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

Chapter 12

Relation of Mechanical Vibration to the Digestive System

    The functions of digestion and assimilation are associated with physical (mechanical) and chemical processes, which under atonic or otherwise impaired conditions may be restored by the judicious employment of mechanical vibration, alone or in combination with indicated auxiliary measures.

    Mechanical vibration is therefore a valuable means for inducing the functional activity and correcting other derangements of digestion.  The applications require skillful regulations as to site and adaptations of speed, stroke, pressure, and time to the conditions present and to the patient's natural resistance.

    Constitutional vibratory treatment, i.e., the spinal treatment, when not prolonged, will produce a general sedative effect associated with a sense of buoyancy.

    THE SALIVARY GLANDS get their nerve supply from the sympathetic and from a cranial nerve.

    "1. The sympathetic nerve [Landois and Stirling. Text-Book of Human Physiology, 4th edition, page 251] gives branches (a) to the sub-maxillary and the sub-lingual glands derived from the plexus on the external maxillary artery; (b) to the parotid gland from the carotid plexus.  These nerve fibres can be traced to the superior cervical ganglion and from thence through the cervical sympathetic into the cord.  "

    "2. The facial nerve gives branches to the sub-maxillary and sub-lingual glands from the chorda tympani which accompanies the lingual branch of the fifth nerve."  The branches of the parotid arise from the tympanic branch of the glosso-pharyngeal nerve (dog).  "The tympanic plexus joins the otic ganglion, and this ganglion sends branches to the auriculo-temporal nerve (itself derived from the third branch of the trigeminus), which as it passes upwards to the temporal region under cover of the parotid, gives branches to this gland."

    "The sub-maxillary ganglion, which gives off branches to the sub-maxillary and sub-lingual glands, receives fibres from the tympanico-lingual nerve (chorda-tympani) as well as sympathetic fibres from the plexus on the, external maxillary artery.

    Sajous [The Internal Secretions and the Principles of Medicine, pages 272 and 275] states that over the blood vessels of the sub-maxillary gland (of a dog) are "entwined sympathetic fibres from the superior cervical ganglion which fibres are enclosed in a common sheath with the main sensory nerve present, the vagus," which strengthens the belief that they must in a measure govern the quantity of blood distributed to the organ." His deductions in regard to the functional mechanism of the sub-maxillary are as follows:

    "Some fibres of the chorda tympani are distributed to the secreting elements to excite and govern their metabolism; the remaining fibres of the same nerve are distributed to some of the glandular arterioles, but not to those which supply capillaries to the secreting elements.  While the gland is in the passive state the blood flows equally through all arterioles.

    "When the gland is active, the chorda tympani constricts the arterioles to which it supplies fibres, and thus forces the bulk of the blood through the, free arterioles and thence into the glandular capillaries.

    "The rapidity of the blood-flow through the organ is concurrently increased through sympathetic constriction of the extra-glandular arterial branches functionally connected with the gland."

    Arnold ["Effects of Vibration on the Back." Medical News, March 18, 1905] believed that the vaso-constrictor neural cells for the salivary glands are in the 2nd, 3rd and 4th dorsal segments and the vaso-dilator neural cells of the sub-maxillary and sub-lingual glands are in the nuclei of the 7th cranial and of the parotid glands in the nucleus of the 9th cranial.

    IF THE SYMPATHETIC NERVE which contains vaso-constrictor as well as secretary fibres be stimulated it causes a thick secretion in the sub-maxillary abounding in mucin, thereby increasing the normal specific gravity of the secretion.  Contraction of the blood vessels and lessening of the rapidity of the venous circulation also result.  It is probable that "the nerves exercise a direct effect upon the secretory cells, apart from their action on the blood vessels." Ludwig demonstrated that while secretion is active the rise in the temperature of the glands is 1.50 C., and according to Landois and Stirling [Landois and Stirling. Text-Book of Human Physiology, 4th edition, page 255], whether the stimulus be electric or other stimulus "of the peripheral end of a glandular nerve the following changes occur:

    "(1) Vaso-motor changes, causing alterations in the blood supply and blood-flow.

    "(2) Chemical and histological changes in the gland-cells connected with the elaboration of the organic and possibly of the inorganic constituents of the saliva.

    "(3) Changes by which water is secreted, i.e., passes through the basement membrane and gland-cells and the consequent movement of the fluid through the cells and ducts.

    "(4) Electrical changes which do not seem to be associated with the vaso-motor changes, for the electrical variations are readily abolished by atropin which does not affect the vaso-motor changes."

    Stimulation of remote sensory nerves, as the sciatic, affects the parotid gland reflexly, causing secretion of the saliva (Owsjannikow and Tschierjew).  When considering the effect of vibratory stimulation upon the glands it is well to mention the results of one of Colombo's experiments.  He found that "the parotid gland did not respond so quickly as the salivary.  Increased secretion occurred after 5 minutes' massage but 10 minutes were required for the maximum secretion." Less time is required for the induction of a corresponding effect with mechanical vibration.

    Cyriax [Elements of Kellgren's Manual Treatment, page 290] reports cure in a case of EPIDEMIC PAROTITIS, the treatment being as follows: "Vibrations (manual) and shakings, followed by frictions on the salivary glands and on the swollen lymphatic glands; running vibrations from above downwards along the sterno-mastoids; frictions on the facial nerves and on the nerves lying in the sub-maxillary region.  General treatment for fever."

    Mechanical vibration applied to the glands should be administered with the rubber-covered disc or cup-shaped vibratode and may be applied by friction or interruptedly.  Vibration of the PAROTID GLAND, which "lies upon the side of the face immediately below and in front of the external ear" should be begun behind the ascending ramus of the jaw and continued downward.  In front of the external ear vibrate forward.  Then follow the line of Steno's duct - "to a finger's breadth below the zygoma from the lower part of the concha to midway between the free margin of the upper lip and the ala of the nose."  The vibration should be applied lightly with a medium stroke.

    Vibration of the SUB-MAXILLARY GLAND should begin halfway between the angle of the jaw and the mentum as it is below and to the inner side of the lower jaw.  Vibrate up and forward in the direction of Wharton's duct with interrupted vibratory applications.

    The SUB-LINGUAL GLAND can be reached behind the chin.  Vibrate upward and forward.

    THE PHARYNX, extending from the "under surface of the skull to the cricoid cartilage in front and the intervertebral disc between the 5th and 6th cervical vertebrae behind," receives its nerve supply from the pharyngeal branch of the pneumogastric.  This branch, which is "the principal motor nerve of the pharynx, arises from the inferior ganglion of the pneumogastric, receiving a filament from the accessory portion of the spinal accessory, passes across the internal carotid artery to the upper border of the middle constrictors Here it divides into filaments communicating with those from the external branch of the superior laryngeal, the glosso-pharyngeal and sympathetic to make the pharyngeal plexus which supplies the pharyngeal muscles and mucous membrane.

    The glosso-pharyngeal nerve supplies "fibres of ordinary sensation to the pharynx and is the motor supply of the stylopharyngeus and the superior and middle constrictor.  It is found "below and internal to the horizontal ramus of the jaw.  "

    When applying mechanical vibration to the pharynx use the small cup-shaped vibratode, beginning posterior to the ascending rami and administer vibratory interruption or friction from above downward.

    IN CHRONIC FOLLICULAR PHARYNGITIS mechanical vibration has already been demonstrated of value.  Morse treated a case successfully by vibrating "deeply over the cervical spinal nerves, and externally over the glands of the neck," presumably to control the vaso-motor area of the head to lessen congestion, and to unload the lymphatics, particularly the cervical glands.  To this treatment may be added vibratory friction of the neck anteriorly and posteriorly.

    MECHANICAL VIBRATION PROMOTES to a marked degree the functional activity of the liver, stomach, and intestines - both promoting absorption and increasing peristaltic activity.

    HEPATIC ACTIVITY MAY BE INDUCED (1) directly by applying over the liver interrupted vibration with moderate or deep pressure and medium stroke followed by vibratory friction; (2) indirectly or reflexly by the application of abdominal vibration or spinal stimulation.

    Professor Colombo of Turin demonstrated in respect to binary secretion that, "after ten minutes of trepidation (shaking or vibration) and of tapotement or percussion the quantity of bile increased considerably in the next four hours.  The cholestrin and the binary soda salts were most abundant.  After twenty-five minutes of friction and of petrissage the same results were obtained as after ten minutes of trepidation and tapotement; the maximum result was obtained by combining ten minutes of friction and petrissage."  These observations are of great interest and importance in vibration therapy; because they well illustrate the relative effects of various modes of application in respect to time.  Vibratory stimulation by increasing binary excretion assists in staying putrefaction, aids in the emulsification of fats, increases intestinal secretion and peristalsis, and supplies a natural purgative and intestinal antiseptic.

