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

Chapter 7

The Relation of Mechanical Vibration to the
Heart, Blood-Vessels, and Ductless Glands

    PERCUSSION OF THE HEART yields dulness of two type - superficial and deep. (1) Superficial or absolute dulness is elicited by weak percussion only, representing "that portion of the heart not covered by lung tissue."  A small part of the heart posterior to the sternum and uncovered by lung tissue yields a resonance because "the percussion blow is conveyed by the sternum to the adjacent lung structure." (2) Deep or relative dulness is elicited by strong percussion.  The deep cardiac dulness, which concerns us in the study of the heart reflex of Abrams, "extends vertically from the 3rd rib and ends at the 6th, but owing to the cardiac merging in the hepatic dulness, this lower limit cannot be accurately ascertained, while transversely at the 4th rib it extends from just within the nipple line to slightly beyond the right of the sternum."

THE AREA OF CARDIAC DULNESS varies in pathological conditions, and as any change from the normal should be considered when studying the reflex action of the heart, a brief summary of such changes is here noted.  In hypertrophy and dilatation it is increased from above to the left and downward when the left ventricle alone is involved.  The dulness is "broader and increased toward the right side" when the right ventricle is involved.  When there is hypertrophy of both ventricles "the apex beat is rounded and diffuse." In hydro-pericardium the outline of "precordial flatness is a blunt cone" and different positions change the area.  The presence of tumors, pleuritic effusions on the left side, retraction of the lung, or "infiltration of lung adjacent to the heart" may apparently increase the cardiac dulness when the heart is normal.  Diminished area of dulness is found in atrophy of the heart, absorption of fat in wasting disease, emphysema of the lung and mediastinum, and pneumo-pericardium.  For diagrammatic illustrations of heart dulness in disease the reader is referred to Butler's "Diagnostics of Internal Medicine."

A BRIEF REVIEW OF THE NERVOUS MECHANISM OF THE HEART is of value in the analysis of vibratory or concussional effects upon the heart.  The heart's action according to Howell [Text-Book of Physiology], is under control of:

"1. Efferent nerve fibres from the central nervous system through the vagus nerves (inhibitory nerve fibres).  Their stimulation slows or stops the heart beat.

"2. Efferent nerve fibres from the central nervous system through the sympathetics (accelerator or augmentor fibres).  Their stimulation accelerates or increases the force of the heart beats.

"3. Afferent nerve fibres.  Their stimulation pathologically may cause sensations of pain."
The branches of the vagus [Cunningham's Manual of Practical Anatomy, page 67] supplying the heart are:

"l. Cervical branches, except lowest on each side, as a rule join the sympathetic cardiac branches and lose their identity.  The lowest cervical cardiac branch of left pneumogastric goes to the superior cardiac plexus.  The lowest cervical cardiac branch of right pneumogastric goes to right portion of deep cardiac plexus.

"2.  Thoracic cardiac branches are from trunk of right pneumogastric and go to deep plexus.

"3.  Recurrent laryngeal branches of pneumogastric go to deep plexus."

    The cardiac branches of the sympathetic are:

1. Upper sympathetic cardiac from upper cervical ganglion.

2. Middle sympathetic cardiac from middle cervical ganglion.

3. Lower sympathetic cardiac from lower cervical ganglion.

    The cardiac branches of the vagus and of the sympathetic form the cardiac plexus which are tabulated by Cunningham as follows:
a. "Superficial cardiac plexus" 1. Superior cardiac branch of evmpathetic of left side. 
2. Lowest cervical cardiac branch of left pneumogastric.
b. "Left portion of deep cardiac plexus" 
1. It gives off a branch to left auricle. 
2. A branch to left anterior pulmonary plexus. 
3. To form left coronary plexus.
1. Middle and lower cardiac, branches of sympathetic of left side. 
2. Upper two cervical eardiae branches of pneumogastric. 
3. Cardiac branches of the left recurrent laryngeal.
c. "Right portion of deep cardiac plexus" 
1. It gives off a branch with filaments for right auricle. 
2. A branch to right anterior pulmonary plexus. 
3. To join superficial cardiac plexus and form right coronary plexus.
1. Three cardiac branches of sympathetic of right side. 
2. Cervical cardiac branches of right pneumogastric. 
3. Thoracic cardiac branches of the right pneumogastric. 
4. Cardiac branches of the right recurrent laryngeal.

    The influences of the cardiac nerves have been summarized by Engelmann [Howell.  Text-Book of Physiology, page 565] as follows:

"l. The chronotropic influence, affecting the rate of contraction.
    a. Positive chronotropic actions causing an acceleration of the rate.
    b. Negative chronotropic actions causing a slowing of the rate.

"2. The bathmotropic influence, affecting the irritability of the muscular tissue.
    a. Positive.
    b. Negative.

"3. The dromotropic influence a:ffecting the conductivity of the tissue.
    a. Positive.
    b. Negative.

"4. The inotropic influence affecting the force or energy of the contractions.
    a. Positive.
    b.  Negative.

    THE IRRITABILITY OF THE HEART is of concern to the student of vibration.

    Landois [Text-Book of Human Physiology, page 115] states that:

1. A weak stimulus alone not of sufficient strength to affect the heart when repeated may affect the heart as "the heart is capable of summation of individual stimuli.

2. A stimulus (even the feeblest) that will excite a contraction has "a maximal effect." (Bowditch, Kroiaecker and Stirling).

    THE MAGNITUDE of the heart's beat depends not on the magnitude of the stimulus, but on the condition of the ventricle (or the heart) [Foster.  Text-Book of Physiology, page 303]. This probably explains why one operator might obtain no result from vibration and another operator would get results, the element of strength and the number of stimuli being important.

    THE CARDIO-INHIBITORY CENTER can be stimulated reflexly [Landois and Stirling.  Text-Book of Human Physiology, 4th Edition, page 849] by stimulating sensory nerves; or the central end of one vagus, if other intact, or by stimulating the sensory nerves of the intestines, which "arrests the heart's action," as proved by the tapping experiment of Goltz.  Stimulation of the cervical sympathetic, the abdominal sympathetic or the splanchnic nerve directly (Asp and Ludwig) produces the same effect.  "Very strong stimulation of the sensory nerves, however, arrests the above named reflex effect upon the vagus.  The action of the heart may be arrested by stimulation of the vagus, not only by means of electrical stimuli but also by chemical (common salt, glycerine), or by mechanical stimuli.  As a rule, the right vagus is more powerful than the left." The vagus lies under the sterno-mastoid between the internal jugular vein and the internal and common carotid arteries.  Cyriax [The Elements of Kellgren's Manual Treatment, page 159] has the patient bend "the head forwards or sideways" and by passing the finger "in front of the muscle or behind it" and giving friction "transversely across the nerve, cardio-retardation or
eructations or even vomiting may result."  If mechanical vibration is used in the same manner the soft cup-shaped vibratode is to be preferred.  The automatic rhythm of the heart, the force of its contraction, and the power of conduction ("the capacity for conducting muscular contractions") are influenced by stimulation of the vagus.  Abdominal vibration with the disc vibratode and cap shield has been found by the author to lessen the pulse rate.  "The inhibitory neural cells for the heart are located in the nuclei of the 10th and llth cranial nerves and their paths to the heart are through the 10th nerve." (Arnold.)

    A rhythmical interrupted stimulus of a frequency of eighteen to thirty per second is necessary to produce cardiac inhibition.

    Sajous' [The Internal Secretions and the Principles of Medicine, page 452] recent conclusions relative to the heart, are as follows:

    "Inhibition is a morbid process due to excessive vasomotor contraction of the coronaries causing a reduction in the quantity of blood supplied to the heart walls.

"1. No cardiac inhibitory apparatus exists as a physiological entity.

"2. Active inhibition of the heart may be caused by excessive stimulation of the vagus.  "Abrams considers that the best site for exciting the vagus is "the region of the spine in juxtaposition to the vertebral exits of the upper spinal nerves (at about the spinous process of the 4th dorsal vertebra).

    The writer has demonstrated that if the ball vibratode be applied on each side of the spine alternately between the transverse processes of the 7th cervical and lst dorsal or 2nd and 3rd or 3rd and 4th dorsal vertebrae for five minutes the pulse rate will often be lowered.

    THE RELATION OF THE HEART BEAT TO THE PRESSURE is thus stated by Foster [Text-Book of Physiology, page 323]  "'The rate of the beat is in inverse ratio to the arterial pressure,'  a rise of pressure being accompanied by a diminution, and a fall of pressure by an increase of the rate of the rhythm.  This, however, only holds good if the vagus nerves be intact.  This is opposite to what we would naturally expect; for a high blood pressure means an increased resistance to the ventricular systole and a larger quantity of blood flowing through the coronary arteries, and naturally with a resulting increase in the heart's action, we would expect an increase "in the rate of rhythm as well as in the force of the individual beats." [Text-Book of Physiology, page 323]

    In one instance the pulse rate was lowered by the writer from 87 to 69 with a five-minute vibratory treatment, and the pressure was lowered at the same time 4 mm. which does not conform to Foster's law.  The writer has also noted a lowering of both pulse and arterial tension from intervertebral vibration between the 2nd and 3rd dorsal vertebrae.  The following case is illustrative.
Miss S. November 3rd before treatment tension 152 mm. pulse 70
    after treatment tension 144 mm. pulse 66
  November 4th before treatment tension 144 pulse 80
    after treatment tension 140 pulse 74
  November 5th  before treatment tension 142 pulse 78
    after treatment tension 138 pulse 67

    The arterial tension was reduced by the writer in one case from 188 to 180 mm., and the pulse rate from 96 to 90 by intervertebral vibration between the 7th cervical and the lst dorsal vertebrae.

    Cyriax cites a case where accompanying other conditions there was irregular heart action, the "whole body shook, and every third or fourth beat was missed," with a systolic murmur in the mitral area.  Pulse was 130 per minute.  "Heart vibration (manual) and shaking with frictions on the left 4th and 5th dorsal nerves near the spine, together with stomach exercise, caused the "intermittency and irregularity to almost disappear" and the pulse fell to 108.  Sleep followed.  The symptoms returned the next morning.  The same treatment relieved the heart condition and the pulse fell to 100.  Sleep followed. On awakening the heart was better - more regular, and the intermittencies and the murmur had disappeared.  The pulse was 112.  Treatments were continued twice daily for the next two days, when the "heart was quite normal beyond slight acceleration of pulse."

    Landois [Text-Book of Human Physiology, 4th edition, page 759] states that the vagus can be stimulated mechanically occasionally by digital "compression against the cervical portion of the vertebral column, but alarming attacks of syncope have been observed to follow this procedure." Arterial tension was also reduced in another case by the author from 120 to 112 mm. and the pulse rate from 86 to 80.  Apparently the vagus was affected or "efferent nerve fibers from the cerebral nervous system through the vagus" or the adrenals were affected. There at least resulted a "reduction of the vagal vibratory rhythm" causing a lower number of heart beats per minute.  Butler believes that "a decreased pulse rate may be due to pneumo-gastric irritation or paralysis of the cardiac sympathetic nerves and ganglia."

"3.  Passive inhibition of the heart is primarily due to insufficiency of the adrenals."

    The reasons for this are embodied in the following general summary of the functional mechanism of the heart:

"1. The nervous supply of the heart is derived from the general motor (sympathetic) and vagus systems.

"2. The general motor plexuses and nerves maintain the normal tonic contraction of the coronaries and other cardiac vessels and insure distribution of the blood among the muscular elements.

"3. The vagal plexuses and nerves incite and govern the rhythm of the heart, reducing or increasing its beats.

"4. Increase of the vagal vibratory rhythm (impulses) causes quickening of the heart-beats.

