Some Recent Experiences in 
Clinical Surgery. 
(Illustrated by Notes of Cases, Pathological Specimens, and 
Patients ) 
BY 
DONALD MACLEAN, M. D. 
REPRINTED PROM THE 
Transactions of the Mich. State Medical Society 
FOR 1886. SOME RECENT EXPERIENCES IN CLINICAL 
SURGERY. 
(Illustrated by Notes of Cases, Pathological Specimens, and Patients.) 
DONALD MACLEAN, M. D. 
The first subject to which I desire to call the attention of the 
Association is the common one of diseased knee joints. 
Two cases have recently occurred in my public practice which 
have seemed worthy of presentation here, for the reason that 
they represent in a practical manner two important pathological 
conditions, demanding widely different methods of treatment, 
viz: in the one resection of the joint, in the other amputation 
of the thigh. A pathological specimen obtained from each one 
of these cases I have brought with me for inspection by those 
members of the Association who may feel an interest in the 
subject. Not only so, but one of the patients, viz., the one in 
which resection was performed, is present in the flesh for the 
purpose of giving ocular demonstration of the result of his 
treatment. 
Case 1. Charles M. , set. 19, Alpena, Mich., Englishman. 
History: about seven years ago, patient says that he had his left 
knee bruised between two logs. Notwithstanding the use of 
liniments, plasters, blisters, etc., the effects of this injury per 
sisted, and the joint grew steadily worse until August, 1884, 
when patient came to the University hospital at Ann Arbor, 
where Dr. Sullivan, in my absence, examined the knee and applied 
a plaster of Paris cast. From this the patient states that he 
experienced great relief. 
On October 10th following, patient returned to the hospital 2 
EXPERIENCES IN CLINICAL SURGERY. 
and was examined by myself. The symptoms at that time 
pointed to chronic synovitis, and I advised continuance of the 
treatment by plaster cast, together with general tonics. He soon 
left the hospital feeling much relieved and in good spirits. 
On November 23,1885, patient once more entered the hospital. 
He then stated that all had gone well with his knee until March, 
1885, when lie had the misfortune to give his knee a very severe 
wrench, in consequence of which he was confined to bed for two 
months. From that time until the date of his admission to the 
hospital the joint continued painful and swollen in spite of 
treatment, which consisted chiefly of extension by weight and 
pulley, with plaster casts. 
On admission at this time, November 23d, the general swell- 
ing of the joint; the thickened, gelatinous condition of the 
synovial membrane; the deep, gnawing pain, aggravated at 
night; the great tenderness on pressing the joint surfaces 
together, all testified unmistakably to general degeneration of all 
the joint structures, with ulceration of the articular cartilages. 
At the same time it seemed quite certain that the disease was 
confined to the immediate neighborhood of the articulation. 
In view of all the facts stated, I advised resection, and the 
patient gladly assenting, the operation was performed on January 
14, 1886, in presence of the medical class. It was accomplished 
by making one long curved incision over the front of the joint, 
dividing the ligamentum patellae, but retaining it and the patella 
in the superior flap. The bones were not wired, but the flaps 
were drawn firmly together and supported by deep button 
sutures. The dressing consisted of antiseptic gauze and cotton 
wadding applied all over the surrounding parts, after they had 
been freely irrigated by a solution of mercuric bichloride, 1 to 
2,000. Over these dressings a plaster of Paris cast, with a long 
posterior splint, was applied. 
January 18th. Dressings removed, when only about half 
a drachm of discharge could be detected. Irrigation, antiseptic 
dressings and a cast were applied. No rise of temperature BY OONALO MACLEAN. 
3 
occurred, and healing by first intention took place throughout 
nearly the whole extent of the wound. 
January 19th. A wrought iron splint, together with a plaster 
cast, was so applied as to admit of the thorough dressing of the 
wound, from which, however, there was not at any time much 
discharge. 
February 20th. Walked out with crutches. 
June 3d. Patient appeared before the class and walked from 
one end of the amphitheatre to the other without crutch or cane. 
His general health is completely restored, and here he is to speak 
for himself. (Patient looked healthy and walked freely without 
crutch or cane in presence of the Society. He still wore a light 
plaster cast as a precautionary measure.) 
