The fourth case supposes the cancer is inoperable but the child viable. In the interest of the child, immediate cesarean section is the best thing to do; it is much better than waiting until term. At term this operation will have to be done anyhow, and the earlier it is done, the better the woman can stand the strain. There is a risk that she will die from the first operation done to deliver the viable child, but she may licitly take this risk, as she might licitly run into a burning house to save a child, even if not her own. She may also licitly refuse the first operation. CHAPTER X APPENDICITIS IN PREGNANCY Primary appendicitis in pregnancy is very rare; recurrent appendicitis is not so rare. When appendicitis goes on to suppuration and perforative peritonitis the condition is worse in pregnant women than in the non-pregnant. In pregnancy protective adhesions, walling off, are less likely to occur; the inflammation is more intense owing to increased vascularity; thrombosis and phlebitis are more frequent; drainage may be obstructed and the burrowing of pus widespread; tympany, too, causes dyspnoea earlier. About 75 per cent. of the cases occur after the third month, and the earlier the appendicitis appears, the better the prognosis. During labor the contracting uterus sometimes tears open an adhesive appendix, or ruptures a pus sac and starts a general peritonitis. This condition may be mistaken for a general sepsis which is puerperal. Acute appendicitis is likely to be confused with an inflammation of a Fallopian tube. When the appendicitis is perforative abortion, infection of the uterine contents and death of the child happen in most cases. Labor is very painful when appendicitis is present, and the uterine contractions are often weak. After delivery many forms of infection of the uterus and its adnexa are possible. 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.