[Extracted from the American Journal of the Medical Sciences for January, 1872.]] 
CASE 
OF 
CICATRICIAL CONTRACTIONS AFTER BURNS 
INVOLVING THE 
CHIN AND NECK, 
SUCCESSFULLY TREATED. 
OURDOK BUCK, M.D., 
SCRGEON TO THE LATE NEW YORK HOSPITAL AND ST. LUKE’S HOSPITAL, ETC. ETC 
(Read at a Meetiug of the New York Academy of Medicine.) 
WITH FOUR WOOD-CUTS. 
Alex. S., in February, 1869, when two years and one month old, was 
severely burned from his clothes taking fire while handling lucifer matches. 
The parts mbst seriously involved were the chin and front of the neck. 
Under surgical treatment, cicatrization was completed in the month of 
June following, when the patient accompanied his family to their summer 
residence in the country. In October, IBTO, when three years and nine 
months old, patient came under the author’s charge, his condition being 
as follows : A broad cicatricial band of dense structure extends from the 
inferior border of the chin in a direct line downward to the upper margin 
of the sternum and clavicle, approximating the chin and sternum to within 
about two inches of each other, and obliterating the prominence of the 
chin and the natural front profile outline of the neck. The band extends 
on the left side of the chin along the border of the jaw to its angle, but 
on the right side only to a point below the angle of the mouth. Its 
anterior surface is furrowed and ridged vertically, and a little below its 
middle is traversed horizontally by a single knotted ridge. At both lateral 
edges of the band, the adjacent continuous sound skin, which is very 
supple, recedes and forms a deep pocket behind the band itself, so that the 
fingers pressing from opposite sides are easily made to meet, with the skin 
only intervening. When the band is put upon the stretch by elevating 
the head, the left half of the under lip is drawn down, and with it the 
lower jaw is kept separated from the upper, permitting the end of the 
tongue to be habitually exposed to view, and the saliva to escape constantly 
from the mouth. 2 
Patient also suffers extremely from a tormenting itching, which often 
suddenly attacks the cicatricial parts, and provokes him to scratch and pull 
upon the band in an almost 
uncontrollable manner. 
Fig. 1. 
His mother is of the opinion 
that for several months past 
the parts have undergone no 
change. His general health 
is good. 
Fig. 1 shows the patient’s 
condition as just described. 
Operation.—With the aid 
of Prof. A. C. Post, and Drs. 
C. M. Bell, J. N. Beekman, 
and Robert Watts, an opera- 
tion was performed on the sth 
November, 1870, as follows: 
The patient being under the influence of ether, the entire cicatricial band 
was divided into three serrated triangular flaps, interlocking each other. 
One of the three flaps was central, with its apex upward at the symphysis 
menti; the other two were lateral, with their apices downward and resting 
on the clavicles. They were formed by two diverging incisions carried 
from the symphysis downward and outward to either edge of the band at 
the clavicles. From these terminal points an incision was made along 
either margin of the band, upward and outward, to the edge of the jaw. 
The three flaps were then dissected up from the subjacent loose connective 
tissue, from their apices towards their bases. 
Special care was taken to continue the dissection along the base of each 
flap beyond the limit of the cicatricial skin, and to divide every filament of 
contracted connective tissue that limited the free movement of the skin on 
the subjacent parts. The head could now be thrown back and made to 
move freely in every direction. The next step was to reapply the detached 
flaps to the extensive raw surface from which they had been dissected up, 
while the head was at the same time kept elevated and maintained in its 
natural position. The adjustment of the parts to each other was secured 
by pin sutures inserted at points where the greatest support was required, 
and also by numerous thread sutures between the pin sutures. 
