably come
under the observation of many critics, and a host
of sympathetic friends will not fail to give them
more or less valuable advice. The result has been
that these face-blotches — tumours, morbid growths,
port-wine stains, birth-marks, moles, etc. — being pro-
nounced incurable, continue to harass the mind of
the unfortunate victim. He is an outlaw from society
by reason of this affliction, and he has to pass his
long weary days with the finger of reproach secretly
pointed at him wherever he goes, " a proverb and
by-word among the people."

B

2 FACE AND FOOT DEFORMITIES.

Those who stare so unmercifully at every eccen-
tricity that comes under their notice, forget, or they
would not be so unkind, that the man or the child
who is the victim of this social ban has had to run
the gauntlet of a hundred critics already during each
day of his customary pilgrimage through the streets.

Fortunately the rapid advances in the know-
ledge of electricity and galvanism during recent years
as applied to modern surgery, permit us to attack
some of these disfigurements with every probability
of successful eradication. Nevertheless, it appears
that such progress in surgical manipulation has out-
stepped the popular creed on the subject. Diseases
and blotches which were once considered incurable
may now be safely and effectually removed by one
of the many beautifully constructed instruments
which are being gradually introduced to public notice,
and that without leaving any appreciable deformity.
Of course the new skin or scar tissue will not have in
all cases the same velvety structure as that of the
sound skin, but this is a trifle compared with the
marked beneficial results of obliterating the deformity.
Some people have very erroneous ideas about these
growths. They think the roots are so deep that it
would be dangerous to remove them, or that being in
the neighbourhood of some important structure, as for
example the eye, the sight would be destroyed.

Then again, if it is a wart or hairy mole, whether
small or large, they resolve to consider this a trifle
" not worth troubling about." It is all very well to
joke about these birth-marks being " beauty spots," but
young ladies in their teens would certainly prefer to

FACE AND FOOT DEFORMITIES. 3

have their features unspotted by such disfigurements.
A blemish which is very obvious to strangers, people
become so habituated to, that they take little notice of it
themselves. Visitors cannot help, much against their
will, fixing their eye upon the blemish, evidently to the
discomfiture of both parties. Sometimes it is the scar
of a burn that has contracted the skin into a number
of rugosities. These rugosities may be removed with
the greatest ease in some cases, although the bulk of
the scar tissue must continue to distort the features
and render them unsightly. The rigidly contracted
scars may destroy the natural outlines of the face
by drawing the skin into a very distorted shape.
The scars will often drag down the eyelid so as to
expose the lower part of the eyeball together with
the conjunctiva. Under these circumstances the
deformity is very great. The lower eyelid is for all
practical purposes destroyed. It no longer lubricates
the delicate membrane covering the eyeball. Sand,
dust, and grit will find their way into the eye not only
at the lower part, but also under the upper lid. The
result of this will be that the conjunctival membrane
both ocular and tarsal will become permanently
thickened, and not unlikely the cornea will also become
opaque and the power of sight obscured. As a still
further development of mischief consequent upon
such chronic irritation will be choroidal changes and
atrophy of optic disc, which I need only mention by
way of warning, so that an attempt may be made to
rectify this deformity without delay.

The ramus of the lower jaw is often obscured by a
firm cicatricial band extending from the face to the

B 2

4 FACE AND FOOT DEFORMITIES.

clavicle, thus obliterating the outline of the neck in
this situation.

These strong bands of scar tissue may be very-
lumpy and unsightly, but we may well hesitate before
dividing them, as the resulting cicatrix may be worse
than that caused by the original burn. We may as a
rule safely, and with considerable advantage, smooth
down the rugosities by the cautious use of Paquelin's
cautery.

The large red sluggish veins and venous capillaries
which spread over the surface may be destroyed by
caustics, as for example nitric acid, ethylate of sodium,
etc. Subcutaneous division of the fibrous bands which
glue down the skin and integument to the deep fascia
may often liberate the neck, and remove the distortion
to some extent. All such operations must be
undertaken with care, remembering that it is impos-
sible to recreate that which has been destroyed, viz.
the velvety elastic sound skin. The surgeon will
therefore have his plans well matured before cutting
boldly through a rigid band of scar tissue.

Besides the unsightly "liver marks," " port-wine "
stains, tumours, and growths so frequently displayed
on the face, there are others that grow on the body.
Because they are out of sight patients resolve to
leave them out of mind, but they may degenerate
after years of inert growth into a rapidly fungating
and destructive disease, such as cancer. Sometimes
the superficial veins of the face become dilated, tor-
tuous, and hypertrophied, giving a peculiar " mapping
out " character to the vessels of the cheek and also
of the nose. This is very common in cases of hyper-

FACE AND FOOT DEFORMITIES. 5

trophy of the right side of the heart, or from valvular
incompetence. If such turgescence of the capillaries
is general, and evenly distributed over the face, no
local treatment is desirable, but in some cases only a
few of the venous trunks are prominently marked out
as causing an unsightly " spray " of purple streaks, and
these may be obliterated, by the use of the needle
cautery, without leaving any scar or mark.

''Port-wine mark" or "liver stain" is one of the
most unsightly disfigurements to the face of any of
these congenital growths. It is very diffuse, often in-
volving the whole of one side of the face like a
splash of some purple dye, and the colour is so
persistent and so purple, that these blotches may
be seen at almost any distance. The sight of
them is naturally very repellent at close quarters.
Consequently, the victims of this unaccountable freak
of nature have to submit to many uncharitable re-
marks, however much they may try to pass unnoticed
through the world. Fortunately for treatment, this
growth is all on the surface like the display in a shop
window, and may therefore be destroyed without
doing permanent damage to the proper structures of
the face. These purple vessels ramify in the skin,
which though unusually thin and transparent is of
normal texture. It is not necessary to destroy the
skin in our attempts to destroy the vessels. No large
effort has at present been made to deal effectually
with these deformities, because, as I have already
said, they are generally pronounced incurable, and
the unfortunate victims are condemned to a life of
perpetual worry because surgeons do not care,

6 FACE AND FOOT DEFORMITIES.

as a rule, to meddle with them. Some dermato-
logists, having made the skin their special study, have
treated this deformity by making numerous transverse
incisions in all directions across the face ; the incisions
being like the furrows left in a field by a plough
which has turned up all the weeds together with the
soil which clings to their roots. The result of such
treatment is undoubtedly beneficial to some extent, in
that it breaks up and destroys these tortuous purple
vein capillaries, but it also of necessity destroys the
surface skin which covers the vessels and imparts
beauty and character to the features. These capillary
vessels are situated in what is called the true skin, the
result of such destruction must be the formation gene-
rally of scar tissue which is parchmenty, and, as we
see often in the case of a burn, this is very unsightly.

The plan of treatment which I have adopted with
some success is to attack only the vascular trunks.
Instead of scarifying these together with the sur-
rounding skin, I transfix the vessels with the needle
cautery, and thus seal them up at the distal and
proximal ends, causing absolute arrest of the blood ,
current, and the formation of hundreds of microscopic
equidistant scars which are vertical to the surface.
These scars resemble the sebaceous puncta, or the
sweat-pores, in the natural skin. The scars being
vertical through the thickness of the skin, they are
practically invisible, and being designed so as to destroy
that which is subjacent to the surface with as little of
the cuticle or superficial layer of the skin as possible,
the result has been found very satisfactory. Each
puncture is surrounded by a ring of sound skin

FACE AND FOOT DEFORMITIES. 7

which has small capillaries ramifying through it to
keep up the nutrition. These numerous small islets
of sound skin contribute to preserve the normal varia-
tions of vascular supply which are dependent upon
the inhibitory action of the vaso-motor nerves, as dis-
played in the two extreme conditions of blushing from
nervousness, and pallor from fright.

Before commencing the operation I prepare the
skin by hardening it, and I then spread a coating of
collodion over the portion of growth which I propose
to destroy. A thin metal plate perforated with holes
about one-eighth or one-sixteenth of an inch apart is
firmly pressed over the portion of skin to be operated
on. With a series of rapid punctures all equidistant,
and all through the substance of the skin, I obtain the
desired effect. I prefer to do about a square inch at
one sitting, and then cover the whole with carbolic
oil dressing, to favour the separation of the minute
eschars. (Vide the chromo drawings giving the exact
appearance of the patient before and after the treat-
ment by thermo-puncture.) The result of these opera-
tions is given in the Appendix.

The skin of the face is so transparent and delicate,
and blemishes are so conspicuous, that any growths
such as moles, scars, warts, or naevous structures, how-
ever minute they may be, are sure to attract attention.

It is very desirable for parents to recognise the
importance of early removal of these blemishes, and
to understand that successful and total extirpation of
the growth may be accomplished without much
disfigurement, especially in favourable cases. The
amount of "splash" varies so much, as also the

8 FACE AND FOOT DEFORMITIES.

character of the abnormal growth, that it is impossible
to determine beforehand the actual benefit to be
derived. Often the tissue of the face is gathered up
in parts by numerous elevations distributed over the
growth, causing additional anxiety to the possessor
of this abnormality. Or there may be mingled with
it some naevoid growth, so that the outline of the
face is lumpy and very much covered with shot-like
masses which are highly vascular.

Aneurism by anastomosis may occur in the tissue
of the face. It appears as a prominent swelling
usually of one cheek, of a blueish colour, and filled
with tortuous vessels which ramify through it. Some-
times a vibratory thrill may be felt, or a pulsation
synchronous with the heart's action. When compressed
the vessels will empty, and then expand after the
pressure is taken away. They m.ay be met with at all
periods of life. Although it is probable that this
condition of dilated, tortuous and sacculated vessels
existed in an embryo condition from infancy, some
local cause may have aroused the activities of growth,
so that at a later period of life the dormant character
is changed into an actively developing tumour. We
may generally succeed in tracing tortuous vessels
leading to it both above and below the growth. This
form of tumour is very vascular, and it would be risky
to cut into it, as the bleeding is generally very free.
It may be ligatured at the base of the growth, or
the blood supply can be cut off by ligaturing the trunk
vessels of supply.

Mother s marks and njevoid growths are very
common. They grow with considerable rapidity.

FACE AND FOOT DEFORMITIES. 9

spreading from the centre outwards. There are two
or three distinct varieties of this form of growth.
Some are entirely subcutaneous, involving chiefly the
veins and venous sinuses in the cellular tissue covering
the muscles and other structures under the skin ;
others are mottled and not elevated above the level
of the surrounding skin. It is sometimes difficult in
these cases to determine the precise character of the
growth. Naevus growths are the result, as it may
be called, of a " freak of nature." The smaller veins
and capillaries ramify in the normal and healthy
skin like the ultimate twigs of a tree. Just as, in a
forest, the small branches of neighbouring trees inter-
mingle without amalgamating, so should it be with the
vascular trunks and their terminals. The vessels inter-
digitate as it is technically called ; but where a naevus
growth appears the ultimate radicals have become
fused, so that there is a permanent collision of blood-
currents, causing venous and vascular dilatation, dis-
tension and sacculation, with hypertrophy of vessels
in the surrounding connective tissue. Having had the
charge of one of the largest surgical cliniques in
London for children during a period of fifteen years,
I have had an unusually large number of such cases
under my care. During the past five years I have
operated upon over two hundred cases of naevus, many
of them being multiple, and some of them very large
and in very critical situations. (Vide chromo drawing
of child with a naevoid growth involving the whole of
the soft tissues of the nose. The precise method of
destroying this growth is given in the Appendix.)
Naevi, mother's marks, and erectile tumours are

lo FACE AND FOOT DEFORMITIES.

synonymous names for describing a variety of vascular
growths which occur frequently in children on the
face. The structure varies considerably, being in
simple cases flat and level with the surrounding skin, in
others protruding like a button or cherry from the sur-
rounding healthy skin, and very defined in its outline,
or it may be wholly or almost wholly subcutaneous.

These latter are called venous naevi, because they
involve the subcutaneous veins especially. They
become considerably distended when the child screams
or cries. The subcutaneous nsevus may be mistaken
for a fatty tumour, being elastic and compressible,
but as a rule they are characterised by a small spray
of purplish and dilated veins on the surface, indicating
the character of the growth beneath.

The subcutaneous variety is sometimes encapsuled
with a firm fibrous membrane. These growths are as
a rule stationary, though they will occasionally spread
with great rapidity. More often the naevus flattens out
with the growth of the integument, having a pearl-like
tissue in the centre, and an undulating nevoid struc-
ture all round. So that it would appear to grow
more by a natural process of development, than by
any intrinsic tendency to proliferation.

I have also found a doughy character about them
quite distinct from that of lipomatous tumours.
By firm compression we may succeed in driving out
the blood from the sacculi as we should empty a
sponge, and then we can feel the sinuses gradually
filling again when the pressure is taken off".

Where the naevus has been rubbed by the friction
of the clothes it may ulcerate, especially in delicate

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FACE AND FOOT DEFORMITIES. ii

feeble children, and thus a natural cure may^ be the
result. But this only happens occasionally.

Mr. Erichsen, in the ' Science and Art of Surgery,'
vol. ii. p. yG, says under the heading of naevi of the
cheek, that " mother's mark admits of no satisfactory
treatment in most cases ; the subject of it must submit
to continue through life to exhibit the characteristic
discolouration." It is partly for the purpose of show-
ing that, by the use of modern instruments of precision,
we may successfully remove such marks, and without
any serious or ugly scarring of the face, that I have
written this small monograph. Naevus of the lip may
require to be treated as a hare-lip, the growth being
excised by a V-shaped incision, and the edges ap-
proximated with the short harelip pins which I have
had made for my use. The method of removal by
setons, vaccination, and caustics, I do not approve of,
as they seldom destroy the growth effectually.

Sometimes pressure properly applied will obliterate
a ngevus ; as for example those on the vertex of the
head over the longitudinal sinus, or over the parietal
eminences. It will be necessary to secure a firm base
upon which to exert the pressure, and the subjacent
bone must be well ossified. A small coin, as for ex-
ample a halfpenny, may be placed firmly over the
swelling and secured by strapping. Then a capiline
bandage brought under the chin and twisted upon itself
over the tumour, so as to carry the ends round the fore-
head and again over the compress, may suffice if pro-
perly applied. Small nsevi may be destroyed by
nitric acid. I have sometimes removed prominent or
pendulous nsevi by excision, but I generally repent of

12 FACE AND FOOT DEFORMITIES.

using this method, on account of the bleeding and
the difficulty of obtaining union of the wound. It
generally gapes, and is a long time closing by granu-
lation, or the pus may burrow subcutaneously, setting
up cellulitis all around.

I need not describe the various methods of applying
the ligature for the purpose of strangulating the base
of the growth, as the different plans are well described,
with accompanying woodcuts, in the text-books of
surgery.

A very common variety of nsevus on the face is
called neevus araneus because it resembles a small
spider. There is a globular prominence in the centre,
with tortuous radiating vessels all round the central
growth, spreading like the legs of a spider. They are
commonly situated on the cheek, the nose, and the
eyelid. By destroying the central prominence with
the needle cautery, the tortuous vessels which derive
their blood from it will become reduced in time to
their natural dimensions.

I think it very important to remove unsightly vas-
cular growths as early as possible. I do not agree with
those who advocate delay to see whether the nsevus
will disperse. Though, as I have already described,
it may spread out and leave a parchmenty structure
surrounded by distended veins, I do not think this
is at all a satisfactory termination. The method of
removal by operation is so simple and so easily
effected with scarcely any resulting scar, that I think
parents are to blame if they allow their infants to
grow up without resorting to operative measures.
The galvanic puncture of subcutaneous naevi is, I

FA CE A ND FOOT DEFORMITIES. 1 3

think, a very unsatisfactory method of dealing with
these growths. We never know how far the sloughing
may extend subcutaneously and destroy that which
is not structurally at fault. The irritation caused by
electrolysis to the patent vein-sinuses has occa-
sionally set up phlebitis and extensive cellulitis. I rely
almost entirely upon the ligature passed underneath
a firm steel pin which has previously transfixed the
base of the growth. In this way all the large tortuous
vessels are strangulated, the spongy texture is forcibly
compressed, and the resulting scar is almost nil.

Growths about the size of a small pin-head may
be effectually destroyed by cutting a piece of porous
wood, as for example the end of a " match," to a very
fine point and dipping it in acid, either acetic or nitric,
and then cautiously planting the point in the centre
of the growth, so that it destroys the vessels which
are feeding it, and carbonises the surrounding inte-
gument to a slight extent, so as to obliterate the main
trunks. Care is of course necessary to limit the
destructive process to the adventitious growth con-
stituting the deformity. It is hardly worth while to
" rig up " the needle cautery for such small growths
when the nitric acid may be applied so expeditiously,
and with such decidedly good effect.

Warts are hypertrophic growths of the papillse of
the skin, caused often by some local irritation, as a
scar or a small surface wound, which failing to close
properly, the epithelial covering of the papilla takes
on excessive growth, resulting in hypertrophy and
elongation of this group of papillae. Some skins are
very susceptible to the formation of these warty

14 FACE AND FOOT DEFORMITIES.

growths, and they appear to spread in some cases by
inoculation. They may ulcerate at the base and
thus a spontaneous cure is effected. Warts may be
sessile, i.e. growing from a broad base, or conical and
pedunculated, having a small attachment to the skin.
Pedunculated warts sometimes form where a cuta-
neous vein has been pricked. As the wound does not
quite close, the encircling epithelium develops con-
centrically in excess. If irritated by rubbing, etc., or
if caustics are imperfectly applied, they will grow
more rapidly. The surgeon can destroy them with
great ease by tying a thread round the base, or by
first transfixing with a needle so as to get the thread
well below the root. Conical warts which rise above
the surface may be transfixed at the base, and a thread
tied firmly below, so as to cause mortification of the
growth. Unless the root is thoroughly destroyed it
will grow again. Hence it would be useless to
attempt to remove them without consulting a surgeon,
although it may seem a very simple thing to do.
( Vide lithograph to illustrate a very unusual develop-
ment of papillomata in the mouth, on the chin, and
on the front part of the neck.)

Small warts may be effectually destroyed by the
careful application of strong caustics. It is foolish to
delay the treatment because it may appear a trivial
matter, for these papillomata are very disfiguring, and
if neglected they may develop into some active form
of growth, as often happens where the wart has been
repeatedly irritated by washing the face, etc., or, as
with chimney-sweepers, they may become cancerous.

Bums of the face and severe injuries may cause, by

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FA CE AND FOOT DEFORMITIES. 1 5

their subsequent contraction, great disfigurement.
Such contractions may be cured by plastic surgery, por-
tions of integument being selected from available places
to cover in the deformity or gap. Methods of effecting
such transpositions of skin are described elsewhere.

Parents must not forget that boys at school may
get very much bullied and laughed at if they have
blemishes or marks on their body. These surface
growths can be so easily removed or destroyed without
any pain by placing the child under chloroform that
those who, for sentimental reasons, recoil from a simple
operation that would confer marked and permanent
benefit upon a child, are very much to blame.

I constantly come across adults with squint eye,
which might have been cured in infancy, but un-
fortunately the harrowing details which some ignorant
persons have falsely told about the operation, have
deterred the parents from submitting to the ordeal.

No doubt many cases of modified squint are reme-
diable by the use of properly adjusted glasses, and
these should be given to the child early, before the
muscles of the eye have become rigidly contracted.

Wens on the scalp or in the neighbourhood of the eye
are usually caused by the blocking up and subsequent
dilatation of the sebaceous glands which are part of the
normal structure of the skin. They project on the
surface, having a smooth oval or conical shape. The
contents are cheese-like, and they are inclosed in a
firm parchment-like bag, the counterpart of the dilated
and overgrown follicle. I have seen cases of great
disfigurement from such tumours being dotted over
the scalp and being allowed to increase to the size

1 6 FACE AND FOOT DEFORMITIES.

of a small orange. In some cases these tumours
lie in the deeper structures underlying the muscles of
expression and do not appear to have originated from
a blocked sebaceous follicle. These can also be
enucleated without any difficulty, and it is important
to do so, because as they continue to grow they press
upon important structures, and may cause absorption
of the subjacent bone. It is not necessary to give
chloroform in all cases. If preferred the tumour may
be frozen and the sac of matter drawn out of its en-
casement through a small incision of the skin. Some
highly nervous patients have come to me repeatedly
for the removal of these sacculated growths, and
have sat quite composedly while the incision was
made across the frozen tumour.

Pigmentary Cha7iges occur in the deeper layers of
the epidermis or scarf-skin. These changes may be
manifested either in excess or deficiency of pigment,
and they may occur in patches or spots, or in a large
area of the skin. Heat and light have the effect of
producing yellowish-brown spots, generally round,
sometimes irregular in shape, on exposed parts of the
body, especially the face, of children and adults with
fair complexions. These are called freckles.

Moles are congenital spots of varying size and
shape, and there is a decided excess of pigment in
them, sometimes presenting quite a black appearance.
They are occasionally very prominent, and may vary
from the size of a pin's head to two or three inches
in diameter. There are often several of them on the
body. I recommend the removal of those that are
unsightly, because this may be effected without any

FACE AND FOOT DEFORMITIES. 17

difficulty, and because they have occasionally turned
to cancer in after life.

Large moles are usually circular but sometimes
oval or irregular in shape, upon the surface of
the skin. They may be raised above the surface of
the surrounding skin, and be slightly nodular like
aggregated warts and covered with down or hair.
They are sometimes very large, even three or four
inches in diameter. Most people are troubled with one
or two on the surface of the body. If not on ex-
posed parts of the body and small, they may be
left alone, but when appearing on the face, neck
etc., they should be removed early because they are
so disfiguring. Moles are as a rule congenital, but
they may appear later in life. We may also have a
mole projected forward by the growth of a naevus at
the base. These are sometimes called pigmentary
naevi. Such growths sometimes degenerate into a
form of cancer, especially what is called the melanotic
variety. I recommend excision or ligature of pro-
minent moles according to size.

It is a great mistake for parents to conclude, as
they often do in these congenital cases, that it is right,
to accept this condition without attempting to re-
move it. Such fatalism, if it should enter into the
calculations of daily life, would be found a serious
barrier to general improvement, such as we are effect-
ing little by little in the houses and lives of our poorer
populations more particularly.

Sometimes the whole of the cutaneous surface
becomes involved in a deep bronze colouration. This
is seen in Addison's disease of the suprarenal cap-

c

1 8 FACE AND FOOT DEFORMITIES.

sules. I have succeeded in blanching portions of the
skin in these cases by freezing it with ether, which
causes the pigmented cuticle to exfoliate, leaving
flesh-coloured skin beneath. When such ugly blotches
are limited to one part of the face, and so cause annoy-
ance by their unsightliness, they may be easily re-
moved by rubbing with acids, which destroy the
epidermis without blistering or scarring the true skin.

Leucoderma is a condition of localised absence of
pigment, as seen in the case of the white elephant
that was shown in this country. The skin and the
hair growing on the skin are quite white, because the
rete Malpighii is destitute of pigment. Albinism is
a condition of universal absence of pigment through-
out the body.

Freckles are flat spots of pigment, generally small,
very numerous, and appearing mostly on the face,
forehead, etc. Fair children with transparent skins
are especially liable to them, if they visit the sea-side
or are much exposed to the direct rays of the sun
without proper sun-hats to shade the face. These
spots may in some cases be removed when they cause
disfigurement by carefully applied lotions of acetic
acid, ether, etc. ; but as a rule, it is best to leave them
alone.

Horny grozvths appear on different parts of the face
The structure is generally epithelial and due to an
aggregation of stratified epithelium, growing upon an
inflamed or irritated follicle which has in process of
time developed into an unsightly excrescence. These
may be effectually removed with safety and without
the fear of recurrence.

FACE AND FOOT DEFORMITIES. 19

Horns consist of an accumulation of condensed
epithelium, and are marked on the outside by lines
which show the mode of growth and development.
They usually grow from a matrix which is more or
less vascular. They are sometimes connected with
cancerous warts. The only treatment to be efficacious
is excision. If they are found to grow from the
interior of a cyst they require to be dissected out.

SECTION II.

FACE ERUPTIONS — ABSCESSES, ULCERATIONS,
PARASITIC DISEASES, SURFACE TUMOURS, ETC.

Face Eruptions come under the care both of the
physician and the surgeon, though they are often
claimed for treatment by specialists in dermatology.
It is very important to remember that the outward
manifestation of an eruption is but, in too many cases,
the index of a constitutional taint, which will need
very careful and scrutinising treatment before we
arrive at the primary cause of this outburst of disease
on the surface. Hence the necessity of caution and
latitude of observation before we commence to treat
the disease.

The skin of the face being so much exposed to
atmospheric influences, it is very frequently the seat
of chronic eruptions that are difficult to cure. The
blistering effects of exposure to the direct rays of
the sun, and the drying effects of exposure to blasts
of cold east wind, will be followed in many cases by

C 2

20 FACE AND FOOT DEFORMITIES.

scaly furfuraceous eruptions, especially about the
angles of the mouth, where the saliva keeps up the
irritation caused by any cracks or fissures. Children
often have patches of chronic eczema on the cheek
and round the mouth. Adults with very tender thin
skins often suffer from unsightly blotches mapped out
on different parts of the face. The application of
irritants, as toilet vinegar or rose-water, will only in-
crease the mischief. Even preparations containing
glycerine, so often vaunted before the public eye, will
increase the irritation. Besides careful attention to
the general health, it may be necessary to place some
emollient application to act as a protective to the
denuded skin. A lotion which has been used with
considerable success in these cases consists of 30
grains of calamine, 10 of oxide of zinc, and 10 minims
of glycerine to lime-water an ounce. The small quan-
tity of glycerine is enough to fix the protective with-
out causing any local irritation.

It may be well that I should define briefly the
more frequent and transitory eruptions of the face.

Erythema may be described as a persistent inflam-
matory blush on the surface of the skin, generally in
patches and slightly elevated. It is attended with
heat and tingling. It may terminate in deeper
seated dermatitis, or in resolution with a furfuraceous
desquamation. It is accompanied by slight fever and
is ushered in with some general malaise, shivering,
headache, pains in the limbs, etc. The characteristic
blush is recognised by its immediate disappearance
under pressure, and quick return when the pressure is
taken away. It may be produced by some irritant

FACE AND FOOT DEFORMITIES. 21

to the skin, or by exposure of the face to harsh dry-
winds, or to the direct rays of the sun.

A diffused patch of redness often occurs with the
dyspeptic, the bon vivant, or the habitual drunkard.
It may also occur in a chronic form in delicate
constitutions, from what is called " poverty of blood,"
languid circulation, and a tendency to local con-
gestion of the surface capillaries. Females at the
period of the menstrual climacteric, or when suffering
from irregular menstruation, may have large distri-
buted patches over the face. What is often called
scurvy of the face, in which large, well-defined patches
of livid redness occur, often with some excoriation
or peeling, is of an erythematous character. It is
sometimes mistaken for simple cutaneous erysipelas.
When associated with some irregularity of bowels the
eruption may disappear very suddenly. There maybe
slight desquamation of skin when the eruption subsides.

E. simplex may be associated with derangements
of the digestive organs. Erythema is very liable to
attack symmetrical parts of the body. The face may
become considerably puffed up by the inflammation
spreading into the subcutaneous cellular tissue. In
these cases the disease must be designated as ery-
sipelas if associated with febrile symptoms.

E. marginatimi is a patchy eruption, more elevated
at the edges than in the centre, E. papulatum con-
sists of numerous small rounded elevations about the
size of a pea and of a deep red hue, with a radiating
blush all round each papule. This form of eruption
tends to become chronic or intermittent. There may
be, in addition to the symptoms enumerated above,

22 FACE AND FOOT DEFORMITIES.

some nausea, vomiting, pains in the back and head,
loss of appetite and general malaise. It may appear
as an epidemic in hospitals and buildings where many
people are housed together, and where the sanitary
arrangements are defective.

E. nodosum may occur on the face and arms as a
sequel to vaccination. Brawny circumscribed patches
of redness about the size of a florin surround a central
vesicle or ulcer, having an irregular or punched-out
appearance.

The treatment of this disease is very simple. The
inflamed patches should be protected from exposure.
Warm lotions of lead and opium may be applied to
relieve the heat and tingling, or warm water dressing.
In the chronic forms a stimulating lotion may be
required, as sulphate of copper in elder-flower water,
or sulphate of zinc in rose-water. The primae viae
must be attended to, especially in spare and delicate
subjects ; warm baths, gentle aperients, and light and
nutritious diet. Anaemic patients with menstrual
irregularities may require saline aperients with aloes
and iron, followed by tincture of calumba, extract of
cinchona, nourishing food, and some light wine.

Erysipelas of the face is a disease which usually
commences with marked febrile symptoms, shivering,
pains in the back and limbs, loss of appetite, quick
pulse, dry hot skin, and much thirst. There may be
swelling of tonsils and some cynanche. The skin
swells and the redness becomes very diffused, spreading
rapidly with no well-defined margin. There is a
burning or tingling heat of the skin, and consider-
able tumefaction of the eyelids, so that they often

FACE AND FOOT DEFORMITIES. 23

become quite closed up. Vesications appear on the
surface and exude an acrid, clear, transparent serum,
which may blister the adjacent sound skin wherever
it spreads.

The patient has decided constitutional disturbance,
with nausea and vomiting, headache, high fever, and
occasional delirium, with recurrence of chills and
rigors. The pulse is quick and the temperature very
high. The disease terminates in desquamation of the
cuticle on the tenth or twelfth day. Suppuration
may occur in the cellular tissue under the skin, with
sloughing or mortification. Well-planned incisions
may be necessary to evacuate the pus.

Traumatic erysipelas originates in some local injury
which may or may not have caused a wound of the
surface. Brewers' draymen, cabmen, and those who
indulge to excess in alcoholic drinks, and are much
exposed to the inclemency of the weather, are very
liable to erysipelas following upon some slight abrasion
of the skin, especially of the head. Death may result
from inflammation attacking some internal organ, as
the brain. There may be some asthenic fever of a
typhoid character, quickly prostrating the patient, or
there may be phlebitis, with purulent deposits in lungs,
liver, etc.

The disease must be promptly treated with bark
and ammonia or tonics and antiphlogistic measures if
the fever is very pronounced. Calomel and Dover's
powder may be required to allay the fever and pro-
cure sleep. The tincture of iron and chlorate of
potash are relied upon generally as useful in these
cases, preceded or not by a saline draught as haustus

24 FACE AND FOOT DEFORMITIES.

sennse co., or the pulv. jalapas co. Nourishing food,
such as beef tea, egg and milk, etc., must be given,
and wine if necessary. Large Hnseed-meal poultices
sprinkled with carbolic lotion must be applied to the
surface where the erysipelas is inclined to spread.

Urticaria, or nettlerash, is a localised ephemeral
congestion of the skin. It appears on the cheek often
of highly sensitive females and those of a rheumatic
tendency, especially after some error of diet or ex-
posure to east wind, etc., causing gastric disturbance.
The characteristic wheals vary considerably in size and
elevation above the surface. They usually give rise to
much stinging and tingling sensations, increasing at
night or when seated before the fire. We know how the
eating of shell-fish, and sudden changes of temperature,
may be followed by the appearance of this eruption.
In the acute variety the eruption quickly fades, but
in chronic urticaria it will be necessary to regulate
the diet and prescribe change of air and other methods
for improving the general health.

Occasionally I have had under my care cases of
nettlerash caused by the habit of unlimited use of
prescriptions that were only intended to serve the
particular emergency for which they were given.
Now that economical principles, and co-operative
stores are considered interchangeable terms, such
mistakes are more often made, and patients have to
suffer in consequence. The transitory eruption may
become very chronic. The slightest excitement in
persons of an irritable delicate skin may bring out a
copious eruption. Some alterative medicine, the
mineral acids or bark, and ammonia with hydro-

FACE AND FOOT DEFORMITIES. 25

cyanic acid, and careful dieting, will usually suffice
for the cure of this eruption. If the disease should
recur frequently, a combination of quinine and arsenic
may be required for the cure.

Eczema is the most common skin disorder. It is
a derriiatitis or inflammation of the skin, and appears
as a diffused eruption, more or less covering the face.
There may be a discharge of clear fluid from the sur-
face of the vesicles, which concretes and forms a scab
or crust, having a deeply inflamed substratum of skin.
There are many varieties of eczema. It may be
associated with impetigo, in which case the eruption
is more defined, and the vesicles more circumscribed,
and the contents purulent. These pustules may co-
alesce, and the scales which form a crust on the surface
like a shield, may cause considerable irritation. The
cuticle is sometimes raised into papules or vesicles.

