Civil War Washington

CASE.—Private William Semmons, Co. F, 14th New York Heavy Artillery, aged 20 years, was wounded at Petersburg, March 25th, 1865, by a fragment of shell, which entered the right cheek, fractured the zygomatic process of the malar bone, comminuted the ramus and body of the inferior maxilla, lacerated and opened the ducts of the parotid and maxillary glands, and removed all the integuments of the cheek, leaving the right angle of the mouth hanging loose. He was taken to the field hospital of the Ninth Corps, where about two inches of the alveoli of the superior maxilla was excised and the wound stitched. On April 1st, he was transferred to Armory Square Hospital, Washington. Owing to his inability to swallow, liquid food and stimulants were introduced by the stomach pump. On September 21st, he was transferred to De Camp Hospital, New York Harbor, and discharged from service on October 21st, 1865. On October 26th, he was admitted to the New York Hospital. The wounded parts had been completely cicatrized for more than two months. The face was extensively disfigured. The chin, owing to the absence of the lower jaw, had retracted and lost its prominence. On the right side of the face a cicatrix extended from the middle of the zygoma to the angle of the mouth, at which latter point it was deeply depressed and closely adherent to the alveolar margin of the upper jaw, from which the teeth had been carried away. This adhesion had drawn up the upper lip and lengthened it considerably toward the right side. The lower lip having been detached by a laceration vertically at the right angle of the mouth, and also horizontally by another laceration crossing the upper part of the chin, nearly an inch below its vermilion border, had dropped below its proper level and become adherent, leaving a separation between the two lips at the right angle of the mouth of a finger's breadth, which exposed the end of the tongue to view, and permitted a constant escape of saliva. Irregular cicatrical lines crossed each other below the left angle of the mouth, one of which passed across the left cheek nearly to its middle. All that remained of the lower jaw was the upper half of the ramus on the right side, and the entire ramus, with the angle supporting two molar teeth, on the left side. From the point where the right angle of the mouth adhered to the upper jaw, a free, callous, thick border of skin stretched across the cavity of the mouth and terminated at the left angle of the jaw, to which it firmly adhered. This was, evidently, the lacerated edge from which the lower lip had been torn by the original injury and had remained separated. It performed the important office of a substitute for the lower jaw, affording support to the tongue, the attachments of which were felt connecting with its posterior surface. The last upper molar tooth on the right side remained in situ. All the upper teeth between it and the left canine were gone, those beyond the canine on the left side remaining. Upon introducing the finger into the mouth, it was found that the body of the tongue was bound on the right side to the adjacent parts by adhesion, and its movement of protrusion thereby limited. Mastication being impracticable, the patient was restricted to the use of soft solids and liquids. Deglutition was unimpaired. His articulation was very defective, owing to the confinement of the tongue by the adhesions. In consequence of this defect, the patient was averse to using his voice, and preferred making himself understood by signs and the use of a pencil and paper. His health was good, his complexion florid, and his general appearance robust. On November 7th, Dr. Gurdon Buck performed the following reparative autoplastic operation: The lower lip was detached by a horizontal incision extending along the cicatricial line crossing the chin, to a point below the left angle of the mouth. The entire thickness of the lip, with its lining mucous membrane, was divided. Its vermilion border, which had shrunken into a fan-like shape by cicatrization, could now be straightened out and applied to the upper lip throughout its entire length. To form a new angle for the mouth, a point was chosen at the margin of the upper lip, equidistant from the median line with the left angle, and at this point the border was pared away obliquely. A corresponding point was chosen on the lower lip and pared in the same manner. The two fresh cut surfaces were brought into accurate apposition and secured by sutures. The adherent right extremity of the upper lip was dissected up from the alveolar border of the jaw, and from this point an incision was carried outward and upward, along the upper margin of the cicatrix crossing the cheek as high as the zygoma. The skin and subjacent tissue were detached freely toward the orbit and temple. Another incision was then commenced below the left angle of the mouth, at a point where the incision detaching the under lip terminated, and carried to the right, across the chin, at a finger's breadth below the free callous border above described as constituting a substitute for the lost jaw. This incision was continued on obliquely upward and outward, over the cheek below, and close to the cicatrix as far as the zygoma. A third incision, beginning at the starting point of the preceding one, below the left angle of the mouth, was carried perpendicularly downward a distance of two inches upon the neck. In its course a cyst, of the size of a dollar, was encountered, filled with a brownish, transparent, viscid fluid, such as is met with in ranula, and was dissected out entire. The angle included between these two incisions, as well as the integument below, crossing the right cheek, were extensively detached from the parts beneath. An upper and lower flap, including the entire right cheek and nearly the whole chin, were thus formed. They were separated by the cicatrix crossing the cheek, which had been left in situ. After paring off the surfaces of the cicatrix, the edges of the flaps were brought together so as to cover it up, and secured by sutures. At the right angle of the mouth, reconstructed in the manner already described, the flaps above and below were matched to the lips and also secured by sutures. Sutures were introduced in close proximity throughout the entire extent of the flaps, so as to maintain their edges in accurate adjustment. Four of the sutures were twisted and were inserted, one at the right angle of the mouth, two upon the right cheek at points where they would afford the best support to the flaps, and one at the angle of the flaps, below the under lip. The newly constructed mouth was of medium dimensions, the lips maintaining themselves in contact and retaining the salivary secretion. The adjustment of the different parts to each other was effected without any strain upon the sutures at any one point. No adhesive plaster was used. Liquid nourishment was directed to be given through a tube, and water dressings to be applied to the face. The case progressed favorably, and by November 10th, adhesions had taken place throughout almost the entire extent of the flaps, and all the pin sutures, with most of the thread sutures, were removed. A free discharge of pus was taking place at the lower extremity of the incision under the chin, where the cyst was removed. Strips of adhesive plaster were applied at points where their support seemed needed. A superficial slough of the size of a copper cent had formed over the zygoma, which could not, however, mar the result of the operation. The suppuration below the chin gradually diminished, and ceased entirely in a few days, every part of the wound healing completely. On December 12th, 1865, the patient left the hospital to return to his home. The ability to maintain the lips in contact, and thus retain the saliva, constituted an immense amelioration of his condition. His improved appearance, and some improvement of articulation, were also results highly gratifying to the patient.