CICATRICIAL CONTRACTION FROM BURNS: 
DEFORMITY OF FACE AND OF BOTH HANDS: 
REPARATIVE OPERATIONS. 
EY 
ALFRED C. POST, M.P., LL.D., 
NEW YORK. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1879. CICATRICIAL CONTRACTION FROM BURNS: 
DEFORMITY OF FACE AND OF BOTH HANDS: 
REPARATIVE OPERATIONS. 
BY 
ALFRED C. POST, M.D., LL.D., 
NEW YORK. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1879. CICATRICIAL CONTRACTION FROM BURNS: DEFOR- 
MITY OF FACE AND OF BOTH HANDS: REPARA- 
TIVE OPERATIONS. 
J. W., born at Cutchogue, L. I., Dec. 25, 1876. On the 27th 
October, 1877, he fell over with a high chair to which he was 
tied. Ilis face fell on the upper rim of a hot stove: the backs 
of both hands were brought into contact with the side of the 
stove, the commissure which joins the thumb and index finger 
of the right hand embracing a projecting bar of iron: the back 
of the left hand was burned much more severely than that of 
the right. Cicatrization was complete in about three months. 
Before the healing of the sores a number of pieces of bone were 
discharged from the left hand. 
Nov. 6,1878. The present condition of the child is as follows: 
General health good: mental and bodily development beyond 
the average: the right angle of the mouth is rounded, thickened, 
and indurated: a cicatricial ridge extends from the right com- 
missure of the lips to the front of the chin, and obliquely upward 
and outward to the lobe of the ear, varying in breadth in differ- 
ent parts from half an inch to an inch. 
Eight Hand.—The thumb at its distal joint is acutely flexed 
and immovably bound down to the palm of the hand by very 
dense cicatricial tissue. There is complete luxation at this ar- 
ticulation. The distal phalanx of the index finger is subluxated 
outward at an angle of about 45°, and is quite immovable. 
The index and middle fingers are webbed together on their dor- 
sal surfaces from the commissure to the articulation between the 
first and second phalanges. The web does not involve the palmar 
surface. There is free motion of all the articulations of the fin- 
gers, with the exception of the distal articulation of the index 
finger. 4 
CICATRICIAL CONTRACTION FROM BURNS. 
Ijeft Hand.—The thumb and ring finger are substantially free 
from deformity, and enjoy perfect motion. The ring finger is 
slightly drawn back by a cicatricial band, which, however, does 
not interfere with its movements. The little finger is drawn 
obliquely backward and outward to an extreme degree by a 
dense mass of cicatricial tissue. The distal phalanx is slightly 
flexed, and there is a little perceptible motion. The index and 
middle fingers are much distorted, drawn backward,and immov- 
ably fixed. The index is dwarfed and thrown behind the medius. 
The distal end of the medius is bent backward. A very thick, 
hard cicatricial mass, in which the index, middle, and little fin- 
gers are imbedded, occupies half of the dorsal surface of the 
hand, which is drawn back on the forearm. 
I began the treatment to-day (Nov. 6th), with an attempt to 
improve the condition of the right hand. I made a longitudinal 
incision on the dorsal surface of the index finger about three- 
fifths of an inch in length, extending over the distal extremity 
of the second phalanx and the proximal extremity of the third 
phalanx, dividing the skin, the extensor tendon, and the peri- 
osteum. I then carefully separated the periosteum from the 
bone, and with Liston’s bone-forceps divided the bone of the 
second phalanx a quarter of an inch from its extremity, and 
removed the end of the bone. I also excised the cicatricial band 
by the contraction of which the end of the finger had been dis- 
torted. After this I was able to draw the end of the finger into 
its normal position; but it required some effort to hold it there. 
I then dissected up a triangular flap from the palm of the hand, 
the base of the triangle towards the articulation of the first 
phalanx of the thumb with the corresponding metacarpal bone, 
the apex towards the little finger, dividing the cicatricial mass 
on each side, but the thumb remained fixed, or was liberated to 
a very slight degree. I then excised the distal end of the first 
phalanx of the thumb in the same -way in which I had operated 
on the index finger, and about to the same extent, after which 
I was able to bring the terminal phalanx of the thumb into a 
nearly straight position. I divided the web connecting the index 
and middle fingers, up to the commissure. 
