From the foregoing remarks, the Student will be enabled to appreciate the value of this injunction concerning support to the perineum, and to know how it ought to be executed. He knows that a folded napkin extending from the lower part of the sacrum up towards the top of the vulva, should be pressed against the parts in such a manner as to protract or continue the inclined plane of the sacrum, whereby extension of the head will be enforced, and no danger occur of its being too strongly propelled against the now thin tissues, which might be lacerated were the head not to follow the curved line of its movements.

The degree of pressure made by the hand must be proportioned to the exigencies of the particular case. It should always assist the perineum to compel the head to undergo extension; and, where the tissues yield with difficulty, so as to furnish grounds to fear their laceration, the further advance of the head may be safely counteracted for a time by firm pressure, and by advising the woman to refrain, which she should continue to do until the soft parts acquire a sufficient dilatability.

The young practitioner, and the Student, should be warned against falling into a habit of beginning too early to support the perineum. If the part should be too early pressed upon with a napkin, it might become heated, and thus lose its disposition to dilate; and it is assuredly unnecessary to sustain it, or support it, until a certain degree of extension has put it in some danger of being lacerated.

Cord round the Neck.-The head is born; perhaps the cord is turned once, or even thrice around the child's neck, which it encircles. so closely as to strangulate it. Let the loop be loosened, by pulling the yielding end of the cord sufficiently to enable it to be cast off over the head. If this cannot be done, let the child pass through it by slipping it down along its body over the shoulders. Should it seem impossible to slip the cord over the head or shoulders either, it should be let alone; and in a great majority of cases it will not prevent the birth from taking place, after which, the cord can be cast off. Should the child seem to be detained by the tightness of the cord, as does happen, or in danger from the compression of its jugular vessels, the funis may be cut with the scissors, and tied after the delivery. Under such a necessity as this, a due respect for one's own reputation should. induce him to explain to the bystanders the reasons which rendered so considerable a departure from the ordinary practice indispensable. I have known an accoucheur's capability called harshly in question upon this very point of practice. I never felt it necessary to do it but once.

The Shoulders. If the shoulders should not rotate, so as to bring one of them under the arch, that motion may be given by one or two fingers, introduced, and made to act upon the shoulder nearest the pubis, so as to draw or push it into its proper place. If difficulty occur, and the shoulder does not advance, press the child back against the edge of the perineum, and that will often afford room for the advance of the shoulder, which had been thrust over the top of he brim of the pelvis by the resiliency of the edge of the perineum which is pressed against the posterior part of the child's neck, and so pushes the opposite side of the neck against the pubis. I have sometimes caused the shoulders immediately to descend, by merely pressing the perineum downwards and backwards; the shoulder, which was jammed up above the top of the symphysis pubis, slipping down behind the symphysis, as soon as the cause that pushed it forwards (namely, the pressure of the perineum) was withdrawn. Sometimes the shoulder nearest the sacrum, and at others that nearest the pubis, escapes first. The Student will readily perceive which one he ought to assist; and he will at times be compelled to try one, and then the other, uncertain which is likely to emerge first.

It is considered bad practice to drag out the body, except in very peculiar circumstances-the womb and abdominal muscles being sufficient for that end; for if it be permitted to come away slowly, we shall have a more complete contraction of the womb, and a more ready detachment and extrusion of the placenta. Therefore, it is better to leave the expulsion of the body to nature, merely removing any cause of delay that may obviate its descent and escape. Where the delay is great, and the child becomes very black in the face and the respiration is either not established or in an unpromising condition, we are fully warranted to expedite the delivery by making use of one or more fingers, fixed as a blunt crotchet in the axilla.

Soon after the child is born, the accoucheur should place his hand on the woman's abdomen, in order to learn the state of the womb.

How to treat the Child.-As soon as the child is born, lay it on its back, out of reach of the waters, which sometimes stand in a deep puddle by the breech of the mother; the child ought never to be exposed to the danger of suffocation.

Take care not to move it too far from the woman, as by an incautious, sudden movement of the child to a considerable distance, the umbilical cord might be violently stretched or even broken. Such an imprudence might even invert the womb; indeed, it is needful to be very careful not to stretch the cord suddenly, either before or after the severing.

If the infant breathes regularly, it is well; if not, blow suddenly into its face, and drop some cold spirit on the region of the diaphragm. These, and a few smart slaps or frictions, are, in general, all that are demanded. Take care that the infant be not rudely or suddenly handled. It ought not to be agitated by any violent or hasty motions. In many of the instances, life is already nearly extinct, and so, the child can no more endure to be rudely handled or shaken than a fainting girl. It is enough to see and know that the child lives-that its heart is beating and its diaphragm moving, for these are the two great motive powers of life. If the diaphragm moves, it is removing the atelectasis of the lungs and pouring the oxygen upon the blood; but oxygeniferous blood, sent forward to the brain by the contracting heart, extricates the biotic force from the neurine; that force is life made manifest in the motion it excites.

