70 JOURNAL NATIONAL MEDICAL ASSOCIATION Medical Association, 'Washington, D C I have associated with me Dr John E Hunter, Lexington, Ky., and Dr C M Wade, Hot Springs, Arkansas Dr Charles W Stiles, of the Marine Hospital Service at Washington, D C., before an audience of the City and County Health Officers of Tennessee assembled here April 6, 1910, made the startling statement that "the Negro is the reservoir for disease in the South." This impression is being made evervwhere And herein it seems to me that a strange and somewhat peculiar mission is now being evolved for the Negro physician -T-his new mission for the Negro physician is to defend his race from the impressions now being made and the efforts put forth to prove us a menace to society and the nation on the theory that "the Negro is the reservoir for disease in the South." It is therefore imperative on the part of the Negro physician to find out for himself if such charges are true If true, then work to alleviate them; if false, let the world know it You will greatly aid us in the prosecution of our division of the work if you will kindly send to us the reports of any cases of Pellagra you may have on record or under your treatment, or put us in touch with any physician you may know who has a case 537 Main Street, Nashville, Tenn Extra-Uterine Gestation By F A BRYAN, A B., Al 'D., 'Dallas, Texas One of the greatest discoveries into an oosperm (better known as a man ever made concerning himself, fertilized ovum) and retained within was when Von Baer in 1827 detect- the uterus where it may develop into ed the human ovum and established a foetus and is in due course of time the nature of the human ovary extruded as a living child As members of the profession we As to the location where the ovum know that the ovum when mature becomes fertilized, there has been a escapes from its follicle in the ovary great deal of uncertainty, but at and falls into the coelomic ostium of present we have positive proofs that the fallopian tube, through which, fertilization has taken place in the under favorable environment, it is follicle which is in the ovary, and in conveyed by the muscular action of the fallopian tube, as well as the that tube into the uterus cavity of the uterus After the ovum has reached the When an oosperm is found in any uterus, if it comes in contact with a part of the genital tract other than spermatozoon, it is thus converted the cavity of the uterus it is termed Read in the Division of Surgery of the Lone Star State Medical, Dental and Phar- nmaceutical Association at the 23rd annual session, held at Houston, Tex., Nov 9-lI, '09, JOURNAL NATIONAL MEDICAL ASSOCIATION "Extra-Uterine" and as it may occur in the ovary or tube we call it respectively ovarian or tubal pregnancy Concerning ovarian pregnancy, medical history tells us that more than two hundred years ago the profession believed in it but critical examination of the recorded cases shows that what was supposed to be an ovarian foetus was in some instances a dermoid, and in others an extra-uterine foetus sequestered in the folds of the broad ligament In recent years, the discovery of the tubal mole has furnished a criterion of extra-uterine pregnancy, and has led active investigators to formulate a postulate on which the occurrence of ovarian pregnancy could be based They urged that an early embryo in the membranes, contained in a sac in the ovary, should be forthcoming To prove the idea laid down, Kouwer in 1893 performed coeliotomy upon a woman of thirtyfive who showed signs of severe abdominal bleeding The abdomen was opened and in it was found a large quantity of blood, and the source of bleeding was a swelling the size of a nut in the right ovary The diseased ovary and tube were removed as well as the blood clot, and patient made a slow but good recovery The examination of the specimen some time after, demonstrated through a cross section, the presence of an early embryo in a sac furnished with chorionic villi and contained in an ovarian follicle A point of great importance was also cleared up in the clinical account of this patient, viz.: That in the uterus 71 a decidua had formed and in a few days after the operation this was discharged with the characteristic pains of labor With so many reports of this kind the whole subject of ovarian pregnancy now stands in new light, opening a wide field of research for those who have the opportunity to carefully investigate suspected cases of early ovarian pregnancy Let us turn our attention to our second division of Extra-Uterine Ges- tation-Tubal Pregnacy Concern- ing the cause or causes of this phenomenon we have no records, and until reliable evidence is furnished as to the situation in the genital passages where ovum and spermatazoon normally meet, there will always be room for doubts Tubal pregnacy may happen in women who have been married eight, ten or even twenty years A fallopian tube may become gravid in the newly married or in the mother of a large family Both tubes may, in very exceptional cases be gravid concurrently, or one tube may become pregnant years after its fellow Very rarely two oosperms are retained in the same fallopian tube, giving rise to twin pregnancy of the tube Tubal pregnancy may complicate uterine pregnancy In looking over the records of tubal pregnancies we will find that the condition is very apt to occur in women who have been sterile many years and that the fallopian tube is more likely to become gravid than one that has been through the process of inflammation 72 JOURNAL NATIONAL MEDICAL ASSOCIATION Diagnosis: The signs of extrauterine pregnancy vary according to the stage of gestation Before primary rupture or abortion, the