CSMSJ Vol. I, No. 7 (July 1864)

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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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