On the right side of the neck it was necessary to excise a thick fold of 
cicatricial skin rendered redundant in the new adjustment. On the left 
side of the neck it was found necessary, in order to relieve tension and 
facilitate the approximation of the edges of the flaps, to make an incision 
five inches long through the thickness of the skin across the base of the 
neck from before backward, on a line parallel with the edge of the wound, 
and two inches distant from it. The edges of this incision gaped widely 3 
apart, and the desired effect was produced. The raw surface resulting from 
this side incision was coated with lint saturated with collodion, which, on 
stiffening, formed an artificial scab. A covering of soft lint was spread over 
the other parts, and strips of adhesive plaster were applied to secure the 
whole. Though the operation was necessarily protracted, and the loss of 
blood considerable, there was no extreme depression of the vital powers in 
consequence. A good degree of reaction followed, and, aided by an anodyne, 
the patient passed a pretty comfortable night. At the expiration of forty- 
eight hours sloughing had destroyed all the flaps, except about one inch in 
breadth along their bases. The sutures were removed in succession, and 
the sloughs got rid of as fast as they separated. Special care was taken, in 
dressing the wound, to hold the detached skin, that had escaped sloughing, 
in close contact with the subjacent surface by means of long strips of ad- 
hesive plaster carried high up on either side of the face and over the 
temples, and on the sides across the nape of the neck. At the same time, 
the head was also kept well elevated. The wound took on healthy action 
after the separation of the sloughs, and the patient’s general condition 
was all that could be desired. The detached skin became adherent, and 
cicatrization progressed favourably. The exuberant growth of granula- 
tions was repressed by the energetic use of solid nitrate of silver, not 
merely passed over the surface, but plunged deep into the substance of the 
granulations. This was sometimes repeated daily. Caustic potash was 
also applied, but at much longer intervals, and only at points where the 
growth was not sufficiently controlled by the nitrate of silver. At the 
expiration of about four weeks, when the dimensions of the sore had con- 
siderably diminished, a stiff leather stock, protected by a covering of canton 
flannel, was adapted to the neck and worn constantly, so as to keep the 
head elevated and oppose the disposition to contraction in the direction of 
flexion. As cicatrization advanced, the newly formed cicatricial tissue 
manifested a tendency to develop itself into salient corded bands, which, if 
left uncontrolled, would have reproduced to a greater or less degree the 
original deformity. To prevent this effect, the bands were divided at two 
or more points across their entire thickness, and to a short distance on 
either side through the neighbouring skin, and deep enough to expose the 
subjacent loose connective tissue, thus permitting the fresh-cut edges to 
yawn widely apart. This had the effect of breaking up the continuity of 
the bands and neutralizing their action. These operations were repeated 
successively, with the aid of etherization, on the Ith, 12th, and 29th De- 
cember. The leather stock, worn for the support of the head, proved 
after a time objectionable on account of its chafing the skin and producing 
ulceration. While endeavouring to devise some substitute for the stock, 
my attention was directed to a brace used by Drs. W. E. Vermilye and C. 
T. Poore, in the treatment of caries of the cervical vertebrae, which seemed 
admirably adapted to my purpose. At my request, Dr. Poore adapted one 4 
to my patient. On the 21st of January it was applied, and lias been worn 
constantly since, except at night. It consists (see Fig. 2) of two padded 
steel bands, arranged parallel to each other, one on either side of the 
spine, and adapted flatwise to the natural curve of the back. It extends 
lengthwise from the last cervical vertebra to the top of the sacrum. 
Fig. 2, 
These vertical bands are joined below by a broad padded metallic band, 
which passes half round the body behind and just above the hips. At 
their upper ends the two verti- 
cal bands are joined by a cross- 
piece, c, Fig. 2a, to which a steel 
ring or collar, d, Fig. 2a, of an 
oval shape, is joined by an up- 
right piece, c d, so as to stand 
horizontally and afford a support 
in front to the chin. A segment 
of the ring in front, e, where it 
Fig. 2a. 5 
corresponds to the chin, is covered with chamois leather, and forms a shelf 
for the chin to rest upon. On one side, near its middle, the ring has a 
hinge joint, /, which permits it to be opened in two halves, and thus facili- 
tate its removal and reapplication. By means of a screw at the joint over 
the nape of the neck, a lever action is made to elevate the ring in front and 
regulate the height of the chin. Two shoulder-straps, gg, Fig. 2, and an 
apron, h, Fig. 2, with three straps at either lateral edge, serve to fasten 
the brace in close contact with the body. 
The brace, besides supporting the chin in an elevated position, and 
thereby resisting the contraction of the cicatricial formation in a vertical 
direction, exerts, by means of the straps which pass over the front of the 
shoulders, a constant outward traction upon the skin covering the lower 
part of the neck and upper part of the chest, the effect of which is also to 
resist contraction laterally and keep the cicatricial surface flat and smooth. 
Another important advantage of the brace is, that it compels the patient, 
whenever he wishes to move his head in any direction, to elevate it so as 
to clear the chin-piece, or, in other words, by voluntary muscular action to 
stretch the cicatricial bands. In addition to the brace, patient has worn 
constantly, night and day, a cravat of canton flannel two fingers wide, 
secured around and in close contact with the neck by an elastic strap and 
buckle, for the purpose of holding the new cicatricial surface in contact 
with the subjacent parts. From its first application the patient has worn 
the brace uninterruptedly except at night, and so comfortably as scarcely to 
restrict his activity or enjoyment. A progressive improvement has taken 
place in the under lip. It 
has regained its natural form 
and functions, and the saliva 
no longer escapes uncon- 
trolled. 
Fig. 3. 
Fig. 3, copied from a pho- 
tograph taken April 22d, 
shows the final permanent re- 
sult. 
