In order correctly to understand Brandt"s treatment of prolapse of the uterus, in which the actual massage manipulations are less important than the other manipulations and a particular kind of local gymnastics, it is advisable to recall the anatomical conditions and the numerous changes which (more or less important in each separate case) may underlie the abnormal condition in question.

As an introduction we must remember that sinking or forward-falling of the vagina and uterus is found mostly in child-bearing women, especially after numerous confinements, and often after extensive tearing; and that increased weight of the uterus owing to metritis or subinvolution or fibroids, also laxness of the surrounding parts either due to sudden emaciation or to conditions of degeneration after severe diseases or during senility, form predisposing causes. A less usual cause may be increased abdominal pressure in forcible effort or strain generally, or in defaecation. The position of the uterus in relation to the vagina is also to be considered, in that an increase or diminution of the normal angle between the two apparently increases the possibility of prolapse, especially if such a position (which may occasionally arise merely as a result of a distended bladder) becomes permanent for any reason. Finally, we would remark that in many cases of prolapse the sinking of the vagina is primary, and causes lengthening of the cervix and finally prolapse.

In order to obtain a correct idea of these cases we must not persist too much in the narrow idea of the uterus as an organ suspended in its position by folds of peritoneum, by the sacro-uterine and pubo-vesico-uterine ligaments, as well as by the broad ligaments and round ligaments (but especially by the first two). One glance into the female pelvis will show us that these adnexa even in a virgin, and to a still greater extent in multiparae, allow some sinking of the uterus, although much cannot take place without a stretching particularly of the sacro-uterine and pubo-vesico-uterine ligaments. Besides this suspension apparatus, the position of the uterus depends also upon a supporting apparatus, and it is in the conditions mentioned above which cause changes in these supports and their muscles, especially in levator ani, that we find the most important causes of prolapse. For details as to the structures forming the floor of the pelvis I refer the reader to the anatomical text-books and diagrams, and especially to the dissecting room, and will only draw attention to the fact that the middle fibres of the funnel-shaped levator ani, running in a sagittal direction covered both above and below with fascia, surround the rectum and vagina on both sides, that the muscle gives fibres to the space between the two which is filled with connective tissue, and in this manner surrounds the vagina on three sides in its under part, and assists in fixing its position and under certain conditions con-tracts it. According to Ziegenspeck it takes part also, especially when the uterus has not a retroverted or retroflexed position, in preventing prolapse, by drawing the upper part of the vagina forward and slightly upward, so that it becomes more horizontal and consequently gives a better support to the cervix. At a somewhat lower level than levator ani, towards the front of the pelvic outlet, and covered on its upper surface with a layer of pelvic fascia and on its under surface with the perineal fascia, we have the deep transversus perinei muscle (Henle), or the urethro-genital diaphragm (Henle), which allows a passage for the urethra and vagina, and has a great influence on the position of the vagina and its ability to resist a force distending it. Finally, for the fixation of the vagina we must remember the whole of the perivaginal connective tissue, especially that portion of the figure-of-8-shaped collection of muscle-fibres whose posterior portion is formed by the external sphincter ani, and whose anterior portion is known as sphincter vaginae.

With the above facts in view we may pass on to a description of Brandt's method with all its details in the treatment of prolapse. He introduces the treatment by giving a gentle tapotement (with flat hand or closed fist) over the sacral region, while the patient stands bent slightly forward with the arms stretched forward and hands supported against a wall or boom; this aims at producing a stimulation in the corresponding nerve centres. Then the patient lies upon a plinth in the position described above, with the head raised, pelvis lifted, legs flexed and abducted, and with the feet together. The doctor sits as above described on the patient's left side. The prolapsed uterus is now replaced in the ordinary way, along with the possibly accompanying cystocele or proctocele, as far as possible into the normal anteflexed position; if this cannot be done, it is then replaced by the mechanical manipulations already described in this chapter, a task which may sometimes delay further treatment. When the uterus is fully replaced, Brandt's so-called "double treatment with lifting" is performed, i.e., a process which requires an assistant. The assistant * kneels upon the plinth between the patient's knees and lifts the uterus and its adnexa from the outside in the following way : - leaning over the patient with hands fully supinated and ulnar borders in contact, she inserts the three middle fingers between the uterus and the pubic bone, exerting a fairly forcible pressure upon the abdominal wall; with her hands gliding over the abdominal wall she then grasps the uterus and draws it in the direction of the abdominal cavity + as far as it will go without causing undue pain or using too much force (i.e., it is brought much higher up than its ordinary position). At the same time the doctor's left index finger follows the vaginal portion of the cervix in its movements as far as possible, and carries this backwards; when the lifting carries the cervix out of reach the finger is kept as high up as possible in the vagina to grasp it again as it descends and push it backward. This "double treatment" is repeated three or four times; during every drawing-lip the normal anteflexed position of the uterus is controlled in the above manner. (As already said, a retroflexed or retro-verted uterus is never lifted.) When these liftings have been performed the so-called double treatment and the need for an assistant is over. The doctor, who continues to sit in the same position, performs small kneadings with the three middle fingers of the right hand, pressing through the abdominal wall, with the object of stimulating the hypogastric plexus on both sides and the posterior part of the sacro-uterine ligament. If the uterus is swollen or there are remains of inflammation present an ordinary kneading is performed. Later the doctor performs gentle nerve frictions with the right hand towards the left hand, which acts as a support outside the labia majora, in order to stimulate the inferior pudendal nerves if there is any prolapse of the vagina. Similarly the wall of the vagina, if lax, is pushed up and worked upon with small, limited, but tolerably firm frictions, while it is pressed against the posterior surface of the pubis. When this is complete the patient actively raises the lower part of the back and the pelvis from the plinth, so that she rests with only the neck and upper part of the back and feet upon the couch; in this position she performs a few *eccentric abductions and concentric adductions, the patient holding the knees together while the doctor parts them against the resistance of the patient, the patient then closing her knees against the resistance of the doctor. This aims at strengthening levator ani (see below). After several repetitions of this movement the doctor again inserts the index finger of the left hand into the vagina, draws the cervix backwards if it is not already drawn back, and, continuing to fix it in this position, assists the patient with his right hand to raise herself from the plinth, and does not remove his finger until she is standing, so that he has all this time controlled and fixed the position of the uterus, which otherwise may easily fall suddenly back as the patient raises herself. Finally the treatment ends in the same way as it began, i.e., with gentle tapotement over the sacral region. Often the patient may, with advantage, lie for an hour face downwards on a sofa.

* For this Brandt always employed a woman "gymnast."

+ There is no need of a lubricant to facilitate the gliding of the hands over the abdominal wall.