many difficulties encountered in the effort to reach a positive diagnosis of chronic suppurative appendicitis in pregnant women. The gravid uterus may exclude the indications usually obtained from palpation and percussion, and almost all of the usual signs of the disease may be attributed to pregnancy alone. These difficulties all increase after the fourth month. Before this time appendicitis may be mistaken for extra-uterine pregnancy, salpingitis, tubercular peritonitis, displaced kidney, ureteral calculus, hydronephrosis, fecal impaction, or typhoid fever. The difficulties encountered in distinguishing between the presence of gallstones and appendicitis should be referred to in this connection from the fact that gallstone trouble and appendicular disease frequently coexist.

The following points should be considered in the effort to reach a diagnosis of this affection: The disease is more liable to be met with in early adult life than later, presumably because lymphoid tissue is most abundant from childhood up to the age of thirty years; and a damaged appendix is likely to do all the mischief it is capable of doing, at the first grave opportunity, which, in this case, is the first pregnancy. Nevertheless it may be possible for a chronic appendicitis to remain latent during the first pregnancy and become aggressive at a later pregnancy.

Recurrent attacks of vomiting are likely to be met with, and if there is a purulent collection, fever may be an accompaniment. These attacks of vomiting are often treated as unavoidable concomitants of pregnancy, especially if pregnant vomiting has been an early symptom of gestation; but pregnant vomiting is more continuous, has more continuous nausea, with, perhaps, abnormal craving. The vomiting of appendicitis recurring at intervals of several days or several weeks is often preceded by constipation and followed by diarrhea. Attacks of diarrhea, attended with localized pain and nausea, with more or less vomiting, and preceded by constipation occurring once in two or three weeks, should always attract attention to the appendicial region.

The pulse becomes rapid and jerky even in tha absence of fever, and it is often an indication of the gravity of the case.

This sign is as important in pregnancy, as has been claimed by Shrady and Willy Meyer in non-pregnant cases.

While slight fever is likely to develop with attacks of vomiting and diarrhea, it may not reach a high point. In many instances it is not noticed by the patient or her attendant. Increase of temperature and pulse is due to ptomaine absorption, and is more likely to occur when there is ulceration of the mucous membrane or some peritoneal infection. Distinct chills are rarely met with, but chilly creeps suggest the presence of pus. Rapid breathing may be caused by pain or the presence of adhesions, which interfere with respiratory movements or free diaphragmatic action. The development of a sub-phrenic abscess is very liable to restrict respiratory action.

Whilst rigidity of the recti muscles favors the diagnosis of appendicitis in the early stage of pregnancy, we may not be able to place it in evidence, when the abdominal muscles are all distended by the gravid uterus, at the later stages. Circumscribed rigidity of the abdominal walls over the abscess may be frequently found. Tympanites is detected with difficulty.

Cyanosis of the abdominal walls will give rise to a serious prognosis, as it is the result of an apparent vaso-motor paralysis that portends a fatal termination in many instances.

Hyper leucocytosis is developed in consequence of pregnancy, especially after the third month, hence the blood count is not available for the diagnosis of pus accumulations in the later stages of pregnancy, but may be placed in evidence in the earlier stages.

The pain and tenderness of appendicitis in pregnancy cannot always be located at McBurney's point, but may be nearer the posterior aspect of the abdomen, especially after the sixth month of pregnancy, because of the displacement of the colon by the gravid uterus, which presses it against the parietes to the outside and posteriorly. Intermittent pain in this locality is less reliable as a diagnostic sign than continuous tenderness. Pain at the side of the gravid uterus at a point above the head of the colon may be due to a tubo-ovarian abscess, and the appendix may become adherent as a result of a pyosalpinx or tubo-ovarian inflammation; yet inflammation appears to travel

more frequently in the opposite direction, from the appendix® to the ovary.

Sudden pain at a point over the cæcum, attacks of vomiting and diarrhea, persistent localized tenderness are all important signs. As nausea is a reflex symptom, it may be present in mild cases and absent in severe ones. (Barbat).