    The nervous supply of the liver [Sajous.  The Internal Secretions and the Principles of Medicine, page 360] consists "first, of terminal subdivisions of the general motor system (splanchnic-sympathetic), which furnish nervous energy during the passive stage of functional activity by insuring tonic contraction of all, vessels, and, second, of terminal subdivisions of the vagus, which excite and govern the active stage of functional activity by regulating the calibre of the hepatic arterioles and by supplying nervous energy to the hepatic cells."  Arnold ["Examination of the Back," Medical World, March 18, 1895] stated that the vaso-constrictor neural cells of the liver are "from the 6th dorsal to the 1st lumbar segment, but chiefly in the 10th, llth and 12th dorsal segments and that the vaso-dilator neural cells are in the nucleus of the 10th cranial nerve."

    The effects [Landois and Stirling. Text-Book of Human Physiology, 4th ed., page 338] of nerve stimulation on binary secretion are as follows: "All conditions which cause contraction of the abdominal blood vessels, e.g., stimulation of the ansa Vicussenii, of the inferior cervical ganglion, of the hepatic nerves, of the splanchnics, of the spinal cord (either directly by strychnia, or reflexly through stimulation of sensory nerves), affect the secretion.  Stimulation of the nerves around the hepatic artery causes at first, an acceleration, and afterwards slowing of the secretion." A rapid and copious blood supply favors secretion the velocity influences it more than blood pressure.  A more copious supply of blood to other organs, e.g., to the muscles of the trunk - during vigorous exercise, diminishes the secretion.  "Stimulation of the spinal cord, from which the motor nerves of the larger bile ducts and gall-bladder pass, causes acceleration of the out-flow, which is afterwards followed by a diminished out-flow.  Direct stimulation of the liver, and reflex stimulation of the spinal cord, diminishes the excretion.  By stimulation of the sympathetic at the lowest cervical and first thoracic ganglion, the hepatic vessels at the periphery of the liver lobules become contracted and pale. (Cyon.)" [Landois and Stirling. Text-Book of Human Physiology, 4th edition, pages 330 and 340]

    "Francois-Franck and Hallion [Sajous.  The Internal Secretions and the Principles of Medicine, page 1012] have shown that the  vaso-motor nerves of the liver leave the spinal cord by the rami below the fifth, i.e., the sixth (dorsal) down to the second lumbar.  These limits have been confirmed by Langley.  The former physiologists remark however that 'centrifugal excitation of the vertebral nerve (composed of 4 or 5 of the lower cervical nerves) after section of the upper rami communicantes (from the first to the fifth) no longer produces hepatic vaso-constriction' -  statement which implies that stimulation of the vertebral nerve does produce hepatic vaso-constriction.  The manner in which this effect is brought about, Francois-Franck and Hallion were unable to explain, however, they ascribed them, therefore, to 'reflex action' or to some unexplained 'indirect influence.'"  This influence according to Sajous is due to overactivity of the adrenals.

    Landois [Landois.  Text-Book of Human Physiology, page 321] states that "stimulation of its (the splanchnic nerve) central extremity causes relaxation of ducts and bladder, while stimulation of the central end of the pneumogastric causes their contraction, together with relaxation of the sphincter of the duodenal orifice.

    Mechanical vibratory treatment for relieving TORPIDITY OF THE LIVER is applied as follows.  With the patient lying in a prone position, apply interrupted vibration with moderate pressure and medium stroke with a ball vibratode to the dorsal region of the spine, and note the points of tenderness.  Then apply vibratory friction over the liver posteriorly with the disc vibratode moving from the spine outwards over the spaces between the ribs.  After a rest of a few minutes, with the patient in the first position, he should then lie upon his back and interrupted vibration should then be applied with moderate pressure and medium stroke over the liver anteriorly, employing medium speed and a stroke suited to conditions of each case.  "One of the causes of the excretion of bile is the interrupted periodic compression of the liver from above by the diaphragm at every inspiration."

    The observation has been made by the writer that in many cases of morbid states of the liver, tenderness is elicited by interrupted vibration with the disc vibratode below and internal to the inferior angle of the right scapula.  These areas of tenderness correspond to the 6th and 7th dorsal nerves which may be vibrated at their vertebral exits between the 6th and 7th and 7th and 8th dorsal vertebrae with the ball vibratode.

    PERCUSSION OF THE LIVER elicits according to Butler [Diagnostics of Internal Medicine, page 464]:

    Limits of covered dulness:

  • Upper
    • 4th space in mammillary line.
    • 7th space in midaxillary line.
    • 9th space in scapular line.
    Limits of exposed dulness:
  • Upper
    • 6th rib in mammillary line.
    • 8th rib in midaxillary line,
    • 10th rib in scapular line.
Limits of exposed dulness:
  • Lower
    • 3 1/2 to 4 in. below ensiform appendix in anterior median line.
    • Costal margin in mammillary line.
    • 10th space in midaxillary line.  Fuses with dulness of right kidney in scapular line.
    THE LIVER REFLEX OF CONTRACTION (Abrams) is obtained by vibrating with the ball vibratode for five or ten minutes with short rest intervals between the 1st and 2nd, and the 2nd and 3rd lumbar vertebrae.  This procedure is indicated in hepatic engorgement unless contraindicated by the nature of the cause of such engorgement as in abscess or cancer of the liver.  In combination with high colonic flushings it relieves the symptoms of such engorgement.

    THE LIVER REFLEX OF DILATATION (Abrams) is elicited by prolonged spinal vibration with few interruptions for five or ten minutes between the llth and 12th dorsal vertebrae.  It must be remembered that mild applications stimulate but strong or long continued exhaust or inhibit an action; therefore in vibratory administrations proper discrimination must be observed.

    Vibratory treatment of the liver is contraindicated in cancer of the liver, in acute attacks of hepatic colic, in cases of acute gastro-duodenitis, and in hepatic abscess.

    Mechanical vibratory treatment applied with upward stroking to the extremities will temporarily relieve oedematous conditions due to interference with circulation as in CIRRHOSIS OF THE LIVER and NEPHRITIS.  The writer employs for this purpose a rubber-covered disc vibratode with interrupted vibration over the inguinal glands followed by vibratory friction centripetally from the knee to the groin.  Dusting the surface with a dusting powder greatly facilitates the administration of the friction.  To the knee-joint apply deep interrupted vibration with deep pressure and medium stroke, after which apply vibratory friction from the ankle to the knee, followed by deep interrupted vibration to the foot and interrupted vibration on the sole of the foot under the instep.  When giving the above treatment, the posterior as well as the anterior surface of the limb is treated.  Properly applied joint movements may be used with advantage to assist the process.

    FOR THE APPLICATION OF MECHANICAL VIBRATION TO THE GALL-BLADDER employ deep interruptions at about the 9th costal cartilage outside the edge of the right rectus muscle, downwards and inwards toward the median line.  Follow the line described four or five times across.  The vibratode best suited for the purpose is the flat disc, which should be crowded up to where the lower edge of the liver can be located.  During the administration the abdominal muscles should be relaxed.  The gall-bladder and the ureters "are the parts least excited by stimuli."  If interrupted vibration is applied with pressure with a disc vibratode relaxation is induced.

    WHEN GALL STONES ARE PRESENT, however, vibration is sometimes contraindicated and in any case if applied the greatest care must be observed.  In order to break up binary calculi which have become impacted, Professor Bartholow recommended "that firm friction be made with the fingers along the inferior margin of the ribs toward the epigastrium and umbilicus while the opposite side posteriorly is supported by the other hand spread out and firmly applied." Vibration may be so applied, but the author favors the use of light, olive oil, and diet, succinate of soda or surgical measures.

    THE CARDIAC END OF THE STOMACH is situated "just below the level of the junction of the 7th costal cartilage with the sternum," and the PYLORUS is "near the end of the cartilage of the 8th rib."  Any stimulation affecting stomach secretion affects proteid digestion.  The peristaltic action of the stomach is affected by direct stimulation as massage or mechanical vibration.

    When PERCUSSING THE STOMACH it should be remembered that the thorax and liver overlap above, and the transverse colon is in close proximity below.  "The normal stomach tympany begins at the site of the apex of the heart about at the 4th intercostal space in the axillary region, extending below this into the abdomen so that its greater curvature extends from about the 9th costal cartilage, across the abdomen above the umbilicus to the right of the median line."