After waiting for the oozing of blood to cease, I brought to- 
gether with sutures the wounds on the back of the index and 
of the thumb, and a part of the wound in the palm of the 
hand. I then applied a felt splint adapted to the dorsal surface CICATRICIAL CONTRACTION FROM BURNS. 
5 
of the forearm, hand, thumb, and fingers, securing the different 
parts to the splint with adhesive strips and a bandage. The 
wound had previously been thoroughly washed with carbolic 
acid, 1 to 40. The distal end of the index was not as fully 
adducted as I had desired, nor was that of the thumb as fully 
extended, but there was a very marked improvement in the 
position of these parts. 
7th. I found the patient in a very good condition, bright and 
playful. The dressings did not seem to have been in any degree 
disturbed or loosened. 
The wound was dressed on the 8th and 10th, and afterwards 
daily, washing the parts freely at each dressing with carbolic 
acid, 1 to 40. 
27th. The wounds have made favorable progress. Nitrate of 
silver has been applied to exuberant granulations as often as 
necessary. Passive motion has also been made from time to 
time. There has been an improvement in the position of the 
thumb and finger. The wounds are nearly healed. The inter- 
digital space between the index and middle fingers has been 
maintained, as far as possible, by crowding strips of adhesive 
plaster up to the commissure during the healing process. 
December bth. The wounds are entirely healed. The inter- 
digital space is not as perfect as immediately after the operation. 
The thumb is in a good position, but its motions are limited. 
The terminal phalanx of the index finger is nearly in a perfect 
position. The child is to go home into the country for a week 
or two. I gave directions to support the index with a splint in 
a straight position, and to apply passive motion freely to the 
thumb to increase its mobility. 
19/A. Patient has returned from the country in a good con- 
dition. To-day I performed the following operation on the left 
hand. I made a longitudinal incision on the dorsal aspect of 
the index finger, exposing the remains of the phalanges, and 
removing them, preserving the soft parts as a covering for the 
middle finger. I excised the principal part of the thickened 
and indurated cicatricial tissue which bound the middle finger 
to the back of the hand, and then brought the middle finger 
forward into a moderately flexed position. As a large portion 
of the dorsal surface was destitute of integument, I covered it 
in part with the skin removed from the index, securing it in 
place with fine sutures. I also divided the dense cicatricial 6 
CICATRICIAL CONTRACTION FROM BURNS. 
bands confining the little finger in its abnormal position, and 
brought it into a state of moderate flexion. A considerable de- 
nuded surface was left on the back of the hand, and on the 
dorsal surface of the little finger, to heal by granulation and 
cicatrization. As the first phalanx of the middle finger was bent 
backward, the second phalanx forward, and the last phalanx 
backward, and immovably fixed in that position, I excised the 
distal extremity of the second phalanx, and was thus enabled to 
bring the part into a better position. I secured the palmar sur- 
face of the forearm and hand to a stiffened felt splint, with 
digital prolongations for the middle, ring, and little fingers, which 
were secured to the splint in a moderately bent position. The 
middle and little fingers could not be brought into perfect shape, 
and much was necessarily left to be accomplished by subsequent 
treatment. 
25th. For several days past, I have applied caustic potassa to 
the raw surface of the inodular tissue covering the dorsal aspect 
of the first phalanx of the little finger, reducing the thickness 
of the indurated mass. To-day I removed the sutures connect- 
ing the flap taken from the index finger with the dorsal portion 
of the middle finger. The flap retains its vitality throughout, 
and is adherent to the subjacent parts at the proximal extremity, 
but not at the distal end. The exposed surface on the back of 
the hand is granulating, and presents a healthy appearance. 
The dressings are renewed daily, the parts are freely washed 
with the carbolic lotion, and passive motion is applied. 
