396 THE ABDOMEN AND PELVIS 



Both in pregnancy and in large tumours the vascular supply 

 of the uterus is much increased, and the slipping of a ligature 

 gives rise to formidable haemorrhage. 



A Vaginal Examination is best carried out with the patient 

 in the dorsal position, the thighs being well flexed and abducted. 

 The labia majora should first be separated, as this act draws 

 apart the labia minora and prevents their inversion into the 

 vagina by the examining fingers. The middle and index fingers 

 are then inserted, and a thorough examination of the vaginal 

 fornices may be made. 



Through the anterior fornix the base of the bladder can be 

 felt, and, when the surgeon uses his free hand to exert pressure 

 on the anterior abdominal wall in a downward and backward 

 direction, the body of the uterus can also be examined, if it is 

 in the normal position. In the lower part of the anterior vaginal 

 wall, the urethra can be recognised as a rounded cord and may 

 be rolled against the arcuate (subpubic) ligament. 



Through the posterior fornix, the fingers can palpate the 

 contents of the utero-rectal fossa. A prolapsed ovary is at once 

 recognised on examination by the characteristic sensation 

 aroused in the patient. The rectum lies in close contact with 

 the lower part of the posterior vaginal wall, and scybalous masses 

 can be recognised by the fact that they pit on pressure. When 

 the rectum is empty, the sacral promontory can be reached 

 with the tip of the forefinger. The distance between it and the 

 pubic symphysis can be estimated ; normally, it amounts to 

 4| inches. 



Through the lateral fornices, the conditions of the broad 

 ligaments may be estimated, and tumours, collections of pus 

 in the uterine tubes, or the enlargement due to extra-uterine 

 pregnancy may be recognised. 



The uterine tubes, when healthy, cannot be palpated, but 

 in the presence of salpingitis they can readily be made out on 

 vaginal examination. When a calculus is impacted in the lower 

 part of the ureter, it may sometimes be located per vaginam, 

 but the normal ureter, like the normal tube, cannot be felt 

 through the fornix. 



The Female Perineum. The rectal triangle shows no differences of 

 importance, and the description given on pp. 373-375 holds good for this area 

 in the female. 



In the urogenital triangle the sexual differences require further description. 



The labia majora are two folds of skin which surround the urogenital 

 fissure. They commence in front at the mons veneris, a rounded elevation on 



