suppurations, in which the common pus-producing organisms (staphylococci and streptococci) are present.

Our methylene blue tests in the plates gave us the same results as those with gentian violet, except that twice as much of the methylene blue was required as of the violet. We used methylene blue, as I have said, because we thought that it might not be destroyed in the tissues as rapidly as gentian violet; it has been demonstrated that methylene penetrates the tubercules (experimental tuberculosis) to quite an extent, and even the tubercle bacilli themselves, and that it retains its original quality for some time after coming in contact with the body tissues. When we tried methylene blue on the anthrax bacillus, which is Grampositive and susceptible to the gentian violet, we got the same reaction on the plate as with gentian violet; but in animal experiments the results were unsatisfactory. When we treated the cultures of the anthrax bacillus for two hours with the methylene blue, they still killed the guinea pig after hypodermic injection. On the other hand, the gentian violet protected the guinea pigs. In seven injections that we made with anthrax bacilli that had been treated with gentian violet, extending over a period of eight weeks, we have not killed a guinea pig. Our control animals were killed with a relatively small number of the untreated bacilli; so even when you apply gentian violet to the animal, you may get satisfactory results. The methylene blue was disappointing. We did not get satisfactory results in any attempts to immunize animals against anthrax with gentian violet. The toxin appears to be affected as well as the bacillus, which we hoped would not be the case.

In the study of the action of coal-tar dyes on bacteria there is a large field for the chemist, bacteriologist and physician. If we can improve some of these dyes by increasing their bactericidal action, and making them more stable in the body, and at the same time not increase their toxicity, we shall have the ideal chemical agent for the disinfection of animal tissues.

THE PRESIDENT: Is there any further discussion on Dr. Churchman's paper? If not, I will ask him to close the discussion.

DR. JOHN W. CHURCHMAN (New Haven): The discussion has already closed itself, but I would like to say a word regarding the anthrax experiments. I do not know whether you quite understood what Dr. Rettger referred to. I said that the organisms can be killed in two ways either by staining them and then planting them in suitable media, or by adding the dye to the media on which they are growing. His experiments were with stained anthrax organisms. If you planted these on agar, they would not grow; but the question is, would they grow in the body, where the conditions are more favorable for bacterial

growth? I have done experiments on mice, and have never been able to save a single mouse. These animals are extremely susceptible to anthrax, and one organism will kill a mouse. Dr. Rettger's work was with the guinea pig, a much less susceptible animal; and he injected stained organisms. A few of the anthrax germs lived, but not enough to kill a guinea pig; although enough to kill a mouse.

Our purpose was to see whether we could produce immunity by giving organisms whose virulence was reduced sufficiently to let the animal survive. I wish to pass around one more plate, which is a colored representation of plates planted with two pigment-bearing organisms: one, Gram-positive; and the other, Gram-negative. In this you will see in a striking way the difference between the effect of the dye on the two kinds of organisms.

Prolapse of the Uterus.

OTTO G. RAMSAY, M.D., NEW HAVEN.

Prolapse of the uterus is a subject of perennial interest, as we all, the specialist as well as the general practitioner, see many cases in the course of the year's work. Any suggestions as to new methods in its treatment are of value, as we all want to be in a position to give the best advice to our patients possible and unfortunately the surgical treatment of prolapse is not always followed by the satisfactory results we hoped for.

Because of these possible poor results after prolapse operations, I have ventured to ask a few moments of your time to consider an operation which we have found successful in a certain group of cases.

Before, however, considering the technique of the special operation, I should like to call to your attention the varying types of prolapse which may occur, and the reasons why some of the operations are failures.

Prolapse of the uterus is simply a hernia and naturally follows when the relationships of the pelvic tissues or the pelvic floor are disturbed, either by trauma, by displacements, or possibly by congenitally weak tissues. If we take for our standard of normal conditions a young healthy woman who has not borne children, we find the vaginal orifice drawn closely up under the arch of the symphysis, the vaginal walls in apposition, and the uterus lying forward in easy anteflexion.

In such a woman any muscular effort merely serves to tighten the pelvic floor, the anteflexion is increased and the cervix, if it impinges at all on the posterior vaginal wall, does so at an acute angle.

Now if this same young woman has a retroflexion or, more frequently, a retroversion, there is another possible picture. In this case, when there is a muscular effort, the uterus is driven lower into the pelvis, the cervix impinges on the vaginal wall

at an obtuse angle and naturally tends to slip downward towards the vaginal orifice, and though each effort is resisted by the pelvic ligaments, there comes a time in many of the cases when, as the result of the constant downward pressure, the cervix reaches and then projects through the vaginal orifice, and I think this is the explanation of the rare form of prolapse in the nulliparous

woman.

Why it does not more frequently happen is due partly to the fact that beginning prolapse is painful and is treated by pessary or operation to relieve the displacement and partly due to the fact that, in many of the retroflexions, the fundus is so far back that it either prevents the cervix impinging on the vaginal wall or the bending is so sharp that the cervix still lies in its normal acute angle relationship to the posterior vaginal wall. In other words, a descensus or prolapse is more apt to occur with a retroversion than with a retroflexion.

Now let us consider for a moment the more frequent varieties due to trauma. This trauma is almost always childbirth, and, as a fact, in cases of prolapse we almost without exception get a history of one or more difficult labors. Following these the prolapse may come on within a few months or a year, or the condition may not be noticed for years after the labor, until the tissues, as a result of the menopause, have lost their elasticity.

On examining one of these cases, one of several pictures may be presented, depending on the variety. Most frequently we see a gaping vaginal orifice with bulging anterior and posterior vaginal walls, or the cervix may project between them or be found by the examining finger just between the orifice, the fundus lying in retroversion.

In another variety, the more or less relaxed vaginal orifice is filled by a rounded tumor which may be recognized as the anterior vaginal wall and bladder. In this case the cervix is either pulled down as a whole with accompanying retroversion or there is an elongation of the anterior lip.

In another group the cervix is found projecting several inches through the dilated vaginal orifice; there is a complete prolapse

of the anterior vaginal wall and a partial prolapse of the posterior wall.

On searching for the uterus it may rarely be found outside the pelvis, lying in the prolapsed sac in retroflexion, or more frequently there is found an elongation of the cervix, the uterus still lying somewhere in the pelvic cavity, though probably low down and always retroverted.

Finally there are cases in which there is a complete prolapse of both the anterior and posterior vaginal walls, the uterus in these cases usually lying entirely outside of the pelvic cavity in the prolapsed sac and in retroflexion.

Of course these are merely pictures of the most marked types and we can get any gradation from the beginning descensus with retroversion to the complete prolapse of all the genital viscera.

Now, in considering the development of these different varieties, there is one constant factor at work, that is a change from the normal relationship of the pelvic floor. This may be primarily a retroversion or retroflexion, which means a change in the relationship of the cervix to the vaginal walls. It may be a tearing or a stretching of the suspensory ligaments of the bladder which allows it to descend and change the relationships. It may be bad tears of stretching of the levator muscle and pelvic fascia, allowing the vaginal orifice and the canal to drop from its normal relationship close up under the symphysis.

As a result of this, the vaginal walls which were held up closely in apposition, separate and begin to roll out when there is any exertion or when the patient is on her feet. Then there comes the drag on the cervix and one of two things happens,— either the uterus comes down as a whole, or more frequently the descent of the cervix is more rapid/and we get an elongation of the cervix, though the uterus is always dragged on as is shown by the fact that it is always retroverted or retroflexed.

These are the main facts to be remembered in studying the development of prolapses.

With this short synopsis of the cause of development, we are ready to consider the question of operative treatment. If