"5. Excessive vibratory rhythm of the vagus (or spinal accessory) causes arrest of the heart-beats: i.e., inhibition.

    "Foster believes [Text-Book of Physiology, page 313] that spinal accessory nerve fibres pass from the bulb to become a part" of the vagus trunk in the dog and that these spinal accessory fibres supply the inhibitory fibres to the heart.  The spinal accessory nerve can be reached "at about the middle of the posterior border of the sterno-mastoid" or "at a point in the trapezium in a line drawn directly backwards from the middle of the clavicle." (Cyriax.)

" 6. Reduction of the vagal vibratory rhythm causes, when physiological, slowing of the heartbeats.

" 7. Reduction of the vagal vibratory rhythm, when pathological, especially when due to adrenal insufficiency, results in quickening and weakening of the heart-beats, through loss of vagal control.

"8. Cessation of the vagal vibratory rhythm (as after division of the vagus on both sides) is followed by marked quickening and weakening of the heartbeats, through loss of vagal control.

    The preceding summary gives a physiological working basis for vibratory research work in connection with the treatment of certain cardiovascular derangements both functional and organic.

    Kirke states that in a frog the heart's condition, site of stimulation and intensity of stimulus applied to the vagus determine the resulting effects, inhibition or increased activity.  Varying results are obtained [Foster. Text-Book of Physiology, page 308] depending upon whether "we stimulate (1) the vagus in the cranium before it is joined by the sympathetic, (2) the sympathetic fibres before they join the vagus, (3) the vagus trunk containing both the real vagus and the sympathetic fibres.  A very prolonged inhibition [Foster. Text-Book of Physiology, page 309] may be produced by prolonged stimulation.  The total effect of stimulating the vagus fibres is not to exhaust the heart, but rather to strengthen it; and by repeated inhibitions carefully administered, a feebly beating heart may be nursed into vigorous activity."  It is under such conditions that a person who has fainted can be revived by spinal concussion of the 7th cervical vertebra or by intervertebral vibration between the 7th cervical and the lst dorsal vertebrae.

    ACCELERATION OF THE HEART BEAT or strengthening of the contraction of the heart (Heideinhain and Lowit) or the latter effect only may be induced by stimulation of certain accelerating fibres in the cervical sympathetic. (Pawlow.)

    Foster [Text-Book of Physiology, page 317] says that stimulation of the augmentor fibres sometimes "increases the rapidity of the rhythm," which increase may be conspicuous or slight, and yet "a more constant and striking effect is the increase in the force of the beat.  The output of the heart is increased, which may occur in spite of a concomitant rise of arterial pressure so that the effect of the action of the augmentor nerves is distinctly to increase the work of the heart, and this may take place even though no marked acceleration occurs." These facts should be considered when employing mechanical vibration.

    THE ACCELERATOR CENTER is believed by Howell [Text-Book of Physiology, page 575] to be in the brain.  He says, that "since stimulation of the upper cervical region of the cord causes acceleration it seems evident that the paths must begin somewhere in the brain." The accelerating [Arnold. "The Importance of the Physical Examination of the Back in General Diagnosis."  Medical News, March 18, 1905] set of neurons for the heart come principally "from the sixth cervical to the first or second dorsal segments.

    Experimentally the accelerators are stimulated [Howell. The Text-Book of Physiology, page 573] in branches communicating with the inferior cervical ganglion, or the stellate, the first thoracic ganglion, is stimulated.

    The inferior cervical ganglion may be vibrated by applying the vibratode on the head of the first rib, the head articulating with the body of the 1st dorsal vertebra, on each side of the spine.  It communicates with the 7th and 8th cervical (Krause says 8th cervical and lst dorsal) spinal nerves whose exits are reached between the transverse processes of the 6th and 7th cervical, and the 7th cervical and lst dorsal vertebrae.  Anteriorly the inferior cervical ganglion is "behind the clavicular insertion of the sternomastoid."

    The sympathetic [Foster. Text-Book of Physiology, page 309] was stimulated in the neck, at Sy. Fig. 40 the nerve being cut below so impulses could only "pass up to the vagus and then down the mixed vagus trunk to the heart. The beat of the heart was augmented." The beats increased in frequency or force or most generally in both.  "A heart which has almost ceased to beat by proper stimulation of the sympathetic may be called back into vigorous activity." Sajous [The Internal Secretions and the Principles of Medicine, page 446] says, "that we are here dealing with stimulation of the adrenals, seems probable.  The anterior pituitary body becomes activated under these circumstances, through the carotid plexus."  Not only is the vagus stimulated, but the suprarenal glands are stimulated, which Sajous says represents "the most effective means to bring about the effects witnessed."  "This is affirmed by Foster who says that the augmentation resulting from the stimulation of the sympathetic is followed by a period of reaction in which the beats are feebler, in other words augmentation is followed by exhaustion and indeed by repeated stimulation of these sympathetic fibres, a fairly vigorous heart, especially a bloodless one, may be reduced to a very feeble condition.'"  Sajous believes that the vagus incites and governs the active stage of the functional processes, of the heart and other organs supplied by it.  He also believes that: stimulation of augmentor fibres affects first the adrenals and secondly the vagus.  Foster [See Fig. 40] "traces augmentor fibres in a frog from the spinal cord by the anterior root of the third spinal nerve through the ramus communicans to the corresponding sympathetic ganglion G" and thence by the second ganglion G", the annulus of Vieussens, and the first ganglion G' to the cervical sympathetic Sy and so by the vagus trunk to the superior vena cava." The course of the augmentor and inhibitory fibres in a dog is represented in Fig. 41.

The same authority [Foster. Text-Book of Physiology, page 316] says that stimulation of these several cardiac nerves has shown the presence of augmentor fibres "in some or other of the nerve, passing from the lower cervical ganglion (middle cervical ganglion?) and the adjoining vagus trunk from the annulus of Vieussens, especially the lower ventral limb, and sometimes from the stellate ganglion itself (receiving branches from the lst, 2nd, and 3rd thoracic spinal nerves and from the 7th and 8th cervical nerves).  The results differ a good deal in different individuals, and there are reasons for thinking that the nerves in question may contain efferent fibres other than augmentor fibres by reason of which stimulation of them may give rise to
other than pure augmentor effects."

    The application of mechanical vibration between the transverse. processes of the 7th cervical and lst dorsal vertebrae, where the 8th cervical nerve has its exit often results in a lowering of the pulse rate as the following cases illustrate.

Miss N. Sitting, pulse 82; lying, pulse 76.
Mr. T. Sitting, pulse 84.

    After five minutes' application of vibration between the transverse processes of the 7th cervical and lst dorsal vertebrae on each side alternately.

Miss N. Sitting, pulse 76; lying, pulse 72.
Mr. T. Sitting, pulse 80.

    Sometimes but more rarely vibration applied over the same site gives accelerating effects as:

Mr. -. Sitting, pulse, 74.

    After five minutes' vibration.

Sitting, pulse 80.

    V. Bezold and others have observed that some accelerating fibres are found in the cervical sympathetic.  A few accelerating fibres reach the heart through the vagus and their stimulation may cause an accelerated heart-beat or strengthen cardiac contractions.  The excitability of the inhibitory vagal fibres is exhausted more quickly than that of the accelerating fibres, "but the vagus fibres are more excitable than those of the accelerans." [Landois & Stirling.  Text-Book of Human Physiology.  4th ed., page 854]

    The same authors state that if the nervus accelerans is stimulated, a long latent period ensues before the frequency of the heart-beat is affected.  If the vagus and accelerans fibres are stimulated at the same time, only the inhibitory action of the vagus is induced.  If during the stimulation of the accelerans the vagus is suddenly stimulated a reduction occurs in the number of heart-beats; but if vagal stimulation ceases an accelerating effect is again noted.  Adrenals tend to strengthen and reduce pulse-rate, but vagus under excessive oxidation tends to quicken it.

    The preceding offers an explanation of the varying effects obtained from the application of mechanical vibration over the same site, the element of time - duration of treatment - being important.  When vibration was given between the transverse processes of the 7th cervical and the 1st dorsal vertebrae in all cases of cardiac insufficiency that were associated with a high arterial tension, and in most other cases of high tension where vibration has been applied between the transverse processes of the second and third dorsal vertebrae the result has been a lowering of the blood pressure usually accompanied by a lowering of the pulse rate.  An increased frequency in the pulse rate has been the exception, not the rule.  Occasionally only a strengthening of the pulse beat has occurred with no variation in frequency.

    Butler [Diagnostics of Internal Medicine, page 370] believes that "increased frequency of pulse may be due to paralysis of the pneumogastric or to irritation of the sympathetic nerves or the intracardiac ganglia."

    It is "evident that stimulation of the 'augmentor' fibres," says Sajous [The Internal Secretions and the Principles of Medicine, page 449] "increases the rapidity and the force of the heart-beat by increasing the functional activity of the adrenals and, as a result of the increased oxidation processes thus obtained, that of the vagal centers.  The excess of adrenal secretion increases the force of the heart-beats, while the overactivity of the vagal centers increases their number." Foster [Text-Book of Physiology, page 317] says, that when the augmentor fibres are stimulated "in the case both of the auricles and ventricles the extent of the systole is increased.  It would seem also that both cavities undergo a larger expansion.  They are filled with a larger quantity of blood during the diastole." The heart's work is increased.

    Von Ziemssen found that when mechanical stimuli were applied to the heart from without, "slight pressure on the auriculo-ventricular groove caused a second short contraction of both ventricles after the heart-beat." Strong Pressure causes the cardiac muscle to act very irregularly.  This fact should therefore be considered when exerting pressure with the vibratode over the heart muscles.

    Cyriax [Elements of Kellgren's Manual Treatment, page 192] who has used manual vibrations over the heart believes "that the vibrations act by tending to restore the normal equilibrium between the two sets of fibres, augmentor and inhibitory, which has become disturbed through increased or decreased excitability of either of them and refers the reader to Levin's [Tidskrift. Gymnastik, 1892] statistical report regarding the effect of heart vibration.  He noted that in pathological conditions of the heart, tenderness over the 4th and 5th dorsal nerves of the left side was elicited by frictions over said nerves.

    The nervous system as a medium for influencing the heart's functions is a most important field for the application of vibratory stimulation.  Oertel and Graham have for years obtained good results from local treatment so directed.  Yet some who consider vibratory stimulation of the nerves of prime importance, vibrate other parts as well.  The branches of the spinal nerves sometimes apparently govern more than one function as in the vagus of the frog, the stimulation of which may cause either inhibition or increased activity, "according to the position where the stimulus is applied, the intensity of the stimulus aiad the condition of the heart." [Baker and Harris.  Kirke's Handbook of Physiology]

    Since the limitations of spinal stimulation are not as yet fully demonstrated it will take time and experience with the administration of mechanical vibration and other physical measures to discover their relative values.

    The nerves in their various relations will be more fully considered in a following chapter.  Local or central stimulation requires selective study of the pathological conditions present to be corrected employing the treatment indicated as based upon the findings and the demonstrated physiological action of mechanical vibration.

    VIBRATION OF THE HEART according to Oertel's or Kellogg's method of manual massage may be accomplished with a nicety of precision and control of force hardly possible to obtain with the hands.  With the patient standing, use vibratory friction over the chest walls downward and inward from the axillary line.  For this purpose a rubber-covered disc vibratode is preferable.  Applied in this manner it helps to perfect expiration and favorably influences the heart's nutrition.  It is so used in the following conditions:

"l. When the heart muscle is weak from deficient nutrition, Anemia or corpulence.

"2. When the arterial system is imperfectly filled and there is passive congestion as a result of insufficiency of the myocardium.

"3. When there are valvular lesions or obstruction to the circulation, the pressure of tumors, or contraction of the pulmonary orifice.  Emphysema and curvature of the spine increase the demands of the heart.

