the bones; in the latter case, necrosis of the nasal bones takes place, and the bridge of the nose is flattened, the tip is turned up, and a most unsightly deformity is produced. Gummata also occur in the tissues over the cartilage of the tip of the nose, leading to ulcers which generally yield readily to anti-syphilitic treatment, and leave only scars. or some slight deformity about the margin of the nostrils.

Nodular syphilides may cause widespread destruction of the nose. They commonly commence about the tip of the organ, which is rapidly destroyed. The diagnosis is difficult in early cases; the affection is apt to be confounded with lupus, the chief points in the diagnosis being the more rapid spread of the syphilitic lesion, the absence of the characteristic apple-jelly nodules, the larger size of the nodules and the extension of the disease to the bones. In advanced cases the bony structures of the nose may be destroyed completely, so that nothing is left of the organ but an oval opening on the face. The disease also extends along the nasal cavity, destroying the vomer or the hard palate.

TREATMENT.-The treatment of the primary and secondary lesions presents no points of difference from that already recommended for the disease in general (see Vol. I. Chap. XI.). The gummatous form of the disease affecting the frontal bone is dealt with in connection with diseases of the skull (see p. 362). The nodular syphilide of the nose is more important in that it spreads with great rapidity and the deformity is irreparable; therefore the patient must be brought under the influence of anti-syphilitic remedies as rapidly as possible.

TUBERCULOUS AFFECTIONS.

These may occur as tuberculous ulcers of the skin, as lupus, or as an intermediate condition between the two, often described under the name

of 'scrofuloderma.'

TUBERCULOUS ULCERS OF THE SKIN.

These ulcers usually occur in connection with tuberculous glands in front of the ear or as a secondary result of tuberculous disease of one of the facial bones, such as the malar or the orbital margin of the superior maxilla. In the latter cases, the skin becomes fixed to the bone when the ulcer heals, and the contraction may interfere with the movements of the lower eyelid, or may lead to ectropion.

TREATMENT.--Whenever an abscess forms it should be opened, scraped, injected with iodoform and glycerine emulsion (see p. 118), and stitched up. When there is an ulcer situated over diseased bone, the former should be scraped and the latter removed. As soon as the surface thus left is granulating and healthy, it should be skin-grafted (see Vol. I. P. 52). It will be necessary to put the patient under the best hygienic

conditions, and injections of tuberculin may do good (see Vol. I. p. 522). When there is eversion of the lower eyelid, the ordinary operation for ectropion should be performed after the disease has passed off; this is described under the plastic surgery of the face (see Chap. XLI.).

TUBERCULOUS LUPUS.

This is the most common tuberculous lesion of the face; it occurs chiefly upon the cheeks or the tip of the nose, and presents wide variations in virulence. The disease may last for years and is very intractable; unless its ravages are checked, it may cause the most distressing deformities. It begins with the deposit of one or two nodules in the skin, around which fresh nodules develop, and these may or may not ulcerate. On the face, the disease spreads in the skin, but does not penetrate for any distance into the subcutaneous tissues. On the nose, however, the tubercles penetrate deeper and destroy the cartilages, so that after a time the cartilaginous portion of the nose may be lost. The nasal bones are never affected and the bridge remains intact; this serves to distinguish the condition from syphilitic destruction of the nose. The disease may

spread from the nose to the lips and into the nostrils. Apart from the unsightly sores and scars and the destruction of tissue, the ulceration gives rise to other deformities which are both unsightly and serious, such as ectropion, contractions about the lips which distort the mouth, and narrowing of the orifices of the nostrils, so that the patient is unable to breathe properly.

TREATMENT.-The various methods of treating lupus have been already referred to (see Vol. II. p. 15); we need therefore say nothing further on the matter here, especially as the remarks in the former volume refer appropriately to the affection as it occurs on the face.

INFLAMMATORY AFFECTIONS.

There are no special points concerning the acute inflammations of the skin and subcutaneous tissues of the face.

ERYSIPELAS.

The face is the most common seat of the so-called 'medical erysipelas,' in which no definite point of entrance of the micro-organisms can be made out. The chief importance of erysipelas of the face is that it has a great tendency to spread to the scalp, and there is always, therefore, the risk of acute inflammatory processes in that region.

TREATMENT.-This does not differ in any way from that already described for the affection in general (see Vol. I. p. 197).

III.

GG

TUMOURS.

SEBACEOUS CYSTS.

These are not uncommon; in the case of the cysts situated on the face, the wall is much thinner than in those which occur on the scalp. TREATMENT.-The method of removing these cysts has been already fully described (see Vol. II. p. 20). To avoid unnecessary scarring, the incision should be planned so as to lie as far as possible in the natural folds of the cheek. Injury to the facial nerve is not likely to happen, if the superficial part of the cyst wall is properly defined, and the soft parts separated from the rest of the wall with a blunt dissector.

DERMOID CYSTS.

Dermoid cysts occur chiefly about the outer angle of the orbit, in the line of the inter-maxillary cleft, in the middle line in front, or sometimes in the substance of the cheek (see Fig. 200). The cysts about the external angle of the orbit, which are the commonest, may communicate with the interior of the skull through an aperture in the frontal bone, but they are always external to the dura

mater.

TREATMENT.-In removing these cysts more care is required to avoid the branches of the facial nerve than is necessary in the case of sebaceous cysts, because dermoid cysts are more deeply situated. The incision over the tumour should be parallel to the branches of the nerve, and, been as the cyst wall has reached, the rest of the separation should

FIG. 200.-LINES ALONG WHICH
DERMOIDS OCCUR.

as soon

be done with a blunt dissector, and the cyst removed entire.

