A large portion of chin

pistol wound of the throat

One night in May 1832 the duty medics at St Thomas’s Hospital in London suddenly had a particularly difficult case to deal with. It was subsequently reported in the London Medical and Surgical Journal:

Joseph B. aged 24, a Frenchman, of sanguine temperament, whilst partially inebriated, on the evening of May, in an hotel in Gracechurch Street, suddenly declared his intention to destroy himself, and before the attempt could be prevented had placed a duelling pistol to his throat…

A terrible idea. A shot to the throat is unlikely to be trivial, and unlikely to kill quickly. All he succeeded in doing, when he pulled the trigger, was making a horrible mess of his face.

…by the discharge of which he blew off the left horizontal ramus of the lower jaw, and a portion of the right, as far as the canine tooth, the greater part of the left superior maxillary and palate bones, so that the orbit and mouth were one common opening, exposing the pterygoid processes and pharynx, the vomer likewise being exposed, and the nose turned somewhat to the right side; a fracture extending through the nasal into the orbital process of the right superior maxillary bone; considerable haemorrhage had taken place, but had almost subsided soon after his arrival at the hospital.

This long list of facial bones and other structures makes clear the extent of the injury. It was a real shocker. Part of the lower jaw had been blown clean off, and much of the front of the skull destroyed. The mouth now communicated with the left eye socket – that is a nasty mess by anybody’s standards.

Grays anatomy facial bones
The vomer and other bones of the nasal cavity, from Gray’s Anatomy.

Mr. Tyrrell, under whose care he came in, was immediately sent for, and by the time he had arrived, by the application of cold water, all haemorrhage had ceased. The pistol must have been held in an oblique direction, so that the slugs with which it was loaded entered at some distance under the jaw, did not wound the tongue, carried away most of the floor of the orbit, and then passed into the ceiling of the room, leaving the eye uninjured, which still performs its function.

This sounds promising; but the socket around it had been shattered, which made it unlikely that the eye could be preserved or remain functional for very long. The surgeon did his best to help the patient.

Mr. Tyrrell brought the widely divided parts into apposition by suture; an opening, however, to the extent of an inch remains superiorly, where everything which passes to the pharynx may be perceived.

A footnote supplies a particularly charming detail:

A large portion of the chin was picked up by the officer that brought him to the hospital, who wrapped it in a piece of brown paper, and brought it with him in his pocket.

“What have you got there, officer?”

“The patient’s chin, sir.”

Much of the soft tissue around the mouth and throat had been destroyed, which made any attempt at reconstruction challenging.

It was impossible to make any apposition of the injured parts, so that the tongue, which was lying on the throat, was raised by a fold of lint, and supported by a poultice. His pulse was soft and ample at his admission, and has altered but very little throughout. His nutriment, which has consisted of beef tea, arrow root, and wine, has been administered till lately by the stomach pump; the power of deglutition [swallowing], however remaining; this method has been discontinued, and his food conveyed to the pharynx by being poured into a paper tube.

The stomach pump was a recent invention, first demonstrated a decade earlier. I have previously written about its controversial genesis here.

No secondary haemorrhage has occurred, and but little sloughing; most of the surfaces are in a healthy granulating condition; the patient’s strength keeps up, and to all appearance he will do well.

Surprising. This must have been a particularly unpleasant experience, with no anaesthetics available and little effective analgesia apart from opium. The pistol ball must have missed the major blood vessels of the neck, since a lacerated jugular vein or carotid artery would surely have killed him within a matter of minutes. He was lucky that he was still able to swallow – however, with such terrible facial injuries it is difficult to imagine what his later life must have been like.

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