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. CHAPTER XI PUERPERAL INSANITY AND STERILIZATION 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. As in other forms of insanity, hereditary predisposition is found in from 25 to 30 per cent. of the cases. Alcoholism, sepsis, and neuroses like hysteria, chorea, and epilepsy, are the predisposing elements. The most common immediate exciting cause during pregnancy is toxemia from faulty metabolism and excretion. Other frequent direct excitants are mental worry from poverty, desertion, seduction, and the like troubles. Prolongation of the lactation period beyond the usual time for weaning, from the ninth to the twelfth month, is common among ignorant and lazy women. Some women prolong lactation in the erroneous notion that it prevents renewed impregnation. Such lactation is injurious to the child, as a rule. Ploss says hyperlactation is frequent in Spain, and that some Japanese, Chinese, and Armenian women may nurse their children for years, but this practice is undoubtedly injurious, especially among European races. The women get tabes lactea with emaciation, asthenia, anemia, backache, pain in the breasts, neurasthenia, cramps, and blindness. The uterus atrophies in some cases and may be permanently injured. Insanity is not unusual.