THE LYMPHATICS, which finally discharge their contents into the blood stream at the junction of the subclavian and internal jugular veins by means of the thoracic duct on the left, and the right lymphatic duct on the right, are remarkably influenced by vibratory stimulation, particularly so in respect to drainage and metabolism.  The same is true of all lymphatic glands - those of the neck, the mesenteric, mediastinal, axillary, inguinal, popliteal, and the coeliac glands.  For stimulation to greater activity of the functions of the glands, the application of interrupted mechanical vibration with moderate or deep pressure with the rubber-covered disc is very effective.

    Cyriax [Vibrations and Their Effects] thinks that "The anatomical arrangements of the lymphatics in all tendons, fasciae and aponeuroses is such that the slightest pressure or stretching with subsequent relaxation promotes the onward flow of the lymph (Ludwig and Schweigger-Seidel).  Centripetal vibrations must have the effect of furthering the lymph flow in these parts; they no doubt act in the same way on the lymphatics of other parts.  Centrifugal running vibrations have the opposite effect.  Ledermann found that vibration materially hastened the absorption through the skin."

    The lymphatic vessels, most numerous in muscle fasciae, between and around the muscle in subcutaneous tissue are readily acted upon and the lymph stream directed to the outlet by vibratory friction.

    When the stroke is percussive much of "the energy conveyed by the process (percussion) is expended on the skin and its reflex and sensory powers are highly stimulated by the application." The lacteals are probably susceptible to vibration, and their metabolic processes are possibly affected.  Water, peptones, glucose and soluble salts pass into the general circulation, being emptied from the hepatic vein into the inferior vena cava.  Their course is through the lymph-spaces of the villi, passing by endosmosis through the walls of the capillaries to the blood stream going through the portal vein and thence to the hepatic.   The emulsified fat is forced from the villus by the contraction of the muscles around it on into the lacteal, and is thence carried into the general circulation through the, thoracic duct.  Through vibratory influences affecting the circulatory system absorption is affected, as in absorption is less rapid the fuller and more tense the blood vessels are" - and "is the quicker the more rapid the circulation of the blood."   The lymphatic circulation can be increased by interrupted vibration or vibratory friction according to the part treated for both produce tissue massage and exercise.  This is of importance in treating inflammatory conditions, and enlarged glands, and in promoting absorption in cases of local oedema, dropsy and similar conditions, and also in reopening obstructed lymph channels.

    The main force promoting the chyle and lymph flow depends (1) on difference in pressure in the thoracic duct and in the commencement of the lymphatic vessels, which is due to muscular contractions of the villi as before stated, aided by muscular contraction of the fibres of the vessels and by intermittent pressure arising from muscular contractions in different parts of the body.  (2) Respiratory movements are important factors-inspiration increasing the flow in the veins and expiration diminishing it as well.  (3) The nervous system as shown by Goltz and Hoffman also influences the flow.

    Vibratory action, therefore, either impulse or friction, affecting contraction, accelerates the lymphatic circulation.  While the body is at rest Reibmayr observed that the flow of lymph nearly ceased.  These glands are safeguards in infectious processes and their activity is necessary in order to effect, good drainage.  The necessary activity may be induced by interrupted vibration or vibratory friction, varying with the part treated, each being especially applicable to different structures.  To stimulate the glands of the neck employ interrupted vibration with the rubber-covered disc vibratode and over the vessels apply vibratory friction.  If the glands at the elbow are to be stimulated apply deep interrupted vibration to the axillary glands and around the shoulder joint, then apply vibratory friction centripetally to the arm.  Follow this with deep interrupted vibration with moderate or deep pressure around the elbow joint.  Then apply centripetal vibratory friction to the forearm, followed by deep interrupted vibration with moderate or deep pressure with the disc vibratode around the wrist joint, and employ vibratory friction from the tips of the fingers, on the dorsal surface, to the wrist, and from the tips of the fingers, on the palmar surface, to the wrist.  Absorption is assisted by stimulating the lymphatics communicating with the adjacent glands.

    Horvath of Keiff has discovered that bacteria reside mostly in the lymphatics; and Meltzer seems to have demonstrated that bacteria cannot withstand continued vibrations, which suggests the importance of vibration of the lymphatic glands except under some conditions when it might scatter the infection.