The specimen obtained from this case was exhibited to the 
Society, and constituted a beautiful illustration of ulceration 
extending right through the cartilages of the joint and affecting 
the bones to a considerable depth. Elimination of the disease, 
consolidation of the bones, and consequent restoration of the 
limb to usefulness, will, in young adults, be more surely and 
quickly obtained in this form of disease by resection than by 
an}7 other mode of treatment; that is to say, after the usual con- 
servative procedures have been tried and have failed, as they will 
sometimes do. 
Case 2. The following case is interesting and instructive as 
showing a state of matters in which resection was contra-indicated 
and a more radical procedure called for. 
John R. , set. 37, Bennington, Mich. In January, 1875, 
patient’s left knee was injured by a block of wood falling on it, 
but from this complete recovery seemed to have been attained. 
Two years later patient says that he fell when running and 
severely wrenched the joint. A swelling in the popliteal space 
resulted from this injury, but has long since entirely disappeared. 
On admission the knee presented very little external signs of 
disease ; it was not swollen nor deformed. Nevertheless it was 
immovable and extremely painful, more especially at night—so 4 
EXPERIENCES IN CLINICAL SURGERV. 
much so that sleep was greatly interfered with. Patient stated 
that last year he was under Dr. T. A. McGraw’s care, at St. 
Mary’s Hospital, Detroit, the treatment then consisting mainly of 
the application of the actual cautery and the use of plaster of 
Paris casts. After four months of this treatment he says that 
lie was not any better. 
It should be noted here that never during all the years dur- 
ing which his case had lasted had he been confined to bed, or 
the knee been subjected to continuous extension and counter 
extension. This was at once resorted to at the University 
hospital, but with no appreciable benefit beyond securing sleep. 
Amputation was advised as the only alternative, on the following 
grounds: 
First—The long standing and intractable character of the dis- 
ease testified clearly to the fact that the structural lesions were 
too deep seated and too extensive to admit of effectual relief, 
except by a radical operation. 
These lesions I conceived to be the following: (a) Ulceration 
of the articular cartilages and joint surfaces; (b) infiltration 
(fungous) more or less thorough of all the articular structures; 
(<c) osteomyilitis of the femur to an extent impossible to deter- 
mine precisely without an operation. 
Second—The patient’s age and his worn-out condition, as well 
as the extent to which the thigh bone was affected, contra-indi- 
cated the operation of resection. 
Third, and lastly, the patient himself was utterly tired of his 
limb, and nothing would satisfy him except amputation. I am able 
to show you the specimen obtained from this case, one glance at 
which is sufficient to demonstrate the perfect propriety of the 
operation. The medullary canal of the femur is seen to be dis- 
organized all the way up to the upper third. 1 may state, in 
conclusion, that this patient made a somewhat slow but ulti- 
mately complete recovery, and left the hospital with an excel- 
lent stump on April 2d. 
If time and opportunity permitted, I might present here a good 5 
BY DONALD MACLEAN. 
many cases from my own experience, to prove that such cases as 
the two here recorded are now-a-days frequently saved from all 
operative interference by proper care and management applied 
soon enough. I refer to physiological rest by continuous exten- 
sion and counter extension plaster of Paris casts, which afford 
rest, protection and pressure, and in certain carefully selected 
cases in which there is deep pain, with marked nocturnal exacer- 
bations; the actual cautery. When the medullary canal of the 
femur has become disorganized by destructive inflammation, as 
in the case here recorded, amputation is. in my opinion, the only 
resource left. 
CARCINOMA MAMMAS. 
At the meeting of this Society, held in Grand Papids two 
years ago, I reported the case of Mrs. C., on whom I had oper- 
ated eight different times within one year, for cancer of the 
breast, the disease having returned in seven different spots after 
the breast had been amputated. Inasmuch as it is now five years 
and a half since the first, and four and a half since the last oper- 
ation, it seemed to me that it might be interesting to the mem- 
bers of the Association to have the privilege of seeing and exam- 
ining this patient with her numerous scars, for themselves, and 
she is here now for that purpose, and it will be seen that she is 
in excellent health, and that there is as yet no symptoms of a 
return of her malignant and inveterate enemy. The practical 
deductions from this inspiring case were fully elucidated in my 
former report. 
