Mechanical Vibration
M. L. H. Arnold Snow, M.D.

Chapter 11

The Therapeutic Application of Mechanical Vibration to the Nervous System

    THE BLOOD VESSELS OF THE HEAD receive their vaso-motor supply largely from the cervical sympathetic, the nerves reach the vessels not alone through the cervical sympathetic, but other tracts as well.  Spina thinks that the cerebral vessels have a special vaso-motor center extending to the 3rd cervical vertebra.  Stimulation of the sympathetic supplying the cerebral vessels results in a slowing "of the blood current in the small cerebral arteries and increases the resistance in them."  Vaso-dilatation of the head often results from stimulation of the abdominal sympathetic and vaso-constrictor effects arise from energetic vibration (manual - Cyriax) in the coronal suture.  The vaso-constrictor neural cells for the brain, face, scalp, eye and mucous membrane of the nose and mouth are found in the second, third and fourth dorsal segments (Arnold). ["Examination of the Back." Medical News, March 18, 1905]

    "The vaso-dilator neural cells for the face and scalp are in the nuclei of the seventh and ninth cranial nerves, for the mucous membrane of the nose, the soft palate, mucous membrane of the upper lip and gums in the nucleus of the seventh.  Those for the floor of the mouth, the lower lip, the mucous membrane of the cheek, the lower gums and the tongue in the nucleus of the ninth."

    The writer has relieved CEREBRAL CONGESTION by applying interrupted vibration with the ball vibratode between the second and third dorsal vertebrae on each side alternately for two periods of five minutes each, an interval of a few minutes' rest following the five minutes, thus reducing the blood pressure.

    INSOMNIA when associated with nervousness is best treated by removing the cause of the over-excitability of the nervous system and by lowering the blood pressure.  These results may be induced by the d'Arsonval current or mechanical vibration.  An agent inducing sleep, according to Sajous, causes "constriction [Sajous. The Internal Secretions and the Principles of Medicine, page 1265] of the arterioles of the anterior pituitary body (including its test organ, which governs the adrenals) and also of the arterioles of the thyroid gland, "and this center lowers general metabolism which in turn by affecting the heart and blood vessels, causes general vaso-dilation.  This increases the quantity of blood "in the splanchnic area and other deep vessels, and withdraws a corresponding quantity of blood from the peripheral organs, including the cerebro-spinal system.  Lessened metabolic activity and diminution of adrenoxidase inhibit the functional activity of the neurons and provoke unconsciousness.

    Insomnia is often favorably affected by mechanical vibratory treatment applied to the neck, thereby relieving cerebral congestion or by centrifugal friction toward the extremities for the purpose of inducing the blood from the head, thereby relieving the brain.  Abdominal vibration favors sleep also.  Relaxation, lessened nerve irritability and diminished arterial tension are the indications met by mechanical vibration.  Local causes which influence the conditions must also be treated according to indications.  Attention should be given to a proper application of spinal vibration in conformity with the indications of each ease.  Cyriax calls attention to the fact of Charcot's vibrating casque having been used to promote sleep.  Body vibration will also induce sleep.

    IN CEREBRAL ANAEMIA, centripetal friction or localized spinal vibration should be employed.  Regulation of diet, and hygiene - as baths, outdoor exercise, and proper attention to the bowels are indicated.

    NERVOUS HEADACHE may often be benefited by vibratory stroking as it has a sedative effect on cutaneous nerves.

    MIGRAINE, OR HEMICRANIA is caused [Sajous. The Internal Secretions and the Principles of Medicine, page 1522] by "toxic wastes" (Sajous thinks probably the purin group) stimulating the sympathetic center thereby causing general constriction of the arterioles, except those which cannot contract; because their walls are functionally or organically weak.  When the sympathetic system alone is stimulated, there results a contraction of all the other arterioles of the body except those of the affected region causing "pressure and hyperaemia of the local nervi nervorum.  "A second form of migraine, the vaso-motor form, is due to sympathetic irritation plus stimulation of the vaso-motor center, resulting in a general vaso-constriction except in the "diseased or lax" arterioles which are dilated.  It is like the first form, only aggravated.  The blood pressure is raised, and there is pupillary contraction.  Migraine may be caused directly or reflexly by overeating, improper diet, uterine disorders, or excessive muscular fatigue, carious teeth, eye-strain, nasal or ophthalmic affections or adenoids.

    The treatment should be directed according to Snow, to " (1) improving the general nutrition, (2) to lessening the nervous irritability by restoring or establishing a proper stability of the nervous system, (3) to correcting or removing exciting causes, as far as possible, which induce attacks, and (4) to relieving the attacks when they do occur."

    The first indication calls for colonic flushings or saline purgatives; light, light baths, or hot air baths to promote elimination, outdoor exercise, and dietary restrictions as; water freely, milk, koumiss, zoolak, cooked fruit and vegetables - a meat free diet, no eggs, coffee, tea, or stimulants.

    The second may be successfully managed by local or general vibratory treatment, with other physical measures as d'Arsonvalization if necessary, depending upon indications.  The stroke, speed and pressure exerted should be adapted in every case to the condition of the patient.  Above all, no pain must be caused by the treatment.  A soothing effect is to be sought.  Vibratory stroking from before backward and from the occiput down and outward and over the neck anteriorly with a rubber-covered disc, and interrupted vibration with moderate or deep pressure over the painful areas, is sometimes useful.  Kellogg believes that sometimes there are "points of induration or thickening in the trapezium and scaleni muscles "which seem to have some relation to some attacks of migraine.  Such cases should receive indicated local treatment with the disc vibratode.  Vibratory treatment of the liver and abdomen, which will improve digestion, associated with a restricted diet, are often indicated, as well as applications of proper spinal vibration with the ball to meet conditions, Cyriax [The Elements of Kellgren's Manual Treatment, page 161] believes that the 2nd cervical nerves seem to have fibres supplying the head and uses frictions on the nerves to relieve congestive headaches with good results frequently.  He says such frictions have an antipyretic effect.  The posterior roots [The Elements of Kellgren's Manual Treatment, page 160] are "posteriorly near the middle line as they emerge from the trapezium " and the anterior roots are "more externally and anteriorly under cover of, and in front of that muscle.  " The vibratode should be placed over the site of these branches and the frictions should be from "before backwards " to the vertebral exit of these nerves.  Cyriax [The Elements of Kellgren's Manual Treatment, page 456] also remarks in regard to CHRONIC HEADACHE, that although it is supposed that myositis of the neck muscles may be a cause, and massage of the neck muscles gives good results in this trouble, he believes that the muscular condition is secondary, "due to a primary nerve irritation" and says "much quicker results can be obtained by nerve vibrations.

    He uses [The Elements of Kellgren's Manual Treatment, page 220]for "fevers or chronic headache from hyperaemia cerebri to soothe and reduce cerebral excitement,"

1. Head lifting.

2. Vibrates or works on those parts of the head demanding special attention.

3. Nerve frictions, general and also local if required.

4. Repeats head lifting.

    The commonest form of this type of head exercise is as follows:
One hand administers Double supraorbital nerve fiction or vibration, or frontal vibration. 
Coronal suture vibration. 
Sagittal suture Vibration. 
Double parietal vibration.
The other hand administers Double great occipital nerve (emerges through trapezium muscle and runs upwards and outwards in the scalp) friction. 
Double second cervical nerve friction. 
Occipital suction movement. 
Occipital vibration movement.

    Mechanical vibration may be given with the cup-shaped rubber vibratode, shortest stroke, medium rate of speed and little or no pressure over the indicated sites.  It should be given for five minutes or longer.

    To meet the third requirement, pelvic treatment per rectum with the static wave current and correction of constipation are often indicated.