patient gives a definite history of a missed menstrual period after having been previously regular, and she experiences pelvic pains which induce her to seek medical advice Examination reveals an enlarged fallopian tube, where there is no history of old tubal disease or any fact in the history of patient suggesting septic endometritis or gonorrhoea, the presumption favors gravid fallopian tube At the time of primary rupture or abortion: The tube bursts or abortion occurs before the twelfth week The effect upon the patient depends on the seat of rupture If it takes place between the mesometrium, the symptoms will be less severe than when the tube bursts into the coelum, because the pressure exercised by the blood extravasated into the tissue of the mesometrium tends to check hemorrhage, whereas the coelum will hold all the blood the patient possesses and yet produce no hemostatic effect in the form of pressure The symptoms of intra-peritoneal rupture are those characteristic of internal hemorrhage The patient complains of feeling as if something had given away suddenly This is followed by general pallor and faintness, sighing respiration, subnormal temperature, rapid and feeble pulse, sometimes vomiting, and in some cases death ensues in a few hours The symptoms of rupture are often accompanied by hemorrhage from the vagina, and shreds of decidua will be passed so that it simulates in many points early uterine abortion Error in such circumstances may be avoided by examining the shreds discharged from the uterus If they are found to be chorionic villi pregnancy is clearly uterine One of the most dreadful calamities to which women can be subjected is the rupture of gravid tube as it destroys life with such rapidity Rupture of gravid tube is often simulated by lesions of other abdominal organs, for example: (1) Perforation of stomach and intestine, (2) Sloughing of vermiform appendix, (3) Rupture of a Pyosalpinx, (4) Acute intestinal obstruction, (5) Renal colic, (6) Axial rotation of ovarian tumor, (7) Strangulated hernia Symptoms from date of rupture to term:-Sometimes after rupture, the symptoms of shock pass off and the embryo continues its development In many instances the patients believe themselves pregnant As the embryo increases in size the abdomen enlarges, but differs from uterine gestation in that the enlargement is lateral instead of median From the third month onward the leading signs of tubal gestation may be summed up as follows:-(]) Amenorrhoea is occasionally found, (2) There may or may not be milk in the breast, (3) Uterus slightly enlarged, cervix usually soft as in normal pregnancy and os patulous, (4) A large and gradual swelling on one side, and behind the uterus, (5) When a woman in whom exists suspicion of tubal gestation is suddenly seized with collapse and signs of internal JOURNAL NATIONAL MEDICAL ASSOCIATION bleeding, it is indicative of rupture of gestation sac Symptoms at term:-In spite of risks besetting the life of extra-uterine child, and that of mother, the pregnancy may go to term, then a remarkable series of events ensue:-(l) Paroxysmal pains come on resembling those of natural labor accompained by a discharge of blood and mucus, and dilatation of os, (2) Unavailing labor may last for hours or weeks, (3) Mammae may secrete milk for several weeks These signs sometimes pass away and as the amniotic fluid is absorbed, the abdominal swelling subsides Months or years later, suppuration takes place in the sac, and foetal tissues may be discharged through belly wall, rectum, vagina, or bladder and give clue to character of abscess The diagnosis of extra-uterine pregnancy is nearly always beset with anxiety and this is especially intensified when complications exist It is well therefore, to remember, that tubal pregnancy may be repeated, tubal pregnancy may be lateral, uterine and tubal pregnancy may be concurrent, and pregnancy may ensue on the sequestration of a full grown extra-uterine foetus Treatment:-Treatment of ExtraUterine Gestation is of two kindsExpectant and Operative Expectant:-This is only possible in early stages of tubal pregnancy and is a survival of the period when collections of blood in the female pelvis were commonly called hematocele The custom was to keep patient with extra pelvic hemorrhage at rest in 73 bed for many weeks and in some cases for many months until the blood was absorbed In some patients suppuration occurred and pus discharged itself through rectum, vagina, bladder, or slowly through the abdominal wall Under the expectant plan, I am giving reference of a case that fell to my care the early part of this year Was called to see a MIrs A on the 20th of JanuaryPatient 28 years old, had been in very good health, had given birth to children, the youngest years old Since the last child, had had two premature deliveries one and the other months Found patient suffering with severe pain from a mass in right ovarian region, and had missed two menstrual periods On examination of genital tract, found everything normal with the exception of a tender area in the right lateral fornix; made no diagnosis but treated symptoms The pain kept up in spite of opiates but not as severe The following evening I was summoned hastily, and on entering the room I was told that she had fainted, and at a glance I could see that the pallor was indicative of hemorrhage somewhere On examination of pulse it was almost too frequent and feeble to be recognized Stimtulants were administered,and to my surprise, mass and tenderness over right ovary had gone Examination per vagina gave a softer feeling to os than day before I concluded that I had a rupture of gravid tube into the folds of the mesometrium