January 20, 1879. The application of caustic potassa was con- 
tinued only a few days after the last report, but a slight appli- 
cation of nitrate of silver was made daily until three days ago, 
since which time it has not been required. For the last fort- 
night, the three fingers of the left hand have been drawn to- 
gether with adhesive plasters, and have been secured to a bent 
splint by adhesive plasters and bandages. The dorsal surface of 
the little finger is entirely covered with integument, and that 
of the middle finger nearly so. The granulating surface on the 
back of the hand is greatly reduced in size, and presents a 
healthy appearance. I determined to-day to leave the parts 
undisturbed for forty-eight hours, intending hereafter to dress 
the wound at intervals of two days. 
February 13th. The wound is entirely healed. The little fin- 
ger is in an extended position, but can be flexed to a moderate CICATRICIAL CONTRACTION FROM BURNS. 
7 
degree at the metacarpophalangeal articulation, and very 
slightly at the other articulations. The middle finger is shorter 
than the ring finger, and nearly double its breadth. Its distal 
phalanx is bent outward toward the thumb. Near the distal 
extremity, there is a slight separation between it and the integ- 
ument transplanted from the index. To-day I performed the 
following operation: I exposed the terminal phalanx of the 
middle finger by an incision on its dorsal surface, and divided it 
with bone forceps, removing more than a quarter of an inch of 
its proximal extremity. I also removed a longitudinal strip of 
integument from the dorsal surface of the finger, about a quarter 
of an inch in breadth, including the edges of the cleft near the 
extremity of the finger. The edges of the incisions, after being 
washed with the carbolic lotion, were then brought together 
with sutures. I then dissected up a triangular flap of integu- 
ment from the dorsal surface of the forearm near the wrist, the 
base of the flap extending on each side of the cicatrix on the 
back of the hand, the apex about three and a half inches upon 
the forearm. Bending the hand upon the forearm, the apex of 
the flap was drawn down about two inches, and the sides of the 
chasm thus produced were united transversely by pin sutures. 
The sides of the flap were then united with the outer edges of 
the wound by pin and thread sutures, fortified by strips of ad- 
hesive plaster, and the forearm and hand were secured by their 
palmar surface to a bent splint. The object of the triangular 
flap was to diminish the tendency to subsequent retraction of 
the hand backward on the forearm. 
After completing the operation, as above described, on the 
left hand, I performed an operation on the right hand, to give 
more liberty of motion to the thumb in a backward and out- 
ward direction. Finding that it was attached to the palm of 
the hand by a broad and thick band of cicatricial tissue, which 
prevented full extension and abduction, I divided this band by 
four parallel incisions extending through its whole thickness. 
Cloths wet with a carbolic lotion were then applied, and kept 
in place by a bandage, reserving the use of a splint for a subse- 
quent dressing. 
I applied a felt splint to the dorsal surface of the fore- 
arm and hand, fixing the thumb in an extended and abducted 
position. I also dressed the left hand, finding the wounds in a 
satisfactory condition. 8 
CICATRICIAL CONTRACTION FROM BURNS. 
15th. Removed all the pin and thread sutures from the left 
forearm and hand. The edges of the wound on the forearm 
from which the flap had been taken remained in contact, and 
were secured by adhesive strips. The edges of the flap receded 
a little, but were kept in place by strips of adhesive plaster. 
There was a little suppuration, but the general appearance of 
the parts involved in the operation was favorable. 
28th. The wounds at the junction of the right thumb with 
the palm of the hand are entirely healed. I deem it expedient 
to keep the parts still on the stretch. The wound on the middle 
finger of the left hand is healed. Its extremity is still bent 
outwards, and is fixed in that position. The wound on the back 
of the hand is nearly healed, and there is considerable liberty of 
motion at the wrist-joint. 
March 10th. The wounds are all healed. 
21 st. The patient being etherized, I performed the following 
operations:— 
I. I dissected out an additional portion of the superfluous 
integument on the outer side of the middle finger of the left 
hand. I then incised the periosteum over the second phalanx, 
and with cutting forceps removed an additional portion of that 
bone, overcoming the curvature of the end of the finger, which 
I secured to a splint in a straight position. 
II. I divided the web uniting the upper part of the space 
between the first phalanx of the index and the first phalanx of 
the medius of the right hand. I divided this web nearer to the 
middle finger than to the index, and, to gain additional space, 
dissected a triangular flap with its base extending on each side 
of the web, and its apex extending up on the dorsum of the 
hand. I was able then to bring the edges of the integument 
together with sutures on the ulnar side of the index. Strips of 
adhesive plaster were also applied around the index, and others 
around the medius from the commissure downward. 
