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Botulinum Toxin in Clinical Dermatology
 Botulinum Toxin in Clinical
Dermatology
edited by
Anthony V Benedetto DO FACP
Clinical Assistant Professor of Dermatology
University of Pennsylvania School of Medicine
Philadelphia
PA, USA
and
Dermatologic SurgiCenter
1200 Locust Street
Philadelphia
PA, USA

LONDON AND NEW YORK

 © 2006 Taylor & Francis, an imprint of the Taylor & Francis Group
First published in the United Kingdom in 2006 by Taylor & Francis, an imprint of the Taylor &
Francis Group, 2 Park Square, Milton Park, Abingdon, Oxfordshire, OX14 4RN.
Tel.: +44 (0) 20 7017 6000 Fax.: +44 (0) 20 7017 6699 Website: http://www.tandf.co.uk/medicine
E-mail: [email protected]
“To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of
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transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or
otherwise, without the prior permission of the publisher or in accordance with the provisions of the
Copyright, Designs and Patents Act 1988 or under the terms of any licence permitting limited
copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P
OLP.
Although every effort has been made to ensure that all owners of copyright material have been
acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or
editions any omissions brought to our attention.
Although every effort has been made to ensure that drug doses and other information are presented
accurately in this publication, the ultimate responsibility rests with the prescribing physician.
Neither the publishers nor the authors can be held responsible for errors or for any consequences
arising from the use of information contained herein. For detailed prescribing information or
instructions on the use of any product or procedure discussed herein, please consult the prescribing
information or instructional material issued by the manufacturer.
A CIP record for this book is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Data available on application

ISBN 0-203-49505-5 Master e-book ISBN

ISBN 1 84214 2445 (Print Edition)

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 Dedication

This book is dedicated to all those who have mentored and supported me throughout my
past endeavors. Also to those who have given me the confidence and their invaluable
assistance which has helped bring this challenging project to fruition, including friends,
colleagues, family, and most of all Dianne.
 CONTENTS

Foreword xiii
Jean Carruthers
Preface xv
Anthony Benedetto

Prologue The psychology of cosmetic treatment 1

Matthew Silvan
Chapter 1 Pharmacology, immunology and current developments 16
Roger Aoki
Chapter 2 Facial anatomy and the use of botulinum toxin 36
James Spencer
Chapter 3 Cosmetic uses of botulinum toxin A in the upper face 50
Anthony V Benedetto
Chapter 4 Cosmetic uses of botulinum toxin A in the mid face 152
Anthony V Benedetto
Chapter 5 Cosmetic uses of botulinum toxin A in the lower face, neck and 201
upper chest
Anthony V Benedetto
Chapter 6 Muscle contouring with botulinum toxin 254
Michael S Lehrer
Chapter 7 Other dermatologic uses of botulinum toxin 270
Kevin Smith and Francisco Pérez-Atamoros
Chapter 8 Dysport®: a European botulinum type A neurotoxin 291
Gary Monheit
Chapter 9 Botulinum toxin B 305
Neil Sadick
Chapter 10 Botulinum toxin in the management of focal hyperhidrosis 321
Oliver Kreyden

Appendix The preparation, handling, storage and mode of injection of Botox® 364
1
Appendix Consent to have botulinum treatments for facial and body wrinkles 368
2
Appendix Patient treatment record 371
3
Appendix Muscles of facial expression 373
4
Appendix Side-effects and contraindications to BOTOX® injections 377
5
Index 379
 CONTRIBUTORS

K Roger Aoki PhD

Vice President, Neurotoxins Research Program
Biological Sciences
Allergan, Inc
2525 Dupont Drive
Irvine
CA 92612
USA
Anthony V Benedetto DO FACP
Clinical Assistant Professor of Dermatology
University of Pennsylvania School of Medicine
Philadelphia
PA
USA
Oliver P Kreyden MD
Praxis Methiniserhof
Baselstrasse 9
Muttenz 4132
Switzerland
Michael S Lehrer MD
Clinical Assistant Professor
Department of Dermatology
Hospital of the University of Pennsylvania
3400 Spruce Street
Philadelphia
PA 19104
USA
Gary D Monheit MD
Monheit Dermatology Associates
Ash Place, Suite 202
2100 16th Avenue South
Birmingham
AL 35202
USA
Francisco Pérez-Atamoros, MD
Centre Dermatologico Tennyson
Tennyson 241
Polanco
Mexico City 11550
Mexico
Neil Sadick MD
Sadick Dermatology & Aesthetic Surgery
772 Park Avenue
New York
NY 10021
USA
Matthew E Silvan PhD
Department of Dermatology
St. Luke’s-Roosevelt Hospital Medical Center
1090 Amsterdam Avenue
New York
NY 10021
USA
Kevin C Smith MD FACP FRCPC
Suite 201–6453 Morrison St.
Niagara Falls
Ontario L2E 7H1
Canada
James M Spencer MD MS
Professor of Clinical Dermatology
Mt. Sinai School of Medicine
1 Gustave L.Levy Place, Box 1047
New York
NY 10029
USA
 FOREWORD