The contour of the chin 
and front of the neck is re- 
stored to its natural form and 
dimensions, and the head en- 
joys entire freedom of motion 
in all directions. The new 
cicatricial parts present a stel- 
lated form, with a centre situated just above the notch of the sternum, 
from which two prolongations radiate downward, one towards the right, 
the other towards the left side, extending as low down as the second rib. 
A third prolongation ascends along the left side of the neck to the angle 6 
of the jaw. From the edges of these principal prolongations there are 
given off smaller ones in diverging directions, the whole resembling the 
figure of a fern leaf. The cicatricial surface is smooth and flat, and its 
tissue is supple and movable on the subjacent parts. 
Remarks.—The method of treatment which has resulted so successfully 
in the present case consists essentially in— 
1. The excision of the cicatricial tissue, at least of its indurated and 
nodulated portion (which in this case was effected by the sloughing pro- 
cess), and the complete detachment of the remainder from the subjacent 
parts, so as to permit freedom of motion and perfect restoration of the 
natural position. 
2. The maintenance of the parts in their restored natural position by 
the best adapted mechanical appliances, kept up not only during the heal- 
ing of the raw surfaces, but for a long time, even for months afterwards, 
until all tendency to contraction has entirely ceased. 
3. The repression during the healing process of the new granulation 
growth, where it tends to be exuberant, by the energetic application of 
caustics, such as solid nitrate of silver, and solid stick of potash. 
4. The free division of the new cicatricial formation wherever it shows 
a tendency to develop itself into salient corded bands. Each band should 
be cut across at two or more points through its entire thickness, and the 
incision extended on either side of the band into the adjacent skin to a 
short distance, so as to permit the newly divided edges of the cut to yawn 
wide apart. These proceedings are in exact conformity to the method 
laid down and recommended by Dupuytren in his Legons Oro.les, vol. 
ii,, art. i., p. 66 et seq., Paris, 1882. The late Mr. Henry Earle, of 
London, at a much earlier period, reported, in vols. v. and vii. of the 
Med.-Chir. Transactions, cases of cicatricial contractions from burns, in 
which the hand and forearm, and also the neck and jaw, were involved, 
and which were successfully treated by the same method. Both authors 
insist on the indispensable necessity of mechanical appliances long con- 
tinued, to maintain the natural position of the parts and antagonize the 
persistent tendency to recontraction. Mr. T. H. James, Surgeon to 
Devon and Exeter Hospital, subsequently to Mr. Earle, reported, in vol. 
xiii. of the Med.-Chir. Transactions, similar cases successfully treated 
upon the same plan. Mr. James, in a recent pamphlet On the Results 
of the Operations for Cicatrices after Burns, London, 1868, gives his 
additional experience with brief notes of seven cases that occurred between 
1825 and 1846, all of them involving the neck and jaw, and treated suc- 
cessfully. Of the result of most of these cases Mr. James was able to 
inform himself for years after the treatment, and ascertained the perma- 
aience and completeness of the cure. The mechanical support which he 
employed consisted of an upper arch adapted to the base of the jaw, and 
of a lower arch adapted either to the sternum and clavicles, or to the upper 7 
part of the thorax, as the state of the integuments might require. From 
the centre of the lower arch was raised a steel frame perforated with a 
screw, which acted on the upper arch beneath the chin. The two arches 
were united behind by uprights springing from the lower arch, and fur- 
nished with hinges where they joined, so that by working the screw the 
distance between the two arches might be further increased. Such is 
Mr. James’s description of his supporter, a figure of which is given in 
his pamphlet, and also in vol. xiii. of Med.-Chir. Transactions. The 
brace used in the treatment of this case, possesses, in the opinion of the 
author, decided advantages over Mr. James’s supporter. It leaves the sore 
surface free of contact with the brace, allows greater freedom of motion 
to the head and neck, and can be worn with more comfort by the patient. 
The author was encouraged to undertake the present case by the complete 
success of his friend Prof. A. C. Post, in the treatment of a child with 
cicatricial contractions from a burn, binding the dorsum of the hand in a 
position of extreme extension and in close approximation to the forearm. 
So perfect was the restoration of the parts to their natural position and 
functions, that the child has since acquired a good degree of proficiency in 
playing the melodeon. 
The author’s acknowledgments are also due to Dr. Post for his valuable 
co-operation in the treatment of the present case, in which he was asso- 
ciated with him in consultation. 
Supplementary Report.—The patient continued to wear the brace daily 
till he left the city to spend the summer in the country. During the whole 
month of August the brace was left off entirely, and without any apparent 
detriment. It was thought, however, a safe precaution to resume its use 
again, and have it worn two days in the week only, from rising in the 
morning till dinner-time. 
November 15, 1871. The patient was examined to-day, and the favour- 
able condition of the chin and neck already noticed was found to be fully 
maintained, as well in regard to the freedom of motion of the head and 
neck as to the appearance of the parts. 
No. 46 West 29th St., November, 1871.