When the perineum has been injured so that the lower portion of the vagina loses its support and the equilibrium of the pelvic contents is destroyed, two distinct phenomena occur: The uterus falls as already described, and at the same time the lower part of the vagina begins to fall, so that there appear a prolapse of the anterior vaginal wall, or a cystocele, and a prolapse of the posterior wall, or a rectocele. The condition finally produced will depend upon which prolapse takes place the more rapidly--that of the vagina or that of the uterus. [Illustration: FIG. 67.--Complete prolapse of the uterus.] If the prolapse of the lower vagina progresses faster than that of the uterus, then the vagina will begin to drag upon the cervix, to which it is attached, and under these circumstances the uterus will be subjected to two downward forces--intra-abdominal pressure from above, and traction of the vaginal walls acting from below. [Illustration: FIG. 68.--Prolapse of the vagina and the vaginal cervix, with great elongation of the supra-vaginal cervix.] 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. [Illustration: 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.