462 APPLIED ANATOMY. 



finger is then passed beneath the tumor and it is peeled off the pelvic floor, it cart 

 then be raised up and its base ligated much like the pedicle of an ovarian tumor. 

 If this is carefully done the parietal peritoneum will not be broken through and there 

 will be little or no bleeding. 



Tumors of the Broad Ligament (intraligamentary tumors). Certain tumors 

 originating either from the structures of the broad ligament or ovary, or side of the 

 uterus, grow between the layers of the broad ligament. Parovarian cysts arising 

 from the remains of the Wolffian body are of this character. These intraligamentary 

 cysts are retroperitoneal. The Fallopian tube is spread over and adherent to their 

 upper surface. As they grow down they come in contact with the ureter, which 

 becomes adherent to the bottom and sides of the growth. The liability of injury to 

 the ureter is the greatest danger in these cases, and can only be escaped by search- 

 ing for, recognizing, and avoiding it. These growths are exposed by splitting the 

 peritoneum covering them and then shelling them out. At times they are large 

 and formidable and extremely difficult to remove. 



Extra-Uterine Pregnancy. The most dangerous factor in operating for 

 extra-uterine pregnancy is hemorrhage. The tumor is usually tubal in position. The 

 bleeding comes from the sac, therefore loosening and isolating it should be done with 

 the greatest care to avoid rupturing it. If already ruptured the blood is to be 

 rapidly sponged out, the uterus recognized and grasped with the hand, which is 

 then slid outward until the ruptured tumor is felt and drawn up. The blood comes 

 to the tumor from the ovarian artery and uterine artery. To control the former a 

 clamp is placed on the broad ligament close to the pelvic wall. To control the 

 latter a clamp is placed low down on the broad ligament close to the uterus. The 

 active bleeding then ceases. 



Vaginal Hysterectomy. The uterus if not much enlarged can be removed 

 through the vagina when, as is the case in multiparae, it is lax and capacious. 



The cervix is grasped and drawn down to the vulva and the mucous membrane 

 incised in the anterior fornix and posteriorly close to the uterine tissue. The bladder 

 is pushed up and separated from the cervix by dry dissection with occasional snip- 

 ping of fibrous bands by scissors until the peritoneum at the level of the internal os 

 is reached. The peritoneum, which from this point up is adherent to the uterus, is 

 opened and divided to the broad ligaments on each side. Douglas's sac is next 

 opened posterior to the cervix and close to it, and the opening enlarged with the 

 finger to the broad ligaments. A clamp is now placed on each broad ligament low 

 down to control the uterine arteries. By hooking the finger above the fundus it can 

 be brought back and down and out, the ovaries usually coming with it. The re- 

 maining portion of the broad ligaments is then either clamped or tied to control the 

 ovarian arteries. Some operators use clamps alone, others use ligatures. Vaginal 

 branches which bleed are grasped with haemostats and ligated. The ureters, which 

 lie 1.5 to 2 cm. (^ to ^ in.) away from the cervix, are pushed outward when the 

 opening in Douglas's sac is enlarged, and will be avoided by not placing the clamps 

 too far away from the cervix. 



Laceration of the Cervix. The cervix is made accessible for operation by 

 grasping it with tenaculum forceps and drawing it down to the vulva. It is there 

 held to one side, which renders the laceration easily accessible for excision and the 

 introduction of sutures. Bleeding is controlled by the sutures. 



THE FEMALE EXTERNAL GENITALS. 



The labia majora meet anteriorly in the anterior commissure and posteriorly in 

 the posterior commissure. 



The space between the posterior commissure and the anus, about 3 cm. ( i % 

 in.) is the perineum (Fig. 465). 



The labia minora divide anteriorly to form the prepuce above the clitoris and 

 the fr<znum on its lower surface. Posteriorly they fade away into a thin crescentic 

 fold of mucous membrane called \hefourchette. The space between the labia minora 

 is the vestibule. The meatus or urethra is in the vestibule 2.5 cm. (i in.) behind 

 the clitoris. It is surrounded by a ring of mucous membrane and in introducing the 



