336 DIAGNOSIS. 



send for me as soon as the waters should break; not being sent for 

 the next day, nor the day after, I supposed they had had recourse 

 to the advice of some other practitioner, and thought no more of it. 

 Six weeks afterwards, being called upon again, I confess I was sur- 

 prised, for I supposed the woman had been delivered long before. 

 This time the symptoms persisted, and delivery took place. M. 

 Nivert has published in the Clinique des Hopitaux a case of the 

 same kind which he met with at my amphitheatre. MM. Gerdy 

 and Tanchou assure me that they have witnessed cases nearly simi- 

 lar, and I have, myself, since met with two others. 



§. II. To determine the Position. 



When the existence of labor is no longer doubtful, we must en- 

 deavor to learn in what position the fcetus presents. 



805. The vertex is in general easily known by its round and 

 regular shape, by the posterior fontanel, and occipital point, by 

 the anterior fontanel; the sagittal, transverse, and lambdoidal su- 

 tures, and by the parietal protuberances; however, when the head 

 has been for a long time engaged, the teguments occasionally 

 form so large a tumor upon its summit, it is itself sometimes 

 so elongated, that one has need of some practice in order not to 

 mistake it. It is in many cases so movable, and particularly so 

 high up, as to render it difficult to distinguish it with certain- 

 ty from any other part. As long as the membranes remain un- 

 broken, we ought, besides, not to try to reach it except in the 

 absence of the pains; otherwise we should be liable to rupture 

 them prematurely. We can, therefore, best judge of the presenta- 

 tion of the fcetus, at the moment when the waters come off; the 

 upper oval of the head may then be touched throughout its whole 

 extent; the integuments are not yet swelled, and the bones have 

 not had time to ride over each other. In the three varieties of the 

 occipito-anterior position, the posterior fontanel approaches more or 

 less near to the pubal semi-circumference of the pelvis, and is be- 

 hind one of the acetabula or the symphysis pubis, while the frontal 

 fontanel is more or less elevated behind, and looks towards the op- 

 posite point of the pelvic cavity; in the varieties of the posterior 

 position the fontanels are disposed of in the inverse directions. Al- 

 though it approaches very near the centre of the straits, the pos- 

 terior fontanel, notwithstanding, almost never corresponds to it ex- 

 actly; both in the anterior and posterior positions, this fontanel is 

 always placed upon a much lower plane than that occupied by the 

 anterior fontanel. In order more correctly to distinguish the dif- 

 ferent varieties of the vertex, we should endeavor to recognise the 



