[The existence of Bandl's so-called ring is by no means universally ac cepted. Quite recently Lusk read a paper before the Am. Gyn. Society (vol. 9 of Transactions), and stated that in two cases of autopsies of women dying in the last months of pregnancy he had been unable, as well as Welch, to find any trace of this ring. He gives it as his opinion that it would be well to abandon the term " ring of Bandl" and " ring of Mul ler," because neither of them are at all constant.—Ed.] 3d.—Condition of the orifices and cavity of the cervix.—This is very different in the primipara and the multipara.
A. Primipara—The external os ceases to be a transverse slit and be comes round,—a cupola with smooth and regular borders. The great point is that it remains closed until labor. Only when touch has been re peatedly practised, or when uterine contractions have occurred in the later months of gestation—attempts at abortion—do we find the os externum slightly patent. It can, however, be forcibly passed, and then the wid ened cervical cavity is reached. The os internum is firmly shut and re mains so until obliteration of the cervix. The cervix is long, conical and the apex points downwards. (See Figs. 34-39 inclusive.) B. JIultipara.—The external os becomes round, bell-shaped, and the borders are irregular, with hard, projecting nodules separated by notches, which are the remains of lacerations in previous pregnancies.
The internal os is easily reached. This orifice remains closed until term; but sometimes it is open,—during the last weeks,—and the finger may reach the membranes. It is never as wide as the external os; and the finger feels itself in a canal which narrows from the external to the in ternal os:—a cone with the apex upwards. The diagnosis of the epoch of pregnancy can only then be made in multiparte from the permeability of the cervix.
Once obliterated, all that remains of the cervix is a depression—the os tinem—closed in primiparm, open in multiparm.
4th.—Direction.—Normally, the cervix points backwards and down wards, to the sacro-coccygeal articulation, is in the middle line, and occu pies the axis of the superior strait.
During pregnancy, when the body leans toward the right, the cervix points to the left;—of course, when the uterus leans toward the left, the cervix points to the right, but this is rare, as we have stated.
Again, the uterus, leaning forward, throws the cervix backwards; and this is best marked in from engagement of the head which, pushing before it the lower segment of the uterus, causes the cervix to rise upwards and backwards. At the end of pregnancy the cervix is sit uated high up behind and to the left.
In multiparm it is the same, except that it does not rise as high up. At the commencement of pregnancy the heavy uterus causes a lowering of the cervix.
III. Structural Changes in the Body and Cervix of the Uterus.—Each layer demands separate study:—serous, muscular and mucous.
1st. Serous changes.—During gestation, the peritoneum plays a large part in the changes of the economy. To-day we do not believe that it, and the broad ligaments, merely unfold;—but all authors, from the re searches of Jacquemier and Rouget, admit that there is hypertrophy and hyperplasia of the peritoneum, as well as distension and unfolding of that membrane.
Traces of this distension are found in the inequalities and cicatrices met with around the tubes, the sub-pubic ligaments and the ligaments of the ovary.
The chief point is, that the peritoneum not only does not thin out, but thickens at some points, elsewhere preserving its normal condition.
It is impossible for the peritoneum to distend enough to accommodate the uterus unless it undergo hypertrophy.
The sub-peritoneal cellular tissue becomes less dense and more areolar, and, Depaul states, this affords facility of movement to the peritoneum which may be an obstacle in Cesarian section.
2d. Changes in the muscular Layer.—These are remarkable. When empty, the uterus is composed of a dense, firm, compact tissue, like bacon, which cannot be separated into layers. During pregnancy this is com pletely changed.
The muscular fibres, so small in an empty uterus, increase in every direc tion, but especially in length, and new elements arise, as is proved by Robin, KUlliker and Schatz. The connective-tissue develops along with it, so that, finally, there results a purely muscular organ, strong enough to expel the foetus. At the same time the fibres tend to become striated, like the voluntary muscles. In this organ modern anatomy has discov ered several layers.