2020 HUMAN ANATOMY. 



more nearly horizontal than vertical in direction. As a result of this position of the 

 uterus, it will be seen that the lower surface of the cervix presents against the pos- 

 terior vaginal wall, and that, therefore, this wall of the vagina must be longer than 

 the anterior. The posterior wall is usually about three and a half inches long ; and 

 the anterior about two and a half to three inches. The length of the ordinary finger 

 is about three inches ; it can, therefore, reach the anterior fornix of the vagina and 

 anterior lip of the cervix. To explore the posterior fornix of the vagina considerable 

 pressure is required. To palpate structures in Douglas's cul-de-sac the bimanual 

 method of examination will be necessary, and a relaxed abdominal wall, to obtain 

 which a general anaesthetic may exceptionally be required. An empty bladder facili- 

 tates a bimanual examination. In the knee-chest posture the vagina becomes dis- 

 tended with air, permitting a more thorough visual examination of its walls. The 

 rectum posteriorly, and the base of the bladder and the urethra anteriorly, are within 

 reach of the finger in the vagina. Calculi, either in the lower ends of the ureters 

 {vide supra) or in the bladder, can be removed through the anterior vaginal wall 

 (page 2015). 



The intravaginal portion of the cervix uteri can, with little or no pain, be grasped 

 by a tenaculum and drawn down towards the vaginal orifice so that local applications 

 can be made. It is so insensitive that such applications, even when strong and irri- 

 tating, do not necessitate the use of an anaesthetic. Since it is the part of the cervix 

 most exposed to traumatism and infection, it is the most frequent seat of pathological 

 lesions, such as the so-called "erosions." Persistent — i.e., unhealed — lacerations 

 are often sources of irritation, of reflex pains, and of some forms of dysmenorrhcea. 

 Much of the pelvic pain, associated with them, is probably due to pelvic lymphangitis 

 or lymphadenitis (Penrose). These lacerations seem to invite the development of 

 cancer. Primary involvement of the body of the uterus is comparatively rare, the 

 great majority of cancers of the uterus beginning in the cervix. As a result of the 

 relations and contiguity of the cervix to surrounding important structures, such as the 

 bladder, ureters, and rectum, the prognosis of cancer of the cervix is less favorable 

 than that of the body of the uterus, where infiltration of neighboring structures does 

 not occur so early. As a rule, dissemination by lymphatic- channels from carcinoma 

 of the cervix, affects first the sacral or the iliac glands; carcinoma of the body of the 

 uterus is more likely to involve the lumbar glands surrounding the common iliacs, 

 the aorta, and the vena cava. Pressure on the last-named vessel may result in 

 oedematous swelling of the lower extremities or in ascites. 



An hypertrophied cervix shows as an increased projection into the vagina and a 

 deepening of the vaginal fornices. This condition may be a cause of sterility. 



The vagina is most roomy in its upper portion, and is narrowest at its lower 

 end, where it passes through the triangular ligament and is surrounded by the con- 

 strictor vaginae muscle. This favors the retention of blood-clots within the vagina 

 during the menstrual period and after labor. Spasmodic contraction of this muscle 

 (vaginismus) is described as being sometimes strong enough to prevent coitus and 

 to call for surgical treatment, though such cases, if they exist at all, are due to reflex 

 irritation, such as from urethral caruncle. The dilatation of the vagina seems to be 

 limited only by the pelvic wall. In nullipara the rugosity of its mucous membrane — 

 necessitated by its great changes in diameter — is marked. The transverse folds 

 favor retention of secretions and of discharges resulting from infection and render 

 sterilization of the vagina difficult. Vaginitis may be followed by endometritis, as 

 the uterine and vaginal mucosae are directly continuous. 



The hymen rarely may have no opening, when it will require incision to relieve 

 the obstructed first menstrual flow. The exact importance to be attached to the 

 presence or aDsence of the hymen in medical jurisprudence is still undetermined. 

 While it is usually broken at the first coitus, it may remain intact until the first 

 parturition. Therefore its presence does not prove virginity. Its original perfora- 

 tion may have been large enough to leave little or no evidence of the membrane, 

 so that its absence does not prove that coitus has taken place. 



Fistulce between the bladder and vagina (vesico- vaginal), between the urethra 

 and vagina (urethro- vaginal), between the rectum and vagina (recto- vaginal), and 

 between the cervical canal and the bladder (utero- vesical), may occur. 



