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286; heart disease and dropsy, 651; liver diseases, 127; diseases of
the nervous system, 1,065 ; urinary organs, 277 ; old age, 413; stillborn,
390; all other causes, 3,718.

Now, I wish to speak of the defect in the census of 1890.

It will be observed that from the first census, in 1790, the decennial



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246 The American Practitioner and News.

increase amounted to an average of over 34 per cent up to 1870, the
first census after the civil war, which was 22.63 per cent. This low
increase is easily accounted for as the eflFect of the four years' war. In
1880 the increase came up to over 30 per cent, and in 1890 went back
to 24.86 per cent. Now, how is this great falling oflF in population
increase to be accounted for ? Why, only on the ground of failure on
the part of census enumerators to list all the inhabitants. There were
no epidemic diseases in the country that year or during the decennial
period calculated to diminish the number of our population. The
death-rate was quite low, being only 13.98. From the consideration of
these facts it can only be inferred, as before remarked, that a large per
cent of the population was not enumerated.

Now, we will speak of Kentucky. Our population in 1880, according
to the census of that decennial period, was 1,684,600, and the returns of
1890 only gave us 1,858,600. In 1870 we had a population of 1,321,-
000, and, as above stated, 1,684,600 in 1880, an increase of 363,600, or
27.50 per cent. Now, if we had increased in population at the same
ratio during the decennium from 1880 to 1890 as we did from 1870 to
1880, we should have had a population of 2,148,000 in 1890, and at the
same ratio of increase we should have next year 2,719,000.

Since the period from 1880 to the present there has been a great
increase in business enterprises. Many factories have sprung up, and
a great increase in mining operations, to say nothing of agricultural
and commercial matters, all of which is greatly calculated to induce
immigration to the State.

We have had no epidemic diseases to curtail the number of the
people more than the ordinary diseases. Our greatest epidemic was
the yellow fever of 1878, which was two years previous to the time we
are alluding to, and occurred during the centennial period in which
we had an increase of 27.50 per cent.

Now, the only inference we can draw from these calculations is that
over 200,000 of our population were left out in taking the census of
1890. Had all of our population been tabulated, our death-rate would
have been much lower than stated. Another material error was made
in enumerating the colored population in 1890, which only gives 268,-
173, whereas the census of 1880 gives 329,000. The births among the
colored folks that year were 7,504, of which number 514 died the same
year. We are satisfied of the fact that the negro population did not
decrease in numbers, but on the other hand greatly increased during



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The American Practitioner and News, 247

the ten years. It is to be hoped that the census to be taken next year
will be more correct.

My main object in writing this paper is to again draw the attention
of our profession and philanthropists to. the fact that our great State
has no census reports of her vital and mortuary statistics. We have
the old law of 1874 still extant, slightly modified or improved, but it
seems little attention is given it. I have seen no reports published.
The law of 1874 ^^ very good if it was observed by everybody con-
cerned, but it is not sufficiently plenary in its provisions to induce due
observance.

For ten years I reported births and deaths, complying with the law,
handing the reports to the County Clerk, who was to forward them to
the State Auditor to be embraced in his annual reports, but if any were
ever published I am not aware of it. It was said that many of the
reports were not forwarded, as the clerks received no remuneration for
such work.

I think the reports of births and deaths should be made compulsory
on the part of physicians and midwives, allowing them a certain fee
for their trouble, but I apprehend but few physicians would receive a
compensation for such work. Professional pride would be a sufficient
inducement to comply with the law. All they would ask for would be
blanks furnished them. I think the whole matter should be under the
direction and control of the State Board of Health. The reports should
be forwarded to the Secretary direct, and their publication supervised
by him, and due compensation allowed him for his work.

Kentuckians are a proud people, and should not be satisfied to be
in the rear of any other State. We stand high in every particular
except knowledge pertaining to the character of our diseases causing
death, and increase of population by the birth-rate. In every other
respect we stand equal to any of our neighbors, and in some things
ahead.