"4. As an accompaniment of treatment of the heart by mountain climbing.

    Kellogg advocates the period during expiration as the time best adapted for massage of the heart.  He wishes the patient to recline, and then manual massage is directed from each axilla "toward the sternum," at the same time applying the greatest force "between the fifth and eighth ribs, the maximum of pressure falling over the latter."

    THE PHYSICAL AND PHYSIOLOGICAL EFFECTS OF VIBRATORY STIMULATION ON THE CIRCULATION will vary with the methods of administration and other physical conditions.  When the circulation is accelerated by vibratory stimulation the increased heart's action usually indicates a rise in the arterial tension.  Lessened frequency is usually found with lowered tension, dilatation of the blood vessels and increased production of heat.  Reflexly an alteration in the exchange of oxygen and CO2 in the lungs produced by the greater demands for tissue combustion affects the respiration.  Mechanical vibration can be so applied as to restore the equilibrium of the blood stream and raise the temperature of the, body.

    THE EFFECT OF VIBRATION ON THE HEART and blood vessels is described by Cyriax ["Vibrations and Their Effects." Lecture given before the Ling Association, London, on January 5, 1906] as follows:

    "(a) On the heart.  That vibration can diminish an excited cardiac action has been shown by Winternitz, Levin, Hasebroek, Nebel, Ziegelroth and Achert.  Siegfried found very little effect, Bechterew and Tschigawej, a varying one.

    "In stoppage of the heart during chloroform administration Strassmann, Korte, and Kumpf, found a strong manual vibration on the heart one of the best methods of causing it to beat again." (Heart reflex of Abrams.  Snow.)

    "Heitler found that vibration of the heart set up by the so-called hacking over it raised the tone of the cardiac muscle and diminished the size of the organ. (Abrams' heart reflex.  Snow.)

    "The theory that heart vibration acts chiefly in a reflex way through the sensory nerves and the vagus has been advocated by Heiligenthal, Nebel, Murray and Lorand.  Bjorksten and Ziegelroth on the other hand, considered that it acted directly on the heart itself; Heitler and Hasebroek incline to this view."

    From recent investigations the author may add that mechanical vibration may be applied to induce either an inhibitory action through vagal stimulation, or the heart 's action may be accelerated.  The pulse rate may also be accelerated or diminished.

(b) On the blood vessels.  Most authors, Bjorksten, Zander, Bechterew, and Colombo, consider that the effect of vibration is to cause the blood vessels to contract and the blood pressure to rise, though, according to some of these mentioned, a subsequent dilatation with fall of blood pressure may result. (The blood pressure may be made to fail or rise.  Snow.)

    THE HEART REFLEX described by Abrams [Spondylotherapy. The Heart Reflex of Contraction, page 201] is elicited by: "1. Irritation of nasal mucosa. 2. Irritation of gastric mucous membrane. 3. Irritation of rectal mucosa. 4. Irritation of oesophageal mucosa in act of swallowing. 5. Percussion of muscles. 6. By psychic influences." 7. By intervertebral vibration, or vertebral concussion of the 7th cervical vertebra.  This reflex he describes as "a contraction of the myocardium of varying duration."  This may be due to an effect sometimes observed by stimulating the accelerators, i.e., to "strengthen the contraction of the heart,"which may establish an equilibrium, or accepting Sajous' views the action may be due to a secondary effect on the vagus and indirectly on the adrenals.  This effect may be induced by an interrupted vibration or concussion applied to the spine of the 7th cervical vertebra, or as demonstrated by the author by interrupted vibration applied between the transverse processes of the 7th cervical and lst dorsal vertebrae.  Abrams observed that although the reflex is usually more noticeable in the left ventricle, in some cases it is confined to the left ventricle; but, on the other hand, when muscle percussion is used the right ventricle only contracts.  Normally this is of short duration.

    It is of interest to note the effect of manual frictions on "the lower cervical nerves of the sympathetic system as observed by Cyfiax. [Elements of Kellgren's Manual Treatment, page 162]

    "As a general rule there is temporary vaso-constriction which is followed by a certain amount of vaso-dilatation with improved and slowed cardiac action."  Fainting may often be relieved by this method.

    To ELICIT THE HEART REFLEX OF CONTRACTION the writer uses a ball vibratode with a vibrator regulated to give a percussion stroke of rather low rate.  If the vibrator is applied over the spine of the 7th cervical vertebra, the part should be first powdered with a dusting powder and the vibratode be applied over an intervening thickness of rubber belting or leather for protection of the tissues from the friction.  The application should be usually for three minutes with a few interruptions.  After a rest of one minute, another seance of five minutes is given if the response has been inadequate.  Care must be taken not to use too great pressure and no friction should under any condition be allowed, otherwise it may chafe the skin.  If intervertebral vibration is employed, the ball should be applied directly upon the skin, alternately on each side of the spine between the transverse processes of the 7th cervical and lst dorsal vertebrae.  A medium rate of speed and full stroke should be used.  The latter is the method preferred by the writer.  The patient may either sit erect, or lie upon an operating table face down, during the administration.

    If mechanical vibration is applied to the PRECORDIAL REGION to induce the reflex, the rubber-covered disc vibratode is used.  The author reduced the blood pressure 10 mm. on two occasions with local vibratory treatment over the heart in the case of a child.  Dr. Peckham has employed local heart vibration with spinal vibration and auto-condensation and is convinced that the local heart vibration is a great tonic.

    In determining the heart reflex of Abrams the deep cardiac dulness only is to be considered for the area of superficial dulness will vary with "the position of the overlapping lung-borders." These are of course affected by stimulation of the lung reflex of dilatation "which may diminish the area of superficial dulness even to obliteration." [Abrams. Spondylotherapy, page 204]

    IN RELATIVE VALVULAR INSUFFICIENCY, in cases in which the valves are otherwise normal, but relaxed and not competent to close the orifices completely, permitting regurgitation, the murmur as present has been caused by Abrams to temporarily disappear by an induction of the heart reflex.  The effect is to overcome the dilatation of one of the chambers of the heart, which in these cases is always distended with blood and incompletely discharging its contents at systole.  He used the sinusoidal current or mechanical percussion over the precordial region with a percussion hammer to induce the reflex.

    CARDIAC INSUFFICIENCY due to myocardial changes or valvular lesions occurs: 1. When hypertrophy does not follow. 2. When the hypertrophied heart is overworked. 3. When degeneration takes away its motor power.

    When due to myocardial disease it occurs as follows: [Abrams. Spondylotherapy, page 213]

"1. Arrhythmic form: pulse is irregular, intermittent and lacks force and volume.

"2. Form with accelerated pulse (tachycardia) and paroxysms of palpitation.

"3. Form with attacks of pulmonary oedema and cardiac asthma, with dyspnoea equally inspiratory and expiratory."

    Abrams states that in these cases if "a good heart reflex can be obtained the prognosis is as a rule favorable." He induces the reflex by his method of vertebral concussion of the spine of the 7th cervical vertebra.  The author elicited the same reflex by prolonged vibration between the transverse processes.

    This is accomplished by interrupted vibration with the ball vibratode applied alternately on each side of the spine, between the transverse processes of the 7th cervical and 1st dorsal vertebrae, employing moderate pressure and a fairly low rate of speed for three or five minutes with one long and several short intervals of rest.  The author has employed this method with gratifying results in the treatment of cardiac insufficiency characterized by arrhythmia.

    TO TEST MYOCARDIAL INSUFFICIENCY Abrams compares the blood pressure taken previously with the blood pressure taken after the heart has been concussed with a pneumatic hammer.  If the latter mvfigure shows a marked increase, the myocardia is held to be very strong; if there is a marked decrease, myocardial insufficiency is present; if there is a difference of but a few millimeters, there is indication of myocardial sufficiency.  The author noted the following:

    Mr. L.'s tension, 140mm.

    After a few vigorous blows over the precordial region. - Mr. L.'s tension, 155 mm.

    This marked rise signified that the myocardium was strong which interpreted according to Abrams, meant that this patient's pressure would be lowered not by vibration over the 7th cervical which tones up the heart muscle, but over the spines of the 2nd and 3rd dorsal vertebrae or by the writer's method in the intervertebral spaces between the transverse processes of the 2nd and 3rd dorsal vertebrae.  A vibration of five minutes' duration over the spinous processes of the 2nd and 3rd dorsal vertebrae in one case caused the tension to drop from 160 to 140 nun.  Further vibration between the transverse processes of the 2nd and 3rd dorsal vertebrae gave a further fall to 130 mm.

    MYOCARDITIS is amenable to treatment by the induction of the heart reflex if the myocardium responds.  Symptomatic treatment by diet, elimination and for the improvement of nutrition are indicated. The duration of treatment by the induction of the heart reflex may be five minutes or less or more according to results obtained.  In some cases the author has obtained good results in five minutes; in others better results were obtained in ten minutes.  Ten minutes is commonly the time required.

    OVER-STRAINED HEART characterized by the presence of ventricular dilatation with feeble heart tones, and an irregular or intermittent, feeble, rapid pulse, has been successfully treated by the induction of the heart reflex.

    The author has found the employment of vibration in the same manner very effectual in the treatment of high blood pressure associated with goitre.  The application for five minutes of interrupted vibration over the spine of the 7th cervical vertebra caused in one case a fall from 125 mm. to 112 nun.  Dr. A. B. Hirsh of Philadelphia, to whom the author is indebted for his assistance in making investigations and demonstrations, noted also a relative softening of the pulse.

    Theoretically this method should be applicable to the treatment of mitral incompetency particularly when complicated by hypertension, also in mitral stenosis, in which the heart may be slightly enlarged, in tricuspid regurgitation, which is a state of relative insufficiency, showing usually an increase in the area of dulness to the right of the sternum and in tricuspid stenosis with which dulness is increased especially to the right of the sternum.

    Failure of general nutrition, disturbance of the local nutrition of the heart, very severe muscular exertion, and mental emotions also cause an interruption of cardiac compensation.

    The induction of the heart reflex may be employed in all conditions of cardiac insufficiency occurring in the following conditions if degenerative changes render it incompetent as in hypertrophy, or if the hypertrophied heart becomes overburdened.

    Hypertrophy of the left ventricle alone [Osler. Practice of Medicine], or with general enlargement of the heart caused by:

    "(a) Conditions affecting the heart itself:

"1. Disease of the aortic valve.

"2. Mitral insufficiency.

"3. Disturbed innervation with overaction, as in exopthalmic goitre, in long continued nervous palpitation, and as a result of the action of certain articles such as tea, alcohol, and tobacco."

    "In all of these conditions the work of the heart is increased.  In the case of the valve lesions the increase is due to the increased intraventricular pressure."

    "(b) Conditions acting on the blood vessels:

"1. General arteriosclerosis with or without renal disease.

"2. All states of increased arterial tension induced by the contraction of - the smaller arteries under the influence of certain toxic substances, which affect the minute capillary circulation, render greater action necessary to send the blood through the distant subdivisions of the vascular system.

"3. Prolonged muscular exertion."

    Hypertrophy of the right ventricle is caused by:

"1. Lesions of the mitral valve, either incompetence or stenosis causing increased resistance in the pulmonary vessels.

"2. Pulmonary lesions, obliteration of any number of blood vessels within the lungs as in emphysema or cirrhosis.

"3. Valvular lesions on the right side occasionally cause hypertrophy in the adult.

"4. Chronic valvular disease of the left heart and pericardial adhesions.  "

    "Dilatation with hypertrophy:

Of the left auricle.
1. In lesions at the mitral orifice such as mitral stenosis.

Of the right auricle.
1. When there is greatly increased blood pressure in the lesser circulation as in mitral stenosis or pulmonary lesions.

