Civil War Washington

CASE.—Private Rowland W——, Co. E, 4th New York Heavy Artillery, aged 46 years, was wounded at Ream's Station, Virginia, August 25th, 1864, by a fragment of shell, which destroyed and completely carried away the inferior maxillary bone and soft parts, commencing two inches anterior to the angle on the right side, carrying away the chin and all the soft parts down the neck, on a level with the hyoid bone, destroying tho floor of the mouth completely, allowing the tongue to protrude and hang down on the neck; deglutition and articulation were impossible. Three of the right lower incisor teeth, with the corresponding alveoli loosely connected with the tissue, remained, and were allowed to stay in that position until the healing process took place, as they gave a partial support to the tongue and submaxillary gland, which was not injured. The wound extended across to the left side, carrying away all the teeth and jaw bone, except those previously mentioned, to a point as high up as the angle of the inferior maxillary on the left side. He was admitted to Lincoln Hospital, Washington, August 28th, 1864. His general health was bad from scurvy. The patient did well, and improved rapidly. On December 9th, he was furloughed for thirty days, and, at the expiration of his furlough, he was readmitted to hospital in good condition. On January 20th, 1865, an operation was performed to construct a floor for the mouth—no anaesthetic was used. Preliminary to the operation, two molar teeth were extracted from the right-hand fragment of the lower jaw. An incision was made two and a half inches in length down the median line of the neck, terminating one inch above the thyroid cartilage. Two lateral incisions, one upon each side, of equal length, right-angled to the vertical incision, these incisions corresponding to the base of the jaw. These flaps were then carefully dissected up, brought together at the middle incision, and secured by three hare-lip needles, the parts being supported by adhesive straps. Frequent application of dry lint was made to protect the parts from the injurious effects of the saliva, which was being constantly secreted. The healing proceeded rapidly, the parts uniting by first intention. Power of articulation and degustation was much improved. The needles were removed on the third day. On April 22d, 1865, the parts being in a favorable condition, ether was administered, and a second operation was performed. Two incisions, one on the right and one on the left, parallel to the inferior border of the inferior maxillary bone, each three inches in length, severed both the facial arteries, which were secured by ligatures. The upper flaps were carefully dissected up, as far back as the angle of the jaw upon each side. The anterior edges of these flaps were freely incised, as well as the superior edge of the parts remaining after the first operation. The flaps were then brought into apposition and retained by four hare-lip needles, two in the upper flap forming the lip, and one upon each side, uniting the lower edge of the flap to the freshened edge of the parts after the first operation. Dry lint dressings were applied, and the patient was fed through a gum catheter. The hare-lip pins were removed from the longitudinal incision on the third day, the others being removed on the fourth day, at which time the remaining pins, together with all the sutures, were removed, the parts being supported throughout the remainder of the treatment by straps of adhesive plaster. On the morning of the 27th of April, secondary hæmorrhage occurred from the left facial artery, which was readily controlled by digital compression. Owing to the constant secretion of saliva from the sublingual gland, which was carefully preserved during the operation, a slough was produced at the junction of the inferior angle of the flaps. This was checked by the application of a week​ solution of nitric acid. On June 23d, the patient was discharged at his own request. A fistulous orifice, one-fourth of an inch in diameter, only remaining, in consequence of the constant secretion of saliva, from the sublingual gland, which prevented the parts from closing by granulation. He is able to articulate quite plainly, which he has hitherto been unable to do since the date of his injury. Until the completion of this operation the patient was compelled to assume a recumbent position to receive his nourishment, or even a swallow of water. He can now take his food and drink without any difficulty, in an erect posture. By the use of a rubber button, properly adjusted to the fistulous orifice, the secretion of saliva was prevented from making its exit externally. The appearance of the patient, both before and after operation, is shown by photographs Nos. 167, 168, 169, 170 and 186, Surgical Series, A. M. M. The photographs were printed from negatives prepared at Lincoln Hospital, under the direction of Surgeon J. Cooper McKee, U. S. A., who was the operator in this case. On November 8th, 1869, Ward forwarded a letter to the Surgeon General in reference to a pension. He wrote that he was obliged to live on milk diet. The letter, with photographs and a history of his case, was forwarded to the Pension Office. He is a pensioner.