Female Perineum 445 



dexterity in operating, the student and young surgeon should lose no 

 opportunity of rehearsing the operation on the cadaver, both of the 

 child and of the adult. 



Median perineal cystotomy is the operation of cutting into the 

 bladder through the middle line of the perineum ; should the incision 

 be made for the extraction of a stone, the word ' lithotomy ' takes the 

 place of ' cystotomy.' Cystotomy is performed for exploration, and for 

 intractable inflammation of the bladder. Median lithotomy is an 

 excellent operation for the extraction of small stones or foreign bodies, 

 as no blood-vessel of importance is wounded ; it is an operation of dila- 

 tation rather than of cutting, and is thus performed : A rectangular 

 staff with a median groove is passed into the bladder ; its elbow is 

 lodged in the membranous urethra, where it is readily felt through the 

 perineum when the patient is placed in the lithotomy position. The 

 surgeon makes an inch-long button-hole in the median line, down to 

 the elbow, and passes a steel director along the groove of the arm 

 and into the bladder. The staff is then withdrawn and the finger is 

 ' screwed ' along through the membranous and prostatic urethra. 

 The stone is felt, and then the director is withdrawn and the forceps 

 are introduced. 



The only parts incised are the skin and the superficial fasciae 

 for about an inch ; the base of the triangular ligament and the com- 

 pressor urethras and the membranous urethra. The prostatic urethra 

 is dilated, the prostate itself escaping the knife. The risk of haemor- 

 rhage may be disregarded. As the opening is made high up under 

 the pubes, where the arch is extremely narrow, this operation does 

 not serve for the extraction of a large stone. 



The perineum of the female is much shorter than that of the 

 male, only about an inch intervening between the vulval and anal 

 openings. In the female the longitudinal lateral folds (labia majora) 

 fail to meet (in the male they are fused together to form the scrotum). 

 Thus, the vulva is a cleft between the lateral halves of an undeveloped 

 scrotum. The deep layer of the superficial fascia is continued along 

 the labia majora and the rami of the pubes up into the inguinal region 

 of the abdomen. The transversus perinei is but a rudimentary band ; 

 the erector clitoridis corresponds to the erector penis, and the sphinc- 

 ter vaginas represents the accelerator urinas ; the ' artery of the bulb ' 

 supplies the vaginal wall. The triangular ligament supports the 

 urethra, much as in the male, and contains the compressor urethras, 

 but the base of the ligament is defective owing to the passage through 

 it of the vagina. 



Tillaux cleverly demonstrates the closeness of the resemblance be- 

 tween the female and male perineum, by uncovering the muscular tri- 

 angle, and then splitting the bulb down the middle line, and separating 

 the lateral halves. The median cleft thus represents the vulva, and 

 the halves of the bulb of the urethra represent the bulbs of the 