2. Narrowing of tricuspid orifice.

    The heart reflex of contraction is also of use theoretically in the treatment of dilatation of the heart when due to [Osler. Practice of Medicine, page 635] "a weakened wall yielding to a normal distending force." When the dilatation is due to "a normal wall yielding under a heightened blood pressure," vibration applied in the intervertebral spaces between the 2nd and 3rd dorsal vertebrae or to their spines should be indicated.

    "A weakened wall [Osler. Practice of Medicine, pages 625, 636] occurs in:

1. Myocarditis in fevers and infections.

2. Acute endocarditis or pericarditis.

3. Anemia, leukemia, and chlorosis.

    A normal wall yields to heightened blood pressure when an increased quantity of blood is to be moved or an obstacle is to be overcome.  The pressure may bring only hypertrophy.

1. Severe muscular effort.

2. All forms of valve lesion.

3. All conditions increasing the tension of the blood in the pulmonary vessels as emphysema."

    Dr. Victor G. Vecki [Physiologic Therapeutics, September, 1910] reports a case of heart failure treated by spinal concussion as follows:

    "A moribund patient had an apex pneumonia and during the course of her disease the conventional cardiac stimulants were employed.  Suddenly during the night, however, she became extremely cyanotic and pulseless and it was determined to concuss the seventh cervical spine to awaken, as it were, the enervated heart.  No percussion apparatus was at command and, in lieu of the latter, the palmar surfaces of the fingers were applied to the seventh cervical spine, and, with the clenched fist, the dorsal surfaces of the fingers were struck a series of short and vigorous blows. (Whether the sympathetics were acted upon or the vagus wisely and repeatedly affected producing activity is not yet determined.  The writer has raised the arterial tension from 140 to 160 mm. with a two-minute vibratory treatment between the 7th cervical and lst dorsal vertebrae.  The pulse was at the same time increased from 64 to 70 beats per minute).

    "The latter method of concussion was continued for about ten minutes with intervals of rest.  Soon after concussion was commenced the cyanosis became less evident and the pulse was again perceptible.  Every two hours during the night this method was continued and thereafter at less frequent intervals until convalescence was established.  It was evident to the nurses and others that after each seance of the concussion treatment there was an immediate evanescence of the cyanosis and the pulse always became stronger and less frequent."  Dr. Vecki also considers it of value in pneumonia.

    THE HEART REFLEX OF DILATATION [Abrams. Spondylotherapy, page 221] is elicited by spinal concussion of the 9th, 10th, llth and 12th dorsal vertebrae.  He notes that here is an increase in the area of dulness but no increase in the diameters of the heart as shown by the X-ray.  The heart can increase the size of its chambers without increasing "the tension of its walls."

    ANGINA PECTORIS is due to an organic lesion - sclerosis of the coronary arteries - with consequent inability to respond to the normal impulses of their vaso-motor nerves which otherwise regulate the volume of blood supplied to the heart muscle, and the increased resistance of a general circulation under these conditions constitutes a grave complication - "increased demand for work to be done by the poorly nourished heart." Toxaemia, directly or indirectly is the underlying cause, and its removal is indicated.  A restricted diet devoid of meat and limited in quantity is important.

    For relief of the condition Abrams recommends a trial of "concussion of the lower dorsal vertebrae" to induce a heart reflex of dilatation.  The writer believes, as a preventive measure, however, that as angina pectoris is accompanied by increased arterial tension, the lowering of the blood pressure is naturally indicated to lessen the labor of the heart.  This may be accomplished by mechanical vibration or high frequency auto-condensation.

    PSEUDO-ANGINA of which there are three forms, neurotic, vaso-motor and toxic, should be treated as indicated by their causes.

    CARDIAC ASTHMA is sometimes relieved by vibrating between the transverse processes of the 7th cervical and 1st dorsal vertebrae.

    ANEURYSMS OF THE THORACIC AORTA [Osler. Practice of Medicine] may be according to Bramwell:

1. Latent with no physical signs.

2. Those which cause intrathoracic pressure.

3. Those which appear as tumors and that cause pressure and other symptoms.

    An aneurysm may cause an abdominal pulsation on either side of the sternum "usually above the level of the third rib and most commonly to the right of the sternum, either in the first or second interspace." If the innominate is affected the pulsation may be at the sternal notch or in the neck.  Posteriorly the left scapulae region is the usual site for pulsation when present.  Aortic aneurysm in chronic aortitis may cause interscapular pain "especially on the left side."

    To diagnose the presence of aneurysm other than by the use of the X-ray, vertebral or intervertebral vibration or concussion is used.  Abrams found that the aortic reflex of contraction lessens the symptoms and the reflex of dilatation accentuates their presence.

    Normally the transverse dulness [Abrams. Spondylotherapy, page 258] of the aorta at the level of the manubrium is 2 or 3 cm. to the right of the sternum and 1.5 to 2.5 cm. to the left of the medial line.  If the transverse dulness at this point exceeds 5 cm., it indicates a dilated aorta or an aneurysm.

    THE AORTIC REFLEX OF CONTRACTION produces a diminished, area of dulness corresponding to the position of the aorta.  It is induced by vibrating between the 7th cervical and 1st dorsal vertebrae and is used in diagnosing thoracic aneurism as cited in Chapter VI as well as in its treatment, - according to Abrams [Spondylotherapy, page 261] ten minutes' concussion of the spine of the 7th cervical vertebra.  It contracts the aneurysm and favorably affects the symptoms present.  The author would suggest the application of intervertebral vibration between the transverse processes of the 7th cervical and lst dorsal vertebrae.

    ANEURYSM OF THE ABDOMINAL AORTA connected with the front of the aorta near the coeliac axis, forms "a pulsating tumor [Keen. Gray's Anatomy] in the left hypochondriac or epigastric regions usually attended with symptoms of disturbance of the alimentary canal as sickness, dyspepsia, or constipation and accompanied by pain which is constant, but nearly always fixed in the loins, epigastrium, or some part of the abdomen, radiating pain being rare."

    When an aneurysm of the abdominal aorta communicates with the back part of the abdominal aorta the pulsating tumor "presents itself in the left hypochondriac or epigastric regions" with alimentary canal disturbances.  Pain usually occurs as fixed in the back caused by pressure or displacement "of branches of the solar plexus and splanchnic nerves and as lancinating pain along those branches of the lumbar nerves pressed upon."

    Normally over the 12th dorsal vertebra resonance is obtained; but, if the 9th, 10th, llth and 12th dorsal vertebrae be concussed (Abrams) or in the author's opinion, their intervertebral spaces vibrated, the resonance gives way to a dulness on percussion which dulness measures about 5 cm. (Abrams).  If this dulness at the 12th dorsal vertebra is greater than 6 cm. he interprets it to mean "a dilated aorta and if the dulness is irregular," an aneurysm. [Abrams. Spondylotherapy]  He induces a reflex contraction of the abdominal aorta by concussion of the spine of the 7th cervical vertebra.  The author has demonstrated that for this other effects vibration of the intervertebral spaces produces the same results as concussion of the spine and in this instance advises vibration between the transverse processes of the 7th cervical and lst dorsal vertebrae.

    THE AORTIC RELEX OF DILATATION [Abrams. Spondylotherapy, page 22] causes an increase in the dulness normally present and an increase in the symptoms if an aneurysm be present.  It is elicited by vertebral concussion of the last four dorsal vertebrae and is induced by affecting the vasodilators. (Abrams.)  Intervertebral vibration as in other cases will produce the same effect.

    PALPITATION OF THE HEART may be present in "an organic [Landois and Stirling. Text-Book of Human Physiology, 4th ed., page 70] condition of the heart itself, especially where the cardiac muscles are weak, in cases of dilatation and hypertrophy of the left ventricle, where the heart is gradually becoming unable to overcome the resistances offered to its work, and especially during exertion when the heart is taxed above its strength."  Spinal vibration with the ball vibratode between the transverse processes of the 7th cervical and lst dorsal vertebrae is indicated.  Palpitation also occurs when there is low blood pressure as in anemia and in fatty heart where there is increased muscle excitability.  Direct or reflex nervous conditions may cause it as stomach or bowel derangements.

    If dilatation of the stomach be present, vibration or lavage of that organ should be employed before treating the functional condition directly.  If a uterine fibroid is the cause, the X-ray should be systematically employed to reduce it, unless surgical intervention is found to be absolutely necessary.  Palpitation should be treated as a symptom, and the cause discovered and remedied when possible.  Mechanical vibratory treatment should be employed as indicated

    IF THERE BE HEAT FLUSHES, TACHYCARDIA, OR IRREGULAR HEART ACTION, mechanical vibration is indicated alone, or as conditions demand, combined with other appropriate physical measures, as light, static electricity, or hydrotherapy.  Heat flushes associated with a high blood pressure can be benefited by interscapular vibration between the 2nd and 3rd dorsal vertebrae, if there is no cardiac insufficiency, associated with dietetic and hygienic measures, daily baths and outdoor exercise.  The frequency of tachycardia may be lessened by spinal vibration with the ball vibratode applied in the interscapular region or abdominal vibration with the disc vibratode, or if due to cardiac insufficiency vibration between the transverse processes of the 7th cervical and 1st dorsal vertebrae is indicated.  Interrupted vibration with the rubber covered disc vibratode employing moderate pressure, applied to the solar plexus and the lumbar ganglia (two inches on each side of the umbilicus) in succession, making the application three, four or five times at a sitting, has a marked effect on the sensations of internal heat, the effect depending on the strength of the stimulus.  If the stimulus be too strong or too prolonged, it will not control the condition.  External parts are warmed by lowering the blood pressure.

    IN THE STUDY OF BLOOD PRESSURE four factors are to be considered. [Howell. Text-Book of Physiology, page 499]

"1. Rate or force of heart-beat.  If increased the pressure rises, and vice versa.

"2.  Resistance of blood flow especially peripheral. (a) Decrease or increase in width of vessels results normally in a vaso-constriction of the small arteries with increased arterial and diminished venous pressure or vaso-dilation with diminished arterial and increased venous pressure.

"3. Elasticity of the arteries.

"4.  Quantity of blood in the system.  Great loss would cause a fall of blood pressure."

    In general the first three factors concern us the most and of the three the first two are of prime importance.  As blood pressure is being more closely studied, high pressure is found not to be so frequently due to arteriosclerosis as formerly thought; but to be the ultimate cause.  Auto-intoxication is the most common cause of hypertension, and the ultimate cause of arteriosclerosis.

    The first two factors depend on (a) the demands for work to be done either from the demands of exercise or hypertension, causing variations in the ventricular force which varies the demands on the heart muscle, and (b) vaso-constrictor effects.

    Two states are recognized in cardiac weakness: [Abrams. Spondylotherapy, pages 248 and 253]

"1.  If the cardiac ventricular force is weak and vaso-constrictors compensate the blood pressure may be high.

"2.  If the cardiac ventricular force is weak and vaso-constrictors do not compensate, the blood pressure is low."

    MYOCARDIAL INSUFFICIENCY has already been considered but another easy method of testing it as noted by Abrams is to compare the pulse taken with the patient lying and sitting.  When he is sitting the pulse should show an increase of four to six beats per minute.  If instead it is lessened, the pulse rate being higher when lying than when sitting, it indicates cardiac insufficiency.  An illustrative case that came to my notice was as follows:

                                Tension               Pulse
Dr. P.     Lying          140 mm.               90
              Sitting         140 mm.               82

    After interrupted vibration was applied between the transverse processes of the 7th cervical and, lst dorsal vertebrae, the conditions reversed as follows:

                                 Tension                                       Pulse
              Sitting           145 mm. immediately after.
              Lying            135 mm. a few minutes later.       84
              Sitting           135 mm.                                     90

    It may be here noted that a temporary rise in arterial tension may be noticed to be followed later by a fall.

