DYSTOKIA BY DISPLACEMENT. 285 



the uterus 'and its contents, by their own weight, have a tendency to 

 escape from the hernia and fall into the abdomen ; at the same time the 

 foetus is more accessible to the hand of the obstetrist. 



Should the os be contracted, it must then be dilated by the hand ; if 

 the membranes are intact, they are to be ruptured ; should the foetus 

 make an unfavorable presentation, which is not very frequent in these 

 cases, this can be rectified ; and if the creature is dead, which is nearly 

 alwavs the case when assistance has not been rendered sufficiently early, 

 and the membranes are ruptured, it can be all the more easily removed. 



When the foetus presents anteriorly and the head can be seized, this 

 should be brought into the pelvic inlet, and cords attached to the lower 

 jaw, or Schaack's head-collar forceps (to be hereafter described) may be 

 employed ; then having secured the head, the fore limbs are sought for, 

 and brought into the passage one after the other, where they are also 

 secured by cords around the pasterns. Sometimes these limbs cannot be 

 found, owing to their being bent back against the body of the foetus, and 

 this will certainly render delivery more difficult. 



Should the foetus present posteriorly, the case is more unfavorable ; 

 though if the hind limbs can be found and brought into the vagina, then 

 delivery may soon be effected if there are no other complications. 



Cords being fastened to the pasterns, sufficient and well-directed trac- 

 tion should be employed on them, the hand of the operator remaining in 

 the pelvis if necessary, in order to guide the passage of the foetus. Saint- 

 Cyr suggests that an intelligent assistant may at the same time be directed 

 to make methodical pressure on the hernia, in order to complete its 

 reduction, which is effected when the contents of the hernia are returned 

 to the abdomen. 



At times this reduction is easy, and at other times it is extremely diffi- 

 cult. In the latter instances, all the more care is necessary that the ex- 

 ternal manipulations are not too forcible, if it is desired to have a living 

 foetus. Should the resistance prove greater than the means which may 

 safely be employed to overcome it, then a surgical operation must be 

 determined on. When the muscles of the abdomen prove an obstacle to 

 the escape of the foetus from the hernial sac, and produce a kind of 

 strangulation, an incision may be made through them in the most con- 

 venient part, as in the operation for strangulated hernia of the intestine. 



In other cases the Csesarean operation may have to be resorted to, 

 and speedily, if the mother or progeny, or even both, are to be saved. 

 Recourse to this formidable measure will only be had in particular 

 instances : as when the mother or foetus are valuable, and other means 

 have failed or are not likely to succeed. 



And in uterine hernia this operation is undertaken in far more favor- 

 able condition, than in some other circumstances which necessitate its 

 adoption. In this accident only the skin, and perhaps also occasionally 

 the tunica abdominaiis, has to be cut through to expose the uterus, 

 which has not to be sought for among the mass of intestines and labo- 

 riously withdrawn from their midst ; indeed, it generally occupies the 

 whole of the hernial tumor, and so closely, that there is no danger of 

 the intestines escaping during the operation. A simple incision — no 

 larger than is necessary — through the organ, a larger one through the 

 foetal membranes, and the prompt extraction of the foetus therefrom, 

 pretty nearly complete the task. 



If the Caesarean operation is timeously resorted to, the chances are 