Eczema faciei consists of an eruption of minute
transparent vesicles closely aggregated together, very
prominent, having an inflamed areola. The contents
of the vesicles sometimes become purulent. It is
generally attended with burning pain, itching, some
swelling, and considerable irritation. The vesicles
burst, coalesce, and a scab forms, with a yellow crust,
which, when removed, exposes an ulcerated surface
below. The vesicles often appear in crops. The
epidermis desquamates as the disease subsides. There
may be some slight feverishness, with pain and itching
of the eruption. The exudation from the inflamed
base is thin and watery. The eruption, if neglected,
may assume a chronic and indolent character, lasting
in some cases for months, or even years. Infants during

26 FACE AND FOOT DEFORMITIES.

the teething period are very liable to this disease,
especially on the forehead and head, associated with
impetigo. The chronic form is usually characterised by
the formation of fissures in the skin, which pour out a
clear ichorous fluid that quickly dries and forms scabs.

Sedentary occupations in close, ill-ventilated rooms
are a frequent cause of this disease. Shop-girls, who
are badly fed and badly housed, and are otherwise
much neglected as regards the sanitary arrangements
of workrooms and dormitories, frequently suffer from
this disease, as also from acne, etc. Infants with
delicate skins may develop this disease in consequence
of hand-feeding, over-feeding, and bad management.

It may be necessary to give grey powder and jalap
as an aperient, and the local application of lead oint-
ment, or of caps of lint and oiled silk fitted to the head
and moistened with lead and glycerine lotion. The
lint must not be made too wet, as this may favour the
spread of the eruption. The itching can be relieved
by the application of elder-flower water, cherry-laurel
water, etc. In chronic eczema the benzoated zinc oint-
ment, well rubbed into the raw surface after removing
the crusts, will prove very useful. In some cases vaseline,
and in other cases the ordinary petroleum ointment
will be required. Weak carbonate of soda lotion (ten
grains to the pint) to bathe the parts with when red
and inflamed, is often used with advantage. Internal
remedies must not be neglected, generally aperients
to commence with, and there must also be a careful
regulation of diet. The syrup of the iodide of iron
with iodide of potassium in cases of strumous origin
or of suspected syphilitic taint. Cod-liver oil and the

FACE AND FOOT DEFORMITIES. 27

hypophosphite of iron in chronic strumous cases.
Arsenic may be cautiously administered when the
disease is of an indolent character. Adults may
require a course of aperient medicine, the use of
mineral waters, or a few weeks at one of the Con-
tinental spas, such as Aix-les-Bains, Heilbrunn, or
other health resorts established for this purpose.

Impetigo is an eruption of the skin closely allied
to eczema. It is a pustular disease followed by the
formation of thick crusts from the exudation of the
purulent contents. The pustules may be flat and
aggregated together in groups, or they may be acu-
minated and more or less scattered. The pustules
generally have an inflamed base, and the neighbour-
ing lymphatic glands are frequently enlarged and
may suppurate, especially with strumous children.
The eruption frequently seen under the chin of young
children, and followed by an elevated transparent
crust with oozing of fluid beneath, is called " achores."
There is not much constitutional disturbance with this
disease, and the eruption seldom leaves any scar on
the face unless the child has picked at it much.
There are many varieties of impetigo, and it would
seem that some varieties are contagious.

For the treatment of this disease the crusts must
be carefully removed with bathing and poulticing.
The sore places underneath should be constantly
dressed with zinc or lead lotion, or painted with
nitrate of silver, and the zinc ointment applied during
the later stages. Salines, stomachics, and quinine and
iron may be required to improve the general health.

Lichen is an eruption of small, hard, red pimples

28 FACE AND FOOT DEFORMITIES.

which do not disappear on pressure. They are uniform
in size, are slightly raised above the surface, and
have a distinct outline. It is a non-contagious dis-
ease, and it may terminate in desquamation.

The papules of lichen may itch or tingle, and the
irritation of the patient in consequence may increase
the local inflammation. There is usually some
derangement of the alimentary canal requiring proper
treatment and management, including sulphur baths
and cooling lotions.

L. strophulus, or red-gum, appears in infants about
the period of the first dentition. The child requires
some regulation of diet, and a little rhubarb and soda
or fluid magnesia. When the disease resists the ordi-
nary treatment it may be necessary to give arsenic in
small doses, and to lance the gums if required.

Herpes comes out in crops about the angles of the
mouth and forehead, in children and adults suffering
from febrile disorder, pneumonia, etc. The clusters of
vesicles are aggregated together in pearl-like masses
usually about the size of a shilling. Each vesicle is
raised above the surface, uniformly convex in shape
and larger than in eczema. The eruption may have
a distinct " mapping-out " character, as it follows the
course of the facial nerve. There may be considerable
pain when the eruption is developed in the course of
a nerve-trunk, as in shingles. Herpetic eruptions
may fade quickly, or the vesicles may coalesce and
leave a scab on the surface. Herpes should be treated
with some cooling ointment, as vaseline or the oxide
of zinc, and attention given to the general health.

Miliaria is an eruption of very minute, millet-seed-

FACE AND FOOT DEFORMITIES. 29

like, closely packed vesicles, the contents at first trans-
parent and then consolidated. It appears on the face
in children with delicate skins, especially in summer.
The margins of the vesicles, though often surrounded
with a faint blush, are not inflamed, and there are
no constitutional symptoms. The contents of the
vesicles are sometimes purulent. Tepid bathing and
tonics will be required to cure the disease.

Ecthyma is a distributed sparse eruption of a few
large well-defined pustules, each having a callous in-
flamed base like a furuncle, with a deep zone of
inflammation. In each case the scabs should be
removed by bathing and poulticing, and the ulcer-
ating surface below healed by the application of zinc
or lead ointment, or lotion, or the ung. hydr. nitratis.
The nitrate of silver lotion is very useful when the
ulcerating surface is indolent. The patient should
have general tonic treatment and careful dieting. The
eruption may be acute or chronic. The acute form
may be associated with febrile symptoms and loss of
appetite. Large ecthymatous pustules often occur
with scabies in young children.

Pemphigus is an eruption which occurs on all parts
of the body, including the face. It is ushered in
usually by some febrile symptoms such as lassitude,
sickness, etc. It is a somewhat unusual form of erup-
tion, occurring in delicate and ill-nourished infants
and young children, the result often of gastric irritation
from improper feeding, etc. It generally remains
dormant for a few weeks and may become chronic.
The raised blister-like character of the eruption is
very typical, surrounded by a deep zone of irritation.

30 FACE AND FOOT DEFORMITIES.

The vesicles or blisters should be slit up, and the
ulcerating surface of skin beneath treated with some
stimulating lotion, and if the child is in a weak
cachectic state he will require careful dieting, and
quinine, or the ammonia and bark mixture.

Rupia is also a disease of the skin with large bullae
filled with serum or pus. Rupia prominens is a more
chronic variety with superimposed scabs resembling
a limpet shell. The subjacent derma is ulcerated.
It requires the same treatment as pemphigus.

Pityriasis is a superficial irritation of the skin, fol-
lowed by bran-like desquamation. There is often undue
redness of the skin, but less inflammation than with
psoriasis. The diluted nitrate of mercury or the pre-
cipitate ointment may be used in these cases, as also
the borax and camphor lotion. Pityriasis versicolor
is described under the head of Chloasma.

Psoriasis is a somewhat rare disease when it attacks
the skin of the face only. It usually occurs in well-
defined patches over the body. It presents a very
characteristic appearance, consisting of scale-like
masses of epithelium, slightly elevated, and resting
upon a more or less inflamed base. It is so far dis-
tinct from any of the moist eruptions on the face. It
requires local and general treatment. Dilute chryso-
phanic acid or pitch ointment may be advantageously
applied to the surface, and arsenic may be given
internally, together with the perchloride of iron.
Careful washing will be necessary to soften the crusts,
and the inflamed base may be washed with carbolic
soap or the juniper tar soap. Psoriasis is not con-
tagious but it is often hereditary, especially in those of

FACE AND FOOT DEFORMITIES. 31

a gouty or syphilitic tendency. We must therefore
never neglect the due attention to any gastric dis-
turbance that may be present. Where we have a
syphilitic history it will be desirable to give iodide of
potassium or perchloride of mercury internally.

Facial carbuncle is a painful and persistent disease
of the aggregated follicles of the face. Commencing
usually as a small pustule near or on one of the lips,
and surrounded with firm oedematous infiltration, it
spreads rapidly into the surrounding cellular tissue.
The inflammation does not generally pass on to sup-
puration. The surface of the sore has an excavated
appearance dotted over with small sloughs of cellular
tissue. The edges are usually of a red colour with an
even contour. The general health of the patient
quickly participates, and there is often great depres-
sion of the nervous system. There is some feverish-
ness, the pulse is small and frequent, skin hot and
dry, tongue coated, appetite failing, and general
malaise. The blood becomes infected, and the disease
may terminate rapidly in pneumonia or pyaemia, in
consequence of phlebitis of the neighbouring vein-
trunks and the absorption of purulent matter.

Carbuncles are very disfiguring, besides being very
intractable. Generally the health of the patient pre-
viously has been much undermined by some consti-
tutional disorder. They appear as an aggregation of
numerous furuncles or boils, with a deeply inflamed
base and sloughing surface. They may require crucial
incisions through the sloughing cellular tissue, and
stimulating lotions or poultices to favour separation
of the inflammatory products. The patient must

32 FACE AND FOOT DEFORMITIES.

be treated with liberal diet, some light wine, and a
mixture of bark and ammonia or quinine.

Anthrax or Malignant Pustule. — Several cases of
this disease have been recorded by the surgeons at
Guy's Hospital, as occurring among the workmen
employed at the wharves and warehouses of Ber-
mondsey. Bovine anthrax has been recognised for
many years as a prevalent malady among cattle,
especially those of foreign importation ; but it seems
only of late years to have been traced as directly
communicable to man. The skin-dressers, who have
to handle and prepare the hides which are imported
in large quantities from abroad, have been the prin-
cipal sufferers. The face being the exposed part of
the body, is occasionally rubbed or scratched by the
hand, and so a process of auto-inoculation takes place.
Within a few hours a red swelling appears, and this
is quickly followed by severe constitutional symptoms,
great depression of spirits, rigors, sleeplessness, de-
lirium, vomiting, and high fever. The growth has a
very similar appearance to that of the benign
carbuncle. There is a spreading flat surface of red
inflammatory swelling, slightly depressed in the
centre, and covered with a dark scab or a smooth
pellucid membrane. The skin surrounding the
growth is puffy and oedematous, and the submaxil-
lary glands are large. The margin of the eschar is
usually covered with some distinct vesicles. Numer-
ous bacilli characteristic of this disease were found in
the blood and sputum. Cases that have been treated
promptly by excision have recovered ; others have
died from the disease spreading to the mucous mem-

FACE AND FOOT DEFORMITIES. 33

brane of the intestine and the pulmonary tissue. All
the nodules were found to contain large numbers of
the Bacillus anthracis. There were also serous effu-
sions into the pleural and pericardial cavities. To
successfully combat this disease, the patient must be
treated with diffusible stimulants, as bark and am-
monia or quinine, and plenty of nutritious food, if the
appetite does not fail.

Keloid may appear in a scar of the face after the
removal of any tumour or growth, or after a burn. It
has been known to follow a scraping for lupus. In
this disease the remnants of the scar- tissue become
invaded by a growth which spreads and infiltrates
with claw-like prolongations in the imperfectly de-
veloped fibrous tissue. Scars may remain for years
in a quiescent state, and then from some unexplained
cause they may develop keloid. The growth presents
a raised elastic surface, traversed with distended veins,
giving it a marbled appearance. There may be some
pain as the growth expands. The only remedy for
this condition is excision, or destruction by the actual
cautery, but the disease is very liable to return.

Xanthelasma or vitiligoidea are names for a very
rare disease occurring occasionally on the face, and
especially the eyelids, in the form of tuberous nodules.
An eruption appears on the skin at first of a lichenous
character, sometimes covering the body. These small
spots become raised into papules, forming solid masses
of sessile or pedunculated growths. The tubercles
enlarge, and the apices are often of a pale-yellow
colour, hence the name Xanthelasma. Associated
with this disease, the patient generally suffers from

D

3+ FACE AND FOOT DEFORMITIES.

symptoms of congestion of liver or of diabetes. It is
a very unusual and apparently incurable disease, unless
we proceed to remove the tumours by excision or
cauterisation, and they are, as a rule, too numerous
for such a radical method of treatment.

Abscesses frequently cause great disfigurement of the
face. They may depend upon some deeper-seated mis-
chief, as, for example, the blocking up of the canaliculi
and ductus ad nasum of the lachrymal apparatus, which
is designed for the conduit of the tears in a stream
across the surface of the eye, to the nose. Or they may
be connected with chronic caseation of cervical glands.
Probably the most frequent cause of face abscesses is
caries of the teeth and cellulitis of soft structures sur-
rounding an alveolar abscess. The patient has been
unwilling to have the decayed teeth extracted, and so
the suppuration which occurred in the tooth-socket
has invaded the cheek. Let us warn such that a per-
manent deformity of the face will inevitably occur from
the puckering of the scar which follows the evacuation
of the abscess, and from the adhesions of the skin to
the subjacent bone.

No doubt in these, as in other cases of depressed
cicatrices, it is possible, by a subcutaneous operation,
partly to remove the deformity by dividing the fibrous
bands which result from the healing of the abscess.

When the surgeon has the opportunity of treating
these abscesses in the first instance, he should endea-
vour to evacuate them through the buccal mucous
membrane. In doing so he must make provision for
the removal of the pus so that the patient does not
swallow it, as so frequently happens when he or she

FACE AND FOOT DEFORMITIES. 35

fails to come under prompt medical and surgical
treatment.

Fistulous tracks leading down to decayed bone
may exist for many years as the residuum of facial
abscesses.

Strumous abscesses may occur on the face and
cause considerable anxiety to young people. They
are very chronic and indolent in their develop-
ment and formation. They at first appear as indurated
swellings, with an inflamed base. The skin on the
surface thins, and a sinus forms, which discharges
unhealthy pus of a curdy or caseous character, and the
skin becomes undermined with indolent pale granula-
tions. The modern method of wearing a " Princess "
ruffle may successfully screen the ugly scars and
gatherings of strumous ulcerations and chronic sinuses
round the neck, but it is not so easy to cover up the
face. It is therefore important to treat these cases
promptly, and endeavour to promote a speedy resolu-
tion of the local disease. Scraping away the callous
granulations and the application of caustics may
stimulate the subjacent tissues to healthy action.

Furuncles may appear singly or in crops. They
have a conical shape, hard to the touch, and are some-
times very painful. They have an inflamed base. A
core or slough of cellular tissue forms in the centre, and
a sac of pus develops around it. As the boil comes to
a head the pus finds an exit at the prominent part.

Boils may be protected from the chafing of the
collar by a piece of thick lead plaster spread on wash-
leather, and cut in the centre like a corn-plaster.

Hordeohiui or sty is a small boil on the edge of the

D 2

36 FACE AND FOOT DEFORMITIES.

eyelid in connection with limited obstruction of the
follicles of the Meibomian glands. These boils may
recur, and they may be tedious in their formation. They
should be bathed well with warm water and poulticed.

Ulcers of different kinds occur on the face. We
may have simple ulcers of an indolent character in
people who are subject to ecthymatous ulcerations
on the body. Or we may have syphilitic ulcers,
especially that well-known form of extensive chronic
ulceration associated with caries of the frontal bone,
due either to syphilis or phosphorus poisoning. True
infecting syphilitic sores may appear on the lips, and
these require to be destroyed by caustic, and with
antisyphilitic treatment internally, so as to avoid
secondary symptoms, if possible. Mercurial fumiga-
tion and inunction are the best means of dealing with
syphilitic sores. The remedy in this way quickly
permeates the system and neutralises the poison, or
mitigates the constitutional effects of the disease.

In all these cases it is desirable to remember how
quickly the whole constitution becomes invaded and
the blood poisoned. Consequently, how desirable to
attend to the general health, to brace up the system
by change of air, a sea voyage, if possible, and careful
dieting, and to give iodide of potassium internally.
Syphilitic cases often go from bad to worse in con-
sequence of the injudicious administration of anti-
syphilitic remedies without proper attention to the
primae viae.

Acne is one of those troublesome complaints inci-
dental to young people at the period of adolescence,
just at the time when they should be "coming out."

FACE AND FOOT DEFORMITIES. 37

This disfiguring eruption often appears on the face.
A number of black points are observed dotted over
the surface, which, if squeezed, will exude a worm-like
coil of cheesy matter. Though popularly thought to
be a worm, on account of its round contour and
apparent wriggling motion, as it escapes from the fol-
licle, it is really only a concretion of sebaceous matter
in the skin, where it has gradually accumulated. The
black head is nothing more than a collection of dirt
which has been gradually rubbed into the follicle and
has acted as a cork to prevent the exit of this secre-
tion. However carefully the face may have been
cleansed daily, these black spots will collect in the
follicles of some skins. It is difficult to persuade
patients that they have been deceived by the wormlike
appearance. Occasionally the acarus folliculorum
may be found at the bottom of the follicle Vv'hen
searched for by the microscope. If neglected the fol-
licles will inflame, an effort being made, as it were, to
evacuate the cheesy matter which is blocking them up.
In such cases the skin will be dotted with numerous
pustules, more or less transparent and raised above the
surface. These pustules do not coalesce, but appear
as small red acuminated elevations, with a yellowish
point at the apex. Many of the pustules do not
maturate, but remain as an indolent eruption, the
contents becoming consolidated, and having a hard
base. Some dermatologists limit the definition of
acne to this inflammatory condition, and place the
disease above described, of blocked follicles, under the
heading of hypertrophy of sebaceous follicles. But as
I generally find the inflammatory condition associated

38 FACE AND FOOT DEFORMITIES.

with blocked follicles, I prefer to class the diseases
together and consider the latter as a further develop-
ment of the more chronic disease of the skin.

Stearrhoea is by some authorities described as a
distinct disease, characterised by the oozing out of
a greasy, sometimes offensive, secretion from the
follicles of plethoric people, and from skins that may
be described as " unctuous."

The surface of the skin in acne will be more or less
raised and lumpy by the accumulation of the seba-
ceous matter in the follicles. The irritation caused by
the blocking of these follicles may tend to the forma-
tion of furuncles or boils, which are very unsightly.

Acne inditrata is a chronic variety of the above
disease. In these cases the elevated tubercles on
the surface, caused by the long obstruction of the
tubes, become very prominent, rising like numer-
ous mole-hills on the surface, each about the size of
a small pea. This disease occurs at a later period of
life, when the skin of the face itself has become more
indurated, and the venous capillaries slightly dis-
tended or varicose. The causes of acne may be gene-
rally found to be associated with sedentary habits, a
deranged condition of the digestive organs, or with
excessive indulgence in the use of indigestible food,
or the too free use of alcoholic liquors. Some of the
worst cases of this disease are found associated with
masturbation and in connection with uterine irregu-
larities. Or the disease may be hereditary.

It must not be supposed that any one of these is
the primary cause of the disease. It is necessary to
bear this in mind while directing the main part of the

FACE AND FOOT DEFORMITIES. 39

attack to the primae viae, with a view to regulate the
digestive system, and to see that the important func-
tions of secretion and assimilation are in working
order, to prescribe plenty of outdoor exercise, and to
remember, above all, that young people who are
rapidly expanding into manhood and womanhood re-
quire very careful watching and superintendence to
avoid excesses of all kinds.

The eruption crops out on the surface as a number
of closely aggregated spots or pimples, mostly limited
to the face and upper part of the body. The promi-
nent surface of the spots may be distended with a
little serum or pus, and the subjacent follicle may
inflame, leaving a hardened base. The apertures of
the distended sebaceous follicles are blocked up with
black points or specks.

In restricting the diet, be careful to provide ample
food of a nutritious and easily digested kind, avoiding
such things as raw fruits (except in July*), salads,
shell-fish, savoury dishes, beer, &c.

A very inveterate case of acne indurata occurred in
a young girl, aged nineteen, with extensive scrofulous
disease of the submaxillary glands on both sides of the
neck. The acne was cured in a few weeks by the use of
the ung. sulph. hypochlor. co. and the administration
of arsenic internally, but the large chronic abscesses
in the neck were opened, and a quantity of cheesy mate-
rial was evacuated. The resulting ulceration was very
difficult to cure in consequence of the chain of glands

* This may be thought rather a strange exception, but I desire to
draw a marked distinction between fresh -gathered soft fruits and those
which ripen later in the year.

40 FACE AND FOOT DEFORMITIES.

which pass deeply into the neck being consolidated by
the same tubercular infiltration and caseation. As the
patient's health improved, however, the caverns in the
neck closed up, under the daily application of stimu-
lating lotions of sulphate of zinc or nitrate of silver.

Acne 7'osacea is a somewhat frequent complaint of
adult life. It is a slowly developing disease of the
cellular tissue and follicles of the skin. At first there
is noticed a swelling and distension of the superficial
capillaries, followed by congestion of the surrounding
tissue and blockage of the sebaceous follicles, with
consequent engorgement and swelling. It is doubtful
whether the follicles are the primary cause of the dis-
order. The superficial skin becomes distended, shiny,
and generally coated with moist effusion from the
follicles. The patient may complain of some itching
or irritability, with a sense of heat, especially towards
evening, and there may be some dyspeptic symptoms
which increase the capillary engorgement. The tip of
the nose becomes unusually purplish on exposure to
cold. The same tendency to engorgement may be
noticed in the capillaries of the cheek, presenting a
marbled appearance. In the female it is generally
associated with menstrual irregularities. So that we
may be tolerably certain that in all these cases there
is superadded to the local complaint a general
engorgement of the venous capillaries, and along
with this probably some dilated and flabby con-
dition of the right side of the heart. It will there-
fore be necessary, in the treatment of these cases, to
attend to the primae viae, to see that the liver, the largest
organ of the body and the centre of the portal system,

FACE AND FOOT DEFORMITIES. 41

is not engorged. There must be regulation of diet,
abstinence from alcoholic drinks as far as possible,
except of the lighter kind, as claret and Burgundy.
The patient should take plenty of active exercise in
the open air to circulate the arterial blood and to
increase the vitality of the tissues. He should see that
the waste products are rapidly carried off, not forget-
ting to regulate the bowels, and thus to remove
another frequent cause of congestion of the portal
system. If the patient has the means and ability
to undertake the journey, he should be strongly urged
to visit some of the foreign watering places, such
as Carlsbad and Vichy, or he may go to Cheltenham,
Leamington, &c. The mountain air, change of diet,
and a salubrious climate will greatly assist the mild
aperient waters in effecting a radical change in the
constitution of the patient.

One variety of this disease is observed frequently
among cabmen and omnibus drivers who are addicted
to intemperate habits. The sebaceous follicles are
enlarged and inflamed. The surrounding cellular
tissue becomes infiltrated with spongy material. As
the disease progresses it assumes a nodulated or
tuberculated appearance, and the blocked follicles may
inflame, forming minute pustules with " mattery
heads." The cutaneous veins get more distended,
slightly varicose, and the heat and activity of growth
increase the deformity and discomfort to the patient.
The treatment of this disease is both local and consti-
tutional. The digestive system must be attended to,
alteratives and stomachics may be required. We must
not be misled by the somewhat bloated appearance

42 FACE AND FOOT DEFORMITIES.

of the face to assume that the patient is in robust
health. The character of the pulse and the condition
of the body generally will show that he is in rather
a feeble state of health. He must be encouraged to
observe moderation in the use of alcoholic drinks, and
in some cases total abstinence will be required. The
local treatment must not be neglected. If persevered
in, it will usually effect considerable relief, and if taken
in time it may suffice for a cure. The patient should
bathe the nose frequently with warm water or the
carbonate of soda lotion. A little mercurial ointment
may be rubbed into the follicles to favour the softening
and absorption of the concreted blocks which are dis-
tending the tubes. When the congestion is allayed,
the hypochloride of sulphur ointment may be rubbed
in. Brecknell and Turner's skin soap is recom-
mended for the face. When the disease has pro-
gressed for some months it may be necessary to
resort to removal of the diseased integuments, retain-
ing that part of the nose which is not involved in the
disease. Some very successful results have been
obtained, and the ingenuity of the surgeon is often
displayed in providing sufficiently healthy skin from
the neighbouring integument to take the place of that
which was diseased.

The iodide of sulphur ointment, ten grains to the
ounce, is very useful in chronic acne, as also the
liquor hydrarg. perchlor. lotion.

Molluscum is a disease of a more chronic character,
with enlargement of the sebaceous follicles and re-
tained secretion. The eruption appears generally on
the face and very rarely on the body, as indolent

FACE AND FOOT DEFORMITIES. 43

tumours, which are sessile or pedunculated, and con-
taining a cheesy kind of matter. Each tumour appears
semi-transparent, from the skin being distended over
it. It is a contagious disease, and it may crop out
on the surface in distinct groups or colonies. It
is characterised by the appearance on the skin of
round soft tumours, slightly umbilicated, varying in
size, though averaging that of a small currant. There
is no pain or local irritation, but simple hypertrophy
of the sebaceous follicles. These tumours are dis-
tinguished from warts by their softness and uniform
character, their colour, and the central depression at
the apex ; and from fatty tumours by their elasticity
and slow growth. As to treatment, the more solid
growths require to be carefully dissected off or excised,
and the base destroyed with caustic.

Lupus may be described as a strumous degeneration
of the skin, followed by rapid ulceration, which may
and often does destroy the subjacent bone, causing
very great disfigurement. There are four varieties of
lupus, viz. L. exedens, L. non-exedens,L. devorans, and
L. erythematosus. They may all occur in children and
young people with delicate or strumous constitutions.
The breath is offensive, and the tongue is coated with
a cream-coloured fur. There are symptoms of flatu-
lence and gastric disturbance, and generally a feeble
action of the organs of nutrition and assimilation.
There is usually some anaemia and a flabby condition
of the skin and muscles. It is eminently a disease
of youth, being rare before the age of ten and during
adult life. It is associated with the strumous dia-
thesis, and is more frequent with girls than boys.

44 FACE AND FOOT DEFORMITIES.

In L. exsdens the ulcerative process attacks the
deeper-seated tissues, and appears generally on the
face, first as one or two small brownish specks, which
may become confluent as the disease spreads. The sur-
rounding skin inflames and the epidermis swells, be-
comes raised above the surface, and a crust forms with
spreading ulceration of the skin beneath. It is often
difficult to distinguish this disease from syphilitic
ulceration. This variety is sometimes called L. ser-
piginosus, on account of the ulceration extending
unnoticed under the thick crust of epidermis. Fresh
crops of papules and tubercles appear in the neigh-
bourhood of the nose, and the disease will spread sub-
cutaneously. The ulceration may extend very deep
into the tissue of the skin, destroying areolar tissue,
muscles, cartilage, periosteum, and ending in destruc-
tion of bone. The eyelids may be dragged down
and the features much distorted.

Lupus exedens often occurs on the alse of the
nose of children and young people of a strumous
temperament, and is very destructive and rapid in its
spread. It is a simple local growth, and if attacked
boldly may be quickly destroyed with powerful
caustics or cauterisation ; the surgeon being careful
to remove all remnants of the disease.

In some cases the disease will creep on, and heal in
the part first attacked, leaving a serpiginous ulceration
and a scar resembling that from a burn, the rugae of
which radiate towards the spreading sore. The con-
traction of the cicatrix may cause considerable defor-
mity by dragging down the nose to one side, or by
obliterating the alse of the nose.

FACE AND FOOT DEFORMITIES. 45

L. devorans or Noli-nie-tangere commences with
destructive ulceration of the various structures beneath
the skin. Muscles, tendons, cellular tissue, cartilage,
&c., being quickly involved in the spreading ulcera-
tion. It often begins at the tip of the nose, and
spreads into the septum nasi, or roof of the mouth.
This variety does not spread so rapidly as L. serpi-
ginosus.

Lupus may be distinguished from ordinary stru-
mous ulceration by the absence of a tendency to
spread from the centre outwards, also by the absence
of tubercles or papules around the sore. The
lymphatic glands may be involved in scrofulous ulcera-
tion, but this rarely occurs in lupus.

In the Section of Dermatology at the International
Medical Congress of 1884, Professor Dutrelepont
opened a discussion on the aetiology of lupus. He
stated his belief that lupus is really a tuberculosis of
the skin. Not only are the histological characters of
the lupus nodules and the miliary tubercle very
similar, but the specific bacillus of tuberculosis is
found in both. The clinical course of the two diseases
also presents, as he thought, some very marked points
of resemblance, the slow course, for example, of some
forms of phthisis, accompanied with many relapses.
But the most important and most direct proof has been
found in the inoculation of small pieces of lupus tissue
into the cornea of rabbits, and the growth of distinct
tubercle at the point of inoculation. He was fol-
lowed by several speakers, who considered that the
slow course and frequent recurrences in lupus were
very like the course and relapses of tuberculosis.

46 FACE AND FOOT DEFORMITIES.

As regards the treatment of lupus, experience seems
to show that any treatment short of eradicating the
disease only stimulates it to spread. Powerful caus-
tics have been applied, which only tend to enlarge the
area of ulceration, unless they are applied so effectu-
ally that they burn out the disease. The constitu-
tional treatment should be pushed also with vigour.
Careful attention to hygienic measures must not be
neglected. The patient must have plenty of pure
air, good food, and exercise in the open air. The
ordinary tonics may be given, such as quinine and
iron, or the mineral acids, also cod-liver oil, and the
liquor arsenicalis, iodide of potassium, and the iodide
of iron. To eradicate the disease I should recom-
mend that the patient be placed under chloroform,
and the whole of the ulcerating surface exposed by
the removal of the crusts. With a sharp spoon or
curette the morbid growth may be scraped away, so
as to leave a raw surface to heal by granulation, after
applying strong carbolic acid to the denuded derma.
A solution of jequirety or chloride of zinc paste, or a
stick of chloride of zinc may be passed firmly over the
growth, or the fumes of nitric acid may be used, so that
the base of the growth can be destroyed, and a poul-
tice may then be applied to liberate the charred crusts
which remain. Since the introduction of Paquelin's
cautery we have a quick and very effectual method
of dealing with these surface growths.

Lupus non-exedens is a variety of the disease cha-
racterised by less vigorous development, and it is less
destructive in its tendencies. It commences as a
small tubercle of a reddish-yellow colour. There is

FACE AND FOOT DEFORMITIES. 47

little if any ulceration, but the tubercle seems to
grow subcutaneously, and it may spread all over the
face. The treatment is much the same as for lupus
exedens, but the cauterisation need not be quite
so deep. Caustic potash may be painted on the sur-
face with much effect. The syrup of the iodide of
iron and cod-liver oil may be given internally.

Lupus erythematosus generally manifests itself on
the nose, cheek, or eyelids. It does not destroy the
soft tissues or the cartilages so rapidly as the other
forms of lupus. The scabs are of a pearly whiteness,
and are very difficult to remove. It is a non-tuber-
cular growth, not raised above the surface, and it
appears in the otherwise robust, and less seldom in
the scrofulous or consumptive. It begins in patches
of a purple red colour, and these may be covered
with scabs or crusts, underneath which a scar tissue is
formed, as with the other forms of lupus. It generally
progresses very slowly, commencing as a small,
punched-out, callous ulcer, with a red, irritable base.
This growth may be destroyed by the actual cautery,
or by Paquelin's thermo-cautere, or by the applica-
tion of caustic potash in solution. The usual tonic
treatment in these cases is necessary.

The milder forms of lupus are best destroyed by
using a weak solution of nitric acid. The disease
may be aggravated by exposure to cold winds or
furnace heat, or by mental anxiety and poverty.

It may be distinguished from syphilitic ulceration,
because this occurs, as a rule, only in adults, and
may spread from the throat outwards to the surface.
There may be papules around, but they will be of a

48

FACE AND FOOT DEFORMITIES.

coppery colour, and a history of syphilis may be
traced in such cases. The edges of the ulcer in
syphilis are foul and sloughy. The margins are
sharply cut and not indurated.

Cancruni oris commences with swelling and redness
of the cheek near the angle of the mouth, with some
sloughing of the mucous membrane and offensive
breath. A mouth-wash may be used of chlorinate of
soda, and chlorate of potash should be given as a
medicine. The ulceration of the mouth extends
rapidly, and the child's health suffers in consequence

Cancrum oris. Model 26*, Guy's Hospital Museum.

of swallowing the foul discharges. If not promptly
cauterised the cheek soon becomes perforated, and
the glands of the neck enlarge. The treatment must
be heroic, the whole of the sloughing surface must be
destroyed with the actual cautery or with solid
chloride of zinc, or fuming nitric acid. The child
must have plenty of nourishing food, beef tea, eggs,
milk, and wine, etc. Quinine and iron should be
administered internally. The child is generally very
feeble from insufficient food, and from living in the

FACE AND FOOT DEFORMITIES. 49

midst of foul odours, and other evil effects of over-
crowding, so that it is needful also to remove it from
such pernicious insanitary conditions. The drawing
which I append is from a model in the museum of
Guy's Hospital.

