123 SURFACE AND SURGICAL ANATOMY. 
light into it through a speculum introduced into the empty bladder after dilating the 
urethra. The patient is placed in the genu-pectoral position, so that the bladder may 
become inflated with air, the coils of intestine being displaced upwards. In the distended 
condition of the We celer: the mucosa has a dull white appearance, except in the region of 
the trigone, which shows a pale pink injection; when the bladder is contracted the 
mucosa appears injected throughout. The ureteral orifices, placed about one inch apart 
and connected by a slight transverse ridge (inter-ureteric fold), present the appearance 
of fine transverse slits situated upon small and somewhat injected elevations of the 
mucosa. Every minute or so a jet of urine will be seen to issue from the orifice. Having 
in this way located the ureteral opening, a catheter or bougie may be passed into it 
along the speculum. 
By rectal examination the finger can palpate, from below upwards, the recto-vaginal 
septum, the cervix uteri, the posterior fornix of the vagina, the apex of the pouch of 
Douglas, and the body of the uterus. By washing out. the rectum and introducing ¢ 
speculum into the bowel, with the patient in the genu-pectoral position, the rectum 
becomes inflated with air; the finger can now feel very distinctly the posterior surface 
of the uterus and the Fallopian tubes, and by running the finger outwards along the pro- 
minent fold formed by the utero-ovarian ligament the ovar y is also very distinctly felt. 
On opening the abdomen by a mesial incision extending from the umbilicus to 
the pubes, and looking into the pelvis from above after displacing some coils of 
the small intestine upwards, the fundus of the uterus, directed forwards and a 
little upwards, is seen resting upon the postero-superior surface of the bladder. 
Behind the uterus is the rectum, and between the two the pouch of Douglas, 
containing the pelvic colon and the lower part of the ileum. The ovary lies a 
little below the level of the brim of the pelvis upon a triangular shelf, bounded in 
front by the broad hgament, behind and internally by the utero-sacral ligament, 
and behind and externally by the pelvic wall. When the vermiform appendix 
overhangs the brim of the pelvis its tip may come into close relation with the right 
ovary, a condition which often leads to a difficulty in distinguishing an inflam- 
mation of that ovary from appendicitis. The round ligaments are seen passing 
forwards and outwards from the anterior aspect of the cornua of the uterus to 
the internal abdominal rings, which he immediately in front and to the inner side 
of the terminations of the external iliac arteriés. Below and at the inner side of 
the round ligament, as it leaves the pelvis, is the deep epigastric artery. By pulling 
the uterus upwards the attachments of the broad ligament to the floor and lateral 
walls of the pelvis are brought into evidence, as also are the utero-vesical and 
recto-vaginal peritoneal pouches; the former is shallow, while the deepest part of 
the latter covers the upper fourth of the posterior wall of the vagina, and comes 
into relation, therefore, with the posterior fornix. 
The ureter crosses the brim of the pelvis in front of the bifurcation of the 
common iliac artery 1$ in. external to and a little below the centre of the sacral 
promontory. The corresponding poimt on the anterior abdominal wall is at the 
junction of the outer and middle thirds of a line joining the anterior superior 
spines of the ilium. After crossing the termination of the common iliac artery 
from without inwards the ureter curves downwards and forwards behind the perito- 
neum of the postero-lateral wall of the true pelvis; in front of it are the Fallopian 
tube and ovary. Before reaching the bladder it enters the parametric connective 
tissue, in which it curves downwards, forwards, and inwards about three-quarters of 
an inch external to the lateral aspect of the cervix uteri. 
The uterine artery in the first part of its course runs downwards and forwards 
a little external to the ureter; at the level of the internal os it curves inwards in 
front of the ureter and then divides into uterine and vaginal branches. 
In the operation of hysterectomy care must be taken not to injure the ureter ; it 
is important, therefore, to keep in mind its relation more especially to the uterine 
artery and to the cervix uteri. 
The ovarian artery enters the pelvis between the layers of that portion of the 
broad ligament known as the infundibulo-pelvic ligament; it is here that the vessel 
may be most readily hgatured in abdominal hysterectomy, and in ovariotomy. 