    GASTRIC SECRETION may be induced by stimulation, -  mechanical, chemical, or thermal.  Landois and Stirling consider the function to be a reflex one, the special center for which is probably located in Meissner's plexus.  The same eminent authorities acknowledge that there are indications also that a connection exists "perhaps indirect between the central nervous system and the gastric glands." It was said by Pilgrim that stimulation of the glands can be produced by stimulating the vagi in the neck, but on this point authorities differ.  Landois and Stirling state that "there is no nerve passing to the stomach whose stimulation causes a secretion of gastric juice as the chorda tympani does in the sub-maxillary glands," but Pawlow "found that direct stimulation of the vagus produced a flow of gastric juice."

    Colombo demonstrated that after massage the quantity of fluid exuded from a "gastric fistula for two hours was more than double that which flowed through in the same time without massage.  A massage (manual) of fifteen minutes gave the maximum secretion.  If massage was applied for a longer time the mucus increased, the gastric juice was more diluted.  Hydrochloric acid and pepsin did not increase." The author had skiagraphs taken before and after vibration following a bismuth dose.  Vibration was given between the lst and 2nd and 2nd and 3rd lumbar vertebrae for 10 minutes.  The skiagraph showed a 50 per cent increase in motility.

    Experiments have also been made demonstrating the effects of manual massage upon the stomach with salol which is not soluble in the stomach.  Ewald and Eccles experimented and found, according to Graham, that "in most cases under natural conditions without massage, salol could be detected in the urine in forty-five minutes after its administration; but after massage upon abdomen for fifteen minutes the reaction of salol was obtained in thirty minutes," and according to the same authority, Hopadze "showed that abdominal massage hastened the food from the stomach from fifteen to seventy-five minutes."

    The general motor (sympathetic) and the vagus systems supply the stomach.  Sajous believes [ Sajous.  The Internal Secretions and the Principles of Medicine, page 309]:

    1. That the general motor system (sympathetic) and supplies efferent nerves which maintain tonic arterial contraction and control functional efficiency" during the passive state, while the vagus system (supplying sensory and motor nerves) is superadded during the active state and "assumes control of the digestive process."

    "2. The extrinsic efferent nerves from both systems, constitute its extrinsic vaso-constrictor system, by means of which the flow of blood in the organ is increased."

    3. The intrinsic efferent nerves are formed of (1) the branches of the "general motor system" (sympathetic system) each of which divides into two branches, one going to the arterioles, and the other supplying the muscles and glands, and (2) of branches of the vagus "which inosculate with the general motor filaments and plexuses, except with those distributed to arterioles that supply capillaries to the glands and probably end in the muscularis mucosae.

    Arnold thought that the vaso-constrictor neural cells of the stomach were in the 4th to the 9th dorsal segments and the vaso-dilator neural cells of the stomach were in the nucleus of the 10th cranial nerve.

    Landois and Stirling [Landois. and Stirling. Text-Book of Human Physiology, 4th ed., page 281] regard Auerbach's plexus as its motor center, the vagi conducting the impulses. "Stimulation of the vagi in the neck causes contraction of the pylorus (and upward from the pyloric end) when the latent period may be seven seconds. Stimulation of the splanchnics in the thorax arrests the spontaneous pyloric contractions, the left splanchnic being more active than the right (Oser)." Other fibres "pass from the spinal cord in the anterior roots of the nerves from the sixth to the twelfth dorsal, passing in the splanchnic nerves to the solar plexus, and thence to the stomach."  If the splanchnics be stimulated, the muscular movements of the stomach cease, and the sphincter of the pylorus relaxes (Kirke).  Pilgrim claimed that stimulation of the fourth dorsal would open the pylorus.  The cardia may be opened reflexly by stimulation of the sensory abdominal nerves (e.g., of the kidney, uterus, intestine), or irritation of the sciatic.  Landois and Stirling locate the center for the contraction of the body of the stomach in the corpora quadrigemina.

    "The efferent paths lie in the vagi, but chiefly in the cord, and from the latter emerge to the ganglia of the sympathetic.  Inhibitory centers lie in the upper part of the cord, and the efferent paths are in the sympathetics and splanchnics."  "Mechanical stimulation causes contraction of the muscular layers directly affected." [Landois.  Text-Book of Human Physiology, page 281] The visceromotor accelerating cells for the stomach according to Arnold are principally in the tenth cranial nerve, possibly also in the eleventh and the inhibitory visceromotor cells are chiefly. in the fourth to the ninth dorsal segments.

    MECHANICAL VIBRATION APPLIED TO THE STOMACH improves the general tone, and increases motor and glandular activity, thereby aiding nutrition.

    MECHANICAL VIBRATORY TREATMENT OF THE STOMACH should never be administered directly after eating, and the bowels should be as nearly evacuated as possible, and the bladder emptied.  Vibration should not be applied over the abdomen with so much force as to cause pain.  If the patient be ticklish avoid too light vibration.  If the abdomen be sticky from perspiration dust it with talcum powder before vibrating.  Vibration may be followed by visceral lifting, if advisable, for the purpose of restoring the viscera to their normal positions.

    VISCERAL LIFTING, a plan followed by Kellogg, is accomplished as follows: The operator, standing at the left side of the patient, his back being toward the face of the patient, places "the ulnar edge of the two hands, with the fingers extended, just above Poupart's ligaments and parallel with the ligaments, the fingers pointing toward the pubes.  From this position the hands are moved slightly upward, the edge of the hands being made to sink as deeply into the abdomen as possible without severe pain.  The arms being slightly rotated at the same time, and the hands drawn upward in such a way as to grasp the contents of the abdomen and drag them upward." This should be done during inspiration.  At the same time use inspiratory lifting, that is, the patient having expired the air from the lungs should "make the movement of inspiration by lifting the upper chest forcibly while keeping the glottis closed."

    With the flat rubber-covered disc vibratode vibrate from the cardiac end of the stomach using interrupted vibration or vibratory friction proceeding downward and slightly inward.  Then vibrate over the pyloric end of the stomach upwards and slightly outward.  This area should be gone over about three times, pressure being regulated according to the patient's tolerance.  In pathological conditions of the stomach, vibration of the 6th, 7th and 8th dorsal nerves on the left side will usually elicit tenderness, and eructations often occur.  An application of static sparks over these sites also causes eructations.  When the pylorus is affected, the same nerves on the right side are tender.  The 6th, 7th and 8th dorsal nerves should be vibrated at their origins or exits employing the ball vibratode, and moderate speed in order to produce these effects.  The tenderness is treated by prolonged interrupted vibration.

    REFLEX DILATATION OF THE STOMACH (Abrams) is effected by concussion or vibration of the spinous process of the 1lth dorsal vertebra.

    REFLEX CONTRACTION OF THE STOMACH (Abrams), is produced by vibration by applying the ball vibratode between the transverse processes of the lst and 2nd, and the 2nd and 3rd lumbar vertebrae for five or ten minutes as effects may demand with a rest period of a few minutes after the first five minutes' treatment.  This can be used to empty the stomach.

    VOMITING is a reflex act induced by afferent and efferent stimuli "occurring in consequence of contraction of the walls of the stomach, the pyloric sphincter being at the same time closed." The center "is connected with the respiratory center [Landois. Text-Book of Human PhysioIogy, 4th ed., page 282], hence any agent increasing respiratory movements has a favorable effect upon vomiting."  The "afferent impulses may be discharged from (1) the mucous membrane of the soft palate, pharynx, root of the tongue (glosso-pharyngeal nerve) as in tickling the fauces with the finger, (2) the nerves of the stomach (vagus and sympathetic), (3) stimulation of the uterine nerves (pregnancy), (4) the mesenteric nerve (inflanmation of the abdomen and hernia), (5) nerves of the urinary apparatus (passing a renal calculus), (6) nerves to the liver and gall duct (vagus), (7) nerves to the lungs in phthisis (vagus)."

    The efferent impulses are carried by the phrenics (diaphragm), vagus (oesophagus and stomach), and intercostal nerves (abdominal muscles)." [Landois and Stirling.  Text-Book of Human Physiology, 4th ed., page 282]  Dr. W. E. Green of Arkansas reports the cure of a case of persistent vomiting following two operations for its cure.  The ball vibratode was used on alternate days for deep interrupted vibration "in the interspaces over the transverse processes of the third and fourth dorsal nerves, and throughout the splanchnic region." He probably induced dilatation.  There was present at first a pyloric stricture.  In spasmodic stricture of the pylorus, vibration of the fourth or fifth dorsal is indicated.

    THE PANCREAS is situated, behind "the linea alba, about two or three inches above the umbilicus," half way between the ensiform appendix and the navel and corresponds to the 2nd lumbar vertebra.  Its head is in the duodenal curve and its tail reaches the spleen.