Congenital Syphilitic Eruptions may give rise to
various deformities about the face, either by the pro-
duction of scars or from the outbreak of disfiguring
skin lesions. The characters of such eruptions are
various. They may crop out as disseminated squamous
eruptions like chronic eczema, or as mucous tubercles
about the mouth and nostril, or as red indurated
nodules or papules with an inflamed areola, generally
leaving a coppery stain as the eruption fades. The
complexion of the face in these cases is characteristic ;
it is more or less " muddy," presenting the so-called
cafe ait lait tinting of the cheeks and forehead. The
lips may be thick and excoriated. Radiating fissures
all round the mouth will often be seen in these cases.
There are also constitutional symptoms, such as snuf-
fling at the nose, distended alse, and flattened bridge
of the nose. The child may be rickety, emaciated,
suffering from tabes and general marasmus. There
may be syphilitic nodes and cranio-tabes ; also some
chronic intertrigo of pudenda, and condylomata, or
mucous tubercles around the anus. Such children may
lose flesh rapidly, and they often die from inanition.
The treatment of these cases must be prompt and
decisive, by a course of antisyphilitic remedies as
follows : — Hydrarg. c. creta, iodide of potassium, with
the syrup of the iodide of iron, and the inunction in
some cases of mercurial ointment.

E

so FACE AND FOOT DEFORMITIES.

Parasitic Diseases. — Scabies may occasionally ap-
pear on the face, but very rarely. This is a vesi-
cular or pustular disease, caused by the presence of
an animal parasite, the acarus scabiei, or sarcoptes,
which burrows under the skin and deposits its eggs
there. Very quickly the disease spreads, from the
active habits of the male itch insect, travelling over
the surface of the skin. The disease is thus favoured
by the dirty habits of the poorer classes. Children
that are badly fed and poverty-stricken suffer most
severely from the spread of parasitic diseases. A
vesicle or pustule appears where the female insect
has burrowed and deposited the eggs.

The child should have a good lather of carbolic
soap and water before the fire, and then the sulphur
ointment can be rubbed well into the softened skin. It
may be necessary to give sulphur baths. The pustules
of itch are disseminated, generally on parts which
are protected from friction, as the folds of the skin.

A thickened inflammatory condition of the eye-
lids and eyelashes may be caused, in the first in-
stance, by pediculi. This occasions considerable local
irritation, and swelling of the Meibomian glands and
follicles. A glutinous secretion blocks them up, and so
the eyelid swells and becomes very unsightly. This
disease is called blepharitis, and it will need careful
attention to reduce the swelling, and to sponge away
the crusts which form at the roots of the eyelashes.
Strumous children often suffer from blepharitis, not
caused by any animal parasite. In each case cleanli-
ness, and the regular use of the dilute citrine ointment,
will effect a cure if persisted in daily for some time.

FACE AND FOOT DEFORMITIES. 51

Very careful bathing with warm water will soften down
the glutinous exudation which clings to the lids, and
distends the follicles under the skin.

Of vegetable parasites, we have, for example, ring-
worm, i. e. Tinea tonsurans^ occurring often on the
forehead. These parasitic diseases are of course very
contagious. Ringworm appears first in patches about
the size of a shilling or sixpence, with a raised red
margin. The surface is covered with loose laminated
scales which are opaque and peel off. The hairs
which are involved in the disease become brittle and
break off near the skin, so that the scalp presents the
characteristic "stubble-field " appearance. The spores
of the fungus infiltrate into the tissues of the bulb and
hair follicles. The mycelium and sporules of the
disease spread in all directions among the roots of the
hair. When the spores are thus deeply imbedded in
the follicles of the skin, it is difficult to eradicate the
disease. We have a variety of local applications suit-
able for the treatment of this disease. It is important
to see that the parasiticide penetrates to the base of
the follicles, and not to neglect general treatment.

If the disease is in well-defined patches, I some-
times brush the surface firmly with iodine or rub in
the ung. hydr. amm. or the ointment of sulphur and
acetic acid or the oleate of mercury. Disseminated
ringworm is best treated with a lotion of equal parts
of sulphurous acid, glycerine, and liquor hydrarg. per-
chlor., constantly applied, or strong carbolic acid.

Tinea circinata may occur on the cheek. It is
a disease of a furfuraceous character and without
much constitutional derangement. It often occurs in

E 2

52 FACE AND FOOT DEFORMITIES.

strumous or delicate children. Some dermatologists
consider that this is not a parasitic disease of itself,
but an herpetic eruption with the grafting upon it of
tinea tonsurans. It may be painted with acetic acid
or iodine, and some tonic treatment administered.

Tinea sycosis may attack the skin which is covered
by whiskers or the beard. Sycosis is a pustular
disease of the hair follicles of the face, especially of
the chin and upper lip. It is developed first by in-
flammation of the roots of the hair, and is increased
by any attempt to keep the part shaved. Conical
pustules form on the surface, and a dry scab concretes
over the eruption and mats the hair. The disease
appears to originate in a vegetable parasite, which
attacks the epithelial lining of the follicles. There
is considerable local itching, pain, and swelling of
the parts. The irritated skin bleeds very freely.
The deeper tissues of the skin swell and harden,
and there may be small abscesses form in the sub-
cutaneous cellular tissue. If the disease continues
unarrested the hair follicles will be destroyed, the
beard falls out, and baldness is the result. The
disease is propagated by the mycelium or spawn of
the vegetable parasite which is found blocking up
the follicles and destroying the hair-bulbs. It is, of
course, most needful to beware of "easy shaving
shops " where cleanliness is not rigidly attended to.
Those who require to go to the barber must select
the man that uses every precaution to prevent the
spread of parasitic disease.

It is important to remember that every disease
that attacks the chin is not sycosis. We often have

FACE AND FOOT DEFORMITIES. 53

impetigo limited to the chin or upper lip, but this is
not sycosis. A microscopic examination of the root
of the hair will determine the precise character of
the disease. Sycosis is a very difficult disease to
eradicate. It may last for years. It is important to
attend to the general health, especially of the di-
gestive organs. Mild aperients and alteratives may
be required, followed by vegetable tonics. The
beard, instead of being shaved with a razor, should be
kept close cut with a sharp pair of scissors. The
iodide of lead or the iodide of sulphur ointment may
be rubbed into the eruption with care and diligence.
Merely to smear the surface will not suffice. The fol-
licles being shaped like the finger of a glove, an
attempt must be made to press the healing ointment
down into the open ends of the follicles. Careful
attention to diet and regimen, and the avoidance of
spirits and highly seasoned food must be attended to.
The eruption may be bathed with a sulphate of
copper or sulphate of zinc lotion, about five grains to
the ounce, or carbolic lotion, and the face washed with
the juniper tar soap.

Tmea favosa occasionally attacks the chin and eye-
brows. The mycelium and sporules of the Achorion
Schonleinii cause the spread of this disease. It con-
sists of cup-shaped yellow crusts resembling a honey-
comb. These crusts are often very extensive, and
they emit an offensive odour. The hair-follicle in the
centre of the crust is quickly destroyed by the fungus.
It may be associated with pediculi of the face.
Lotions or ointment containing sulphur and mercury
will be required in these cases to destroy the fungus.

54 FACE AND FOOT DEFORMITIES.

Chloasma^ or liver-spot, otherwise called Pityriasis
versicolor, appears sometimes on the forehead, of a
dull brownish-yellow colour. I think it is doubtful
whether we should not consider the two diseases
chloasma and pityriasis versicolor as quite distinct
one from the other. Some dermatologists favour a
parasitic origin for these diseases. The microsporon
furfur has been discovered in pityriasis versicolor,
but I think the patches of chloasma indicate more a
deposit of pigment in the rete mucosum, in conse-
quence of retarded circulation from nerve prostration
and general debility. It is often the result of want
of cleanliness, but generally from some enfeebling
debilitating cause, specially of a neurotic character,
as in myxoedema and degenerative changes in the
structure of the heart. The lotion of perchloride of
mercury is useful in these cases. The patient must
be treated on general principles. The digestive and
assimilative organs must be carefully attended to.
Preparations of quinine, iron, and arsenic are generally
required to follow gentle aperients.

Surface Tumours of the Face which involve the
skin only, do not often come under treatment. There
are, of course, an endless variety of tumours connected
with the deeper structures, but these I do not propose
to describe, as the deformity in such cases is the result
of the forward growth of the tumour towards the sur-
face, rather than being in itself a direct cause of
deformity and disfigurement.

Lipoma is a disease of the integumentary coverings
of the nose, it does not involve the bones or the carti-
lages. This growth must of course be distinguished

FACE AND FOOT DEFORMITIES. 55

from the ordinary Hpomatous or fatty tumour which
may be found on different parts of the body. The
structure is quite different, and appears to partake of
the character of a general hypertrophy of the adipose
tissue and sebaceous foUicles with infiltration into
the surrounding cellular tissue, and is also followed
by engorgement of the neighbouring vessels. It is a
disease situated generally at the apex, and spreading
laterally along the alae of the nose. Sometimes it is
more pendulous than others, so that as the patient
walks his nose swings about like the pendulum of a
clock. Sometimes it is nodular and very vascular,
and the surface capillaries are distended and blocked
with sluggish blood, giving the growth the strawberry
colour which is so characteristic and so unsightly.
This is a simple painless growth, and develops slowly.
Fortunately the removal of it may be effected with
great ease, and without the danger of a recurrence.
The growth should be carefully dissected off the
cartilage without removing the mucous lining of the
nostril. Possibly a little plastic surgery may be de-
sirable to provide a fresh covering of adjacent sound
skin for the denuded cartilages.

Fatty tumours appear sometimes on the face in
the substance of the cheek or lip. They may be
pendulous or sessile. When the patient has a number
of these growths scattered over the body, some will
be found occasionally on the face, and require to be
removed on account of their unsightliness. When
acting as Surgeon to the Westminster General Dispen-
sary I removed a large fatty tumour from between the
genio-hyoglossi muscles in the exact situation of ranula.

56 'FACE AND FOOT DEFORMITIES.

The patient came under my care with a swelling
which showed very prominently when the mouth was
open, tilting up the tongue and also projecting down-
wards, giving a double chin appearance and inter-
fering with his power of speech. The mucous mem-
brane of the floor of the mouth was distended over
it, and it projected above the teeth. The tumour had
apparently a uniform outline. It was quite elastic.
I proceeded to remove it by an incision as for ranula.
Instead of the usual glairy fluid escaping, I found
the opening in the mucous membrane blocked up
by a white smooth surface tumour, which I seized
with vulsellum forceps and found that it was of a fatty
nature, the size and shape of a Geneva watch. I suc-
ceeded in freeing it from the cellular tissue covering
the muscles which embraced the lower edge of the
tumour. The case progressed favourably, and the
man's power of vocalisation returned to its normal
condition. The specimen is, I believe, unique. It is
now in the museum of the Royal College of Surgeons.

Primary cancer of the face, as distinguished from
cancerous tumours which involve the face subse-
quently by spreading from the deeper structures, may
be formed in two or three distinct varieties, viz. rodent
cancer, epithelioma, and melanotic sarcoma.

Simple warts or cracks of the lip if irritated by
smoking. Sic, may develop into a form of cancer or
rodent ulcer which requires prompt excision.

Rodent cancer occurs in old people, and ulcerates
very slowly, but it may invade the deeper structures,
and it shows no tendency to heal. There is often
severe pain in this disease as contrasted with lupus,

FACE AND FOOT DEFORMITIES. 57

which is almost always painless, except when irri-
tated by caustics, etc.

Rodent cancer commences frequently over the malar
bone, beneath the lower eye-lid, extending by a slow
growth towards the nose. It is essentially a disease
of old age, rarely occurring under fifty years of age.
It is sometimes described as a local cancerous growth
with the peculiar character of spreading by con-
tiguity of structure, rather than through the neigh-
bouring lymphatics and glands. It first appears as
a permanent tubercle on the skin, and two or three
may form afterwards close by, which coalesce with
the primary tubercle. This little prominence ulcer-
ates and forms a fungating mass with a deeply
excavated ulcer. The surrounding tissues become
callous and eroded by the spread of the disease. It
infiltrates the neighbouring glands and subsequently
involves the osseous tissues. As it spreads it invades
the nerve-trunks, and then the patient suffers a great
deal of pain. The treatment must be very decisive,
no half-measures will suffice. Powerful escharotics
must be used for its destruction, or the galvanic
cautery. The results of early destruction of these
growths are very satisfactory, for the glandular tissues
do not as a rule become permanently involved in the
disease at first. Scraping the surface of the ulcers
will sometimes suffice to destroy the heterogeneous
growth of the epithelial elements. Upon the de-
nuded surface we may sometimes do some skin-
grafting with evident benefit to the patient for the
obliteration of the deformity, taking care to destroy
the growth first in all cases.

58 FACE AND FOOT DEFORMITIES.

Epithelioma commences as a small dry wart which
cracks and ulcerates. It frequently appears at the
junction of the skin and mucous membrane, and so is
distinguished from rodent cancer, which it greatly
resembles in the early stages of development. The
outline of growth in epithelioma is more rugged and
uneven, and the surface is raised and papillated. The
lymphatic glands become involved very early. There
are distinct microscopic characters which distinguish
the one from the other, showing the epithelial cells
undergoing rapid proliferation, with large granular
contents, the nuclear elements expanded, and the
growth itself extending along the course of the
lymphatics into the neighbouring structures without
any line of demarcation. Epithelioma in consequence
of its infiltrating character has a tendency to recur in
the part from whence it has been removed. So that
this growth requires to be treated promptly and
expeditiously to effect a satisfactory cure. It may
remain dormant for many years, causing very little
pain or inconvenience. Suddenly without any very
clear cause it may expand, fissures appear on the
surface, and then the disease quickly involves all the
neighbouring structures. It may be excised or burnt
out by escharotics, such as chloride of zinc, the actual
cautery, &c. It sometimes appears on the end of the
nose, and frequently at the lower lip near the angle of
the mouth. If the teeth be examined it will generally
be found that those which are adjacent to this fungating
ulcer are worn down by the constant friction of a
pipe without a mouthpiece. The long clay pipe used
to be considered a frequent cause of this disease in old

FACE AND FOOT DEFORMITIES. 59

men, who being past work are seldom able to exist
without the soothing effect of a little tobacco. For the
removal of these growths it will be necessary to make
a V-shaped incision on either side through sound tissue,
piercing through the mucous lining to the mouth, so as
to avoid any infiltrated or swollen gland tissue. The
lines of incision should approximate just above the
depression which exists midway between the lip and
the chin. The haemorrhage should be controlled by
compression, first of all with dressing forceps, or the
forceps specially designed for the purpose, and then
with strong harelip pins we may place the raw edges
in accurate coaptation. Torsion may be required to
arrest the haemorrhage from large bleeding vessels.

Large sarcomata, myeloid tumours, adenoid growths,
&c., develop in the tissues of the face, including the
parotid gland and adjacent cervical glands. These
I merely allude to en passant as surface deformities.

Sebaceous cysts may appear on any part of the
face. They consist of a concretion of epithelial
debris caused by the prolonged closure of some one
or more cutaneous and subcutaneous follicles. The
contents are putty-like and are generally enclosed in
a distinct sac of a pellucid membrane, which must be
carefully shelled out at the operation, otherwise the
tumour will grow again. Sometimes the sac will be
adherent at the base, and as they generally lie under-
neath the superficial muscles, the attempt to remove
them must be undertaken with considerable care.
They increase slowly, but they have been known to
excavate the subjacent tablet of bone by the pressure
of the ever-increasing contents. They are usually

6o FACE AND FOOT DEFORMITIES.

round or oval in shape, and move under the examining
finger with an elastic feel. Before commencing the
operation for their removal, it is occasionally desirable
to pass a pin below the tumour and then to tie a
silk thread underneath so as to bring the tumour
prominently to the surface, and also to fix it, so that
when the usual incision is made across the tumour, the
contents may be promptly evacuated together with
the sac. Many congenital tumours on the face consist
of a combination of solid and cystic growth, present-
ing a honeycombed appearance, and having contents
which vary much in character. We have also blood-
cysts, dentigerous cysts, mucous cysts, dermoid cysts,
hydatids, congenital hygromas, and other varieties
of cystic growth forming in the substance of the cheek,
etc. All these require to be excised, unless the
attachments are too deep.

Warts and wens I have placed in the introductory
section, under the head of " Structural Deformities."

We may have congenital absence of one or more of
the bones of the face, causing considerable deformity.
Such cases scarcely come within the range of thought
for rectifying the deformity, as they are not capable
of much if any improvement, as a rule.

Dental Abscess. — Amongst the poor particularly,
who are exposed to rough weather, and are very loth
to go to the dentist, it occasionally happens that an
abscess around the fang of a tooth may spread to the
jaw and the glands of the neck, requiring an incision at
the dependent parts to evacuate the pus. If great
care is not taken, the resulting scar will pucker, be-
come adherent to the jaw, and form a permanent pit

FACE AND FOOT DEFORMITIES. 6i

or depression in this situation, and it may terminate
in necrosis of the subjacent bone.

Decayed teeth may give rise to many deformities
of the face more or less permanent. They may set
up a chronic osteitis of the jaw, with diffuse swelling
of the soft tissues covering it, and probably abscess.
If neglected, there may be necrosis of the alveolar
border of the jaw, which may invade the antrum,
destroy the incubating permanent teeth, or spread into
the substance of the lower jaw, causing abscess in the
neck just below the chin. The seventh nerve occa-
sionally becomes involved in these abscesses of the
face, and then we may have facial paralysis with a
loss of expression on that side. The face muscles
being flaccid and inert, the features become distorted
in consequence of the unbalanced action of the
muscles on the opposite side of the face.

Salter relates in his book several cases of loss of
sight following abscess in the antrum. When the
antrum is much distended by the accumulation of
pus there will be much distortion of the face.

A case of extensive superficial necrosis of the upper
jaw and malar bone came under my care lately at
the Victoria Hospital. I removed the necrosed por-
tions with cutting pliers and gouge, and found that
the disease extended up to the orbital border of the
malar bone. I then passed the gouge through a
fistulous track situated just below the lower eyelid
which led to the carious cavity, and removed the
exfoliating surface. The wound was plugged with
oiled lint, and the extensive surface of bone which
had necrosed gradually rounded off, and became

62 FACE AND FOOT DEFORMITIES.

covered with mucous membrane. The large promi-
nence on the cheek caused by the superficial cellulitis
and inflammatory exudation subsided, but the opera-
tion rather tended to increase the. deformity which
had already appeared on the eyelid. By the ex-
treme eversion of the lower eyelid and conjunctiva
caused by the binding down of the above-mentioned
fistulous track to the external surface of the malar
bone, the under surface of the eyeball was com-
pletely exposed to the atmosphere, and to sand and
grit. {Vide annexed Plate.) The antrum was not
involved.

At a subsequent operation, having a firm base of
solid bone covered with mucous membrane to depend
upon, I proceeded to make a horizontal incision just
below the eyelid, and over the prominence of the malar
bone. I then dissected up the lower eyelid, which,
instead of being convex, was concave and depressed
into a deep pit by the large swelling over the malar
bone. The conjunctiva was completely everted, and
the upper eyelid was dragged downwards and out-
wards by the contracting cicatrix, causing a very
marked deformity in this situation. I dissected up
the lower eyelid from its deep attachment, and by
making two short vertical incisions at each end of
the horizontal incision, I displaced the flap inwards to-
wards the nose, and raised it up to the normal situation
covering the eyeball. The conjunctiva was retained
in its position of accurate apposition to the eyeball by
a coarse silk suture which perforated this membrane
in two places, and was then passed down over the
malar prominence and into the mouth by transfixing

u

K^

?v

vJ

FACE AND FOOT DEFORMITIES. 63

the buccal mucous membrane close to the cavity of
the canine tooth.

The drawings will show how completely the promi-
nent swelling of the face has subsided, how the
unsightly pouch over the malar bone was obliterated,
and also how the new lower eyelid was formed by
transposing the integument and conjunctiva from this
situation.

I need not now refer to the many causes of face de-
formity induced by paralysis of the opponent muscles,
to wry-neck, fixity of jaw, epileptic spasm, hemi-
plegia or chorea. These require special management,
besides local treatment, and I am only describing the
surface deformities of the face. I desire to confine
myself almost exclusively to the more usual types of
face deformity.

Salivary fistula may result from the formation of
an abscess or tumour in the neighbourhood of Steno's
duct, or from destruction of the cheek by lupus or
cancrum oris, or from sabre wounds. Calculi im-
bedded in the duct may cause an abscess to form,
which being incised will be found to communicate
direct with the parotid gland. The fistula which
forms in consequence of the continued flow of saliva
along the duct must be diverted so as to empty the
contents through the buccal mucous membrane. This
may be done by tracking the direction of the tube
with silk and perforating the cheek, leaving the silk
i7i sitti until the new channel is complete, and then
paring and closing up the external opening with
sutures.

64 FA CE AND FOOT DEFORMITIES.

SECTION III.

INJURIES OF THE FACE — INCISED WOUNDS, FRAC-
TURES AND DISLOCATIONS, BURNS AND SCALDS,
ETC.

Injuries of the Pace may be said to occur very
frequently among those engaged in dangerous occu-
pations, as the manufacture of explosives, or in build-
ing operations, &c. Children often come under the
surgeon's care suffering from incised or lacerated
wounds of the cheek or forehead, or from bruises or
sub-fascial extravasations, as occasionally happens
when the vessels under the occipito-frontalis muscle
are damaged. In such cases there will be a cir-
cumscribed swelling fluctuating on pressure, com-
municating a sensation as though the frontal bone was
depressed. There may, or may not, be symptoms of
concussion. The child should be kept away from
school, and have an evaporating lotion applied if there
is pain. Or he may have a bandage and compress to
promote absorption of the effused blood. He may
have fallen down on a sharp stone, or some mischievous
playmate may have thrust a knife or pointed instru-
ment into the face, either purposely or accidentally,
or the wound may be self-inflicted by playing with
swords, guns, &c. The eye, being well protected by
the eyelids and orbital prominences, seldom gets
injured ; but considerable deformity results from
wounds of the face when they are not properly closed
at the time. The skin, too, of the face is so very de-
licate in texture, that it requires very careful manage-

FACE AND FOOT DEFORMITIES. 65

ment to approximate the divided edges. Often the
surgeon will strap together the edges of the wound
quite accurately, but the movement of the muscles of
expression, as in laughing, or of the deeper muscles
of mastication may cause it to gape. I never trust to
anything but very fine needles for face wounds of all
sizes. I have had some specially made for me corre-
sponding to the smallest needle that is manufactured,
and this being furnished with a glass head, may easily
be transfixed across the wound. I do not care to cut
off the point, because this is unnecessary. I simply
press the point into a piece of cork to protect the sur-
rounding skin, after I have fixed the needle with fine
silk in the usual way. Whenever the skin is divided,
an attempt must be made to have the resulting scar
which is inevitable, as linear as possible, so that it may
scarcely be seen when the child grows up. Parents
must not be disappointed if they find the scar increase
in size, for, like all other tissues, it grows with the
growth of the body. When we have primary or
immediate union by agglutination of the clean cut
edges, the wound should heal at once, and the line of
cicatrix be scarcely visible. Besides careful adjust-
ment of the edges, it is important to keep the deep
parts of the wound in contact with the fascia beneath.
I often find this rule neglected by dressers and house
surgeons. However well adjusted the surface wound
may be, the inner edges are often allowed to bleed
subcutaneously, inflammation will then occur, and the
wound will not unite. I always put a firm pad and
strapping over the suture needle, and a bandage round
the head to keep up constant and equally distributed

F

66 FACE AND FOOT DEFORMITIES.

pressure. It often happens that a child from falh'ng
out of bed, or tumbling off a wall and alighting on
some sharp or rough stones may have a severe gash
in the forehead, with a depressed fracture of the outer
table of the skull, or the inner, more brittle table, may-
be fissured and the dura mater torn, in which case
there will probably be escape of cerebro-spinal fluid.

It is astonishing the slight amount of cerebral
disturbance resulting from extensive fractures of the
skull in young children. I had a case of this sort
under my care recently at the Victoria Hospital in a
boy aged six years. The probe passed in for about
an inch through a vertical fissure into the interior of
the skull, penetrating through the right frontal
eminence, and there was a quantity of bony callus and
fibrous thickening around. The pus which formed
subcutaneously, gravitated downwards, and I had to
make a counter opening. The inner side of the in-
tegument had a granulating surface, and the perios-
teum was very vascular, bleeding freely at each
dressing. I had a strip of lint charged with a solu-
tion of nitrate of silver passed subcutaneously across
the fissure, and a pad of lint placed externally so that
the thick oedematous condition of the skin and the
distension of the veins soon subsided. The fissure in
the skull closed up very well. The child was kept at
rest in bed, and a capiline bandage applied over all.
There were no cerebral symptoms from first to last
during the child's stay in hospital. As far as I can
remember, there was very little evidence of concussion
symptoms at the time of the injury. The child was
not admitted for some days after the accident. It

FACE AND FOOT DEFORMITIES. 67

was the prominent swelling of forehead that prompted
the mother to bring the child to the Hospital.

Children playing with edged tools may suddenly
inflict serious and irreparable damage in a moment
of irritation. There are many lesions and deformities
of the face caused by bullet wounds, sword thrusts,
and numerous other sharp instruments, which require
careful management so as to make the resulting scar
as linear as possible. It is unnecessary to refer to
these in detail.

Fractures and Dislocations of the lower jaw I might
almost omit, only the risus sardonicus, so characteristic
of the latter deformity, seems to compel a passing
allusion to it. The fixity of the jaw, with gaping
mouth, pain at the temples from spasm of masseter
and pterygoid muscles, and the alarm and discomfort
occasioned by this condition, are well known to most
surgeons. Any attempt to forcibly close the jaw will
be sure to end in failure. Some people are habituated
to partial dislocation, when gaping or laughing some-
what immoderately. The articulating surface slips
momentarily out of the glenoid cavity from relaxation
of the surrounding ligaments, but the temporal and
masseter muscles, firmly contracting when the jaw
is depressed, facilitate the operation of reduction so
that it can generally be replaced without much
difficulty. Sometimes an attempt to crack a nut
may cause this dislocation. No time should be
lost in effecting replacement of the dislocated jaw.
The patient should be placed in an arm-chair, and
the head fixed against the chest of a person stand-
ing behind him. The surgeon, after protecting his

F 2

68 FACE AND FOOT DEFORMITIES.

thumbs with a bandage or roll of lint, plants them
as far back as possible upon the alveolar margin of
the jaw, and presses firmly down to bring the glenoid
head of the bone into relation with the margin of the
glenoid cavity. The muscles will then quickly draw
it up into its place. The patient should be fed upon
slops for a few days, so as to keep the jaw at rest and
favour the contraction and consolidation of the cap-
sular ligament. He should also have a bandage or
leather strap round the chin and head to keep the
lower jaw steady while the ligaments are becoming
consolidated.

Fractures of the lower jaw seldom occur. The signs
are very obvious. There is drooping of the jaw, unusual
mobility, crepitus of the fragments, loosening of teeth,
and haemorrhage in the mouth. The fracture may be
about the middle or near the neck and coronoid pro-
cess. They require to be treated with moulded leather
or gutta-percha splint, and the mouth kept closed as
much as possible with a bandage tied over the head
for four or five weeks. The adjacent teeth may be
tied together with wire. The upper jaw may also be
crushed by severe external violence. The bone being
rather brittle and hollow it breaks without much force.
There is flattening of the face on this side, haemorrhage
in the mouth, and the crepitation may be felt on ex-
amination within the mouth. The fragments should
be removed if possible, and loose teeth tied together.

Fractures of the nasal bones will cause considerable
deformity to the face, especially where the nose is very
prominent. Unfortunately, this injury occurs rather
frequently in over-crowded streets and thoroughfares

FACE AND FOOT DEFORMITIES. 69

from people being knocked down and run over ; also in
consequence of railway collisions, &c. The fracture may
be simple, or it may be compound and comminuted.
The fragments being crushed into the nasal cavity
may block it up, and the turbinated bones may also
be damaged. There is usually very free haemorrhage
from the nose in these cases. The surgeon must
replace the fragments as skilfully as he can with
dressing forceps and retain them in position with pads,
strapping, and bandages, and plug the nostrils so
as to arrest the haemorrhage.

Very extensive deformities result from burns and
scalds of the face in consequence of the contraction
of the cicatrix. The sound skin being dragged from
all parts, causes a serious distortion of the features,
and obliteration of the normal outlines of the face.
The surgeon must bear in mind the importance of
promoting a surface healing of the skin, which is in
part destroyed by the burn, so as to leave as little
contraction as possible. It may be necessary to fix
the head by some apparatus. Though the healing may
be slow in such cases, it may be better in the end, by
leaving less deformity from the contraction of the scars.
Each case requires to be carefully studied on its own
merits, so as to fit in by a plastic operation some sound
integument to the deformed part, after dividing the
prominent constricting bands of callous skin. The
surgeon must be quite sure before commencing his
operation that he has sufficient integument for trans-
position, otherwise he may find that division of these
bands will cause a gap which cannot be filled in, and
the last state of the patient will be worse than the first.

70 FACE AND FOOT DEFORMITIES.

Removal of Cicatrices. — It is well known how much
mischief and deformity is occasioned by the con-
tracted cicatrices of burns about the face and neck
dragging down the elastic integument concentrically,
till all the features are distorted. When the eyelids are
drawn down, the red conjunctival membrane is exposed.
The delicate membrane covering the eyeball becomes
thickened, and the sight blurred by the irritation of
dust, which gets access to the eye because the eyelids,
being designed to keep foreign bodies out, cannot
close. ( Vide adjoining woodcuts, showing results before
and after operation, from Fergusson's ' Surgery.')

Patients must not be too sanguine of success
in regard to the removal of such cicatrices. We may
divide the rigid contracting bands but we cannot create
new tissue. The body is covered by skin which if
destroyed we cannot replace. Still I have reason to
say that many of these deformities may by a well-
planned operation be considerably mitigated, if not
altogether removed. Though the skin covers the body
without redundancy or folding, yet we can often borrow
a little from the neighbourhood without endangering
the sound skin, and this we must endeavour to do.
The surgeon must take accurate measurements of the
tissue available for , the purpose before dividing the
scar, and it may be desirable to plan the operation to
be done in stages, so as to avoid making a huge gap
which we afterwards find it impossible to close with
sufficient breadth of sound skin. The new cicatrix
which forms after the division of an old band will
contract the tissues just as before. Our aim should be
to arrange for the contraction in a direction which

FACE AND FOOT DEFORMITIES.

71

72 FACE AND FOOT DEFORMITIES.

would not be so fatal to free movement, and not be so
likely to disfigure the face. We may effect much by
the careful and constant inunction of warm oil to
soften the scar-tissue, and then by applying an ex-
tending apparatus to stretch it in the desired direction.
The particular methods of operating for the removal
of such deformities are described under Section IV.

SECTION IV.

PLASTIC SURGERY— NOSE, HARELIP, ETC.

Plastic Surgery. — On no part of the body has the
surgeon been able to show more abundant success
in the cure and obliteration of deformities than on
the face. Opportunities abound for the exercise of
his ingenuity and skill in adopting measures for trans-
planting sound skin where it happens to be loose or
free, and moving it to a situation where it can cover
over an ugly scar or deformity, constituting one of the
greatest triumphs of modern surgery. There have
been numerous cases of cure effected by this method
of plastic surgery. As, for example, in the provision
of a flap of skin from the forehead to cover the un-
sightly openings to the nostrils, when these are ex-
posed to view by a falling-in of the arch, either as
the result of disease of the nasal bones, or from severe
injury. The provision of a new eyelid to take the
place of that which has been destroyed is an opera-
tion of this kind, and is usually very successful. The
public appear to be still very ignorant of the real

FACE AND FOOT DEFORMITIES. 73

powers possessed by surgeons at the present day for
obliterating deformities, or we should not see so con-
stantly as we do, exposing themselves to public gaze,
frightful specimens of humanity doomed to perpetual
banishment from society, because they do not know
what effectual means the surgeon is able to use in
order to rectify this deformity.

There is one apparent disadvantage of our modern
civilisation as regards plastic surgery, and it is that
we are debarred from expej'imenta in corpore vili, as
would be done among barbarous tribes where slavery
prevails. A person of exalted rank suffering from
such deformity would have no difficulty in obtaining
from a slave the substitution of a faulty member, and
the unfortunate slave would be condemned to a life of
ignominy and reproach in consequence.