    The fourth requirement usually calls for high colonic flushings and local treatment as conditions are presented.  In the vaso-motor form, intervertebral mechanical vibration with the ball vibratode between the transverse processes of the 2nd and 3rd dorsal vertebrae as indications demand for five or ten minutes with intervals of rest or d'Arsonvalization to lower blood pressure correct the arterial tension.  Vibration between the 3rd and 4th dorsal vertebrae for three or five minutes dilates the pupil.

    NEURITIS, local, disseminated, or general, is an inflammation of one nerve or several nerves.  In some cases it is occasioned by the constitutional condition of the patient, when it often occurs as a peripheral neuritis.  The pathology of neuritis may be divided into (1) parenchymatous, and (2) interstitial, in which the blood vessels and lymphatics are most extensively involved; (3) another form known as "segmental peri-axillary neuritis," in which type the normal and degenerated segments alternate.  This form occurs in senility, after diphtheria and the use of toxic agents as lead.

    Dana [Sajous. The Internal Secretions and the Principles of Medicine, page 1530] thinks "that when there is organic disease of the nerve itself such as neuritis the disease cannot be, strictly speaking, called neuralgia."  In the following the terms will be considered separately as far as possible.

    Some consider neuritis as a vaso-motor nerve disease, and believe that the relief and cure depend upon the correction of the blood supply to the affected part, which is probably only true so far as any other inflammatory process might be so considered.

    Sajous [The Internal Secretions and the Principles of Medicine, page 1537] states that it is "a vascular disorder of the perineural and interstitial connective tissue frame-work of the nerve and that the nutritional disorders of the muscles, skin, etc., are due to pressure by engorged vessels, serous effusion, etc., upon, or destruction of the nerve fibre bundles (axis cylin-ders) which these inflamed structures surround."  When the cell bodies in the central ganglion are involved "the inflammation extends towards the cere-brospinal axis and gradually destroys the ganglion."

    The time necessary to effect a cure will vary from a few days to twelve months, or even longer, in some chronic cases.

    For the treatment of neuritis employ the static wave current with a flat metal electrode next to the skin over the areas of great tenderness as present about the shoulder or hips or elsewhere for twenty minutes, and then apply static sparks to all points of pain or tenderness after which use interrupted vibration with the disc vibratode at first superficially, to be followed later with deeper pressure for two or three minutes over the areas of greatest pain.  The interrupted impulse should be prolonged sufficiently to relieve the pain.  The spinal region corresponding to the origin and exit of the affected nerves should also be vibrated with the ball vibratode for five minutes.  The exit usually requires a longer vibratory treatment, as it is usually most painful.  In some chronic cases after the relief from pain an application of light vibratory friction to the affected area may be found desirable for the atrophy.

    THE MODUS OPERANDI OF MECHANICAL VIBRATION when it is scientifically applied in inflammatory processes is that it relieves local stasis and promotes absorption.  As the neural congestion is due to "an accumulation of toxic wastes in the blood with intestinal torpor" and consequent auto-intoxication and resultant pain from the presence of toxic wastes, indications are to remove the intestinal accumulations by colonic flushings or castor oil and correct the diet as in migraine.  Water should also be partaken of freely.  In the treatment of the neuralgia that so frequently accompanies neuritis, general vaso-dilatation is indicated which may be accomplished by mechanical vibration applied to the spine (see Chap. VII) or d'Arsonvalization, or by local treatment to cause constriction of the peripheral arterioles or to cause "depletion of perineural arterioles and therefore of the endoneural capillaries." [Sajous. The Internal Secretions and the Principles of Medicine, page 1544]

    Hot Epsom salt baths as sometimes given in the treatment of rheumatoid arthritis prove palliative in some cases.

    BRACHIAL NEURITIS is characterized by pain in the region of the shoulder with or without pain along the course of a nerve or nerves belonging to the plexus as the musculo-spiral, median, ulnar, and circumflex, and is accompanied in some cases by disorders of sensation as tingling, or areas of coldness or extreme heat.  The sites of pain in the region of the shoulder are as follows: (1) the point of the shoulder, (2) a site one or one and one-half inches downward anteriorly from the superior line of the shoulder and one or more inches toward the median line, (3) the center of the scapula, (4) at the outer border of the scapula where the arm joins the body, (5) in the interscapular region, and (6) a point one or two inches above the superior border of the scapula and about two inches from the spine, and (7) just below the inferior angle of the scapula.  Over the sites of the origins as well as the sites of exit of the affected nerves, tenderness is elicited.

    The routine treatment consists of the application of the static wave current with a shoulder electrode or a rectangular electrode placed over the shoulder from before backward for twenty minutes, followed by static sparks to the tense muscles.  Prolonged mechanical vibration follows with the ball vibratode in the intervertebral spaces over the sites corresponding with the origin and exit of the involved nerves.  The most sensitive places should be vibrated the longest.  A five or ten minute spinal vibration is very effective in relieving tension of the parts supplied by the affected nerves.  Local vibration with the disc vibratode over the sensitive sites about the shoulder joint is also indicated.  Sometimes spinal vibration in the lower dorsal region is indicated where difficulty is experienced in raising the arm.

    Treatment should be at first daily, and later every other day or as the progress of the case warrants.

    When treating neuritis due to an injury it should be remembered that if a sensory nerve is affected, anaesthesia, thermo-anaesthesia or analgesia may be present, but the muscular sense is seldom lost.  In cases in which septic infection is present the lightest touch of the sensitive area will elicit pain.  In these cases hot air treatments are indicated.

    SCIATICA is a localized inflammatory affection of the sciatic nerve, manifested by pain.  It is now acknowledged by authorities in all cases to be associated with a local neuritis, either involving the nerve itself or the plexus.  Starr, who refers to it as a neuralgia of the nerve, states that "in all cases in which an autopsy has been obtained, an interstitial neuritis with congestion of the vessels, hemorrhages in the sheath and secondary degenerations of the nerve fibres have been found pain may occur in the whole or any part of the distribution of the nerve, but is generally most intense over the sacro-sciatic notch.  Points of tenderness may also be found in some cases above the hip-joint (on a line with a man's hip pocket), near the posterior iliac spine, just below the crease of the buttocks, in the middle of the thigh posteriorly, the back of the knee, and posterior to the external condyle of the ankle.  When a neuritis has become chronic, perverted sensations as of heat, cold, and numbness are noticeable.  Intrapelvic pressure usually causes bilateral pain.

    It is necessary that a careful diagnosis be made from (1) coxalgia in which pain usually first appears on the inner side of the knee and there is "a rigid position of adduction with slight rotation," (2) lesions in the cauda-equina where the trouble is almost always bilateral, and there is incontinence of faeces and urine; and (3) sacral caries characterized by sacral tenderness, and pain on motion involving the pelvis, (4) Involvement of the sacro-lumbar cord as in Goldthwait's disease and (5) pelvic affections.

    The treatment of sciatica comprises the use of the static wave current applied with a flat metal electrode over the sacro-sciatic notch or higher up for twenty minutes followed if necessary, by static sparks, and mechanical vibration.

    Mechanical vibratory treatment of sciatica, applied directly to the nerve trunk, is usually of benefit.  The pressure employed should be light at first.  Best results, are obtained if interrupted vibration is applied superficially at first, to be followed later as the pain lessens by heavier vibration administered at the sacro-sciatic notch with the disc vibratode for the purpose of producing an inhibitory effect, i.e., in cases in which the lesion is at the notch the most common site.  Prolonged vibration with the ball vibratode over the exit and origin of the affected nerve is beneficial.  Interrupted vibration over the tense muscles gives comfort.  Sometimes the pressure of faecal impaction causes pain in the sciatic nerve, in which case a rectal vibratory colonic flushing and spinal treatment will afford complete relief.

