THE FEMALE PELVIS. 1435 



the lateral angle of the bladder, it lies in front of the antero-lateral aspect of the 

 upper part of the vaginal- wall. 



The relation of the pelvic portions of the ureters are of special importance in 

 the female as their close relation to the cervix uteri and upper part of the vagina 

 renders them liable to injury, more especially in the -operation of hysterectomy 

 performed for malignant disease of the uterus. 



The uterine artery, in the first part of its course, passes downwards and forwards 

 a little anterior and lateral to the ureter. At the level of the orificium internum 

 uteri it takes a medial direction and passes along the inferior border of the broad 

 ligament, and crosses, above and in front of the inferior part of the ureter, from 

 lateral to medial side ; it then passes above the lateral fornix of the vagina and 

 finally ascends close to the side of the body of the uterus, and ends by anasto- 

 mosing with the ovarian artery below the isthmus of the uterine tube. 



The ovarian artery enters the pelvis minor between the layers of that portion of 

 the broad ligament known as the ligamentum suspensorium ovarii ; it is here that the 

 vessel may be most readily ligatured in abdominal hysterectomy, and in ovariotomy. 



The lymph vessels from the inferior part of the vagina pass to the superficial 

 vaginal and sacral glands, while those from the rest of the vagina, from the cervix 

 uteri and from the body of the uterus, pass to the hypogastric, the external iliac, 

 and the sacral glands. The hypogastric glands are situated on the side wall of 

 the pelvis in close relation to the origins of the branches of the hypogastric artery. 

 The sacral glands form a chain along the medial side of the anterior sacral foramina. 

 The lymph vessels from the fundus of the uterus, and from the ovary, terminate in 

 the glands around the aorta. 



The external genitals are fully described elsewhere (p. 1324). 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 vaginse. In passing a catheter the instrument is directed along 

 the forefinger (introduced just within the ostium vaginae with the palmar surface 

 towards the symphysis pubis) to the base of the smooth vestibule, where it is 

 tilted slightly upwards so as to bring its point opposite the urethral orifice. 



The larger vestibular glands, about the size of a bean, are placed on each side 

 of the posterior third of the orifice of the vagina, below the urogenital diaphragm. 

 Their ducts, nearly one inch in length, open posteriorly between the hymen and 

 the posterior commissure (fossa navicularis). Abscesses and cysts not infrequently 

 develop in connexion with these glands. The bulbs of the vestibule are two piri- 

 form collections of erectile tissue situated on each side of the vestibule, between 

 the bulbo-cavernosus muscle and the inferior fascia of the urogenital diaphragm. 

 Kupture of these bodies gives rise to the condition known as pudendal hcematocele. 



The cervix uteri projects downwards and backwards into the roof of the vagina 

 so as to leave a distinct fornix between the two. The relations of the fornix are of 

 so much practical importance that for descriptive purposes it is customary to sub- 

 divide it into an anterior, a posterior, and two lateral portions. The anterior fornix, 

 which is shallow, is related to the base of the bladder and to the utero-vesical pouch 

 of peritoneum. The posterior fornix, which is deeper, extends upwards for some 

 little distance in front of the anterior wall of the lowest part of the pouch of 

 Douglas. The septum between the two is formed merely by the wall of the vagina ; 

 hence the readiness with which the pelvis may be drained by puncturing it and 

 pulling a tube through the opening from the pelvis into the vagina. 



The lateral fornix lies below the medial part of the base of the broad ligament. 

 An incision carried through it would therefore open into 'the parametric cellular 

 tissue and would expose the uterine artery as it passes transversely to the uterus, 

 after crossing above and in front of the lower part of the ureters. 



Vaginal Examination. 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 median plane, where it 

 will impinge against the posterior aspect of the introitus vaginae, whence it is inserted 