Far from advocating a return to such relics of bar-
barity, I would merely remark here that cases have
been known where volunteers have willingly surren-
dered the skin of their arm, if it could not be obtained
from the patient, to cover over a face deformity.
Failing such help the surgeon must do the best he
can with the patient himself. He must endeavour to
get a transposition of integument to obliterate the
deformity and rectify the unsightliness from the most
available source, always remembering to have a con-
necting link of sound skin so as to keep up the nutri-
tion through the vessels which convey the blood to
the flap. The effusion of plastic lymph will agglu-
tinate the raw edges so as to close the wound. The
surgeon must be careful to plan his incisions so that
there may be good primary union of the approximated

74 FACE AND FOOT DEFORMITIES.

freshly incised edges with as little delay as possible.
He must also see that by proper padding and support
the flap is kept well in its place and the circulation
gradually re-established through the connecting link
of skin.

Deformities of the Nose may be congenital or caused
by some severe blow or fall upon the ground or from
ulceration of the septum. Such a crooked condition of
the prominent feature of the face is very disfiguring.

Infants are sometimes born with imperforate nos-
trils, or absence of the nose, but this is a very rare
condition. If the tube is merely closed by a mem-
branous fold of mucous membrane, this may be
removed by a crucial incision, the flaps being reflected
inwards to unite with the lining membrane.

Considerable deformity of the nose may result from
severe blows or from disease of the nasal bones.
These cases require special treatment for rectifying
the deformity, and in children who have small and
undeveloped noses every effort should be made to
rectify the deformity while the cartilages are easily
manipulated, and when even the bones may be care-
fully divided and set in the mesial line erect. Sub-
cutaneous osteotomy may often suffice to remove
severe deformities of the nasal bones.

Polypus nasi may cause some deformity of the
nose by lateral distension of the ala as it presses
upon the mucous membrane. These growths may
be removed, as a rule, without much difficulty by
evulsion with dressing forceps.

The bridge of the nose may be absent, either from
congenital deficiency, syphilitic or strumous ulcera-

FACE AND FOOT DEFORMITIES. 75

tions, or from damage. The deformity is, of course,
very great. Such cases require some skill to obliter-
ate or mitigate the deformity. The nose being the
most conspicuous feature of the face, it is a very
difficult thing to rectify deformities thereof.

Dislocation of the bones of the nose may be rectified
by forcible manipulation and leverage of the septum
nasi into its proper position. Long standing cases
are seldom able to be cured.

There may be congenital deficiency of the vault of
the nose from syphilitic disease, or there may have
been necrosis of the many delicate and spongy textured
bones of the nose or of the septum, the result of
strumous or lupus disease tending to atrophy.

Some very successful attempts have been made to
remedy this very serious deformity by transplanting
flaps of integument from the cheeks, the forehead, or
the arm, to cover over the nose, and to serve as a
screen to hide the unsightly caverns which show so
prominently in these cases. Where the nostril is
blocked by deformity, as from the alse being collapsed
and lying against the septum, the voice is much
altered and becomes nasal in character. It is de-
sirable, if possible, by careful packing of the nostril
and distention to make this nostril patent.

Before commencing to operate for the provision of
an artificial nose, the surgeon must take accurate
dimensions of the locality where the nose is to be
placed with a piece of thin cardboard. This may be
placed on the forehead or arm, whichever is to supply
the flap for covering in the gap, and the sound flap of
skin should be traced out with ink the required size.

id FACE AND FOOT DEFORMITIES.

Some little allowance must be made for the contraction
of the skin during the healing process. If taken from
the forehead as usual, the connecting link of skin, just
close to the bridge of the nose, at the lower part of the
forehead, must be twisted upon itself to allow of the
flap coming down and covering the nose. If it be
desired to provide a long septum for the nose this may-
be obtained from the upper lip. The margin of the
collapsed nose must be deeply incised, following the
outline of the alae nasi, so as to get a firm bed of
support for the new flap of integument, and then
with a very sharp knife and with brisk rapid incision
the traced outline of integument may be incised and
the flap rapidly turned down and stitched with wire
sutures in the new situation.

The flap should be lightly sponged so as to arrest
the bleeding and remove all clots before approxi-
mating the cut edges. Great care will be necessary
to see that the vivified edges are not glazed over, but
are perfectly " fresh," and are brought together very
accurately with the sutures. There must be no ten-
sion of the sutures, otherwise the flap may slough.
The columna nasi may then be dissected up from the
lip and united to the edge of the flap with fine sutures.
The nostrils should be dilated, kept open, and fixed
in situ by the insertion of plugs of cotton-wool and
cork, or by the use of quills to prop up the new nose.

The wound in the forehead or the arm left by the
removal of the flap must be partly closed with sutures
and the upper part allowed to granulate, so that it
may close up by degrees without leaving a very un-
sightly scar. (Vide case of Mr. Wood's reported in

FACE AND FOOT DEFORMITIES.

77

the Medical Times and Gazette, June 22nd, 1867,
and the subjoined woodcuts.) Pads of lint rolled

into a convenient shape may be applied outside
^o as to bolster up the new flap and support it

78 FACE AND FOOT DEFORMITIES.

during the first few anxious days when the heaHng
process is proceeding, the slightest disturbance of
which may be fatal to the success of the operation.
The surgeon must not be too sanguine of success in
these cases, for notwithstanding the success of some
plastic operations, failure from some unaccountable
cause must not be omitted from our calculations.

Plastic surgery of the eyelids is sometimes re-
quired for eversion of lid or loss of substance, as
the result of burns, wounds, &c. Such an operation,
if done carefully, will very materially improve the
patient's appearance. Sometimes what is called the
gliding operation will suffice, viz. the subcutaneous
dissection of the skin and the transposition of it by
means of sutures to the required position. Sometimes
the eyelid will become adherent to the ball of the eye,
together with the formation of a hard and knotty
cicatrix. A flap may be made from the loose integu-
ment below the eyelid, and then lifted into its new situa-
tion after removing the unsightly scar. There it may be
fixed with several fine sutures and carefully padded
with lint and strapping, so as to make the union as com-
plete and absolute as possible throughout the whole
of the inner surface of the transposed flap.

As regards the several attempts which have been
made, more or less successfully, by plastic opera-
tions, to cover the gap occasioned by the destruction
of parts of the face by disease, by the contracting
cicatrix of burns, by cancerous disease, &c., the
mode of designing the respective flaps must de-
pend largely upon the amount of available skin in
the neighbourhood, as also upon the size of the gap to

FACE AND FOOT DEFORMITIES. 79

be covered in. The Taliacotian operation consists
in the transplantation of a piece of skin from the
inner and upper aspect of the forearm, and shaping
it to fit over what remains of the nasal bones and
cartilages. After paring and reviving the edges, the
surgeon incorporates and agglutinates it to the cor-
responding edge of the cheek and lip at the base of
the nose, in the situation where the nose would nor-
mally find its junction with the cheek.

In making plastic operations it is important to
divide the soft parts freely from the subjacent bone.
The integument of the face being elastic and mobile,
it may be skilfully adjusted to fill in the gap occa-
sioned by the malformation or the disease. The
drawings which describe the accustomed methods of
performing these plastic operations may be found in
most manuals of surgery.

Harelip is a deformity so obvious and so disfiguring
that it requires very little description and still less
argument in support of the very simple and effective
operation for the obliteration of this deformity. Plastic
surgery has its peculiar triumph in an operation of
this kind. The double surface for accurate coaptation
secures that primary union, so essential for success,
shall be obtained if possible in all cases.

Harelip is caused by a congenital deficiency in
the commissure or pillars of the upper lip. Very
rarely indeed has the under lip been subject to the
same kind of deformity. The dimensions of the gap
vary considerably. In some cases the fissure extends
up into the nostrils and is connected with a fissure in
the hard palate. In other cases there is a V-shaped

8o FACE AND FOOT DEFORMITIES..

gap exposing the gums and only partially involving
the upper lip. The smaller the deformity the easier,
of course, it will be to effect a radical cure. When
associated with cleft palate, the deformity is very
great and the disfigurement very serious. There may
be a double fissure of the lip with a central portion of
lip between, attached to the intermaxillary bone.

Embryologists will understand the particular
reasons for the remarkable deficiency in this com-
missure. Speaking generally, the development and
closure of the blastoderm in the embryo proceeds
from the circumference towards the centre or mesial
line, closing over the visceral and branchial arches,
so that all the surface tissues in the central line of
the body are formed by this final act of closure.
It is easy, therefore, to suppose that some acci-
dental circumstance disturbing the developmental
processes at this early period of embryonic life will
prevent the closure of this labial cleft. It would
seem to be associated with a congenital proclivity, as
the deformity often happens with successive children
of the same parents. Though somewhat resembling
the normal fissure or gap seen in the hare, it of
course differs materially in being an abnormality,
and in being situated at the side, the mesial column
being entire both in single and double hare-lip.
The cleft is usually found connected with the left
nostril. The adjacent edges are covered with mucous
membrane continuous with the free margin of the
lips. It is a mistake if parents allow their children
to grow up without the simple operation necessary
for the closing of the cleft. When the teeth form,

FACE AND FOOT DEFORMITIES. 8i

the harelip is still more marked, as they show up the
gap much more distinctly.

To remedy this deformity, the infant should be
put under chloroform, say at three months old, and
placed on an operating table, with the head raised
towards the light. When the child is very flabby and
feeble it may be desirable to postpone the operation,
and meanwhile so to regulate the diet that after
being properly nourished, it may be in a fit state
of health for the subsequent operation and the re-
sulting reparative process. It is essential that the
vitality of the tissues should be maintained in a
healthy state, so that the plastic material which ag-
glutinates the wound should be quickly and firmly
organised. Some surgeons advise division of the
frenum, and dissecting up of the mucous membrane
from the jaw, but I do not find this necessary in the
ordinary simple cases of harelip. I think it im-
portant to do as little as possible in the way of cutting
to any part except the fissure, because the child is
sure to suffer more pain in consequence. Feeling
with the tongue the cut edge of the mucous mem-
brane, the parts become disturbed. This causes it to
cry much more. By operating early we can adjust the
flaps as required. The jaws not being fully developed,
there is usually plenty of freedom and redundance of
tissue about the upper lip. As the child grows, the
lip will be sure to develop according to the natural
requirements for accurate adaptation to the under lip.

The dotted lines on the drawings show different
methods of paring the edges before bringing them
together.

82

FACE AND FOOT DEFORMITIES.

It is important to commence the incision by trans-
fixion from above with a narrow-bladed knife, and
to cut downwards and outwards, curving the incision
slightly towards the labial border so as to prolong
the raw edges which require to be approximated.
( Vide drawings.) To prevent haemorrhage from the
coronary arteries, the lip should be compressed
with broad-bladed forceps with nearly parallel blades

like dressing forceps, so as to distribute the com-
pression. The lowest pin should be passed first, with
the double object of securing the coronary arteries
and of accurately adjusting the labial borders so
that they may unite with as little deformity as
possible. The pins must be passed, like a skewer
in meat, through the thickness of the lip, and then
buried in it towards the buccal edge, but never to
transfix or pierce the lip so as to appear on the buccal
surface. Care must be taken not to stretch or strain

FACE AND FOOT DEFORMITIES. 83

the tissues unduly, and so to pass the pins that they
will not cut out. I have had some harelip pins speci-
ally made of all sizes, so that it will not be necessary to
cut off the free ends. I cover the point with a piece
of cork, and protect the skin subjacent to the point
and glass head, with small pieces of strapping. The
silk used to draw the edges together should be well
waxed. Before fixing the edges, ascertain that the
lower margin is level with the rest of the lip. If it
should be V-shaped, the surgeon has not removed
enough of the labial margin, and should do so before
he approximates the edges.

As regards the different modes of operating for
harelip, I think it important to allude to some of the
leading features of the operation as performed by
myself. As I have already said, I do not agree
with some surgeons that division of the frenum
labise, or dissection of the labial mucous membrane
off the maxillary bone is necessary in all cases. I
seldom require to resort to this, I have operated
in very extreme cases with complete fissure and entire
absence of both hard and soft palate, except as a
rudimentary remnant, and I have found coaptation of
the pared edges effected without any dif^culty. More-
over, by retaining the connection to the frenum and
alveolar mucous membrane, I find that I am better
able to secure fixation of the flaps and less disturb-
ance of the healing process by the movements of the
patient and the spasmodic irritation of the facial
muscles. When we have to depend so much upon the
good behaviour of the baby and the avoidance of cry-
ing, I think it is undesirable to have a source of irri-

G 2

84 FACE AND FOOT DEFORMITIES.

tation within the mouth occasioned by the divided
frenum. I also adhere to the short harehp pin, as
securing a firm leverage, and a solid bar of distributed
compression over all the tissues of the lip. By this
means the haemorrhage is best controlled and the
movements also. I generally unite the labial border
of the gap with a silver wire suture. It is desirable
to give some specific instructions to parents about the
dieting and general management of the child, as these
cases are generally left to the care of the mother. I
have little confidence in the use of mechanical appli-
ances after operation, to relieve tension of the lip, for
the muscles which lie under the skin cannot be
effectually controlled by any retentive apparatus.

Some slight modification of the usual operation
will be necessary in cases where the cleft is irregular
or not quite through the thickness of the lip.

The after-treatment of these cases must be carefully
attended to. The mother must endeavour to pacify
the infant as soon as possible. There will be no
objection to giving it the breast or the feeding-bottle
with a good nipple. The child should suck without
effort, and so the boat-shaped feeding-bottle should
be used. Let the baby sit up when taking its food,
to avoid choking or anything that might cause a
sense of irritability to the larynx, as this might pro-
voke a cough or a sneeze, and thus strain the sutures.
If the child should gape or cry, the mother or nurse
should approximate the cheeks with the finger and
thumb. Be careful to keep it out of draughts to avoid
a cold or influenza. Any discharge from the nose
might collect around the sutures and set up cellulitis
which would interfere with primary union. The sur-

FACE AND FOOT DEFORMITIES.

85

geon need not be in a hurry to remove the sutures,
though he must carefully watch that they do not cut
out. In some cases of vigorous children the wound will
consolidate quickly, others will be longer. Strapping
should be applied after the removal of the pins. I do
not believe in the use of Hainsby's truss for con-
trolling the tendency of the facial muscles to strain
open the wound. It may be a cause of irritation

to the child. The adjoining woodcut, taken from
Fergusson's ' Surgery,' will show the effect of this
retentive apparatus.

I prefer to dress the wound, after removing the
sutures, with Leslie's strapping, dumbbell-shaped, ex-
tending across the entire surface of the cheeks and
round the angles of the lower jaw. I sometimes fix
two firm pads on the cheek with strapping, and over

86 FACE AND FOOT DEFORMITIES.

all I pass a strip of muslin a yard long and an inch
wide, having first obtained some fixation for it at the
occipital protuberance. The free ends are then brought
round under the ears and crossed over the mesial
line of the lip, so as to compress any irregularity and
to keep the lip firmly supported against the alveolar
process of the jaw. After crossing the muslin, the
free ends are taken back to the occipital protuberance
and firmly tied there, another layer of strapping
covering it all in.

A simpler method of approximating the cheek
muscles is to stitch together with coarse silk the
broad pieces of strapping already fixed to the cheeks,
crossing the ends over the upper lip and tying them
together, another piece of strapping being used to
cover in the silk.

In double Jiarelip there are two fissures, one on
each side of the middle line with a central protrusion
of the isolated portion connected with the septum
nasi, and some modification of the operation is
necessary. This protrusion of bone corresponds to
the premaxillary bone in the vertebrate animals. It
is a question whether to remove it before the plastic
operation or to forcibly depress it into the proper
position between the maxillary bones. Sometimes
this bone appears twisted upon itself, causing much
deformity of the jaw. With a strong pair of forceps
the surgeon may place it in position between the
superior maxillae and retain it there. The operation
should be performed before dentition has commenced.
The closing of this gap in the mouth facilitates the
action of sucking by providing a proper vacuum

FACE AND FOOT DEFORMITIES. 87

between the tongue and the palate. A healthy
child may be operated on during the first month or
six weeks with success under chloroform, as infants
take the anaesthetic very well, and are really much
quieter than those that are a little more knowing.
The younger the infant, provided it is in robust
health, the more satisfactory the union, and the
scar is of course relatively smaller and less per-
ceptible in after life. I rarely find it necessary
to do more than divide the free border of the gap
from th& nose downwards. I then carefully approxi-
mate the raw edges with as little delay as possible.
There is so much mobility of the lip upon the fold
of the cheek that if the edges can be drawn together
without undue straining, I prefer to leave the buccal
mucous membrane intact. In some children we may
apply a spring truss for approximating the cheeks and
relieving tension upon the sutures, but careful strapping
will suffice in most cases to keep the parts at rest. I
think there is less risk of haemorrhage after the opera-
tion, and the child will be less likely to disturb the parts
by thrusting its tongue to the front, if the buccal side
of the wound is carefully approximated. Having
secured the coronary arteries between the finger
and thumb of an assistant or with dressing forceps,
the free edge of the gap must be carefully and
uniformly pared and the arc of the fissure also
carefully denuded of mucous membrane. Strong
harelip pins should be used, with spear-shaped
points, varying in size from half-an-inch upwards,
so that there is no necessity to use the cutting
pliers to remove the ends, with the consequent

88 FACE AND FOOT DEFORMITIES.

delay and disturbance of the flaps. The harelip
pins must be passed deeply into the substance of
the lip, care being taken not to transfix it, but to
bring the points through the incised margin and
towards the buccal side so as to compress the
coronary arteries. Having then transfixed the corre-
sponding part of the right side of the fissure the
edges may be drawn together with a strong silk
thread passed several times over the projecting
extremities of the pin and crossed underneath. The
same method of fixation may be used with a second
and sometimes a third pin. The red margin of lip
and that of the nose may sometimes require special
approximation with a silk or v/ire suture. Care must
be taken to shape the flaps so that there shall not be
a pendulous portion rather than a gap at the margin
of the lip. I place a piece of cork on the sharp end
of the pins and protect the skin from pressure by
small pieces of strapping. After the sutures have been
applied so as accurately to adjust the edges of the
wound both front and back, the whole may be covered
with a strip of strapping from ear to ear, the cheeks
being approximated at the same time. Fortunately
the child's cries do not seem to have much effect upon
the healing process. The action of the orbicularis
oris muscle, it might be thought, would disturb the
healing process, but in consequence of the wound
having a double free edge the adhesion is generally
primary and immediate. If in double harelip the
proboscis-like bone protrudes so as to interfere with
the coaptation of parts, it may be removed with
pliers, prior to the operation, after dissecting it away

FACE AND FOOT DEFORMITIES. 89

from the nose portion of integument, or it may be dis-
located forcibly backwards to bring it level with the
superior maxillae.

Ordinary cases of double harelip may be treated in
the same way as for simple harelip, viz. by carefully
adjusting the two fissures after paring the edges.
If the nose is flattened and the central tongue of
skin small in bulk, it may be necessary to dissect this
up so as to tilt forward the nose and bring down the
median commissure. In order to form a new columna
for the nose this process may be affixed to the apex
and by approximating the two extreme borders of
each fissure, the line of suture will be single instead
of double ; but I prefer to make use of this central
portion of the lip to act as a stay to the outer edges
of the incision by transfixing it with one of the hare-
lip pins. The intermaxillary bone is often very
prominent, and projects in a very unsightly fashion
beyond the nose. Some surgeons advise the removal
of this bone, but I generally retain it if possible as a
support to the flaps, so as to prevent the child having
an underhung appearance in after life, as would
happen if the child were without incisor teeth in the
upper jaw. It is so necessary in the surgery of
children, not only to rectify the existing deformity,
but to make careful calculations so as to anticipate
as far as possible the result of such surgical operations
in adult life, and by attention to small matters of
detail, adapting skin to skin with accuracy, we may
secure for the patient immunity from unsightly scars,
and thus greatly add to his comfort and welfare in
after life.

90 FACE AND FOOT DEFORMITIES.

Plastic operations on the lower lip may be required
after removal of cancerous and other tumours if in
this situation. The ingenuity of the surgeon will be
necessary to construct two flaps from the cheek to
fill up the deficiency.

Generally the V-shaped gap may be closed in by
prolonging the angles of the mouth outwards through
the orbicularis muscle, and by displacing the cheek
inwards to cover over the incisor teeth. Or by an
incision downwards and outwards along the ramus
of the jaw, the mucous membrane being carefully
dissected off the bone, the raw edges may be tilted
pp and united in the mesial line.

To restore the upper lip destroyed by disease or
injury, an incision may be made, passing upwards along
the sulcus of each ala nasi. The mucous membrane
should be dissected off, and the flaps displaced
mesially under the nose to cover the teeth. Large
gaps are often occasioned by the destructive effect of
lupus of the cheek. This requires a well-planned
operation for paring the retracted callous edges, and
dissecting off" the mucous membrane so as to approxi-
mate the edges accurately.

SECTION V.

OTHER DEFORMITIES OF THE LIPS.

Excessive gi'owth of hair on the face of females,
forming an embryo beard or moustache, is a lifelong
annoyance to the victims, and especially to young
people. It is a great eyesore and vexation. Many
would gladly suffer much to have the growth of hair

FACE AND FOOT DEFORMITIES. 91

stopped. Efforts have been made by extraction to
destroy the growth, but this does not touch the hair-
bulb, and so the hair grows stronger next time. With
great patience and determination on the part of both
patient and operator it is possible to depilate each
hair separately, and with caustic or actual cautery to
destroy the bulb, so that the hair may not grow again.
A fine needle with a point of iridium has been made
by Mr. Ladd, the optician, to be connected with a
Grove's battery. The point being heated, was passed
into the vacant hair-follicle, so as to destroy the hair-
bulb. Mr. Milton, Surgeon to St. John's Hospital, tells
me he has used this needle with success in these cases.
Hairy moles of large and small size appear awkwardly
upon the face and attract the attention of passers-by.
These may be removed in the same way as for naevoid
growths.

There are several varieties of disease which involve
the mucous membrane and deep structures of the lip,
requiring careful consideration and treatment.

The simple cracked lip may be caused by the
continuance of cold frosty weather. It appears
usually at the middle line. When the child laughs
or cries it will split again, and be very painful.
Generally these cracks, especially those at the angles
of the mouth, are caused by a feverish condition of
the patient, the digestive system being out of order.
Strumous children with flesh that heals badly are
very frequently subject to these painful fissures. A
gentle aperient may suffice to cool the blood, and a
little vaseline may be rubbed deeply into the fissure.
When the edges become callous and indurated from the

92 FACE AND FOOT DEFORMITIES.

crack remaining open for some time, the surrounding
lip becomes infiltrated, swollen, prominent, and un-
usually red. It should be treated by the application
of the solid nitrate of silver, carefully passed with a
fine point into the deepest part of the furrow. If the
upper lip is involved, evert the mucous membrane,
and it will be seen to spread up almost as high as the
gum. In long standing cases it may be necessary to
incise gently the base of the crack, or even to pare
the edges and bring them together with fine sutures.

Some of the most characteristic symptoms of con-
stitutional syphilis are radiating fissures and excoria-
tions around the mouth which are difficult to heal.

Cracks at the angles of the mouth are sometimes
very indolent, because the constant movement of the
lips and mouth keeps them from healing. The food also
gets into the crack and irritates it, as also the saliva.
These fissures often occur in strumous children and
those that have a syphilitic history.

Small ncBvoid growths frequently occur on the lips.
They vary much in character, sometimes being
prominent and button-like, at others involving the
deep structure of the lip and showing little on the
surface. Transfixion with a needle, and the silk tied
under a small pin passed beneath the growth, will
effectually obliterate it.

I have operated on several cases of naevoid growth
in the substance of the lips, both upper and under.
I generally destroy the naevus by the application of
the actual cautery to the buccal mucous membrane,
taking care not to pierce the skin or do damage to the
inteerument of the face.

FACE AND FOOT DEFORMITIES. 93

Sometimes the whole thickness of the Hp is in-
volved in an ugly mass of infiltrated and hypertro-
phied cellular tissue, causing the lip to pout consider-
ably. We may require either to cauterise, or what
is probably better, to excise the growth, and to
pare the edges that they may be brought together
with pins, as in harelip, and the resulting deformity
will be almost nil. When naevus occurs on the cheek
and shows little on the surface, I prefer to destroy it
by passing the Paquelin point quickly into the centre
of the growth, so as to destroy it deeply and circum-
ferentially. The external wound will then be small
and the deep part cavernous. The cavern will close
by granulation after the destruction of the growth at
the fountain head.

We have a simple method of removing subcutaneous
naevi by the application of a ligature, which, burrow-
ing under the sound skin, will destroy the growth
without interfering with the healthy skin which covers
the naevus. This subcutaneous method is described
in the text-books, and I have had some successful
cases of obliteration of large diffuse nevoid growths
by the application of such a ligature. Vaccination is
seldom successful in the case of naevi, because it does
not destroy the roots of the disease.

Chancre of the Lip may occur at any period of life,
and young people who have contracted the disease
may suffer considerably in consequence of their folly.
The true Hunterian chancre is raised above the sur-
face, is button-like, with a central depression and
indurated edges. The neighbouring glands soon
become tender and swollen. This disease must be

94 FACE AND FOOT DEFORMITIES.

treated very promptly with caustics or excision, as
the patient may suffer all the usual and distressing
symptoms of secondary syphilis.

Prompt measures for excising the disease are also
required in the case of epithelial cancer of the lip.

The differential diagnosis of these two diseases is a
question of importance, though not usually of any dif-
ficulty. Cancer of the lip is a disease of old age ; it
does not involve the lymphatic glands so early as with
chancre. Cancer destroys all the surrounding struc-
tures by its irregular eroding development. Cancer of
the lip occurs mostly in males, and chancre in women.

Cysts of the Lip occur generally in the mucous
membrane of the lower lip. The skin is usually free on
the front towards the buccal surface. These growths
are raised above the surface, and are covered by
thin membrane of a semi-transparent character, and
they contain a viscid glairy mucus. The}- may be
multiple like a bunch of grapes, though generally
they appear singly. The character of the growth is
simple and non-malignant. They are painless and
grow slowly unless irritated by a projecting tooth.
Such cysts are probably developed from some ob-
structed follicular gland. They should be evacuated
and the floor and wall of the cyst cauterised with
nitric acid or some other escharotic, otherwise the
fluid will tend to recur and the cyst to reform.

Congenital cystic growths may form in the cel-
lular tissue of the lip, especially of the lower lip, and
towards the buccal surface, causing hypertrophy of the
mucous glands. These must be excised or ligatured,
and the subjacent membrane should be cauterised.

FACE AND FOOT DEFORMITIES. 95

Adults sometimes suffer from a serpiginous ulcera-
tion creeping into the submucous tissue of the lip,
and showing itself on the surface by small blisters and
fissures. A little vaseline rubbed in and covered with
goldbeater's-skin or collodion will allay the irritation.

Myxomatous tumours occasionally appear in the
substance of the lips, as also gliomata. These should
be removed as soon as their character has been
detected.

Several cases of malformation of the ears and of
complete absence of the meatus have been reported,
and the method of relieving the deformity described,
but this hardly comes within the scope of my treatise,
and I have had little personal experience of beneficial
operations upon the auricular appendages for such de-
formities, so that I pass this by. I have had to remove
several naevoid and polypoid growths from the auricle.

Considerable deformity of the face often results
from paralysis or spastic irritation of the portio dura
nerve, also from alveolar abscess in connection with
decayed teeth. These require general as well as
local treatment.

SECTION VI.

DEFORMITIES OF EYELID AND EYEBALL —
DISEASES OF CORNEA, ETC.

Injuries of the Lids. — Ecchymosis into the areolar
tissue of the eyelid may be caused by a blow upon
the eye, presenting a very unsightly appearance, the
blood from the damaged venous capillaries having
escaped into the subcutaneous cellular tissue. Eva-

96 FACE AND FOOT DEFORMITIES.

porating lotions or soothing poultices may promote
absorption of the effused blood.

Emphysema of the eyelids may also be caused by a
severe blow upon the cheek fracturing the lachrymal
or ethmoid bones. A little gentle pressure may be
required to disperse the emphysema.

Woimds of the eyelid should be carefully closed
v/ith fine sutures. A deformity called coloboma may
result from the imperfect closing of a wound in the
upper lid. This may be rectified by excision of the
ugly scar.

Caustic alkalies and mineral acids may be spurted
into the eye accidentally or out of mischief, and they
may produce very destructive effects. The surgeon
should neutralise the poison and then apply some
castor oil to the damaged conjunctiva and endeavour
to avoid the formation of adhesive bands between the
eyeball and the lid.

Lime, sand, or splinters of metal imbedding them-
selves in the eye should be promptly taken out with
a scoop or needle.

Subconjunctival ecchymosis may take place as the
result of violent exertion, as from coughing or retching,
or from a wound. The appearance of the blood under
the semi-transparent membrane is very distinct, and it
may alarm the patient. A little gentle pressure and
a cooling lotion will favour the absorption of the
effused blood.

Penetrating wounds of the cornea or conjunctiva
may cause considerable damage to the delicate struc-
tures of the eye. There may follow chemosis of con-
junctiva, escape of aqueous humour, or even the lens

FACE AND FOOT DEFORMITIES. 97

and vitreous, and prolapse of the iris. The eye should
be closed and kept at perfect rest with cotton-wool com-
press, and bandage over all. The resulting scar may-
be linear or it may form a large leucoma or opaque
spot, which prevents the access of light to the fundus.
Atrophy of disc and blindness may result from this
severe damage to the eye.

Wounds and Excavations of the cornea and con-
junctiva may be caused by sharp instruments, or from
a spiculum of stone, glass, or metal being thrust into the
eye, or from contusion of the eyeball. If the wound
penetrates the cornea there will probably be prolapse
of the iris. This should be returned by gentle pres-
sure, and the sphere of the cornea searched in case
any foreign body is lodged in the tissue or in the
anterior chamber. It will require some dexterity on
the part of the surgeon to extract these minute bodies,
which if left may set up serious mischief in the eye.
After removal the eye must be kept at rest and the
light shut out. The patient should have a sedative
draught, and atropine should be instilled into the eye
daily, until the inflammation has subsided.

Ptosis signifies a drooping of the upper eyelid,
generally from a paralytic condition of the third
nerve, which controls the levator palpebrse muscle.
It may be accompanied by headache, giddiness, and
cerebral congestion. If so, some active derivative
medicines will be required. It may be associated
with cerebral tumour or ramolissement, and then it
is attended with dimness of vision and a sluggish
dilated pupil. If the ptosis has come on gradually
without any assignable cause it may be desirable to

H

98 FACE AND FOOT DEFORMITIES.

ascertain whether there is any occult cause for it,
such as intestinal irritation, ascarides, morbid cravings,
masturbation, or general feebleness from loss of appe-
tite, or a tendency to mental depression.

The drooping of the upper eyelid may be so
marked that it covers the eyeball unnaturally, and
even falls over the pupil. Such cases may be effec-
tually rectified by the removal of an elliptical piece
of skin from the upper eyelid midway between the
edge of the lid and the eyebrow, and by the approxi-
mation of the divided edges.

The same kind of operation, though to a less extent,
may be required for inversion of the eyelid, with
turning in of the eyelashes, so that the conjunctiva
becomes irritated. This is a very needful operation,
because the protracted irritation caused by the in-
verted eyelashes produces thickening of the membrane
and opacity of the cornea. The kind of operation
which it may be desirable to make depends much
upon the character of the inversion, and the condition
of the tarsal cartilage. In some cases a vertical in-
cision near the angle of the eyelid will suffice to evert
the tarsal border, and in others that are more trouble-
some, it may be necessary to cut away the whole of
the free border, so as to destroy the roots of the eye-
lashes.

Spasmodic twitching of the eyelid, which produces
a visible quivering of the skin around the orbit, is an
intermittent deformity which occurs in people of an
irritable or nervous temperament. Like most spas-
modic affections, it is decidedly increased under severe
mental anxiety or strain, and it is often caused by

FACE AND FOOT DEFORMITIES. 99

intestinal irritation. Careful dieting, aperient medi-
cines, and tonics may suffice for its cure.

Epicanthtts is a deformity of the eyelid caused by
a folding in of redundant skin at the inner corner of
each eye, partially concealing the caruncle. It is often
observed in children that have a depression in the
vault of the nose. By excising a vertical fold of
integument just below the eyebrow and approxima-
ting the edges we may remove this redundant tissue.