    Double sciatica, "with chronic muscular contractures," has been reported successfully treated by Rochelle.  He employed heavy vibration "over the 6th to the 12th dorsal and 5th lumbar nerves with vibration of liver and spleen anteriorly."

    Sciatic neuritis should be treated to relieve the neural congestion as well as the pain as outlined under neuritis.  Absolute rest is seldom essential in these cases, a limited amount of restricted exercise is usually to be preferred.

    HERPES ZOSTER (shingles) characterized by intense pain along the course of the nerve, without and later with reddish patches which develop into vesicles is an intercostal neuritis with neuralgic pains where the inflammation "has advanced beyond the preliminary plasmatic hyperaemia."

    The treatment if early consists of prolonged applications of radiant light and heat from a 500 candle power incandescent lamp until the affected portion of the body is pink, this should be followed by a thorough administration of the static brush-discharge over the localized area, and the static wave current for twenty minutes over the spinal seat of the trouble followed by the prolonged application of mechanical vibration with the ball vibratode with gradually increasing pressure over the vertebral exits of the affected nerves which completes the treatment.  This routine should be repeated daily until the condition is cured.  Late treatment of this condition consists of the static wave current, static sparks, d'Arsonval current with two metal electrodes and mechanical vibration, spinal with the ball vibratode and local with the disc vibratode.

    NEURALGIA characterized by pain is present as a symptom of neuritis usually, but not always.  There are various localized pains so designated - intercostal, cervico-occipital involving the upper four cervical nerves, facial, podalgia, plantar neuralgia, gastralgia, cardialgia, nephralgia, and neuralgia of the liver, rectum, testicles, and ovaries.  By some it is thought to be a peripheral disease, but most authorities regard it as not necessarily so, but a symptom due to central lesions or neuritis referred to the periphery.  It presents a general constriction of the arterioles due to stimulation of the sympathetic center, followed later by relaxation of the affected arterioles due to stimulation of the vaso-motor center causing general vaso-constriction thereby flooding them. [Sajous. The Internal Secretions and the Principles of Medicine, page 1540] In general the pain is "due to pressure upon the nervi nervorum."  A nutritional disturbance of the central sensory regions is supposed to be the most frequent cause.  Constipation or incomplete evacuations are frequently causes.  If there be advanced organic disease, treatment with mechanical vibration or other mechanical measures is of little avail, for it will not relieve the pain when it is impossible to remove the cause.

    The symptom may be pain together with numbness, tingling, burning, and sensitiveness, and may be also associated with automatic or reflex muscular spasms, sweating, eruptions or flushing.  The pain may or may not be intermittent.

    Treat the cause and if possible remove it.  The treatment for neuralgia in general is the same as for neuritis.

    Starr states in respect to facial neuralgia, that "vibrations maintained by a tuning-fork electrically vibrated, the end of the fork being in contact with the end of the fingers of an expert masseur, have given relief in some cases." In our experience, the use of light and a metal electrode over the surface with the static wave current for 20 minutes followed by the static brush discharge effects a cure except in cases due to diseased tissue, or carious teeth.

    In treating neuralgia as a rule apply the vibratode interruptedly over the painful site or interruptedly or with friction where the nerve is nearest the surface.  In the intercostal form apply it to the inferior border of the rib, i.e. of the uppermost rib at the site of the pain.  The vertebral exit of the affected nerve should also be vibrated with the ball vibratode for five minutes or more as indicated to afford relief.

    The site of the plexus as well as the nerve trunk should receive treatment in most cases.  In employing interrupted vibration with a fairly slow rate of speed over painful areas, apply it lightly at first, but as soon as it can be borne, gradually increase the pressure, the diminution of pain being a guide as to the increase of pressure.  If deep pressure be first used the pain will cease sooner, but the treatment is not so satisfactory to the patient owing to the extreme sensitiveness of the part.  The pain may gradually diminish and may cease entirely during the first treatment, but if it does not, do not persist after a reasonable length of time.  As a rule treat the case daily.  It may be best to treat some very obstinate or acute cases twice daily for several days until the pain is gradually subdued and then "bridge" accordingly.

    Mechanical vibration when applied to painful, areas acts not only directly but indirectly upon the nervous system as upon a special nerve as when it relaxes muscular contracture, thus relieving tension and removing pressure.  Thereby the food supply of the nerve is increased, the blood pressure lowered and elimination increased.  The fact has long been recognized, as noted by Snow in respect to the "Physiological Action of the Various Static Modalities."  "The action upon metabolism of vibratory influence has long been recognized by physiologists, such as that attributed to the heart's impulse."  Mechanical vibration improves the nutrition by overcoming local stasis, and restoring circulatory conditions.  It may be a derivative measure or may be used directly over the nerve.  Interrupted vibration with the rubber-covered disc, superficial, deep or compressing in character, may be used, the degree of pressure being regulated by the pain produced, i.e., as pain diminishes, increase the pressure.  What Starr has written relative to massage is applicable to administrations of mechanical vibration.  He says: "Massage to be useful should be painless.  I have seen severe injuries of nerves follow the painful manipulation of unintelligent masseurs and osteopaths, and the statement which such individuals often make, that if their manipulations cause pain they are thereby doing good, is absolutely false."

    Longer treatments are advisable for acute than for chronic cases.  Sufferers from neuralgia habitually have used firm pressure over points of tenderness or pain, which are generally in the vicinity of a joint or bony surface.  Compressing interrupted vibration may likewise be applied to such points.  It has been demonstrated that "light and rapid percussion temporarily aggravates pain, but slow and heavy blows set in an obtunding effect at once."

    Kellogg has made use of the nerve percuter of Dr. Mortimer Granville of London in the treatment of nerves, to induce vibration, but objects to the apparatus because it gets so easily out of order.  He has, however, had good results from another percuter.  Granville believes "that pain is due to disharmony or morbid vibration in a nerve, and has found in his experience that acute, sharp pain is best relieved by musical vibration of a low tone (to interrupt speedy vibrations of pain), while dull heavy pain is best relieved by high-keyed vibrations (to interrupt slow vibrations of pain).  He thinks that relief is obtained by interruption of the discordant nerve vibration which he considers the cause of the pain." He considers the rate of speed employed to be an important factor.                          I

    On the other hand, Dr. Pilgrim believed that "the essential factor both in the mechanical stroke and in the electric current as regards their effect on nerve tissue, is, it would seem, intensified natural vibration) which is a still different theory relative to vibratory effects.  He said, that with certain vibration rates, amplitudes, timbres and associated rates, general sensation is influenced, and he theorized in respect to muscles that as the primary elements of striped muscle are of unequal lengths and varying degrees of tension, to induce a general contraction "several rates of oscillation" are necessary.

    Time and experience will solve these problems and determine the various rates and methods of treatment and their respective status in vibratory therapeutics.

    Treatment of neuralgia should include the induction of general vaso-dilatation as induced by spinal mechanical vibration, or d'Arsonvalization, or locally vibration to induce constriction of the peripheral arterioles or to deplete the perineural arterioles and therefore the endoneural capillaries.  An accompanying neuritis should be treated as outlined under neuritis.

    DISORDERS OF SENSATION, as paraesthesia or numbness and hyperaesthesta of functional character may often be benefited by mechanical vibratory treatment.  For cutaneous anaesthesia use interrupted vibration with the disc vibratode employing moderate pressure.  The interruptions should be very rapid.  Hyperaesthesia, however, is most effectively treated with interrupted vibration, with the disc vibratode usually employing moderate pressure which is graduallv increased and of longer duration.

[NOTE: Several pages of detailed tables follow which have been included as graphic files. Page 356, 357, 358, 359, 360, 361, 362, 363, 364, 365, 366, 367.]

