Second Manual Reduction. —This is effected either by the rectum or the'vagina, with one or two fingers or even the whole hand. Gosselin used the first. All these measures have been successful, but the result is sometimes only obtained by their combination and by repeated at tempts.
Third : The Instrumental Method. best known instrument is Evrat's baguette, introduced by the rectum. Then come the spatula of Petit, Roederer's spoon, pessaries, bladders introduced empty and then distended, and the lever. If these means fail, recourse must be im mediately had to artificial abortion. [The simplest and most effective method of replacing the retroverted, flexed uterus, is to make the patient assume the knee-chest position, lift up the perineum by means of Sims's speculum, and then, very exceptionally, pneumatic pressure and gravity will replace the uterus. If not, pressure may be made on the fundus in the posterior cul-de-sac, by a sponge pro bang or roll of cotton held in the dressing forceps. Occasionally, especially near the end of the third month and after, it will *be necessary to dislodge the fundus from under the sacral promontory before it can be replaced.
This is accomplished by hooking a tenaculum in the anterior lip of the cervix and pulling downwards. Unless the fundus is adherent or the sacral promontory very projecting, these measures will suffice. After reposi tion, a suitable retroversion pessary should be worn till the end of the f o u rth mon th.— Ed.
Sacculation of the Meru& Partial retroversion, or sacculation of the uterus, is an unusual form assumed by the pregnant uterus, which has furnished Depaul the occa sion for a very complete work from which we have borrowed the following description.
Depaul keeps the name sacciform dilatation of the posterior wall, for this modification of the shape of the uterus has a special origin and depends neither upon a simple flexion, nor upon any other change in the uterine axis. The explanation is found in the unequal growth of different parts of the organ, The eases collected by Depaul, from his private practice, and from different authors, are not numerous, for they are only a dozen, and one of these was erroneously diagnosticated. So it is a rare phenom enon, but it only deserves the more attention on this account, because of the difficulties of the diagnosis and of the dangers for both mother and child which it entails. Depaul begins by stating that certain parts of
the uterus grow proportionately much more than others, and that, gener ally, the anterior wall developes much more fully than the posterior one. But, exceptionally, this abnormal development may occur in the posterior wall. In this case, if the presenting fcetal part is engaged in the pelvis, it must.push before it this posterior wall of the inferior uterine segment. The cervix, instead of being directed backward, is turned forward toward the symphysis which it touches. It is much higher in the pelvis than the posterior part of the inferior segment of the uterus, which descends toward the vulva, forming a tumor which is in contact with the hollow of the sacrum, and variable in form, in accordance with the part of the foatus which it encloses. In the case of Parise and Depaul, hypertrophy and tension of part of the circular fibres of the external os were super added.
Pathogeny.—Depaul denies any causative relation between this condi tion and retroversion, for the latter occurs in the first months, and saecu lated dilatation in the last two months. Without denying that kyphosis may have some etiological influence, as some authors say, he states that nothing of the sort existed in the cases he has seen. He further rejects constipation, and the consequent straining efforts, invoked, a,s causes, by Billi, and partial retroversion, suggested by Frank. Ile shows that Mende first adopted the idea of primary dilatation of the posterior wall, suggested by Kiwisch and Scanzoni, and that the opinion of Chailly and IIyernaux relative to abnormal insertion of the cervix into the inferior uterine seg ment, rests upon no anatomical basis. Depaul believes that the deformity depends upon uterine flexions, particularly anteflexions which antedated pregnancy. If pregnancy occurs in these cases, the posterior wall, no longer in its normal state, will become much more hypertrophied than the anterior, because, owing to the character of its tissues, it cannot respond so fully to the stimulus of fecundation. The disproportion ex isting before pregnancy will persist and even be increased. The posterior wall will be more and more depressed into the pelvic cavity, the anterior will rise in the same proportion, and thus the cervix will come to be placed against the upper border of the symphysis or even several finger breadths above it.