THE FEMALE PELVIC ORGANS. 459 



The lymphatics of the body of the uteius communicate with those of the cervix 

 below and at the cornu pass out as four or five trunks along the broad ligament 

 between the ovary and Fallopian tube, being joined by branches from the ovary. 

 They pass through the infundibulopelvic (suspensory) ligament and follow the ovarian 

 vessels to empty into the aortic nodes below the kidney. The ovarian lymphatics 

 form four to six trunks which ascend with the ovarian vessels to end in the lower 

 aortic nodes. Opposite the fifth lumbar vertebra they communicate with the trunks 

 from the body of the uterus. 



Pelvic Examinations. In making a digital examination the introduced finger 

 recognizes that in the nullipara the vagina is narrow, admitting only one finger, 

 and rugous on its anterior and posterior walls. In multiparae it is smooth and admits 

 two fingers. As the pulp on the palmar surface of the finger is used and not the side, 

 the finger is to be directed posteriorly into the hollow of the sacrum and then brought 

 anterior (Fig. 462). As the cervix enters the anterior wall and therefore, if normal, 

 points down and back, and is about 6. 5 to 7. 5 cm. ( 2 j^ to 3 in. ) from the vulvar orifice, 

 it is usually within reach of the tip of the finger. In the nullipara it is felt to be hard, 

 rounded, and projecting distinctly into the vagina with a small os. In multiparse it 

 is larger, softer, not so prominent, its os is wider and often irregular in shape from 

 lacerations. The uterus is often displaced so that the os may look forward or to one 

 side. The normal uterus is not firmly fixed but is movable and can be readily moved 

 up and down by the examining finger. If it is in a normal anteverted position it 



FIG. 462. Digital vaginal examination. Ovary slightly prolapsed but as yet has not descended entirely into 



Douglas's pouch. 



can be felt between the finger of one hand within and firm pressure with the tips of 

 the fingers of the opposite hand from without just above the symphysis pubis. When 

 the uterus retains its normal almost straight shape and falls either forward or back- 

 ward it is said to be in a position of anteversion or retroversion. If the uterus is bent 

 on itself in the shape of a curve it is then said to be anteflexed or retroflexed. In 

 anteversion the external os points down and back, and the fundus can be felt with 

 the other hand above the pubes. In retroversion the os looks downward and for- 

 ward and the body of the uterus cannot readily be made out by bimanual palpation. 

 If anteflexed instead of anteverted it is more difficult to feel the uterus through the 

 abdominal walls but its fundus can be felt through the anterior vaginal wall in 

 front of the anterior lip of the cervix. If retroflexed its projecting rounded fundus 

 can readily be felt in Douglas's sac just behind the cervix. By a digital examina- 

 tion one determines the amount of mobility of the uterus, its size, its position, the con- 

 dition of the cervix, whether or not it is the seat of indurations such as occur from 

 cicatrices and cancer, whether it is lacerated, etc. Growths like fibroid tumors 

 projecting from the anterior or posterior walls can also be felt. Particularly in thin 

 subjects relaxed by anaesthesia the broad ligaments can be followed to the sides and 

 even normal ovaries be recognized. When prolapsed they fall into Douglas's 

 pouch and can be felt posterior to the cervix. Enlarged Fallopian tubes can be felt 

 as distinct masses either fixed to one side of the uterus or prolapsed into Douglas's 

 pouch. Renal calculi impacted in the ureter at its vesical end can be felt between 

 the middle and upper end of the vagina to one side or the other. 