    VASO-MOTOR INSUFFICIENCY is determined as follows by Abrams' method used by the writer.

Patient A.

    Blood pressure taken in recumbent position 180 mm.

    Blood pressure taken in sitting position 168 mm.

    A fall of 12 mm.

    The fall shows an abnormal relation indicative of vaso-motor or vaso-constrictor insufficiency.

Patient B.

    Blood pressure taken in recumbent position 90 mm..

    Blood pressure taken in sitting position  102 mm.

    An increase of 12 mm.

    The rise shows the normal relation in which the vaso-constrictors acted.  They increased the resistance by the normal constrictor effect, which caused a rise of arterial tension with its accompanying fall of venous pressure.

SPLANCHNIC NEURASTHENIA (so-called by Abrams: Spondylotherapy, page 345) - is characterized by abdominal sensitiveness, tenderness and enlargement of the liver, gaseous accumulations and an exaggeration of the "cardio-splanchnic phenomenon" so-called by Abrams.  If the lower part of the sternum "contiguous to the heart" is percussed it is resonant or hyperresonant.  If the patient then lies down and the same area is percussed, after compressing vibration has been applied to the stomach, it will be dull or flat in the normal person - the cardio-splanchnic phenomenon.  In splanchnic neurasthenia this phenomenon is exaggerated, there is an increased area of dulness.

    Splanchnic neurasthenia is treated by spinal vibration.  There is under these conditions an accumulation of blood in the splanchnic area owing to a lack of tone in the, vaso-motor nerves.  This condition may cause syncope.  If the ball vibratode be employed to give intervertebral vibration between the 2nd and 8th dorsal vertebrae for five minutes or so, the cardio splanchnic phenomenon is shown.  It tones up the vaso motors of the splanchnic vessels and thereby lessens intra-abdominal congestion.  Conditions associated with relaxed abdominal parts and intra-abdominal stasis are benefited by the same treatment.  In studying these cases the author has noted as Abrams previously noted, that in those so affected, there is lower blood pressure when sitting or standing than when lying, as the following cases will illustrate.

                Tension                     Pulse
Mr. H.     Lying 148 mm.             72
               Sitting 135 mm.             82
               13 mm.

               Tension                      Pulse

Mr. W.    Lying 135 mm.              65
               Sitting 126 mm.              72
               9 rnm.

    The author vibrated these patients between the 2nd and 3rd dorsal vertebrae with the ball vibratode and lowered the tension with a reversal of conditions - the tension being higher when sitting than when lying.  In cases characterized by a cardiac insufficiency, vibration between the 7th cervical and lst dorsal vertebrae has reversed conditions.  Abrams speaks of five methods among which is abdominal massage which has the same effect on the pulse rate as interscapular vibration or vibration between the .transverse processes of the 2nd and 3rd dorsal vertebrae.  In some cases the author's experience agrees with that of Abrams in that concussion of the 2nd to 3rd dorsal spines relieves "intraabdominal congestion.  "The patients immediately feel relief.

    A case presenting the symptoms of a splanchnic neurasthenic had the following record.

                Tension                       Pulse
                 Lying 110 mm.            62
                 Sitting 108 mm.           60

    In this case there was a cardiac and a vaso-motor insufficiency.  The cardiac insufficiency was treated by vibrating between the transverse processes of the 7th cervical and lst dorsal vertebrae with the ball vibratode, with the following result.

                 Tension                     Pulse
                  Lying 108 mm.           66
                  Sitting 110 mm.          66

    The sphygmomanometer according to Abrams [Spondylotherapy, page 244] measures only the force of the left ventricle; for the determination of the sufficiency of the right ventricle he uses auscultation.

    The following is Howell's view of vaso-motor reflex of control of the rise and fall of arterial pressure.

"Afferent  fibres giving vaso-motor reflexes.

I. Pressor fibres.  Cause vascular constriction and rise of arterial pressure from reflex stimulation of the vaso-constrictor center - e.g., sensory nerves of the skin.

II. Depressor fibres.  Cause vascular dilatation and fall of arterial pressure from reflex inhibition of the tonic, activity of the vasoconstrictor center - e.g., depressor nerve of heart.

III. Depressor (or reflex vaso-dilator) fibres.  Cause vascular dilatation and fall of arterial pressure from stimulation of the vaso-dilator center - e.g., erectile tissue, congestion of g lands in functional activity.

    HIGH BLOOD PRESSURE is caused by pain, chronic inflammation of the kidneys which leads to cardiac hypertrophy, and an increase in peripheral resistance due to the vaso-motor disturbances.  Cardiac hypertrophy with dilatation, Graves' disease, goitre, and some neuroses increase the tone of the vasomotors.

    LOW BLOOD PRESSURE is present with exhausting diseases, infections, the insomnia of low resistance, cardiac failure, hemorrhages, chlorosis and in advanced tuberculosis.

    Foster observes that the "general arterial tone of the body is maintained and that an increase or decrease of vaso-constrictor action, in particular arteries or in arteries generally is brought about by means of the bulbar vaso-motor center."

    BLOOD PRESSURE WHEN LOWERED BY STIMULATION OF THE DEPRESSOR falls gradually.  If the heart-beat [Foster. Text-Book of Physiology, page 343] is not markedly changed with a lowered blood pressure, the fall of pressure must be due "to the diminution of peripheral resistance occasioned by the dilation of some arteries." He believes that possibly "those dilated are chiefly those of the abdominal viscera, governed by the splanchnic nerves."

    In man a nerve homologous to the depressor in a rabbit is found arising "from the vagus from the junction of the vagus and superior laryngeal nerves, but quickly joins again the main trunk of the vagus. [Sajous. The Internal Secretions and the Principles of Medicine, page 1125]  Almost all parts of the vascular system can be thrown into dilatation by the depressor nerve" and therefore a fall of blood pressure ensues, which Sajous attributes to "the depressor nerve inhibiting the functions of the thyroid gland and pituitary body, and through the latter that of the adrenals. [Sajous. The Internal Secretions and the Principles of Medicine, page 1126]

    "When the central end of the depressor nerve in a ,rabbit was stimulated "a surprising fall of arterial pressure accompanied by a slight decrease in cardiac frequency" ensued (Ludwig and Cyon). [Sajous. The Internal Secretions and the Principles of Medicine, page 1125]

    THE "DEPRESSOR NERVES are those through which the adreno-thyroid center regulates the circulation of the anterior pituitary body and of the thyroid apparatus. [Sajous. The Internal Secretions and the Principles of Medicine, 1133] the depressor nerve can "inhibit the functions of the thyroid grand and anterior pituitary body by constricting their arteries."  (This "reduces general oxygenation and metabolism throughout the entire body, including the muscularis of all vessels, thus causing them to relax, i.e., to dilate.) It also influences the abdominal and peripheral vessels."  [Sajous. The Internal Secretions and the Principles of Medicine, page 1128]

    BLOOD PRESSURE WHEN LOWERED BY CARDIAC INHIBITION [Foster. Text-Book of Physiology, page 344] (vagal stimulation) falls suddenly.

    Blood pressure may be affected "by stimulating or depressing one or more centers in the spinal system, and particularly and in many instances solely, those located in its chief center - the posterior pituitary body.

    BLOOD PRESSURE MAY BE LOWERED by depressing the sympathetic center which causes a general dilation of the arterioles which "allows an excess of arterial blood to enter the capillaries in general.  This passive hyperemia of the capillaries may when excessive "excite the peripheral end-organs of sensibility," and tingling, flushing and headache are induced.

    BLOOD PRESSURE MAY BE LOWERED by inhibiting the functional activity of the vaso-motor center.  The depression of the vaso-motor center permits the blood vessels to dilate.  The blood retreats as it were from "all peripheral structures, the skin, cerebral spinal system, etc., including the pituitary body, to collect in the great central channels, " in consequence of which "the functions of all centers including the adrenal center are likewise depressed, and the production of adrenoxidase being correspondingly reduced, general nutrition is impaired.  Depression of the vaso-motor center causes "ischaemia of the peripheral organs and therefore the hypothermia and cyanosis sometimes witnessed." [Sajous. The Internal Secretions and the Principles of Medicine, page 1310]

    These observations are of importance to the practitioner who uses the vibrator scientifically whether in research work or therapeutically.

    BLOOD PRESSURE MAY BE MADE TO RISE OR FALL "BY AFFERENT [Foster. Text-book of Physiology, page 344] IMPULSES passing along other nerves than the depressor."  When afferent nerve stimulation induces a rise in arterial tension and there is no "increase in the heart-beat, such at least as could give rise to it, the rise must be due to the constriction of certain arteries."  Foster believes that the arteries affected are "those of the splanchnic area certainly, and possibly, those of other vascular areas as well."  When afferent nerve stimulation shows a fall, the result is "very similar to that caused by stimulating the depressor.  " He [Foster. Text-Book of Physiology, page 345] observes, furthermore, that "the condition of the central nervous system seems to determine whether the effect of afferent impulses on the central nervous system is one leading to augmentation of vaso-constrictor impulses and so to a rise, or one leading to a diminution of vaso-constirictor impulses and so to a fall of blood pressure."

    In connection with the lowering of blood pressure it is of interest to note (Fig. 41), the arrangement of the augmentor (sympathetic) fibres in a dog.  The rami communicantes connect the sympathetic with the 2nd and 3rd dorsal nerves whose exits in man are between the 2nd and 3rd and 3rd and 4th dorsal vertebrae which are reached by intervertebral vibration between the 2nd and 3rd, and the 3rd and 4th dorsal vertebrae.  Mechanical vibration in man in these sites for five minutes, followed by a brief interval of rest, and then another five minutes of vibration, will often reduce blood pressure.  Whether we affect the pneumogastric (see page 184) or filaments noted by Bradford and Dean [Sajous. The Internal Secretions and the Principles of Medicine, page 474] that emerge from the cord located from the 2nd to 6th dorsal, "and in respect to maximum effects on a level with the 3rd, 4th and 5th nerves, which cause pulmonary vaso-constriction and a fall of aortic pressure," is to be determined.  The pulmonary vaso-constrictors ascend the chain up to the lst thoracic ganglion.  The 2nd to the 6th dorsal nerves may be related through their origin to the 6th and 7th cervical, and 1st, 2nd, 3rd, 4th and 5th dorsal vertebrae. (See Table Chapter VI.)

    In the TREATMENT OF HIGH BLOOD PRESSURE the cause must be removed if possible, and measures, hygienic, preventive, or therapeutic, be taken to abate or diminish it.  If due to arteriosclerosis, two stages should be noted. [Sajous. The Internal Secretions and the Principles of Medicine, page 1560] The first stage includes (1) "general adynamia, which entails (2) hypocatabolism and therefore, an accumulation of toxic wastes in the blood, the cause in turn of (3) the vascular lesions."  The second stage is marked by functional derangements of organs due to noticeable organic lesions.  Two indications are to be met: - (l) to reduce the waste products, and (2) to counteract the morbid process by drugs or physical measures [The author] which affect the depressor [Sajous. The Internal Secretions and the Principles of Medicine, page 1562] nerve, causing "constriction of the arterioles through which the anterior pituitary and the thyroid apparatus are supplied with blood.  The supply of adrenoxidase (besides thyroidase) being diminished, the metabolic activity in the vascular walls is reduced, and the chief pathogenic process is thus controlled."

    In the second stage, if the tension is high, vibrate to support the hypertrophied heart.

    As before stated high blood pressure can be lowered by vibrating in the intervertebral space between the 2nd and 3rd or 3rd and 4th dorsal vertebrae, unless there is a weakened heart muscle with compensatory vaso-constriction (Abrams) when it can be lowered by vibrating in the intervertebral space between the transverse processes of the 7th cervical and 1st dorsal vertebrae.