The old Bluegrass State ought to get a new move on herself and
take as much interest in the affairs pertaining to the welfare of her
population as she does in all departments of business affairs. Above
every thing, our profession should not allow our standing and achieve-
ments in the past to become dimmed or tarnished by neglect of present
duty. We are proud of our professional renown, being in this particular
ahead of any other State. We should be stimulated by recalling to

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248 The American Practitioner and News.

memory the names of Brashear, McDowell, Dudley, Drake, Gross, the
Yandells, and many other noted medical men.

Louisville is the only city of the State where regular reports of
births and deaths are made, the report of births being only a recently-
enacted ordinance.

It is to be hoped that an eflFective law will be enacted by our next
legislature by which we can have correct reports of our vital and
mortuary statistic.

The report of the Health OflScer for Louisville for last year is very
favorable for the sanitary condition of the city. The population is esti-
mated at 225,000, which is, no doubt, very nearly correct, the number
of whites being 184,950 and the colored 40,050. The death-rate for the
whole population was 13.59 per 1,000 inhabitants, the whites being
11.85 ^^^ ^^^ colored 21.62. This rate is a fraction lower than that
of 1897, it being 14.40 for the whole population; white, 13.60 and
colored 20.00.

I intended to give a prorated statement of vital and mortuarj' sta-
tistics of the State for last year from the census of 1890, but on account
of the error on the part of the enumerators, such a report would be of
little utility. I will state, however, what it is under the imperfect cen-
sus of 1890. At the same ratio of increase as took place from 1880 to
1890 pur gain would be 410,000, making the population for the year 1898
2,268,000.

Mbadow Lawn, Ky.



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TWO CASES IN WHICH THE ORDINARY CLINICAL EVIDENCES
AND MICROSCOPICAL EXAMINATION WERE MISLEADING.

BY M. F. CCMDMES, A. M., M. D.

Professor in Physiology, Ophthalmology, Otology, and Laryngology in the Kentucky School of Mediane ;

a Member of the American Medical Association and the Kentucky State Medical Society;

ophthalmic Surgeon to the Louisville City Hospital and the Kentucky School

of Medicine Hospital^ and Consulting Ophthalmic Surgeon to

Sts. Mary and Elizabeth Hospital, Etc.

The subject of the first case was Mr. Robertson, of , Ind.,

who consulted me in 1892 concerning a morbid growth on the surface
of the right eyeball, at the margin of the cornea and the sclera on the.
temporal side. It was a harmless-looking growth, almost free from



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The American Practitioner and News. 249

color, apparently looking ver>' much like a mass of pale white granu-
lation tissue, having almost no red color, but slight pinkish hue.

At the time of his first visit I removed the growth clean down to
the surface, thinking that it was of a simple nature. Within six
months he returned, the growth having almost the identical appearance
it had at the first visit. Again I removed it by cutting it away as
before.

One year after the second operation he appeared again with
the growth considerably larger than at the first visit. At this time it
was subjected to microscopic examination and found to present the
appearance of small round-celled sarcoma. This did not astonish me
very much, at the same time the only clinical evidence that would lead
me to believe the growth was of this nature was its prompt return each
time after removal.

In January, 1896, after I had removed all that could be cut away
with the knife, I seared the open surface with a cautery wire. Even
this did not prevent its return.

In March, 1896, I made a cut sufficiently wide to include every
particle of the growth, and removed every thing down to the sclera.
All of the open surface was then curretted with a small, sharp instru-
ment. The wound healed readily, and at this writing there is no
evidence of any return. The vision in this eye has not been aflFected
in the least, and the man's health is perfect. To the casual observer
this growth would be considered unimportant, yet microscopically it
appeared to be of the most malignant variety, but the final termina-
tion of the case proves that the microscopical test was of no value, and
that the ordinary clinical appearance was most reliable.

The second case was in the person of a young man with a growth
in his nose. I saw this case in 1896. The man was pale from the loss
of blood, and the history of the case pointed very strongly to the growth
being sarcoma. An attempt to remove the growth was followed by
profuse hemorrhage, and the operation had to be abandoned for the
time being. Portions of this growth were examined time and again in
the two succeeding years, and each time all of the microscopical evi-
dences of small round-celled sarcoma were present. The tumor was
finally removed, and it has now been three years since I first saw the
case, and the patient is well and bids fair to live out the ordinary span
of life.