P. S.—In the former paper only six operations are described, 
whereas the current number was eight. Two were accidentally 
overlooked in copying from the hospital case book. 
The only other patient that I wish to occupy the attention of 
the Association with, on this occasion, is this man, for whom on 
March 1st, of this year, I performed Syme’s ankle-joint ampu- 
tation. It will be observed that the stump is of perfect form 
and constituted for the all-important function of bearing the 
weight of the patient’s body, and that, too, without anything in 6 
EXPERIENCES IN CLINICAL SURGERY. 
the shape of an artificial appliance. You see that although as 
yet but recent, even now he can stamp on this hard floor with 
his naked stump without flinching. This is the only stump in 
the body, so far as I know, in which this can be done, unless, 
perhaps, it is in some of the modifications of Syme’s operation. 
The following is a condensed history of this case: 
A. C. C. , eet. 40, farmer. Last spring, while roller skat- 
ing, patient says that he sprained his ankle. Some weeks after- 
wards, viz., in the latter part of May, the foot as a whole, 
suddenly became inflamed and swollen, but was not painful. In 
fact it never at any time was painful. Pus formed at various 
points and was evacuated, and sinuses resulted which refused to 
close. On admission, the foot was greatly swollen, the dis- 
charge from the sinuses was slight in quantity, and ichorous 
in quality. On probing the sinuses no dead nor carious bone 
could be felt. The superficial textures of the foot were evi- 
dently involved in the universal process of disorganization. 
All voluntary power over the joints of the foot and toes was 
lost, and the foot had come to be a useless and unsightly burden, 
with no reasonable hope of being benefited by any form of treat- 
ment. In these circumstances, amputation through the ankle- 
joint was recommended, and at once performed. The recovery 
has been fairly rapid. Seven weeks from the day of operation, 
patient appeared before the class and stamped with his naked 
stump on the floor with as much force as any one could do with 
a heel that had never been diseased at all. He was then dis- 
missed from the hospital, and has since been at his home, from 
whence he has kindly come to-day, a long distance, for the pur- 
pose of bearing the most unanswerable testimony to the elegance 
and practical perfection of Syme’s ankle-joint amputation. 
On dissection, the foot (which I am glad to be able to exhibit 
to those members of the Society who may desire to examine 
it) was found to constitute a perfectly typical case of what Bill- 
roth describes as “ ostitis ftmgosa, where there is as yet no 7 
BY DONALD MACLEAN. 
destruction of the inflammatory new formation, but where inter- 
stitial granulation tissue has grown all through the bone.”—(Bill- 
roth’s Surgical Pathology, p. 413, D. Appleton & Co., 1872.) 
The morbid process in this instance, it will be plainly seen, 
had not confined itself to the osseous and articular tissues, but 
had involved and disorganized the muscular, tendonous, and other 
structures of the foot as well. The disease had not, however, 
passed beyond the ankle joint. The specimen seems to me to be 
a very striking one, indeed, well worthy the careful inspection of 
those interested in surgical pathology. 
NERVE STRETCHING FOR SCIATICA. 
J. R. , set. 35, laborer, Harrison, Mich. ; admitted March 
22, 1886. Patient states that for fourteen years past lie has suf- 
fered more or less frotn sciatica. For four years his sufferings 
have been very severe and almost constant. On examination it 
was found that the whole trouble was confined to the sciatic 
nerve, and that it centered chiefly immediately behind the hip 
joint. 
The administration of croton oil in 2-drop doses did no good, 
neither did the application of fly blisters over the seat of the 
pain. 
April 9th. Chloroform was administered, the sciatic nerve 
exposed by a straight incision, commencing above the lower 
margin of the gluteus maximus and extending downwards over 
the biceps muscles for six inches. The nerve was then easily 
found, the finger hooked under it, and force enough used to lift 
the leg right off the table. The force was applied so as to draw 
the nerve downwards from the trunk, and then in the opposite 
direction, viz., upwards from the foot. 
The wound healed by first intention, and the sciatica at once 
disappeared, although the patient complained of a good deal of 
pain of a different character from the old pain. 