    Sajous [The Internal Secretions and the Principles of Medicine, page 385] believes that:

    "l. When the pancreas is in the resting state, the general motor mechanism (sympathetic) maintains the tonic contraction of the vascular supply and alone transmits impulses to all the structures of the organ, including the glands which, during this period, elaborate their secretary products.

    "2. When as a result of physical (reflex) or psychical stimuli the pancreas becomes functionally active, the vagus impulses impose their rhythm upon the general motor nerves, and the vagus system assumes control of the secretary process."

    The nerves which supply it are from the "hepatic, splenic and superior mesenteric plexuses to which the pneumogastric and splanchnic nerves send branches."  If the "central end of the vagus or certain sensory nerves, as the crural or sciatic, be stimulated suppression of the normal (pancreatic) secretion results."  It has been claimed that the vaso-constrictors of the pancreas are from the fifth dorsal to the second lumbar.  The vaso-dilators are said to be mostly in the vagus.  Arnold states that the vaso-constrictor neural cells are in the 8th to 12th dorsal segments with some above the 8th, and the vaso-dilator neural cells are in the nucleus of the 10th cranial nerve.  The blood vessels are dilated during the act of secretion [Landois. Text-Book of Human Physiology, page 307].  Direct stimulation of the gland itself by induction shocks stimulates or excites secretion.  Mechanical vibration applied directly over the gland should produce practically the same result.  A rubber-covered disc vibratode should be used to apply interrupted vibration or vibratory friction when treating the gland itself.  In vibrating the gland, begin at the splenic end, and if vibratory frictions are used, apply friction from the splenic end toward the patient's right side when the direction should be to the right and slightly downward and outward following the line of the pancreatic duct.

    CONSTIPATION is characterized by "an abnormal sluggishness and imperfect evacuation in the movement of the intestinal contents through their canal," which may be due to (1) atonic conditions caused by insufficient blood supply in debilitated states, as relaxed abdominal walls, atony of the intestinal tract; (2) obstructive causes as an interference mechanically with fecal expulsion as fibroid tumors, hypertrophy of Houston's valves, of the sphincter, or of the levator ani muscles, accumulation of feces, uterine and vaginal displacements; (3) habit; (4) various diseases of the spinal cord as tabes, hemiplegia and transverse myelitis; (5) a pulling down of the recto-vaginal septum; (6) anomalies, as congenital dilatation of the colon, or congenital strictures; (7) lead poisoning; (8) hernia; (9) peritonitis; (10) displacement of the right kidney, obstructing the lumen of the duodenum; (11) spasm of the pylorus, or the muscles of the intestine, as in hysteria and neurasthenia; (12) diseases of the secretive organs and intestinal tract, including chronic affections of the liver, stomach, intestines, enteritis, colitis, and fissure of the anus; and (13) venous obstruction which causes hypertrophy of the mucous and sub-mucous coats and impairs peristalsis. (14) A very important cause is the formation of a "pouch, changing the direction of the inter-abdominal rectal pressure to that of the vaginal, at right angles to it, and making it difficult for the rectal sphincters to relax and void the contents of the bowels."  Another classification of causes includes dryness of the feces, and differences in the functional activity of muscles and motor nerve apparatus in the intestines.

    Regarding the causes of atonic and spastic constipation Reed [Reed.  Diseases of the Stomach and Intestines, page 767] states that "Glenard considered displacements of the stomach and intestines as chiefly responsible, while Emminghaus traces habitual constipation to degenerative changes in the splanchnics, and Dunin thinks it attributable mainly to central functional anomalies in the nervous system.  Boas finds it difficult either to deny or confirm these theories, but points out that in any fully developed case of neurasthenia, with constipation, there is likely to be found a vicious circle."

    DEFECATION may be either voluntary or involuntary, the beginning and end of the act being voluntary, while the remaining part of the act is involuntary.  An accumulation of feces and gases presses or stretches the fibres and induces peristalsis.  The sphincter is contracted tonically during the intervals between defecation. The defecation centers are thought by Schafer to be under the control of the sacral nerves, but others think the lumbar nerves govern defecation.  Reed locates the center at the second segment of the lumbar part of the spinal cord, at 9th, 10th or llth dorsal vertebra.  The sphincter is also influenced by a cerebral center located, it is supposed, in the optic thalmus.  When the feces and gases pass from the sigmoid, they stimulate the rectal mechanism, and an impulse to evacuation is induced.  According to Kirke, "the stimulus, however produced, is transmitted to the center in the cord through the hemorrhoidal and inferior mesenteric plexus, and is then reflected to the muscles of the rectum through the pudendal plexus, resulting in a relaxation of the sphincter, a contraction of the muscular gut walls, and expulsion of the feces."

    By compression of the abdominal viscera, the feces are aided in their downward course, when they reach the uppermost Houston valve on the left wall they may rest there, or be pressed onward to the next lower valve on the right anterior wall.  The feces thus gradually approach the anus, during which time the levator ani muscles "draw the canal upward and over them."  The levator ani not only thus raise a part of the pelvic floor but prevent distension of the pelvic fascia.  Hyrtl says that "the levatores ani are related to the anus like two cords of a tobacco pouch." It is thought that an inhibitory seat in the brain in the optic thalmi allows the fecal mass to pass through the anus without causing it to close reflexly.

    THE AMOUNT OF FECES normally passed in twenty-four hours should be about five ounces and should consist of about seventy-five per cent. water, which depends, according to Landois and Stirling, partly upon the food and partly on the "energy of the peristalsis."  When the peristalsis is very energetic, the feces are more watery, because the fluid from the food does not have time to be absorbed.  They state also that "the quantity of water taken has no effect upon the amount of water in the feces."  It is thought by O'Beirne that when the desire to go to stool is unheeded that the feces go back to the sigmoid by means of a "reverse peristalsis," but Gant states that his experience is that it is only exceptionally that the feces are returned to the sigmoid.  "In most instances digital examination revealed an accumulation of feces in the rectum.  In a few the earlier examination revealed a like condition, while those made later showed the rectum to be empty."  "Again, the lower rectum may be found empty, but procto-scopic examination will reveal the feces above and unsupported by the valves, moreover, if the entire fecal mass is not discharged at stool, the remaining portion may sometimes be seen above the valves."

    HABIT is a matter of great importance, either as a prevention or cause of constipation - sedentary habits, improper diet, too rapid eating, irregular time for eating and going to stool, the use of cathartics, and failure to drink enough water are the most common to be noted.  Considered from a mechano-therapeutic view-point, Cyriax [Cyriax. "Mechano-Therapeuties in the Treatment of Chronic Constipation." British Medical Journal, 0ct. 8, 1910], when considering chronic constipation, claims that "three features are apparent:

    "1. Diminution in the expulsive power of the intestine.

    "2. Diminution in the function of abdominal sympathetic.

    "3. Diminution in the power and tone of the muscles of the abdominal wall."

    THE INTESTINES RECEIVE THEIR NERVE SUPPLY as follows [Byron Robinson.  The Abdominal and Pelvic Brain, page 318]:

    "1. The cranial nerve (the pneumogastric). (Sajous believes that the 'vagal system probably alone excites and regulates intestinal functions during digestion as well as during intervals).'

    "2. The spinal nerves especially those entering at the distal and proximal bowel segment.

    "3. The sympathetic system."

    The sympathetic nerve supply includes:

    (a) Billroth Meissner plexus "supplying glandular structure and has to do with secretion.

    (b) Auerbach plexus supplying muscles.

    (c) Solar plexus.

    (d) Lateral chain of sympathetic ganglia on each side of the vertebral column from which arise the great splanchnic nerves."

    He stated that the sympathetic nerve causes the periodic movement, rhythmic in character.  Pfluger noted that if the splanchnics were stimulated the movements of the bowels were prohibited, "the bowels become pale and the blood vessels anemic." The splanchnic supplies motor and vaso-motor nerves to the blood vessels of the intestine and also sensory fibres.
THE SMALL INTESTINE (Arnold ["Examination of the Back."  Medical News, March 18, 1905] and Reed [Diseases of the Stomach and Intestines, page 52] receives its vaso-constrictor neural cells from the 6th dorsal to the 2nd lumber segment, and its vaso-dilator neural cells in the nucleus of the 10th cranial nerve.

    Inhibition of the action of the small intestine is stated by Arnold to be chiefly in the spinal cord segments corresponding to the vaso-constrictor neural cells supplying the part.  He states that probably there are some inhibitory paths in the 10th cranial and some accelerators in the cord.  The same author believed that the accelerating cells for the small intestine were "chiefly in the nucleus of the 10th and possibly of the llth cranial nerve."

