in which the treatment was started three to seven hours before the terminations of labor. The percentage of successful cases is increasing as we become more familiar with details of the treatment.

A study of the failures is of interest. In several the treatment was started too early. Labor had been in progress some hours but the uterine contractions were not sufficiently frequent or regular. Inertia developing, the treatment had to be abandoned. In some the second dose was given at too long an interval after the first. The majority of failures, however, were cases apparently quite suitable for the treatment, but though they dozed between pains, retained their memory perfectly throughout the duration of labor. In the majority of failures the maternal pulse did not go above 100 even with prolonged and excessive medication. One patient had 7/100 gr. of scopolamine during thirteen hours. She seemed to respond to the drug in every way, yet maintained her apperception of pain perfectly and the memory was retained at every test. If after three or four injections, amnesia is not obtained it is better perhaps not to push the treatment any further. In the majority of successes the maternal pulse rate was consistently elevated, and ranged between 100 and 130 when the patient was well under the influence of the scopolamine and full amnesia had been obtained. One patient developed a rapid weak pulse running between 140 and 160 for two hours after delivery, with active delirium, but with quiet and regular respiration. She was one of the successful cases and remembered absolutely nothing after the first injection. There is usually recollection of the pains that occurred before the treatment was started.

Involution of the uterus as observed by daily measurements of the height of the fundus proceeded normally. Many of the more intelligent patients expressed themselves as not feeling any more exhausted the day following than the day before the baby came, and several private patients who had previously read descriptions of the work at Freiburg were eager to get out of bed the first day. But we saw no reason to curtail the routine length of the lying-in period.

The disadvantages claimed by those opposing the treatment are chiefly two, fetal asphyxia and postpartum hemorrhage. It is evident that these objections are the result of improper technic. Our observations in 100 cases on these points are as follows: In the 100 primiparae delivered without the use of scopolamine there were two instances of postpartum hemorrhage so profuse as to require packing, and moderate hemorrhage thirteen times. In our scopolamine cases there were two instances of rather severe hemorrhage, controlled without packing, and eight cases of moderate bleeding. In other words the tendency to hemorrhage seems to be less, rather than greater. The two severe hemorrhages we encountered were cases in which pituitrin had been given more than an hour before delivery and were probably due to the atony from the wearing off of the effect of the pituitrin, as has been observed by Madill and Allan of the Rotunda Hospital.

As to the occurrence of fetal asphyxia; in the hundred delivered without scopolamine there were seven instances of asphyxia at birth, two of them requiring tubs and artificial respiration for twenty minutes. In the scopolamine babies the majority cried at once without any evidence of being under the influence of a drug, eight were moderately apneic, but responded promptly to flagellation and tubs, and two required artificial respiration for fifteen and twenty minutes. The asphyxia that occurred was in those cases where there was delay of the head on the perineum. Under the old technic the frequent severe fetal asphyxia was plainly due to the repeated doses of morphine. At present the initial dose of narcophin is well worn off before the baby is born. In rare instances with extreme restlessness of the mother it may be necessary to repeat the narcophin once in a very small dose. It is important not to do this in cases where delivery may be expected within two hours. There was one stillbirth in the untreated hundred and one baby that died in the first twenty-four hours. In the scopolamine series there were two stillbirths, and one death of a child of an eclamptic, twenty-four hours after birth apparently of a toxemia similar to its mother's.

One of the stillbirths occurred after forceps delivery on account of delay at the outlet for two hours with the cord around the neck, and one with an abnormally short cord tight around the neck. In both of these cases the fetal heart was heard distinctly and unchanged in rate twenty minutes before delivery. We feel these stillbirths were due rather to a faulty mechanism of labor and would have occurred the same without the administration of the scopolamine.

