until the cervix lies fairly between the hands; the upper surface of the uterus is felt to curve backwards. In a favourable case (with lax abdominal walls) we can do the bimanual examination on a still deeper plane, and get both hands to meet behind or at least fairly embrace the retroflexed fundus. Having ascertained that the fundus uteri is retroflexed, we ask ourselves whether it be fixed or movable-whether it can be replaced or not. In making our diagnosis we at the same time take a step towards treatment. To ascertain the mobility of the fundus, make steady pressure on it upwards; observe whether it gives way before the finger, and whether, on its yielding, the flexion becomes undone or the uterus simply rotates as a whole; note also whether this manipulation causes pain.

The rectal examination has this advantage, that the finger passes upwards over the free surface of the fundus without displacing it. It is indispensable in cases where the rigidity of the abdominal walls prevents our getting the uterus between the hands in the bimanual. The drawing down of the uterus with the volsella is an additional help in such cases, as it enables the finger in the rectum to reach the fundus.

The sound confirms the diagnosis in doubtful cases, and tells us further whether the retroflexed uterus is enlarged. Before using the sound, we must palpate the uterus carefully to ascertain that it is not becoming enlarged with a growing ovum and inquire as to the patient's menstruation. We curve the sound to correspond with the degree of flexion ascertained on bimanual examination. If introduced with the concavity directed backwards, it passes into the uterine cavity without our having to make the rotation (v. Fig. 93); through the posterior fornix, we feel the end of it in the retroflexed fundus; it usually passes in beyond the two and a half inches. We can also learn from the sound whether the uterus can be replaced or not; but it is better to get the information from the bimanual examination. The sound is of most use in differential diagnosis.

Differential Diagnosis.-The following are the conditions arranged in the order of frequency, which might be mistaken for retroflexion :

Fæcal matter in the rectum gives rise to difficulty only on superficial examination. We should always decline to give an opinion as to the condition of the pelvic organs when the rectum is loaded. If this be attended to, no mistake in diagnosis will be made under this head.

Pelvic deposit in the pouch of Douglas gives rise to more difficulty, because it may closely simulate the condition found in retroflexion-"a body felt through the posterior fornix and moving along with the cervix." Such a deposit will be proved not to be the fundus uteri by our finding the latter in another position. If inflammation is present, it is difficult to make the examination necessary to ascertain this; we may not be justified in using the sound just where it would give us the desired information. Such cases present great difficulty in diagnosis, and the true condition can only be ascertained on repeated examination or after the inflammation has subsided.

Cellulitis behind the cervix is rarely present in such a form as to give rise to a mistake in diagnosis, unless the inflammation renders the necessary examination difficult.

A myoma projecting posteriorly from the lower segment of the uterus resembles, in form and firmness, the retroflexed fundus. On bimanual examination, however, we find that we have between the hands a larger body than the uterus alone. The fundus may also be felt to the front, and distinct from the tumour. To ascertain its position, it is best to make the bimanual examination with the sound in the cavity of the uterus. Fig. 198 shows the information given by the sound, if we suppose that the structure to the left of the figure is the rectum. A fibroid tumour accompanied by inflammation presents great difficulty.

If the ovary be prolapsed, enlarged through inflammation, and adherent to the posterior aspect of the uterus, it simulates (on vaginal examination) the retroflexed fundus. So also does a small ovarian tumour lying in the pouch of Douglas, though it is softer and more elastic than the uterus. The bimanual examination, supplemented if necessary by the use of the sound and the drawing down of the uterus with the volsella, enables us to ascertain the exact position of the fundus and its relation to the tumour.

PROGNOSIS.

The prognosis depends upon the mobility of the uterus, and the possibility of replacing it. It is always less favourable where inflammation is

present; though we have seen considerable exudations become after a time absorbed, and the uterus again movable so that it could be replaced. As regards the probability of future conception, our statements should be guarded; though the probabilities are greatly increased if we can replace the uterus.

Whether a permanent cure of the displacement (so that the uterus will keep its normal position after the instrument is removed) is often effected, we have not much definite information. A priori, we should not expect that the stretched utero-sacral ligaments would readily become shortened again unless a pregnancy supervene. The curability of the retroflexion depends, according to Mundé, on the recentness of the displacement; "recent displacements of any variety are the only cases which offer a fair chance of complete recovery by any of the mechanical means at our disposal." The length of time during which a pessary must be worn so as to effect a cure of recent puerperal retroflexion is, according to Mundé, six months to a year.