    If the vagus is stimulated "the movements of the small intestines are increased" (Braam Houckgeest).  Landois and Stirling [Landois and Stirling.  Text-Book of Human Physiology, 4th ed., page 289] state, however, that the inhibitory nerve of the small intestine is the splanchnic while the capillaries contain arterial blood.  When this changes the splanchnics are stimulated and peristalsis is increased.

    THE LARGE INTESTINE receives its vaso-constrictor neural cells from the llth dorsal to the 2nd lumbar segments, probably the vaso-dilator [Arnold.  "Examination of the Back."  Medical News, March 18, 1905] neural cells for the first half of the large intestine are in the nucleus of the 10th cranial nerve.  The accelerating cells for the ascending part of the large intestine are probably found in the nucleus of the tenth and possibly in the eleventh cranial nerves.  Arnold believed that the inhibitory neural cells of same correspond to its vaso-constrictor neural supply, and that probably the tenth may contain inhibition paths and that some accelerators may be found in the cord.

    Reed [Reed.  Diseases of the Stomach and Intestines, page 61] says that the colon is innervated partly by the sympathetic and partly from the lower spinal nerves.  He says that the vaso-constrictors are from between the 6th dorsal and 2nd lumbar segments, and that the vaso-dilators are from the same part and from the pneumogastrics.  Landois [Text-Book of Human Physiology, page 720] states that the lumar branches of the sympathetic "contain inhibitory fibres for the descending colon and rectum."

    Reed states, that the vaso-constrictors of the sigmoid flexure and rectum are from the 10th dorsal to the 4th lumbar segments and that, the vaso-dilators are from between the lst and 4th sacral segments.  It should be noted that the vaso-constrictors of the genital organs come from the lumbar nerve roots and their vaso-dilators from the sacral nerve roots.

    The neural cells (Arnold) for the external sphincter are "probably in the last sacral and to some extent in the coecygeal segments."

    If the nervi-erigentes, partly formed by fibres that leave the cord in the sacral nerves (2nd to 4th) [Howell.  Text-Book of Physiology, page 706] be stimulated, contraction of the longitudinal rectal fibres occurs, and the action of the circular fibres is inhibited, even when the hypo-gastric nerves are stimulated by which they are supplied and whose stimulation has "an inhibitory effect on the longitudinal muscles" (Fellner).

    Malay measures and methods have been employed in the treatment of constipation, among the most satisfactory have been dietary, exercise, electrical, and mechanical means.  Each has its particular field.

    IN THE TREATMENT OF CONSTIPATION due regard should be paid to causes, as they determine the initial step in the treatment.  Atonic conditions with relaxed abdominal walls may require systematic adapted exercises, and in cases of the aged or weak, or those who cannot or will not exercise a proper abdominal support is necessary.  Irregular habits of going to stool demand regularity.  As habit has a marked influence over constipation it is essential that the patient be trained to elect a particular time for going to stool, and sit for twenty minutes if necessary always abstaining from exertion or straining.  If the desire comes on during the day ignore it if possible until the next day at the stated period and thus begin to establish a regularity.  Fibroid tumors require the use of the X-ray every other day for ten minutes until a dermatitis occurs.  A rest should ensue until the disappearance of the dermatitis when a second series of rayings should follow.  A hot douche within and a cold cloth over the surface when raying may prevent dermatitis (Nagelschmidt).  Spasms of the pylorus require a restricted diet and treatment from the 50 candle power incandescent lamp.  Diseases of the secretive organs and intestinal tract demand special treatment suited to the case in question.  Dryness of the feces calls for the use of agar-agar and the copious drinking of water.

    The diet should in all cases be strictly regulated and restricted to foods calculated to assist peristalsis and of a character that the residue will be sufficient in quantity, and of a non-intoxicating nature not disposed to ferment.  Zoolak, milk, koumiss, toasted bread, unsweetened zwiebach and cooked fruits are an effective and acceptable diet.  A more liberal diet includes in many cases a diet of triscuit, shredded wheat biscuit, cracked wheat, oatmeal, farina, unsweetened zwiebach, home made graham bread (a day old), carrots, white turnips, spinach, lettuce, string beans, celery, stewed fruits, plums, peaches, or pears with thin syrup, fresh apples, or grape fruit, nuts except almonds (unless blanched) and soups not made from meat stock.  Agar-agar owing to its affinity for water makes the stools softer.  It may be soaked in milk and eaten, or boiled like oatmeal with a few mvfigs or other fruit to flavor it.  The equivalent of a few teaspoonfuls of the dried agar-agar is sufficient daily for a child.  An adult dose may even be half a cupful, measured dry.  A small baked sweet or white potato with the jacket on, to be thoroughly masticated, is allowed occasionally.  Hot water at meals and a copious drinking of water daily, is employed on general principles.  Flesh, fish, fowl, oysters, shell fish and eggs are usually prohibited.  Food should in all cases be thoroughly masticated.  Exercises advocated by Dr. Watson L. Savage and others are the liver squeeze; flexion of the knees on the chest; describing a circle with the feet, legs in apposition, and knees not flexed; and other movements executed with the patient lying upon a hard surface or table, and untrammeled by corsets, skirts or other clothing.  They are useful adjuncts in some obstinate cases.  These exercises should be done before breakfast, after drinking freely of water.

    Among mechanical means, the Taylor and Zander machines were the forerunners of the mechanical method of today.  They were followed by the use of the oscillator which gives a general vibratory treatments passive exercise of the body and the abdomen in particular.  Such treatment has proved very efficacious in the hands of some operators by applying the belt to lumbar spine, to the side, over the liver, and to the abdomen.  The first treatment being from three to five and seven minutes, the stroke being at first six millimeters, and later increased to ten; with the motor speed adjusted to the patient's sense of greatest efficiency which is usually at the highest rate.  This treatment is continued as a rule for about twenty-six days.  Selective, harmonic electric vibration is also a favored measure used by Dr. Morris W. Brinkmann.

    THE TREATMENT OF CONSTIPATION BY MECHANICAL VIBRATION calls for attention to a few details. (1) It is essential that the bladder be emptied before the treatment is begun. (2) If the skin is sticky, owing to excessive perspiration, dust the surface over the abdomen with talcum powder. (3) The application of heat, dry or moist, to a hypersensitive abdomen, before vibratory treatment will make the surface less sensitive. (4) A high enema of warm water and soap-suds or a saline enema preceding the local vibratory treatment is essential as a routine in obstinate cases of constipation. (5) Relaxed abdominal muscles necessitating particular attention to position, are a requisite.

    The patient should be properly prepared.  The administrations can be made directly to the skin or over the undervest.  It is a waste of time and the unnecessary expenditure of much energy on the part of the physician to attempt in any case to vibrate over other clothing than an under garment.

    The general vibratory treatment which should be instituted on the first day of treatment consists of spinal stimulation followed by an abdominal massage, and in most cases an internal rectal vibratory treatment.  Vibratory treatment of the liver and spleen is usually indicated.  The treatment should be thorough and given systematically with regard to technique.  The vibrations should be mild at first, then gradually increased in pressure depending on the density of the part and the conditions present.  The system of bridging the condition of relief from treatment to treatment, lessening the frequency as the requirements permit, is to be followed.

    Moderate pressure is recommended to be applied between the transverse processes on each side of the spine.  Tolerance to pressure increases during an administration and during the course of the treatment.  Pressure should be light at first, being gradually increased.  Too heavy pressure, especially when prolonged, inhibits, and may cause nausea and weariness.  Sensitiveness to impression is only an approximate measure of irritability, for, as Luderitz found, the motor nerve fibres are paralyzed sooner than the sensory by continuous pressure, which should be taken into consideration.

    The treatment should be administered with care to avoid the production of contractions or pain.  During the external treatment pressure should be graduated in order to avoid the induction of unpleasant effects.  It is advisable always to begin the treatment by vibrating the spinal nerves, using a small ball vibratode, employing a medium stroke, and moderate pressure on each side of the spine, alternately from above downward, to elicit points of tenderness.  The sensitive sites should be given slightly prolonged interrupted vibration.  Otherwise the spinal vibration should be limited to the nerves whose centers are involved in the case under treatment.  It is thought that the treatment of opposite sides alternately intensifies the effect on nerve centers.

    DIVULSION OF THE SPHINCTER is necessary in some cases.  This may be accomplished by mechanical vibration.  A pyramidal vibratode is employed, with fairly rapid speed, and full stroke, for five minutes daily.  The vibratode should be gradually introduced.  As the tissues relax it can be gradually worked inward.