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250 The American Practitioner and News.

These two cases show very clearly that the time has not yet arrived
when sarcoma can be determined by the microscope. In other words,
there is no way of diflFerentiatinp^ between granulation tissue and small
round-celled sarcoma.

LOUISVILI*K.



Keports of Societies*



THE LOUISVILLE MEDICO-CHIRURQICAL SOCIETY.

Stated Meeting, July 14, 1899, V\^iUiain Cheatham, M. D., President, in the Chair.

Exhibition of X-ray Photographs, Dr. T. L. Butler : I have here a
few X-ray pictures which may be of interest to the members of the
Society, especially from the medico-legal aspect. Three weeks ago a
doctor from Indiana brought a young lady to this city, and outlined to
me the history of the case, which was about as follows : That she had
received an injury to her elbow some time before, and had not gotten
what she thought was a very good result. She could pronate and
supinate pretty well, but there was only partial flexion and extension.
The doctor in the case had diagnosed the injury as a dislocation asso-
ciated with a fracture, which he claimed had been thoroughly reduced
and properly treated. It seems that she ran across two or three rival
doctors in that part of the country, and they told her that she had an
unreduced dislocation of the radius forward. A distinct lump could
be felt not over the radius, but midway between the radius and ulna.
She told the doctor who had treated her that she intended suing him
for damages, but he succeeded in getting her to come here to have
some X-ray pictures taken before instituting suit. The first picture is
taken with the arm in such position that the light comes from above
downward ; it shows both bones to be in perfect position, but an irreg-
ular mass can be seen ; this is now bone, but it was at first callus.
The picture shows something which is very unusual, viz., the old line
of fracture; this is perfectly shown. There is no dislocation. I do not
think there could have been any displacement at the time, because it
would have been impossible to have gotten the fragments in such good
apposition. The position is perfect, and you can see distinctly the
line of fracture, also the lump of callus, now bone, which doubtless
interferes materially with flexion and extension. This is evidently



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1 he American Practitioner and News, 251

what the doctors felt when they told lier she had a dislocation of the
radius forward. It is not that, as the two pictures before you demon-
strate. It has now been two years since the accident; the pictures
were, taken four weeks ago, and I have since received a letter from the
doctor, who stated that the idea of a damage suit has been abandoned.
I am satisfied I saved the doctor a suit for malpractice by taking these
photographs.

This is the second medico-legal elbow case I have had where I am
satisfied I saved the doctors damage suits.

I show another X-ray picture of a hand which contains a piece of
steel. It is simply shown to demonstrate how plainly the foreign body
can be seen. The case contains no other features of especial interest.

Discussion. Dr. L. S. McMurtry : I have been very much interested
in the work Dr. Butler has been doing, and have been more and more
impressed with the utility of X-ray work in cases such as the doctor
has reported. It seems to me it is going to have an extensive field of
usefulness in a very admirable way, as he has illustrated in suits for
malpractice.

Dr. A. M. Cartledge : Pathologically the case reported by Dr. Butler
is of great interest, and the question arises just as to the nature of this
bony enlargement near the head of the radius. Dr. Butler says that
the radiograph shows that the joint is intact and all right, and I am
inclined to look upon this enlargement as either originally a chipped
piece of bone from the head of the radius which has become nourished,
or a form of exostosis. It has been so long since the injury that it can
hardly be callus.

This picture reminds me of a case that was seen some time ago of
an ununited fracture of the radius at about the junction of the middle
and lower third, where non-union was very evident ; but there seemed
to be a bridge of bone, which I took to be a splinter, that cast a shade
in the picture. The fracture was sustained in January of the present
year. We cut down upon it and wired the fragments together. The
shadow cast over the radiograph proved to be a loose spicula of bone
which was underneath and detached from the rest of the bone.

