1392 CLINICAL AND TOPOGRAPHICAL ANATOMY 



vaginal orifice wdth the hymen or its remains; (5) the fossa navicularis; (6) the 

 fourchette; (7) the skin over the base of the perineal body. 



These parts have been described elsewhere, and only those points which are of 

 importance in a clinical examination will be alluded to here. 



The labia majora are two thick folds of skin, covered with hair on their outer 

 surface, especially above, where they unite {anterior commissure) in the mons 

 Veneris. They contain fat, vessels, and dartos, but become rapidly thinner 

 below, where they are continuous at the front of the perineum (their ^posterior 

 commissure) . 



When the above folds are drawn aside, the labia minora, or nymphae, appear, 

 not projecting, in a healthy adult, beyond the labia majora. They are small 

 folds of skin, which meet above in the prepuce of the clitoris, and below blend 

 with the labia majora about their centre. Sometimes, especially in nulliparae, 

 they unite posteriorly to form a slight fold, the fourchette. 



The glans clitoridis, covered by its prepuce, occupies the middle line above. 



Below it comes the vestibule, a triangular smooth surface of mucous mem- 

 brane, bounded above by the clitoris, below by the upper margin of the vaginal 

 orifice, and laterally b}^ the labia minora. In the middle line of the vestibule 

 and toward its lower part, about 12 mm. (^in.) below the glans clitoridis, and 25 

 mm. (1 in.) above the fourchette, is the meatus or opening of the urethra (figs. 

 1034, 1037). 



The vaginal orifice lies in the middle line between the base of the vestibule 

 above, and the fossa navicularis below. Its orifice is partially closed in the virgin 

 by a fold of mucous membrane, the hymen (fig. 1037). This is usually crescentic 

 in shape attached below to the posterior margin of the vaginal orifice, and with 

 a free edge towards the base of the vestibule. In some cases it is diaphragmatic 

 i. e. attached all around, but perforated in the centre (fig. 1037). 



The schrivelled remains of the hymen probably constitute the carunculae 

 hymenales. On either side of the vaginal orifice, at it lower part, lie the racemose, 

 muciparous, vestibular glands (glands of Bartholin), situated beneath the super- 

 ficial perineal fascia and sphincter vaginae. Their ducts run slightly upward and 

 open, external to the attachment of the hymen, within the labia minora. In 

 relation to the upper two-thirds of the vaginal orifice, placed between the uro- 

 genital diaphragm behind and the sphincter vaginae in front, are the vascular 

 bulbs of the vestibule, rupture of which produces pudendal haematocele. 



Fourchette and fossa navicularis. — The fourchette, as stated above, is the 

 posterior commissure of the labia minora. Normally the inner aspect of this is 

 in contact "uith the lower surface of the hymen. When the fourchette is pulled 

 down by the finger, a shallow depression is seen, the fossa navicularis, with the 

 fourchette for its posterior, and the hymen for its anterior, boundary. 



Internal organs.- — The examinations through the vagina and anus will be 

 considered first, followed by uterus and appendages, ovary and ureter. 



Examination per vaginam. — The finger, introduced past the gluteal cleft, 

 perineum, and fourclicttc, comes upon the elliptical orifice of the vagina, and notes 

 how far it is patulous or narrow; the presence or otherwise of any spasm from the 

 adjacent muscles; then, passing into the canal itself, the presence or absence of 

 ruga?, a naturally moist or a dry condition are observed. In the anterior wall the 

 cord-like urethra can be rolled between the finger and the symphysis; and further 

 up tlian this, if a sound be passed, the posterior wall of the bladder. The anterior 

 wall of the vagina is about 6.7 cm. (2^ in.) long. The posterior wall, 7.5 cm. (3 

 in.) long, forms the recto-vaginal septum, and through it any faeces present in 

 the bowel are easily felt. The cervix uteri is next felt for in the roof of the vagina, 

 projecting downward and backward in a line drawn from the umbilicus to the 

 coccyx. Besides its direction, its size, shape, mobility, and consistence should be 

 noted. The os uteri sliould form a dimple or fissure in the centre of the cervix. 

 Of its two lips, the posterior is the thicker and more fleshy feeling of the two. 

 '^I'he vaginal culs-de-sac or fornices an; next explored. These should be soft and 

 elastic, giving an impression to the finger similar to that when it is introduced 

 into the angles of the mouth. An}^ resistance felt here may be due to scars, 

 swellings connected with the uterus (displacements or myomata), effusions of 

 blood or inflammatory material, and, in the case of the lateral culs-de-sac, a 

 (lisf)lared or enlarged ovary, or dilatations of the Fallopian tubes. The posterior 

 cul-de-sac is iiiufli dcejx'r than the anterior, and, owing to the peritoneum 



