to the present it has been the general custom to use the suture with its various modifications for the repair of the lacerated perineum, or else the serres-fines of Vidal des Cassis. In regard to the latter, however, it should be stated that they only bring the skin together, and that hence they are only suitable for superficial rents. A deep lace ration must be sutured in order to obtain complete union. The sarres fines, also, when they are left for some time, penetrate the skin, and they must be frequently changed. Were sufficient adaptation obtainable to promise union, then they would be of great advantage in case of simple lacerations, and fewer ruptures would be allowed to go unrepaired and un healed, for the great obstacle in the way of general use of the suture is the pain which it causes. With the serres-fines this objection is not en tirely done away with, however, for although their application gives rise to less pain than the passage of a needle, yet the latter is far preferable in that the serres-fines must be frequently changed. Since now the vaginal sutures do not cause so much pain as those externally, it has been suggested that we may attain union of even deep lacerations with certainty by passing a number of deep vaginal sutives to bring together the muscles, and that serres-fines be used externally to hold the surfaces of the external rent together. I have used this method on three occasions and twice obtained an excellent result, as well as spared the patients much pain. The use of the serres•fines is so simple that Valenta favors giving them into the hands of midwives.
For the purposes of the suture, the following have been used: 1. The simple suture of silk, catgut or the like. 2. The furrier's or running suture. 3. The silver suture. 4. The hare-lip suture. 5. The quill suture. The simple suture of silk is the oldest, best and most readily used. Catgut cannot be used on the perineum, for the reason that it is absorbed too quickly, and union is often retarded by suppuration. It is recommended by Hildebrandt for the vaginal sutures. It is noted that where silk is used there is generally in a few days some discharge with fetor, although the patient has no fever, still I have never seen unfavora ble results. I have used boiled silk, but notwithstanding have noted the fetor.
The silver suture has much to recommend it. The sutures may be left longer without their cutting through or leading to purulent discharge, for they do not absorb. Wire has the disadvantage, however, of requiring to be twisted or shotted. I prefer the latter to the twisting, since it re quires no special instruments as twisting does, and it holds longer than knotted silk. The other suture methods, which are all in principle more or less like the quill suture (Balkennaht), are all good, since they hold the edges well together if superficial sutures are superadded.
The best position for the woman for the primary operation in case of incomplete rupture is on the side, especially for the general practitioner, who must repair the lesion without an assistant. Any one may hold up
the buttock so that the physician may see the lacerated surfaces. A large greatly curved needle is then to be passed through both wounded sur faces, and the suture is thus drawn through and tied. Care must be taken to bring the vaginal mucous membrane well together, and to ac complish this it may be necessary to insert some superficial sutures, which is best done with the patient in the dorsal position.
In the primary repair of a complete laceration, the woman should lie across the bed, since it is necessary to obtain exact apposition of both the vaginal and the rectal mucous membrane, lest there remain a recto-vaginal fistula. To obtain a good view of the vaginal rent, it is essential that the wounded surfaces should be pulled well apart, and this is only possible in the dorsal position. In order that the entire wounded surface should be united, it is necessary to bring the parts as exactly together as they were before the receipt of the injury. To pass all the sutures first, as Hilde brandt recommends, and then by drawing them together to satisfy our selves that there will be exact apposition is the best way to obtain thorough union. But this method is not so convenient on account of the liability of the separate sutures becoming tangled. We recommend first to place the rectal sutures and to tie them. Particular attention must be paid to the careful adaptation of the edges of the rent at the upper angle and at the anus, and the remaining sutures are to be passed deeply, so as to catch up the muscles. The after-treatment of the primary operation, consists in frequent douching of the vagina, and the application of iodoform gauze. In case of pain, the local application of compresses wet in a weak solution of tincture of opium is the best. We have latterly used iodo form collodion a great deal, and can recommend it highly. It is com posed of 15 to 30 grains of iodoform to two and a half drachms of elastic collodion. Immediately after suture this is painted over the surface, and gives us an antiseptic occlusion bandage. It burns a trifle, but it does not interfere at all with the healing process. We formerly used the balsam of Peru, but while it is a good antiseptic, it burns for a longer time than does the iodoform collodion. It is not essential to tie the legs together; on the contrary, it may prove harmful by causing retention of secretion. Only when the thighs are markedly stretched apart is suffi cient traction made on the perineum to endanger the sutures. Behrer has by measurement determined that sixteen inches is the allowable limit of separation of the thighs. Rest in bed is the only additional necessary precautionary measure. The material used for suture must, in case of the primary operation, be either disinfected silk or wire, never catgut, since it is absorbed too quickly.