Signs and palpation shows that the anterior wall is not so prominent or so uniformly rounded as usual, and that it is, sometimes, a little flattened. If the bag of waters is broken, one may see the outlines of the fcetus. If the lower ketal part has not engaged, which is the exception, it forms a prominence above the pubes, in front. On palpating in front, we see that the posterior part of the uterus is largely developed, and has occupied. all the available space in the corresponding part of the abdominal cavity. Generally, even when the patients reach full term, which is not always, the volume of the organ does not seem to correspond to the period in question. The finger introduced into the vagina shows the posterior vaginal wall to be very short, which is the reverse of the normal state. The corresponding cul-de-sac is effaced, and this wall drawn forward seems to end in the prominent part of the fcetal tumor. The finger, instead of entering deeply to encircle the tumor, passes obliquely from below upward, and from behind forward, and is con ducted, in spite of itself, toward the centre of the pelvis. Here, again, the shortness of the posterior vaginal wall is not real. The upper part covers the ketus and the cul-de-sac is lifted above the symphysis, with the cervix. In following the anterior vaginal wall, we seek long and vainly for its upper end, and therefore for the anterior cul-de-sac. Sometimes we do not succeed, even with two fingers, and it is in these cases that the utility of introducing the whole hand is apparent. But this is not always possible, even with chloroform, and the deep position of the tumor ob structs the movements of the hand. It has, in some cases, been impossi ble to reach the anterior cul-de-sac, and it has been necessary to use a flexible rod passed upward, behind the pubes. When we have once reached the os, we find it closed or partly opened, softened or indurated, directed forward or downward, and more or less mobile. The bladder, being for cibly drawn upward and forward, occupies an unusual position, and to penetrate its cavity, the sound should be exceptionally long. The stretched urethra is in close proximity to the posterior wall of the symphysis, and to find its external orifice, it must be sought much higher, for it is, as it were, hidden behind the anterior pelvic wall. The differential diagnosis must exclude osseous or fibrous tumors attached. to the anterior sacral
wall, fibromata, cysts of the recto-vesical septum, fibrous tumors of the posterior lip of the cervix, pelvic hematocele, retroversion, ovarian cysts, uterine fibromata affecting the body and the upper part of the organ, fibromata of the alxlominal wall, or of abdominal viscera, extra-uterine pregnancy and complete obliteration of the cervix. The last-named con dition led Depaul into error, in his second case.
is very serious, but there is a difference between cases in which the cervical dilatation is moderate, and those in which it is excessive. In the former case, labor is longer and the cervix dilates less easily, but the deviation may correct itself, little by little, until the child can enter the pelvis, particularly if the pelvic extremity presents. The life of the fcetus is almost always sacrificed, Frank's case forming the sole exception. But, when the cervix is drawn forward and above the sym physis, the difficulties are much greater. The part of the fcetus contained in the sac formed by the posterior wall, receives the force of the uterine efforts, which cause the tumor to descend even to the vulva. The uterine tissue becomes inflamed, thin and painful, and may even be lacerated or become gangrenous. The cervix, placed beyond the sphere of uterine action, does not dilate, even at the end of several days of labor. Some times the posterior lip becomes rigid and opposes a new obstacle to explo ration. Metritis and peritonitis may be the results of this forced labor. The women are quite exhausted, and putrefaction of the child being super-added, when the membranes have been ruptured some days, aggra vates the situation. Still, the majority of the mothers have survived.
Treatment. —The conditions under which we are called are very varia ble, hence the impossibility of prescribing a line of conduct applicable to all c.ases. The indications are to reach the c,ervix, and to draw it down ward. If the child presents by the feet, to draw them down and to seek to have them engage; to seize them with a noose and to extract, so soon as dilatation is complete; to see if the tumor can be displaced; to incise the cervix, if it is rigid; and finally, as a last resort, to do vaginal hyster otomy, i.e., to open the inferior segment, through the vagina and to thus extract the fcetus.