    THERMOVIBRASSAGE has been used by Hitchings ["Thermovibrassage, A New Method of Treatment." Journal A.M.A., October 27, 1906] in the treatment of neuralgia as well as bruises, sprains and other conditions.  "A resistance coil is inserted into the same space ordinarily occupied by a ball vibratode.  The case surrounding the coil is of metal, and screws on the vibrator shaft just as an ordinary vibratode screws on.  From a plug switch on the bale of the vibrator a short cable passes into the case to connect with the coil wires, and part of the current which runs the vibrator is shunted through the coil circuit at pleasure by turning a switch on the bale beyond the plug switch, but between the switch controlling the current supply for the vibrator motor and the latter." If the heat switch is turned on for thirty seconds, after the vibrator is running, and if it is then turned off in the following thirty or forty seconds, a temperature of about 1080 F. will result.  Treatment is begun at this temperature.  The heat switch is turned on again for ten to twenty seconds and the temperature is raised.  Vibration continues whether the heat switch is on or off.  His report is as follows: The patient had suffered for years from attacks of trifacial neuralgia.  "No particular exciting cause had ever been found after repeated examinations.  Different forms of treatment had been tried with little or no result.  Dry thermovibrassage as hot as could be borne with comfort, was given over the tender spot, painful areas, and heck for five minutes.  The pain stopped completely before the treatment was over, and the patient felt drowsy, and took a nap.  There was no return of the pain until another attack came on three weeks later."

    While treating of neuralgia a consideration of the subject of "REFERRED PAIN," of which Head, Dana, Schmidt, Butler and others have made a scientific study, is important.

    Head's explanation of the phenomena is that a stimulus to an internal organ causing pain induces centripetal impulses, which are generally below "the threshold of consciousness," to be carried to a particular spinal segment.  A disturbance which may be local but is usually diffused occurs here in which are involved some fibres connecting this same segment with a definite area of the surface of the body.  Sensation and localization are more highly developed in the skin than in the viscera so that consciousness refers the pain to a definite surface of the body instead of the affected viscera.

    Mackenzie believes that the pain in visceral disease is "not felt as such in the organ, but is referred to the peripheral distribution of the cerebrospinal nerves in the external body wall.  Through an error of subjective localization the sensation is then interpreted as having its site in some adjoining internal structure, for example the stomach in gastric ulcer, or the heart in angina pectoris."

    Starr says, "They are referred by consciousness not to their actual point of origin, but to the part of the body from which sensations usually come when received at the particular segments irritated."

    As given by Starr:

    "The pain in eyestrain may be felt in the forehead or in the back of the neck.

    "The pain [Starr. Organic Nervous Diseases, page 100] produced by decayed teeth may be felt in the temple or behind the ear, instead of in the jaw.  Severe pain in the back of the head is a common symptom of uterine disease or of inflammation of the bladder.

    "Pain down the left arm is a common symptom of ear disease, and may be attended by hyperaesthesia in the region of the fourth and fifth dorsal nerves on the chest.

    "Pain in the wrist on the flexor surface is frequently felt in disease of the uterus ovaries or bladder.

    "Pain under the right shoulder blade is common in enlargement of the spleen.

    "Pain between the shoulder blades is a very common symptom of gastric affections of any kind.  It may be attended by hypereasthesia in the epigastric region, and the nearer the disease to the cardiac end of the stomach, e.g., ulcer, the higher the pain is felt.  In severe vomiting pain may be felt on the back of the arms or even down the back of the forearms.

    "Pain across the small of the back is common in colitis or in impaction of the faeces within the

    "Pain across the upper sacral region is very common in uterine disease.

    "Pain over the outer side of the hips is usually due to ovarian congestion.

    "Pain down the inner side of the legs is also due to the same cause.

    "Pain down the inner side of the knee is an early symptom of hip-joint disease.

    "Pain in the heel is a frequent symptom in lithaemia, and may also be felt in ovarian diseases."

    According to the same authority regions of referred pain after Dana are:
Cerebrospinal nerves Distribution Associated ganglia of sympathetic Distribution
I. Trigeminus facial  Face and anterior scalp 4th cervical Head
II. Upper 4 cervical Occiput, neck ... 1st cervical ... Head, ear
III. Lower 4 cervical and 1st dorsal Upper extremity 2nd and 3rd cervical, 1st dorsal Heart
IV. Upper 6 dorsal Thorax 1st to 6th dorsal Lungs
V. Lower 6 dorsal Abdomen, upper lumbar 6th to 12th dorsal Viscera of abdomen and testes
VI. 12th dorsal and 4lumbar Lumbar region, upper gluteal, anterior and inner thigh and knee 1st to 5th lumbar Pelvic organs
VII. 5th lumbar and 5th sacral Lower gluteal, posterior thigh and leg 1st to 5th sacral Pelvic organs and legs

    The general principle for treating these conditions is to vibrate the spinal centers and treat the functional or organic disorder present.  Starr noted that sharp counter-irritation where the pain is will frequently improve the condition of the viscus as well as relieve the pain.  This agrees with the results obtained from the administration of other modalities.  Reed ["The Autonomic Manifestation and Peripheral Control of Pain Originating in the Uterus and Adnex." Journal A.M.A., March 25, 1911] in considering visceral pain and its expression in superficial muscle or muscles states that "the pain itself can be partially and, as a rule, entirely, inhibited by inhibiting the muscle sensibility in the hyeralgetic areas."

    James Ross suggested that the pain is in such cases referred to parts supplied by sensory cutaneous nerve fibres, ending in the same segments of the cord as do the afferent fibres of the viscus diseased.  "Referred pain will occur in the skin areas of those roots which have white rami, of those from which the pelvic nerves arise, and of those nerves, if any, with which the vagus afferent fibres are intimately connected.  And there should not be primary referred pain in any other skin areas." Quincke made a study of sympathetic sensations.

    According to Schifer the "earliest attempt to determine which spinal nerves innervate a given abdominal viscus was made by Bulgak in 1877."  Other investigators were Bradford, Bechterew, Mislawsky, Bayliss, Starling, Schafer and Moore.

[Page 372 and 373 table graphics.]

    HYSTERIA is a functional neurosis.  It is due to auto-intoxication, mental strain, pelvic disorders or some agent increasing the arterial tension with resulting hyperaemia of the nervous elements [Sajous. The Internal Secretions and the Principles of Medicine, page 1862] of the posterior pituitary body causing hyperaesthesia of its centers, characterized by lost control, either
mental or physical or both, and marked by varying degrees of anaesthesia, paralysis, contractions, or other perverted conditions which call for removal or treatment of the cause.  An examination of most of the patients elicits a tenderness of the uterus which is in most cases successfully treated by daily applications of the static wave current to the uterus per rectum for twenty minutes.  Amenorrhoea may be relieved by a combined static and mechanical vibratory treatment for lowering the tension and to promote increased elimination and better functionalactivity.  These patients should have careful psychic, dietetic, and hygienic management.  If environment is not conducive to best results, a change where strict enforcement of prescribed routine treatment can be enforced is beneficial.  Sun light, daily baths, outdoor exercise, outdoor sleeping, when possible, colonic flushings of one quart of saline solution 1100 F., twice a week, and a non-auto-intoxicating diet but nutritious are recommended.  Sajous believes that saline enema "increase the fluidity of the blood and inhibit the irritability of the centers in the posterior pituitary body."  It is absolutely necessary in conjunction with mechanical vibratory treatment that moral restraint and control should dominate these patients.  Tact, firmness and removal of local conditions that are apt to influence the affection are of prime importance, and call for careful investigation in every case.  In addition to these, a spinal vibratory treatment with the ball vibratode applied to the intervertebral spaces for a general constitutional effect and to lower blood pressure is indicated in most cases.  Sometimes a general vibratory treatment meets other conditions.  Regulated exercise and static electricity are valuable adjuncts.  A rubber-covered disc vibratode applied to the areas of anaesthesia with rapid interruptions is beneficial as are also static sparks.  The treatment of disordered sensory symptoms is of secondary importance.