    ABDOMINAL VIBRATION has a curative effect on constipation, assists digestion by increasing the functional activity of the pancreas, liver and stomach, promotes muscular nutrition, increases absorption, and renal elimination, strengthens the muscles of the abdomen, and increases nervous and circulatory activity, and slows the pulse rate.

    In treating the abdomen, apply compressing or deep vibratory friction, employing a flat disc vibratode, using a medium stroke for the purpose of relieving intestinal stasis and to assist in dislodging feces, as well as to stimulate the vascular system.

    It is always preferable, as there is apt to be a quantity of feces present, to treat the lower part of the bowel as the first step in the treatment.  In that event, commence on the left side a short distance from the sigmoid.  Use vibratory friction downward and inward six or seven times, gradually beginning higher up, finally proceeding from beneath the ribs downward and inward to the point of termination.  Then vibrate the transverse colon, working from left to right, gradually lengthening the line of advance as you approach and pass the median line.  Then begin a little below the hepatic flexure and apply vibratory friction in the same manner as in the preceding description, using deep pressure and moving upward six or seven times, gradually lengthening the line of advance.  Extend the vibration lower and lower until the caecum has been thoroughly vibrated.  Finish by a deep circular friction from right to left, moving over the surface ten or twelve times, repeating the operation if deemed necessary like cannon ball massage, using a ball vibratode or the cap shield of some vibrators.  The speed should be slow, because parts containing unstriped fibres after being stimulated react "for a long time after the stimulus is withdrawn."

    In a Thirty-Velly fistula, Fubini estimated the rate of motion of a smooth sphere of sealing-wax along the intestine.  It took 55 seconds to travel 1 cm. (2-5 of an inch).  An induction current greatly increased the motion, to 1 cm. in 10 seconds.

    Landois and Stirling state that "the strong peristalsis which precedes defecation, can be aided, and to a certain degree excited, by rapid voluntary movements of the external sphincter and levator ani, whereby the plexus myentericus of the large intestine is stimulated mechanically, thus causing lively peristaltic movements in the large intestine."  These movements may also be excited by the action of mechanical vibration by the employment of an internal rectal vibratode which procedure should follow the abdominal vibration.

    When administering an INTERNAL RECTAL VIBRATORY TREATMENT the rectal vibratode should be well lubricated and introduced while in motion to avoid shock.  Great care must be taken, however, not to overstimulate the intestine; lest dysperistalsis be induced.  For "all stimuli applied to the plexus myentericus increase the peristalsis which may become so very violent as to cause evacuation of the contents of the large intestine, and may even produce spasmodic contractions of the musculature of the intestines."  The administration should be from three to five minutes, using a short stroke, and a rate of speed which will give the maximum width to the loops that are formed by the vibration of the vibratode.  In some cases, the first treatment is made slightly shorter.  In using the short rectal vibratode have the patient lie with his back toward the machine, and knees flexed.  In many cases, the treatment is more easily given when the patient is in the knee-chest position.  In very obstinate cases a flexible rubber vibratode, twelve to fifteen inches long is of service, it being introduced while the patient is in the knee-chest position.  Duration of this treatment should be about three minutes, a moderate rate of speed and full stroke being employed.  If the stimulus be strong and long continued, overstimulation and exhaustion, otherwise termed "intestinal paresis," takes place, that is, "continued congestion of the intestinal blood vessels ultimately causes intestinal paralysis."

    In chronic cases, and when impaction is present, copious high injections of warm water are advisable, at first daily.  Care should be taken that these injections be properly administered ' which under no conditions should be left to the patient, as in most cases it will be improperly done.  A special vibrating colon tube from eighteen to twenty-four inches in length should be employed.  Not more than one, or one and one half quarts of quite warm water are generally necessary, and it should be retained as long as conveniently possible, a saline solution of one quart 1100 F, twice a week being advisable in some cases.  Such enemas increase the fluidity of the blood and assist the elimination of "pathogenic toxic" wastes.  With the patient in the knee-chest position, and the rectal vibratode, well vaselined, inserted in the cap shield and connected to the douche tank, start the vibrations and allow some of the water to flow, to carry the air out of the tube.  Then slowly insert the tube while it is vibrating.  Allow the vibrations to continue while the first quart or half quart flows, then stop the vibrations while part of the remainder flows.  While the last part flows, continue the vibrations.  The following day an oil enema, 20 tablespoonfuls or a cupful if sufficient, of warm olive oil are given in the same manner to soften adherent masses.  This enema is usually retained for twelve hours, when but a cupful is used.  Water and oil enemas are given alternately until no hard scyballa appear in the movements.  Rectal vibratory treatment may be indicated in connection with the external treatment for the purpose of toning up the bowels or to overcome spasmodic strictures.  When soap is mixed with the water-enema, green soap or soft soap is to be preferred, as, according to Bolton, irritating rashes may appear "on the day following the injection" when, hard soap is used.  He makes this statement from results from observation of 903 enemata.

    Vibratory treatment of constipation should be administered daily until the bowels move regularly, after which, for a time on alternate days, gradually lessening the frequency as the bowels become normal.  The majority of these cases are practically cured in a few weeks' time.  A retroverted uterus which complicates the condition will require treatment.  The static wave current per rectum for twenty minutes every day for a month during an intra-menstrual period and every other day the following month, will in most cases remove this obstacle unless adhesions are present.

    Mechanical vibration in conjunction with a regulated diet together with systematic exercise, when indicated, is the treatment par excellence for constipation.  When carefully administered, mechanical vibration is absolutely painless, harmless, and productive of the most gratifying results.

    CONTRA INDICATIONS FOR VIBRATORY TREATMENT are the presence of ulcer, cancer, hemorrhage, acute inflammations or febrile states.

    IN THE TREATMENT OF MUCOUS COLITIS as Koehler [Geo.  P. Koehler, M. D. Some Remarks on the Signa, Symptoms and Treatment of Mucous Colitis.  Medical Sentinel] has so well said it is best:

    "1st.  To eliminate as far as possible any known cause.

    "2nd.  To use the best possible means of overcoming stasis of the bowel, and procure, if possible, normal evacuations of the contents.

    "3rd.  To use necessary means to restore and improve the natural tone of the mucous membrane and muscular coats of the intestines."

    Mucous colitis responds favorably to a daily vibratory treatment of the abdomen when employed in conjunction with a modified Van Noorden's diet [Van Noorden.  Mucous Colitis], which follows, together with exposure to the X-ray over the abdomen for ten minutes every other day (one milliampere at 14 inches or an equivalent), until a reaction occurs, and the wearing of a proper abdominal support either a corset or abdominal supporter.  Mechanical vibration to the spine, liver, stomach and spleen are indicated if there is constipation.  Oil enemas, 20 tablespoonfuls of warm oil (pure olive oil, owing to deleterious effects of an acid in cotton seed oil) may be injected through the rectal vibratode (see Fig. 58).  These are of the utmost importance.  Daily hot baths of very short duration or a cold sponge, when followed by prompt reaction, and outdoor life are essentials.

Modified Van Noorden Diet

    In the morning in bed at seven o'clock. - Three-tenths of a quart of milk and cream (two parts of milk and one part of thick sweet cream); then, usually, a rub with moderately cold water.

    At eight o'clock. - One-half pint of Kissengen water.  It can be made from Kissengen tablets.

    At nine o'clock. - Three-tenths of a quart of the above milk-cream mixture or of thin tea or coffee with much cream; sometimes, also cocoa prepared with cream.  In addition one slice of coarse bread, with butter.

    At eleven o'clock. - Soup made from leguminous plants; in addition whole -wheat bread with plenty of butter.  Also a glass of Kissengen water.

    At one o'clock. - Some meat dish (the author prefers none if indican present in urine).  In addition vegetables of different kinds (except onions, cabbage, or turnips), boiled or baked potato with butter.  Fruit with coarse skins and large seeds, as currants, gooseberries, cranberries, boiled, or a pound of grapes.  One glass of Kissengen water.  After eating rest in bed for an hour and a half with hot applications to the abdomen.

    At four o'clock. - A light lunch similar to the breakfast, at nine o'clock.  Then a walk of one and one-half to two hours.

    At seven o'clock. - Supper like the dinner; sometimes, also junket or fruit-soup.  In addition a slice of graham bread or zwiebaeli, unsweetened, with plenty of butter.

    At nine o'clock. - Three-tenths of a quart of the milk-cream mixture as in the morning.

    This diet must be continued for some time, 6 months or a year in some cases.

