RECTAL EXAMINATION. 65 



the bowel to a variable extent, according to the degree of distension of the bladder. 

 Between the bladder and rectum are the vesiculse seminales and the terminal por- 

 tions of the vasa deferentia. When the bladder is full, the recto- vesical pouch of 

 the peritoneum does not usually reach below a line an inch and a half from the base 

 of the prostate. 



In contact with the upper surface of the levator ani is the recto-vesical fascia, 

 forming the deep boundary of the perineal space. It extends from the side wall of 

 the pelvis downwards and inwards to the side of the rectum, to the bladder and 

 prostate. Its line of attachment to the bladder on each side runs upwards and 

 backwards immediately above the prostate, and external to the position of the 

 vesiculse seminales ; and it is essential, in the operation of lateral lithotomy, that 

 the bladder be opened entirely below this level. If the incision be carried through 

 the fascia beyond this line, then the pelvic cavity will be opened, and extravasation 

 of urine into the loose areolar tissue will probably follow. 



EXAMINATION OF THE PELVIC VISCERA. 



Rectal examination in the male. On passing the finger into the rectum 

 in the adult male, the constriction (anal canal) caused by the internal and external 

 sphincters is first encountered, the internal sphincter extending one inch above the 

 anal orifice. The soft mucous membrane of the bowel is then felt more or less 

 doubled into transverse folds (folds of Houston, plicce, transversaks recti) : these 

 are usually three in number, the largest being found on the front and right side of 

 the bowel about three inches from the anus, and on a level with the extremity of the 

 recto-vesical pouch of peritoneum, while another is placed on the left side about one 

 inch higher ; and the third, which is less constant, is on the left side, posteriorly, 

 below the first. These folds are visible when the rectum is examined with the aid 

 of a speculum, the body being placed in the genu-pectoral position. They some- 

 times render the introduction of the finger or an instrument beyond a certain point 

 difficult or impossible. The columns of Morgagni (column rectales] and the small 

 folds of mucous membrane (valves of Morgagni) directed upwards which join them, 

 with the enclosed recesses (sinus rectales], are not to be felt, but are easily seen with 

 a speculum. The mucous membrane of the anal canal is thicker and drier than the 

 velvety lining membrane of the bowel higher up. It often presents small polypoid 

 projections from its surface. 



Through the wall of the bowel numerous objects may be felt : In front is the 

 base of the triangular ligament, a little distance above which is the apex of the 

 prostate. The outline of the prostate is readily made out, and above it the bladder 

 may be felt if distended. The vesiculae seminales are not to be recognized unless 

 enlarged, and even then only their lower parts by a finger of average length. 



Behind, after passing over the soft posterior part of the perineum (ano-coccygeal 

 body), the tip of the coccyx is reached and the finger explores the hollow of the 

 sacrum. From this there passes out on each side a resistent band consisting of the 

 small sacro-sciatic ligament and the coccygeus muscle, which lead to the ischial 

 spine. 



On each side, the ischial tuberosity and the wall of the true pelvis are felt, and 

 in this way the condition of the structures at the back of the acetabulum, in the 

 neighbourhood of the caecum, or of the large vessels may be determined. 



This examination of the pelvis is easier in the infant, and is aided by bimanual 

 examination, one hand being placed on the lower part of the abdomen. In the 

 infant the parts felt are the same, except that the prostate is scarcely 

 perceptible. 



Rectal examination in the female. In the female the anus is placed 



