Operation is much less difficult in the first half of gestation than in the latter months. At the beginning of gestation the operation does not, as a rule, cause abortion. Late in pregnancy appendicitis rapidly goes on to suppuration and perforation, with a high mortality. Hirst says that where there is reason to suspect suppuration a median incision should be made and the pelvic cavity examined for possible areas of infection. John Deaver says, "Always cut down on the sore spot and do not handle the uterus." An infected uterus after cesarean section complicated with appendicitis has to be amputated.
The diagnosis between appendicitis, ectopic gestation, twisted ovarian tumors, ureteritis, and ureteral stone is to be made. In a discussion of a paper by Finley on Appendicitis in Pregnancy,[117] Dr. John Murphy of Chicago, a great authority, advised operation as soon as the diagnosis is made, and he was of the opinion that this diagnosis is not difficult to make in pregnancy. Deaver said a diagnosis of catarrhal appendicitis is not seldom very difficult to make. This form is very rare in pregnancy. Deaver is not of the same opinion as Murphy as to operating as soon as the diagnosis is made in all cases. Where there is a general peritonitis, operation commonly only makes matters worse by spreading infection. The mortality of cases of appendicitis in pregnancy left without operation is as high as 77 per cent.; where the cases are operated upon within forty-eight hours after diagnosis the mortality is 6.7 per cent. and it would be better if the operation were done within twenty-four hours. Finley says that in the fifteen cases reviewed in his paper the operation did not cause abortion. Deaver tells us the muscular rigidity in the right groin characteristic of appendicitis is often missing in pregnancy, and that sometimes the pain is on the left side of the belly.
[117] _Jour. Amer. Med. Assoc._, December 24, 1912.
From 8 to 10 per cent. of all insanity in women develops during the puerperium--the incidence is about one case to 400 births. Puerperal insanity in nearly 70 per cent. of the cases begins within the first two weeks after parturition. Next in frequency of occurrence is the period of lactation, especially in multiparae. Insanity during pregnancy itself is relatively rare, and it begins usually after the fourth month.