Botulinum toxin A is the most exciting new drug from the past century. Dr Alan Scott
deserves the credit for the originality of his idea to use a drug rather than a surgical
procedure to repair misaligned eyes. Alastair and I have seen our idea of using it for a
cosmetic treatment flower from a rather strange ‘fringe’ idea to seeing BTX-A injections
becoming the world’s most frequently administered aesthetic procedure. Groups of
physicians who were once skeptical of its rationale and effects now are ardent users and
supporters.
In the wake of the wildly unsafe use of a non-human-approved botulinum neurotoxin
in Florida in late 2004, this book is a very timely addition to the scientific literature.
Safety and predictable efficacy are of paramount concern to aesthetic physicians. None of
these goals can be reached without the knowledge of anatomy, aesthetics, physiology,
injection technique, numbers and placement of units of BTX-A which are all stressed in
this excellent book. The aesthetic physician authors who have contributed to this work
are well respected and authoritative and deserve to be read and studied. One of the great
results of the cosmetic revolution started by BTX-A is that many physician groups who
did not traditionally learn from each other now greatly value the modern hybrid aesthetic
approach—as exemplified by this book.
Jean Carruthers
Clinical Professor
Department of Opthalmology
University of British Columbia
Vancouver
Canada
February 2005
 PREFACE

It is quickly becoming very difficult to remain up to date with what is being published
about botulinum toxin. This small instructional manual was written to organize what
dermatologists and other physicians need to know about treating patients for cosmetic
purposes with injections of botulinum toxin A. Recently, several therapeutic indications
for the use of botulinum toxin in dermatology have also been proposed. Many of these
indications have been included in this text.
Currently, the only FDA approved botulinum toxin A for cosmetic use in the USA is
BOTOX® Cosmetic. It is approved only for the treatment of glabellar frown lines.
However, the majority of the cosmetic corrections that are done with BOTOX® Cosmetic
are performed on an off-label basis. Consequently, prior to the printing of this book, there
has been no established text detailing the many different injection techniques presently
available.
Who are the patients who seek cosmetic enhancement, and why should we treat them?
Dr Matthew Silvan presents us with a glimpse into the psychological aspects of someone
seeking to cosmetically improve their outward appearance. Why does one seek the help
of others to modify, and hopefully, improve upon their natural appearance? Is it a means
to create a façade of deception for others, or is it a way to transform themselves inwardly
and improve their self image? With some insight into the mind of the ‘cosmetic patient’,
this textbook begins with a historical perspective on the development of the medical use
of botulinum toxin presented by Dr Roger Aoki, Vice President of Neurotoxins Research
Program in Biological Sciences at Allergan, Inc. Over the years, Roger has helped me
and a score of others understand the essential concepts concerning the pharmacology and
immunology of botulinum toxin.
There is much emphasis on anatomy in this text. No one should attempt to administer
botulinum toxin unless they possess a solid working knowledge of the mimetic muscles
of the face. Ideally one should be able to visualize the functional anatomy of a particular
facial muscle or set of muscles while gazing upon a patient and deciding where to place
the needle and inject the next unit of botulinum toxin. Not only is there a full chapter
dedicated solely to the muscular anatomy of the face by Dr James Spencer, but anatomy
is again discussed in the ‘Functional Anatomy’ section of the individual chapters dealing
with how to inject BOTOX® Cosmetic.
Many physicians have their favorite manner in which they inject botulinum toxin,
some of which are reliable and reproducible, others of which are not so reliable and
reproducible. This text attempts to cull the many different techniques of well-known
physician injectors who use botulinum toxin regularly, and who get excellent and
reproducible results. By emphasizing the proper way to inject BOTOX Cosmetic®, we
can alert the neophyte injector on how to carefully select the appropriate patients,
produce acceptable results, and avoid complications.
The chapter written by Dr Michael Lehrer describes a technique of reducing muscle
bulk and girth with botulinum toxin. These techniques are practiced by physicians in
areas of the world where oversized muscles create an unacceptable cosmetic dilemma for
which invasive interventions occasionally are performed. Botulinum toxin now provides
a non-invasive way to accomplish similar results. Drs Kevin Smith and Francisco Pérez-
Atamoros then give us a glimpse of what may be in store for us in the future. They
discuss controversial uses of botulinum toxin A that are in the purview of a practicing
dermatologist, some therapeutic, and some cosmetic, but they all seem to work and
produce remarkable outcomes.
Next Dr Gary Monheit gives us an overview of Dysport®, the other botulinum toxin A
that is currently being used in other parts of the world outside the United States. Soon
Dysport® will be available for use by physicians in the United States under the tradename
of Reloxin®. A chapter on the comparative uses of botulinum toxin serotypes B and A is
presented by Dr Neil Sadick, who puts into perspective our understanding of the currently
available botulinum toxins. Dr Oliver Kreyden, one of the first and foremost users of
botulinum toxin for hyperhidrosis in Europe, concludes our compilation of dermatologic
uses of botulinum toxin by contributing a detailed chapter on the pathophysiologic
rationale and the therapeutic use of botulinum toxin in suppressing localized
hyperhidrosis.
Finally if it were not for Drs Jean and Alastair Carruthers, many of us in dermatology
would not be injecting botulinum toxin for cosmetic and therapeutic purposes. It is
because of them and their many disciples that most of us continue to learn and develop
different ways to treat various problems in different areas of the body with botulinum
toxin. Thank you Drs Carruthers for your insight, genius, and encouragement.
Anthony V Benedetto DO, FACP
March 2005

Notes on the text

Chapters 2, 3, 4, 5 and 9
Please note that each line drawing of facial muscles in the above chapters depict
superficial muscles on the left hand side of the diagram, and deep muscles on the right
hand side of the diagram.
 Prologue
THE PSYCOLOGY OF COSMETIC
TREATMENT
Matthew Silvan

