As the traction is exerted upon the lower part of the cervix, and the body of the uterus is sustained by the uterine ligaments, which resist the downward traction, the isthmus, or point of junction of the body and cervix, is dragged out or stretched, so that in some cases a very marked elongation of the supra-vaginal cervix, or the part of the cervix above the vaginal junction, appears. This elongation is sometimes so great that the length of the uterine cavity from external os to fundus measures six or eight inches. Such elongation of the cervix is usually found to a greater or less degree in every case of marked prolapse of the uterus caused by injury to the perineum. Such a condition should be described as prolapse of the uterus with elongation of the supra-vaginal cervix ([Fig. 68]). In many cases the prolapse of the vagina and the elongation of the cervix are the most marked features, the body of the uterus falling but slightly below its normal level. The cervix will be found protruding some distance from the vulva; the vagina will be found turned inside out; while the fundus may be felt approximately at its normal level in the pelvis, and the presenting cervix and the body of the uterus are connected by a round, cord-like structure about the size of the little finger, which is the stretched, attenuated supra-vaginal cervix.
Fig. 69.—Prolapse of the vagina and cervix, with elongation of the supra-vaginal cervix.
As a result of the traction upon the cervix the blood-flow from the infra-vaginal cervix is impeded, and passive congestion results in hypertrophy. This hypertrophy is increased by irritation of the infra-vaginal cervix from friction against the clothing and from urine, etc. In such cases the presenting cervix becomes much larger than normal, sometimes measuring two or two and a half inches in diameter.
It will be seen that very pronounced structural changes are present in old cases of prolapse of the uterus. The uterine ligaments and the pelvic attachments become so stretched and atrophied that they can never become functionally useful again. The normal shape and size of the uterus become very much changed from elongation of the supra-vaginal cervix and hypertrophy of the infra-vaginal cervix. The vaginal canal becomes patulous and stretched several times beyond its normal dimensions, and the delicate mucous membrane, from exposure, becomes tough and cutaneous in character. The large protruding mass of uterus and inverted vagina stretches the genital outlet far beyond its normal dimensions, and the muscular supports that may have remained after the original perineal injury undergo atrophy from pressure.
Fig. 70.—Prolapse of the vagina and the vaginal cervix, with elongation of the supravaginal cervix. Extensive ulceration.
Accompanying the prolapse of the uterus is usually prolapse of the bladder and of the anterior wall of the rectum, producing a condition already described under Cystocele and Rectocele.
Women who do hard manual labor are those who suffer with the most marked forms of uterine prolapse. The form of prolapse accompanied by elongation of the supra-vaginal cervix is usually characteristic of the hard-working woman. Such prolapse of the uterus is common among the Western Indian women, who return immediately after delivery to hard labor and horseback-riding.