This consists of two parts:

TREATMENT.

1. Replacement of the retroflexed uterus;

2. Retention of it in its normal position by suitable means.

The first question which suggests itself on discovering a retroflexion is, whether we can replace the uterus; this has been ascertained at the same time as we made the diagnosis.

The two obstacles to treatment are the presence of existing inflammation and the fixation of the uterus in its abnormal position. The former must be treated by blistering, hot water injections, and the use of the glycerine plug; these may have to be continued for a month or more, and then we may attempt the reposition. This last may be impossible through the firmness of the flexure or the presence of old adhesions. It must be left to the operator to determine how much force he is justified in employing. Sometimes it is necessary to put the patient under chloroform. In cases where we cannot replace the uterus, benefit may be derived from simply supporting it with a pessary.

Let us suppose that we are treating a case suitable for reposition, after inflammation has subsided.

1. Methods of Replacing the Retroflexed Uterus.

These are the three following:

(1.) By bimanual vagino-rectal manipulation;

(2.) With the sound;

(3.) By genupectoral posture, combined with traction on the uterus with the volsella and (if necessary) pressure on the

fundus with the finger in the rectum.

(1.) The bimanual manipulation is the safest method, and can be at once proceeded with as soon as we have diagnosed the pathological condition. We thus make the diagnosis, form the prognosis, and begin the

Fig. 210.

Reposition of the retroflexed uterus with the finger in the rectum.

treatment at one examination. The replacement is best effected with the index finger in the vagina and the middle finger in the rectum. If with both fingers in the vagina we make pressure through the fornices, we simply push the uterus, as a whole, upwards. With the finger in the rectum, however, we get behind the uterus and push it forwards. Place the patient in the dorsal position; pass the fingers into the vagina and rectum, as in the accompanying diagram (Fig. 210). Make steady gradual pressure on the posterior surface of the fundus with the middle finger. Direct the pressure to one side of the middle line, so as to keep the fundus clear of the promontory of the sacrum. With the index finger placed in front of the cervix, push it backwards and thus rotate the fundus forwards.

VOL. II.-4

Having by this manœuvre brought the fundus uteri to the front (into the position indicated by the dotted line in the diagram), make with the external hand steady downward pressure so as to get between it and the hollow of the sacrum and thus depress the fundus still more to the front. A glycerine plug is now placed in the vagina to keep the uterus in position. The plugging should be chiefly in the anterior fornix, so as to exert upward pressure on the cervix and thus favour the tilting of the fundus forwards. On the following day, if there be no indication of inflammation, a pessary may be introduced.

(2.) Replacement with the sound has the advantage that it causes less discomfort to the patient; it is therefore the method generally employed. We may have the sound already in the uterus to make sure of our diagnosis, and (without withdrawing it) we can proceed at once to effect the reposition. In the employment of force we require to be more careful than in the bimanual manipulation, because the sound gives us greater leverage, the pressure is being made on the mucous membrane of the uterus, and there is not the same delicate sense of resistance as when the finger is immediately in contact with the uterus. The end of the sound. should not be too much curved. If the flexion be pretty acute, so that the sound requires to be well curved to pass easily into the body of the uterus, we should first reduce the acuteness of the flexion by repeatedly passing in the sound more and more straightened. Having by this means. partially converted the retroflexion into a retroversion, we proceed to reposition as follows. The sound lies as in position 1 in the figure (Fig. 211); the direction of the handle is backwards, and the roughened face. looks to the back; the intra-uterine portion (1) also has the curve backwards. Now lay hold of the handle loosely, rather allowing it to lie between the fingers than grasping it. Carry the handle upwards towards the patient's right buttock (as she is on her left side) forwards with a wide sweep and downwards again towards the couch, the shaft describing half of a cone. The sound thus comes to lie in position 2 in the figure: the direction of the handle is forwards, and the roughened face is now to the front; the intra-uterine portion of the sound has also rotated, so that the curve is now forwards, but the uterus as a whole is still to the back (Fig. 211, 2, 2). Now carry the handle of the sound gently and slowly backwards, in a straight line, towards the perineum. The sound now lies in position 3; the roughened surface is to the front, but the handle is now directed backwards; the fundus uter is consequently in its normal