Introduction

A consideration of the psychological issues related to cosmetic treatments, from surgical

face lifts to non-invasive procedures such as BOTOX®, forces us to look at ourselves in a
deeper way. It makes us confront our vanity and look at who we are and who we want to
be. In addition, since cosmetic treatments are often used to stave off the effects of aging,
their usage is intimately connected to our sense of our bodies, our sexuality, and even to
our mortality. But how can we understand the differences between vanity and wanting to
look our best? What does it mean to grow old gracefully? To pathologize the search for
beauty and any effort to make one look younger, healthier, or just be more physically
attractive seems contrary to a physician’s clinical and personal experience. However, to
see the use of BOTOX® and other cosmetic treatments as divorced from psychological
meaning is also problematic and avoids the complex and subtle nuances of how we think
about ourselves and how we look at our patients. Ultimately, the individual decision to
change one’s looks is complex and multidetermined. It is influenced by our culture, our
sense of our selves, and the ubiquitous wishes, fears, and conflicts that are in all of us.
As the reader of this book is primarily concerned with the science and therapeutic uses
of botulinum toxin, the following comments are applicable to that specific population.
However there are currently no experimental data yet published in peer review journals
that can tell us specifically who are seeking BOTOX® treatments. We do not know what
their psychological motivations are, with what conflicts they struggle, or what psychiatric
diagnosis they carry. We may presume that, since BOTOX® is a less invasive medical
intervention than cosmetic surgery, this group of patients may differ somewhat from the
cosmetic surgery population. However, more than likely psychological factors are present
in all patients who seek even the least invasive cosmetic treatments. Placing cosmetic
treatments in a psychological and social context, illustrates that regardless of what one
actually does there are core motivations and pressures that drive our patients to us to alter
their appearance. Individual differences may exist, but the central psychodynamics that
drive us and our patients are still quite generalizable. In addition, this chapter will
describe how psychopathology may be assessed and, more importantly, how the presence
of conflict and motivation is distinguishable from the pathology that may preclude
cosmetic treatment.
Let us begin with some anthropologic and historic observations about beauty, age, and
the use of cosmetics. Culture, in terms of how it values and defines beauty either directly
or indirectly, influences behavior. By exploring the use of cosmetic treatments in more
 Botulinum toxin in clinical dermatology 2

depth, dermatologists can more effectively understand patients and the often complex and
subtle expressions of the needs and wishes that bring them to the office. By articulating a
more comprehensive and complex understanding of a patient’s psychology,
dermatologists are in a better position to assess whether the treatment they are offering
will be what their patient actually wants and needs. By listening more acutely to their
patient’s words, dermatologists are also better able to recognize those patients for whom
cosmetic treatment is contraindicated and even dangerous. In covering this wide range of
issues it behooves the cosmetic practitioner to recognize the psychological complexity of
the work s/he is doing, the multi-determined motivations with which patients arrive, and
the way in which this perspective can enhance the practice of their profession.

History

The search for beauty is not new or specific to this time in history. These concerns have
been with us for millennia, although how they are expressed may shift from one extreme
to the other. A review of sociologic, anthropologic, and literary sources can be extremely
useful in helping us reflect on who our patients are today. Fossil records show that
Neanderthals used ochre as a deodorant and later primitive man used vegetable dies and
mineral pigments for adornment and make up1. So even before Narcissus looked at
himself in a pool of water we have been concerned, consumed, and even obsessed with
beauty. Simon2 reports on a seventh century physician from Alexandria who practiced a
form of cosmetic surgery. De Gama sought the fountain of youth and Oscar Wilde’s
Dorian Gray was willing to sacrifice much to look young and beautiful. As Kligman3
notes, Cinderella was probably the first ‘extreme makeover’. In the mid 1900s Pope
Pious XII said that cosmetic procedures used to increase the powers of seduction or
vanity were sinful and morally unlawful4. Today you cannot turn on the television or
open a magazine without reading about beauty, cosmetics and which star had what plastic
surgery. While it may be tempting to think that the media is driving this issue, history
tells us otherwise. However, it is true that far more people are having cosmetic treatment.
Yet this seems more a function of an improvement in technology, an increased
availability of affordable options for invasive and non-invasive procedures, and a change
in the social acceptability of cosmetic treatment than a change in who we actually are.
While our conceptualizations of what is beautiful may have changed over time, the
psychological motivations that drive us to alter our appearance have not. While some
might long for the imagined simplicity of the past, others race full speed into the future.
Yet, as Sullivan5 said, ‘we are all more human than otherwise’ and it would appear that
an aspect of being human is to be concerned about one’s appearance.

Cultural influences

Surveys have shown that some cultures or groups seem far more focused on their
appearance than others6. For example, 61 per cent of Brazilians think that physical
attractiveness is very important as compared to 32 per cent in the US and 27 per cent in
France. Even within the US, regional variations are noted. Southerners are far more
 Prologue 3

concerned with their appearance than Northerners. Moreover, cultural factors profoundly
influence what is considered beautiful and what people are willing to go through to make
themselves that way. In some cultures, at some times, foot binding, grinding and
blackening the teeth7, as well as scarring and piercing8, have all been considered
acceptable body modifications that increased attractiveness. Are the cosmetic procedures
we do today in our culture such as breast augmentation and rhinoplasty any different? On
a conceptual level, the smoothing out of a few wrinkles does not seem like such a big
thing. In fact can this even be considered body modification since it does not
fundamentally change the way we look but only returns our skin and our appearance to a
previous state? In this sense one could place cosmetic procedures along a continuum. At
one end is the use of make up, at the other, complex cosmetic surgery that changes and
modifies the body. In between are things like dieting, going to the gym, whitening teeth,
and treatments such as BOTOX®.
However, the search for beauty is more than skin deep. Data show that there are
distinct advantages to being beautiful aside from being asked to the prom. Researchers
have found that people with good looks are more likely to be hired9,10, promoted faster11,
and paid more12. In a dramatic study about the benefits of being beautiful, Hamermesh
and Biddle13 found that men with above-average looks are paid 5 per cent more than
those with average appearance, while those with below-average looks are paid 9 per cent
less. Finally, Graham14 reports on studies that show that good looks improve one’s
chances in court, make you less likely to get referred to a therapist and generally mean
you will get treated as different or special by the world around you.