    Abrams noted that concussion on the 7th cervical caused rise of temperature.  Sajous notes that the path to increase heat is down the cord to the 1st, 2nd and 3rd dorsal nerve.  The first dorsal nerve has its origin at the level of the 6th and 7th cervical vertebrae (Krause).  Consequently we must reach the governing center of the adrenals. [Sajous. The Internal Secretions and the Principles of Medicine, pages 1023 and 1024]

    HIGH PRESSURE FOLLOWING IN SPASMODIC DISCHARGE STIMULATION OF THE VASO-MOTOR CENTER ALONE, is noted in an experiment by Hill cited by Sajous.  "The vaso-motor center can be stimulated independently of the sympathetic center and vice versa.  Excitation of the vaso-motor center [Sajous. The Internal Secretions and the Principles of Medicine, page 1206] causes "constriction of the larger and deeper vessels in consequence of which an increased volume of blood is forced towards the periphery.  The arterioles may not only remain passive under these conditions, but they may be forcibly dilated by the centrifugal streams, and the blood invade the tissues" causing "excessive hypereamia."

    Masay [Sajous. The Internal Secretions and the Principles of Medicine, page 985]  demonstrated that STIMULATION OF THE PITUITARY BODY (which is a vaso-motor center) or of the medulla oblongata including the BULBAR VASOMOTOR CENTER caused a sudden rise of blood pressure followed by a fall when excitation ceased. depressor [Sajous. The Internal Secretions and the Principles of Medicine, page 988]  Stimulation of the pituitary constricted all the arterioles through sympathetic fibres controlled by the sympathetic center.  The high blood pressure was caused by arteriole constriction and "resulting accumulation and pressure behind the vascular obstruction." [Sajous. The Internal Secretions and the Principles of Medicine, page 992]

    When the SYMPATHETIC CENTER [Sajous. The Internal Secretions and the Principles of Medicine, page 1206] IS STIMULATED the sympathetic terminals whose function is to regulate the "media calibre of the arterioles during their dilation and contraction at each pulsation exaggerate this function: they reduce this mean calibre.  Some drugs as digitalis at first or
when small therapeutic doses are given increase the propulsive activity of the arterioles for the abnormal narrowing of these vessels is followed by their reflex dilation (strictodilation - Sajous) the increase of the propulsive power being due to the fact that both dilation and contraction of, the vessels are exaggerated.  Gradually as the dose is increased, the sympathetic stimuli become so energetic that the arterioles are kept constricted, the vaso-dilator reflex action being increasingly overpowered."  When constriction causes obliteration of their lumen, "circulation in the heart muscle" is arrested and death follows.

    Reichert, [Sajous. The Internal Secretions and the Principles of Medicine, page 1226] Vulpian, Mayer and Klapp found "that after division of the upper portion of the spinal cord (the path also of the adrenal secretary nerves) strychnine could no longer raise the arterial pressure."

    When the ADRENO-THYROID CENTER IS STIMULATED there results an increase in oxidase and thyroidase (thyroid and parathyroid secretion).  Sajous says "This means that the protective properties of the blood are enhanced by augmenting its proportion of auto-antitoxin.  " As the adrenal center is the heat or thermogenic center "there is a rise of temperature."

    The effects of digitalis illustrates the STIMULATION OF THE "TEST ORGAN AND THROUGH IT THE ADRENAL CENTERS, AND ALSO, but with less violence, THE SYMPATHETIC CENTERS (only when the average therapeutic dose is given), which enhances the propulsive action of the arterioles.  The drug increases the arterial pressure largely by increasing the peripheral resistance without centric vaso-motor stimulation" which Sajous believes indicates that the adrenals are "the source of the vaso-constricting influence, for Langley found, in a series of experiments with adrenal extract, that its action 'runs parallel with the action of the sympathetic nerves on the blood vessels' and that 'in many cases the effects produced by the extract and by electrical stimulation of the sympathetic nerve correspond exactly.' As the peripheral arterioles are governed by the sympathetic, the adrenal secretion corresponds in its action with that of this nerve, because its action (as adrenoxidase) on the arterioles is the first to manifest itself, owing to their diminutive size.  Digitalis acting mainly through the adrenal secretion also increases the peripheral resistance." Von Broeck noted in regard to the effect of digitalis on metabolism; that the elimination of urea and carbon dioxide was increased while the blood pressure was high and was diminished with its fall.

    BLOOD PRESSURE MAY BE RAISED [Sajous. The Internal Secretions and the Principles of Medicine, page 1222] by stimulation of the TEST ORGAN AND IN CONSEQUENCE THE ADRENAL CENTER.  An increased production of adrenal secretion increases the contractility of the right ventricle, and also increases the quantity of adrenoxidase in the blood, and thus increases the organic metabolic activity.  The heart muscle and the arteries receive more nutrition and become more active, and thus raise blood pressure.

    From experiments [Sajous. The Internal Secretions and the Principles of Medicine, pages 1012, 1013] STIMULATION OF THE VERTEBRAL NERVE, made up of four or five of the lower cervical nerves, through the rami communicantes, causes an increased vascular tension in the liver due to the general rise of blood pressure probably due to the production of an excess of adrenoxidase, caused by the excessive adrenal secretion.  "Hardly any other agent will produce such an enormous increase of pressure" writes Schafer referring to injections of adrenal extract after division of the vagi, as direct stimulation of the vaso-motor center.  The writer has observed the following in respect to vibration with the ball vibratode between the transverse processes of the 2nd and 3rd cervical vertebrae.

    Mr. S.  Tension 110 mm.  Pulse 74.  After two minutes' vibration, tension 116 mm.  Pulse 72.

    Mrs. S. Tension 106 mm.  After two minutes' vibration, tension 112 mm.

    Adrenoxidase, according to Sajous, is the " activating agent in all metabolic processes.  An excess in the blood enhances its oxygenizing power in proportion.  "This blood in the vasa vasorum of the arteries and veins, he states abnormally stimulates and contracts the muscular portion of the vessels, reducing their calibre.

    THE BLOOD TENSION CAN BE RAISED empirically (Abrams) when low by applying vibration in the intervertebral spaces between the transverse processes of the 6th and 7th dorsal vertebrae.  If due to a weakened heart muscle, associated with no compensatory action on the part of the vaso-motors, by vibrating in the intervertebral space between the 7th cervical and 1st dorsal, the pressure may be raised in some cases.

    During experimental work with the vibrator the author has caused the blood tension to rise from 140 mm. to 160 nun., the vibration being applied for two minutes between the transverse processes of the 7th cervical and lst dorsal vertebrae.

Mr.  L .
Before treatment, pulse 68 tension 130 mm.
After 1/2minute treatment, pulse 64 tension 140 mm.
After 1/2 minute more treatment, pulse 68 tension 140 mm.
After 1 minute more treatment, pulse 70 tension 160 mm.

    The influence of the stimulation may last for some time after treatment.  Possibly the accelerating fibres of the vagus were stimulated.  Blood pressure is sometimes lowered and the pulse beat strengthened by vibrating at the same site, noted especially when there is a weak heart muscle with compensatory vasomotor action (Abrams).  In which event the inhibitory fibres of the vagus respond to stimulation and its accelerating fibres respond "by strengthening the contraction of the heart" as Heidenhain, Lowit and Pawlow have noted as possible, or the governing path [Sajous. The Internal Secretions and the Principles of Medicine, page 1024] to the adrenals may be reached and inhibition of adrenal activity result.  A re-establishment of equilibrium follows with consequent fall of pressure.  Possibly this is due to the action of the vagus noted by Landois when the accelerators and the vagus are both irritated. If the vagus and accelerator are irritated "simultaneously [Landois. Text-Book of Human Physiology, page 761] only the inhibitory action of the vagus makes its appearance."

    When we vibrate in the intervertebral space between the 7th cervical and lst dorsal vertebrae, the sympathetics (inf. cervical ganglion) may sometimes respond and induce results as heretofore noted experimentally by other methods in the hands of other observers; because the inferior cervical ganglion is situated "between the base of the transverse process of the last cervical vertebra and the neck of the first rib.  The head of the first rib articulates with the body of the first dorsal vertebra.

    "THE EFFECT OF MECHANICAL VIBRATION ON THE LUMEN of the arteries is influenced by their elasticity and tonus which normally controls the blood pressure, thereby equalizing the blood current and determining the amount sent to each part, their lumen being under the control of the vaso-constrictors and vaso-dilators or rather stricto-dilators.  Their elasticity and the responsive action of the vaso-motor nerves regulate the blood supply to the organs and tissues of the body.  It must be remembered that when the arteries contract, the capillaries which have no muscular walls dilate, owing to the pressure exerted; and when the arteries dilate, the capillaries contract owing to the resiliency of the latter.

    THE EFFECTS OF MECHANICAL STIMULI "ON BLOOD VESSELS may be due to their action on the peripheral nervous mechanism (supposed ganglia along the course of the vessels).  The arteries may contract so much as to almost disappear, but sometimes," observes Landois and Stirling, "dilatation follows the primary stimulus." It has been found that in order to obtain the maximum vaso-constrictor effect (by stimulating the center) as indicated by the maximum blood pressure from 10 to 12 strong or 20 to 25 moderately strong shocks in one second are necessary.  Waves of vaso-constriction and vaso-dilatation may occur in succession from frictions (manual) is the belief of Cyriax [Elements of Kellgren's Manual Treatment, page 152].

    Consideration of the vaso-constrictors and vaso-dilators belongs properly in the chapter devoted to the relation of mechanical vibration to the nervous system.  Their relation, however, to the study of the blood vessels and the manner of influencing pathological states depending on the constriction and dilatation of said blood vessels renders it necessary to refer to them here. The author wishes to call attention to Sajous' [The Internal Secretions and the Principles of Medicine, page XII. Volume II] conclusions on the subject which are as follows:

"1. That it is the function of the sympathetic center (in the posterior pituitary body) and of the sympathetic system to governthe calibre of all arterioles, and to regulate, through the spiral muscular coat of these vessels, the volume of blood admitted into the capillaries of any organ, including those of the brain and nervous system.

"2. That the vaso-motor center governs the calibre of the larger vessels only, i.e., of all vessels that are larger than the arterioles:-veins and larger arteries.

"3. That active vaso-dilation exercised through vaso-dilator nerves is limited to the arterioles.

"4.  That dilation of an arteriole is due to constriction by the terminal fibres of a cranial nerve (the vagus, for example) of the vasa vasorum which supply its walls with adrenoxidase-laden plasma, thus causing ischaemia and relaxation of its muscular coat.

"5. That while this process, "stricto-dilation," serves to admit an excess of blood into an organ when the functional activity of the latter is to be increased, the sympathetic fibres, when the organ's functions are to cease, restore the arterioles to their normal calibre.

"6. The cranial and sympathetic filaments distributed to the arterioles carry on an additional and more important function than that of maintaining their tonus.

"7. These nerves, owing to the presence in the walls of the arterioles of spirally disposed muscles, endow these vessels with a special property; that of increasing the vis a tergo motion of the blood in order to overcome the resistance of the capillaries."

"8. The sympathetic center (in the posterior pituitary body) provokes sleep by constricting arterioles of the anterior pituitary (including its test organ which governs the adrenals) and arterioles of the thyroid thereby lowering the functional activity of the anterior pituitary body and of the adrenal system.  Lowered metabolic activity follows, which in cardiac and vascular muscular fibres, causes a general vasodilation, resulting in an accumulation of blood in the splanchnic area, and ischaemia of the cerebrospinal system."

