Basing his deductions on the figures given by Hegar and Hecker in regard to the mortality in pelvic presentations, Pinard, in accord with Maffei, Hegar, Chantreuil, and Budin, forcibly insists on external version in case of pelvic presentations, and declares that : " 1. In breech presen tations, cephalic version is possible; 2. It is dangerous neither for mother, nor for child." If these two propositions are perfectly true, they are still open to certain objections, one of which has already been mentioned by Pinard himself: " The breech may recur again after a number of vet. sions." It is true that this may be prevented by the application of a binder, but we have seen that certain women will not tolerate the binder. If, however, we grant this objection, there is another, which we believe to be grave, and it is the following: Pelvic presentations are especially serious in primiparm, for in them the resistance offered by the cervix and the soft parts is much greater than in multiparte. In the latter, pelvic presentations are not very grave, and for our part we have always seen such presentations, whether complete or incomplete, terminate happily in them. If there is an instance where external version ought to be practised by preference, in pelvic presentations, it is in primiparte. Now, amongst the contra-indications to cephalic version, Pinard cites presentations of • the breech in the primipara. Whence the dilemma, either version is use ful in case of primiparte, and therefore why in such instance is it contra indicated? or it is useless and impossible. and why then attempt it? Why, above all, reserve version for multiparte, where labor is easy, and entails danger neither for the mother nor for the child ? If it be true that cephalic version by external manipulation is without risk for either mother or child, it is also, we think, useless in multiparre, often impracticable in primiparm, that is to say, just where it is really useful. Therefore do we reject it in both cases, and here we are in agreement with Pajot and with Depaul.
The first, the great indication for external version, and for us it is abso lute, is presentation of the trunk. Herein all authorities agree. When, during pregnancy, the position is transverse, we must perform cephalic version, and endeavor by every means in our power to maintain the new position.
The second indication is, for us, pelvic deformity, and herein we accord fully with Tarnier and his pupils, but we hasten to add where pregnancy has reached term. Pelvic presentations, it has been seen, are more favor able before term, (Milne, Goodell, Budin), and therefore podalic version is indicated; but, at term, vertex presentations are more favorable, and, therefore, cephalic version should have the preference.
The third indication is abnormal insertion of the placenta, all the more so since abnormal presentations are usually associated: According to Pinard, external version is contra-indicated: 1. In certain pelvic presentations, in primiparao especially; 2. In multiple pregnancy; 3. In certain cases of shoulder presentation, where there exists uterine deformity; 4. During labor.
Here, again, we differ from our colleague. In regard to his third contra-indication, we believe it theoretical rather than practical, for it is difficult, if not impossible, to recognize, during pregnancy, the uterine deformity to which he has reference, (median partition), and in the pre sence of a transverse presentation we believe in always attempting ex ternal version.
In multiple pregnancy, it is only after the birth of the first fcetns that external version is possible, and then it is very easy.
The contra-indication as to labor seems to us too absolute. Wigand states as conditions where it is possible: The waters have not entirely escaped, or but a little while; the uterine pains are neither irregular • nor spasmodic. Hubert says that external version may succeed during labor, at times even after the waters have entirely escaped. We believe that version by external manipulations should be attempted in transverse presentations, even at the beginning of labor. It is difficult; it will often fail; but the fear lest thereby we cause prolapse of the cord or of a limb, or produce a face presentation, does not appear to us well founded. Even where it fails, we may still resort either to the bipolar method or else at the right time to podalic version.
The conditions necessary for success in external version are: 1. The diagnosis of abnormal presentation must be precise; 2. The uterus must not be too irritable; 3. The foetus must be moveable enough to allow of change of position without injury to the uterus. The membranes must be intact, or at least there must remain in the uterus considerable liquor amnii; 4. Version once performed, the vertex must be maintained in its position.. (See Transverse Presentations, Vol. I.) External Version before Labor.—Operative Method.—The oldest and simplest method, but so useless that it has long been renounced, was to cause the woman to lie on her side, to the right if the head was deviated to that side, and vice versd, a pillow under the abdomen, and to leave her in this position until the vertex had lodged at the superior strait. In transverse presentations this method always fails, and to-day all authori ties resort to the following manoeuvre, as described in Pinard's work: " Before operating, the woman should be made to assume the dorsal posi tion, the legs extended, and slightly separated. If, during the manipula tions, the uterus should contract, we must stop, and await relaxation.
1. " The head is in one of the iliac foam, and the breech is in the opposite flank.—One hand is to be applied to the vertex, the other to the breech, and by slow, sustained pressure exercised in opposite directions on the foetal poles, bring them into the median line." Nivert, on the contrary, counsels that pressure be alone made on the cephalic end, for the reason that pressure applied to both poles in op posite directions simply amounts to nothing. We cannot agree in this, but believe with Pinard that pressure on the breech is much more effica cious than that on the vertex, since it is more readily transmitted to the vertebral column; and further, where the infant is large, or the uterine axis transverse or oblique, exclusive pressure on the head amounts to nothing.