Age

Maybe our cultural obsession with beauty and cosmetics is due to the unconscious drive
of the species to propagate. Those who look beautiful are thought to be more youthful
and thus more fertile. Maybe this is a reflection of a change in society such that age and
wisdom are no longer revered in the way that they were. Nevertheless, agism is quite
evident in the US. For example, single women of a certain age still despair of being able
to find a partner and older workers frequently are fired or treated less favorably than
younger ones. In an interesting and relevant study, Johnson15 looked at perceptions of the
elderly. Analysis of the data revealed that attractive features are associated with
youthfulness and unattractive features are associated with aging. His findings also
indicated that, even in the elderly, beauty is associated with more socially desirable
personality characteristics, more positive life experiences, and greater occupational
status. He concludes that ‘maintaining or recapturing youthful vigor is an important
determinant of judged attractiveness’.
Growing old is something that few people do without some degree of psychological
conflict. In part it may be that focusing on one’s wrinkles, receding hairline, or growing
paunch is a displacement for no longer being fertile or able to hunt effectively. As we
age, doubts about one’s ability to work or make love appear even in the absence of any
‘real’ evidence to the contrary. In addition, there is an almost universal fear of death and
dying which all of us deny to a greater or lesser extent. As we struggle with getting older,
Other documents randomly have
different content
 Rhubarb Fool.

Tuesday.

Tapioca Soup.
Brown Stew of Beef.
Apple Cheesecakes.

Wednesday. (High Tea.)

Rissoles (made of remains of yesterday’s stew.)

Brown Scones.

Thursday.

Stuffed Haddocks.
Tomatoes and Macaroni.

Friday.

Mutton Chops.
Boiled Potatoes.
Sago Pudding.

Saturday. (Lunch Party.)

Fried Sole.
Roast Fillet of Veal with Mushrooms.
French Beans. Potato Croquettes.
Charlotte Russe. Victoria Sandwiches.
Custard in Glasses.

Food List.
£ s. d.
Two rabbits 02 6
One pound of neck of mutton 00 6
One and a half pounds of chuck steak 0 1 3
Quarter of a pound of ox kidney 0 0 2
Three mutton chops at 5d. 0 1 3
Four and a half pounds of fillet of veal at 1s. 1d. 0 4 10½
Plaice 0 0 9
Fresh haddock 0 0 9
Two soles (one and a half pounds at 1s. 2d.) 0 1 9
Rhubarb 0 0 4
Half a pound of apples 0 0 1½
Small tin of tomatoes 0 0 4½
Half a pound of beans 0 0 4
Half a pound of mushrooms 0 0 6
Potatoes 0 0 6
Finger sponge cakes 0 0 6
Half a pint of cream 0 0 9
One ounce of gelatine 0 0 3½
Twelve eggs 0 1 0
Tin of corned beef (breakfast three days) 0 0 11
Quaker oats 0 0 6
Half a pound of tea 0 0 10
Flour 0 0 5½
Milk 0 1 9
Bread 0 2 2
Two pounds of fat for rendering 0 0 4
One and a half pounds of butter 0 2 0
One pound of castor sugar 0 0 3
One pound of loaf sugar 0 0 1½
One and a half pounds of demerara 0 0 2½
£1 8 0½
(To be continued.)
 “OUR HERO.”
A TALE OF THE FRANCO-ENGLISH WAR
NINETY YEARS AGO.
By AGNES GIBERNE, Author of “Sun, Moon and
Stars,” “The Girl at the Dower House,” etc.

CHAPTER XXVII.

MORE ABOUT SIR JOHN MOORE.

NOTHER backward glance is needful here to
bring the story of Sir John Moore up to the
present date of my tale.
In the year 1806 about twelve thousand British
troops, under the command of Sir John Stuart,
had in hand the task of saving Sicily from the
grip of Napoleon; but the tortuous policy of
their Sicilian majesties, the lack of honesty and
of public spirit, and the underhand cabals and
oppositions there, hindered far more from being done than was
done.
A short time after the English victory at Maida, in which and in the
retreat following the French lost in killed and wounded over five
thousand, while the English lost only about two hundred and fifty, Sir
John Stuart was recalled, and old General Fox, brother of Mr. Charles
Fox, then Prime Minister of England, was sent out. Why the brave
Stuart should have been thus set aside does not appear, except that,
as quaintly remarked by one of Moore’s brothers, “it was a strong
proof of fraternal affection” on the part of Mr. Fox.
Sir John Moore, who superseded Stuart, was appointed second in
command under General Fox. And at this date occurred his one love
affair.
Some mistaken reports on this subject have gained currency. Even
lately the assertion has been freshly made that Moore, when he
died, was engaged to Lady Hester Stanhope, niece of Mr. Pitt. This
was not the case. Lady Hester was his friend; the most intimate
woman-friend—though by no means the only one—that he had
outside his own home circle; but though he both admired and loved
her, it was as a friend only, not as a lover. He seems never to have
thought of marrying her. On the conclusive authority of General
Anderson, who for twenty-one years was with him constantly in the
closest possible intercourse, and from whom Moore appears to have
had no secrets, there was but one whom Moore ever seriously
wished to marry, and this was Caroline Fox, daughter of the old
General in command at Sicily.
That the niece of Mr. Pitt should have been his most intimate
woman-friend, and the niece of Mr. Fox his one and only love, reads
curiously in the light of party politics. But Sir John was no party man.
The great Minister, Pitt, had for him an unbounded esteem and
affection, on the one side. And Fox, on the other, at a time when a
movement was in progress to make Moore Commander-in-Chief in
India, sent for him, and frankly informed him that “he could not give
his consent” to this scheme. “It was impossible for him,” he said, “in
the state in which Europe then was, to send to such a distance a
General in whom he had such entire confidence.” Moore stood
outside mere political warfare, grandly and simply, as representative
of his country.
Amid the fighting, the difficulties, the perplexities, of Sicilian politics
and struggles, he found time to fall profoundly in love. And he did
not marry. He did not even let the girl know that he loved her.
Why not?
Well, the matter stood thus. Caroline Fox was very young—not yet
eighteen. And Moore was already in his forty-sixth year. There was a
discrepancy of nearly thirty years between the two, and Sir John did
not think it right, at her early age, even to give her the choice. He
was not of a nature to love lightly, or to give up his wishes easily,
and it was a hard fight. Harder far this conflict than all his battles
with the soldiers of Napoleon. Yet he conquered, and to the young
girl herself he spoke not a word which might have opened her eyes.
To Anderson he explained his reasons, with a frank and touching
simplicity, the echo of which comes down to us now through ninety
years and more.
“She is so young,” he said. “Her judgment may be overpowered. The
disparity of age is not perhaps at present very apparent, and my
position here, my reputation as a soldier of service, and my intimacy
with her father, may influence her to an irretrievable error for her
own future contentment. My feelings therefore must be suppressed,
that she may not have to suppress hers hereafter with loss of
happiness.”
Can anything surpass the quiet grandeur of that “must”?
This surely is an ideal character—no true flesh and blood—so
somebody may object. What! a man in the prime of middle age,
eminently handsome, accomplished and fascinating, the idol of his
friends, the darling of his country, well off as to worldly goods, with
still in all probability a magnificent career before him—that such a
man, when deeply in love, should pause to view the question simply
and solely with regard to the girl’s happiness, not to his own—that
he should humbly question whether, though he might fairly hope
then and there to win her, she might not in later years regret her
action and wish herself free! This is such a hero, no doubt, as has
sometimes figured in fiction. An ideal hero—but——
But the whole is true. There is no idealising at all here. John Moore,
actually and literally, without any varnishing, less than one hundred
years ago, loved and decided thus, thought and acted and was the
same that I have tried, however ineffectively, to picture for the
present generation.
Such a story of one in the first decade of the nineteenth century
may well serve as an inspiration in unselfishness for those who live
in the last decade of the same century. The grandeur of this man
was that he thought always of others before himself—that he lived
for Duty. Where Duty pointed or seemed to point down a pathway,
no matter how hard and thorny the road, there unhesitatingly Moore
walked.
Yet there is another side to the question, which must not be ignored.
Grandly as Moore acted, in obedience to his own convictions, it may
well be that he made a mistake here. His very unselfishness and
humility, both of which are an example for us, may none the less
have led him into a course of action which, while one admires it, one
dares not hold up for general imitation.
For it is, to say the least, conceivable that Caroline Fox might herself
have been by that time deeply in love with Moore—that already the
happiness of her whole life might have hung upon his speaking.
True, he had not sought her, and he did not seek her. But he was
intimate in the house; he was a man of extraordinary attractive
power; and his personal fascinations might well have taken captive
her girlish heart, without the slightest conscious effort on his part. If
things were so, or had been so, how sad it would have been that,
from a sense of duty most nobly carried out, he should have denied
happiness to her as well as to himself! In such cases it does seem—
at least, from the woman’s point of view—that the choice ought to
have been given to her; that she ought to have been allowed to say
for herself either Yea or Nay. If he thought her too young to know
her own mind, he still might have simply declared his passion, and
have insisted upon leaving her ample time for consideration.
He never did propose for that young girl.[1] Moore was not a man to
decide one way and to drift another. Had he lived, he might no
doubt have spoken in the end. But in 1806 he had less than three
years of his fair life remaining.
The Queen of Sicily, an odd fantastic woman, took dire offence at
him, finding that she could not bend him to her will. An attempt
made by her to draw General Fox into steps which could only have
resulted in disaster, was strongly discountenanced by Moore, to
whom the General appealed for advice, and she wrote a torrent of
abuse of him to the English Government.
At about this time General Fox, on account of failing health, was
recalled, and the supreme command was given to Moore. He soon
after saw the Queen, and explained to her the falsity of certain
reports which had been told her about things he was supposed to
have said.
A little later, fresh Napoleonic successes drove her to despair, and
she then sent for him again. He found her weeping over a copy of
the Peace of Tilsit, just signed between France, Russia and Prussia;
and he stayed nearly two hours, doing his best to raise her spirits.
When he took leave she said, graciously enough—
“Great pains have been taken to prejudice me against you, and not
without effect; but your plain frank manners have removed every
unfavourable impression, and nothing shall make me think ill of you
again. For I perceive, Monsieur Moore, that you are an upright man
who flatters nobody. You are a little reserved, and do not give
confidence easily. I esteem you on that account the more. I hope,
however, at last to acquire your confidence, and I shall be flattered
by it.”
This is all very well, but apparently the Queen made no effort to
undo her harsh misrepresentations of him to the English
Government.
Early in 1808 Moore reached England, and then he had his last
holiday. Four months of rest were granted to the hard-worked
warrior, who during thirty years had held himself utterly at his
country’s service, fighting for her in all parts of the world almost
without intermission, and being at least four times wounded. At this
date he was looked upon by competent judges as the foremost man
in the whole British Army—as the one to whom above all others
England, in her hour of need, would turn.[2]
The chief part of his holiday was spent at the quiet Surrey home of
his brother, with his mother and sister, and one is glad to know that