April 25tli. Having had some local pain, together with a 
marked rise of temperature, my assistant, Dr. Sullivan, detected 8 
EXPERIENCES IN CLINICAL SURGERY. 
some deep fluctuation at the seat of operation, and at once made 
a free incision and evacuated 18 ounces of pus. From this time 
on till May 25th steady improvement took place. The sciatica 
had disappeared, and he was dismissed cured. 
In January, 1880, I performed this operation in a very aggra- 
vated case, and at the meeting of this Association at Lansing, in 
May of that year, I reported the case as a perfect success. Six 
years have now elapsed since that report was made, and I am 
happy to be able to record now the fact that up to the present 
time that patient has continued to enjoy absolute immunity from 
the painful disease which for two years had entirely incapacitated 
him for work of any kind. Since then I have performed the 
operation many times, and with almost uniform success. In one 
case the relief was so long delayed that it seemed very doubtful 
whether the operation had anything to do with its ultimate 
occurrence. 
On the whole, the testimony based on my experience is 
unequivocally in favor of nerve stretching as a safe and reliable 
means of relief in this obstinate and painful affection. 
STONE IN THE BLADDER, WITH A NUCLEUS OF CHEWING GUM. 
Case 1. C. J. , aet. 23, Orleans, Mich.; admitted October 
27, 1885. For five years patient has suffered from symptoms of 
stone in the bladder, the result of passing a piece of chewing 
gum into the bladder. On examination the stone was at once 
discovered, and the operation of lithotomy recommended. 
October 29th. The left lateral operation was performed, and a 
stone weighing 278 grains was extracted. A careful search was 
made, and the piece of gum was found and is here shown, along 
with the fragments of stone. Patient made good recovery. 
Case 2. W. L. , set. 11, Harrison Co., Mo.; admitted 
November 16, 1885. When eight months old patient suffered 
from measles, whooping cough and diarrhoea in rapid succession, 
and at that time commenced to have painful urinary symptoms, 
and from these he has continued to suffer more or less ever since. 9 
BY DONALD MACLEAN. 
On examination, the presence of several calculi was at once 
detected, and the left lateral operation performed. Three stones 
were very readily removed, and a fourth discovered. The latter 
was removed with some difficulty, owing to the fact that it was 
adherent to the roof of the bladder by a broad, rough surface, 
distinctly shown in the specimen here presented. By means of 
the forefinger of my left hand, hooked up behind the pubes, I 
succeeded in dislodging this calculus, which was then easily 
removed from the bladder with the forceps. Patient made a 
rapid and complete recovery. 
Case 3. The following case is not exactly a recent one, as it 
occurred two years and a half ago, and still I desire to record it 
here on account of some interesting and peculiar facts involved 
in it: 
Mr. Le V. , aet. 42, had the misfortune to fall from a 
scaffold, in July, 1879, injuring his spine so severely that 
paralysis, almost total, of the lower extremities and the sphincters, 
resulted. Patient spent a whole year in the Homoeopathic hos- 
pital at Ann Arbor, but without receiving any benefit whatever. 
In process of time patient’s means became exhausted, and he was 
compelled to become an inmate of the Wayne county poor house, 
wdiere I was asked by Dr. E. O. Bennett, the Superintendent, to 
see him, on March 27, 1884. 
I found him suffering intensely from symptoms of stone in the 
bladder, with absolute incontinence of urine. His condition 
was indeed wretched. I at once determined to do what I 
could to afford him relief, and accordingly performed the left 
lateral operation, and removed the two large stones which I have 
already exhibited to many of the members of this Society, each 
stone being larger than a pullet’s egg. The result of this opera- 
tion was better than I had dared to hope for. All pain was 
immediately relieved, the wound healed kindly, and, wonderful 
to relate, the patient at once and permanently recovered complete 
control over the sphincter of his bladder, and from that time to 10 
EXPERIENCES IN CLINICAL SURGERY. 
the present has continued to enjoy a painless and comparatively 
happy existence. 
Case 4. Stone in the female bladder. On September 24th, 
1885, Dr. Hayden, of Lansing, called me to see a lady patient of 
his, who was suffering severely from symptoms of stone in the 
bladder. On examination the diagnosis of stone was at once 
confirmed. Among the other distressing symptoms, incontinence 
of urine was one of the most urgent. Chloroform having been 
administered, the urethra was rapidly dilated by forceps, and the 
two large oxalate of lime stones, here presented, were removed. 