Entropion being caused by the contraction of the
ciliary margin of the eyelid, the upper border of the
lid is inverted as well as the follicular apparatus.
Some surgeons have considered this deformity to
be caused by a contraction of the tarsal conjunctiva.
A perverted action of the orbicularis muscle is sup-
posed by others to cause this inversion, and Mr,
Haynes Walton has proposed to divide the muscle
by a vertical incision, and thus to check the spasm
which causes the inversion. Another method of
curing this deformity is to remove a narrow slip of the
muscle with the superjacent skin, parallel with and
close to the tarsal margin. By dissecting the muscle
away from the cartilage and approximating the cut
edges, we may succeed in everting the lid.

Trichiasis is a deformity characterised by a growing
in of the eyelashes, so that they rub against the sen-
sitive membrane covering the ball of the eye, which
is called the conjunctiva. It is caused either by
congenital inversion of the ciliary margin of the tarsal
cartilage, or it is due to chronic inflammation and con-
sequent thickening of the margin of the eyelid, so that
it contracts upon itself and inverts the follicles of the

H 2

loo FACE AND FOOT DEFORMITIES.

ciliary processes. Various operations have been pro-
posed for the removal of this cause of irritation. If
the eyelashes are plucked out they will grow again.
An elliptical piece of the eyelid may be excised, and
the gaping edges approximated, by which means the
tarsal border may be everted. Another and a neater
method, though more difficult in execution, is to
transpose the margin of the ciliary follicles by four
parallel incisions, so that a narrow strip of skin about
one-sixteenth of an inch in width is interposed by
plastic transposition between the ciliary follicles and
the conjunctiva. A connecting link of skin is of
course retained at the outer and inner canthus to
keep up the vitality of the transposed strips. Another
method of effecting the same object is to dissect off
the hair bulbs from the cartilage, after reflecting a flap
of integument, so as to expose the deep attachments
of the hair follicles.

Ectropion, or excessive e version of the lid, may be
caused in a variety of ways. Chronic inflammation
of the conjunctiva which has been neglected or im-
properly treated, ulcerations about the margins of the
lids and in the follicles, abscesses in the lachrymal
duct, burns and other destructive ulcerations of the
skin of the face, may cause a dragging down of the
eyelid.

In extreme cases we not only have eversion of
the lid, but exposure of the conjunctiva, causing con-
siderable irritation to the sensitive membrane cover-
ing the eyeball, which should be always kept moist
by the constant washing of the locomotive lids.

In these cases a satisfactory operation is not always

FACE AND FOOT DEFORMITIES. loi

possible, because the amount of destruction or wasting
of the lower eyelid is often very great, and it is
difficult to restore the remnant of lid to its proper
position as a cover to the eyeball. A V-shaped piece
of tarsal cartilage, and integument covering it, may be
removed in simple cases. In more severe cases it may
be necessary to cut down horizontally through the
eyelid upon the conjunctiva, and drawing that mem-
brane through the wound to raise and invert the tarsal
border of the lid upwards towards the globe. The
redundant membrane may then be cut off and the
edges of the wound approximated in the usual way. —
Vide lithograph of plastic operation upon the lower
eyelid.

I have devoted a sub-section to the consideration
and treatment of surface deformities of the eyeball.
This will be found at the end of this section.

Encysted steatomes, called chalazion, are often found
as pearl-like swellings under the skin of the eyelid,
easily shifting under the pressure of the finger, and
circumscribed so that the removal may be effected
without difficulty. The contents may be putty-like
or fluid, according to the length of time allowed for
growth, and the amount of inflammation, if any, that
may have occurred in the primary formation. They
sometimes show more prominently on the outer sur-
face, but at others they press inward upon the eyeball,
and may be best enucleated by dividing the tarsal
conjunctiva. If the growth is distinctly more pro-
minent towards the surface, and there is thinning of
skin over, doubtless it would be simpler and better to
remove the cyst by an external incision.

I02 FACE AND FOOT DEFORMITIES.

Strabismus or squint is a deformity of the face
either congenital or acquired, and characterised by
the absence of parallelism between the optic axes of
the two eyes. Such parallelism is more apparent than
real, for there is generally some slight divergence of
the optic tracks to give wider scope of vision. When
using the eyes for near vision, we often unconsciously
try to relieve the tension of the ciliary muscle by
making use of the internal recti muscles to concen-
trate the optic axes upon the object which we are scru-
tinising with some care. The action of the ciliary
muscle is to compress the lens and render it more
convex for the inspection and examination of near
objects. When the strabismus is but slight or of
recent development it may be corrected by the use
of convex glasses to cure the hypermetropia which is
blurring the sight for near vision.

Strabismus is frequently the result of brain dis-
turbance, as from the deposit of tubercles in the
membranes of the brain.

Very pronounced cases of convergent strabismus
cannot be cured without the division of the internal
recti muscles. The operation is very simple and
quite painless under chloroform, and the marked
beneficial effect which follows is very gratifying. In
unilateral squint it will suffice to divide the rectus
muscle on that side. If parents desire to delay the
operation they will endanger the sight of the eye, as
the nerve atrophies in consequence of not being used.
There must therefore be no hesitation as to the ad-
vantage of submitting to the operation when the
surgeon has decided upon it. I prefer the valvular

FACE AND FOOT DEFORMITIES. 103

incision through the conjunctiva and then through the
capsule of tendon, so as to leave a dependant incision.

It is necessary that the child should be supplied
with suitable glasses to correct what remains of
hypermetropia and to keep up the balanced action
of the two eyes.

When the eyeball is everted, it is seldom desirable
to divide the external rectus muscles, as this de-
formity often recurs.

Disease of the antrum, malar bone, or alveolar
abscess, may cause a glueing down of the eyelid, so
that the lid becomes everted.

Abscesses in the neighbourhood of the orbit may
cause the lid to be involved in the puckered cicatrix,
so that not only is it drawn down and the conjunctiva
everted, but the upper lid also has to yield to the
contracting force of the scar, and the result is an
acquired ptosis, even to the extent of overlapping
the pupillary aperture.

Ophthalmia tarsi is an inflammation of the pal-
pebral conjunctiva and the free edge of the lids.
It is attended with disordered secretion from the
Meibomian glands, so that the lids become glued
together, especially at night. There may be con-
siderable pain and soreness. It is usually chronic
and difficult to cure. The roots of the eyelashes may
be destroyed. There may also be some gastric dis-
turbance. The health must be attended to. There
must be frequent bathing of the eyelids with warm
milk and water, and the edges should be smeared with
dilute citrine ointment at night. Astringent collyria
may be required if the conjunctiva is inflamed.

I04 FACE AND FOOT DEFORMITIES.

Blepharitis signifies an inflammation, either acute
or chronic, of the deep tissues of the lid, especially
the follicles and glands. If the disease is allowed to
go on unchecked the eyelids become thickened and
lumpy. There is an accumulation of hardened se-
cretion around the eyelashes at the margin of the lid.
This must be carefully sponged away every morning,
or else the follicles will become obstructed and the
disease increase. By carefully everting the lid so as
to expose the outlet of these follicles, and by warm
bathing to soften down the secretion and open up the
follicles, we may succeed in allaying the irritation.
Some dilute citrine ointment should be rubbed into
the follicles, not merely smeared on, but with the
definite purpose of pressing it into the follicles, so as
to act as an absorbent to the products of inflam.mation.

Symhlepharon is an adhesion between the lids, or
if one lid, usually the upper, to the eyeball, the result
of acute ophthalmia. The patient requires a plastic
operation to remove the deformity. Division of these
cicatricial bands may be advantageous, and then the
application of some fine sutures to approximate the
edges, but we must not expect any very good results.

One of the most unsightly deformities about the
eyelid is that of destruction of the hair bulbs from
chronic inflammation, and consequent atrophy of the
tarsal cartilage, with eversion of the lid and exposure
of the red margin of the conjunctiva. This deformity
occurs in delicate strumous children, many of these
having been neglected in infancy. The patients con-
tinue through life to suffer from chronic inflammation
of the conjunctiva, caused by the access of dust and

FACE AND FOOT DEFORMITIES. 105

irritating particles to the eye ; there is also usually
some photophobia and blepharospasm. The eye
should be bathed with soothing lotions to allay the
spasm and chronic inflammation. Glasses should be
worn to protect the eyes from dust, &c.

Obstructed lachrymal ducts may cause temporary
or permanent disfigurement.

Inflammation of the lining membrane of the ducts
may produce swelling, and consequent inability to
pass the tears through the ductus ad nasum, so that
they fall over the cheek. Warm bathing or poulticing
will subdue the inflammation and remove the obstruc-
tion in some cases.

When the canaliculi are closed as the result of
chronic inflammation, they should be slit up on a fine
probe or grooved director.

Obstruction of the lachrymal sac from chronic thick-
ening of the mucous membrane is not uncommon
in delicate or strumous children. The tears escape
on to the cheek instead of flowing down through the
canaliculi to the nose. The lachrymal sac becomes
distended with mucus and muco-pus. The skin over
the sac will then inflame, and a fistulous track will
form, if the abscess is allowed to open on to the
surface of the face. Unless this is operated on so
as to re-establish the aqueduct for the tears, an un-
sightly swelling with puckered edges will be seen
just below the tendo oculi on that side.

Simple acute inflammation of the sac may be re-
lieved by leeches, fomentations, and aperient medicine.
When the sac first becomes distended the patient
should endeavour to evacuate the contents by gentle

io6 FACE AND FOOT DEFORMITIES.

pressure upon the outside, so as to open up the
duct.

To restore the ducts to their normal condition, and
to close up the fistulous track, it will be necessary-
after the inflammation has abated to slit up the
canaliculi, and to pass some silver probes down
through the lachrymal- duct to the nose. This
probing should be repeated daily till the ducts
remain patent.

Catarrhal ophthalmia often causes distinct de-
formity of the face from swelling and tumefaction of
the eyelids. There is considerable smarting, heat,
and pain in the eye, with a sensation of grittiness, as
though dust had got into it. It often, in fact, de-
velops in consequence of sand or grit becoming
lodged in the meshes of the conjunctiva. Sparks
from a furnace or splinters from iron, &c., may pene-
trate this membrane and lodge in the cornea, setting
up inflammation all round. Those of a rheumatic
constitution, exposed to draughts of cold east wind,
and living in an unhealthy atmosphere, such as dark
and ill-ventilated dwellings or crowded offices, fre-
quently suffer during the winter months from catarrhal
ophthalmia. The pain may be very severe or it may
be slight. Want of exercise, excessive use of stimu-
lants and tobacco, nervous prostration, inducing sleep-
lessness, imperfect digestion, &c., may all be important
factors in the causation of this disease, and require
consideration when treating these cases. The sight
becomes blurred when the inflammation has spread to
the ocular conjunctiva. There is some intolerance of
light, and considerable lachrymation. The disease

FACE AND FOOT DEFORMITIES. 107

may be slight and transient, or it may involve the
whole membrane, both tarsal and ocular. As the
disease progresses the conjunctiva becomes very red,
and a thick purulent discharge may occur. The
semilunar fold and caruncle are also red and swollen.
There may be some ulceration, especially where the
conjunctiva is reflected on to the eyeball. If the
sclerotic is involved the patient will suffer from photo-
phobia and lachrymation. There is almost sure to
be considerable debility and nervous prostration, re-
quiring general treatment. This disease may become
chronic. There is generally a sense of fulness and dis-
comfort in the eye, and the lids glue together at night.
It is desirable to use the lotio arg. nitras, 2 grains to
the ounce, or the lead lotion or rose-water, and to bathe
the eye with lotio papaveris. The surgeon must not
fail to search for a foreign body which may be lodged
in the eye. For this purpose he must evert the lid,
and with a probe, carefully used, he may succeed in
extracting the splinter from the conjunctiva.

Purulent ophthalmia or ophthalmia neonatorum is a
disease per se, occurring in delicate infants, generally
the offspring of mothers that are subject to vaginitis.
In such cases the edges of the lids become glued
together and the discharge is very abundant so that
pus collects under the eyelids which distend and
become suffused. It also presses upon the orbit.
Prompt measures must be taken to cure this disease,
as the cornea very quickly becomes destroyed by the
spreading inflammation, and the eyeball collapses in
consequence. The surgeon should evert the eyelid and
carefully syringe out all the pus and flakes of lymph.

io8 FACE AND FOOT DEFORMITIES.

He should then with a stick of modified caustic, i.e.
equal parts of argenti nitras and potassse nitras, touch
the exposed surface of the conjunctiva. Care must
be taken, in everting the lids, not to press upon the
globe of the eye, because if the cornea is very soft
and ulcerating, it may burst open and thus lead to
the destruction of the eyeball. Some astringent
collyria may be necessary, as alum or acetate of lead,
to favour the subsidence of the inflammation.

Purulent ophthalmia in adults begins with the same
symptoms. The conjunctival membrane is very red
and inflamed. It may become distended by sub-
conjunctival infiltration overlapping the edge of the
cornea. The patient suffers considerable pain in
the temples, with headache, and prostration. He is
generally very feeble, with a pallid face and irritable
or depressed temperament. It may be caused by the
introduction of lime, sand, &c., or by an unhealthy or
miasmatic atmosphere, as in the Egyptian variety,
which is contagious. We know how rapidly this
disease will spread in crowded barracks, schools,
and hospitals, unless rigid measures are adopted for
checking its progress.

In the milder cases the purulent secretion becomes
arrested by the astringent lotions, but in the severe
cases the conjunctiva will ulcerate and the cornea
may slough, leading to prolapse of iris, chemosed
conjunctiva, and destruction of the sight.

Very careful treatment will be required to combat
successfully this disease. The patient should have a
soothing treatment at first, with a sedative at night to
relieve the pain. He may then have nutritious food

FACE AND FOOT DEFORMITIES. 109

and careful dieting, with a mixture of quinine and
iron or some useful tonic and stomachic, and plenty
of fresh air.

Goiiorrhoeal ophthalmia is produced by the appli-
cation of gonorrhoeal matter to the eye. It has a
very rapid development. There is considerable local
irritation and the pus is thick and abundant. There
is generally some chemosis of the ocular conjunctiva,
and the disease may spread to both eyes, probably by
inoculation. To save the eye it will be necessary to
resort to active measures of treatment as the cornea
may slough within a few hours unless the inflamma-
tion is subdued. The membrane must be touched all
over with the modified caustic. The patient may have
some poppy fomentation to relieve the pain and a
Dover's powder at night. He usually requires tonic
supporting treatment, as bark and ammonia, also
nourishing food. Leeches to the temples may be
required, and the lids may be smeared at night with
the citrine ointment.

Phlyctenular or strumous ophthalmia is character-
ised usually at the commencement by extreme photo-
phobia; the eyelids being kept spasmodically closed
and the head turned away from the light, and the
tears flow in abundance. At the junction of the cornea
with the sclerotic there are one or more red specks
or circumscribed ulcers, and the sclerotic zone of
vessels around the margin of the cornea may be also
inflamed, forming a closely meshed network of vessels.
We may succeed in apparently curing the disease, but
it will return again in the course of a few months.
The children attacked are usually of a strumous

no FACE AND FOOT DEFORMITIES.

temperament, and may have fissured lips, ulcerations
behind the ear, swollen glands in neck, &c. A gentle
aperient, as rhubarb and soda, may be required at
the commencement of treatment, followed by iron
tonics, cod-liver oil, &c. It will be desirable to place
the child in a healthy home, with plenty of fresh air
and nourishing food. The photophobia may be re-
lieved by bathing the eye with poppy fomentation
and by the instillation of atropine drops, two grains
to the ounce, or the ung. flav. dil. may be found
useful. Iron and quinine may be given internally.
The eyes should be protected from the light by the
use of shades. If an astringent lotion is required we
may use the solution of acetate of lead.

Pterygium is a triangular deformity of the con-
junctiva, consisting of enlarged and distended vessels
radiating from the cornea outwards over the hemi-
sphere of the sclerotic. It seems to develop gradually
and is not associated with conjunctivitis.

Surface Deformities of the Eyeball. — Tumours of
a fibroplastic, fatty, papillary, or cancerous nature may
form on the conjunctiva. These should be ligatured
or excised.

Pinguecula is a small fibrous tumour which appears
on the eyeball close to the corneal margin, of a tri-
angular form with the base towards the cornea. It
may be surrounded by a spray of dilated vessels.
These are harmless growths, which may or may not
be removed by excision or ligature, according to the
amount of annoyance to the patient.

Diseases of the cornea are various and usually
cause much disfigurement. In simple inflammation

FA CE AND FOOT DEFORMITIE S. in

the cornea becomes opaque, red, and swollen, like
steamy glass. A zone of pink vessels surrounds the
margin of the cornea.

Keratitis is generally associated with much photo-
phobia and lachrymation. Children who suffer from
keratitis are usually of a strumous or anaemic constitu-
tion. There is usually some opacity of the cornea.
There may be some constitutional disturbance, fever-
ishness, etc. Fomentations, atropine, and blisters to
the temples may be required, as also tonic treatment.

Opacity of the cornea may be interstitial or on the
surface, and it may occur in one large patch usually at
the centre, or the cornea may be stippled, i.e. numerous
small opacities are dotted over the cornea, and these
are interstitial. Sometimes the patch is a mere hazi-
ness, at others it is quite opaque and pearl-like. These
opacities are more or less permanent, especially
when the deposit of lymph is very abundant. Large
opacities are called leucomata. These cannot be
cured by excision, but we may remove the unsightly
character of this deformity by tattooing the leucoma
with Indian ink. When, as generally happens,
the pupil is blocked up by such opacity it will be
necessary to make an artificial pupil by excising a
portion of the iris corresponding to a transparent
part of the cornea by the operation called iridectomy.
By making such a window through the curtain of the
iris the rays of light can pass unhindered to the retina
through the transparent media.

Ulcers of the coj^nea appear frequently in strumous
and delicate children, especially those who have
suffered from privation. Ulceration may also follow a

FACE AND FOOT DEFORMITIES.

severe attack of the exanthemata, measles and small-
pox. The ulcer may have an excavated appearance,
with well-defined edges, or there may be a spray of
dilated vessels from the conjunctiva extending to it,
with some localised opacity, showing some active
efforts at repair. Or the ulcer may give rise to con-
siderable keratitis, photophobia, and constitutional
disturbance. The disease must be treated promptly
with mydriatics and tonics, nourishing food, and fresh
air. The child should wear a shade and avoid any-
thing that might press upon the eyeball. Let the atro-
pine be dropped in daily. It acts as a direct sedative
to soothe the inflammation. It also, by dilating the
pupil, relieves the tension upon the cornea, and favours
the healing process. The ung. flav. dil. is useful in
these cases. A five per cent, solution of cocaine has
also proved useful as a sedative in these cases.

Staphyloma is a conical protrusion of the cornea,
generally the result of undue distension of the anterior
chamber with aqueous fluid and the consequent
thinning of the cornea. It may lead to perforation
and hernia iris. In acute cases the eyelids must be
kept closed to support the cornea, and atropine drops
must be instilled daily, to dilate the pupil and remove
the iris from contact with the cornea. It may be
necessary to tap the anterior chamber.

Co7iical cornea consists of a general protrusion of
all the tissues of the cornea, the membrane retaining
its transparency. It gradually increases in extent,
and causes considerable disturbance of all the visual
apparatus, amounting in severe cases to total depriva-
tion of sight. The deformity is caused by excessive

FA CE AND FOOT DEFORMITIES. 1 1 3

secretion of the aqueous humour, and distension of
the anterior elastic lamina of the cornea. It is capable
of being reduced by tapping the anterior chamber,
and removing a portion of the iris by iridectomy.

A reus senilis is an annular deformity of the cornea
caused by the deposit of fatty material in the outer
zone of the cornea, close to its attachment to the
sclerotic. There is no cure for it.

Syphilitie keratitis commences usually at the centre
of the cornea. The substance of the cornea becomes
hazy and covered with white specks of opacity be-
tween the laminae. There will probably be some
increased vascularity of the corneal vessels. In a
few weeks' time the other cornea becomes similarly
invaded, unless active measures are taken to arrest the
disease. There are usually the evidences of consti-
tutional syphilis, — the pegged defective teeth, broad
and flat nose, thick upper lip, fissured margins of the
lips, peculiar muddy complexion, etc., all indicative
of the disease, — the child should be treated with
nourishing food, iron tonics, as the iodide of iron or
the perchloride, and some iodide of potassium.

Stippurative keratitis is a still more serious disease,
the laminae of the cornea may be destroyed and the
pus will collect in the lower part of the anterior
chamber, and this is called hypopion. Atropine
should be dropped into the eye daily in these cases.

114 FACE AND FOOT DEFORMITIES.

SECTION VII.

DEFORMITIES OF NEUROTIC ORIGIN.

Choreic Spasm. — I have had boys under my care who
have acquired a habit, as it would appear, of making
grimaces. When talking or in company, the muscles of
one side of the face will spasmodically contract, draw-
ing up the angle of the mouth and the cheek into
all kinds of contortions. No amount of scolding or
punishment will remedy this awkward and irregular
co-ordination of muscles. The surgeon would do
well to inquire into the habits of the boy, and pre-
scribe some constitutional treatment with a view of
strengthening the nervous system during the period
of growth and adolescence, and check any bad
debasing habit that he may have acquired. The teeth
should be examined to ascertain that there is no source
of irritation to the dental nerves, setting up a reflex
action in the contiguous branches of the portio dura
nerve.

Parents should particularly see that the mental
powers of their children are not being over-wrought.
The prevalent idea of educating boys in large schools,
and forcing them all up to the required standard, not-
withstanding the varying amount of brain power and
general capacity, is most pernicious in its conse-
quences. I will not say more on this subject, as
I have written elsewhere on the prevalent evils of
"high-pressure education."

More often these choreic spasms are due to ex-

FA CE AND FOOT DEFORMITIES. 1 1 5

treme nervous sensibility, hysteria, and want of
proper control over the complex and highly sensi-
tive nerve organisations. We must not, however,
blind our eyes to the possible existence of some
minute bony exostosis pressing upon a nerve or
thickening the nerve - trunk so as to cause this
local spastic contraction. It is astonishing what
change of air will effect in such cases, especially if
accompanied with change of scene and occupation.
It might be advantageous to send a boy suffering in
this way to school on the Continent. If he has been
living in a malarious or relaxing climate, arrangements
should be made to send him to a dry bracing place.
Sometimes galvanism to the opposite muscles may
suffice. Soothing remedies are as a rule preferable, as
liniments, rubbed in where there is much muscular
spasm. Also the subcutaneous injections of morphia
or other hypodermic sedatives where the excessive
activity is localised.

Paralytic deformities from hemiplegia of the face
muscles, the result of brain lesion and apopleptic
seizures, may be alluded to here as a not uncommon
cause of face deformities. Such paralysis is not
amenable to surgical treatment, and therefore as a rule
it comes under the care of the physician, the treatment
being directed to improvement in the general health. I
shall therefore make no further allusion to the subject.
Possibly the aid of the surgeon may be invoked in
cases of stillicidium lachrymarum, the consequence of
paralysis of the orbicularis muscle, and also in cases
of constant dribbling of saliva from the mouth in
these paralytic cases ; but there is very little local

I 2

Ii6 FACE AND FOOT DEFORMITIES.

treatment that can be depended on for the cure of
these cases.

The general paralysis of the insane causes drooping
and relaxation of the facial muscles so that there is
the customary vacant stare of imbeciles from loss of
power in the muscles of expression. This of course
is irremediable. The face muscles, in connection with
the muscular system generally, may undergo fatty
degeneration in imbeciles, so that there is a decided
loss of feature. The emotional expression under
animation which gives force and character to the
individual is lost in such cases. Spasmodic action of
the portio dura nerve may give rise to a kind of
tetanic spasm of the orbicularis, and other face muscles,
in patients with much mental anxiety or torpidity of
liver. Such cases may be relieved or cured by the
careful regulation of diet, and by directing treatment
to the liver and alimentary canal.

Facial paralysis may occur in cases of abscess in
the petrous portion of the temporal bone pressing
upon or destroying the portio dura nerve. It depends,
of course, upon the amount of damage to the facial
nerve, whether the child will recover the power in the
muscles of the face. The deformity is most marked
on the opposite side to the paralysis, especially when
the child cries or laughs. Sometimes the petrous
portion will come away as a mass of necrosed bone in
cases that have been much neglected.

FACE AND FOOT DEFORMITIES. 117

PART II.
THE FOOT.

SECTION VIII.

DEFORMITIES INDUCED BY INJURY OR DISEASE —
DISLOCATIONS OF THE ANKLE, AMPUTATION
STUMPS, ETC. ; INGROWING TOE-NAIL ; SIMPLE
ONYCHIA, ONYCHIA MALIGNA, ETC.

Considerable deformity of the foot results from
severe sprain or contusion of the ankle. Not only do we
have in these cases effusion into the synovial membranes
and burss, but the soft tissues become infiltrated from
damage to the vessels. The surgeon must be careful
to diagnose this injury from fracture of the bones.
If neglected the foot will swell up considerably. The
astragalus may be slightly displaced and also the
fibula. The effusion around the joint may cause
chronic swelling about the ankle, requiring active
treatment and firm bandaging to promote absorption.
Absolute rest in bed is the only effectual way of
treating these injuries. A rectangular splint may be
fixed to the inside of the leg and foot, and an evapor-
ating lotion or ice-bag applied to the dorsum of the
foot. The bed-clothes must be supported by a cradle,
so as to keep the foot as cool as possible.

1 1 8 FACE A ND FOOT DEFORMITIES.

If there is any wound or serious damage to the soft
parts, this may be treated with carbolic lotion or
fomentations.

Separation of the tarsus from the metatarsus. — A
case of this kind came under my care at the Victoria
Hospital, in a child eight years of age. She had
caught her foot, when running, between the bars of a
grating, and gave it a severe wrench. She had been
treated for contusion of the foot, but the parents find-
ing after six weeks of treatment that she had lost all
power with the limb, and was obliged to walk with
crutches, they brought her to the Hospital.

Finding the forward part of the foot quite loose and
moving freely upon the tarsus, I placed it in a firm
encasement of plaster of Paris, including the toes and
the ankle-joint. The limb was kept at perfect rest
for three weeks, and the general swelling of the foot
subsided. Consolidation of the ligaments took place,
so that in the course of another month she was able to
get about without any lameness and to put the weight
of her body upon the damaged foot.

Dislocation of the Ankle-joint may occur outwards,
as in severe cases of Pott's fracture, also inwards,
backwards, and forwards.

In the outward displacement, the fibula is generally
broken just above the ankle, the foot becomes loose
and everted, and the outer edge raised, and a vacancy
occurs at the inner ankle where the lateral ligaments
have been torn away. The upper fragment of the
fibula is turned inwards, giving the appearance of a
hollow in the leg above the outer ankle. The strong
ligaments which bind the astragalus to the os calcis

FACE AND FOOT DEFORMITIES. 119

are also torn away in some cases. The astragalus
being displaced from its normal relation to the articu-
lating surface of the tibia, may in all these dislocations
be felt as a prominent swelling, away from the tibia.
The foot is more or less rigidly fixed by the spasmodic
contraction of the muscles of the leg.

With the laceration of the internal lateral ligament,
there may be a small fragment of the tibia broken off.

For the inward dislocation of the foot, much greater
force is required, and it is therefore a much rarer
form of dislocation. In these cases the foot is
inverted, the outer ankle shows very prominently, and
the sole of the foot being inclined upwards and in-
wards, the end of the fibula is nearly level wth the
ground.

These dislocations are caused by some severe strain
and twist, as in falling off a roof or jumping from any
great height To correct this deformity the foot
should be taken in hand without delay, and promptly
restored to its normal position. The leg should be
flexed on the thigh so as to relax the muscles, and
the limb may then be put up on side splints with foot-
pieces. When the swelling has subsided plaster of
Paris encasement, or gum and chalk bandage may
suffice to keep the ankle fixed.

Dislocation backwards may occur from the foot
being gripped or checked during a fall forwards, with a
heavy momentum upon the body. The capsular liga-
ment will be torn, and the fibula may be broken. In
this case the heel will be very prominent at the back,
and the foot foreshortened with the tibia protruding
upon the dorsum of the foot. The foot must be

I20 FACE AND FOOT DEFORMITIES.

extended with the leg flexed and brought forward,
and then placed in a retentive apparatus. There is
not generally so much damage to the bones and soft
parts in this dislocation as in the other varieties of
dislocation of the ankle. The astragalus itself may-
be displaced either forwards or backwards, and em-
bedded among the tendons, so that reduction may
be impossible. In such cases it will be necessary to
consider the propriety of excising this bone, so as to
restore the foot as far as possible to its normal
position under the tibia.

Compound dislocations may occur in the same way,
and they probably happen more frequently from
severe railway accidents, the crush of brewers' drays,
etc., than from ordinary accidental falls. When acting
as Resident Assistant Surgeon at St. Thomas's Hos-
pital, I had several of these cases admitted from the
Nine Elms Goods Station, and from the coal depdts.
Coal-heavers are generally a very clumsy and boosy
class of men, and they often come in for these serious
injuries. Unfortunately there is usually so much
damage to the vessels and soft parts that erysipelas
is very likely to supervene, or the patient may have
delirium tremens, and so there is a large per-centage
of deaths from compound dislocations of the foot.
The question of amputation will of course have to be
carefully considered in such cases.

For the treatment of these injuries it will be neces-
sary to examine the amount of damage to the soft
parts, and to act promptly in accordance with past
experience of the merits or demerits of conservative
treatment. The surgeon will not fail to inquire into

FACE AND FOOT DEFORMITIES. 121

the habits of the patient, and give him the chance
of preserving the limb if possible. Since the intro-
duction of antiseptic treatment we have been able to
hold out better hopes of retaining the limb, though it
may require long and tedious treatment. The soft
parts must be cleansed and approximated as far as
possible, and the limb put up on a Mclntyre splint or
other fixation apparatus, to keep the joint steady.
The wound to be dressed antiseptically.

Dislocation of the other tarsal bones is extremely
rare, so I shall make no further reference to these.

Hypertrophy of the foot is occasionally met with from
excessive growth of all the soft parts, or it may be
limited to one or more toes. In such cases it will be
necessary to consider carefully the question of ampu-
tation, though in consequence of the absence of any
malignant disease developing in the foot, it may
suffice to treat the case by elastic compression and
suspension, so as to promote absorption of the effused
or hypertrophied cellular and adipose tissue.

There are many diseases of tropical climates found
among the natives, such as those caused by their habits
of walking barefoot through marshy ground and rice
plantations that are full of animal life. Prominent
among these are the fungus disease or Madura foot,
elephantiasis, cellulitis of foot from poisonous plants,
snake bites, penetration of earthworms, as the Guinea
worm, etc. I have no experience of tropical disease,
and must therefore refer my readers to such writers
as Norman Chevers, Fayrer, Macnamara, etc., who have
spent most of their lives in India, and have made
good use of their opportunities for studying such

122 FACE AND FOOT DEFORMITIES.

diseases, I must also refer my readers to the section
on the Face for a description of the diseases which
correspond to those that are to be found on the foot.

Among the most frequent deformities of the foot
are stumps, the result of gangrene or partial amputa-
tion of the foot or toes, and various abnormal con-
tractions of the foot after excision of bones and the
removal of tumours,

I have had some very satisfactory and good per-
manent results from excisions of bones of the tarsus
and metatarsus. I have given in the Appendix par-
ticulars of a typical case of deformity after excision
of the largest bone of the foot — the os calcis — show-
ing what may be done by conservative surgery of the
foot. The illustration shows the limited amount of
deformity resulting from this operation.

It will be observed that I am not discussing the
general surgery of the foot and face, my object being
to limit myself to surface deformities as far as pos-
sible. Concerning questions of excision or ampu-
tation, there is very little of novelty to write on this
subject. I must refer my readers to the current text-
books on Surgery for information on the deep surgery
of the foot.

Chilblains are caused by local congestion of the
skin at the extremities, where the circulation of blood
is always very feeble. In the case of weak or deli-
cate young people with deficient vital energy, there
is a tendency to stasis of blood in the capillaries,
and this particular form of congestion is the conse-
quence. Young people must be warned against the
lazy habits of toasting their toes on the fender, and

FACE AND FOOT DEFORMITIES. 123

of keeping at home, instead of taking a brisk consti-
tutional every day, however much it may grate against
their incHnations. The three volume novels have
much to answer for, in the production of chilblains.
Young women are especially liable to this complaint,
and it may last on and off for years. Sudden changes
of temperature, as a thaw after a long frost, are very
likely to produce this disease. The symptoms at first
are tingling and itching of the affected extremities,
then tenderness, and finally vesication, if unchecked,
tending in some cases to indolent ulceration of the
integument. Some suffer in the hands, and others in
the feet only. The exact time of commencement of the
swelling, redness, and irritation is generally about the
same, daily, for each individual attacked. There is a
predisposition to this complaint in families, from an
asthenic condition of the blood causing feeble circu-
lation in the extremities.