    FLAT'ULENCE ["Aerophagia & Flatulenee."  C. 0. Spivak, M. D., Medical Record, April 29, 1905] may arise from:

    "1. Fermentatioin.  Food may undergo acid fermentation (lactic, butyric) or alcoholic fermentation.

    "2. Putrefactioin.  Albuminous substances may undergo decomposition.

    "3. Alimentary.  Certain articles of food and drink produce flatulency as cabbage, beans, peas, carbonated waters, etc.

    "4. Intestinal respiration.  Flatulence due to exchange of gas (CO2 & N) between the blood and the contents of the stomach and intestines.

    "5. Aerophagia, or swallowing of air may cause flatulence.

    Flatulence may cause palpitation, distress, shortness of breath, irregular movements and pain, often supposed to be heart disease."

    Abdominal vibration in connection with the regulation of general hygiene, diet, and in some cases the use of a proper abdominal support, are indicated.  Spinal vibration applied at the exit of the 6th, 7th and 8th dorsal nerves on the left side of the spine sometimes causes eructation of gases. The ball vibratode is used here as always for applying spinal vibration.  Aerophagia calls for special treatment ["Aerophagia & Flatulenee."  C. 0. Spivak, M. D., Medical Record, April 29, 1905] as an abdominal support and correction of habit.

    REFLEXLY THE INTESTINES MAY BE CONTRACTED (Abrams) by vibrating between the lst and 2nd and 2nd and 3rd lumbar vertebrae.  It is indicated in the treatment of atonic constipation.  Abrams believes that the circular fibres may thus be made tonic.

    THE INTESTINAL RFFLEX OF DILATATION (Abrams) can be elicited by concussion or vibration of the spine of the llth dorsal vertebra.  He recommends its induction in the treatment of spastic constipation.  He believes that it tones up the longitudinal fibres.

    VIBRATORY TREATMENT OF THE RECTUM with the rectal vibratode for five minutes, will tone up the parts and relax spasm of the sphincters.  Spinal vibration may or may not be necessary.  Apply prolonged rectal vibration for inhibition.  Tenderness of the 4th sacral nerve Cyriax [The Elements of Kellgren's Manual Treatment, page 165] noted as often present in rectal affections.

    IN THE TREATMENT OF DIARRHOEA colonic flushings - vibratory or otherwise - are indicated followed by a leucodescent light treatment for sedation.  If dilatation of the stomach be present, causing retention of food, then the stomach reflex of contraction should be induced.  The author has employed mechanical vibration between the 10th and llth dorsal alternately with that between the lst and 2nd and 2nd and 3rd lumbar vertebrae successfully.

    Chronic diarrhea is sometimes due to irritation caused by the presence of retained feces.  In these cases a high enema should be employed and may be followed with rectal vibratory treatment or static electricity in the form of the rectal administration of the wave current to tone up the parts.  Abrams employs concussion alternately on the spines of the first three lumbar and the 11th dorsal vertebrae.

    THE KIDNEY "lies on the quadratus lumborum and psoas muscles opposite the two lower dorsal and two upper lumbar spines; the right about 3/4 of an inch lower than the left.  The upper border is on about a level with the space between the llth and 12th dorsal spines, the lower border being as low as the third lumbar spine.  "It is accessible to pressure just below the last rib, on the outer edge of the erector spinae."

    The nerve supply of the kidney is from the "renal plexus, which is formed by branches from the solar plexus, the lower and outer part of the semilunar ganglion, and from the lesser and smallest splanchnic nerves."  The vaso-motor fibres come from the spinal cord mostly in the 10th to 13th thoracic spinal nerves (dog), and are likely affected by reflex stimulation.  "The vagus [Landois.  Text-Book of Human Physiology, page 516] innervates the intrinsic unstriated musculature of the kidney."

    Cl. Bernard and Eckhard [Landois and Stirling.  Text-Book of Human Physiology, 4th ed., page 545] claim that stimulation of the splanchnic, whose "renal vaso-motor fibres, which, in part at least, leave the spinal cord at the first dorsal nerve and pass into the sympathetic nerve," causes less urine.  Section of the renal nerves causes polyuria "increased by stimulation of the spinal cord below the medulla oblongata as the contraction of the blood vessels throughout the body, still further raises the blood pressure within the glomeruli."  Irritation of the cervical sympathetic lessens the secretion [Landois. Text-Book of Human Physiology, page 516]. The vaso-constrictor nerves respond to electrical stimulation when rapid and of short duration.  Stimulation of these causes a "shrinkage in volume of the whole organ [Howell. Text-Book of Physiology, page 811].  "Stimulation [Howell.  Text-Book of Physiology, page 811] of the peripheral end of the renal nerves also causes a diminution in the volume of the kidney."  "Vaso-dilator fibres are best excited by slow rhythmical stimulation (2-5 shocks per second)." According to Bradford [Howell.  Text-Book of Physiology, page 811] the vaso-dilators of the kidney come from the llth, 12th and 13th dorsal (dog) which when stimulated increase the functional activity of the organ.

    If the KIDNEY IS DISPLACED Kellogg's method of replacement is as follows: After making movements to replace the stomach and bowels, the operator proceeds as follows for the right kidney. (The same is true for the left kidney and spleen, only "the fingers of the right hand" are placed behind).  "Standing upon the right side of the patient the fingers of the left hand are placed behind, while those of the right hand are placed upon the abdomen; and by movements of the two hands the location of the kidneys is determined.  While gently pressing the kidneys upward, the patient is asked to take repeated deep breaths.  With each exhalation an effort is made to press the kidney up under the ribs of the right side by gentle pressure.  As it moves upward and approaches its position, the right hand is shut and the closed fist is made to follow the kidney and hold it in position while the patient takes a number of deep respirations." This should be followed by abdominal vibratory friction for toning the relaxed abdominal muscles and also to increase the elimination of urine by accelerating the function of the kidneys and thereby increase the excretion of "waste products, chiefly nitrogenous bodies and salts," the excretion of water and perhaps even the reabsorption of "water from the uriniferous tubules."

    The amount of urine secreted depends upon the differences of pressure between the blood in the glomeruli and the pressure within the renal tubules.  "The secretion depends partly on the blood pressure as in (1) Increase [Landois and Stirling.  Text-Book of Human Physiology, 4th ed., page 536] of the total contents of the vascular system so as to increase the blood pressure (2) Diminution of the capacity of the vascular system, provided the pressure within the renal area be thereby increased, "which latter may be caused by stimulation of the vaso-motor center," (3) Increased action of the heart." (4) The fullness of the renal artery governs the rise or fall of urinary secretion.  The blood's composition also affects it slightly.

    MECHANICAL VIBRATION MAY BE APPLIED TO THE KIDNEYS as follows: With the disc vibratode apply interrupted vibration or frictions over the kidneys.  The 10th, llth and 12th dorsal nerves may be vibrated at their exits with the ball vibratode to stimulate the renal plexus.  If vibrated anteriorly, frictions are given, from without inwards beginning three inches above and three inches external to the navel after Cyriax's method.

    THE KIDNEY REFLEX OF CONTRACTION [Abrams.  Spondylotherapy, page 360] is induced according to Abrams by concussion of the spine of the 12th dorsal or 7th cervical vertebra.  Vibration may be likewise applied.

    THE KIDNEY REFLEX OF DILATATION (Abrams) is elicited by vibrating with the ball vibratode between the 6th and 7th and 7th and 8th dorsal vertebrae, or the 10th dorsal spine.  In diseases of the kidneys the 10th, llth and 12th dorsal nerves are tender [Cyriax.  The Elements of Kellgren's ManuaI Treatment, page 165].

    Mechanical vibration may also be employed to relieve oedema when present in cases of renal trouble; the effect, however, is only palliative.  In certain conditions, especially inflammation of the kidneys, it must be applied with the utmost caution.

    THE BLADDER receives its vaso-constrictor neural cells chiefly from the llth dorsal to the 2nd lumbar segments probably occasionally from the 3rd and 4th lumbar segments, and its vaso-dilator cells from the 3rd and 4th sacral segments (Arnold).  Inhibition of its muscular coat with contraction of the sphincter of the bladder can be aroused in the 2nd, 3rd and 4th lumbar segments and the opposite effects in the 2nd, 3rd and 4th sacral segments (Arnold).

    INCONTINENCE is sometimes cured by applications of supra-pubic mechanical vibration with the disc vibratode which may be applied either by the interrupted or frictional method.  Spinal vibration may also be applied with the ball vibratode as indicated.  "Kellgren [Cyriax. The Elements of Kellgren's ManuaI Treatment, page 168] found that vibrating or shaking over the bladder has the extraordinary effect of relieving cough and rendering respiration freer.  Sympathetic nerves over the bladder [Cyriax.  The Elements of Kellgren's ManuaI Treatment, page 168] are affected by vibrations or shakings in an upward direction just over the symphysis pubis about an inch from the middle line.  This often leads to an immediate desire on the part of the patient for micturition; in some cases a rush, of blood to the head also ensues."