I pushed my adrenalin and patient rallied well On fourth day a discharge of blood from 74 JOURNAL NATIONAL MEDICAL ASSOCIATION the vagina was present, and on the fifth day they had saved for my examination a mass that had been passed per vaginam that morning, which was truly the decidua as was proved by microscope I was positive my diagnosis was correct Patient with tonics and good attentien got along nicely and at present is up and complains of no pelvic troubles Surgical Treatment This is the treatment par excellence and is divided into two classes, viz.: Abdominal section before rupture of gravid tube, and abdominal section after rupture of gravid tube The first is very seldom done as you cannot get patient's consent for such an operation without there is "something doing " The second class is the operation that we are called upon to to save life of our patient, and if done in time the death-rate hardly ever exceeds 20 per cent Under this head I will give you a report of a case that we had and operated on at the Bluitt Sanitarium:-Patient ordinarily healthy; occupation, school teacher; was suddenly seized with cramps at her post, and physician summoned; temporary relief given and ambulance carried patient home On close examination at home, physicians diagnosed rupture of gravid tube and advised immediate operation Patient nor relatives would consent and she was slowly sinking With all skill known, remedies stopped the most alarming symptoms, and patient thought she was recovering The third day temperature went up and the physician took the bull by the horns, and as the "sweet chariot was swinging low," the patient and relatives consented for operation On opening the abdominal cavity, the dark blood had completely filled the coelum; this was mopped out and the seat of rupture ligated and sutured Everything was done that modern surgery could do, but as the red lantern had already been out from septic hemorrhagic infarct, there was nothing to expect only the self-vindication that one gets when his diagnosis is plainly confirmed In concluding this paper, it would not be complete without reporting a case that was the most interesting of all the ectopic cases I have ever seen A small multipara took suddenly ill and her physician diagnosed rupture of gestation sac and advised immediate operation, which was without reluctance consented to On opening the abdomen, there was not the general extravasated blood and clots that was found in the previous case, but instead in the folds of the broad ligament on the left, there was a large dark mass On puncturing this sack dark blood oozed out and later a fluid, then next came rushing up a foot of a foetus, about 32 months with its chord and fragments of placenta, which had peeled off from its seat in the fallopian tube Foetus, tube, ovary and gestation sac, all removed, and patient made an uneventful and rapid recovery Today she is again pregnant and in six weeks her physician tells me he expects her to be under his care for what he hopes will be a normal confinement JOURNAL NATIONAL MEDICAL ASSOCIATION Gentlemen of the profession, after your diagnosis for ectopic is made, and rupture takes place, if you will operate at once, the chances are 75 that you will help to hold up the 80 per cent ratio of recoveries that your books tell you of in the operative cases of Extra-Uterine Gestation Chronic Gonorrhoea By PETER F GHIEE, Al D The profession at large is at last directly into the posterior urethra yielding to the conviction that the gives a most favorable site for the long-lived, subtle gonococcus is by lodgment and growth of the gonofar a more potent depopulator than coccus It is considered that chronic the insiduous cause of syphilis That gonorrhoea and chronic gonorrhoeal gonorrhoea is a greater menace to prostatitis are practically synonymous the body politic, is a generally admit- terms You are sure to find in a ted fact The popular impression of rebellious intractable gonorrhoea in the relative character of the two the male, in the absence of stricture diseases has been greatly changed after diligent search, a more or less within the last few years It has serious involvement of the prostate been stated that when we consider and its adnexia The more this fact the vast range of pathological condi- is appreciated the better we are pretions which gonorrhoea may cause or pared to make the proper diagnosis lead to, it is one of the most formid- and treatment of most of the ills, if able and far-reaching infections by not all, that follow in the wake of which the human race is attacked chronic gonorrhoeal inflammation We are all quite familiar with the A review of the literature on gonorrhoea shows that there is not a single ever-present morning drop that perorgan in the body which at one time sists in spite of wind or weather; in or another may not be attacked by fact with all the rest of the train of this infection When we add to this symptoms that go to make up the the indirect effect of gonococcaine, picture: increased frequency of urinathe disease under consideration takes tion, frequent outbreaks of the old on a most serious aspect Its very discharge, reflex pains extending to commonness makes it the more dan- various parts of the body, seminal emissions, and premature ejaculation; gerous Should we think of chronic gonor- and the many other symptoms that rhoea as being centered anywhere it may be called to mind with these would undoubtedly be in the prostate symptoms, though complex, followThe position of the prostate gland ing chronic gonorrhoea And with its numerous ducts emptying they not indicate that the inflammaRead before the National Medical Association in Boston, August, 1909