The average duration of labor in these hundred primiparae was sixteen hours, as against eighteen hours in the untreated hundred. The third stage averaged thirteen minutes as against sixteen minutes in the untreated hundred. Hence there was no prolongation of labor. The average duration of labor after the first injection was six hours. In general, the effect on the course of labor was a rather more rapid dilatation of the cervix than usual, followed by a delay in the advance of the presenting part at the outlet and especially on the perineum. This constant delay on the perineum was rather disconcerting at first and resulted in an increase in the number of low forceps extractions until we began to use pituitrin, which obviated the use of forceps in most of our later cases. In all there were seventeen forceps extractions, as compared with eleven in the untreated hundred primiparae. Eight of these seventeen operations were done for arrest of the head at the outlet with strong pains, and would have been required in any case. Two low median forceps were done because of the fetal heart falling below 100. One of these babies was moderately asphyxiated at birth but promptly revived. Six were done for inertia with head at the outlet, and we would avoid these now with the use of pituitrin. One low forceps was done because of an intrapartum eclamptic seizure of the mother with the head on the

perineum. As mentioned previously the perineal lacerations were greatly reduced in number owing to the slow escape of the head through the vulva. To this extent inertia with the head on the perineum may be said to be an advantage. There were forty-seven lacerated perineums in the untreated hundred primiparae and thirty-six in the hundred primiparae delivered under scopolamine semi-narcosis.

It thus appears that the few disadvantages of the treatment are ones that may be avoided by constant observation of the case. We count the fetal heart every fifteen minutes. The administration of the scopolamine and the memory test must be carried out with watch in hand and all the details of Krönig10 and Gauss followed methodically to obtain the greatest number of successful amnesias.

Naturally the obstetrical side of the case is followed and managed exactly as though no scopolamine narcosis were being employed. Even closer attention than usual must be paid to the progress of labor and abnormalities promptly corrected as they arise.

And now as to the limitations of the treatment.

In the ward service

of a large hospital it is only in a fraction of the total admissions that the scopolamine semi-narcosis is feasible. The patients many times come in too far advanced in labor and often the resident staff are too busy to give the case the prolonged personal attention that is necessary.

On the other hand it is not only to be admitted but to be emphasized that the method is only a practical procedure for general practice in private houses when the finances of the patient permit the transfer of a complete working force to her room for the entire duration of labor. We tried eight cases in the tenement service with six successes, but the services of one or two attendants were constantly required throughout the course of labor and the remainder of the family was locked out.

We feel assured, however, that we have in this a valuable method of abolishing the woman's recollection of the ordeal of labor in from 60 to 70 per cent. of cases; and we believe in conscientious and painstaking hands, by strictly adhering to the above described technic, that the possible dangers may be foreseen and avoided.

REFERENCES.

The literature is extensive. The most important and more readily accessible articles, published or abstracted in English, are the following: 1. Steffens. Arch. f. Gyn., 1903, lxxxi, No. 2.

2. Hocheisen. München. med. Wchnschr., 1906, liii, No. 37.

3. Veit. Therap. Monatsschr., 1908, xxii.

4. Newell. Trans. Amer. Gyn. Soc., 1907.

5. Steinbuchel, von. Beitr. z. Geb. u. Gyn., Chrobac's Festschr., 1903.

5. Steinbuchel, von. Centralbl, f. Gyn., 1902, No. 48.

6. Gauss. Arch. f. Gyn., 1906, lxxviii, No. 3.

7. Gauss. Centralbl. f. Gyn., 1907, xxxi, No. 2.
7. Gauss. Munch. med. Wchnschr., 1907, liv, No. 5.

8. Krönig, Deutsch. med. Wchnschr., 1908, xxxiv, No. 23.
9. Mansfeld. Wien. klin. Wehnschr., 1908, xxi, No. 1.

10. Krönig. Surg. Gyn. and Obstr., May, 1914.

11. Krönig. Brit. Med. Jour., 1908, ii.

12. Hatcher. Jour. A.M.A., 1910.

A REPORT ON TWO CASES OF APPENDICITIS COMPLICATING PREGNANCY.

