FEMALE GENITAL ORGANS 1391 



to the underlying muscular coat than that of the rectum, hence in prolapse the mucosa of the 

 rectal ampulla is the first to be extruded. 



Peritoneal relations. — The peritoneal chamber of the rectum has no covering of peritoneum 

 behind, and the peritoneum, at first covering its first aspect and sides, leaves the sides 

 obliquely and finally is reflected onto the base of the bladder (or the vaginal fornix in the 

 female), at the level of the inferior rectal fold, 8 cm. from the anus. 



Blood-supply. — (1) The superior haemorrhoidal artery, a continuation of the inferior me- 

 senteric, reaches the rectum behind, via the pelvic meso-colon and bifurcates at once. The two 

 branches run round on either side below the peritoneal reflection; giving off secondary branches 

 that pierce the muscular coat about the level of the inferior transverse fold, or anterior perit- 

 oneal reflection. Joining the submucous layer, these arteries run down in the rectal columns 

 to the anal canal, where they anastomose with (2) the middle haemorrhoidal arteries, branches 

 of the hypogastric (internal iliac) and (3) the inferior haemorrhoidal l)ranches of the internal 

 pudendal. The veins correspond. Their free anastomosis in the haemorrhoidal plexus under 

 the rectal columns, the union afforded here between the portal and systemic veins, the absence 

 of valves in the superior haemorrhoidal veins, and the constriction they are subject to in passing 

 through the muscular coat, are some of the anatomical causes of the frequency of haemorrhoids. 



The branches of the superior haemorrhoidal artery to the rectum anastomose but little 

 with one another, as compared with the sigmoid arteries to the pelvic colon. The main trunk 

 of the superior haemorrhoidal usually receives a large anastomotic branch from the lowest 

 sigmoid artery 1-2 cm. below the sacral promontorj^, upon which the upper part of the rectum 

 is dependent for its blood-supply after ligature of the superior haemorrhoidal. Hence in high 

 excision of the rectum it is important to place the ligature on the superior haemorrhoidal above 

 the sacral promontory if sloughing of the gut is to be avoided.* 

 For lymphatics of the rectum see p. 735. 



Supports of the rectum. — The anal canal is fixed by its attachment to the levator ani and 

 perineal body. After division of the perineal body and recto-urethral muscle in front, the 

 rectum is readily separable from the back of the prostate and recto-vesical septim^i. When 

 the levator ani has been divided on each side and the peritoneum opened, as in the perineal 

 operation for excision of the rectum, the gut cannot be pulled down freely. The hand passed 

 up behind it in the hollow of the sacrum meets on each side with a dense fibrous layer running 

 from the sacrum opposite the third foramen onto the side of the rectum. This "is the rectal 

 stalk (Elliot Smith) and consists of dense fibrous tissue round the nervi erigentes from second, 

 third and foiu-th sacral foramina and the middle haemorrhoidal vessels. It lies about 2.5 cm. 

 above the levator ani, and after division of it the bowel is easily freed, so that the whole of the 

 rectum and part of the pelvic colon may be drawn out at the perineum without tension. 



Rectal examination. — The following points can be made out by the finger introduced into 

 rectum: — (1) The thickened, roll-like feel of a contracted external sphincter; (2) the narrower, 

 more expanded, internal sphincter extending upward for 2.5 cm. (1 in.) from this; (3) 

 the rectal insertion of the levatores ani, which here narrows somewhat the lumen of the gut; 

 (4) above the anal canal, with its contrasting capaciousness, is the more or less dilated rectum 

 proper; (5) the condition of the ischiorectal fossae on either side; (6) the membranous urethra in 

 front, especially if a staff has been introduced; the instrument now occupies the middle line, 

 and has the normal amount of tissue between it and the finger, thus differing from one in a 

 false passage (in a child an instrument is especially distinct); (7) just beyond the sphincters, or 

 3.7 cm. (li in.) within the anus, lies the prostate; (8) converging toward the base of the prostate, 

 and forming the sides of the triangular space, are the vesiculae seminales and ejaculatory ducts. 

 These can rarely be felt unless diseased and enlarged; any enlargement of the sacculated ends 

 of the deferential ducts is much more perceptible; (9) it is within this triangular space that the 

 elasticity of a distended bladder can be felt. (10) Usually the lowest of the transverse folds 

 (folds of Houston), semilunar in form and about 1.2 cm. (^ in.) in width, can be made out (fig. 

 1116). (11) Behind, the coccyx and its degree of pliability and the lower part of the sacrum. 

 It may also be possible to feel enlarged sacral nodes and a growth from the other pelvic 

 bones. 



The above examination refers chiefly to the male.^ It remains to refer to rectal examination 

 in the female. Anteriorly, the soft perinaeal body and recto-vaginal septum will be met with, 

 and, thi'ough the latter, the cervix and os uteri, and, higher up, the lower part of the cervix uteri. 

 More laterally the ovaries may be felt, but the uterine or Fallopian tubes, unless enlarged and 

 thickened, are not to be made out. The student should be familiar with the feel of a healthy 

 recto-uterine or recto-vesical pouch, according to the sex, and the coils of intestine which it 

 may contain, so as to be able to contrast this with any collection of inflammatory or other 

 fluid or mischief descending from the upper pelvis, e. g., from the vermiform appendix. Pos- 

 teriorly, certain structm-es are met with in either sex. After a very short interval (sphincter 

 and ano-coccygeal body) the finger reaches the tip of the coccyx and explores the hollow of the 

 sacrum. On each side are the ischial tuberosity and waif of the true pelvis. The finger 

 hooked lateralward and upward, comes on the border of the falciform process of the sacro- 

 tuberous (great sacro-sciatic) ligament, passing between the above-mentioned bones. 



FEMALE GENITAL ORGANS 



The external organs will be considered first, followed by the internal. Under 

 the external organs are included, for convenience sake, the labia majora and 

 minora at the sides; and, in the middle hne, from above downward — (1) The 

 glans clitoridis vdth its prepuce; (2) the vestibule; (3) the urethral orifice; (4) the 



* H. Hartmann. Annals of Sm-gery, Dec, 1909. 



