From the Confederate States Medical and Surgical Journal, Vol. I, No.
7 (July 1864). Richmond: J. B. McCaw, Ed., p. 104-106
ART. V. – Operations in Reparative Surgery. By CHAS.
BELL GIBSON, Surgeon P. A. C. S.
W. M. Wyatt, private, Page’s battery, 1st
regiment Virginia artillery; age 46; occupation a farmer; was admitted into
General hospital, No. 1, Richmond, Sept. 17, 1863. Wounded 13th
September in the face by a piece of shell. His condition, on entering the
hospital, was as follows:
The lower jaw was fractured and carried away from the first
molar tooth of the right side, near the angle of the jaw on the left side; the
tongue was badly lacerated, and the soft tissues forming a portion of the
cheeks, the whole lower lip, and the original covering of the chin had been
carried away.
His appearance was frightful and most pitiable, and as
sloughing had commenced, the prognosis was most unfavorable.
Fortunately, however, in a few days the sloughing process
ceased, and although suppuration was profuse and very offensive, the granulating
process at last became fairly established, and by the 10th November
(in fifty-four days after receipt of injury) he was well enough to go to his
home on furlough. He had been told that an attempt might be made to improve his
appearance by an operation at a future day, and he accordingly returned to the
hospital early in January.
By this time cicatrisation had occurred. Irregular and
lumpy cicatrices extended into the cheeks, from the corners of the upper lip
(which had not been involved in the wound) and down upon the throat; and the
tongue appeared in the chasm representing his mouth, adhering to the traverse
edge of the cicatrix two inches below the border of the upper lip.
After careful inspection as to the best means of relieving
the deformity, it was determined to attempt to make a new lower lip, by
dissecting up the tissues of the throat and cheeks, sliding them to a level with
the border of the upper lip, and securing them in position by sutures.
The operation was performed on the 10th of
January, 1864, without chloroform, as it was desirable the patient should not
incur the danger of blood passing into the air passages; and the extreme
suffering, necessarily attendant, was borne with patience and courage rarely
witnessed.
An incision three inches long was made downwards in the
centre of the tissues of the throat, terminating about the middle of the thyroid
cartilage. From the termination of this incision another was carried, first on
the right side and then on the left, upwards and backwards towards either angle
of the jaws, each to the extent of three inches; and thus two flaps were marked
out. These flaps were then dissected (about one-fourth of an inch in thickness)
from the sub-jacent tissues; so that, when the dissection was competed, the two
flaps, each being seized at the central incision, could be raised and brought up
so as to present an opposing margin or surface to the upper lip. As had been
anticipated, it was found that the flaps now required to be incised so as to
prevent the edges by which they were to be united to each other in the centre
from overlapping; and accordingly about a quarter of an inch in width was
removed from each flap along the edges. Then, being again brought up to the
border of the upper lip, the flaps were united, in a central line, by
interrupted sutures of silver wire. Two incisions were then made from either
angle of the new mouth outwards, and the lumpy and unsightly cicatrices, before
mentioned, were cut out, and the wounds also united by silver wire. Adhesive
strips and a bandage completed the operation. The lateral dissection of these
flaps, of course, left a considerable space on the throat and neck of raw
surface. The was expected to granulate and cicatrize, in due time, under water
dressing. Directions were given to very careful attendants as to diet and
drinks, and an anodyne administered.
On the fourth day the parts were examined, and with the
exception of the suture at the upper end of the central line, which had
ulcerated through, all was doing well; perfect union had occurred. It was deemed
best, however, as the sutures were not producing irritation, to leave them; and
thus they were not removed till the tenth day. At this time the parts were
perfectly consolidated; the flaps not only united in the centre, but adherent to
the subjacent surface. The wound below was suppurating and granulating kindly.
On the 1st of March the patient left the
hospital again, for his home, greatly improved in appearance and in his power of
articulation. It is probable that some contrivance may be adopted by which he
will one day bee able to masticate his food.
It is regretted that the record of a case has been lost, in
which the upper lip and nostrils were extensively mutilated by a portion of
shell, and in which plastic surgery was also made eminently useful. The
operation was performed in General hospital, No. 1, in the fall of 1863, upon a
patient named Cook, from Georgia. He was returned to his regiment, and when last
heard from he was on duty with it.
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