FREQUENCY AND PROGNOSIS OF VERSION.
It is nearly impossible to make any distinct statements in regard to ver sion, for aside from transverse presentations, many authors prefer it to the forceps, while others, and we are of this number, much prefer the for ceps when it is possible to use it. • Thus while Sickel found the proportion to be nearly 1.3 in 100 labors, Ricker found it to be .81 in 100, and in 530 cases where the cause was noted, we find: Ploss, from his researches found: 3,575 versions in 316,891 labors in the German hospitals, or 1 in 88 cases, 214 versions in 67,129 labors, in England, or 1 in 313. In France, 1 in 110.
The following statistical tables show the differences, according to the authority and country: [The table has been condensed so as simply to give the totals. A second elaborate table gives the results in the German, Swiss and Russian Maternities from 1789 to 1865. The total number of confinements was 316,891 with 3,575 versions, or 1 in 88 labors.—Ed.] As for the prognosis, if version, practised at the time of election, that is to say, under the most favorable conditions, is, in general, not a seri ons operation for either the mother or for the child, it is not always so, and unfortunately favorable conditions are rarely present in the majority of cases where we are called upon to perform version. (We are speaking now, of course, purely of podalic version by internal manipulation.) The less the amount of liquor amnii, the longer the duration of labor, the greater the contraction of the uterus, particularly if repeated attempts at version have been made, the more difficult the operation, and the graver the prognosis for mother and for child. The more expert the operator, the greater the chances of success. As for the mortality statistics, it is im possible to give accurate figures, for the reason that the cases where ver sion was easy have not been separated from those where it was difficult, nor, further, into classes according to the indication calling for opera tion. The most we can say is that the infantile mortality is far in excess of the maternal.
From Zweifel's figures we learn that of 53 cephalic versions, 70 per cent. of the children were born alive, and only one mother died; the infantile mortality rate was thus 28.3 per cent., and the maternal 2 per cent. These figures seem high, but many of the versions were performed during labor by Braxton Hicks's method; whilst cephalic version as we practise it, purely by external manipulation made during pregnancy only, is absolutely inoffensive both for the mother and the fcetns.
Podalic version, internal, is, on the other hand, more serious. Accord ing to Zweifel, of 3,475 cases, 1,434 infants, 41.2 per cent. were born alive,
whilst 58.9 died. Of 3,475 versions, 8.4 per cent. of the mothers died.
Madame Lachapelle lost one child out of every 3.96; Carus, Osiander, Kiwisch, Michaelis, 1 out of 2; Ricker, 1 out of 10; Hater, 1 out of 14; and Churchill, out of 542 versions, taken indiscriminately, lost 1 child out of 3 and 1 mother out of 15.
Sickel, out of 447,163 children, noted 3,781 versions—that is to say, 1 out of 118.10; of which 3,703 were podalic version, by one or two feet, 1 out of 120.28; and 78 cephalic, 1 out of 5,732; of 3,475 infants born by podalic version, 1,434 were born alive, and 2,041 dead. Of the same number of mothers, 3,184 were living and 291 dead.
The reason for the gravity of this operation is evident, when we re member the complications and the obstacles which we have noted. When ever, then, there is room for choice, we much prefer the forceps to ver sion. The forceps, in skillful hands, is an inoffensive instrument.
Version, in skillful hands, is always a serious operation, and we cannot better impress this than by repeating the words of our master, Depaul: " With my forceps, I am perfectly at ease, for I am sure of never doing harm, while I never perform version without apprehensions." We must remember, however, that what complicates version is the extraction of the fcetus. Aside from traumatic lesions to which it is liable, the grav est danger for the fcetus is the retention of the head and the consequent asphyxia. Therefore certain authors have endeavored to make the infant breathe, while the head is still in the pelvis. Pagh advocated introduc ing two fingers into the mouth, forming a gutter with the hand for the air to pass along, and later devised a special canula for bringing the air to the fcetus. Similarly with Weidmann, Necking, Blick, the younger Baudelocque.
All these methods seem to us theoretical rather than practical, and we had better spend all our time in extracting the fcetus. The same criti cism applies to the proposal of Wigand and of Ritgen, to apply a ligature to the cord as soon as the body is born, and thus to prevent cerebral anaemia. It is not anaemia which kills, but asphyxia, and again, there fore, the best remedy is to deliver the child as soon as possible.
We append Pajot's table, wherein are resumed the rules for podalic version.
Pelvic Version after Paid.
We must not think of version unless: the os is dilated or dilatable: the head must be above the brim: intact membranes are favorable.
Version is indicated whenever the life of the child or mother is in dan ger. When circumstances allow of choice, forceps should be preferred. Version may be divided into: