There are various methods of applying mechanical vibration, but up to the present too little attention has been given to the determination of scientific modes of application, Two methods in general are in vogue, one having central nerve stimulation as its basis, the other being founded on manual massage including friction particularly.

    THE APPLICATION OF MECHANICAL VIBRATION is subject to great latitude, varying from the employment of a portable machine operated by hand power to an elaborate apparatus whose motor power is electricity.  The average physician has little time for manual massage, which naturally falls to a trained masseur; and as this is written for physicians and not for masseurs, the application of the various hand devices for administering mechanical vibration by percussion, concussion or tapping will not be considered.  In order to familiarize the reader with what has thus far been accomplished, a few methods will be included.

    THE BASIS FOR TREATMENT for the application of mechanical vibration as treated by Pilgrim [Mechanical Vibratory Stimulation] - based on central nerve stimulation is as follows:

    The spinal cord is
(1) "The principal seat of reflex nerve-action.
(2) It is the center of the vaso-motor system.
(3) It exercises an automatic action over the arterial tone and various viscera.
(4) It is the index of abnormal action in many parts of the body."

    From this standpoint, vibratory treatment for the relief of pain may be applied in three ways, as summarized by the same authority.

(1) "Application of the inhibitory stroke to the spinal nerve centers, supplying sensory fibres to the affected part.

(2) Stimulation of the vaso-motor centers.

(3) Inhibition of the peripheral termination of the sensory fibres."

    "Affected nerve centers are evidenced by the presence of muscles in a state of contraction, atrophy of muscle or muscles overlying the posterior primary divisions of the spinal nerves, and vertebral spreading or deviation.

    Although the patient may be treated in a sitting posture those who use machines generally prefer to have him lie on a narrow hard-cushioned table.  The table should be about six feet long and twenty inches wide in order that the operator may easily reach across during the administration.  For spinal treatment the prone position is assumed with the face down and the arms hanging loosely over each side of the table.  When the thorax is to be treated a pillow may be placed beneath the posterior portion of the chest.

    When mechanical vibration is to be applied to the region of the neck with the patient lying, the patient's head should be turned on the pillow so as to provide a resisting surface, or in some cases no pillow need be used.  It is a recognized fact that an opposing resistance increases the value and efficacy of vibratory treatment.

    It is best that ladies remove their corsets, in fact all clothing about the waist but the undervest, and that a man should remove his vest, coat, suspenders, and stiff-bosomed shirt.

    The following relative to vibratory technique as outlined by Pilgrim may be of interest

    THE DURATION OF TREATMENT is usually from two to four or five minutes and each - individual part should not be treated for a longer time than five or eight seconds for stimulation, or ten to twenty seconds for inhibition - bearing in mind that stimulation, vibratory stimulation, or inhibition depend relatively upon pressure and length of stroke as well as time.  If what is termed stimulation be desired, the brush (multiple point vibratode) should be applied for a few seconds, using light pressure and medium stroke; if vibratory stimulation is desired, a slightly longer application according to Pilgrim, "eight to twelve seconds," with tolerably deep pressure is necessary, and actual inhibition is brought about in from a quarter of a minute to a minute or more, employing deep pressure with the ball.  The writer believes that the condition under treatment the immediate response of the patient to treatment during previous administrations and the after effects must be the guide as to length of time requisite to obtain the effect desired.  Great care must betaken not to make the treatment too long, or, what is a matter of the utmost importance in the writer's judgment, to exert too great pressure, as the treatment might be followed by a sense of great weariness or lassitude.

    IN THE TREATMENT OF PATHOLOGICAL CONDITIONS affecting the organs of special sense the following general plan is adopted.  First, consider the nervous supply of the organ and its general relationship.  If it is indicated to treat the superior cervical ganglion, apply vibration to the upper part of the anterior, border of the sternocleido-mastoid muscle, or if lower in the neck it may be treated indirectly through the other cervical ganglia, applying the vibratode in front of the transverse processes.

    IN VENEREAL DISEASES, according to instructions, based on central nerve stimulation, developed by Dr. Pilgrim, the treatment should be as follows:

(1) " Stimulate with the rubber ball the proper vaso-motor area for the purpose of inducing a more efficient blood flow, and the nerve area in the spine, which controls the nutrition of the genital or other affected organs' which, under such conditions, are quite sensitive to deep pressure.

(2) Stimulate with the brush the lymphatics generally, but especially those along the sides of the penis and in the inguinal region, in order to secure the best drainage possible, relaxing at the same time all contiguous muscular tissue.

(3) Stimulate at their nerve connections at the spine (with the ball), and also directly over the organs, with the brush, the liver, kidneys, spleen and bowels, with a view of accelerating their eliminative action.

(4) Place the patient in the 'Sim's' POSITION, with knees well elevated, shorten the stroke of the vibrator arm and apply a mild treatment to the prostate gland per rectum, using for this purpose the special rectal attachment.

    WHEN TREATING THE AFFECTED SPINAL CENTERS treatment should be applied just inside of the tuberosities of the ischium, deeply, immediately behind the attachments of the perinaeum, using the ball and medium stroke."

    IF THE STIMULATION BE SPINAL, the ball attachment is applied between the transverse processes.  Great care must be exercised to avoid the spinous processes. This treatment is based on the idea that pain is of nervous origin and by treating the centers of such nerves we can act upon the affected part.

    OTHER SPECIAL CONDITIONS are treated in accordance with the theories on which the above line of treatment is based.  One very unique method was recommended by Pilgrim [Mechanical Vibratory Stimulation] for flushing the mesenteric glands in cases of alcoholism or morphinism as follows: "The patient should drink a pint at least of water (hot if for the former condition, and hot or cold for the latter) and then lie on his right side with the knees well elevated.  Vibratory stimulation with the ball should then be applied to the spine between the fourth and fifth dorsal vertebrae, using firm and tolerably deep pressure." This should be continued for one minute and is done to relax the pylorus.  "Next place the hand over the abdomen, just below the stomach, and exert heavy upward pressure with a view to elevating the stomach.  When this is accomplished, the contents of the stomach will rapidly discharge into the abdomen without much absorption taking place through the gastric glands."

    After this stimulate the splanchnic nerves to hasten absorption by means of the mesenteric glands.

    The above is only a brief outline of the method employed by many advocates of vibration.

    THE METHODS that have been followed by other advocates of vibration more closely follow the forms of manual massage.  As an example the following is noted in respect to neuralgia.  One writer states that the best way "of treating neuralgia with vibratory massage, is to 'coup' the pain by immediate application of very powerful vibrations for a short period, one-quarter to one-half minute, and then continue with milder, but increasing vibrations over the pain points and along the course of the nerve, up and down and then finish with vibrations of the initial strength and duration.  There is however one obstacle to the successful carrying out of the above treatment, viz., the inability of most patients to withstand the shock of the 'couping.'  Therefore, one must mostly resort at the beginning to moderately strong vibrations and then increase until the limit, to be determined by the patient.  Milder vibrations will cure but not so rapidly.  The element of time varies" from two to twenty minutes, and two treatments per day have been necessary in some cases.

    THE ACTION OF THE TISSUE OSCILLATOR is somewhat different from that of a mechanical vibrator.  By some its action is regarded as closely resembling that of a mechanical exerciser, such as some of the apparatus of Zander and Taylor.

    In using this apparatus the patient sits or stands, or he may recline when the hand piece is applied to the back or when the new additional vibratory attachment is used.  If the patient applies the hand piece, a chair with arms is desirable, otherwise the chair without arms is to be preferred.  Chairs should be firmly fastened to the floor.  The patient may under certain conditions remove nothing but the hat, in others, as for throat applications, the collar, or for foot applications, the shoes must be removed.  If a woman is to be treated, corsets or tight clothing should be discarded.  In the case of a man, suspenders and stiff-bosomed shirt should be removed.  Of course an application to the exposed skin is oftentimes desirable in order to secure the full effects, in which the clothing to be removed will be determined by the judgment of the operator.

    IF A BODY TREATMENT IS INDICATED the wide belt should be used and the administration made with the patient standing.  Usually abdominal or spinal treatments are best given with the patient standing, as he can more easily hold the belt taut.  In almost all other cases sitting is advised.  An application as a whole may last from a few to seven or eight minutes, although some employ it for a longer period when treating exceptionally vigorous patients.  Usually the effect produced instead of the time will best serve as a guide, but it is well under no conditions to make the treatment exceptionally long.  The same rule obtains as with all cases under mechanical vibratory treatment, viz., the first administration should be made shorter and milder than those following.

    THE FREQUENCY OF TREATMENT is left mostly to the judgment of the operator.  Daily treatments at first followed by treatments three times a week is the general rule, but the rule of electro-therapeutics is applicable to oscillation; a daily treatment unless otherwise indicated is best at first, to be followed later by one on alternate days, every third day, or two or three times weekly, according as the relief can be "bridged over" - that is, the effect produced should last until or almost until the following treatment until the conditions are finally relieved.

    This machine affords a vigorous means of massaging the abdomen.  Observe the law of exercise - do not exercise on a full stomach or immediately following other exercise or exertion.  The dosage should be regulated according to the effect sought, based upon its use according to Monell [A Pictorial System of Instruction, page 611] as follows, to " (1) Accelerate the general or local circulation.  (2) Determine an increased supply of blood to a part.  (3) Increase under-nutrition. (4) Excite over-oxidation. (5) Relieve pain or muscular stiffness. (6) Stimulate internal organs to improve functions. (7) Tone up atonic muscle fibres. (8) Increase secretion, especially of the liver and digestive apparatus.  (9) Increase peristaltic action of the intestinal tract.  (10)  Secure the effects of fine rapid vibration."

    TO REGULATE THE LENGTH OF STROKE an eccentric provided for the purpose should be adjusted to one or one and one-half millimeters for a fine stroke.  A stroke of one and one-half millimeters is best adapted for work about the neck when the smaller belt is used.  The use of over two and one-half millimeters is not advisable when the hand piece is employed.  With the large belt a stroke of from three to eight or nine millimeters may be used according to the size and tolerance of the patient, as well as the condition of the part treated.  Beyond this limit the strokes become actual muscle and body exercisers.

    THE EMPLOYMENT OF SPECIAL APPLICATORS will be considered in connection with the treatment of particular parts.  The use of the hand applicator with this apparatus is illustrated in the treatment of the ear.  Remove the distal end portion of one handle and lock the eccentric on the same side at zero, then unscrew the set screw of the other eccentric and adjust it so as to secure a stroke of about one millimeter and in place of the lower part of the other handle attach the hand applicator. One eccentric being locked, vibrations instead of oscillations occur.  The operator should strap his hand to the applicator and use his finger tips or thumb tip in making the applications, the vibrations being transmitted through the hand of the operator to the patient.  The handle bar should always be rigid during administrations as a deviation affects the vibrations.  It is desirable in the writer's opinion to start the vibrations before applying the hand to the region to be treated and thereby avoid shock and discomfort.  With one finger tip, using well regulated pressure, treatment may be given over an area where administration is indicated, as the Eustachian tube, larynx, or pharynx.

    THE TREATMENT OF MYALGIA OF THE NECK has been followed by good results by the use of the narrow belt in the writer's experience, employing the apparatus as follows: Adjust each eccentric so the stroke will be about one and one-half millimeters and tighten the set screw.  To the lower part of each handle hook on the narrow belt.  Have the patient remove her hat and collar and adjust the belt.  She should sit in the chair at such a distance as to bring the belt taut, and the handles must be in line.  Start the motor at a rapid rate of speed.  At the end of five minutes the patient under such treatment was able to move her neck freely.  When the large belt is used the patient should stand in such a position as to throw a weight of about twenty-five pounds upon the belt in order to keep it taut.

    IN RESPECT TO THE TREATMENT OF THE EXTREMITIES, taking the foot as an example, as it will also demonstrate the method of using the foot rest, the method is as follows: Seat the patient facing the apparatus with legs extended.  It is best, although not absolutely necessary, that the shoes be removed.  Hook the foot rest to each handle bar.  The patient should then place her feet in the foot rest and hold the belt in her hands, or have it fastened around her body, or around the chair, as it must be held taut.  Three or four millimeters as indicated on the eccentric of this apparatus will usually give a stroke of sufficient length for this administration.  The treatment should be continued for about five minutes, unless existing conditions indicate otherwise, and a short rest should follow before the patient leaves the office.  This treatment is adapted to patients suffering from poor circulation and cold feet.

    Electricity can be administered during the treatment with the applicators, but is not considered a valuable combination.  A vibratory attachment also increases the usefulness of the apparatus.  Dr. Morse [Journal of Advanced Therapeutics], of Boston, describes a practical method of treating auto-intoxication as follows: "My first treatment consisted of a gastric lavage, not by the usual method of swallowing a tube, but by having the, patient drink half pint of a solution of sodium phosphate and sodium salicylate, followed by one or two glasses of Poland water, shaking him vigorously by placing the band of the oscillator over and around the stomach, after which having him lie for five minutes on his right side that the solution might gravitate into the duodenum."  This procedure was followed by "a sinusoidal surging current through the duodenum for five minutes and the static wave current over the parts for five minutes."  This treatment caused a marked elimination of toxic material resulting in a rise of temperature, quickened pulse and slightly swollen and tender joints.  An active cathartic was then given to eliminate the toxic material.

    In the adaptation of all machines to therapeutics, the operator must consider many features other than the directions generally given, for the relative strokes, speed, and pressure of and with different machines vary.  He should always test the application of each particular vibratode with varying degrees of speed and stroke and pressure on himself at the same site he is to treat the patient; for without so doing he cannot rightly appreciate effects or obtain the best results.