    Sleep follows when "the intrinsic metabolism of all nerve elements, including those of the cortex is itself reducied." [Sajous. The Internal Secretions and the Principles of Medicine, page 1260] Promotion of elimination, removal of exciting agents with reduction of blood pressure by spinal vibration with the ball vibratode, d'Arsonvalization, or prolonged body vibration (Bechterew and Tschigajew) [Cyriax. Vibrations and Their Effects] are indicated.

    VASO-CONSTRICTION AND VASO-DILATION [Sajous. The Internal Secretions and the Principles of Medicine, page 1124] are thus explained:

"1. Vaso-dilation is due, in the case of arteries and veins, to the diminution of blood-plasma, and, therefore, of adrenoxidase, in the muscular layers of these vessels.

"2. The blood-plasma being supplied to the vascular walls by the vasa vasorum, it is through contraction of these nutrient vessels that dilation of the vessels is caused.

"3. The vasa vasorum receiving their blood-plasma from larger arterial vessels supplied with vaso-constrictor nerves it is through vaso-consiriction of these vessels that the volume of blood circulating through the vasa vasorum is diminished.

"4. It is therefore by vaso-constrictor action that vaso-dilation is produced, 'vaso-dilator nerves' having no existence in fact.

"5. Vaso-dilation being caused by constriction of the nutrient arteries of a vessel, the vaso-motor nerves supplied to these nutrient vessels should not be termed 'vaso-dilators' but 'stricto-dilators.'

"6. The mechanism of vaso-dilation is that through which all exacerbations of activity in any organ, whether belonging to the alimentary, circulatory, locomotor, visual, auditory or any other system, is incited and sustained."

    Impulses from the pituitary reach the peripheral vessels by way of the bulb and its vaso-motor pathways.  "General contraction of all arteries result from exciting the bulbar vaso-motor center, the sympathetic vaso-motor action being limited to the arterioles."  The sympathetic center and the bulbar vasomotor center may be independently stimulated. [Sajous. The Internal Secretions and the Principles of Medicine, page 1203]  They are related through fibres of special sympathetic type. [Sajous. The Internal Secretions and the Principles of Medicine, page 992]

    The cerebral vessels, are thought by Spina to have a spinal vaso-motor center "susceptible of reflex irritation extending to the third cervical vertebra."

    WHEN CONSTRICTION OF AN ARTERY IS PRODUCED, the following effect results according to Foster in: (1) diminished flow through the artery itself; and (2) increased general arterial pressure leading to increased flow through the veins.  It should be remembered that the contraction of an artery is slow and of long duration.  There is also a latent period.  Mechanical stimuli must not, therefore, be too continuous or too heavy unless dilatation is sought, because strong percussion induces dilatation of the blood vessel and light percussion if too prolonged has the same effect.

    THE EFFECT OF DILATATION is (1) to increase the blood flow through the artery, (2) to lessen general pressure, and (3) to lessen the flow through the other arteries.  Dilatation then is especially indicated in the treatment of diseased conditions associated with impaired nutrition.

    VASO-MOTOR DISTURBANCES AS ANGIO-SPASM OR PARALYSES are treated by mechanical vibration or by spinal concussion (Abrams).  For angio-paralyses Abrams applies concussion over the spinous process of the 7th cervical vertebra, and for angio-spasm he concusses over the spinous processes of the 9th, l0th, 11th and 12th dorsal vertebrae.  The application of mechanical vibration to the intervertebral spaces between the 7th cervical and lst dorsal and between the 9th and 10th, 10th and llth, and llth and 12th dorsal vertebrae with medium pressure will obtain the same result.

    IN THE TREATMENT OF A CASE OF ERYTHROMELALGIA, the following may be of interest.  The patient suffered in addition to other symptoms from most violent attacks of paroxysmal pain in the head, - so violent that light could not be tolerated.  The eye would have to be closed to avoid a paroxysm.  Noise could not then be tolerated.  There was intense pain across the head and internal pain as the patient expressed it with a tendency to dyspnoea and palpitation.  Intervertebral vibration between the transverse processes of the second and third dorsal vertebrae lowered the blood pressure and relieved the internal pain.  It also had some effect on the surface pain but not to such a marked degree as on the internal pain.  The adrenals were treated by applying the static wave current over the kidneys and light to the lower part of the abdomen and back to increase the general metabolism.  The following shows the effect of a few days treatment.  A rise in blood pressure (induced by auto-intoxication probably) seemed to invariably increase the severity of the paroxysms.
Nov. 3rd   Tension 170 mm. Pulse 70
  After 5 min. vibration Tension 154 mm. Pulse 72
Nov. 4th   Tension 170 mm. Pulse 70
  After 5 min. vibration Tension 160 mm. Pulse 66
  After 4 min. additional vibration Tension 160 mm. Pulse 64
Nov. 8th   Tension 168 mm. Pulse 80
  After 10 min. vibration Tension 150 mm. Pulse 76
Nov. 9th   Tension 152 Pulse 80
  After 7 min. vibration Tension 150 Pulse 72
  After 5 min. additional vibration Tension 146 Pulse 72

    THE FUNCTIONAL ACTIVITY OF ORGANS is regulated by the "joint action of the terminals of a cranial and sympathetic nerve" [Sajous. The Internal Secretions and the Principles of Medicine, page 1198] and as this activity involves the blood vessels the following is of interest.

"(1) That the sympathetic system does not, as now believed, carry on motor, dilator, secretary, or inhibitory functions.

"(2) That its function is purely vaso-constrictor, its field being limited to the small arteries or arterioles.

"(3) That it is entirely independent of the vasomotor system (whose action is general), being capable, unlike the latter, of influencing each organ individually.

"(4) That its terminals form part of the mechanism of all organs.

"(5) That the specific role of its terminal fibres is to oppose the stricto-dilators and restore the arterioles of an organ to their normal calibre when the functional activity of that organ is to cease.

"(6) That the volume of blood which circulates through any organ, whether the latter be in the passive state or functionally active, is regulated by the joint action of the motor and sympathetic centers in the posterior pituitary.

"(7) When the organ is to become functionally active, the stricto-dilators (fibres of a cranial motor or secretary nerve) cause its vessels to relax and to augment the volume of blood coursing through it; when its activity is to cease, the sympathetic constrictors cause the vessels to contract sufficiently to reduce the blood in transit to the volume required for adequate local nutrition.

    Methods for controlling the vaso-constrictors and vaso-dilators of the organs by vibration will be considered in a following chapter.  The knowledge of the action of mechanical vibration, a recognition of pathological conditions present, and an analysis of effects produced will determine how and when vibration should be applied.

    The writer has observed that when A COLD is treated early by auto-condensation (d'Arsonvalization) it may be aborted.  This treatment lowers blood pressure.  Abrams [Spondylotherapy, page 284] noted that a cold, which he considered as presenting the symptoms of an angio-paralysis, could be aborted by concussion of the spine of the 7th cervical which in many cases lowers blood pressure.  For this effect the author applies mechanical vibration with the ball vibratode between the transverse, processes of the 7th cervical and lst dorsal vertebrae.  Dryness of the air passages or a temporary cough may ensue.  Whether a vibratory treatment between the transverse processes of the 2nd and 3rd dorsal vertebrae which often lowers blood pressure will abort a cold, is yet to be determined.

    VIBRATORY FRICTION APPLIED CENTRIPETALLY to the extremities assists lymphatic and venous circulation in joint affections, oedema, dropsy, and similar conditions.  For this administration the rubber-covered disc vibratode is to be preferred and the surface to be vibrated should be first dusted with talcum powder.  In cases of oedema begin the frictional treatment near the trunk and gradually approach the extremities, and apply interrupted. vibra.tion about the joints. (See Chapter IV.)

    VIBRATORY FRICTION APPLIED CENTRIFUGALLY to the extremities is indicated in deficiency of compensatory hypertrophy of the heart, associated with valvular lesions or pulmonary circulatory obstructions.  It is also valuable in the treatment of INSOMNIA due to congestion of the blood vessels of the head, and all other conditions where acceleration of the arterial flow is sought.  If mechanical vibration be applied to the bowels, it induces a slowing of the pulse.  In an experimental case the pulse was 84 before abdominal vibration and was reduced to 74 following the treatment.  Mechanical vibration also affects the circulation by increasing or diminishing the blood flow.

    From the effects of mechanical vibration applied as a tissue exerciser, it may be inferred that it increases the number of red blood corpuscles and haemoglobin.  Winternitz has demonstrated that exercise increases the number of red blood corpuscles.  It undoubtedly also influences phagocytosis as does manual massage by causing more leucocytes to become phagocytes and by breaking up minute adhesions coincidently increasing circulatory activity.

    IN THE TREATMENT OF CHLOROSIS the activity of the digestive, circulatory, and respiratory systems together with that of the nervous system should be promoted.  Daily warm baths of five minutes' duration, an easily digested diet, open bowels, and regulated daily walks are insisted upon.  Abdominal vibration with the disc vibratode and the ball or cap shield as directed for constipation will stimulate the abdominal sympathetics and promote circulatory activity.  It will induce a local vaso-constrictor effect and thus cause vaso-dilatation in other parts - Cyriax notes the head.  Appropriate exercises, as directed by Cyriax [The Elements of Kellgren's Manual Treatment, page 381] may be advantageously used.

    SECONDARY ANAEMIA due to auto-intoxication may be successfully treated by high colonic flushings, daily baths, outdoor walking, light, the static wave current and spinal vibration of short duration for stimulation and a vibratory treatment of the abdomen, liver and spleen.  Eliminate the poison and increase the metabolism.

    IN PHLEBITIS mechanical vibration is sometimes of benefit.  Morris reports the cure of a case, "complicated with lymphangitis and adenitis.  " He sought to accomplish two objects, viz., " (1) improvement of the systemic condition with a possible reduction of obesity; and (2) the abatement, if not the actual cure, of the local inflammatory trouble.  For the accomplishment of the first indication, deep vibration was applied to the spinal nerve centers of the liver and spleen (Vide Pilgrim's 'Vibration Stimulation,' 4, 5, 6, 7, 8 dorsal), and also to the organs direct, as well as over the abdominal muscles.  It was hoped that this might favorably affect the local conditions."

    He "sought to accomplish the second indication through stimulation with the brush (multiple point vibratode) of the lymphatics in the inguinal region and mild brush applications directly to the affected area, following the venous current throughout, supplemented by the application of the ball with medium stroke, to the lumbar-and dorsal spine."

    Heavy pressure must be avoided and the greatest care exercised in the employment of vibration in the treatment of phlebitis.  The author prefers the use of the high candle power incandescent light and the static brush discharge which is the treatment par excellence in these cases.

    The following,  RELATIVE TO PAIN as it concerns the arterioles, is important in a work on mechanical vibration.

    Pain is commonly due to pressure (Wm. Benham Snow) associated with stasis or tissue infiltration and exerted upon the sensory nerve terminals or nerve trunks of the nervi nervorum; and any agent which indirectly or directly causes diminution of such stasis or infiltration or removes other objects which exert pressure, counteracts pain.

    To reduce the stasis causing pain, four measures may be adopted based on Sajous' findings. [Sajous. The Internal Secretions and the Principles of Medicine, pages 1541-1543]

1. "Secure general vaso-dilation by depressing the vaso-motor center." Vaso-dilation is accomplished by spinal vibration between the transverse processes of the 2nd and 3rd dorsal vertebrae usually.  When there is myocardial insufficiency, vibrate with the ball vibratode between the 7th cervical and 1st dorsal vertebrae.

2. Secure general constriction of the arterioles by stimulating the general sympathetic center.

3. Produce reflex constriction of peripheral arterioles including those of the painful nerves, by irritating directly the cutaneous sensory terminals.  This can be accomplished by local vibration with the disc vibratode.