he had that peaceful break before the end.
It was towards the close of the four months that Roy Baron reached
the Bryces’ London house, after his adventurous escape from Bitche;
and so soon as the first excitement of his arrival was over, his
thoughts turned in the old direction—towards the Army.
Those were not days of competitive examinations or of lengthy
preparation. Boys were taken straight from school, commissions
were given to them, they were put into uniforms and drilled—sharply
drilled too, if they happened to be anywhere within touch of Moore’s
influence—and in the majority of cases Nature was expected to do
the rest. On the whole, Nature did not perform her task badly, with
such material as she had to work upon in these plucky English lads.
Mr. Bryce took upon himself to act as he knew that the Colonel
would have acted if able, and a very brief space of time saw Roy
being transformed into a smart young subaltern, in the same
regiment of infantry where Jack had lately obtained command of a
company.
Meanwhile, at the close of Sir John Moore’s holiday, he was sent off
on another expedition, this time to Sweden, then an ally of England.
He had over eleven thousand men under his command, all as eager
as himself to help the Swedes. But the expedition was rendered
abortive by the extraordinary conduct of the King of Sweden, who
already began to show signs of the madness, for which he was
afterwards deposed.
On the arrival of the English fleet, he flatly refused permission to Sir
John to land any of the troops, unless they were placed entirely
under his own control, to be used how and where he chose. This, of
course, Moore at once refused, and for two months, while he waited
for directions from the home Government, the eleven thousand
soldiers had to remain cooped up on board the vessels. Then came
an attempt on the part of the crazy king to arrest Moore himself
when on shore. Moore evaded the attempt, and at once set sail with
his whole force for England. He wrote to his mother, “This campaign
in Sweden has proved the most painful to me I ever served. It is,
however, now nearly over.”
Many criticisms were passed on his conduct by those who did not
know the ins and outs of the whole affair. But the Duke of York
expressed hearty approval, congratulating himself and the country
on having sent a chief who could be firm to resist such unreasonable
demands as those of the Swedish King.
In the autumn of 1807, when Italy, Holland, Prussia, Austria and
Russia were one and all either conquered, or at the least humiliated
and helpless, Portugal next fell a victim to the rapacious conqueror,
and was made a stepping-stone to the conquest of Spain. In the
quaint language of one of Moore’s brothers, “being wont to eke out
his martial feats with wily stratagems,” Napoleon plotted himself into
a position of power there. Before the end of May, 1808, the French
Army entered Madrid, declaring the whole country subject to the
Emperor of the French, and proclaiming Joseph Buonaparte king.
Then it was that the tide of Napoleon’s successes reached their high-
water mark. From this date, it may be said, the retreat of the waters
began upon land, as earlier their retreat had begun upon the ocean,
at first imperceptibly, for a long while fitfully, yet with accelerating
speed.
Again and again the Spaniards had fought on the side of the French
against the English. But now, at last, the spell seemed to be broken;
now, at last; their eyes were opened. “As a man,” it was declared,
Spain had risen against the Emperor, and a burst of enthusiasm, of
vehement sympathy, rushed through the length and breadth of
England. The Army was mad to fight.
By the time that Moore got home from Sweden, Sir Arthur Wellesley
had already been despatched to Portugal, with a force of nine
thousand men, and the eleven thousand who had been on this
fruitless errand to Sweden were not even allowed to disembark, but
were at once ordered to Portsmouth, Moore being summoned to an
interview with Lord Castlereagh.
An evening or two later, Jack rushed in upon the Bryce circle in hot
haste.
“Jack! Hallo, man! What’s up now? Something out of the common by
the looks of you,” declared Mr. Bryce, as he sat near the open
window; a small and ugly and genial man, in flowered waistcoat,
velvet tights, and silver-buckled shoes. “You’re just in time, my good
fellow. In three days we’re off to Brighthelmstone.”
“And if I might but have had my will, we should be there already,”
added his “better-half” discontentedly.
“How d’you all do? How do you do, ma’am? Find yourself well, Polly?
Heard the news? I suppose not.”
“What news?” at the same moment from Mr. and Mrs. Bryce, Polly
and Molly.
“Sir John Moore is ordered off to Spain, and our regiment is under
orders too.”
“Oh!”—from Molly, under her breath. “And if Roy should be taken
prisoner——”
“Or if he should not!” suggested Mr. Bryce. “Nay, child, we’ll permit
no doleful foretellings. What’s up, Jack? ’Tis no ill news to you to be
ordered to the seat of war?”
“Ill news? No!”—with sufficient energy.
“Yet you look uncommon like to a thunder-cloud—ready to burst.
Hey, what’s wrong?”
“Could wish nothing better than to go, sir. Every man in the Army is
wild to be off. But I’m angry, I’ll admit. ’Tis inconceivable that such a
man as Sir John should have enemies, yet there’s no other
explanation.”
“Enemies where?”
“I’m not so bold as to say. But ’tis a fact that, after serving in Sicily
and in Sweden as chief in command, he’s now to be placed in a
subordinate position as third. I’ve heard Major Napier declaim
against the shame it was that they didn’t make him from the first
supreme Commander in Sicily; but this—why, ’tis infinitely greater
shame. The thing is beyond comprehension!”
“Yet the King and the Duke of York are ever his friends,” mused Mr.
Bryce, passing a meditative hand over his chin. “And Lord
Castlereagh esteems him highly.”
“So all say; but the chopping and the changing that’s to take place
—’tis amazing! There’s Sir Arthur Wellesley in command of one army
gone to Spain, and Sir John till now in command of another, and
both of ’em to be under Sir Hew Dalrymple when he can get to
Portugal, and till he does, Sir Harry Burrard is to act for him. Moore
—the foremost and most brilliant officer England has ever owned—to
be under Burrard and Dalrymple! Has the world gone crazed?”
“For what reason are the changes?” asked Mr. Bryce.
“I know not, sir, and I care not! Sir John has done nothing to merit
such treatment. ’Tis a base shame, and that’s about all that can be
said. But he’ll rise to the top—small fear! When the need arises, he
will be the man whom all will turn unto.”
“Jack, shall we see Roy?” inquired Molly.
Jack had little doubt that Roy would look in. Everything was to be
done in a terrific hurry, and he had come himself to say good-bye
there and then; but Roy would certainly appear. A few minutes later
he called Polly away into the girls’ little boudoir, and said approvingly
—
“That is a brave Polly! No tears and no wailings. ’Tis as should be.”
“Dear Jack, I know well how glad you are to be going, and I would
not hold you back.” Polly spoke courageously, though she looked
white.
“And when I come again—a battered soldier, maybe, with some part
of me missing—— Nay, I did not mean to make things harder for
you, Polly. I was but jesting.”
Polly had difficulty in controlling her shudder.
“Come, come, that was nothing; that was but a foolish jest. You will
bid me God-speed, I know; and you will think of us. Roy is frantic to
be off. Polly, no letter from Verdun?”
She shook her head.
“If I were Denham—kept there all these long years in a purposeless
captivity—and, it may be, never a letter from Polly to cheer him——”
Polly looked sadly at her brother.
“I have not writ to him lately,” she said. “I cannot tell how to write.
What should I do? I have none but you to advise me, and you, too,
will now be gone. Tell me what I should do, Jack?”
“Write again; write often. One letter among many may get to him.”
“But if he should no longer care? If he should by now have forgot
me?”
“He is not that sort. Trust him, Polly; be sure he is trusting you.”
Something of a gleam came to her face.
“You think that? You think I may trust him yet, and not be over
bold? It is so long—over five years!—and no letter from him of later
date than the summer of 1806. May he not have forgot?”
“He will not forget. Roy is convinced on that point.”
“But does Roy know? Jack, sometimes I wonder—if indeed Captain
Ivor loves me still, as once he did—I wonder why does he not ask
me to go out to him there? If he asked me, I would go—I would
indeed! And he has never from the first said any such word; and I
cannot say it. It is not for me to offer to go; but sure, if he wished it,
he might send some words—by some private hand——”
Jack was silent—thinking.
“And there is that French girl—whom Roy is so fond of—always with
them as one of themselves—always near Captain Ivor.”
“But trust him still, Polly dear,” urged Jack. “I cannot know, neither
can you, how things are yet awhile; only I do truly believe that Ivor
is no man to change, or to be fickle in his likings. Whether you write
or do not write, trust him still.”
(To be continued.)