The cord should not be cut until the pulsations have ceased near its placental extremity: it would be vain to wait for its cessation near the child's body, as blood is thrown into the arteries long even after the ligature is applied; in fact, children do sometimes bleed at the cord hours after they have been dressed, if the cord has been imperfectly secured. There is no need to tie the cord twice, unless there be twins; which can always be ascertained by feeling the uterine tumor. Tie only one ligature, and that at the distance of an inch or two from the belly, and cut the navel-string, holding the cord tightly betwixt the finger and thumb. If it be not held, it will spirt the blood sometimes to a good distance, and soil the bed, or even the practitioner's clothes. Conceal the cut end of the placental portion of the cord in the napkin, that its blood may not fly over the bed; and then give the child to the nurse. There is danger of dropping the infant if it be not properly taken hold of. It should be seized with the left hand, by one or both ankles; the back of its neck ought to rest in the arch formed by the thumb and forefinger of the accoucheur's right hand, while its back lies in his palm, and the points of the remaining three fingers are under its right axilla. If held in this manner, it can by no means fall to the ground. I have seen a child taken hold of under the arms by both hands, and lifted up in a manner I thought quite insecure, considering that it is slippery with the waters or blood from which it had just been taken up.

Placenta. In most cases, the placenta comes away in eight or ten minutes-Dr. Hunter thought in twenty minutes. The care required in regard to the placenta is considerable, for no one can say of any labor that it will end well, until the after-birth is completely discharged,

and for at least an hour after that consummation. The French call the delivery of the placenta, emphatically, delivrance, delivery. We should always ascertain, after having given away the child, the state of the womb. To that end, place a hand on the hypogastrium, and if a hard tumor be felt there, the womb is contracted; if the womb is either not to be felt at all, or is very soft and yielding, or very large, a few gentle frictions on the abdomen will cause it to contract; and now, if a finger be passed up to the os uteri, the after-birth will be felt either in it, or just above it; if within it, let the woman bear down immediately, while the cord is tightened by pulling moderately at it. The mass will descend slowly into the vagina, either edgewise or not; if not edgewise, one edge may be hooked down with the finger, and a few efforts of bearing down will expel it from the vulva. Remember that a placenta is as large as a dinner-plate, and the cord inserted in its middle-the os uteri contracted to the size of a dollar. To pull directly upon such a cord would be like pulling off a button from your coat, instead of skilfully unbuttoning it. Such a placenta, buttoned within the orifice, should be dextrously unbuttoned by bringing its edge to the buttonhole, as one would do with his coat-button.

The placenta should be received in the left hand, and turned or rolled round several times by the right hand, in order that the membranes may gather into a string or rope, so that, when they are drawn out, none of them may be left adhering to the uterine surface, where they might give occasion to putrefaction, with offensive and injurious discharges, by detaining portions of blood. A complete, clean delivery ought always to be effected, if possible. If the woman finds, the next day, that portions of membrane are hanging out of the vulva, she becomes alarmed, or at least thinks her medical man careless or igno rant. Notwithstanding that the placenta may be carefully rolled as above directed, we sometimes find that where the membranes have been very much broken by the child, or where they are extremely delicate, the cord or rope we have formed by twisting them is breaking, so that a considerable remnant of them is about to be left in the uterus, which we cannot get possession of without passing up the hand at least into the vagina. My custom, when I find the membranes breaking, is to cease pulling until I have wrapped round my rope of membranes a small rag, which enables me to spin them still more, and thus draw them entirely away: they are so slippery that the rope cannot be twisted with the fingers, but when a dry rag is wrapped round them, we can twine them, and pull them as much as we may think needful. Unhappily, the placenta does not always come away so soon; we may wait half an hour or an hour, for the expulsion of the after-birth,

and yet upon examination, repeated from time to time, discover that it has not come within reach of the fingers. Frictions upon the abdomen powerfully excite the peristaltic fibres of the alimentary canal, but their effects upon the womb are far more decided; it may be said, that when made upon the hypogastrium, they generally compel the womb to recommence its contraction-some wombs are so excitable, that a touch brings on the after-pains; frictions ought, therefore, to be instituted. The consent of parts, also, causes the womb to act as soon as the woman makes a strong bearing-down effort, to which she should be urgently prompted, if needful. When a contraction has been procured by frictions, or in any other way, it may be rendered permanent by pressure; therefore, let an assistant be properly taught to apply the palm of the hand over the uterine globe, and not take it off until told to do so. Such assistant, however, ought to be one worthy of the trust; an ignorant one might, by pressing at an inconvenient moment, indent the soft and relaxed fundus uteri and cause the beginning of an inversion of the organ. I have no doubt that some of the cases of inversion recited in the books were brought about in this way. In all those patients who habitually flood in labor, these precautions ought to be observed. When the hand is removed, a bandage should be ready to occupy its place. If the os uteri be very much closed, it is probable that the placenta will require a long time to come away; and I know no objection to a patient waiting for the spontaneous movement of the organ, where no hemorrhage, or other unusual appearance, is observed. Some writers have been disposed to assign a fixed period, up to which the accoucheur ought to wait, before he resorts to compulsory measures for the delivery. But there can be, or ought to be, no fixed rule on the subject except this one rule, namely, the placenta must be got away, as there is no security while it is left. I have never gone away from a patient leaving the placenta undelivered; never. I think I have never waited for its spontaneous extrusion more than an hour and a half, for I have always supposed that if it would not take place in one hour, there was little prospect of its taking place in twenty-four hours. I cheerfully admit, however, that cases may and do occur, in which a longer delay might be advisable. I have not met with such cases. I wish to be understood as speaking, in this place, of the placenta retained in utero, and not of cases where it is partly expelled into the vagina; for, when in the vagina, I think there can be no necessity for waiting at all; it ought to be removed at once. Ruysch, the celebrated Dutch anatomist, zealously inculcated the doctrine, that, as the expulsion of the placenta is a natural office, it ought not to be interfered with except upon the occurrence of symp