Relief from pain affords no evidence of improvement in these cases; it may be due to the rupture of purulent collections into the peritoneal cavity or to gangrene of the appendix, which may lead to general septic peritonitis.

If the patient suffers from pain in the right lumbar region from brisk walking or rough riding, without much rise in temperature or pulse, it is usually due to the fact that the damaged appendix lies within the range of action of the psoas muscle.

Percussion may furnish but little evidence of diagnostic value. The colon may be loaded and give off a dull percussion sound, the same as an abscess accumulation—or such an accumulation may be pushed to one side by the gravid uterus, leaving the resonant colon firmly pressed against the walls of the abdomen to the outside or posteriorly. While percussion and palpation are of little value to us in locating abscess accumulations, it is well to remember that these accumulations may be expected in some localities more than in others; as, for instance, the ileo-cæcal fossa is one of the most frequent sites for pus accumuations. If the appendix is long, accumulations may form behind the colon, reaching toward the right kidney, the duodenum, and the hepatic pouch. Dullness upon percussion in the flank may be in evidence here, but absence of an area of dullness on the right side posteriorly due to the presence of a resonant colon, should not mislead us.

In about twenty-three per cent. of the cases the abscess is located back of the colon. If the appendix lies above the mesentery of the ilium and internal to the inner layer of the meso-colon, the abscess will be located close to the wall of the gravid uterus, as was noticed in the case reported. When the appendix crosses the pelvis pus may accumulate in the pouch of Douglas. For obvious reasons the presence of pus

is not likely to form a tumor-like protrusion in the abdominal wall during gestation.

Operative Technique.-Attention should be called to the importance of splitting muscles rather than cutting them in the operation to reach pus accumulations during gestation, also to the importance of guarding against the incision of important nerves, which would lead to atrophy of muscular tissue and consequent weakness of the abdominal parietes.

Care must be taken to approximate tissue to tissue, in closing the wound, as the development of scar-tissue is to be guarded against as much as possible.

Attention having already been called to the importance of a brief operation, in order to avoid shock and prevent the onset of labor, we must emphasize the fact that the surgeon should be content with the liberation of pus in the later stages of gestation. Ruptured abscess cases are especially serious. An operation may prove of no avail. We make no mistake when we reach a grave prognosis in such cases, and as surgeons we may be compelled to stand aside and let our medical allies wage the unequal warfare with general septic infection under conditions which can only be palliated, until death closes the history of the case.

PERINEAL LACERATIONS, REGARDING POSTERIOR POSITIONS.

BY C. C. MEADE, M. D.

Every physician who has had any amount of experience does realize the serious results of a lacerated perineum; he also is aware of the fact that the great percentage of these cases have their origin in a posterior delivery. If you consider this assertion too broad, I will put it in another way. A large percentage of perineal lacerations can be prevented if precautions, knowledge, and care of existing conditions are strictly observed. Consequently I take the liberty to reassert that a large percentage of perineal lacerations find their true. and unavoidable cause following posterior positions.

I hope you will not think my preface one of a long-drawnout character; I believe it to be the most important, if not, the most interesting, part of my paper. The students who graduate from our colleges to-day should be taught, second to normal conditions, how to diagnose and how to conduct posterior positions to a safe delivery to both mother and child. I assure you the old adage—“ An ounce of prevention is better than a pound of cure "-is applicable in these cases, for I must strongly impress in this case it is most all in prevention and but little in cure, as it is impossible to expect anything but a laceration of the second or third degree under the care of the most skillful accoucheur unless there should exist a favorable disproportion between fetal cranium and pelvis of the mother.

Prevention. The standard bearer in this case has a magnanimous history, growing out of mental, moral, and physical culture, and the physician is the one who occupies the position and who should have the faculty to present a method of prevention. Under the best of conditions the process is a most tedious one, and probably the results are almost nothing during the first generation of its administration, but the second, third, and future generations will show improvement in the way of development, and though the process is a long one it will lead directly to this subject in which we are so intensely interested to-day.