Sufferers from this painful malady must be en-
joined not to wear tight garters, tight shoes or gloves,
or elastic bracelets on the arms. Gentle friction to
the extremities daily will help the sluggish circulation.
The patient may take a little port wine daily for
lunch, or some warm milk night and morning in bed.
Additional underclothing should be worn to keep
the limbs warrn, and a good supply of blankets at
night. Stimulating liniments may be used to accele-
rate the circulation. The affected toes may be painted
with collodion and castor oil, or the amyl colloid. If
the itching is intolerable, bathe the feet with poppy
fomentations, or apply ung. belladonnse externally.

When vesication or ulceration appears, dress each

124 FACE AND FOOT DEFORMITIES.

toe separately with carbolic oil or zinc ointment.
There may be deep sloughing ulcers form around the
toes and dorsum of the foot, which are very indolent
and difficult to heal. If the ulcers are indolent they
may be dressed with lead or zinc lotion.

I have not given a separate section for skin erup-
tions on the foot, because these can scarcely be called
deformities or disfigurements, and because the several
varieties of skin disease are, for the most part,
described under the heading of Fac€ Eruptions.

Diseased Toe-nails may require treatment in various
ways. They may peel off in laminated shreds, a form
of psoriasis, or they may grow in a very nodulated
fashion, from some disease or defect of the matrix.
Toe-nails sometimes grow very rapidly, and being
neglected, may become hypertrophied, forming a
horny mass, which projects beyond the toe, con-
stituting an impediment to the patient in walking.
It may be necessary to destroy or remove the nail
under these circumstances.

In-growing Toe-nail is a painful and often trouble-
some, though frequent complaint, involving the toes,
especially the big toe. It is caused in part by the
pressure of a badly fitting narrow boot, and also
from the habit of paring the nail at the side, so that
the sharp incisive edge of the toe-nail presses deep
into the sulcus of soft integument which overlaps the
nail at this part. So long as the ulceration commonly
called " proud flesh " continues, the efforts of nature
to heal the sore are unavailing. There is consider-
able pain and discomfort. The treatment must be
directed to liberating the soft tissues from the incisive

FACE AND FOOT DEFORMITIES. 125

pressure of the toe-nail. By pushing a thin strip of
lint or soap plaster, or sheet lead under the lateral edge
of the nail, the ulcer may then heal in the usual way.
The toe should be dressed with stimulating lotions, as
the zinc and lavender, or if the granulations are
exuberant, the base of the sore may be touched with
the solid nitrate of silver.

In long-standing cases, when the nail is deeply
embedded in the granulations, it is useless to attempt
these milder methods of treatment. A sharp pair of
pointed scissors must be pressed under the nail on
this side, and without much difficulty the faulty section
can be quickly slit up and removed. Patients need not
have the dread of this operation which they sometimes
display, in ignorance of the real benefit to be derived
from the removal of this cause of irritation. The
ulcerating process which has been going on for some
time has separated the matrix of the nail at this
part from the nail proper. If the surgeon is expedi-
tious, he will succeed in removing the portion of
loosened nail before the patient has much time to
complain. Directly this is done, the ulcer being freed
from " the thorn in the flesh," as represented by the
in-growing nail, will quickly heal under the applica-
tion of warm water dressing, or lead lotion.

Simple Onychia is a disease of the matrix of the
nail, with suppuration, limited usually to one side of
the nail. It may have been caused by some slight
injury, as a bruise, or by the entrance of a thorn under
the nail. Warm water dressing will usually suffice
to subdue the inflammation. A new nail will pro-
bably form in due course.

126 FACE AND FOOT DEFORMITIES.

Onychia maligna is a disease of the matrix at the
root of the nail, with sloughing of the cellular tissue
around the nail. It commences by inflammatory
swelhngof the terminal phalanx, followed by suppura-
tion underneath the nail, which is often of a very
fcetid character, and there is usually a dusky red in-
flammation all round the root of the nail. The sur-
geon discovers that the nail is quite loose, being
separated from its natural attachments to the phalanx,
and embedded in soft sloughy material, surrounded
by swollen and congested skirt of a livid red colour.
The infiltration of the soft parts all round gives rise
to a very unsightly deformity of the toe. It occurs
in feeble, delicate children. The dead nail must be
raised from the ulcerating surface beneath, and cut
away so as to expose the sloughing matrix, which
should be destroyed with caustics, and then poulticed
or dressed with a soothing lotion, or the liquor potassae
arsenitis, strength i part to lo. The child should
have some tonic treatment, such as chlorate of potash
and perchloride of iron, or the bark and ammonia
mixture. The matrix is often entirely destroyed.

Homy growths and exostoses occasionally develop
from the matrix of the nail at the end of the phalanx,
tilting up the nail so as to become an impediment in
walking. These growths may be excised without
any difficulty, and they are not likely to return.

Deformity from Perforating Ulcers. — Mr. Dent
showed at the Pathological Society last year a case
of symmetrical deformity of the feet following per-
forating ulcers. In this case the phalanges and
greater part of the metatarsal bones in both feet

FA CE AND FOOT DEFORMITIES. 1 27

were destroyed by a gradual process of quiet necrosis.
The integuments of the toes retracted so as to cover
the stumps of the metatarsal bones. The skin of the
soles of the feet became unusually thick and horny,
although the patient was not able to walk any dis-
tance. His maternal grandmother had feet similarly
affected, showing the hereditary nature of the disease.
Two of the brothers had the same condition of ulcera-
tion of the feet.

There are also many deformities from the growth
of tumours, abscesses, ulcers, cellulitis, necroses, ex-
ostoses, ossifying enchondromata, malignant disease,
etc., which I merely enumerate as indirect causes of
deformity of the foot. Also gouty, syphilitic, tubercular,
and rheumatic diseases of the bones and articulations
of the foot, which require to be treated as local and
constitutional affections rather than as deformities.

SECTION IX.

DEFORMITIES INDUCED BY BAD HABITS — FAULTY
BOOTS, BUNIONS, CORNS, DISTORTED TOES, ETC.

Deformities induced, by Bad Habits. — Some chil-
dren acquire bad habits of limping or scuffling along
awkwardly when walking, unless properly checked.
Or they may acquire an awkward posture when
standing, such as stooping, waddling in their gait,
shrugging the shoulders, making ugly grimaces, habits
which they cannot apparently control. Some children
will fall down suddenly and hurt themselves without

128 FACE AND FOOT DEFORMITIES.

any accountable cause, except it be from clumsy
habits of walking and running, rather than from
tripping against any obstacle.

These habits and many others, such as wetting the
bed, are often pronounced incurable, whereas most of
them may be rectified by judicious management and
proper treatment.

As regards deformities of the foot and other bad
habits which children contract, and which if neglected
may develop into some permanent disability, I have
had some encouraging experiences in the treatment of
such cases. Recognising the fact that the child is
budding out into life with an unknown future before it,
possibly with great expectations, I do not despair, when
I remember that a young and green twig may be
gradually trained or twisted in almost any direction,
whereas a hard woody stem will break in the attempt
to alter its configuration.

Under this heading I include those numerous cases
of distorted toes and feet, the result of badly fitting
boots. When we examine the normal foot of a newly-
born babe, or the ideal foot of some Phidian sculpture,
we see at once how terribly nature has been made to
model herself according to the prevailing fancies and
customs of the time.

Judged from the light of Oriental and English
history, it would seem to be the peculiar mark of
good breeding to travesty nature to the utmost ex-
tent by the eccentric fashions which have prevailed at
different epochs. We owe it much to the teaching of
modern sanitarians of both sexes that many of these
bad habits are now being overcome, so that the slaves

FACE AND FOOT DEFORMITIES. 129

of fashion are permitted to mix in genteel society
with liberated limbs and untortured bodies.

An exception, however, must be made as regards
shoes and boots. The Chinese fashion of cramping
the feet so as to reduce them to the smallest dimen-
sions seems to have got a firmer hold upon the jeimes
dames, the consequence being that feet, which would
otherwise appear in due relative proportion to the rest
of the body, are cramped into boots and shoes of about
half the required size. With the view of throwing the
body forward and raising the heels from the ground,
high conical blocks are fixed to the centre of the
sole, and the wearer has to learn the clever feat of
balancing herself upon two or three square inches,
instead of upon the full extent of the plantar surface
provided by nature for her to walk on.

The evil consequences of such folly are immediate
and prospective. Modern young ladies are compelled
to sedentary occupations, because of the trouble and
difficulty of perambulation. Brisk walking becomes
" a bore," and is therefore seldom indulged in. Failing
healthful exercise and occupation, young people get
discontented and querulous. Constipation is the rule
rather than the exception, and, in short, the vigorous
healthy growth of the body, so necessary at the period
when our young maidens are expanding into woman-
hood, is checked, and they must sooner or later reap
the bitter fruit of pandering to such baneful fashions
and customs.

I am constantly being consulted by young ladies
for deformities of the feet occasioned by such bad
habits. The whole weight of the body is thrown on

K

I30 FACE AND FOOT DEFORMITIES.

to the ball of the big toe, so that instead of the
phalangeal bone of the toes being continuous with,
and in a line with, the long bones of the dorsum of
the feet, they are turned up at right angles to these
bones, and the ball of the big toe becomes decidedly
enlarged and prominent.

Partial dislocation of the metatarsal bone of the
great toe is occasioned by this cramped posture. An
unduly arched condition of the foot is caused by the
high French heels and pointed toes of modern shoes
for ladies. The length of the shoe is not more than
three-fourths that of the foot. To accommodate the
foot to this cramped position it is necessary that the
toes should be tilted perpendicularly up, and the meta-
tarsal bones made to lie in an axis oblique to the
plane of the foot, forming with the toes a V-shaped
curve. Consequently, the metatarsal bone gets dis-
placed upwards on to the cuneiform bone ; and there
is no remedy for it but to wear larger and flatter, if
less elegant, boots and shoes. Nature has provided
that the weight of the body should be impinged upon
the keystone of a strong double arch, viz. the astra-
galus. These young ladies, by extreme pointing of
toes, throw the centre of gravity forwards on to the
ball of the great toe, and so the heel serves more to
balance the body, than to act as a main prop for the
superimposed weight of bone and muscle.

In other cases there is an overlapping of the smaller
toes, the bones of the feet get displaced, so that there
is an awkward rise in the centre of the instep which
is often tender and painful. In such cases pre-
vention is of course better than cure, and a return

FACE AND FOOT DEFORMITIES. 131

to the use of boots and shoes which not only do not
cramp the foot is essential, but also such as allow
a broad planting of the sole of the foot upon the
ground, so as to poise in an elegant way the super-
incumbent weight of the body. Let surgeons ask such
votaries of fashion whether it would not be thought
very inelegant and improper to place a statue upon a
narrow tottering pedestal, so small and diminutive
as to require a stick to prop it up ?

Arguing then from analogy, may we not succeed
in convincing at least some of our patients, that the
abandonment of the walking stick, and of the China-
woman's shoe, by no means necessarily involves the
adoption of a charwoman's ponderous sandal, but a
useful and well-fitting encasement to the foot, which
shall allow of the expansion and distribution of pres-
sure equally to all parts, and the consequent elastic
spring of the double pedal arch of the foot that was
once the pride and dehght of our British maidens.

We must warn our patients against depending too
much upon the advice of the shoemaker. Purveyors
of fashion must keep true to the prevailing tastes of
their customers and recommend " what is worn." We
cannot expect a wholesale conversion from the ranks
of park habitues, but let us urge compliance with well
proved hygienic principles of dress upon the more
thoughtful and educated of our patients, for their
comfort and health, and the claims of future woman-
hood.

Instead of the transverse measurement of the foot
level with the toes being, as bootmakers appear
to consider, the narrowest part of the foot, the fact is

K 2

132 FACE AND FOOT DEFORMITIES.

the foot tapers gradually towards the heel, the toes
being the broadest part, in order to give an extended
surface for planting the foot and balancing the body
when walking. Nature has made the inner line of
the foot straight, as seen in young infants, but how
few are permitted to grow up with this proper
symmetry of the foot ! The same causes may give
rise to inversion of the little toe with consequent
bursitis of the pad overlying the joint. The removal
of the cause constitutes the chief indication for treat-
ment. The sufferer should be furnished with properly
fitting boots. It is essential for the ultimate cure of
the inflammation. The distortion of the toe may be in
part rectified by the application of a splint and strap-
ping, after the subsidence of the inflammation. Moist
applications of a soothing character may be required
to allay the irritation, as poppy fomentations, warm
water dressing, &c. In chronic inflammation the skin
may be painted with iodine and protected by soap
plaster. Avoid boots with high heels. See that a
vertical line passing from the toe of the boot to the
heel traverses the middle of the boot. Select a boot
that is not curved inwards by arching it up too much
on the inner side, as is too often the case with cheap
boots. The effect of such incurvation is to foreshorten
the foot, and to throw undue pressure upon the joint
of the little toe.

The rapidly increasing desire of young ladies to
obtain distinction at the competitive examinations
in science, mathematics, &c., will convince them far
more than argument, of the raisoii d'etre of that which
I have been pleading for — the beautifully perfect

FACE AND FOOT DEFORMITIES. 133

structure of the foot, with its double arch, the bones
being wedge-shaped, resembling the upper stones
of an archway. The os calcis or heel-bone being by
far the largest and most solid bone of the foot, shows
that nature designed it to take the chief weight of
the body in walking. The front of the foot should be
used mainly in promoting that elasticity and elegance,
which I trust will soon again become the rule rather
than the exception with the fair sex.

What can be more inspiriting and encouraging than
to watch the elastic spring of a regiment of soldiers as
they march past at quick time in review order? I
should much like to see the jemies dames exchange
their woodeny scuffle for the comfortable spring of a
well-shod foot.

Bunions are usually situated over the joint of the
great toe, at its junction with the metatarsal bone of
the foot. They are caused by inflammation of a bursa
or pad which nature has provided to protect the joint
from undue pressure. This bursa becomes inflamed
by the inversion of the foot under the constant irri-
tation of a narrow boot. The joint being exposed
to injury, and to undue pressure on the inner side,
may also inflame.

We have here a still further development of mis-
chief from badly fitting boots. The big toe and the
little toe are very frequently involved in these ugly
protuberances. Omnibus drivers, butlers, and cab-
men often suffer in this way. Their sedentary occu-
pations and their drinking propensities seem to favour
this deformity. I suppose the constant irritation
caused by the exposed condition of this displaced and

134 FACE AND FOOT DEFORMITIES.

swollen joint accounts for the frequency with which
gout attacks the ball of the great toe.

If neglected these bunions will suppurate and form
an abscess, which discharges very freely, and may
invade the joint structures ; or if inflamed, erysipelas
is very likely to appear in the foot. In such cases the
patient must be encouraged to give absolute rest to
the part, to apply poultices and warm water bathing
when painful, and to dress the foot with a warm Gou-
lard lotion so as to favour absorption of inflammatory
products, and healing of the wound. If the skin is
unbroken, and the swelling large, it may be painted
with iodine. In young people an attempt should be
made to restore the foot to its proper shape by
strapping and bandaging.

Inflamed bunions may give rise to a great deal of
pain and discomfort, from their great enlargement.

When erysipelas appears on the dorsum of the
loot, the patient should be enjoined to give the leg
complete rest for a day or two. Warm lotions may
be applied, as the lead and opium, and the foot may be
encased in lint and guttapercha cloth. It will also
be needful to administer some antiphlogistic treatment,
followed by aperients and iron tonics. Sometimes after
suppurating, these bunions leave a callous indolent
tissue or ulcer, with uneven or hardened edges. It may
be some weeks before these ulcers heal. The biniodide
of mercury ointment, 5 grains to the ounce, may perhaps
be useful, or the simple warm water dressing.

With the packing together of the toes one upon
another in consequence of wearing badly fitting boots
we sometimes get ulcerations between the toes, painful

FA CE AND FOOT DEFORMITIES. 1 3 5

and suppurating corns upon the prominent toe joints,
elevation or depression of one toe so as to project on
the dorsum. Such distorted toes appear sometimes
as an awkward prominence at the sole of the foot.

Palliative measures must be employed in these
cases to cure the corns or ulcers. If the displaced toe
causes much inconvenience it will be necessary to
remove it by amputation. This would be a very
simple operation, and could be done without much
inconvenience, and certainly with permanent and con-
siderable relief to the patient. The necessity of having
perfect comfort in walking must obviously determine
the sufferer in resolving to submit to a temporary
inconvenience, for the sake of a permanent beneficial
result. Some people acquire a habit of walking upon
the heel or the front of the toes, in consequence of
some chronic ulcer on the sole of the foot which has
existed for some months or years, and which they
seem to think incurable. Such cases require prompt
■end decisive treatment to restore the patients to a
condition in which they may walk without lameness
or awkwardness.

Corns are simply caused by local excess of the
epidermis, arranged in a concentric form, and pro-
duced by intermittent pressure from badly fitting
boots. The modern fashion of narrow pointed toes,
causing the whole weight of the body to be thrown
perpendicularly on to the instep by the high heel which
ladies generally wear, must inevitably produce corns,
because the part where all the pressure comes, thus
intermittently, is very tender and sensitive. Anything
which prevents the even spread of the foot, and the

136 FACE AND FOOT DEFORMITIES.

regular planting of the sole of the foot flat down on
the ground, so that the pressure may be distributed,
will produce corns. There is probably an hereditary
tendency to the transmission of these horny out-
growths on the toes.

Corns are either hard or soft, flat, conical, or
laminated, consisting of accumulated nodules of
epithelium, which are dry, hard, and scaly. When
conical they may be shelled out with comparative
ease, and certainly do not need the high sounding
title of chiropodist to signify the person who is
willing to remove them for a consideration. Occa-
sionally corns will suppurate, and if neglected, the
formation of an abscess beneath the corn may lead to
decay of the subjacent bone. Suppuration beneath a
corn may be recognised by severe pain and throbbing
in the part, with swelling and tenderness. The foot
must be poulticed, and as soon as fluctuation is felt,
the pus should be evacuated by incision. Some corns
are peculiarly painful and tender to the touch,
crippling the patient, and preventing him from walk-
ing with comfort. They are usually circumscribed
and consist of tufts of elongated and swollen papillae.

Soft corns are generally found in situations where
the moisture of adjacent parts keeps them infiltrated
with perspiration, as for example between the toes,
and these being vascular are very sensitive and pain-
ful. Children with these infirmities will often acquire
a habit of limping in their walk or inclining to one
side of the body, so that a corn may be the pre-
cursor of permanent mischief to the spine. Conse-
quently in curvatures of the spine we must be sure

FACE AND FOOT DEFORMITIES. 137

that they are not induced by a constant attempt to
avoid throwing the weight of the body on a painful corn.

The treatment of corns is very simple, and the
public are certainly not likely to gain any advantage
by consulting those who are unacquainted with even
the rudiments of anatomy. The hardened cuticle
must be softened by the application of compresses
and warm bathing or poultices. The part must be
protected from pressure by soap plaster. Strong
acetic acid may be painted on the corn to soften it.
When the corn is sufficiently soft it may be extracted
without pain. Nitrate of silver caustic may be applied
in some cases, especially to the soft varieties.

People do not as a rule persevere sufficiently long
with a hard corn. It may be that a protracted illness
in bed will suffice to cure all the corns from which the
patient has been suffering for so many years. Those
who pay regular visits to the chiropodist may certainly
obtain a few weeks of ease, but it is at the cost,
generally, of many more weeks of suffering. Those
who are thus afflicted must arrange to have special
boots made for them, and never purchase ready
made articles. They should avoid the use of patent
leather, and have a material called "pannuscorium"
or a soft substitute for the upper leather.

Distorted Toes. — I need not particularise the various
congenital distortions of the toes, nor those caused
by the habit of wearing badly-fitting boots. There
are, unfortunately, few adults in this country who
do not " know where the shoe pinches." The dusky
races, such as our soldiers are now fighting in the
Soudan, can furnish plenty of illustrations of the

138 FACE AND FOOT DEFORMITIES.

normal growth of the foot when not encased in shoe-
leather. Habitual pressure of the toes will be certain
to compress them into almost any shape, and so they
frequently become square instead of round. Callosities
form on the dorsum of the toes. The ungual pha-
langes are turned under and the joints become raised,
and therefore compressed by the upper shoe-leather.
By the friction of the foot, and the necessary move-
ment of the toes in walking, considerable irritability
may be caused to the skin and to the joint-structures.
The flexor tendons contract, and so add to the mischief.
It may be necessary to divide these tendons subcuta-
neously, and to extend the faulty toes upon splints.

SECTION X.

CONGENITAL AND PARALYTIC DEFORMITIES —
CONTRACTION OF PLANTAR FASCIA ; CONTRAC-
TION OF ONE TOE ; WEAK ANKLES ; CLUB-FOOT ;
VARIETIES OF TALIPES, THEIR CAUSES, CLAS-
SIFICATION, AND TREATMENT ; FLAT-FOOT ;
CHOREIC, HYSTERIC, AND SPASTIC CONTRACTION
OF GROUPS OF MUSCLES ; WEBBED TOES ; SUPER-
NUMERARY TOES.

Congenital and Paralytic Deformities. — There are
many deformities of the foot which require careful
consideration with a view to surgical treatment, but
talipes deformities constitute the bulk of the cases
which come under this definition. When we remem-
ber how much depends upon the correct balancing
of the body upon the complicated mechanism of the
ankle-joint, it becomes important to see that the feet

FACE AND FOOT DEFORMITIES. 139

are properly developed from infancy upwards, that
the joint movements are quite normal, and that
nothing shall interfere with the free and unfettered
movement of all the component parts of the foot.

Infantile paralysis, the result of teething troubles,
&c., may develop some deformity of the foot from the
atrophy of muscles supplied by the paralysed nerves.
In these cases the foot lies in a cold torpid condition,
with the toes pointed and the limb cold. The joints
are very lax, and there may be some pufifiness on the
dorsum of the foot. We may also have a condition of
pseudo-hypertrophic paralysis. Such cases will re-
quire both local and constitutional treatment. Plenty
of nourishing food, and tonics, such as Easton's syrup
and steel wine, to improve the condition of the blood
and nervous system ; plenty of friction and galvanism,
to stir up the slumbering muscles and press them into
action by massage.

Congenital deficiencies, such as those produced by
sporadic cretinism, and unsymmetrical hypertrophies,
do not come under surgical treatment as a rule, be-
cause they are seldom capable of any improvement by
operation. I shall therefore make no further allusion
to these deformities of the foot.

Cojitr action of the plantar fascia may cause consider-
able arching of the instep, and curving downwards of the
metatarsal bones of the foot, such as is seen in Chinese
women, from their self-induced deformity. This is
effected by bandaging and compressing the foot from
infancy upwards, so as to prevent it growing large.
In these cases, where the tendons are not much at
fault, it may suffice to divide the plantar fascia, and

I40 FACE AND FOOT DEFORMITIES.

to extend the leg and foot upon a grooved back splint
with a flat foot-piece, or to use a Mclntyre splint.

Contraction of one toe may cause some inconveni-
ence by the formation of a corn on the prominent
point of the faulty toe, which may subsequently in-
flame. By the irritation of the boot in walking, an
abscess may develop on the dorsum of the deformed
toe. This deformity is caused by contraction of the
digital prolongation of plantar fascia and the digital
tendon, or the toe may be displaced on to the dorsum
of the foot. It generally affects the second toe, and
may give rise to permanent lameness. These bands
of fascia and faulty tendons should be divided sub-
cutaneously, and the toe forcibly extended, and then
fixed on a splint for about eight or ten days.

Weak ankles may be congenital or they may be
associated with an acquired habit of unduly everting
the foot. A consequent fall of the arch may occur in
delicate and rickety children from relaxation of liga-
ments. The general health must be carefully attended
to, with a view of consolidating the bony framework.
Tidman's sea-salt baths, friction, and bilateral splints
to support the ankles must be used in these cases for
some months, until the bones have become firm and
the joints more solid.

Club-foot may be described as having four distinct
varieties, viz. : —

Talipes varus, in which the foot is inverted and
drawn up mainly by the action of the tibialis posticus,
and in part by the tendo Achillis.

Talipes valgus, which is generally associated with
some depression of the pedal arch, and eversion of the

FACE AND FOOT DEFORMITIES. \\\

foot It is more or less dependent upon contraction of
the peronei muscles.

Talipes calcaneus, in which the foot is drawn up
towards the tibia by the action of the extensor
muscles, and the heel is depressed.

Talipes eqidnus is the deformity characterised by
pointing of the toes and elevation of the heel, some-
what resembling the foot of a horse.

As sub-varieties, or combinations, of these, we have
T. equino-varus, T. equino-valgus, T. calcaneo-varus,
and T. calcaneo-valgus.

A further classification is made by some authors
dividing the prime varieties into those which are con-
genital, and those which are acquired. Varus may be
considered as the type of congenital club-foot, and
valgus that of acquired distortion.

There are also several degrees of severity in the
cases which come under treatment. Scarcely two
cases exactly correspond in the amount of muscular
rigidity and contraction. In some cases there is only
a slight elevation of the heel, and the consequent
lameness is scarcely perceptible. The general outline
of the foot in such cases is fairly normal. In other
cases the deformity is very marked.

About nine-tenths of non-congenital deformities
depend either upon spasm or paralysis of certain
muscles or groups of muscles. In paralytic cases the
muscles rapidly waste and atrophy. Some of the
most severe kinds of deformity of the foot occur in
cases of spastic contraction from convulsive affections
in children. Nearly all the muscles of the body may
be involved in this rigidity, induced by some cerebral

142 FACE AND FOOT DEFORMITIES.

disease that is probably of a tubercular character.
Such cases must be pronounced incurable.

Long persistent deformity of a limb under spas-
modic contraction will lead to permanent rigidity,
and the limbs are then, as a rule, drawn inwards by
the flexors, and the joints become stiff. Such de-
formities are seen in the cases of patients recovering
from hemiplegic attacks.

Although the tendency in infantile paralytic affec-
tions is towards recovery, such recovery may not be
complete, though it may enable the patient to walk
with or without assistance.

It is important to remember that club-foot de-
formities may be congenital, the child being born with
such deformity of the foot, or they may be acquired.
The accompanying drawings will show the varying
shapes and contortions of the foot when subject to this
deformity, as also the difference between congenital
club-foot and that which is acquired. In all these
cases there is evidently some amount of paralysis of
the opponent muscles, chiefly the extensors of the foot
as they take their origin from the front of the leg.
I do not find that the paralysis in congenital cases
is as a rule absolute. I am careful to advise gentle
friction of the leg over these muscles to stimulate them
to action after the foot has been liberated, as also
galvanism in some cases. It has been attempted to
account for the existence of congenital club-foot by
some trophic disease of the ganglia and nerve-centres
for directing the co-ordinate action of the opponent
muscles ; but I have my doubts as to the cause and
effect of the alleged desreneration of nerve-cells. I

FACE AND FOOT DEFORMITIES. i43

consider that the distortion is produced in the first
place by a cramping and awkward posture of the
foetus in utero, the foot being kept in this constrained
position sometimes by deficiency in the liquor amnii,
or by the contiguous pressure of the uterine walls, and
superimposed viscera. The growth of a limb and of
its muscles through the period of intra-uterine develop-
ment must inevitably lead to permanent distortion
thereof, in whatever direction the surrounding viscera
may force it. Doubtless our pathologists may be able
to trace some central degeneration of the nerve-
centres, exactly corresponding to the nerves supplying
the faulty muscles, though this may be by some con-
sidered a consequence, rather than a cause of the
deformity. The muscles being rendered powerless by
the cramped position in which they have been held
during the months of intra-uterine life, degenerate in
structure, and so also the ganglia of the brain from
which the volitional acts proceed for the customary
movements of the corresponding muscles. Together
with the defective development of the muscles, there is
a deformed and contracted condition of the small bones
which form the double arch of the foot. These bones,
being similar to the ordinary stones of an arch, are
wedge-shaped and about the size, in infants, of dice.

The longer the foot is allowed to grow in this wrong
direction, the more firmly consolidated will the bones,
ligaments, and tendons become in the altered position
in which they are placed. It will therefore be much
more difficult to rectify the deformity. We must
carefully distinguish between the cases of congenital
deformity, and those which are acquired in after life

144 FACE AND FOOT DEFORMITIES.

from irregular or spasrnodic contraction of certain
muscles or groups of muscles. In the latter case there
is probably some special irritation centrally, or in the
medulla spinalis, and we must treat this condition
before hoping to effect much with the deformity, for
the bones in acquired club-foot are of course not as a
rule developed in a wrong direction.

Each of the varieties of club-foot as depicted in
the drawings may be considered to have varying
degrees of intensity. In some cases the deformity is
only seen under emotion, or when walking carelessly.
If the child is paraded before the surgeon, it may be
clever enough to screen from observation the deformity
which otherwise would be very manifest.

In the treatment which I am endeavouring to
enforce, as alone efficacious for the final and satisfac-
tory removal of congenital talipes, it will be seen that
I lay very particular stress upon the importance of
rectifying the osseous deformities, by long-continued
treatment of the distorted bones and ligaments, be-
sides the customary division of the contracted
tendons. Such treatment to commence at the earliest
possible period of infantile life.

Mr. Adams, one of the acknowledged authorities on
club-foot, in his Jacksonian Prize Essay on the sub-
ject of deformities, has made some very careful dis-
sections to illustrate the morbid anatomy of club-foot.
I quite agree with him that the osseous deformities
are most marked in Talipes varus, and that in the
commonest form of congenital talipes, it is useless to
attempt to cure the deformity without bearing this in
mind in our course of treatment.

FACE AND FOOT DEFORMITIES. 145

The fabric, as it were, of the foot must be entirely-
reorganised, for it has acquired a wrong direction of
growth, and being fortunately made up of a number of
small wedge-shaped bones, jointed together by con-
necting bands of ligamentous tissue, it is quite possible
so to manipulate the foot, and so to divide the constrict-
ing bands, that by a series of consecutive operations,
mouldings, and manipulations, the different stones
(i. e. bones) of the double pedal arch shall be moulded
into something like a correct " plumb," in accurate
adaptation to the articulating extremities of the tibia
and fibula, from which they have been congenitally
displaced.

If the deformity is not corrected in infancy, the
bones, by reason of the weight of the body impinging
upon them in a wrong direction, become still more
twisted and moulded out of their true shape, and so
the obstacles to rectification are increased.

Mr. Adams describes the faulty condition of the
larger bones of the foot in talipes varus as follows : —
"The OS calcis is altered in position to an extreme
degree, but its deviation in form is slight ; in severe
cases it occupies a very oblique, almost a vertical
position, from its tuberosity being drawn upwards by
the gastrocnemius and soleus muscles. Its direction
is also somewhat changed laterally, the anterior ex-
tremity of the bone being directed obliquely forwards
and inwards, and its tuberosity inclined towards the
fibular aspect of the leg, and in severe cases it is
found in actual contact with the fibula. In form the
OS calcis is also somewhat altered, being regularly
arched in the direction of its length, with the con-

L

146 FACE AND FOOT DEFORMITIES.

vexity directed outwards, in adaptation to the curved
position of the foot, but this deviation is not very-
obvious, except in severe cases" (p. 151).

" The astragalus is found, at the period of birth, to
present several important deviations, both in position
and form. In position it is tilted obliquely forwards
and downwards, and to a certain extent displaced
from its socket, in consequence of the altered direc-
tion of the OS calcis and elevation of its tuberosity, so
that the anterior third, or more, of the superior articular
facet, or cochlea, of the astragalus is thrust on to the
dorsum of the foot, where it is covered only by the
elongated anterior portion of the capsular ligaments
of the ankle-joint and the skin. The body of the
bone, or that portion of it which normally enters into
the composition of the ankle-joint, is to a greater or
less extent rotated outwards, so that the external
lateral articular facet is firmly in contact with the
fibula, and appears to be somewhat increased in size,
in consequence of its anterior portion being ex-
truded from the joint. The internal lateral articular
facet of the astragalus is scarcely to be traced, and
in severe cases is not at any part in contact with
the articular surface of the inner malleolus " (p. 151).

"Moreover, the line of the ankle-joint, instead of
being horizontal — when viewed from the front, after
the joint has been laid open — presents an oblique
direction upwards and outwards towards the fibula,
corresponding to the rotation outwards of the astra-
galus " (p. 152).

" The astragalus presents several important devia-
tions from its natural form, and these are observable

FACE AND FOOT DEFORMITIES. 147

in its head and neck, its articular surfaces, and its
posterior border. The articular head of the astragalus
does not present a regularly convex surface looking
directly forwards, as in the healthy bone, but has an
antero-lateral aspect. In a severe case, the articular
surface of the head of the astragalus is divided into
two articular facets, at nearly right angles to each
other, and separated by a distinctly angular ridge and
surface, the larger looking directly inwards and articu-
lating with the displaced navicular bone. The other
looks directly forwards and downwards, and is left
exposed on the dorsum of the foot by the altered
position of the navicular bone, and is covered only
by the elongated portion of the ligament normally
passing from the neck of the astragalus to the edge
of the navicular bone."