    THE BLADDER REFLEX OF CONTRACTION can be elicited, states Abrams [Spondylotherapy, page 359] "with one electrode over the sacrum and the interrupting electrode at the spine of the 5th lumbar vertebra."  In disease of the bladder the sacral nerves particularly the lst and 3rd are found [Cyriax.  The Elements of Kellgren's ManuaI Treatment, page 165] sensitive when the vibratode is applied to the nerve origins.

    MORPHINE HABIT AND ALCOHOLISM and other drug habits in connection with moral restraints may be benefited by mechanical vibration, either by employing Dr. Pilgrim's method of "mesenteric flushing" as described in Chapter III, or by administering the abdominal and intestinal treatment described in the preceding pages.  For the insomnia and restlessness, give a vibratory treatment to relieve the causes.

    IN THE COCAIN HABIT peripheral circulation must be strengthened and in alcoholism the vibration must be directed to the strengthening of the feeble heart as well. (See chapter on Circulation.)

    THE APPLICATION OF MECHANICAL VIBRATION TO THE TREATMENT OF THE PELVIC ORGANS is indicated for the relaxation of contracted muscles which should be treated as muscular contractions elsewhere.  Applications may also be made to the other organs and structures including the rectum, the vagina, uterus, ovaries of the female, and male genital organs as indicated for purpose of sedation or stimulation.

    THE PELVIC PLEXUS SUPPLYING the rectum, bladder, prostate, vagina and uterus, according to Gray, is formed "by branches from the 2nd, 3rd, and 4th sacral nerves and by a few filaments from the first two sacral ganglia."

    The vaso-dilator neural cells for the uterus and ovaries are chiefly in the 3rd, 4th and 5th sacral segments [Arnold. "Examination of the Back." Medical News, March 18, 1905] and the vaso-constrictor cells for the same organs are chiefly from the llth dorsal to the 2nd lumbar segment, probably occasionally from the 3rd and 4th lumbar segments. Arnold stated that inhibitory cells of the muscular coat of the Fallopian tubes and uterus with those which contract the cervix, vagina and perineum are chiefly in the 2nd, 3rd and 4th lumbar segments, and that the neural cells for contraction of the Fallopian tubes and the muscular coat of uterus with dilatation of cervix, vagina and perineum are in the 2nd, 3rd and 4th sacral segments.

    THE MOTOR FIBRES OF THE UTERUS are supplied "from the sympathetic chain, chiefly from the fourth to the sixth lumbar ganglia." (Landois and Stirling.) If the hypo-gastric plexus, whose fibres come from the "last dorsal and upper 3 or 4 lumbar serves, run into the sympathetic and then reach the hypogastric plexus" (Frankenhauser), be stimulated, uterine contraction is induced.  If the nervi erigentes be stimulated, movement results (v.  Basch and Hofman).  The uterus may be made to contract reflexly by stimulating the central end of the sciatic.

    Abrams states that REFLEX UTERINE CONTRACTION may be induced by stimulation over the spines of the first three lumbar vertebrae.  Probably deep interrupted mechanical vibration between the 12th dorsal and lst lumbar also between the lst and 2nd lumbar, and between the 2nd and 3rd lumbar and between the 3rd and 4th lumbar vertebrae, the exits of the last dorsal and first three lumbar nerves, will produce the same effect.

    Cyriax [Cyriax.  The Elements of Kellgren's ManuaI Treatment, page 235] observes that sometimes "supra-pubic uterine frictions, at the side of the symphysis pubis about two inches from the middle line will induce contraction of the uterus.

    "Kumpf [Cyriax.  Vibrations and Their Effects] found very strong uterine contractions to arise from a vibrator, and a less marked contraction from the use of manual vibrations.  Lange also obtained a stimulating effect with his vibrator."

    PROLAPSE OF THE UTERUS may be treated by "lifting up the protruding parts with simultaneous vibration" and interrupted vibration over the posterior sacral nerves and the subtrapezial plexus (found in the trapezium at a point in a line drawn from the middle of the clavicle backwards) as suggested by Cyriax [Cyriax.  The Elements of Kellgren's ManuaI Treatment, page 160]. He states that pelvic disease is sometimes associated with "chronic shoulder ache."

    DISEASE OF THE GENITAL ORGANS is sometimes the cause of tenderness of the 12th dorsal, 5th lumbar, and 2nd to 4th sacral nerves.  The 3rd sacral nerve is particularly sensitive in uterine inflammations or displacements [Cyriax.  The Elements of Kellgren's ManuaI Treatment, page 165]. Interrupted vibrations are indicated over the site of tenderness.


    IN AMENORRHEA treatment is directed to increasing the metabolism due attention being given to diet, baths, outdoor life and hygiene in genera.  Locally a tonic spinal application is made externally with the ball vibratode and a vibratory treatment of the liver, spleen, stomach and abdomen with additional rectal supra-pubic and ovarian vibration is indicated.

    MECHANICAL VIBRATION IS CONTRA-INDICATED in pyosalpinx, tumors, and pelvic abscess.

    OVER THE OVARIES frictional or interrupted mechanical vibration may be applied with the disc vibratode two inches internal to and two inches below the anterior superior spine of the ilium downwards and inwards.

    MECHANICAL VIBRATORY TREATMENT OF THE VAGINA may be employed in VAGINISMUS, vibrating either per vagina or from the rectal site, using a vaginal or rectal vibratode.  The vibratory treatment should be continued for five minutes or more.  A very efficient method is the employment of a static current with the vaginal vacuum electrode for fifteen minutes daily.

    THE PROSTATE AND TESTICLES have their vaso-constrictor supply from the llth dorsal to the 2nd lumbar segment, probably occasionally in the 3rd and 4th lumbar segments. (Arnold.) The nerves of the prostate gland are from the hypo-gastric plexus.  The testicles have vaso-dilator cells chiefly in the 3rd, 4th and 5th sacral segments. (Arnold.)  The visceral afferent nerve fibres which supply the prostate are governed by the 10tb, 11th, 12th thoracic and the 1st, 2nd, and 3rd sacral.  The "motor nerves of the ischio-cavernosus and deep periueal muscles arise from the 3rd to the 4th sacral nerves."

    ENLARGED PROSTATE AND NON-INFECTIOUS PROSTATITIS may be treated by the static current or mechanical vibration.  When employing mechanical vibration introduce a rectal or other specially constructed soft rubber vibratode which has been previously well lubricated.

    Insert the vibratode into the rectum while in motion.  The application should be continued for from three to five minutes or longer, if so indicated.  As with all intra-pelvic administrations the bladder and bowels should be evacuated before treatment.  This method is of no avail in the treatment of chronic enlargement with hyperplasia.  It "accelerates the function of the glandular epithelium," and causes a "more abundant afflux of blood, which favors filtration."

    Schmidt believes that the cases of chronic prostatitis that are most benefited are "(1) where mental condition is influenced by prostatic results; (2) where there are small inflammatory foci; (3) isthmical inflammations combined with old infiltrations in the prostatic urethra; (4) simple sexual exhaustion."  The treatment par excellence for this condition is the static wave current per rectum with a metal electrode for twenty minutes (Snow).  X-ray is sometimes indicated.

    BUBO following specific urethritis, has been reported as successfully treated by Dr. Fechner of New York, in which cases "application by deep pressure was made over the 8th and 12th dorsal and 5th lumbar spinal nerves, and to the inguinal glands."

    IN COCCYGEAL ANTERIOR OR LATERAL, DISPLACEMENTS, the contracted muscles about the part should be treated with local interrupted vibration with the disc vibratode.  After which introduce the rectal vibratode into the rectum, the left hand being placed over the coccyx, the patient lying on her right side with the knees drawn up.  Apply prolonged vibration with suited pressure to relax the contracted parts in order that the coccyx may resume its normal position.  Posterior displacement will require prolonged heavy vibration with the disc vibratode over the posterior surface of the coccyx.  Care must be exercised not to apply too much force.  If the parts are sensitive very light pressure should be used at first and the pressure should be gradually increased.  The static wave current applied by means of a metal electrode fitted over the coccyx relieves tension and soreness.  The brush discharge as well as vibration is excellent for removing the bruises as well as lessening the soreness.

    In the treatment of pelvic conditions mechanical vibration can often be employed to advantage in connection with light, electricity, hydrotherapy, or exercise according to indications.