    NEURASTHENIA is a neuropathic condition which, according to Snow, "partakes in every case of some functional or organic derangement which either may have been primarily the cause of the nervous exhaustion or has resulted from it." There is exhaustion of the sympathetic center as pointed out by Sajous and with a consequent "relaxation and loss of propulsive activity [Sajous. The Internal Secretions and the Principles of Medicine, page 1866] of the arterioles.  "Lessened rapidity of the blood flow causes lessened functional activity of the organs, in consequence of which there is a lack of power generally, organically, mentally and physically.  The relaxed arterioles cause larger quantities of blood to go to the capillaries, thus they become engorged and the resulting effects are pain, tenderness, insomnia, indigestion, an alteration of secretary and excretory functions, dysmenorrhea, false angina caused by engorgement of the cardiac capillaries, anaemia and associated conditions tending to hysteria or hypochondriasis.  The first indication is to remove or treat the cause.

    Mechanical vibration induces functional activity without the expenditure of active energy on the part of the patient.  Constitutional vibratory treatment, however, will be of little value unless the cause for the condition be treated and relieved.  The capillary congestion should be removed and nutrition should be promoted.  In the treatment of this condition apply interrupted vibration to the spine with the ball vibratode, special regions being vibrated to meet conditions.  Also treat according to indications any local condition associated with the trouble.  In all cases stimulate the liver, spleen and solar plexus to awaken sluggish activities.  In some cases a more general treatment may be indicated.  Conditions must be met as found in individual cases.  Treatments include the following as Snow [Wm. Benham Snow. Currents of High Potential of High and Other Frequencies, page 209] aptly says: "Radiant light and heat and mechanical vibration as indicated: d'Arsonvalization for the treatment of hypertension when present and the static and high frequency currents in the treatment of the two types of pelvic inflammation, simple and infected, each ploys an important role." Hygiene including daily baths, outdoor life to a great extent passive and life at the seashore are beneficial.  Sea bathing is recommended when not contraindicated by the patient's condition.  A restricted non-fermentative but nutritious diet is necessary, and environments as far as possible should be made congenial.  The length of time necessary to treat an individual case, and the prognosis will depend upon the chronicity, whether organic disease be present, and on how amenable the cause is to treatment.  For gastroptosis or displacements of other abdominal viscera, the use of a proper corset or abdominal belt is beneficial in conjunction with indicated treatment.  They afford support and favorably affect the abdominal circulation.

    SEXUAL NEURASTHENIA, impotency and prostatitis may also be treated by mechanical vibration either alone or in connection with applications of static electricity.  Employ the rectal vibratode for five minutes or so, using a medium stroke and a fairly rapid speed, taking care that the treatment be not too prolonged.  The best vibratode, in the writer's opinion, is a flexible one of soft rubber about six inches long.  The application has a soothing effect and is not disagreeable to the patient.  As yet little has been published in this line of treatment, but it offers a splendid field for rational investigation.  The treatment par excellence for this condition according to Snow [Wm. Benham Snow. Currents of High Potential of High and Other Frequencies, page 218] is by static electricity.

    SPLANCHNIC NEURASTHENIA (Abrams) characterized by nervous depression "abdominal sensitiveness, tenderness and enlargement of the liver, gaseous accumulations in the bowels and an exaggerated cardio-splanchnic phenomena " has been considered in Chapter VII.  Spinal vibratory treatment is indicated from the 5th to the 12th dorsal nerves inclusive, whose origins are from the 2nd to the 9th dorsal vertebra inclusive. (Morris.)

    CHOREA is caused by (1) waste products due to waste from excessive metabolism, or the result of hypocatabolism, (2) toxins of infectious disease, or (3) autotoxins, " [Sajous. The Internal Secretions and the Principles of Medicine, page 1852] inducing over excitability of the vaso-motor center and causing general vaso-constriction (of the large vessels) and consequent
abnormal functional activity and increased arterial tension.  Them indications are met by reducing the waste products by high colonic saline solution flushings, one quart, 1100 F. twice a week and the use of castor oil, and mineral waters.  Light baths to promote elimination and the application of static insulation with an electrode to the spine and the spark gap widely separated to promote nutrition without excitation prove beneficial.  A non-fermenting nutritious diet, no meat nor eggs being allowed, with daily warm baths of five minutes' duration, to be substituted for a cold sponge if the patient does not react well are essential.  Nutrition should be increased without increase of waste products.  Mechanical vibration between the 2nd and 3rd dorsal vertebrae with the ball vibratode for five minutes or long enough to lower the blood pressure is beneficial.  Outdoor life and in some cases a limited amount of agreeable work may be desirable.  The local manifestations disappear under the general selective treatment.

    EPILEPSY is a functional nervous disease, characterized by almost "abrupt loss of consciousness followed by tonic and clonic spasms ending in coma."  The loss of consciousness may or may not be preceded by an "aura."  The disease is either due to organic lesions of the brain associated with pressure or to functional derangements.  In epilepsy there is an excess of toxic wastes and excessive vaso-constriction and often a rise of arterial tension.

    These indications call for the removal of waste products by means of high colonic flushings with saline solution, and reduction and selection of food to limit the auto-intoxication.  The quantity of food should be limited to the minimum necessary for the patient's physical requirements and should consist chiefly of milk, buttermilk, zoolak, koumiss, toasted bread with butter, fresh cream cheese, cooked cereals, cooked vegetables, except onions and cabbage, and cooked fruits.  Uterine troubles should be treated as a rule with the static wave current per rectum for twenty minutes.  Adenoids should be removed when present and gastric disturbances should be corrected.  Other sources of irritation should be treated or removed as indicated.  Mechanical vibration should be so applied as to lower the blood pressure - usually between the transverse processes of the 2nd and 3rd dorsal vertebrae.  Daily baths and an open air life with quiet are beneficial.  Mechanical vibration for the relief of constipation when present, is necessary.

    MELANCHOLIA may be classified as (1) simple, (2) attonita associated with nutritional and circulatory disturbances, with stupidity, and (3) agitated.  Melancholia may be associated with cerebral arterial anaemia.  The cause should be discovered and removed or treated.  Pelvic derangements when present should be relieved.  Nutrition should be increased and general
elimination promoted.  Light baths, the static wave current and general spinal vibration of short duration with the ball vibratode for stimulation and a vibratory treatment of the liver, spleen and stomach with the disc vibratode as well as a mechanical vibratory treatment of the bowels are indicated.  Nutritious, easily digested food, daily baths, exercise in the open air and cheerful environment should be included in the treatment.  If necessary spinal vibration may be employed to increase arterial pressure.

    LOCOMOTOR ATAXIA, a posterior spinal sclerosis, is characterized by "lightning pains, absence of knee jerk, Argyl-Robertson pupil, marked incoordination without loss of muscular power, diplopia, optic atrophy, impotency and unsteadiness on the feet when the eyes are closed."  For the treatment apply long static sparks for the pain, friction sparks for anaesthesia, and the static wave current with a long spinal electrode for improving the nutrition of the cord.  Dysthesia or anaesthesia should be treated with rapidly interrupted vibration with the disc vibratode over affected areas.  The ordinary abdominal treatment with a disc vibratode, and rectal treatment should be employed for constipation.  For the gastric symptoms vibrate the stomach with the disc vibratode and with the ball vibratode vibrate the left 6th, 7th and 8th dorsal nerves near the spine.  A mechanical vibratory treatment of the abdomen should follow as outlined in the following chapter.  Treat conditions as they arise.  Combine with the above vibratory treatment prolonged interrupted vibration with moderate pressure with the disc vibratode applied over the motor points of the affected muscles, particularly on the posterior aspect of the thigh or leg.  This is especially beneficial over the motor points of the gastrocnemei holding the disc long enough to count twelve, six or seven times if the muscles do not relax.  A deep interrupted vibratory treatment with the ball vibratode in the inter-vertebral spaces of the segment of the cord controlling the affected muscles may be given if necessary.