III. I dissected out a cicatricial band on the face, which drew 
downward the right angle of the mouth; and I then elevated 
the right extremity of the vermilion border of the lower lip, 
and secured it by a pin suture to a raw surface prepared for it 
at the junction of the right extremity of the upper lip with 
the cheek. The vacant space thus left below the right angle of 
the mouth was closed by a horizontal flap dissected from the CICATRICIAL CONTRACTION FROM BURNS. 
9 
lower lip a little below the vermilion border and attached to the 
adjacent parts with fine sutures. 
23d. I dressed all the wounds of the hands and face, removing 
all the sutures excepting those immediately below the vermilion 
border of the lip. These were so imbedded in dried blood that 
I could not remove them without disturbing the process of ad- 
hesion. Union has taken place, except at one point below the 
angle of the mouth. I applied over the wound of the face a 
number of linen threads moistened with collodion. The wounds 
of the hands wTere dressed with adhesive plasters and bandages. 
25th. The wound of the face has not been disturbed since the 
collodion was applied, day before yesterday. The wounds of the 
hands were dressed yesterday and to-day; they were doing well, 
except that on the dorsal surface of the left hand there has been 
sloughing of the old cicatrix near the lower extremity of the 
metacarpal bone of the middle finger, over a space of about half 
an inch in diameter. This has perhaps been due to the pressure 
of a felt splint. To-day I left off the splint, securing the middle 
finger by adhesive strips to the ring finger. 
The collodion dressings on the face, having become loose, 
were removed; the remaining sutures also were taken out. The 
wound on the face was supported by strips of India-rubber ad- 
hesive plaster. 
April VUh. The wounds made at the last operation have all 
healed. The middle finger of the left hand is much reduced in 
size; it is somewhat shorter than the little finger, and it is 
nearly straight. The space between the index and middle finger 
of the right hand is restored, there being scarcely a trace of the 
web which united them. The deformity of the right angle of 
the mouth is almost entirely overcome. But the vermilion 
border of the lower lip in that vicinity is thicker than toward 
the opposite commissure. To relieve this deformity I dissected 
out a wedge-shaped portion of the vermilion border and united 
the edges of the wound with three fine sutures. The right 
thumb also being still bound with cicatricial bands so as to pre- 
vent it from being freely abducted and extended, I divided 
these bands by three parallel incisions, and secured the thumb 
to a splint in a position of forced abduction and extension. The 
splint was applied to the radial edge of the forearm, and was 
bent so as to adapt it to the posterior and external surface of the 10 
CICATRICIAL CONTRACTION FROM BURNS. 
thumb. It was composed of two layers, felt next to the limb, 
malleable iron outside. 
19/A. I removed the splint from the right thumb, and found 
the wound in a good condition. Reapplied the splint as before. 
21st. Removed the sutures from the lip. The wound has 
united, and the lip presents an improved appearance. 
The results obtained from the treatment of the complicated 
deformities of the face and hands in this patient fall far 
short of a perfect restoration of the deformed parts to their 
normal shape. But considering the extent of the deformities, 
and the difficulties to be overcome, I regard the result as emi- 
nently satisfactory. The disfigurement of the face, which was 
moderate in degree, has been in a great measure removed. The 
right hand has been greatly improved in its shape by liberating 
the thumb from its imprisoned condition, by restoring the inter- 
digital space between the index and middle fingers, and by 
greatly diminishing the extent of the abduction of the terminal 
phalanx of the index finger. A glance at the drawings showing 
the appearance of this hand before and after the treatment will 
suffice to show the improvement which has taken place. 
