1436 SURFACE AND SUEGICAL ANATOMY. 



upwards and backwards into the canal ; to render the examination more thorough the 

 middle finger also may be introduced. When the uterus is in its normal position the 

 vaginal part of the cervix uteri is felt as a knob-like body projecting downwards and back- 

 wards into the upper part of the canal. In nulliparse the orificium uteri externum 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 recto-uterine pouch of Douglas ; this pouch, though normally empty, is the frequent 

 site of displaced abdominal and pelvic organs, and collections of intra-peritoneal 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. In 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 inferior half of the anterior vaginal wall the urethra may 

 be detected as a cylindrical, cord-like thickening which may be rolled against the inferior 

 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 inferior aperture of the pelvic 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 side wall of the pelvis. In health the ovaries are freely 

 movable. The healthy uterine tubes cannot, as a rule, be felt per vaginam. 



Examination of Interior of Bladder. The whole of the interior of the bladder 

 in the female can be readily seen by reflecting 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 bladder the mucosa has a dull 

 white or straw-coloured appearance, except in the region of the trigone, which shows a pale 

 pink injection. The ureteral orifices placed a little more than one inch apart and con- 

 nected by a slight transverse ridge (inter-ureteric fold), present the appearance of fine 

 oblique slits situated upon small and somewhat injected elevations of the mucosa. 



Rectal Examination. 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 recto-uterine pouch of Douglas, and the body of the uterus. By washing 

 out the rectum and introducing a 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 uterine tubes, and by running the 

 finger laterally, along the prominent fold formed by the utero-ovarian ligament, the ovary 

 is also very distinctly felt. 



THE BACK. 



Median Line of the Back. In the median line of the back is the vertebral 

 furrow, which is deepest in the inferior thoracic and superior lumbar regions, where 

 the sacro-spinales muscles are most prominent. Over the superior sacral region, 

 where the sacro-spinales muscles are tendinous, is a flattened area forming an equi- 

 lateral triangle, the angles of which correspond respectively to the posterior superior 

 spines of the two iliac bones and the third sacral spine. The vertebral spines can be 

 palpated at the bottom of the vertebral furrow ; they become more distinct when the 

 vertebral column is flexed, and, as pointed out by Holden, they become mapped out by 

 reddened areas when friction is applied along the furrow. The identification and 

 counting of the spines will be facilitated if it is remembered that the first thoracic 

 is more prominent than the vertebra prominens (seventh cervical), that the third 

 thoracic is on a level with the root of the spine of the scapula, the seventh thoracic 

 its inferior angle, the fourth lumbar with the highest part of the iliac crest, and 

 the second sacral with the posterior superior iliac spine. 



Lateral Region of the Back. Above the spine of the scapula is the supra- 

 scapular region, which is padded by a thick mass of muscle consisting of the supra- 

 spinatus and levator scapulae, covered by the superior part of the trapezius ; the 

 two latter muscles may be thrown into relief by shrugging the shoulders. 



In the interscapular region are the rhomboid muscles which are thrown into 

 prominence by bracing back the shoulders. 



