SURGERY.
Case of Elongation of the Under Jaw, and Distortion of the Face and
JVeck, caused by a burn, successfully treated. By Dr. S. P. IIul-
lihen, of Wheeling, Va.
Miss Mary S------, aged 20, daughter of the Hon. Wm. S----, of
Ohio, came to Wheeling in the spring of 1848, to obtain relief from the
effects of a very severe burn, which she had received fifteen years
before.
The burn was principally confined to the neck and lower part of the
face, and its cicatrix produced a deformity of the most dreadful charac-
ter. Iler head was drawn forward and downward—the chin was con-
fined within an inch of the sternum—the under lip was so pulled down
that the mucous membrane of the left side came far below the chin—
the under jaw was bowed, slightly downward, and elongated, particu-
larly its upper portion, which made it project about one inch and three-
eighths beyond the upper jaw. In front there was scarcely any ap-
pearance of either chin or neck; she was unable to turn her head to
either side; the cheeks and upper lip were dragged considerably down-
ward ; she could not close her eyelids ; she could not bring her jaws to-
gether but for an instant, and then only by bowing her head forward ;
she was unable to retain her saliva for a single instant, and, as might be
expected, her articulation was very indistinct.
She had been taken to the city of New York, some years before,
for the purpose of being relieved of this deformity, and was placed
under the care of two of the most distinguished surgeons in that city,
as I was informed by her father, who performed an operation of dissect-
ing up the cicatrix on the neck, then raising the head, and sliding up
the cicatrix from its original position, leaving a raw surface below to
heal up by granulation. I need scarcely add that the operation was
entirely unsuccessful.
After a careful examination of the case, it became evident that such a
complicated deformity could be best remedied by performing three sepa-
rate operations: one upon the jaw; another upon the neck; and a
third upon the under lip.
To remove the projection of the under jaw seemed to require the
first attention. Unless that could be done, the other operations, how-
ever successful, would add but little if any to the personal appearance
of the patient. This lengthening of the jaw had taken place entirely
between the cuspidatus and first bicuspid tooth of the right side, and
between the first and second bicuspides of the left. By this elongation,
the teeth just described were separated on both sides about three-fourths
of an inch. To saw out the upper edge of these elongated portions of
the jaw, and then to divide that part of the jaw in the front of the spaces
thus made,.by sawing it through in a horizontal manner, so as to permit
the upper and detached portion to beset back in its proper and original
position, appeared to be the only possible way of remedying the defor-
mity. This plan 1 therefore adopted, and performed the operation on
the 12th day of June in the manner now to be described.
The operation was commenced by sawing out, in the V shape, the
elongated portions, together with the first bicuspid on the left side, each
section extending about three-fourths of the way through the jaw. I
then introduced a bistoury at the lower point of the space from which
the section was removed on the right side, and pushed it through the
soft parts, close to and in front of the jaw, until it came out at the lower
point of the space on the left side. The bistoury was then withdrawn,
and a slender saw introduced in the same place, and the upper three-
fourths of the jaw, containing the six front teeth, was sawed off on a
horizontal line ending at the bottom of the spaces before named, (see
Fig. 1,) the detached portions beinst still connected, on the outer and
inner sides, to the jaw be-
low, by the soft parts.
After having, with the bone-
nippers, removed from the
detached portion the cor-
ners which were created
by the horizontal and per-
pendicular cuts of the saw,
it was set back so that the
edges, from which the V
shaped sections were removed, came together as represented in Fig. 2,
Thus it will be perceiv-
ed that this portion of jaw
and teeth, which before pro-
jected and inclined outward,
now stood back and inclin-
ed inward, and in its proper
and original place.
In this position the jaw
was secured, by passing
ligatures around the cuspi-
dati in the detached portion, and the now adjoining bicuspides in the sound
portion. Then taking an impression of the jaw in very soft wax, a cast
was procured, and a silver plate struck up and fitted over the teeth and
gum, in such a manner as to maintain the parts in that same relation,
beyond the possibility of movement.
The patient declared that the operation gave her little or no pain.
There was a little swelling
about the chin during the
first three days after the
operation, but not the slight-
est uneasiness. In this way
the case progressed; the
gum healed in a. few days;
the jaw united strongly,
and in the time bones usu-
ally unite ; and the wearing
of the plate was discontin-
ued within six weeks after
the operation was performed. (Fig. -3 represents the manner of closing
the jaw before the operation. Fiff. 4, after the operation.)
The deformity of the jaw
being now removed, the
next thing to be done was
to relieve the confined con-
dition of the head, and the
distortion of the face and
neck resulting therefrom.
This I determined to ac-
complish, if possible, after
the manner recommended
by Prof. Miitter in similar
cases; and I accordingly per-
formed this operation on the 31st day of July, assisted by Dr. Frissell.