By JAMES W. MARKOE, M.D., Attending Surgeon.

John B. Deaver in the last edition of his work on appendicitis says: "I have seen a number of cases of appendicitis in pregnant women in whom, as a consequence of delay in operation, the right uterine adnexa have become infected, and most serious conditions-in some instances death, have ensued. The earlier the operation, the less the likelihood of infection of the right tube and ovary and the less likely, therefore, the development of serious complications. The wisdom of early operations is especially evident from the fact that I have never had abortion occur in pregnant women upon whom I have operated for acute appendicitis unless the right uterine appendages were involved in the disease, and seldom then."

In the earlier years of the Lying-In hospital, few cases of appendicitis complicating pregnancy were observed, as there were no hospital accommodations where such patients could be sent until the present building was completed in 1902. The author desires to report two cases of appendicitis during pregnancy, not because of any special interest in the cases themselves but rather to have them placed on record, and to call attention to the technic used by him in these operations, for it differs somewhat from the non-pregnant cases in that one's efforts must not only be to cure the appendicitis but also the operation must not cause any interruption of the pregnancy.

Since aseptic surgery has been in vogue, operations on pregnant women have proved very successful and as a rule do not interrupt the course of the normal pregnancy, but operations which involve handling of the uterus, that is that portion of the uterus to which the ovaries and Fallopian tubes are attached usually results in abortion. The author further wishes to emphasize the importance of not causing the slightest injury or pressure when operating for appendicitis. The usual technic of the operation is the same until the peritoneum is opened when the greatest care must be used in retracting the greatly dilated vessels in the broad ligaments, ovaries and Fallopian tubes. I feel

quite sure that the abortions which often occur in these cases are caused by the undue handling of these parts. On opening the peritoneum a pad wet in normal salt solution of about the temperature of the body is placed against the uterus, tube and ovary, and then with the assistant's hand or with a flat ribbon retractor, these parts with extreme gentleness are pressed out of the way. This is the first and most important step in the operation. In further manipulations by the operator he must endeavor to work away from the uterus taking care that his instruments or hands do not irritate the uterus or its adnexa.

It is said that the appendix is drawn up into the abdominal cavity by pregnancy but this is not the author's experience and from a study of the cases in the literature it would seem that in many of them the appendix is found below the brim of the pelvis, so that in such cases it is with great difficulty that the cecum and appendix can be drawn into the wound. The actual treatment of appendicitis in pregnancy does not differ at all from that of an ordinary case; in other words a simple catharrhal appendix is removed without drainage, whereas in cases which are complicated by abscess needing drainage, they must be drained as in an ordinary case.

The following two cases will illustrate the difference between a case in which no injury was done to the pregnant uterus because the greatest care was taken and the appendix was not adherent to it in any way, as against the second case in which an abscess involved the right side of the uterus, Fallopian tube and ovary, making it necessary to remove these and thereby causing considerable irritation to the uterine wall.

The first case went on to labor and had a full time child whereas in the second case the patient promptly aborted.

Case 1. S. S., age 23, para I, was admitted to the Hospital with a history of acute pain in the region of appendix and the statement that she had been in another hospital where they refused to operate upon her because she was five months pregnant. She stated that she had had this pain for some time and that it was steadily increasing and she felt that something must be done to relieve her. Examination showed the abdomen distended by a uterus which would correspond with a five months pregnancy; there was acute pain a little above McBurney's point and some rigidity of the right rectus muscle. She was prepared for operation and an incision was made at McBurney's point. The appendix was found to be adherent to the ascending colon and pointed in the direction of the umbilicus. The greatest care was taken that the uterus, Fallopian tube and ovary were not injured or manipulated in any way, they being held to one side by a nurse with a pad wet with warm normal salt solution. The appendix was removed by the purse string method and the wound closed without drainage. She made an uneventful recovery and four months later returned to the hospital and was delivered of a full term child without complications.