LENT LILIES AND DOCK LEAVES.

 ANSWERS TO CORRESPONDENTS.
STUDY AND STUDIO.
K. Bartlett.—We have attentively read the verses of your friend. It is
always a difficult matter to decide from two or three specimens
whether a girl should “give up writing altogether.” We cannot,
however, say that there are indications here of poetic merit so
great as to afford you the hope she may one day become a poet.
The phrasing is that of a cultured woman, but there is no
originality of thought or expression, and the form needs
improvement. In “Springtime,” the best of the three poems, the
author uses the second person singular and plural indiscriminately
(“thee” and “your”). In the third poem, the conjunction “under
unkind” is unmusical. “Flows” in the first poem, is not an apt
expression for the outburst of the song of birds at dawn. No doubt
the study of good poetry, and practice, would do much to improve
your friend’s capacity for verse-writing, and there can be no
reason, if she has leisure, why she should not persevere. While we
cannot prophesy triumphant success, we can at least say that a
measure of success in writing pleasant lyrics is fully possible.
Thistle.—Your lines are unequal, and the form is incorrect. Compare
these two extracts—

“The fourth of the sisters there

Her own mind knows not yet,”

and
 “Outside that little summer-house
On the lawn so smooth and green.”

Both occupy the same place in the verse, and should therefore
correspond in metre. It is no easy task to write verse that will find
acceptance.
“Bill.”—1. Some friend of yours with a knowledge of musical
composition might set “Marie” to music for you. The lines are very
irregular, and would need special treatment.—2. Your writing is
vigorous and distinctive, but you are inclined to write untidily,
omitting fragments of words and scrawling now and again. If you
never allowed yourself to scribble, and were very careful, you
would write well by-and-by.
Sesame.—We advise you to write to the Secretary of Girton College,
Miss Shore Nightingale, 11, Queensborough Terrace, Bayswater,
London; and to the Secretary of Newnham, Miss M. G. Kennedy,
Shenstone, Cambridge. From these ladies you will obtain full
particulars. With regard to scholarships, we refer you to Mrs.
Watson’s articles on “What are the County Councils doing for
Girls?” in The Girl’s Own Paper for March, July, August, and
September, 1897.

