There still remains, however, a not unimportant part of the treatment. The patient must be instructed on getting up in the morning and after going to bed, as well as several times during the day, to exercise the muscles of the pelvic floor directly, by means of taking the position described above and vigorously closing the knees so as to bring into action levator ani and the external sphincter (in the same way as when a straining effort is made to prevent the expulsion of wind or faeces from the rectum).

Besides mechanical treatment Brandt used no other method except douching the vagina with water at the ordinary temperature of the room, which the patient herself may carry out. Hydrotherapeutic and electrical treatment may, however, be used with advantage.

If we review quickly Brandt's method of treatment we shall find that in every detail, more or less effective, it corresponds to the points of definite therapeutic treatment of prolapse on a pathological anatomical basis. A good many of the manipulations are certainly of slight or indefinite value. In particular it would be as absurd to lay great stress upon sacral beating or nerve frictions upon the hypogastric plexus and sacro-uterine ligament as it would be to deny their use altogether; only in very few cases with particularly slack abdominal wall are they likely to attain their object. The nerve frictions along the course of the inferior pudendal nerves may certainly be omitted without affecting the result. The chief part of the treatment besides reposition, the obvious result of which I may pass over, are the liftings. These aim at opposing all the mechanical conditions present in prolapse. It is doubtful whether the liftings always or often fulfil Brandt's object in stimulating the adnexa, which contain muscle fibres, to contraction through sudden stretching, particularly of the sacro-uterine ligament, as the indirect attachment of the uterus to the floor of the pelvis prevents extreme lifting much more than the said adnexa. On the other hand, quite a small amount of lifting of the uterus above the normal level results in a stretching of inflammatory adhesions, which are so often the cause of alterations in position and of fixation, particularly backward, and which, without stretching, allow very little lifting of the uterus (Ziegenspeck). The liftings thus help to restore mobility to the uterus. The resistance exercises performed by the adductors, as explained above, aim, according to Brandt, at strengthening the muscles of the pelvic floor, especially levator ani, which is important as a support both for the uterus and the vagina; others also have recognised their importance in this respect. Neither can it be denied that the pelvic muscles, which, from what we have said above, contribute to maintain the normal position of the genital apparatus, to a certain extent take part in exercises for the adductors, especially when the patient takes up the position described, supported only by the shoulders and the soles of the feet. Examination, however, easily shows that, owing to the effect of levator ani on the position of the anus, (1) this muscle and in all probability also the other muscles of the floor of the pelvis are brought into action very slightly and scarcely noticeably in vigorous resisted adduction of the thigh; and (2), on the contrary, levator ani acts much more strongly in strong innervation of the external sphincter muscle, as in holding back the contents of the rectum. For my part I consider, therefore, the useful part of Brandt's gymnastic treatment for prolapse, the exercise in which the patient, as above described, uses the muscles of the pelvic floor, and that these are infinitely more important than resisted adduction, which scarcely strengthens any other muscles than the adductors themselves. Liftings and contraction of the muscles of the pelvic floor are therefore the most important part. Exercises for the adductors and treatment of the wall of the vagina are certainly far less important; the other parts of which the treatment consists are of very little consequence.

* Translator's Note. - This movement is described in Chap. IX., according to the muscle work and not the form of the movement as adduction, concentric and eccentric.

The value of uterine massage for chronic metritis in lessening the weight of the uterus is clear.

It is obvious that Brandt's method of treating prolapse is of more interest than of practical importance, that it can replace operative methods only to a small extent, and that most patients prefer to submit to the simple operation for prolapse with excision of the cervix, kolporraphy and perineorraphy, which produces the desired effect in a short time, and at least in the majority of cases permanently removes the trouble, than go through Brandt's treatment, which usually lasts several months and is much less certain. We must, however, acknowledge that prolapses which have lasted ten years have been really cured by Brandt, and it ought to be remembered that it may be used as a suitable preparation for operation, and that especially the gymnastic part may also be good treatment after operation.

Von Braun-Fernwald and Kreis consider that the following cases of prolapse should be operated upon : -

(a) Those which are combined with severe muscle atrophy;

(b) Those arising in emaciated, decrepit, or senile individuals;

(c) Those which are not improved by three weeks of Brandt's treatment;

(d) Those combined with perineal deficiency;

(e) Those combined with considerable hypertrophy of the cervix. They consider, further, that pregnancy, tumours, fixation of the uterus, and inflammatory processes contra-indicate Brandt's method, which ought scarcely to be considered where there is great development of fat in the abdomen, or very tense abdominal muscles, on account of the difficulty of performing liftings in these cases.

In obstetrics, manipulations are used which may be considered as massage, for defective post-partum contraction of the uterus, and the consequent haemorrhage from the placental site, in which cases, as is universally known, the organ is treated by moderately firm frictions through the abdominal wall, and in this way is stimulated to contraction.