388 THE GENITO-URINARY SYSTEM 



bladder from the disease. While the fingers are in the anterior 

 fornix, bi-manual examination will determine whether or not 

 the uterus is in its normal anteflexed and anteverted position. 



Through the posterior wall of the vagina, the condition of 

 the rectum can be investigated and a higher level can usually 

 be reached than is possible on examination per rectum. Both 

 methods, therefore, should be employed before a diagnosis is 

 arrived at. In addition, palpation of the posterior fornix 

 enables the observer to determine the presence of tumours, 

 exudates, etc., in the utero-rectal fossa. 



During the examination, the condition of the cervix uteri 

 and the character of the external os should be noted. In the 

 virgin, the external os feels like a small dimple, but it is an 

 irregularly transverse slit in those who have borne children. 



The walls of the vagina are lined by squamous epithelium, 

 and the same tissue covers the vaginal portion of the cervix. 

 At the external os, the squamous epithelium merges into the 

 columnar ciliated epithelium of the cervical canal. It follows 

 that malignant disease of the vagina and outer surface of the 

 cervix is of the nature of a squamous-celled epithelioma, which 

 spreads by the lymph stream and does not tend to spread 

 upwards to involve the uterus. 



The lymph vessels from the lower portion of the vagina 

 terminate in the medial group of the subinguinal lymph glands, 

 which lie below the medial end of the inguinal ligament (of 

 Poupart) on the fascia lata of the thigh. 



From the upper part of the vagina, the lymph vessels pass 

 to the external iliac and the hypogastric lymph glands, which 

 lie in relation with the external iliac and the hypogastric 

 (internal iliac) arteries. 



Perineal Laceration. During the delivery of the foetal 

 head or shoulders, the vaginal wall may be ruptured. The 

 tear invariably involves the lower part of the posterior vaginal 

 wall, since this is the area which is put most on the stretch. 

 The skin of the perineum immediately behind the vaginal 

 opening is torn and the perineal body is involved, in varying 