    GRADED EXERCISES FOR MUSCLE COORDINATION are of great assistance to the static electrical treatment.  It is best to begin with a step-up exercise.  With the hands on the hips to help to preserve the body balance, feet in good position, have patient step up with one foot placing it on a foot stool, and then balance himself there while counting six; and then bring the foot to its initial position.  This should be repeated three times, and should be followed by a like exercise with the other foot.  When progress is noted, the feet should be alternated in stepping up.  Care must be exercised not to over exercise, for the muscles become tired before the patient realizes it.  Later other exercises should be gradually introduced, as, higher step-up exercises; standing on tip-toe; forward charging with one foot, both heels being on the floor, patient being in an upright position; forward charging with the knee of the extremity brought forward bent, the stationary leg being rigid, both heels being on the floor; line walking; side stepping; and exaggerated spring walking are also good as control improves.  Practice walking with the toes slightly outward, placing the heel on the floor first, then rolling the feet uniformly from heel to toe so that every part touches the floor improves the normal walk.  Sometimes the movement of making a turn has to be analyzed and the separate movements given to the patient as special exercises if he has difficulty in turning.  During these exercises the patient is allowed to glance at his feet if he desires until he can do the exercise well.  Thereafter he is to practice the exercise, looking directly forwards.  These exercises generally cover a period of months.  Usually the step-up exercise requires a week or two or more before the patient can be advanced to another exercise.  The exaggerated spring walking exercise and walking with the feet in proper position and also rolling the foot uniformly from the heel to the toe are introduced as soon as possible, but the others are introduced only as the patient's proficiency warrants it. An exercise invaluable to facilitate rising from a chair, the patient being seated slightly forward on the chair but upright, is as follows.  The patient being seated in a chair as aforesaid with his hands on his hips, places the right foot slightly in advance of the left with the toes pointing outward.  The patient then with the body rigid inclines slightly forward at an angle and arises at the same time.  He will soon accomplish this with the slightest effort.

    CONTRACTED PUPILS may be dilated and the diplopia be relieved to a remarkable extent by mechanical vibration applied with the ball vibratode between the 2nd and 3rd and 3rd and 4th dorsal vertebrae for three minutes or so.

    Radiant light and heat are also valuable adjuncts to be applied for improving nutrition when indicated, although as a rule tabetic patients do not tolerate light as a normal individual would.  Sometimes hydrotherapy as a "cold brief douche to the spine and to relaxed muscles" is a useful adjunct after the patient begins to improve.  Incontinence is treated as directed in the following chapter.

    PARALYSIS AGITANS is a functional nervous disease, characterized "by muscular weakness, tremors, and rigidity." The cause of this trouble is not definitely understood.  The motor symptoms point to the cortical motor centers.  The sensory symptoms and the "local increase in temperature" as occasionally seen, Gowers believes point to involvement of the sympathetic system.  In the writer's judgment constipation and the consequent auto-intoxication seem to be undermining factors.  This condition calls for colonic flushings, and the institution of an easily digested diet, daily baths, radiant light and heat baths, and the administration of mechanical vibration to improve the general metabolism.  The static wave current may sometimes be found beneficial.  Nutrition should be promoted with the minimum of toxic wastes.  Cyriax [The Elements of Kellgren's Manual Treatment, page 195] also uses exercises and states that in most cases of paralysis agitans "frictions on the extensors on the back of the forearm entirely remove the tremors for a few seconds."  He refers to nerve friction with the fingers.  For exercises in the treatment of this trouble the reader is referred to the works of Cohen and Cyriax.  "Charcot thought very highly of treatment by vibration in this disease and used for it the shaking chair, as well as local vibrations, manual or mechanical.  The feeling of constraint, due to the muscular rigidity is relieved by this application, and its use is thought to bring about favorable alterations in the peripheral nerve-endings, by both reflex and direct stimulation."  Parathyroid extract given according to Berkley is beneficial in many cases.

    ANTERIOR POLIOMYELITIS OR INFANT PARALYSIS being probably due to an infectious process calls for increased elimination.  The use of the 500 candle power lamp, the static wave current with mechanical vibration, and at first passive and later active exercise, is very beneficial in these most trying cases.  The earlier these cases are treated the better the result.  As the cervical or lumbar enlargement is the favorite site of structural changes in the cord, the static wave current is applied to the spine by means of a flat metal spinal electrode 11/2 by 8 inches from above downward or from below upward or in young children the entire length of the spine according as conditions demand and a spark-gap of from ten to fourteen inches is employed for twenty minutes daily.  Mechanical vibration is applied as follows.  With the ball vibratode make interrupted applications alternately on each side of the spine between the transverse processes of the spinal vertebrae corresponding with the part of the cord affected directly and also in the region whose muscles are indirectly affected owing either to lack of power or restricted motion.  The back should be vibrated in this manner two or three times.  When the foot is affected, make slightly prolonged interrupted application with the disc vibratode over the contracted muscles of the sole and about the ankle and the tibial part of the leg.  Otherwise short interrupted vibration should be applied over the remaining portion of the foot and ankle.  After having dusted the surface of the leg posteriorly with talcum powder, apply vibratory friction with the disc vibratode centripetally from the ankle to the knee covering the same surface each time three times in succession.  The entire posterior surface of the leg should be vibrated three times.  Interrupted vibrations are then applied to the knee joint posteriorly then vibratory friction centripetally is given over the thigh as for the leg.  The same procedure is followed in vibrating the leg and thigh anteriorly.  Interrupted vibration is also applied with the disc vibratode over the glutei.  The same line of treatment is followed when an upper extremity is affected.  For the hand, apply centripetal friction over the hand anteriorly and posteriorly three times over each single surface, this procedure being repeated three times over the entire hand.  Interrupted vibration is then applied to the wrist making a resisting surface of the operators other hand.  Centripetal friction is then applied from the wrist to the elbow in the same manner, as when vibrating the hand, followed by interrupted vibration to the elbow-joint and centripetal friction from the elbow to the shoulder.  Interrupted vibration is also applied to the axilla to promote the activity of the lymphatics, and over and around the shoulder joint and the weakened back muscles covering the era, about three times.  Selected passive exercises are introduced as early, as possible and the child is encouraged to initiate movements of the affected parts.  Daily active and passive exercises are very important.  Later the mechanical vibration should be followed by exercises consisting of active movements slowly executed lying down, next like movements, sitting.  Practice in standing erect with the feet placed in the correct position should follow, at first supported, later unhelped.  Coordinate movements of the simplest form gradually increased in difficulty of execution should be done as soon as possible.  The child should be encouraged to use or try to use the affected part in the proper manner.  The prognosis as a rule is good, but both operator and patient must possess patience as the treatment should be continued for six months or a year.  A properly adjusted support or brace not limiting natural movements but restricting unnatural movements is often beneficial.

    OCCUPATION NEUROSES are due to overuse of muscles and consequent nervous strain in (1) movements requiring co-ordination in the performance of skilled technique as in writing, when the flexors are most affected, piano playing, telegraphing, when the extensors are most affected, and similar occupations, (2) movements requiring work of more weight, as shoemaking and painting, characterized by chronic or tonic spasms of flexors or extensors, accompanied with marked fatigue, tremor, pain, and sensory disturbances.  The condition is generally found in neurasthenic individuals, or those of neurasthenic tendencies.  Wm.  Benham Snow believes an accompanying neuritis to be characteristic of the trouble.