INTERNATIONAL CORRESPONDENCE.
Marjory Ingle, aged sixteen, Denmark House, Ely, Cambridgeshire,
would like a French correspondent about her own age. She would
much prefer one well educated and interested in study.
Miss A. Nicholls, Laburnum Villa, Leamington, Miss L. Jones, c/o
Morris Hughes, Castle Street, Llangollen, N. Wales, Mademoiselle
Désirée Tuffli, Châlet à Monruz, Neuchâtel, Switzerland, and Miss
Marguerite Fitzroy Dixon, 19, ix Florence Street, Ottawa, wish to
correspond with Miss Anice Cress, Mysore, S. India, and inquire if
 that address is sufficient. Miss Dixon would also like to write to
Miss Marguerite Rahier.
Mademoiselle Vilma Tuffli, Châlet à Monruz, Neuchâtel, Switzerland,
would like to exchange illustrated post-cards with anyone who
collects them.
Miss Mary Kleyntjens, Maastricht, Holland, wishes to exchange view
post-cards with O Mimosa San.
Edelweiss at Innsbruck would like to correspond with a French girl of
about her own age (19). She knows French pretty well, but has
not much opportunity of writing French letters.
Miss Ruby Tizarel, Trosse House School, Neumark, Germany, will be
glad to write in French, German, or English, and receive answers
in either language from a young lady of about her own age (17).
Miss Nelly Pollak, a German girl, wishes to correspond with an
English girl, aged about sixteen, living in England, or any British
colony. Her address is Vienna, I., Reichsrathstrasse 3.
“Cintra,” aged sixteen, would like a French correspondent.
Miss Wynnie L. Moore Jones, Ladies’ College, Portland Road, Remuera,
Auckland, N.Z., and Miss L. Salmon, c/o E. L. Thornton, Esq., Fonte
da Moura, Oporto, Portugal, would like to exchange New Zealand
and Portuguese stamps for others.
Violet M. and Florence Violet (not Voilet) Foster.—In view of the
increasing applications for foreign correspondents, we cannot
undertake to insert requests from English girls for English
correspondents, unless some special reason is given for their
employing the medium of a magazine. F. V. Foster must not be
offended if we say she should try to improve her writing and
spelling. Violet M.’s letter is a pleasant one, and if she is lonely
through circumstances and unable to find friends, we will consider
her application.
Geraldine wishes to correspond with a Swiss-French or French lady of
good family and education in French. The latter writing in English
 will have all letters returned corrected, and the correspondent will
require her French letters corrected and returned also.

MISCELLANEOUS.
Japonica.—We do not see how “Japonica” can require advice on such
a subject. Most girls of eighteen have some knowledge of the
rules of propriety; and if in doubt as to allowing stray young men
to kiss her, ignorance which we do not believe, she can consult
any older person—her mother, or one of her brothers—as to how
far it is permissible. We often think that such letters as
“Japonica’s” are written by foolish and vain girls to show off, not to
obtain advice. There could be no other motive in writing to us on
the subject.
Winnie has probably not consulted her parents on this point, or she
might find that there is really some very strong objection, of which
she is in ignorance, to the “good Christian young man” whom she
says “she has found.” Tell your parents all about it, and do not try
to persuade us to counsel you to be disobedient to their wishes.
Esmeralda.—Why not take The Boy’s Own Paper, 56, Paternoster
Row, E.C. You might purchase a number and see how you liked it.
Puzzled.—The smell of which you complain arises from the skins
being only partially cured and not thoroughly dried. Skunk,
however, retains an unpleasant odour in most cases. Drying the
skins in a brick oven for a little time, taking care not to burn them,
might do good. But we fear there is little help for this trouble.
Threepence.—There is no royal road to handwriting. It is an art which
must be carefully acquired; and if you wish to improve yours, you
must get some copies and set to work in a painstaking way. Select
a handwriting you admire and proceed to copy it, letter by letter,
word by word. If you persevere, you will succeed in about a
month’s time in making a total change.
Chadband.—1. The Rev. Mr. Chadband is a character in Dickens’s
Bleak House. He was a religious hypocrite. The word
“Chadbandism” is a novelty, applied as it has been lately, in the
daily press.—2. Chauvinism means a blind idolatry of Napoleon I.
Just now it seems to mean a warlike spirit, a blind patriotism. The
word Chauvin is taken from Les Aides de Camp, by Bayard and
Dumanoir; and was made popular by Charet’s Conscrit Chauvin.
Conspuez, which is the word most heard in Paris of to-day, is from
the verb conspuer, which means to spit upon or to despise. A
Bordereau is a memorandum, or account of some occurrence,
event, or conversation. Dossier means a barrister’s brief, and also
a bundle of papers. In the way used, it means what we should call
“the case” against a prisoner. We do not wonder that you are
puzzled if you do not understand French.

FOOTNOTES:
[1] Caroline Fox became later the wife of Sir William Napier,
historian of the Peninsular War.
[2] “Then the most honoured military character of the day.”—Sir
W. Napier.

[Transcriber’s Note—the following corrections have been made to the

text:
Page 426: dignatatem changed to dignitatem—“infra dignitatem”.]
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