" The lateral articular facets of the astragalus present
some important abnormal conditions in respect both
of position and form. They are both partially ex-
truded from the ankle-joint, and appear in front of
the malleoli, in consequence of the altered position of
the astragalus" (p. 153).

" In consequence of the oblique or nearly vertical
position of the astragalus, only the posterior two-
thirds, or less, of its superior articular surface enters
into the composition of the ankle-joint."

" The navicular bone in its displaced position
articulates with the lateral articular facet of the head
of the astragalus, and therefore holds a lateral instead
of anterior position with respect to the astragalus.
In fact, the long axes of these bones are parallel in-
stead of being at right angles to each other. The

L 2

148 FACE AND FOOT DEFORMITIES.

long axis of the navicular bone is therefore parallel
with the long axis of the leg instead of being at right
angles to it" (p. 156).

In extreme cases the navicular bone leaves the
astragalus, being forced upwards towards the inner
malleolus by the contraction of the tibial tendon.

The deviations in the conformation of the other
tarsal bones are also carefully described and deline-
ated by Mr. Adams.

Mr. Parker and Mr. Shattock* advocate a mecha-
nical causation for this deformity. Their opinions
rest on a careful dissection of five cases (three of varus
and two of calcaneus), and on a study of specimens
in various London museums. They contend that
there is nothing special in club-foot, nothing which
may not be found in other joints. In one of the
dissected cases there was histological integrity of the
nerve-centres, of the nerve-trunks, and of the muscles
of the affected limb, but there was also some extra
obliquity in the neck of the astragalus. In another
case, however, there was no such malformation in the
astragalus. Hence, they argue, the insufficiency of
the usually accepted nerve-theory of causation, and of
the theory that the deformity depended on the con-
formation of the astragalus. It was further shown
that the conformation of the astragalus which was met
with in most cases of talipes was the normal condition
in the Simiidse, although these animals were not tali-
pedic. Thus it appeared that some other cause must
be invoked, and they sought it in the environments of

* " Pathology of Congenital Club-foot," Pathological Society's
Trans., 1884.

FACE AND FOOT DEFORMITIES. 149

the foetus during intra-uterine life. As additional
proofs of pressure (besides the talipes), they related
instances of torsion of the bones of the leg and of the
astragalus, and also a case in which depressed patches
of atrophied skin, with bursae beneath, were found on
the external malleolus and on the head of the astra-
galus, comparable with what was found in persons
who had walked on the unreduced talipedic foot.
The varieties of varus and calcaneus were thought to
depend on the date of onset, and in both cases were
exaggerations of positions normal at some time or
other of foetal life.

Mr. Parker said that they did not wish to make out
that all forms were produced in identically the same
way. The physiological calcaneus only lasted a few
days after birth.

Dissection teaches us, says Mr. Adams, that " the
ligaments contribute materially to the permanence of
the deformity at all ages, and experience proves that
the success of the treatment is considerably impeded
by the resistance they offer to the restoration of the
foot to its natural form. Ligamentous adaptation and
contraction maintain the bones so firmly in the de-
formed position, that the foot cannot be restored to
its natural form and position, even after division of all
the contracted tendons. This process of adapted
shortening or defective growth of some of the liga-
ments must be taking place during the period of
intra-uterine development" (pp. 162, 163). So also
are the opposing ligaments found to be elongated.
The deltoid and other strong ligaments of the sole of
the foot often constitute very strong obstacles to the

ISO FACE AND FOOT DEFORMITIES.

surgeon, when endeavouring to rectify the deformity.
It may be necessary to divide these before com-
mencing the moulding process. In some cases of less
severity there is no ligamentous rigidity, the defor-
mity has probably taken place at a much later
period of uterogestation. Appreciable changes in the
muscular structures are not essential to the production
of talipes varus. As a general rule, there is an absence
of any distinct abnormal condition of the muscles.

Mr. Adams then describes the result of some dis-
sections he had made to show the alteration of struc-
ture which occurs in some cases.

Arrest of muscular development may depend upon
some abnormal condition of the nervous centres.
The degeneration may be traced partly to the in-
fluence of long continued inaction. The legs are
usually thin in proportion to the thighs, as if showing
a deficiency of muscular development and nutrition
generally below the knee.

Mr. Adams sums up his arguments by saying
that, " On the whole, I am disposed to agree with the
dynamic or spasmodic rather than the mechanical
theory as applied to congenital talipes varus. The
arguments in support of malposition and pressure in
utero are exceedingly weak. But it is probable that
malposition and pressure in utero may be the cause
of some deformities." The malformation of the as-
tragalus existing at the period of birth depends,
Mr. Adams thinks, "upon the malposition of the os
calcis and navicular bones caused by contraction
of the muscles of the calf and the anterior and
posterior tibial muscles."

FACE AND FOOT DEFORMITIES.

I prefer to associate both these conditions, viz.
intra-uterine compression and spinal irritation, as
proximate causes of the deformity. I connect these
with a distinct and probably subsequent distortion of
the bones and articulating surface; such want of
symmetry in the normal outlines of the bones being
directly traceable to their growth and development in
a posture of constraint. Placing the causation, then,
of such deformities in what would appear to be the
direct order of sequence, I should say we have me-
chanical constraint, which may have been due to a
primary reflex spasm of the developing uterine muscle.
Then we have the dynamic agency of the foetal spinal
cord, as contributing to the distortion by reason of the
incarceration of the foot in such a confined space.
And lastly we have the growth and development of
the bones in the direction which is least affected by
these two causes. The deformed bones always con-
tribute largely to the obliquity of the limb in its
crippled condition as it appears after birth. Whether
the partial paralysis of the opponent muscles is due
to the prolonged inactivity during incarceration, or
that the paralysis was the primal cause of the dis-
tortion, and so of the incarceration, I cannot attempt
to decide.

Certainly there seem to me very strong arguments
against the mechanical theory advocated by Mr.
Parker and Mr. Shattock. For example, do we find
that deficiency of liquor amnii, so obviously associated
with a cramped posture of the foetus in utero, can be
traced as discoverable in such cases ? Then again, as
with many other troubles, do we not find an unusually

152 FACE AND FOOT DEFORMITIES.

large per-centage of club-foot in the children of the
poor as contrasted with the children of the rich ? If
we are to accept the allegation that a mechanical
causation will account for this deformity in most
cases, we should naturally expect to find a large and
increasing per-centage of club-foot among the offspring
of the rich, seeing that the prevailing fashion of the
day, to which so many young married ladies succumb,
viz. that of tight lacing, must make its direct impress
upon the foetus in utero.

I suppose there is not a doubt that uterine dis-
placements have largely increased in numbers during
recent years, not only because young married ladies
go more into society than formerly, but because with
tight lacing and other efforts to keep their figures
in, they succeed in compressing the uterus, and so
interfering with pregnancy.

In the event of a fashionable lady becoming preg-
nant the claims of society have a prominent place in
her thoughts. During the season she resolves to
keep her engagements as long as possible, and the
maid must give the stays an extra squeeze to make
her presentable at Court. Am I presenting an exag-
gerated picture .'' I can only say that my experience
leads me to affirm that such cases are by no means
rare. What becomes then of the theory of compres-
sion in these cases ?

Messrs. Parker and Shattock say that "the sup-
posed nerve-lesions have never been demonstrated."
In the one case which they had dissected " the nerve-
centres and the nerve-trunks were perfectly normal."
Because no nerve-lesion was detected in this case it

FA CE A ND FOOT DEFOR MI TIES. 1 5 3

does not follow that none existed, nor does it prove
that other cases would fail to show any morbid
changes in the spinal cord. Functional disturbance of
the cerebro-spinal system may be due to the most
trifling cause, such as vascular engorgement or slight
effusion into the neurilemma. A few of the multi-
polar cells or conducting fibres may have become
disorganised, and yet the highest powers of the micro-
scope, and a laborious sectionalising of every inch
of the spinal cord would fail to unravel the mystery
of such a trifling disturbance. The effect, however,
upon the distal fibres of the implicated nerve may be
very pronounced, and the observer cannot be blamed
for his failure to discover any pathological lesion.

The argument that the feet of infants naturally fall
into the equino-varus condition would support the
idea of a multiple causation, such as I am advocating.

Flexion of the foot upon the leg by the action of
the gastrocnemius is as natural as flexion of the fore-
arm upon the arm by the action of the biceps. I
think it very important to lay considerable emphasis
upon the direct action of the tendo Achillis to oppose
in great measure the peroneal tendons, and so to in-
vert the foot. We must never forget what a powerful
double muscle we have in connection with this tendon,
and how relatively small the opponent muscles are.

Finding the deformity to be due in most cases not
only to some abnormal contraction of tendons or
muscles, but to a corresponding malposition and im-
perfect development of bones and ligaments, I look
upon the customary division of the constricting bands
as but the first stage of a long process of forcible

154 FACE AND FOOT DEFORMITIES.

manipulation of the distorted limb. It is to these
latter stages that I attach prime importance. The
temptation is great, from the pressure of private prac-
tice, to leave the after treatment to some qualified
assistant or house surgeon. Or in other cases to put up
the limb or the body in some complicated apparatus
with numerous joints, pivots, straps, buckles, screws,
&c., all designed to exert some specific control upon
the distorted and crippled framework of the body. I
must confess that I am a great enemy of the surgical
appliance maker in the treatment of these cases — a
business which, under the high-sounding title of ortho-
paedic mechanician, is, I believe, very remunerative.
Passive extension is simply absurd when you consider
the strong counter forces which you have to contend
with {vide the drawings giving two views of Little's
shoe, as applied to the talipedic foot after division of
tendons). I very seldom use a Scarpa's shoe or its
modifications by Little, Adams, &c., for club-foot,
or an expensive spinal apparatus for curvature of the
spine. I recognise the fact that in each case the bony
frame-work of the body is distorted, and nothing short
of trained muscular force skilfully and repeatedly
applied on the part of the surgeon will rectify these
deformities ; such rectification of the normal curves of
the body to be permanently secured by the immediate
application of a closely enveloping case of plaster of
Paris with certain mechanical additions which I shall
describe hereafter. The plaster of Paris case fitting
like a mould into all the sinuosities and configurations
of the body, forms a solid accurately fitting " external
skeleton," accomplishing that which the bony frame-

Little's shoe applied. One view.

Little's shoe applied. Opposite view,

To face />. 154.

FACE AND FOOT DEFORMITIES. 155

work was designed to do, but at present cannot. It
also serves as a solid retentive apparatus, to con-
serve and support the soft tissues of the body during
the period of growth and development of muscles and
ligaments in their newly acquired positions as they are
brought into serviceable action by the constant and
careful tutelage of the surgeon. With an accurate
knowledge of anatomy and physiology the surgeon
can turn his mechanical genius to the utmost advan-
tage to his little patient, without the risk of damaging
the structures which he is manipulating, and without
buoying up the friends with false hopes that in some
unexplained fashion, the deformity of the bones and
sinews will be rectified by the magic power of the
orthopaedic instrument, with its many screws and straps.

The drawings which I append (see next page), taken
from Erichsen's ' Surgery,' will show what extensive
deformity there is of the tarsal bones in talipes varus,
and how necessary it must be to persevere with the
moulding of these bones in infancy after division of
the faulty tendons and ligaments, before we can
expect to rectify the deformity.

At the International Medical Congress held last year
at Copenhagen, some of the foreign surgeons advocated
the excision of the astragalus and cuboid bones to
rectify the deformity. I have never seen cases re-
quiring such severe measures, and I cannot think it at
all necessary to make a permanent deformity of the
limb and a stiff ankle, in order to restore the foot to
its normal position in relation to the tibia.

Some well-known Scotch surgeons, who are great
advocates of osteotomy for every deformity, spoke in

156

FACE AND FOOT DEFORMITIES.

favour of this method of treating taHpes, but their
objections to tenotomy fell to the ground when they
expressed approval of dividing the tendo Achillis in
some cases. Still less can I approve of Davies
Colley's operation for the removal of a wedge-shaped
section of the tarsus in severe cases of club-foot, in-

cluding portions of the os calcis, cuboid, and cuneiform
bones, except in the case of adults with anchylosis.

It is not necessary to repeat the directions which
may be found in all systematic works on surgery, for
the subcutaneous division of tendons in club-foot
The precautions necessary to avoid wounding impor-
tant vessels and nerves, and to guard against making
the skin wound too large, are also carefully defined in
such treatises.

FACE AND FOOT DEFORMITIES. 157

I would only add, as a precautionary measure, the
desirability of so carefully padding the retracted
tendon and fixing the foot in a splint, that movement
for the first few days will be impossible. I do not
find this sufficiently emphasised by authors. By
doing this we prevent the subcutaneous oozing of
blood, and gain all that we desire by a well-planned
valvular incision.

I look upon the division of the faulty tendon as a
condition precedent to rectification of the deformity.
I therefore dissent from the opinions of many
surgeons who have advocated as a first stage of
the mechanical treatment, the eversion of the foot by
the Scarpa's shoe, and then the division of the tendo
Achillis. The shortening of the fibres of this tendon
in many cases of talipes varus makes it impossible to
evert the foot in a satisfactory manner, until after
the division of the faulty tendon.

Mr. Adams, when advocating the eversion of the
foot before the division of the tendo Achillis, says
that "it must be accomplished gently and very
gradually, the apparatus (Scarpa's shoe modified by
Adams) being removed every other day, that undue
pressure may be avoided." To intermit mechanical
appliances "every other day" must not only be a
great inconvenience, needless expense, and cause of
delay, but it suggests a fault in Scarpa's apparatus,
which Mr. Adams seems to admit, for he says : — " It
cannot be matter of surprise that with great attention,
and in competent hands, good results should follow
the application of an ill adapted instrument " (p. 266).
I am afraid I cannot endorse such a sanguine view

158 FACE AND FOOT DEFORMITIES.

of an imperfect instrument. He then points out the
relative advantages which he claims for his modifica-
tion of this retentive apparatus.

I must not omit to add that Mr. Adams enumerates
some objections to the Scarpa's shoe as an instrument
for talipes varus. He says that "it is very apt to
cause sloughs from undue pressure," and that " it
exerts no influence over the rotation of the anterior
portion of the foot " (p. 268).

Experiments on the lower animals have shown how
unnecessary it is to keep the foot inclined towards the
deformity after tenotomy, and our clinical observations
have also confirmed this evidence by showing that we
can rely upon a satisfactory renewal of attachments
of the cut tendon in almost all cases.

In the treatment of these cases we must not
only divide the rigid tendons and ligaments, but we
must mould the bones into shape, and not forget to
strengthen by friction and galvanism the elongated
muscles on the opposite side, so that, by contracting,
they may help to retain the foot in its proper position.

I do not attach much importance to the effort to
obviate the retraction of the divided tendon, because
it is certain to retract very forcibly within the sheath
so soon as the tension is relieved by the division of
the tendon. I think there must be in all such cases
a well-defined space of at least half-an-inch between
the cut surfaces of the tendon. However wide the
gap may be, I always find in infants and young
children a very satisfactory adhesion set up, and the
formation of a new fibrous cord in place of the
tendinous attachment to the bone. .

FACE AND FOOT DEFORMITIES. 159

This, I think, is mainly secured by the vascularity
of the lining membrane of the sheath, which, being
undivided and remaining in continuity with the bone,
acts in the same way as the periosteum to restore the
natural bond of union between the tendon and the
bone.

Numerous dissections have been made to show how
perfectly the tendons reunite, or rather become re-
attached, after tenotomy. After placing the foot in
its normal position, we are enabled to bring all the
groups of muscles into active exercise, so that the
balance of muscular power may be restored. From
dissections and experiments which I made as a
student for my graduation thesis upon the lower
animals, for the purpose of determining the exact
process of repair of wounds through arterial trunks,
and their final closure or obliteration after ligature, I
have no doubt that a somewhat similar process of
repair takes place in divided tendons. I found that
the terminal portion of artery below the ligature does
not, as was supposed, necessarily slough and die, and
so form a focus for the development of inflammatory
mischief, as alleged by the advocates of acupressure ;
but that in many cases the strangulated end of artery
becomes reorganised by becoming incorporated into
the surrounding tissues. I find also that a fibrous
blastema forms in that part of the sheath from which
the divided tendon has retracted, and this bridges over
the gap between the cut surfaces of the tendon. This
blastema becoming consolidated, then organised from
the surrounding vascular membrane, a new material
is formed, which gradually assimilates itself to the

i6o FACE AND FOOT DEFORMITIES.

tendinous structure, and in this way the tendon is
elongated and repaired.

Any admixture of inflammatory lymph and exu-
dation cells must be regarded as a complication of the
reparative process. The nuclei of the cells coalesce
or become elongated, and form a fibrillar arrangement,
the new material afterwards becoming organised and
consolidated. The new tendinous material is thus
firmly grafted on to the texture of the old tendon.

I quite agree with the generally received opinion as
to the desirability of early operations in cases of
congenital talipes. The more so, because of the
necessity of ample and frequently repeated manipula-
tion and moulding of the bones of the tarsus, so as to
adjust them to the altered axis of the foot. With
infants of a few weeks old, the operation being so
simple and subcutaneous, may be done promptly and
without chloroform if thought desirable. The inter-
osseous ligaments will yield to the moulding process.
Whereas if the operation is delayed, the surgeon
finds that his efforts to rectify the deformity will be
seriously limited by his power of manipulation. We
must also remember that the bones of the tarsus,
especially the large ones, will become ossified in the
acquired position of deformity unless attempts are
made to rectify it. In some extreme cases of talipes
it may be necessary to divide the ligaments which
bind the astragalus to the os calcis and to the navi-
cular bone on the inner side of the foot. In making
use of the various mechanical appliances which have
been constructed at various times, with evident in-
genuity, and introduced to public notice, it is necessary

FACE AND FOOT DEFORMITIES. i6i

to bear in mind that we have to treat the deformity
as a whole, and to seek by the adjustment of a well-
fitting apparatus to rectify the deformity which is
manifest in every tissue of the foot. Consequently
the cleverly designed straps, buckles, elastic bands,
ball-and-socket joints, which have entered into the
construction of most of these appliances, would cause
undue pressure to impinge on one or more portions
of the foot. The result of such adjustments is that
the skin is very liable to slough just where the
pressure is required. This condemnation would seem
to apply to almost all the instruments that have been
brought before our notice.

Talipes varus is by far the most frequent form of
congenital deformity of the foot, and this is generally
modified by elevation of the heel from the ground.

In T. varus the front of the foot is turned inwards
and upwards. The sole of the foot looks backwards.
Thus the inner border of the foot is turned upwards,
and in children that are allowed to walk corns or
callosities will form on the part where the pressure
occurs. The foot being bent upon itself becomes
foreshortened, and there is also some defective de-
velopment of the bones of the tarsus. The navicular
bone is displaced inwards, and the plantar fascia is
firmly contracted upon itself. The anterior portion
of the foot has some independent movement at the
transverse tarsal joint, and so the unnatural curve
and high arching of the foot may be in part rectified
more effectually, by the use of the fixation apparatus
elsewhere described, than by the use of a complicated
apparatus requiring daily adjustment.

M

i62 FACE AND FOOT DEFORMITIES.

When we have what is called T. equino-varus,
the tendo Achillis being the combined tendon of
the great calf muscles, is that which is most at fault.
This is a large solid tendon, inserted into the back part
of the OS calcis by a broad attachment of fibres which
are compacted together from the calf. Fortunately
the tendon may be brought out prominently in relief
by extending the foot, when it will be felt as a
tense band subcutaneously above the heel. In the
treatment of this deformity it will be necessary to
divide the tendon, and thus to bring down the heel.
The patient should be laid flat on the bed and the
heel raised. The surgeon grasps the foot and
extends it forcibly. He then inserts the tenotomy
knife with its thin narrow blade underneath the tense
prominent tendon, close to and parallel with its inner
edge, taking care to avoid the posterior tibial artery
which passes behind the inner ankle. Turning the
sharp edge towards the tendon, with a gentle sawing
motion he divides the tense fibres, without opening
up the sheath or the investing membrane which
covers the tendon.

The after treatment of these cases is what we find
so important in order to secure beneficial results.

The surgeon must persevere for months with the
moulding of bones and friction of muscles and also
the renewal at regular intervals of the fixation
apparatus. The reason why cases so often relapse
is because parents have not been sufiiciently careful
to continue the treatment until all the deformity has
been rectified, and the several tendons brought into
action in the newly acquired position of the foot.

/''?'/"^

E .rBiirgese litk.

We sfc.TIe'wiiaaii&.Co . Imp .

TALIPES VARUS.

Tcface p. 162.

FACE AND FOOT DEFORMITIES. 163

especially when, as usual, there is a partially paralysed
condition on the opposite side to the deformity.

I think it is very seldom that we require to divide
the tibial tendons in infants, because these will stretch
considerably by the use of the retentive fixation
apparatus. In extreme cases, not only must the
tibial tendons be divided, but the long flexor tendons,
and also the fascia which prevents expansion of the
foot to its proper dimensions. Orthopedic surgeons
are, I think, too inclined to classify the respective
deformities, and to associate contraction of the tendo
Achillis with equinus deformity only.

We must not fail to remember the peculiar forma-
tion of the foot. There is a partial absence of relative
symmetry between the respective parts of the foot,
and particularly is this seen in the attachment of the
tendo Achillis. Though, of course, the primary action
of this tendon is to raise the heel, yet so soon as this
is done the strong inner fibres, which are attached by
a broad base to the head of the os calcis, draw the foot
inwards, so that the varus deformity is almost entirely
produced or maintained by the inner fibres of this
tendon.

I do not believe in "irons" for children suffering
from these or any other deformities. They are much
too cumbersome, and to be of any use they must
cripple the child more than when he is without
such appendages. It is absurd to see children going
about with irons and crutches at the same time.
Some few cases of weak ankles I have seen benefited
by the careful application of jointed irons well made
to fit the child. When parents suggest to me, as they

M 2

i64 FACE AND FOOT DEFORMITIES.

often do, the use of " irons," I generally tell them
to spend the money more profitably upon putting
" iron " inside the body rather than outside.

In talipes varus Mr. Adams describes the morbid
anatomy of the bones as follows : — " The os calcis is
altered in position, being drawn up by the action of the
calf muscles. It is also slightly arched inwards in
severe cases. The astragalus is partly displaced from
the socket. The upper articular facet is pressed up
so as to appear on the dorsum of the foot. The lateral
facets are partially protruded from the joint. The bone
appears in extreme cases twisted upon itself, with an
oblique inclination of the body of the bone. The
back of the astragalus is narrow and wedge-shaped,
the navicular bone being drawn upwards."

I do not at all agree with many writers on orthopedic
surgery who say that we must rectify the varus
deformity before dividing the tendo Achillis. We
must not forget that though the muscles corresponding
to the faulty tendons should atrophy and the attach-
ments of the tendon be imperfect, we have the deeper
muscles to rely upon for effecting most of the move-
ments required, and although the results may not
appear equally promising in all cases, we generally
have a useful limb ultimately. No doubt much
depends upon early operations. I have observed con-
siderable wasting of the calf muscles, from division of
the tendo Achillis for club-foot, of children that are
advanced in years.

The method of applying my fixation apparatus for
club-foot is as follows : — ■

The foot is first carefully and powerfully manipu-

FACE AND FOOT DEFORMITIES.

165

lated, the ligaments stretched, and the bones moulded
as much as possible to the correct position.

A circle of webbing is fixed with letter clips
round the foot, a strip of thick tin about one inch
wide is perforated so as to have jagged edges on
both sides. It is then bent at right angles, the
short arm of which goes across the sole of the foot,

level with the joint of the great toe, and is clipped
to the webbing previously applied over the flannel
bandage. The long arm goes more than half-way up
the leg, and to the end of this arm a piece of string is
attached. By pulling the string the foot is levered
into a proper position, and is easily kept so by a
plaster of Paris bandage applied while the extension

1 66

FACE AND FOOT DEFORMITIES.

is being kept up. The muslin clings to the jagged
edges and perforations in the tin, and holds the foot
with a firm grip. The flannel bandage must of course
be previously applied to the foot, ankle, and leg, and
the jagged perforations of the tin will then cling to
the flannel so as to prevent rotation of the limb within
the case.

The child may be allowed to walk about with this

encasement, after it is properly set. In this way the
astragalus and os calcis will be further moulded into
the proper position by the weight of the body. Should
the plaster of Paris break away, a new case must be
applied after carefully moulding the tarsal bones as
before.

One of the direct and most serviceable advantages
of this retentive apparatus over that of Scarpa's shoe
is that the tendency to flat-foot so often observed after
prolonged use of the shoe does not follow in these
cases, because the short arm of the tin is constantly
pressing up the arch of the foot

FACE AND FOOT DEFORMITIES. 167

In valgus cases the fixation apparatus is the same,
but the tin must be applied to the inner side of the foot
and leg, so as to invert the foot and stretch the peronei
and extensor muscles of the leg. The arch of the
foot is generally so much collapsed that the child
walks upon the inner side, and in addition to the tin,
I generally recommend a sausage-shaped pad, made
so firm that the weight of the body will not materially
compress it in walking, and this is placed across the
sole of the foot, so that the tarsal and metatarsal
bones shall be raised gradually into their normal
position, and the arch of the foot be restored by
centre compression and corresponding depression of
the distal ends of the metatarsal bones.

In modified cases, where there is simply relaxation
of the internal lateral ligament and flat-foot, the
sausage pad with a spica bandage of plaster of Paris
around the ankle will suffice^

Non-congenital talipes varus occurs much less fre-
quently as a deformity than the congenital variety.
It is generally caused by some paralysis of the oppo-
nent muscles in infancy during the teething period. In
these cases the foot is usually cold and flabby from
feeble circulation of the blood. The aspect of the limb
is different from that of the congenital variety, because
the condition of the bones is normal. The foot,
instead of being forcibly drawn upon itself in a radi-
ating manner, is inverted en masse at a rectangular
plane with the leg, and the distortion increases with
the superimposed weight of the body in walking. In
consequence of the deformity being positional and
not structural, the rectification of the foot to its

1 68 FACE A ND FOOT DEFORMITIES.

proper position after division of the tendons is a much
simpler affair. The after-treatment will require pro-
bably more care, on account of the paralytic condition
of the muscles, which sometimes -undergo fatty dege-
neration, and also because the soft tissues and the
ankle-joint are much more lax, and the foot easily
returns to the position of deformity.

The extensor muscles may be paralysed, and then
the toes are flattened out and sprayed. In spasmodic
cases the toes are drawn back, and curled upon the
sole of the foot. The patient in walking often
damages the toes, and causes excoriations or corns
upon the points of acquired pressure.

In talipes equino-varus we have a very similar con-
dition, only it is associated with some inversion of the
foot caused by a firm contraction of the tibial tendons,
so that the navicular and cuboid bones become dis-
placed inwards. It may be necessary to divide the
tibial tendons in this deformity, but no rule can be
laid down as the cases vary so much. The calcaneo-
cuboid ligament is often firmly contracted, and re-
quires to be divided in order to liberate the anterior
portion of the foot, which is bent upon itself at the
transverse tarsal joint.

Talipes valgus occurs less frequently in children
than that of varus, being seldom found as a congenital
deformity. With it we have not only eversion of the
foot and relaxation of the internal lateral ligament,
but generally a collapse of the arch of the foot, so that
the patient walks flat upon the ground, without any
spring — his gait resembling the "clod-hopper" style
of the rough country boy who follows the plough.

TALIPES VALGUS.

Conc;enital.

Acquired.

To face p. i63.

FACE AND FOOT DEFORMITIES. 169

The patient scuffles along without properly lifting
his feet, the toes are unduly everted, the foot is
abducted and rotated outwards, and there is not
the flexibility of the ankle in walking, that betokens
the elegant pedestrian, although the foot itself is
abnormally weak and supple. The inner margin of
the foot is markedly depressed towards the ground
by the partial or total obliteration of the longitudinal
and transverse arches of the foot. Porters at the docks
accustomed to carry very heavy weights frequently
suffer from this deformity. The pain caused by pressure
upon the nerves incapacitates them for work, and walk-
ing is very irksome. Hence the importance of prompt
treatment. In extreme cases of talipes valgus it will
be necessary to divide the faulty peronei tendons.
The tendo Achillis is not generally involved. It may
be contracted with elevation of the os calcis or not.
If the heel is decidedly raised from the ground with
considerable deformity, we may term this variety
equino-valgus, and then will arise the question as to
the necessity of dividing the tendo Achillis. There
is very little deformity of the bones in this form of
talipes, though the ligaments are decidedly elongated
and lax, and defective in their structural character.

In extreme cases it may be necessary to divide
the peroneal tendons, and also the extensor longus
tendons. The majority of cases will yield to the
mechanical treatment when it is carefully and con-
tinuously applied for some months.

The perforated tin or iron splint, and the plaster
of Paris bandage exercise a very strong controlling
influence over this form of club-foot. Sometimes one

I70 FACE AND FOOT DEFORMITIES.

or two straight wooden splints fixed to the leg and
foot, with or without a foot-piece, may best provide
for the inversion of the foot.

T. valgus often follows upon deformity of some
other joint of the leg, as, for example, knock-knee, the
effect of which is to throw the foot out and incline the
tibia away from the proper axis of the limb. The
relaxation of the internal lateral ligament of the knee,
and the enlargement of the inner condyle of femur in
consequence of the weight of the body falling upon
the external condyle chiefly, will cause the leg to
incline obliquely outwards, and so force the foot into
a valgus position.

This also may happen when there is strumous
degeneration of the knee-joint with backward displace-
ment of the tibia, because the inner condyle is often
more infiltrated with pulpy degenerative material than
the outer. (See lithograph.)

It is often also a concomitant of hip-joint disease.
The patient swings the leg so as to put the chief
weight of the body upon the sound leg, and then the
foot becomes everted and depressed.

Rickety deformity of the tibia is frequently asso-
ciated with laxity of joint structures, and so the
superimposed weight of the body determines a valgus
deformity.

Flat-foot with little or no contraction of the tendo
Achillis, is a very frequent deformity among young
girls growing apace, without consequent correlative
consolidation of bones and ligaments to support the
increased weight of the body. Such children have
perhaps been brought up with unhealthy surround-

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FA CE AND FOOT DEFORMITIES. 1 7 1

ings, a deficiency of light, air, and nourishing food.
They are compelled to assist in the house work, to
carry heavy weights, as for example pails of water or
coals, and no wonder that in these non-congenital
varieties the foot sprays out, and the arch yields to the
superincumbent weight. The child, that is growing
out of its clothes so rapidly, is also growing into all
manner of awkwardnesses in posture and deportment.
In consequence of the depression of the inner ankle,
which now becomes very prominent and almost
touches the ground, the parents sometimes assume
that their child is double-jointed.

In the valgus deformity as distinguished from varus
there is often considerable pain in walking, so that the
child in time finds it impossible to walk on the
flattened foot. Non-congenital valgus usually affects
both feet.

There is always considerable muscular weakness in
these cases. The child is pale, delicate looking, and
what is called " overgrown," like a plant that is grown
away from the light.

In children, the subject of rickets, we usually find very
lax ankle joints and flat-foot. If the case is treated
early, and the bones fairly consolidated before the
child attempts to walk, the flat-foot may be overcome.
But in all such cases it will be necessary to persevere
with the treatment for some months, to prevent this
troublesome deformity becoming persistent. The
same remarks apply to the treatment of valgus when
it is dependent upon early infantile paralysis. By
galvanising the muscles and applying friction to the
joints, with tonic treatment internally, we may rectify

172 FACE AND FOOT DEFORMITIES.

the deformity before it becomes too late. Valgus may-
result from commencing disease of the ankle-joint, the
child walking on the outer side of the foot to avoid
pressure upon the tibial articulation.