    Mechanical vibration when employed with these patients, if there is no organic, nervous condition when properly applied acts as a tonic and sedative; promoting metabolism and improving nutrition.  The indications are to remove the cause, rest the part, lessen the irritability and later to re-educate the muscles.  Local treatment is always advisable, and many cases also require a constitutional treatment, spinal, static, or vibratory, as indicated to improve the general condition and raise the individual's resistance to normal.  The accompanying neuritis calls for treatment as prescribed under neuritis.

    The mechanical vibratory treatment is as follows: Employ centripetal vibratory friction with at first light and later moderate pressure, with medium stroke, employing the rubber-covered disc vibratode, beginning the application at the ends of the fingers, first on the dorsal side, moving the vibratode from the finger tips over the intermetacarpal spaces, six or seven times, to the wrist-joint.  To the wrist it is best to make applications of deep interrupted vibration.  Anteriorly apply vibratory friction from the finger tips to the wrist, traversing the surface six or seven times.  Also apply deep interrupted vibration three or four times successively to the center of the palm to induce acceleration of the venous circulation.  Then apply vibratory friction to the fore-arm, posteriorly and anteriorly as far as the elbow joint and about the elbow apply interrupted vibration as at the wrist.  Continue the application of vibratory friction to the arm and apply interrupted vibration to the axillary region with the rubber-covered disc vibratode.  Apply prolonged interrupted vibration also over the site of contraction.  Stretching of the arm and shoulder joint is accomplished (1) by the operator and patient grasping each other's thumbs with the corresponding hands and making a few vigorous elastic pulls, the applied force being gradual, but the withdrawal should be rather sudden or (2) by the operator placing one hand on the shoulder and grasping the patient's hand and pulling carefully and steadily with the other hand.  The patient should lie upon his back during such application with the arm raised upward.

    After such treatment of the arm has been persisted in for a time, associated with rest from occupation, and when all spasms at least of the extensors have ceased, employ passive, and later active or resistive movements, as indicated.  These exercises singly or in unison of flexion, extension, and raising the fingers as in playing the piano, and of separating the fingers, gradually increasing in power and duration, two or three times daily.  The exercises should be slowly executed.  These exercises should be passive at first.  When the parts are strong enough to initiate active movements, the patient should be encouraged to do so, care being taken not to overdo.  Light work requiring no complicated finger movements should be gradually introduced before the writing exercises are prescribed.  Wolff cured 157 cases of occupation neuroses, improved 22, and failed in 98 of 277 cases treated.  He employed massage twice daily in combination with "exercises of bending and stretching, spreading and contracting of the hand and arms for hours until the hand was fatigued, and these were repeated until the patient was able to move each finger voluntarily in all directions.  Elementary exercises in writing, prescribed and adapted to each case, also formed part of the treatment.  Fixation of muscles by elastic bands, so as to give special exercises, was resorted to in some cases."  These results were attested to by Billroth, Charcot, Esmarch, and others. (Graham.)  The successes were obtained in the cases which were characterized by tremor and spasm.  The writer has pursued this plan of treatment associated with mechanical vibration instead of massage with marked success.  Exercises were prescribed to be taken late in the evening and early in the morning, as well as at the time of treatment.  Writing exercises must not be introduced too early.  The pen should be held properly, the height of the stool and the desk, the position of the patient, and the manner of writing must be carefully regulated.  Graham makes use of "resistive movements of supination of the forearm, of extension of the hand and of each finger separately."  These he alternated with "massage every few minutes." Treatments twice daily are sometimes necessary.

    HEMIPLEGIA is a paralysis of one-half of the body laterally and is classified with reference to the localization of the lesions and symptoms by Abrams [Clinical Diagnosis] as follows:
Symptoms Seat of Lesion
Hemiplegia with motor aphasia. 3rd left frontal convolution.
Hemiplegia with paralysis of lower facial branches. Posterior limb of internal capsule.
Hemiplegia with hemianaesthesia. Posterior third of internal capsule.
Hemiplegia with crossed paralysis of third cranial nerve. Crus cerebri on same side as paralyzed nerve.
Hemiplegia with crossed facial paralysis. Pons paralyzed.

    From a therapeutic point of view we are most interested in the causative conditions, which are: (1) Embolism; occurring principally in young people, in which case the onset of the paralysis is usually sudden, without loss of consciousness, and usually associated with motor aphasia, and most often occurs in patients in whom a cardiac lesion is present.  (2).  Apoplexy; occurring usually after middle age, of sudden invasion "with loss of consciousness and usually associated with lower facial paralysis," and atheromatous arteries.  White reports excellent results from the treatment of "a case of hemiplegia complicated with persistent insomnia."  He applied the ball vibratode "in the interspaces between the transverse processes of the spinal column from the occiput to the last sacral vertebra" and a multiple point vibratode to the fingers and affected arm.  Insomnia in this case was also relieved.  The writer has noted improvement following a vibratory frictional treatment of the arm in a case where the arm had been affected.

    Apoplexy is preceded by an advanced arterio-sclerosis with high arterial tension and is best treated by the institution of a regime including a diet of easily digested but nutritious food, devoid of meat and eggs; high colonic flushings, or laxatives; the avoidances of excitement; a limited amount of well regulated exercise; and d'Arsonvalization or mechanical vibration to lower and control the blood pressure.

    An application of interrupted vibration with the ball vibratode between the transverse processes of the 2nd and 3rd dorsal vertebrae for five minutes or ten if necessary, will generally lower blood pressure unless there is a cardiac insufficiency when vibration between the 7th cervical and lst dorsal vertebrae is indicated.  Local vibratory treatment as centripetal frictions with the disc vibratode over the muscles and interrupted vibration about the joints will prevent muscular atrophy.  Well directed limited exercises are beneficial.  Cyriax [The Elements of Kellgren's Manual Treatment, page 161] notes "that in some cases of hemiplegia, cervical nerve frictions will cause involuntary twitchings or even coarse movements to take place in the affected area, or leg."

    FACIAL PARALYSIS due to neuritis caused by cold is satisfactorily treated in many cases by applying the static wave current with a metal electrode, molded over the affected nerves and muscles, for twenty minutes daily followed each time by an application of the static brush-discharge.  If the pupil on the affected side is contracted, it may be treated by applying mechanical vibration between the transverse processes of the 2nd and 3rd and the 3rd and 4th dorsal vertebrae for about five or ten minutes using the ball vibratode.  One most interesting case noted an inability to read the lower line of the Snelling test card.  Improvement promptly followed vibratory treatment applied as described.

    Mechanical vibration is effective in the treatment of a few PATHOLOGICAL CONDITIONS OF THE EYE.  "The vaso-constrictor neural cells of the eye are from the 2nd, 3rd and 4th dorsal segments.  The vaso-dilator neural cells [Arnold.  "Examination of the Back." Medical News, March 18, 1905] of the eye are chiefly in the nucleus of the third cranial nerve, probably to some extent in the nuclei of the third and sixth.  The visceromotor cells for the iris and ciliary muscles are as follows: Those which bring about a constriction of the pupil are in the nucleus of the third cranial nerve.  Arnold thinks that the dilator cells for the pupil are found chiefly between the 6th cervical and 1st or 2nd dorsal segments." According to Landois the condition of the blood vessels affects the size of the pupil. [Landois. Text-Book of Human Physiology, page 842]  If they are injected, the pupil contracts, whereas diminution in the quantity of blood results in dilatation of the pupil, hence according to Arnold's findings for vaso-constrictor cells the dilator cells for the pupil would include the second, third and fourth dorsal segments.  Since a segment refers to the site of the root origin of a nerve, the fourth dorsal segment refers to the origin of the fourth dorsal nerve whose exit is between the 4th and 5th dorsal vertebrae.  In the writer's experience dilatation is best elicited between the 2nd and 3rd and the 3rd and 4th dorsal vertebrae.  Landois [Text-Book of Human Physiology, page 749] states that pupillary fibres for dilatation go as far as the second cervical nerve (in the rabbit) and anastomosing fibres pass from there "to the cilio spinal region and thence through the three or four thoracic nerves into the cervical sympathetic."