NÆVI.

These are very common on the face, and naturally call for treatment both from the discoloration they cause when the nævus is superficial and from the swelling when the tumour is of the venous variety.

TREATMENT.-When the nævus is quite small and fairly superficial, excision will probably give the best result and leave the smallest scar. The incision should, if possible, be made parallel to the branches of the facial nerve and along one of the natural folds of the skin. If the tumour is large, it is best to treat the superficial portion by freezing it with CO2 (see Vol. I. p. 262), and the deeper part by electrolysis.

For the large, deep-seated venous nævi of the cheek, electrolysis is

by far the best method of treatment, as excision or cauterisation cannot be employed, on account of the risk of injury to important structures and of the scarring which would result. The method of electrolysis is detailed in Vol. I. p. 256.

'Port-wine Stains.'-Perhaps the most troublesome nævoid condition on the face is that produced by the so-called 'port-wine stains,' and the disfigurement may be so great as to call for treatment. Exposure of the stain to radium or the X-rays until a dermatitis is set up, may cure the affection by producing thrombosis, but the best method is to freeze the surface with solid CO2 (see Vol. I. p. 262).

MOLES.

Moles are frequently met with on the face and are often very disfiguring. They vary in size from that of a small pea up to a pigmented area larger than the palm of the hand. They may be partially or entirely covered with hair.

TREATMENT.-This has already been fully described (see Vol. I. p. 251). Should the patient desire to be relieved of the pigmentation, the only method is to excise the patch. If the mole is small and the incisions are suitably planned, the edges of the wound may be brought together by buried sutures (see Vol. I. p. 136), and the resulting scar may be quite unnoticeable. When the wound is too large to allow of this, Thiersch's skin-grafts, cut as large as possible, should be applied to the raw surface. The slight scarring resulting from this will be far less. noticeable than the pigmentation due to the mole. If the raw surface can be covered by one or two large grafts the scarring will be quite inconspicuous in a short time.

In other cases the patient especially desires to be freed from the presence of hairs upon the mole. Temporary depilation may be obtained by exposure of the hairy part to the X-rays or radium, but in the course of time the hairs grow again. Permanent arrest of the growth of hair can only be secured by destroying the hair bulbs. The most efficacious method of doing this is by electrolysis. Although very effectual, it is very slow and tedious, since each follicle has to be treated separately. It was much used at one time for the removal of superfluous hairs on the upper lip in females. Both methods leave the pigment unaltered in the case of pigmented hairy moles.

For the following details of electrolysis we are indebted to Dr. Arthur Whitfield, Physician for Diseases of the Skin at King's College Hospital:

The battery should consist of dry or Leclanché cells coupled in series. It is seldom that more than ten cells are required for any operation, but if there are eighteen, the battery may also be used for the production of anaesthesia by cataphoresis when necessary. A galvanometer reading in milliampères is also necessary. The needle used varies with the taste of the operator; the platino-iridium needle has the obvious

advantages that it may be easily sterilised in the flame, it may be bent to any angle that may prove convenient at the time, and it is not likely to be broken by the sudden movement of a nervous patient. For all purposes a needle bent at an angle of 45° at a distance of one-third of an inch from the free end is most convenient. The base of the needle may be an octagonal, hollow, metallic cylinder fitting directly on to the terminal of the lead as recommended by Brocq. This arrangement obviates the use of a heavy needle-holder, and is far the most convenient for manipulation in awkward situations such as beneath the chin. The indifferent electrode is usually a large metallic cylinder covered with wash-leather and moistened with salt solution. A lens is usually of advantage and none is more efficient than an ordinary watchmaker's glass.

'The patient should be in a semi-recumbent position on a couch in a good light. The positive electrode may be laid on a piece of mackintosh on the patient's lap, so that she may grasp it when required. Five cells are then put in circuit and, while the indifferent electrode is lying loose on the patient's lap, the needle, attached to the negative pole, is introduced into the neck of the follicle. The direction of the needle should be parallel to that of the hair. In this position, with no current flowing, the sense of touch will inform one, after a little experience, whether the needle is entering the follicle or attempting to pierce the skin. The patient is then instructed to grasp the positive electrode firmly, and the strength of current as indicated by the galvanometer is noted. For the first trial, a strength of about one milliampère is sufficient. After a few seconds, bubbles of hydrogen will be seen issuing from the mouth of the follicle, and shortly afterwards a somewhat yellowish transparent zone will appear around the mouth of the follicle. This is the zone of total necrosis; immediately it appears the patient must be instructed to drop the positive electrode. This yellowish zone should never be allowed to gain a diameter larger than that of a small pin's head, otherwise the scar left will be manifest to the naked eye. The needle is now withdrawn, and after a moment or two the hair may be pulled very gently with epilation forceps. If the operation has been successful, the hair will slide out of the follicle without offering the slightest resistance, and will bring with it the macerated and gelatinous-looking inner root-sheath. If the hair is not loosened, the current must be increased for other hairs, but it must never pass four milliampères for even the stoutest. A medium strength for the chin is about two and a half milliampères, while one and a half will usually suffice for the upper lip. As regards the time during which the current should be passing, from five to fifteen seconds will generally suffice. On no account must hairs be taken during one sitting, which are so close that their respective zones of necrosis must touch.

'It is better never to introduce the electrode for a second time into a follicle, when the first application has failed to loosen the hair. The needle is sure to run down the false passage made on the first introduction,