Flat-foot is found of frequent occurrence in delicate
children of rapid growth. The ligaments which bind
the bones together on all sides become lax, and the
double arch which gives an elegant spring in walking
collapses, and so the child walks upon a broadened-
out flat sole, and as the nerves and vessels are dis-
tributed through this normal arch of the foot, and
become unduly pressed upon in walking, the child
complains often of pain and tenderness. The loss of
spring in the foot makes him soon tired, and he walks
in a slovenly slip-shod way. I find it necessary to
treat these cases both locally and constitutionally.
I place across the sole a firm pad, that will not yield
much to the pressure from above. I strap this on
with several " figure-of-8 " turns round the instep,
and also approximate the metatarsal bones to the
OS calcis by the use of firm strapping, or plaster of
Paris bandage. The child is allowed to walk under
a regulated system of daily exercise, so that the
arch is forced up by the pressure of the pad, and
the tarsal bones come into their proper relation to
the heel. With careful dieting and tonic treatment
the ligaments become consolidated and considerable
improvement is the result. But the parents must
consent to several months of persistent treatment.
It is easier to destroy an arch provided by nature
than to restore it. The surgeon has to struggle
against an effort to perpetuate the collapse of the

FA CE AND FOOT DEFORMITIES. 1 7 3

arch, by the continuous weight of the body favouring
a condition of flat-foot. When the deformity is of
an extreme character we generally have some valgus
associated with it. That is to say, when the longi-
tudinal arch of the foot, which is almost entirely on
the inner side of the foot, collapses, the outer part
of the foot everts, and the external lateral ligament
which binds the astragalus and os calcis to the tibia
becomes stretched, and we have the child walking
sometimes, so that the tibia very nearly reaches the
ground. In these cases it is necessary to apply
splints to the ankle and leg, and to fix them with
plaster of Paris bandage, and to press on the tonic
treatment. We seldom require to divide the peroneal
tendons.

Talipes equinus, so called because it resembles
somewhat the foot of a horse, the heel being raised
and the body resting upon the toes and metatarsal
bones. The foot itself becomes distorted, and the
plantar arch increased. The articulating surface of
the astragalus is felt subcutaneously, and very pro-
minent on the dorsum of the foot.

T. equinus is, as a rule, a non-congenital deformity.
Very slight contraction or rigidity of the tendo
Achillis, accompanied by lameness, may first direct
the attention of friends to this deformity, which, if
neglected, may become more marked, the heel being
raised from the ground.

To test the amount of flexion of the ankle-joint,
place the child in a bed or on a couch and move the
foot up and down. Also notice the range of move-
ment possessed by the patient. We must always

174 FACE AND FOOT DEFORMITIES.

remember that infants, in consequence of the un-
developed state of the gastrocnemius muscle, have a
wide range of movement at the ankle-joint, so that in
many cases the toes may be made to touch the tibia.
When the muscles are well developed the foot can
seldom be raised beyond a right angle with the leg.
Not only do corns form on the prominent parts of the
foot subject to pressure, but the child may acquire a
distorted condition of the spine in consequence of
walking awkwardly. No doubt in many of these
cases the distortion is due, in great measure, to the
firm contraction of all the flexor muscles upon the
metatarsal bones, causing a bending downwards of
the anterior portion of the foot, and a relaxation
of the transverse tarsal articulation, so that besides
a partial raising of the os calcis by the contraction of
the tendo Achillis, the equinus condition is produced
to a great extent by the sloping of the metatarsal
bones. The ligaments which bind the astragalus to
the scaphoid and cuboid bones are considerably
elongated.

Mr. Adams gives a table of 1780 cases of deformities
of the foot, of congenital and non-congenital origin.
Of these, 1016 were tabulated as of non-congenital
origin. T. equinus took the lead, with 401 cases ;
then T. valgus, with 1 8 1 cases ; next, T. equino-varus,
162 ; T. calcaneus, 1 10 ; T. equino-valgus, 80 ; T. varus,
60 cases.

The causes of this deformity are various, but chiefly
unbalanced spasm of groups of muscles from paresis
of the extensors of the leg. There are also traumatic
causes, as, for example, wounds of the calf muscles,

TALIPES EQUINUS.

Acquired

Talipes equinus without paralysis. Talipes equinus with paralysis.

To face p. 174.

FACE AND FOOT DEFORMITIES. 175

abscesses of strumous origin of the leg, anchylosis of
joint-structures, the result of inflammation in or around
the joint. When, as often happens, the plantar fascia
is contracted, as well as the tendo Achillis, it will
be desirable to delay the division of this until after
the healing of the divided tendon. In other cases it
will suffice to divide the plantar fascia, and not the
Achilles tendon.

When the toes are doubled round upon the sole of
the foot, or reflected back by tendinous contraction on
to the dorsum of the foot, it may be necessary to
divide the implicated tendons, so as to rectify their
position. It may be that careful bandaging, and exten-
sion with the perforated tin arrangement will suffice.

It is desirable to divide the tendo Achillis in all
cases of T. equinus where the contraction cannot be
overcome by a suitable appliance. When the anterior
muscles are paralysed or weak, it will still be well
to divide the tendon, so as to rectify the malposition
of the foot. By so doing, we raise the foot and place
it in a position for the anterior muscles to contract.

In talipes equinus, Mr. Adams agrees in considering
that it is useless to try mechanical treatment alone,
except in cases of very slight and recent contraction.
It is necessary to combine with these active and
passive exercises.

Talipes calcaneus is a much rarer form of deformity,
especially in the non-congenital variety. In these cases,
the toes are raised from the ground, the heel depressed,
so that the child walks upon the heel, the foot being
flexed upon the leg by the constricting action of the
anterior muscles. Congenital cases are found where

176 FACE AND FOOT DEFORMITIES.

the legs have been cramped, and doubled up in utero,
as in breech presentations. The muscles which cause
the deformity are the long extensors and the tibialis
anticus.

These cases sometimes undergo spontaneous cure
by the pressure of the superincumbent weight of the
body, and the natural inclination to point the toes.
As the calf muscles, which are usually very strong,
develop with the growth of the body, the heel becomes
raised and the foot depressed. Much may be done in
these cases by resorting to gentle friction of the
muscles of the calf. There is not usually much
rigidity, so that with perseverance we may often suc-
ceed in rectifying the deformity without operative
interference. The paralysed muscles may be stimu-
lated to proper action by friction and galvanism. The
fixation apparatus may be applied to the back of the
leg and sole of the foot, so as to point the toes and
depress the anterior part of the foot. In extreme
cases, a grooved splint with a foot-piece made of tin,
may be applied to the anterior part of the foot, so as
to extend the foot at the ankle. If the tendons are
at fault and rigidly contracted, we must of course
resort to tenotomy before applying the splint.

Non-congenital cases being the result usually of
confirmed paralysis of the sural muscles, the treat-
ment of this condition is not so simple. The plantar
fascia is usually much contracted transversely, so that
the tuberosity of the os calcis and metatarsal bones
are approximated.

In the treatment of these cases we must remember
that wasting and palsy of the calf muscles is a condi-

TALIPES CALCANEUS.

Congenital.

Acquired.

To face p. i-jf>.

FACE AND FOOT DEFORMITIES. 177

tion which we can only hope to remedy by a course
of tonic treatment and galvanism to the paralysed
muscles. I have had no experience of the method
lately introduced of excising an oblique segment of the
elongated tendo Achillis and then splicing the two
ends with kangaroo tendon. It would appear to me,
judging from the descriptions given of the details of
the operation and its results, that " le jeu ne vaut pas
la chandelle," especially in a muscle that is deficient
in vital energy. When we have undue length of
a tendon, that does not, I think, justify excision
of a segment. We know how nature will accom-
modate herself to the altered posture of a limb.
Wherever there is redundancy of muscular or ten-
dinous tissue the fibres will gradually contract,
and the wavy tendon will retract within its sheath.
I have seen attempts to cure varus deformity by
excising a portion of the redundant skin over the
outer ankle. This I consider a most unscientific
method of getting rid of redundant tissue. I prefer
rectification of posture, then compression and stimula-
tion, which must lead to ultimate absorption of the
excess of tissue.

It may happen that the calcanean deformity is
the consequence of mismanagement of a case of teno-
tomy or talipes equinus, so that the tendo Achillis
fails to obtain a fresh link of attachment to the os
calcis after division. Or there may be a constitutional
debility, rendering the reparative process ineffectual.
It often follows upon infantile paralysis at the teeth-
ing period.

Non-congenital deformities of the foot may arise

N

178 FACE AND FOOT DEFORMITIES.

from some definite derangement of the nervous system,
causing partial or complete paralysis of certain groups
of muscles, so that the antagonistic muscles acquire
undue power, and so draw up the foot in the direction
of their contractile power. In other cases we have
central irritation of the nervous system, as in sclerosis
of the spinal cord, which gives rise to various spastic
distortions of a more or less sudden character, such
spastic contractions being especially manifested during
any attempt to excite motor action in the unbalanced
muscles, as for example in the usual clinical methods
of testing reflex action. In all these cases the
deformity is not so pronounced as in congenital cases,
and as soon as the spasm relaxes the foot returns, to
some extent, to its normal position. Except in long-
standing cases where the adductors, for example, have
acquired a very firm unyielding contraction so that
the thighs become fixed and the joints rigid.

I am constantly having cases of a modified condition
of club-foot, or spasm of groups of muscles brought
to me, and the parents are much discomfited because
the child will not display the deformity when told to
parade for observation.

It is much the same with cases of local choreic
spasms of groups of muscles. It is well known that
chorea or St. Vitus's dance is a very prevalent com-
plaint with young girls between the ages of six and
fifteen, and is rarely seen in boys. This disease is
generally much exaggerated under the influence of
emotion.

A case of this sort came under my care recently
presenting some very interesting points for diagnosis.

FACE AND FOOT DEFORMITIES. 179

A pale, fair-complexioned child, with bright auburn
hair and very transparent skin, of seven years of age,
was sent to me by my friend Dr. Pearson of Ken-
sington. The child had aroused considerable interest
in her case, in consequence of her plaintive helpless
condition when these spasmodic attacks occurred.
When unrestrained she always managed to draw her
legs up with her knees to the chin, and any attempt
to rectify this position was followed by extreme ex-
citement, and expression of intense pain referable to
the knees and ankles. The child walked very cau-
tiously on her toes, and seemed very feeble ; she had
very pronounced lordosis under excitement, almost
amounting to opisthotonos. Sometimes she com-
plained of pain in one leg, and sometimes in the other.
By a little moral and firm persuasion she would allow
the surgeon to move the joints slightly without resist-
ance. There was no real rigidity of any of the
joints, or contraction of tendons. There was, however,
evidently some amount of enlargement of the great
trochanter on the left side, which aroused my suspi-
cions and prevented me from determining the case
as that of a malingerer.

The child was put under chloroform, and the legs
then became quite straight without any forcing. She
was put up with a Bryant's splint, and after a few days'
rest in bed she was set to walk, and could get along
fairly well with assistance, though very tremblingly.

The child was dirty in her habits, and had probably
been brought up with very bad home influences.

I had the patient put up with double spica flannel
bandages from ankles to axillae. I then applied my

N 2

i8o FACE AND FOOT DEFORMITIES.

perforated tin splints on both sides, encasing them
in plaster of Paris bandages from the axillse down-
wards, so arranged that she would have free use of
the feet, and could get about fairly well, notwith-
standing the solid investment of both knees and hips.

She was sent down to Margate to restore her
general health, and she came back looking very much
better.

I removed the apparatus and found that she could
walk and run about without any pain or discomfort. I
can only account for the enlargement of the great
trochanter as traceable to some fall that she may
have had in infancy, and being a strumous child the
contusion of the bone, which would have vanished in
a healthy child, set up a dormant ostitis, and remained
as a kind of nest-egg for future trouble.

When we have non-congenital cases of talipes in
children associated with some spasmodic or paralytic
affection of muscles or groups of muscles, the foot is
distorted from unbalanced action of the flexors, the
extensor muscles being partially or wholly paralysed.
In many of these cases the child is subject to fits, or
has some mental aberration, imbecility, &c. The
condition of spastic contraction of the calf muscles
varies, but the feet are usually raised at the heel, and
the child scuffles along on its toes with stiffened and
flexed knees, and is very prone to tumble about. The
muscles may atrophy, but so long as the child gets
about, the nutrition of the muscle keeps up. In some
cases, however, in consequence of the constitutional
delicacy, the muscles not only waste, but undergo
fatty degeneration. Sometimes we have a condition

FACE AND FOOT DEFORMITIES.

of valgus and extreme wasting of the limb from
some early damage to the hip joint and the sciatic
nerve. Infantile convulsions may set up varying
conditions of foot deformity and paralysis.

In all such cases it becomes important to decide upon
the value of operative interference. No doubt these
deformities are not so simply managed as the un-
complicated congenital talipes, for in such we have
simply to treat a local deformity induced apparently,
for the most part, by a local cause. Where, however,
we have to treat a limb which is deformed in conse-
quence of paralysis or irregular spastic action of
groups of muscles, we must carefully consider the
benefit to be derived from a division of the faulty
tendons. I think that in extreme cases the foot is
placed in such an awkward position and the deformity
is so unsightly that it is expedient to divide the tense
bands of fascia and tendons, so that the foot may be
brought down to a position corresponding to that of
the other leg, if only for the sake of symmetry.
Generally, however, the liberation of the foot by
tenotomy will give freedom to the opponent muscles to
contract, and if stimulated by galvanism, friction, etc.,
we may in time get some movement of these muscles
and power developed in them so as to counteract the
drawing up of the foot again into a distorted position.
In imbecile cases where there is much distributed
spasm and tension of muscular action, and in epileptic
cases, it is necessary to treat the case also on con-
stitutional principles. The result of freeing the ankle
may reveal a loose and imperfect condition of the
joint, so that there is no power for putting any weight

182 FACE AND FOOT DEFORMITIES.

upon it. In all these cases it is well to try the effect
of inunction of warm oil and opiate liniment with an
attempt to strengthen the nervous system by pro-
viding change of air to the seaside, and only in
extreme cases of distortion to resort to operative
measures. I have had some very successful cases of
spastic action of the calf muscles where the heel was
slightly raised from the ground, by bandaging the
foot upon a stirrup splint and forcibly stretching the
tendons so as to bring the heel down to its proper
position, and keeping up the extension by the use of
carefully adjusted appliances.

Congenital displacement of toe on to the dorsum of
the foot sometimes requires treatment. In such cases
it will be necessary to examine the deformity with a
view to the removal of so much as is likely to be an
impediment in walking.

Occasionally we have deformities of the foot coming
under treatment for congenital deficiency or excess,
as, for example, when we have supernumerary toes,
or only three or four toes.

Webbed toes, like webbed fingers, sometimes come
to the Hospital for treatment. It is of much less im-
portance to the comfort and freedom of motion of the
foot to divide the web between adjacent toes, than in
the case of the membranous union of fingers. The
division may, however, be accomplished with com-
parative ease, and it suffices to satisfy the parents if
we divide the toes, and remove that which may be
considered an unsightly deformity. The union is
generally very close, so that the adjacent nails almost
touch one another, and this makes it somewhat awk-

FACE AND FOOT DEFORMITIES. 183

ward to separate the toes, because there is a deficiency
of skin to cover in the spaces between them, and so
the heaHng process is sometimes retarded by the slow
formation of cicatricial tissue. I do not care for the
method of dissecting the skin from the dorsum of one
toe and applying it to the lateral aspect of the adja-
cent toe after division of the septum.

Supernumerary toes may be amputated if the surgeon
is convinced that the impediment to the child is suf-
ficient to interfere with his powers of walking, or if
they should necessitate the use of specially made
boots.

EI Burgess ch.iotii.

"Wes-t^^ev/ina-ia ^Co.i

lE.lBxu-^ess o]n.litk.

"West,Kex.a2ia.^5oCQ imp

APPENDIX

GIVING DETAILS OF THE EIGHT TYPICAL CASES SELECTED FOR
ILLUSTRATION IN CHROMO- AND MONOTONE LITHOGRAPHY.

Case i. Extensive Nctvoid Groivth {Fort-wine Mark)
on Face. — H. P., aet. 19, showing the distributed capillary
vascularity of the face which is so graphically depicted in
the Plate, was admitted as an In-patient to St. John's
Hospital, and by the courtesy of Mr. Startin I was enabled
to take charge of the case with him. The growth was not
only deep-seated in the tissues of the face, but it was raised
above the surface in parts. Whenever the patient flushed
up, the growth was highly congested and purple in colour.
There are some similar patches of capillary engorgement on
different parts of the body. She was placed under the in-
fluence of anaesthetics, and I then proceeded to operate with
the fine Paquelin cautery by the stippling process, which
I have already described in the text. I proceeded very
cautiously, only destroying small areas at a time, so as to
avoid any sloughing of the skin or deep destruction of the
derma. I operated about once a week, and after about ten
or twelve operations I succeeded in destroying about two-
thirds of this vascular growth. The gauge of the zinc dia-
phragm used for the thermopuncture is shown at the left-
hand corner.

The next Plate shows the after effect in progress of these
operations upon the face. As the growth was so deeply

1 86 FACE AND FOOT DEFORMITIES.

seated in the tissue of the face, and the surface hardened by
the frequent appHcation of strong caustics during several
previous attempts to destroy the growth, it was found diffi-
cult to treat the case successfully. The centres of each
patch were blanched by the stippling process, as shown in
the second chromo. I hope to bring the result of this and
other cases before the Societies as soon as they are cured.

Remarks by Mr. Startm. — Having carefully watched this
case during the months that the patient was under treat-
ment, I can see no reason why it should not ultimately
prove quite successful. — J. S.

Case 2. Ncevus of the Nose. — Rose — , set. i|-, was
kindly transferred to my care as an In-patient by my col-
league Mr. Pye. The drawing represents very accurately the
amount of distortion of the features by this vascular growth.
Several attempts had been made at this and another
hospital to destroy the nsevus by electrolysis, but without
any appreciable effect. {Vide^. 10.)

The child being put under chloroform, I made a
vertical incision through the apex of the nose and anterior
half of septum. This was of course followed by copious
haemorrhage. With a fine needle-point of the Paquelin
cautery I succeeded in arresting the hsemorrhage and also
in destroying the main trunks of the naevoid growth, by
passing the red-hot point well up under the skin of both
alae of the nose. It was some weeks before the sloughs
separated, so as to leave a healthy granulating surface. I
was careful to preserve the septum, and also the healthy skin
of the nose, from destruction by the cautery.

At a subsequent operation I proceeded to pare the
edges of the cavernous openings which overlapped the
cartilages of each nostril, and then to approximate, as for
harelip, the vivified edges of the bifid septum and alse nasi.
This lozenge-shaped gap was closed in very carefully with
my miniature steel pins, and the wound healed very well,
leaving only a linear cicatrix in the mesial line of the nose.

FACE AND FOOT DEFORMITIES. 187

The result of this operation is well shown at the lower
part of the Plate.

Case 3. Papillomata of Chin, Neck, Buccal Mucous Mem-
brane, etc. — Ernest M., set. 3, was admitted under my care at
the Victoria Hospital, on June 24th, 1884, on account of an
ugly chain of warty growth, extending from the gums in the
median line of the face down to the thyroid cartilage. The
median line of the lower lip was thus involved, both on
the buccal and cutaneous surfaces, with this papillomatous
growth. Some of the warts were sessile, others pedun-
culated. They were all growing from a raised base of
hardened and dark epithelial tissue. The continuous chain
of warts deviated from the middle line as it passed from the
chin to the thyroid cartilage. Some of the warts were
fiUform or brush-like, and very prominent. The others were
about the size of a split pea, and all those on the skin were
deeply pigmented. Those on the gum and mucous lining of
the lip were flat, having the red velvety structure of mucous
membrane. When damaged in mastication, they bled very
freely. {Vide^. 14.)

On July 26th the cutaneous growth was removed by two
linear vertical incisions, designed so as just to include the
mass of papillomata in a wedge-shaped section, without
invading the mouth. The edges of the gaping wound were
then approximated with strong hareUp pins and wire sutures,
some deep and others superficial, and in this way the
haemorrhage was arrested.

On July 31st the sutures were removed and also the
pins, the wound having healed throughout by primary
union.

On October 17th I proceeded to remove the correspond-
ing growth from the buccal mucous membrane. That on
the gums was destroyed with the Paquelin cautery, and
that on the lip by a double ligature transfixed upon a
harelip pin. Mr. Shaw, the Registrar, reports " original
scar hardly apparent."

i88 FACE AND FOOT DEFORMITIES.

The resulting photograph and lithograph show that the
linear scar is scarcely traceable (p. 14).

Case 4, Superficial Necrosis of Superior Maxilla with
Depression and partial Absorption of Lower Eyelid and com-
plete Ectropion. — Edmund K, get. 3^, was admitted under my
care at the Victoria Hospital on the 21st of March, 1884, pre-
senting a very unsightly deformity of face as the result of
cellulitis of cheek, superficial necrosis of subjacent malar and
maxillary bones, and the formation of a sinus over the malar
bone which communicated with the superficial necrosis.
Towards this sinus the loose tissue of the lower eyelid had
been drawn down, so that the skin puckered around the edges
of the sinus. The elevation of the cheek by this inflammatory
thickening caused a pit or pouch to form level with the
orbital plate of the malar bone. In the plastic operation
which I subsequently performed it was necessary to dissect
up the atrophied lid from the inner wall of this crater-like
pouch. (F/^i? p. 62.)

A probe, when passed into the sinus, impinged upon soft
bare bone, but it did not penetrate to the antrum. All the
teeth on the right upper jaw had decayed away, leaving only
the stumps. There was direct communication between the
alveolar sockets, and the germinal membrane surrounding
the embryo teeth of the second dentition. It was in the
bone that encased these teeth that the necrosis was detected.

On March 29th my colleague Mr. Fox, Dental Surgeon,
removed two of the stumps and one embryo tooth lying
loose in the cystic cavity.

On April 19th I dissected up the buccal mucous mem-
brane over the superior maxilla, and gouged away the
superficial necrosis of the malar and superior maxillary
bones. With a tenotomy knife I liberated the puckered
cicatrix and sinus from its deep bony attachments. Sup-
puration continued for a few weeks, necessitating careful
removal of the pus by pledgets of lint packed in the mouth,
so that it should not be swallowed.

FACE AND FOOT DEFORMITIES. 189

At a subsequent operation I made a semilunar horizontal
incision around the outer margin of this crater-like pouch,
and carefully dissected up the remnant of lower eyelid.
This flap was then displaced upwards and inwards, so as
to cover the exposed ball of the eye. The thickened everted
conjunctiva was thus turned inwards, and by passing a silk
suture twice vertically through the conjunctiva, and out at
the mouth, I was enabled to use some traction upon the
membrane to keep it in position against the eyeball, and
so to restore it as a lining membrane in juxtaposition
with the newly formed lid by a plastic operation. {Vide
the Plate, p. 62, for the result of these operations.)

Case 5. Congenital Talipes Varus of both Feet — Treat-
ment delayed by parents for four years — Subsequent rectification
of the Deformity. — A. S., set. 4^, was admitted under my care
at the Victoria Hospital with double congenital talipes varus,
the amount of deformity being the most extreme that I have
ever seen. Both feet were drawn inwards at an acute angle
with the leg, and the boy walked upon the outer edges of the
feet. He walked in a gjaating fashion, lifting one foot over
the other. He could not walk alone, and besides the
deformity there was considerable weakness about the muscles
of the legs. I kept the boy under my care for nine months,
during which time I performed several operations upon the
feet, dividing the Achilles tendons, the tibialis posticus and
anticus muscles of both legs, many of the deep flexor tendons
in the sole of the foot, the plantar fascia, etc. I also mani-
pulated all the bones of the feet, and divided some of the
interosseous ligaments. The feet were encased in the
plaster of Paris arrangement with the extension apparatus,
as described in the text. ( Vide p. 162.)

The photograph showing the after effect was taken two
years after he first came under treatment, and it shows how
completely the boy has gained the power of walking and
running alone. So firmly can he stand now, that the photo-
grapher did not attempt to steady him with the usual prop

I90 FACE AND FOOT DEFORMITIES.

behind. He goes regularly to school, and there is not the
slightest sign of deformity.

The photograj)h shows how completely the astragalus in
each case has been forced back by the digital compression,
into the correct relation to the tibial articulation (p. 162).

Case 6. Acquired Valgus from shortening of Leg, the
result of Hip Excision. — J. S., get. 6, son of a bricklayer's
labourer, came under my care at the Victoria Hospital with
extensive disease of the hip-joint of many months' duration.
It was evident that the disease was in the third stage of
progress. He was quite unable to bear any weight on this
leg. There was also evidence of active mischief progressing
within the joint. Sinuses had formed which could be traced
leading direct to the acetabulum, and there was distinct
grating, and severe pain when the head of the femur was
rotated in the acetabulum. (Fide p. 194.)

The boy's health had also become seriously undermined
from the long-continued purulent discharge, and from the
rapid decay of the joint-structures. There was no question
that excision of the joint would afford the only chance of
preserving his life. Having explained the circumstances to
the parents, I obtained their consent to the operation, and
proceeded to excise the joint by the usual semilunar
incision over the great trochanter. Before enucleating the
head of the femur, I evacuated a large quantity of pus from
the joint. I then discovered that the acetabular cavity
was completely destroyed, and I could pass my index finger
freely into the pelvic cavity. The head, neck, and upper
third of the great trochanter were then sawn across, and the
necrosed portion of acetabulum gouged away. The limb
was fixed to a Bryant splint.

The patient continued to progress favourably, with the
exception that coincident with the partial closure of the
external wound a rectal abscess terminating in a fistula
formed in the buttock, and the pus burrowed under the
gluteal muscles. It was evident that there had been

FACE AND FOOT DEFORMITIES. 191

established a direct communication between the rectum
and the acetabulum by the gravitation of pus within the
pelvis, the perforation of the levator ani muscle, and the
separation of the pelvic fascia at the ileo-pectineal line.

I treated the abscess and fistula in the usual way, by
making some free incisions into the buttock, and by dividing
the sphincter ani upon a grooved director.

The boy made a good though slow recovery. Anew joint
was established close to the old acetabulum. The tissues
became firmly consolidated. The acetabular cavity closed
in entirely, and the drawing {a) which I append shows the
satisfactory cure of this protracted case two years after the
excision, together with the acquired valgus which was under-
going treatment, and was nearly cured when the photograph
was taken. There was only about \\ inch of shortening.

Remarks, — I have cited this case as a typical one of
compensatory valgus caused by unrestricted walking upon a
shortened limb with tilted pelvis j and also on account of the
rarity oi fistula in ano associated with hip disease, serving as
another proof of the generally satisfactory results which may
be obtained from hip excision in the later stages of the disease.
(In fact, I think my experience would go to prove that ex-
cisions in the early stages of the disease are not justified,
on account of the greater mortality at this stage from ex-
cision than when the joint-structures are seriously involved
and the encrusting cartilages destroyed.) I merely append
this remark in parenthesis because I am not now at liberty
to discuss the important question of hip excision and its
consequences.

Case 7. Acquired Valgus from Pulpy Degeneration of
Knee-joint, associated with extreme backward and outward dis-
placemettt of the Tibia. — ^W. L., set. 10, came under my care
as an out-patient at the Victoria Hospital, in the condition
represented by the first drawing on the Plate. The limb
was completely atrophied and useless. He had valgus
deformity of both feet, but especially of the left foot. The

192 FACE AND FOOT DEFORMITIES.

joint-structures were quite disorganised, so that the leg hung
loose like a flail, and he was unable to bear any weight on
the leg. {Fide -p. IT o.)

There was considerable backward displacement of the
tibia, together with pulpy degeneration of the knee-joint
and a very prominent swelling of the inner condyle of the
femur, causing the eversion of the leg which was so marked.

The case seemed in a hopeless condition for conservative
treatment. The boy suffered a good deal of pain in the
knee, and there was also some pain elicited when I ap-
proximated the articular surfaces, although there was appa-
rently no erosion of cartilage. There was almost complete
fibrous anchylosis of the joint-structures. I admitted him
as an in-patient, intending to excise the joint, and so to
bring the outwardly distorted tibia into its proper relation
to the femur, and also for the purpose of removing the
disease in the joint.

A more complete examination of the condition of the
joint, and the subsidence of the acuter symptoms during his
stay in the Hospital, determined me to try the rectification
of the deformity of the foot, and the cure of the disease in
the knee, by complete rest and absolute fixation of the joint.
I placed the leg on a long outside splint, and afterwards on a
straight back splint slightly grooved. Having encased the
limb in a flannel bandage, I then applied a plaster of Paris
bandage from the ankle to the groin, so as to keep the joint
at perfect rest. He was kept in bed for some weeks, when
the swelling of the joint becoming decidedly less, I resolved
upon the continuation of this method of treatment, and
proceeded to tilt forward the tibia by placing a pad below
the popliteal space, so as to bring the head of the bone
again into proper relation with the condyle by the regular
application of a firm calico bandage over the knee. I suc-
ceeded in so everting the joint by a moulding process as to
bring it well on to the straight splint, and then to retain
it there with a strap and buckle. I also broke down the

FACE AND FOOT DEFORMITIES. 193

adhesions under chloroform. The valgic condition of the foot
was cured by the application of the perforated tin apparatus,
and also by the use occasionally of a rectangular outside
wooden splint to invert the foot. The boy was soon
enabled to get about with scarcely any lameness, and go
to school.

The second drawing shows how the muscles of the limb
are developing, and how almost entirely the deformity, both
of knee and ankle, has subsided. He has also some limited
power of flexion of the knee-joint.

Remarks upon Osteotomy for Knock-knee — As soon as
the white swelling had become reduced by the constant appli-
cation of pressure bandages, the question arose whether
osteotomy would be the best method of rectifying this very
pronounced angularity of the knee-joint. Certainly the
amount of distortion was quite up to the average of cases
usually submitted to the osteotomy operation. Consider-
ing, too, his age, and the length of time that the distortion
had existed, it seemed very desirable to take some decisive
steps to rectify the deformity. For reasons which I will not
here detail, I have very grave doubts as to the beneficial
effects of osteotomy, considering the wholesale way that it
is now being performed in some of our British hospitals.
I have carefully weighed the pros and cons of this opera-
tion in my own practice, and have come to the conclusion
that, with perseverance we can, as a rule, in young children,
secure a more useful hmb by patient extension on a straight
back splint with plaster of Paris bandages, though, of course,
there are many cases in which we require to resort to sub-
cutaneous osteotomy for extreme distortions.

Case 8. Deformity of Foot from Excision of Os Calcis.
— B. J., set. 3, the daughter of a draper, was enjoying a
swing with her little brothers on a rocking-horse at Christ-
mas time, when the left foot being caught between the

O

194 FACE AND FOOT DEFORMITIES.

framework and the floor it was severely bruised. Some '
persistent swelling followed, so that the child had to be
kept off her foot, and a chronic abscess formed over the
OS calcis. After taking her to three or four surgeons, she
was brought to the Victoria Hospital. By this time the
swelling had in part subsided. There was no heat about
the foot and no redness, but the skin had certainly thinned
over the os calcis, and there was distinct fluctuation. I
therefore evacuated the abscess by a small incision, and
finding that the sinus did not close, I passed a probe and
detected carious bone, apparently loose within a shell of
investing bone and articular cartilage. The surface of this
decayed bone I gouged away, but finding that the child's
health was failing in consequence of the confinement and
the prolonged discharge, I resolved to excise the os calcis
en masse. After the operation, there was some decided
swelling of the synovial membrane at the ankle-joint, with
pain on pressure of the foot upwards, and it was thought
by some of my surgical friends that the foot must be
amputated.

I resolved to watch the effect of the minor operation first
of all.

The lithograph well shows the satisfactory result of
the operation and the puckered scar indicating the line of
incision. It also shows well the re-formation of a new os
calcis from the portion of periosteum which I left behind,
the re-attachment of the tendo Achillis to the new bone,
the subsequent development of the calf muscles, and the
very limited amount of deformity which resulted from the
removal of this, the largest bone of the foot.

I need not detail the steps of the operation nor the
progress of the patient. It will suffice to say that the child
made an excellent recovery, that she gained complete
control over all muscular movements of the foot and ankle,
that she can flex and point the toes equally well with both
feet. She even runs races with her brothers and sisters,

E.Buc&ess liWi .

West .NewJKiau & Co.iKun.

FACE AND FOOT DEFORMITIES. 195

and beats them in running. The joint-structures are
completely restored to their normal condition, and there is
not the slightest lameness or awkward posture of the foot.

Remarks. — The above case I have selected for illustra-
tion from among my cases of deformity after partial excision
of the tarsus, because it well represents the generally uni-
form success which follows the conservative treatment of
strumous disease of individual bones of the foot.

I may say here, what I could not very well embody in the
text — that local disease of joint structures in the foot, as, for
example, of the metatarso-phalangeal joint of the big toe,
may be successfully treated by excision of the faulty joint or
bone, without having recourse to amputation of the foot,
whether partial or complete. A very useful foot will result
from such treatment in most cases.

As in the case of the os calcis, we can generally trace
some traumatic cause as the starting-point for the strumous
decay of the bones of the foot. I therefore feel it to be
incumbent upon surgeons to retain, if possible, the adjacent
bones which are found not to be involved in the disease.

The recuperative powers of children, even of delicate
constitutions, are so great that under careful and judicious
nursing, such as they may secure at a hospital for children,
we may generally anticipate in these cases a satisfactory
termination to the disease, and a useful limb.

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