But the principal triumph of surgery in the treatment of this 
case is exhibited in the change in the conformation of the left 
hand. Before the treatment, this hand presented an almost per- 
fect thumb and ring finger, while the other parts entering into 
its structure were drawn into a confused and shapeless mass in 
which the three remaining fingers were blended together, so as 
to require a careful dissection to separate them from each other 
and from the mass of cicatricial tissue in which they were en- 
veloped. The hand, as a whole, was drawn forcibly back upon 
the forearm, and firmly fixed in that position by the dense cica- 
tricial mass in which the fingers were imbedded. As a result of 
the treatment, the hand is brought down to its proper position in 
the same plane as the forearm, and is capable of being fiexed and 
extended by the voluntary action of the muscles. The little finger 
occupies its proper place by the side of the ring finger in an ex- 
tended position, but its motions are as yet quite limited. There 
is reason to hope that by the persevering use of passive motion 
there may be a considerable improvement in the degree of mo- 
bility. The middle finger is greatly reduced in length, but 
occupies its proper place on the radial side of the ring finger. 
The thumb and ring finger retain their perfect form and mo- CICATRICIAL CONTRACTION FROM BURNS. 
11 
bility, as before the commencement of the treatment. The hand 
is very far from being perfect, the index finger having been re- 
moved, and the middle finger much shortened, but the remain- 
ing parts of the hand are in their proper relations to each other, 
and the hand as a whole is far from presenting the shapeless and 
unsightly mass which it did before the treatment. 
The following wood-cuts will assist the reader in obtaining a 
correct idea of the character of the deformities, of some of the 
steps in the operations which were performed, and of the degree 
in which the several deformities were relieved by the treatment. 
Fig. 1. 
Fig. 1 is copied from a photograph, representing the deformity 
about the right angle of the mouth. Fig. 2 is copied from a 
photograph exhibiting the same parts after the treatment. 
Fig. 3 is copied from a drawing, exhibiting the palmar aspect 
of the right hand before treatment. An unsuccessful attempt 
had been made to secure a photograph of this hand before the 
operation. Fig. 4 is copied from a drawing representing the 
dorsal aspect of the same hand before the operation of March 
21st, 1879, exhibiting the web which joined the index and mid- 
dle fingers, and the triangular flap which was cut on the dorsum 12 
CICATRICIAL CONTRACTION FROM BURNS, 
Fig. 2. 
Fig. 3. 
Fig. 4. CICATRICIAL CONTRACTION FROM BURNS. 
13 
of the hand to diminish the tension of the parts in that region, 
so as to facilitate the healing of the integument on the opposed 
sides of the fingers, after the division of the web. 
Fig. 5 is copied from a photograph exhibiting the appearance 
of a plaster cast of the palmar aspect of the right hand at the 
close of the treatment. 
Fig. 5. 
Fig. 6. 
Fig. 6 is copied from a photograph exhibiting the appearance 
of a plaster cast of the radial aspect of the left hand, in its de- 
formed condition, before the treatment. The thumb and the 
ring finger are conspicuous at upper part, and are free from 
deformity. The middle finger, shortened and curved, is placed 
behind the ring finger. The index finger is drawn upward and 
backward behind the middle finger, and beyond its terminal 
phalanx is seen the tip of the dorsal surface of the little finger. 
The hand, as a whole, is seen to be drawn forcibly upward and 
backward upon the forearm. 
*Fig. 7 represents the left hand as seen from its ulnar side. 
The little finger is seen deeply imbedded in cicatricial tissue, 
leaving only its distal extremity free. The middle finger is 
seen behind the ring finger, and between it and the little 
finger appears a small portion of the tip of the index finger. 
Fig. 8 is copied from a drawing, giving a general idea of the 14 
CICATRICIAL CONTRACTION FROM BURNS. 
Fig. 7. 
Fig. 8. 
appearance of the dorsal sur- 
face of the left hand before the 
operation which was performed 
on the 13th of February, 1879. 
The principal objects of inter- 
est, as exhibited in this figure, 
are the great bulk of the recon- 
structed middle finger, and the 
triangular flap which was dis- 
sected from the dorsal surface 
of the forearm and hand to re- 
lieve the tension in that region, 
and to give greater freedom of* 
motion to the wrist. 
Fig. 9 is copied from a pho- 
tograph of a cast representing 
the dorsal aspect of the left 
hand at the close of the treat- 
ment. The apparent distortion 
of the thumb is the result of 
the struggles of the child while 
the cast was being taken. The 
thumb itself is entirely free 
from deformity, and its mobil- 
ity is unimpaired. 
Fig. 9.