4. "Secure depletion of perineural arterioles, and therefore of the endoneural capillaries.  "This probably follows local vibration, interrupted or frictional.

    Spinal vibration with the ball vibratode over the spinal segment corresponding to the skin area involved is indicated in the treatment of painful areas.

    Painful or tender spinal areas when not due to organic affections may be relieved by interrupted vibration with the ball vibratode applied four or five times in succession, beginning with moderate pressure and gradually increasing it, in accordance with the patient's tolerance, a moderate rate of speed and full stroke being employed.  For the treatment of sensitive areas other than spinal, the same method is employed, the disc vibratode being substituted for the ball.  Pain due to a diseased viscus or tissue of course will not be relieved by such measures, on the contrary it is apt to be increased.

    "THE THYROID AND PARATHYROID GLANDS" Sajous [Sajous. The Internal Secretions and the Principles of Medicine, page 1072] holds "are not true glandular organs" but that they consist of a capsule, enclosing "a connective tissue reticulum forming tubular cavities lined with a basement membrane, the follicles, whose secreting cells are leucocytes (from the alimentary canal or circulation) whose granules represent the active constituents of the colloidal secretion.  He believes their secretion is carried by the lymphatics and finally reaches the superior vena eava, the heart, and the pulmonary alveoli."

    The nerves [Sajous. The Internal Secretions and the Principles of Medicine, page 1128] to the arteries (vaso-constrictor and vaso-dilator) pass "either by way of the superior laryngeals or through the plexus often formed by the depressor with the sympathetic and vagal nerves." The "vaso-constrictors are sympathetic fibres."  Constriction of the arteries lessens the blood supply and consequently the gland's functional activity is lowered.  Landois thinks that THE THYROID GLAND RECEIVES ITS VASO-MOTOR nerve supply from the superior cervical ganglion of the sympathetics. [Landois. Text-Book of Human Physiology, page 763]

    "By increasing" Sajous believes, "the functional activity [Sajous. The Internal Secretions and the Principles of Medicine, page XII, Vol. II] of the thyroid and parathyroids it (the test organ which is the sensory organ in the partition between the two lobes of the pituitary body) increases, through their secretions, the sensitiveness of all cells, including bacteria, and their vulnerability to phagocytes, inasmuch as:

    "The secretions of the thyroid and parathyroids jointly form the opsonin and agglutinin of the blood:

    "And consequently it follows from certain assertions:

    "That the adrenal system, composed of the pituitary body, the adrenals and the thyroid apparatus, constitutes the immunizing mechanism of the body.

    The vaso-dilator fibres of the thyroid are from the depressor. [Sajous. The Internal Secretions and the Principles of Medicine, page 1129] The adreno-thyroid center regulates the circulation of the anterior pituitary body and of the thyroid apparatus, by means of the "depressor nerves." [Sajous. The Internal Secretions and the Principles of Medicine, page 1133] The thyroid's depressor vaso-dilator fibres - (some of which go to the parathyroids) "jointly constitute the thyro-parathyroid secretary nerve."  Their stimulation increases its activity [Sajous. The Internal Secretions and the Principles of Medicine, page 1130] because the vaso-dilation brings more leucocytes, and this is shown by an increased amount, an excess, of colloid, its secretion.

    GOITRE, an enlargement of the thyroid gland, may be "vascular, cystic, or parenchymatous with colloid degeneration."

    EXOPHTHALMIC GOITRE or Graves' Disease pathologically considered [Wm. Benham Snow. Treatment of Exophthalmic Goitre and Myxoedema] "comprises a progressive hypertrophy with hyperplasia and varying degrees of infiltration of the gland, which in undisturbed cases, progress ultimately to a degree of extreme hypertrophy.  The accompanying tachycardia associated with great dyspnoea is undoubtedly due to the excess of thyroid secretion thrown into the circulation, the same condition being produced by the excessive administration of thyroid extract."

    The indications are, according to the same authority, "(1) to induce cessation of the process associated with increased enlargement of the grand, be it inflammatory, or due to some metabolic disturbance; (2) the coincident diminution of hypersecretion, and (3) the removal of the deformity."

    Our results in the treatment of goitre, simple and exophthalmic, make another link in Sajous' chain of evidence.  He believes that exophthalmic goitre is due to suprarenal overactivity," though initiated through thyroid overactivity." [Sajous. The Internal Secretions and the Principles of Medicine, page 186]  The X-ray treatment of the gland in conjunction with the static wave current and mechanical vibration, is a successful method.  All of the writer's cases have had a coincidental menstrual disturbance which has also received local treatment.  Radiant light and heat are sometimes used as an eliminant.  The X-ray [Wm. Benham Snow. Treatment of Exophthalmic Goitre and Myxoedema] "in repeated regular doses is to inhibit the tissue activity; probably by inducing contraction of the tissues with the induction of inertia in all living cells." The application of the static wave current by "inducing energetically successive contraction and relaxation, as when administered with a discharge not too rapid at the spark gap, initiates an active tissue gymnastics throughout the substance of the gland thereby forcing out all infiltration and removing as elsewhere all inflammatory action and restoring its normal metabolism" (Wm.  Benham Snow).  Mechanical vibration applied over the gland and the lymphatics of the axilla and neck with the disc vibratode promotes elimination and induces the removal of the glandular infiltration.  With the disc vibratode, and a half stroke, apply prolonged interrupted vibration to the goitre, making the left hand a resisting surface on the other side of the gland.  Vibrate first one side, and then the other, four or five times.  Then use vibratory friction of the neck anteriorly and at the side, for circulatory stimulation.  As a supplementary treatment to promote elimination, vibrate the axillary glands, and the liver, and spleen.  Interrupted vibration with the ball vibratode in the interscapular region will lessen the pulse rate.  In some cases prolonged
interrupted vibration, full stroke, with the ball between the transverse processes of the 7th cervical and lst dorsal vertebrae will reduce the arterial tension and indirectly affect the gland.  For this purpose it should be continued for five minutes with a few periods of rest.

    MYXOEDEMA is characterized by "hyperplasia of the connective tissue and mucoid infiltration of the cutis and surrounding organs.  The thyroid gland also becomes atrophied, and it is probably upon the absence of the thyroid secretion that the condition depends."  The lessening of the thyroid would mean according to Sajous' views on the thyroid that the vaso-constrictor fibres of the thyroid were stimulated, with consequent lowering of the metabolism; because the thyroid secretion keeps the test organ functionally efficient and "through it the adrenals," which keeps up the supply of adrenoxidase supplying oxygen to the tissues.  In myxoedema the secretion being lessened there is less adrenoxidase hence less oxygen for the tissues and consequently a deficient metabolism results.

    The treatment calls [Wm. Benham Snow. Treatment of Exophthalmic Goitre and Myxoedema] for (1) to supply the deficiency from some external source (2) to induce, if possible, the functional activity of the gland and (3) to restore so far as can be, the normal metabolism and remove in adults the pronounced characteristic oedema or hardening and thickening of the skin and subcutaneous tissues found in advanced and neglected cases.

    The static wave current applied with a metal electrode over the gland for twenty minutes, the sparkgap being from one to three inches, promotes metabolism and increases the activity of the gland.  "The effect of the current is to remove infiltration, abate inflammation, by removing stasis and re-establishing circulation, at the same time inducing tissue activity.  "The static wave current is also given over the abdomen, a flat metal electrode six by eight inches, being used.  Slow speed and the length of the sparkgap regulated so as not to cause tonic contraction is necessary.  More recently thyroid extract has been used in connection with the treatment with marked success.

    Administer general spinal vibratory treatment with the ball vibratode for its tonic effect.  Do not use heavy pressure.  With the patient lying in the prone position apply deep vibratory friction to the soles of the feet from the heels to the toes six or seven times, interrupted vibration about the ankle, and vibratory friction particularly to the posterior surface of the legs.  Follow this with interrupted vibration to the knees and vibratory friction to the thighs.  After a short rest, With the patient lying on his back, apply vibratory friction anteriorly on the legs and thighs, particularly the thighs, and interrupted vibration to the ankles, knees and inguinal glands.  A vibratory treatment of the abdomen, liver, and spleen, and a stimulating vibratory treatment of short duration with half stroke and moderate speed, should follow, on each side and over the thyroid gland.  The face, tongue, hands, and arms should also be vibrated as conditions indicate.

    Exercises adapted to the use of the particular group of muscles involved should be given daily.  A daily cold sponge is advisable each morning if the patient reacts well.  Dry hot air or radiant light and heat baths twice a week are indicated.  Do not allow these patients to lead a sedentary life, activity is necessary.  Thyroid extract may be used in conjunction with vibratory treatment.

    THE SPLEEN is situated "beneath the 9th, 10th, and 11th ribs, between the axillary lines - lines drawn vertically downward from the anterior and posterior margins of the axilla.  Its upper edge is on a level with the spine of the 9th dorsal vertebra and its lower with the spine of the llth." Vaso-motor fibres of the spleen come from the medulla and Landois [Text-Book of Human Physiology, page 195] states pass through the spinal cord "which is said to contain between the 1st and 4th cervical vertebrae ganglionic cells that likewise influence the contraction of the spleen."

    "THE NERVE [Sajous. The Internal Secretions and the Principles of Medicine, page 390] SUPPLY OF THE SPLEEN is the general motor system (sympathetic) which supplies efferent nerves, which serve only to maintain toxic contraction of the arteries and of the trabecular muscles thus sufficiently activating the flow of blood to the lobular compartments and to the Malpighian corpuscles to maintain their functional efficiency during the passive period, and the vagus system.

    "The vagus system supplies both the sensory and motor nerves that excite and govern the functions of the organ during its active period, which begins about the fourth hour of digestion.

    "When, as a result of reflex stimuli through the efferent gastroduodenal branches of the vagus, the spleen becomes functionally active, the vagus impulses impose their rhythm upon the extrinsic motor plexuses (Extensions of the splenic plexus), and the vagus system assumes control of splenic functions.  As a result,

    "(a) The extrinsic arteries are constricted beyond their normal tonic calibre; the speed of the blood flow into the organ is increased and the blood allowed to slowly accumulate therein (probably owing to restricted calibre of the venous exit), thus causing its dilation.

    "(b) About the fourth hour of the digestive process the arterial and venous calibres are equalized and the splenic products (secretion, leucocytes, broken-down corpuscles, and pigments) are voided into the splenic vein and increased rapidly.  This continues for two to four hours, when the calibres are readjusted by the vagus and the organ resumes the passive state."

    Stimulation of (1) the central end of the sensory nerve; (2) of the peripheral ends of both splanchnics; (3 ) of the peripheral ends of both vagi, causes contraction of the spleen, as does also stimulation of the spleen itself by cold, electricity, or vibration, directly or reflexly by spinal stimulation.

    FOR THE TREATMENT OF SPLENIC CONGESTION deep vibratory friction or interrupted vibration with the disc vibratode should be administered over the side of the gland from the 9th to, and including the llth rib between the axillary lines.  Reflex contraction of the spleen can be induced by vibrating with the ball between the lst and 2nd and 2nd and 3rd lumbar vertebrae following Abrams' method of vertebral concussion.  The treatment should be prolonged for five, ten, or even fifteen minutes as the response warrants.  The same result is obtained by the static wave current.  This is of value in malaria and pathological states characterized by an enlarged spleen.

    DILATATION OF THE SPLEEN is obtained by Abrams [Spondylotherapy, page 352] by concussion of the llth dorsal spinous process.

    Tenderness has been noted of the 9th and 10th dorsal nerves on the left side when the spleen was pathologically affected.  The nerves have their exit between the 9th and 10th, and between the 10th and 11th dorsal vertebrae.  These nerves if conditions warrant should be vibrated locally with the disc vibratode or at their sites of exit with the ball vibratode.