    DILATATION OF THE PUPIL is induced by deep interrupted vibration in the intervertebral spaces from the 7th cervical vertebra to the 5th dorsal with moderate pressure.  Stimulation of the fifth cranial nerve has the same effect.  It is useful in the treatment of some forms of facial paralysis and for the eye conditions of locomotor ataxia.

    MECHANICAL VIBRATION WHEN APPLIED OVER THE EYE in the treatment of eye diseases should be employed in the form of a vibra-massage.  Make the application for but a short time, 30 seconds to a minute or so, and as a rule only once daily, using a soft rubber cup vibratode with the shortest stroke and no pressure over the eye ball.  In all cases indicated constitutional treatment with due consideration of diet and hygiene must be observed.  A study of the blood pressure should be made in every case.

    Mechanical vibration of the eye is indicated for TWITCHING OF THE LIDS, BLEPHAROSPASM and GLAUCOMA.  The greatest gentleness and skill must be employed in the treatment of the eye, avoiding the possibility of causing irreparable injury, such as retinal detachment.  In some cases vibratory treatment alone is effective, while in others a combination with other methods gives the best results.  As with other affections, treatments should vary from twice a day to once a week, according to the indications of the case.

    Vibration like massage "is contraindicated in acute inflammation of the conjunctiva, cornea, sclera, iris, and ciliary body, and after accidents or purposive surgical wounds."

    Mechanical vibration relieves muscular tension, assists elimination, and absorption, and stimulates the functions of the various structures of the eye.

    In a case of GLAUCOMA, treatment consisted of light for ten minutes from a 50 candle power incandescent therapeutic lamp, static electricity for seven to ten minutes with a vacuum tube electrode, and vibra-massage over the eyeball.  d'Arsonvalization was given for the accompanying high tension with marked relief.  These combined treatments were given three times weekly and with a most happy result.  The vibration was given interruptedly each time over the closed lids, the cup-shaped vibratode being held in contact long enough to count ten rapidly.  About ten applications were thus made at each treatment.  It gave a feeling of comfort after the administration of the light and the static current, and assisted in relieving the tension.  The administration must be made with the greatest gentleness and for but a few seconds.

    RETINAL ANAEMIA was successfully treated by the late Dr. Maurice F. Pilgrim by the application of mechanical vibration "over the vaso-motor area in the spinal cord, which influences the blood supply of the eye-at the junction of the fourth and fifth dorsal.  It was also applied to the third and fourth cervical, and over the sub-occipitals, for its derivative effect through relaxation of muscular contractures."  Vibration was not applied over the eyeball for more than six times and then but "for a few seconds."  Treatment was administered daily.

    THE MUSCLES OF THE EYE are supplied by the 3rd cranial, the motor oculi, which also supplies the levator palpebrae superioris, rectus superior, inferior and internal, and the obliquus oculi inferior.  The 4th nerve supplies the obliquus oculi superior, and the 6th the external rectus.  These nerves are best affected by vibrating through their connection with a division of the superior cervical ganglion.

    IN PARALYSIS OF THE MUSCLES of the eye vibra-massage combined with an exercise as stretching and contraction of the affected muscles may be employed.

    SECRETION OF TEARS may be reflexly induced by stimulating the mucous membrane of the nose or by direct stimulation of the cervical sympathetic.

    AUDITORY NERVES are excited by mechanical vibration "of the end-organs of the acoustic nerve due to the wave-motion of the lymph of the labyrinth." The nerves of the auditory canal come from the auricular branch of the pneumogastric and the inferior maxillary of the fifth and these with a branch of the glosso-pharyngeal supply the membrani-tympani.  The muscles of the ear are supplied by the facial nerve.

    The nerves of the middle ear constitute the branches of the otic ganglion.  They comprise a branch of the facial chorda tympani nerve, a branch of the glosso-pharyngeal, one from the carotid plexus of the sympathetic and a branch of the great superficial petrosal.  Those of the Eustachian tube are derived from branches of the sympathetic through the pharyngeal plexus, which comprise also a branch from the superior cervical ganglion, some nasal branches from Meckel's ganglion, and some branches from the pneumogastric and glosso-pharyngeal.  The blood vessels of the ear are derived directly or indirectly from the external and internal carotid.  The vaso-constrictor neural cells for the ear are found in the 2nd, 3rd and 4th dorsal segments (Arnold). ["Examinations of the Back." Medical News, March 18, 1905] The vasodilator [Landois and Stirling] nerves of the blood vessels of the ear are from the inferior cervical ganglion and the first dorsal.

    THE EXTERNAL EAR is supplied by the auricularis magnus, which is made up of a branch of the 2nd and 3rd cervical nerve, a branch from the facial, pneumogastric, inferior maxillary, occipitalis minor, one from the 2nd cervical nerve, and another branch from the posterior division of the 2nd cervical nerve.

    When the tragus is vibrated interruptedly the shortest stroke should be employed and a moderate rate of speed, with a cup vibratode.  Apply the vibration in such a manner as to open and close the external meatus.  In treating the ear locally always make use of a soft rubber vibratode.

    The above method is employed for the purpose of exercising the structures of the middle ear, and should be followed by treatment directed to the Eustachnin tube.  This is best accomplished by applying vibratory friction with light pressure to the neck in the groove behind the car following downward in the space between the angle of the jaw and the mastoid process along the anterior border of the sterno-cleido-mastoid muscle in its upper part.  The latter treatment is instrumental in relieving inflammation and obstruction of the Eustachian tube, and also itching of the throat caused by obstruction of the tube.  For exercising the tympanum a pneumo-massage apparatus has been found useful.

    CHRONIC DISEASES OF THE MIDDLE FAR when suppuration is not present may be treated by mechanical vibration.  In catarrh of the tube it may be employed, and it is sometimes of value for relief of TINNITUS AURIUM.  Tinnitus aurium may be due to either central or peripheral lesions.  Abrams classified them as follows: "To the former (central) belong those noises produced exclusively by pathological ellanges of the structures of the labyrinth; and peripheral, to those due to causes external to the labyrinthal structures.  Noises originating in the labyrinth may be caused by exudation, increased pressure, anaemic and hyperaemic conditions, and from the action of drugs.  These noises are always associated with a disturbance of hearing.  Catarrh of the middle ear frequently gives rise to entotic or subjective noises.  Sometimes the noises come from the vessels, particularly the carotid, which passes in close proximity to the ear.  Other noises emanate from the jugular fossa, and others are produced by muscular contraction, particularly of the masseter" muscles.  If an acute inflammation exists only the parts around the ear should be treated by vibration, not the ear itself.  In ear troubles as in other conditions, the removal of causes, and the building up of tissue resistance is indicated.

    Compressing interrupted vibration or the X-ray is indicated in cases of AURICULAR INDURATION after healing of the incision after operative procedures.

    Success in the treatment of CATARRHAL DEAFNESS has been reported by Bellows, who used rapid vibration, "in and out movement, 15 seconds at a time followed by the high frequency current for two minutes at each treatment." He sometimes substituted the Faradic for the high frequency.

    Vibration may be used more particularly in combination with exercise, static electricity, or some other measure to assist in obtaining the greatest degree of success in the treatment of many of the preceding conditions.