The Pelvis. 273 



be raised one inch, at least, above the pubic margin, and, 

 probably, two inches. He believes that rectal distention 

 has very little, if any, influence in raising the fold of peri- 

 toneum, since, he says, it will flatten out the bladder rather 

 than raise it, though he admits it will elevate the posterior 

 wall, and will be, therefore, of use in the removal of tu- 

 mors of that wall of the bladder. Strong, of Chicago, 

 states that an average of fourteen ounces in the rectum 

 and twelve in the bladder raised the peritoneal fold about 

 one and a half inches. In all probability the rectal bag 

 has very little influence in raising the peritoneal reflection 

 directly, although, it may do so, indirectly, by elevating 

 the base of the bladder and thus providing a support on 

 which the fundus of the distended organ may rest. 



Landmarks. The neck, i.e., the internal urinary 

 meatus, in the adult, lies about three-quarters of an inch 

 behind, and opposite some point (variable) of the upper 

 half of the symphysis pubis, and is situated two, or two 

 and a half inches above the perineum. 



Operations. Lateral lithotomy will be considered 

 when discussing the perineum. In suprapubic lithotomy, 

 the bladder is opened above the pubes but below the fold 

 of peritoneum that is reflected from the summit of the 

 bladder to the anterior abdominal wall. If the rectal bag 

 be used, it should contain, for an adult, about ten ounces of 

 fluid, and for a child of five years of age, about two and a 

 half ounces. The bladder itself should be distended with 

 about ten to twelve ounces for the adult, or three ounces 

 for a child five years old. Greig Smith does not recom- 

 mend any particular amount of fluid to be employed for 

 distending either the bladder or the rectum. He uses an 

 irrigator, the tube of which is attached to a catheter for 

 the bladder, or to a child's toy balloon for the rectum. 

 This irrigator should be raised above the level of the pa- 