I agree with Dr. Butler in regard to the great value of the X-rays
from a medico-legal standpoint. In fact, the last week has made me
believe that all of us have to make use of the X-rays in fracture work.
Briefly I will state that a gentleman came here last week who had



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252 The American Practtttoner and News.

sustained an injury in Cincinnati ; he had been thrown from a trolley
car. His home was in Louisville. A surgeon in Cincinnati had put
a splint upon his hand and arm, and he then came to this city. The
hand and arm were greatly swollen and hurt him considerably. In
taking off the dressing the man told me that he had a dislocation at the
wrist of the ulna, and apparently it looked that way, but in feeling it
I could elicit crepitus. We put his arm under the X-ray and had no
diflSculty in determining that he had a fracture of the lower end of the
radius. I suppose the severing of the ligaments allowed the ulna to
drop slightly, but there was not a dislocation of the ulna ; there was a
fracture of the radius which had been treated for a dislocation.

A day or two afterward we had an old lady with an injury to the
elbow that I am satisfied any of us would have put up for a severe
sprain. There was no crepitus, and it was exceedingly painful. Under
the X-ray a fracture of both bones of the forearm below the elbow
was shown.

The next day I had a gentleman with a fracture of the humerus at
the junction of the middle and upper third. I put this up myself,
having an assistant make extension, with the usual form of splint. He
was comfortable as most such fracture cases are. He came in the
office the following day, and we put him under the X-rays, and found
there was a lapping of the ends of the bone of fully an inch. I took
off the dressing, and with extension thoroughly replaced the bones and
reapplied the dressing. A day or two afterward he was again subjected
to the X-rays, and there seemed to be good apposition of the bones.

I mention these cases to show that eventually it will be necessary
for all of us to have this X-ray apparatus. We know that in oblique
and many transverse fractures most excellent results have been obtained,
even where the bones have not been properly adjusted. It is seldom
that an oblique fracture can be gotten and maintained in perfect appo-
sition. The question is, what position is the court going to take in this
matter in case of a suit for malpractice ? We know that surgeons
throughout all ages have been getting good results even with lapping
of the fractured ends of bones. Since the X-rays have been established,
if we find two months afterward that there is lapping, what is going to
be the medico-legal deduction? Probably the time will come shortly
when we shall all have to use the X-ray apparatus to see that we have
the fracture properly adjusted.

I am glad that Dr. Butler brought up the subject for discussion.



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The American Practitioner and News. 253

Dr. T. S. Bullock : I am very much interested in this work, and
have seen a good many of the pictures Dr. Butler has exhibited. I am
convinced that what the gentlemen have said about the utility of the
X-rays is true. The greatest advance made in the taking of these
pictures is the curtailment of the time of exposure, and I believe that
we will in future hear no complaints from the effects of burns, etc.,
from prolonged exposure. It seems to me, however, in regard to the
point mentioned by Dr. Cartledge, if there were very much overlapping
of the fragments we would be able to tell it without resorting to an
X-ray picture. What we are all after is as near a perfect result as pos-
sible, but in a large majority of the cases cited by Dr. Cartledge the
result would be so good that the patient would not know any thing
about it.

Dr. Iy. S. McMurtry : I would like to mention an illustration of the
practical value of the X-rays in a case shown me by Dr. Keen three
weeks ago in Philadelphia. It was a skiagraph of the kidney where he
had made a nephrotomy for stone. It was very apparent from the skia-
graph that there was another stone about one and a quarter inches
below the first one. The operation would have been incomplete but
for the X-ray picture. If he had removed one stone, which was the
larger one, and discontinued the operation, it would have failed of
relief, whereas the X-ray enabled him to complete the operation by
removing both stones.

Gallstones. Dr. A. M. Cartledge : The specimens I present are of
especial interest only as regards the clinical history of the patient and
the difficulties we had to overcome in the operation. The specimens are
two large gall-stones removed from the same patient. I almost feel
like asking the indulgence of the Society in reporting gall-stone cases,
since they have become so common, and I only do so as the case pre-
sents some special features.