I began by dividing the skin immediately in front of the neck, about
half an inch above the sternum—and then carried the incision back
about three inches on each side. I then commenced a careful division
of the strictures, which were so thickened in front as to extend to the
trachea, and on the sides, as not only to involve the platysma-myodes,
but a portion of the sterno-cleido-mastoideus muscles also. After divid-
ing every thing that interfered with the raising of the head, and the
closing of the mouth, so far as the incision was now made, it became
evident that, to give free motion to the head, the incision on the neck
must be extended back through the remaining cicatrix, which was at
least two inches wide on one side, and about an inch and a half on the
other; this was accordingly done, the whole presenting a wound up-
wards of nine inches in length, and nearly five in width. A thin piece
of leather was now cut in the shape of the wound, but somewhat larger,
and placing it upon the shoulder and arm, immediately over the deltoid
muscle, a flap nearly ten inches in length, and five in breadth, having
a neck or attachment two inches wide, was marked out and then dissect-
ed up as thick as the parts below would permit. This flap was now
brought around, and secured in the wound on the neck by the twisted
sutures ; the sutures were placed about an inch and a half apart; be-
tween each of these sutures, one, two and sometimes three small
stitches were inserted, depending entirely upon the number necessary
to bring the edges neatly together. These stitches were of fine thread
—had a very superficial hold, produced little or no irritation,and served
to keep the parts in better apposition than any other means I could have
devised. The wound on the shoulder was next drawn together about
one-half of its entire extent; the remainder was covered with lint. One
long narrow strip of adhesive plaster, applied around the neck to sup-
port the flap, and over this a cravat tied in the usual way, constituted
all the dressing deemed advisable at this time.
The patient bore this tedious and very painful operation with great
fortitude, and without uttering scarce a murmur. She was somewhat
exhausted, but not from loss of blood; there was no vessel divided of
sufficient importance to require a ligature.
August 1st.—During the fore pqrt of last night the patient was some-
what distressed—was very unmanageable—would talk incessantly, and
occasionally sat up in bed. An anodyne was administered at 12 o’clock,
after which she rested much better, and slept some. Complains of
sickness of the stomach this morning—has vomited three or four times ;
flap very pale; pulse rather weak. Patient directed to refrain from
taking all kinds of drink.
2d.—Patient complains of pain only in the shoulder ; was much dis-
tressed the latter part of last night on account of a retention of urine.
The catheter was employed, and about three pints of urine drawn off,
after which she rested well. Pulse somewhat excited; flap better
color.
3d.—The patient rested well last night—the use of the catheter still
necessary. All efforts to keep the patient from talking and moving
unavailing; color of the flap rather pale, save at the extreme point, and
about two inches along the lower edge, which is assuming rather a dark
blue color ; pulse about the same as yesterday. Removed a pin from
near the point of the flap, and enveloped the neck in cotton batting.
Patient complains of hunger—chicken broth ordered.
4th.—Patient rested well; the use of the catheter still necessary;
complains of slight head-ache ; the color of the flap nearly natural, and
even the point is assuming a healthy hue, and appears to be united ;
pulse almost natural.
5th.—Urinates without difficulty ; bowels moved by injection ;
patient entirely free from pain ; pulse natural.
6th.—Dressing removed ; the flap is united by the first intention,
along both sides, throughout its entire extent; the greater part of the
pins and stitches removed.
7th.—The remainder of the pins and stitches removed ; patient per-
fectly comfortable and cheerful.
10th.—Sat up all day by the window.
15th.—Walked out to take an airing.
During the whole progress of the cure there was not the slightest
swelling or undue inflammation in the flap or about the neck. The
patient was slightly hysterical the first few days, but never complained
of any thing except pain on the shoulder, a slight head-ache of a few
hours’ duration, and the uneasiness occasioned by the retention of urine.
The wound on the shoulder granulated rapidly, and skinned over in
about six weeks after the operation. It was curious to observe that upon
touching the flap after it had healed in the neck, the patient would
always refer the sensation to the shoulder or arm from which the flap
was taken.
The confinement of the head and distortion of the face occasioned
by the strictures, being now removed, the next step was to relieve, as
far as possible, a very great deformity of the under lip.
The under lip, from being dragged down and greatly stretched by the
former projection of the under jaw, was rendered much too large—so
much so that it pouted out an inch or more further than the upper lip.
This, together with a turning out of.the mucous membrane on the left
side, which extended nearly down to the lower edge of the chin, making
the lip too short on that side, was the nature of the deformity yet to be
relieved.
To relieve this unseemly appearance of the lip, the inverted portion
was cut out in a V shape, extending down to the flap in the neck, and
sufficiently large to reduce the lip to the proper size. The edges were
then- brought together and secured after the manner of a single hare-lip.
The wound healed in the most satisfactory manner—the appearance of the
lip was greatly improved, but still there remained a deep depression or
notch in the edge, sufficiently large to keep exposed the tops of two
or three teeth, besides preventing the coming together of the lips on
that side. I now determined to raise if possible, this depressed portion
of the lip, and for this purpose passed a bistoury through the lip, about
two lines from the free edge, first on one side of the depression, and
then on the other, and then carried the incisions downward, to meet at
a point on the lower edge of the chin, as rep-
resented in Fig. 5.
The depressed portion of lip now lying be-
tween the two incisions was next dissected
loose from the jaw, and then raised on a level
with the remainder of the lip, and there re-
tained by pins, after the manner of dressing a
double hare-lip.—the line of union forming
the letter Y. (See Fig. 6.)
This operation was as successful as the
others, and the original deformity being now
removed, the joung lady, though still carrying
evidences of the burn, has the free use of her
head, eye-lids, jaws and lips, and may mingle
in society without particular note or remark.
(Fig. 7 represents the patient before either
of the operations were performed ; Fig. 8,
her appearance three weeks after the last
operation.)
The drawings of the first four cuts, accompanying this report, were
procured through wax impressions of the mouth, and are therefore
exact representations of the position of the teeth, and the manner in
which the jaws closed together. The drawing of the last four cuts
were taken from Daguerreotype likenesses. The Daguerreotype pro-
cess, it is well known, reverses the sides of the face, and having neglect-
ed to direct the attention of the engraver to this fact, these cuts, though
sufficiently faithful to give a very correct idea of the case in all other
respects, represent the right for the left side of the face.
American Journal of Dental Science.