FEMALE PELVIS. 1233 
upwards the greater part, or even the whole, of the rectum may be excised without 
opening into the peritoneal cavity. 
The posterior surface of the prostate, the vesicule seminales, and the external 
trigone of the bladder, may be exposed by making a transversely curved incision, 
convex forwards, between the two ischial tuberosities. The centre of the incision 
passes through the central point of the perineum, immediately behind the bulb, 
while laterally the incision sinks into the ischio-rectal fossa behind the trans- 
verse perineal muscles and the base of the triangular ligament. By dividing the 
anterior or pubo-rectal fibres of the levatores ani the lower part of the rec tum is 
exposed, and may be readily separated from the recto-vesical layer of the pelvic 
fascia. On dividing this fascia the posterior surface of the prostate is exposed, and 
above it the external trigone of the bladder, bounded laterally by the vesicule 
seminales and the terminal portions of the vasa deferentia. 
FEMALE PELVIS. 
The external genitals are fully described at page 1136. The external orifice of 
the urethra, surrounded by a slight annular prominence of the mucous membrane, 
is situated about 1 in. behind the clitoris, immediately above the centre of the base 
of the vestibule—a smooth triangular area at the anterior part of the vulva, with its 
sides formed by the labia minora and its base by the anterior margin of the ostium 
vagine. In passing the catheter the instrument is directed along the forefinger 
(introduced just within the ostium vagine with the palmar surface towards the 
symphysis pubis) to the base of the smooth vestibule, where it is tilted shghtly 
upwards so as to bring its point opposite the meatus. 
Bartholin’s glands, about the size of a bean, are placed one on either side of 
the posterior third of the orifice of the vagina, above the triangular ligament. 
Their ducts, nearly 1 in. in length, open posteriorly between the hymen and the 
posterior commissure (fossa navicularis). Abscesses and cysts not infrequently 
develop in connection with these glands. The bulbs of the vagina are two pyriform 
collections of erectile tissue situated one upon each side of the vestibule, between 
the sphincter vagine and the anterior layer of the triangular ligament. Rupture 
of these bodies gives rise to the condition known as pudendal hamatocele. 
In making a vaginal examination the patient should be placed in the dorsal position, 
with the thighs well flexed ; the index-finger of the right hand is now carried along the 
fold of the buttock towards the middle line, where it will impinge against the posterior 
aspect of the introitus vagine, whence it is inserted upwards and backwards into the 
canal ; to render the examination more thorough the middle finger may also be intro- 
duced. When the uterus is in its normal position the vaginal portion of the cervix uteri 
is felt as a knob-like body projecting downwards and backwards into the upper part of 
the canal. In nulliparz the os uteri is a small transverse slit, whereas in women who 
have borne children it is larger and more or less fissured. Above and behind the cervix 
is the posterior fornix, which is in close proximity to the pouch of Douglas ; this pouch, 
though normally empty, is the frequent site of displaced abdominal and pelvic organs, 
and collections of intraperitoneal effusions and exudations. A loaded rectum can be 
detected through the vagina by the characteristic way in which the contents can be pitted 
by the finger. "Tn front of the cervix is the shallow anterior fornix, through which may 
be felt the body of the uterus and the base of the bladder, while through the lower half 
of the anterior vaginal wall the urethra may be detected as a cylindrical, cord-like 
thickening which may be rolled against the lower border of the symphysis. The ureter, 
especially if enlarged, can be recognised through the antero-lateral fornix, by compressing 
it against the pubic bone. 
By the bimanual examination the pelvic organs are steadied and pushed downwards 
towards the pelvic outlet by the pressure of the left hand applied in the hypogastric 
region, so that they can be more readily reached and palpated by the finger placed in the 
vagina with its palmar aspect directed upwards. The ovary may be felt as a firm body 
about the size of the end of the thumb by pushing the fingers well up into the lateral 
fornix towards the lateral wall of the pelvis. In health the ovaries are freely movable. 
The healthy Fallopian tubes cannot, as a rule, be felt per vaginam. 
The whole of the interior of the bladder in the female can be readily seen by reflecting 
78 