The patient from whom these gall-stones were removed was a man
sixty-four years of age with a long history of troiible in the region of
the liver, and many attacks of what was probably gall-stone colic,
so-called, the inception of his trouble dating about four and a half years
ago, at which time, after severe pain, he was seized with jaundice. He
has been continually in jaundice ever since. He suffered great pain in
the hepatic region with recurring attacks of fever, characterized by
septic symptoms, nausea, etc., which usually kept him in bed from ten



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254 T^f^ American Practitioner and News.

to twelve days. These symptoms occurred more frequently and became
more exhausting ; meantime, during the long cholemia, he developed
hemorrhages from chronic jaundice. He had hemorrhages from the
bladder, one of which looked as if it was going to prove fatal a year
ago. He also had a low-grade of kidney hemorrhage, and later, within
the past few months, has shown well-marked renal changes by way of
tube-casts of various kinds. About a year and a half ago it was dis-
covered that he also had a heart lesion — a valvular heart lesion — which
was by some experienced physicians supposed to be the result of cir-
culation in the blood of toxines due to the profound cholemic state,
an endocarditis with deposits about the valves. The anemia was char-
acteristic and progressive ; the man was as jaundiced as it is possible
for a person to be. A year ago last summer, at the advice of his physi-
cian, Dr. Koehler, who diagnosed gall-stones, he visited Germany to
consult Professor Leyden for diagnostic purposes. After examining
him carefully, Professor Leyden told him he thought his trouble was
calculus impaction — stone in the common duct — that he would not
advise him to be operated upon in view of the condition of his heart,
kidneys, and the anemia, but it was thought best that he should be
carried along under medical treatment until the end should come.
This gentleman consulted some of the first physicians of Germany and
America, and, although history from the inception of the trouble was
what would be considered by nearly every surgeon a clear history of cal-
culus disease, yet it was repeatedly diagnosticated other things. I do
not mean to underestimate the importance of inflammatory conditions
of the ducts of the liver, etc., such things as I have rarely seen exist
except from mechanical causes, yet such things were repeatedly diag-
nosed in this case and kept the man from being oi>erated upon. He
was repeatedly advised not to have an operation performed. Multiple
abscess of the liver was diagnosed, with chronic inflammation of the
gall-passages, with thickening ulceration and profound jaundice.

The question arose, considering the extreme condition of the patient,
what could be done for his relief in an operative way? When I first
saw him I felt that he was a pathological museum, and we could scarcely
hope to get him through an operation so grave as invading the common
duct and bring him oflf the table alive. To begin with, he had a serious
heart lesion; his kidney secretion averaged only about eighteen ounces
in the twenty-four hours, and it was loaded with albumen and casts.
After studying the case thoroughly from all the different aspects, I felt



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The American Practitioner and News. 255

satisfied as to the nature of the trouble, and also felt that an attempt
.should be made to relieve the man by surgical means; in other words,
that he should not be left to die with the stones in him. Dr. Senn, of
Chicago, saw the patient, as did also Dr. McMurtry and others of this
city, all of whom concurred in the opinion to operate.

In this connection I want to speak of the great benefit that we
derived from the use of saline infusion and saline injections in prepar-
ing this man to withstand the ordeal of the operation. By. the use of
half a gallon of saline solution twice a day the secretion of the kidney
was brought up from twenty-two to fifty or sixty ounces during the
twenty-four hours, arterial tension was raised, and altogether the man
was rendered a very much more favorable surgical subject. In dis-
cussing the question of the anesthetic, we finally selected what I
believe to be the lesser of the two evils under such conditions, viz.,
chloroform, and I will say that the man took it nicely. The operation
consumed about one hour. The larger stone I show you, which has
scaled oflf very much, was impacted tightly in the common duct. The
gall-bladder, as I had suspected, was reduced to the size of this stone.
It was very deeply situated and high ; I take it that it was at least
seven inches from the external incision up to where the contracted
gall-bladder was found, and because of the long-continued inflamma-
tory process it had been drawn over toward the median line. The



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