The prevention of laceration is the business of the accoucheur. We have already stated the principles on which this depends, and now we pass to a consideration of the treatment of the rent.
From what we have stated it is evident that the rule should be to re pair every laceration. Although exceptionally union may occur sponta neously in case of slight rupture, we are never certain in any given case that this will happen. We are never in a position to say after delivery whether a laceration will heal spontaneously or not. Our rule should be not to await or expect spontaneous healing. The question now arises, at what time is it best to take operative steps to secure reunion ? That union is always to be aimed at, I have already laid stress upon, and it is self-evident that the best time to secure this is immediately after deliv ery. The more speedily then the lacerated edges are brought in contact, the more likely is union to occur. The next question that arises is, how long after delivery is suture likely to be followed by union ? There are many reasons why immediate suture is often out of the question, the chief of which is that the labor is frequently conducted by the midwife, and it is some hours before the physician can see the patient. We should never wait longer than twelve to sixteen hours. After this period the lacerated edges have become more or less seared over, and we cannot ex pect union except after renewed freshening of these edges, which is pain ful and a source of disturbance to the recently delivered woman, who has already been through sufficient trial and desires rest. Still, after this early denudation the rent heals better, and the woman's chances of after health are much increased. There are very few women who will refuse from mere caprice to have the rent repaired at this time. It is our duty, however, in any event to overcome all reluctance, and to insist on per forming the operation.
Complete ruptures must absolutely be at once sutured. These lacera tions are of such grave import, and the secondary operation so difficult, that it should be considered culpable neglect if the primary operation is not performed. If more than sixteen hours has elapsed since the receipt of the injury before the physician sees it, then union by first intention is not to be expected. In case of incomplete rupture, union by second in tention may still take place by agglutination of the opposed granulations.
It is questionable if this may not result from careful bringing together of the granulating surfaces, On this point authorities differ. Hoist has sutured the granulating rent on the fifth to the sixth day, and Legros on the 13th postpartum, without good result. Hildebrandt also saw union occur on the tenth day, yet he claims that such instances are exceptional, and herein he agrees with Hegar. The only possible objection to imme diate suture is the fact that infection of the patient may occur through the suture tract. We as yet do not possess a method of obtaining union which is not open to this charge. The superficial bringing together of the wounded surfaces by means of serres-fines, is not a certain method. Plasters cannot be used on the perineum, as they may on other portions of the body, for of whatever substance they are made, as they become impreg nated with blood and lochia, they no longer compress the perineum firmly. In case of suture during the lat.r days of the puerperium, the danger of infection no longer exists. If the denuded edges are well disinfected by carbolic or sublimate, and carefully wiped with clean cotton, then clean instruments and clean silk cannot infect, and ordinarily union will take place. To sprinkle iodoform between the edges of the wound, as is advo cated by Behm, is not necessary, and has even in one instance where too much was used prevented union.
The advantage of operating in the late puerperium is that the patient will be cured of her lesion at a time when she must still rest. We must not expect to restore the parts to the condition they were in previously. The vagina will never be made as narrow as it was. The physician need not stop to determine what he ought to denude, since only the granulation surface is to be disturbed, and only the denuded part will grow together. After much personal experience we recommend this tardy suture of the perineum. The time of election depends on the state of the granulations. These must have cleaned off well, all jagged shreds must have disappeared, and the superficies must have the appearance peculiar to healthy granu lations before we should think of suturing. This time is about the eighth day of the puerperium. Chloroform should be administered, and the technique of the operation is similar to that of the perineal suture in general.