In retroversion and retroflexion always replace the uterus before adjusting the pessary, otherwise the instrument will press upon the sensitive uterus, when one of three unfortunate results must occur: (1) The pessary may not be tolerated on account of pain; (2) the pessary may be forced down by pressure from above so near to the vulva that it will fail to do the least good; (3) the uterus, finding it impossible to hold its position against the pessary, instead of taking its proper position will often be bent over it in exaggerated retroflexion, with the cervix between {170} the pessary and the pubes and the body between the pessary and the sacrum, or the whole organ may slip off to one side of the instrument into a malposition more serious than the one for which relief is sought. The safest and most effective method of replacement is by conjoined manipulation, as represented in Figs. 16 and 17. The dotted lines in the former indicate the gradual elevation of the corpus out of the hollow of the sacrum to the pelvic brim, where it may be anteverted by the fingers of the right hand pressed well down behind its posterior wall. During the process of anteversion the index finger of the left hand in the anterior fornix of the vagina presses the cervix back to its place in the hollow of the sacrum, as in Fig. 17. Efficient reposition of the uterus is very often impossible without anæsthesia. [Illustration: FIG. 16. Commencing Reposition of the Retroverted or Retroflexed Uterus by Conjoined Manipulation (modified from Schultze).] [Illustration: FIG. 17. Completed Reposition of the Retroverted or Retroflexed Uterus by Conjoined Manipulation (modified from Schultze).] The replacement is not usually accomplished by drawing the fundus forward and pushing the cervix back directly in the median line. In most cases the fundus sweeps around the arc of a circle on the left side of the pelvis, and the cervix on the right. This is owing to the greater frequency of cellulitis on the left side, and consequent shortening of the left broad ligament. After replacement the organ is to be held in position by a suitable pessary. Bimanual replacement has two great advantages over the more familiar methods of the sound or repositor: first, it is more effective and more {171} permanent; second, the lever action of the sound or repositor, by which the operator may unwittingly use an undue and dangerous amount of force, is avoided in the use of the hands, through which the operation is not only constantly under his control, but also within his appreciation.