Weight, 448 grs. Patient recovered without a bad symptom. 
The incontinence of urine soon disappeared, and her health 
became and has since remained better than it had been for many 
years. 
Photographs and Specimen of Cystic Tumor of the Mouth. 
C. S. , set. 2, Constantine, Mich.; at birth the attending 
physician observed a small cystic tumor, which on pressure 
yielded a slight discharge of bloody fluid. The tumor has 
steadily grown with the child’s mouth. It has pushed the lower 
teeth outwards and now occupies the whole of the cavity of the 
mouth in front of the tongue, which is displaced upwards and 
backwards. The tumor protrudes from the mouth, and consti- 
tutes a most unsightly deformity. It is painful on pressure. 
Careful examination proved that the sublingual glands and ducts 
were not involved in the cyst, although when the mouth is closed 
it presses upon and obstructs the mouths of the ducts. When 
the mouth is open and the tumor protruding, the saliva starts 
from the mouths of the ducts with a spurt, and continues to 
flow freely so long as the mouth remains open. 
The treatment consisted in the excising of a large section of 
the wall of the cyst, and the application of strong tincture of 
iodine freely to the secreting surface. The fluid contents were 
whitish and of a glary nature. The hemorrhage followed the 
section of the cyst wall, requiring the ligature of two very active 
arteries. For a few days the little patient suffered considerably BY DONALD MACLEAN. 
11 
from acute inflammatory symptoms, with general fever, but these 
soon passed off, and on February 4th he was dismissed cured. 
RESECTION OF SHOULDER JOINT FOR CARIES FOLLOWING DISLOCATION. 
A. R. , set. 22, Bangor, Mich. Patient states that on May 
15, 1883, he fell into the hold of a vessel and received a disloca- 
tion of the right shoulder joint. The dislocation was reduced, 
but inflammation set in and an abscess formed. For this he 
was treated at Albany, N. Y., where he says the abscess was 
opened, and where he says the operation of amputation at the 
shoulder was urged upon him by two doctors, but he declined. 
He was admitted to the University hospital in December, 1884, 
and at that time his arm was bound firmly down by old adhesions, 
so that there was practically no movement at the shoulder joint. 
There was a suppurating sinus which led down to the head of 
the humerus, which was found to be not necrosed but carious. 
Resection was advised and performed December 23d, 1884. The 
operation was a very difficult one, owing to the matting together 
of all the tissues involved, and more especially so from the fact 
that the head of the bone was eaten out by the caries, leaving a 
sort of hook-shaped process above, very difficult to distinguish 
from the acromion process. Patient made a rapid recovery and 
soon left the hospital. Efforts were made to obtain information 
from him as to the ultimate result of his case, but in vain, until a 
few days ago, when I was greatly pleased to receive the follow- 
ing most considerate and courteous letter containing the much 
wished for information. I am also happy to be able to exhibit 
the specimen obtained from this case. 
Buxton, Dak., May 31, 1886, 
Dear Dr.—A patient came to consult me about some slight ailment the 
other day, by name of Randall. On examination I noticed a shortened os 
humerus on the right side. Questioning him he informed me that you per- 
formed resection of head of humerus about a year ago last Christmas, at Ann 
Arbor. Thinking you would like to hear the result of your operation, I take 
the liberty to report that he has got complete motion of arm, but cannot raise 
it above the horizontal. It is strong, and inconveniences him very little. He 
was engaged in using a wheelbarrow on railroad grading, and seemed to do his 12 
EXPERIENCES IN CLINICAL SURGERY. 
work with as much ease as if both arms were of an equal length. He is in 
good health and loud in his praises of you. IIis condition could not Ik: better 
than it is. Yours very truly, J. Grassick. 
In addition to the pathological specimens referred to in the 
foregoing list of cases, I am also pleased to call attention to the 
two very remarkable specimens of cystic tumor of the kidney. 
These two specimens were obtained by the operation of nephrec- 
tomy, and both patients recovered, but this paper is already so 
lengthy that I dare not venture to relate the details of these cases 
on the present occasion, further than to state that they were both 
operated on by abdominal section, and that one was fully and 
correctly diagnosed beforehand, while the other was supposed to 
be an ovarian tumor.