    Sajous [The Internal Secretions and the Principles of Medicine, page 1795] observes, that the lymphatic system is poorly self-protected by lack of red blood cells, and hence of adrenoxidase.  Bactericidal and antitoxic ,agents due to adrenal stimulants first appear in the blood to combat toxaemias, so in disease we should endeavor "to increase the proteolytic power and the aggressiveness of the phagocytes by agents which cause their digestive vacuoles to be well supplied with auto-antitoxin (their digestive triad) and to sensitize actively the bacteria." Adrenoxidase is an auto-antitoxin.  Therefore we should increase the functional activity of the adrenals which should be accomplished by stimulating the upper three thoracic nerves.

    The same author notes that "the functional activity of the adrenals is increased proportionally with that of the anterior pituitary body where the latter's activity is increased from any cause.  The anterior pituitary body is directly connected with the adrenals through the cervico-thoracic ganglia, the splanchnic nerves, and the semi-lunar ganglia of the sympathetic nervous system."

    IN METASTATIC PROCESSES, mechanical vibration may be of value alone or in connection with other methods of treatment to relieve accompanying oedema.  The surface to be vibrated should first be dusted with talcum powder.  The disc vibratode should be employed, the treatment being the same as that given for oedema.  The results of such treatment will be permanent or temporary, usually temporary, according to the pathologic process causing it.

    IN CASES OF ABSCESS, open and use the vacuum apparatus of the vibrator giving a vibratory suction to empty the abscess and follow with a prolonged treatment with radiant light and heat.  The condition of the patient should also be improved by regulation of hygiene, diet and exercise.

    LYMPHANGITIS has been treated successfully by Cyriax [The Elements of Kellgren's Manual Treatment, page 381] by "running vibrations (manual) to keep the process from extending toward the body, and frictions, ete., centrifugally down to the infected focus," in connection with exercises to promote metabolism and nutrition, and to further the elimination of the toxins that have been absorbed.  In the treatment of abscess of the foot with reddened areas up the leg and enlarged inguinal glands he used "suction vibrations around the abscess, and centrifugal running vibrations along the inflamed area down to the abscess.  Vibrations over the inguinal glands and a stomach exercise were also given."  The author prefers opening of the focus if pus is present and the use of hot air baths in the treatment of this condition.

    ADENITIS OF A NON-INFECTIVE CHARACTER, may be treated by interrupted vibration over the nearest lymphatic glands, employing the rubber-covered disc vibratode with a stroke suited to the part and using a fairly rapid rate of speed.  Prolonged interrupted vibration over the affected glands and vibratory friction of the lymphatics should follow.  Treatment should be given daily at first.

    In the treatment of NASAL AFFECTIONS the nervous supply of the nose must be considered.  Arnold states that the vaso-constrictor neural cells of the mucous membrane of the nose are from the 2nd, 3rd, and 4th dorsal segments and that the vaso-dilator neural cells are in the nucleus of the 7th cranial.  The nasal mucous membrane -may be directly affected by interrupted vibration with the small cup-shaped soft rubber vibratode, shortest stroke and very light pressure, on each side of the nose on the motor points beginning near the inner angle of the eye near the root of the nose.  This area should be treated about three times.  Vibratory friction from the bridge of the nose downward and at the same time outward, employing the shortest stroke and fairly rapid speed with the same soft rubber vibratode to stimulate the activity of the lymphatics follows.  The hyperaemia of acute or chronic nasal catarrh is relieved by vibratory treatment as indicated above.

    Attacks of HAY FEVER are sometimes relieved by mechanical vibration given as above outlined.  Sajous believes that hay fever is due to "hypersensitiveness of the trigeminal center in the pituitary body - and that stricto-dilatation (the mode of action of all motor nerves) provokes muscular contraction, - the stricto-dilators regulate the flow of blood into sinuses, which thus become engorged with blood, causing the copious secretion, marked obstruction, etc., seen in hay fever."

    For NASAL VIBRATION Witthauer [The Journal of Physical Therapy, page 105.  Text-Book on Vibration Massage with Special Reference to Gynecology.  Dr. Kurt Witthauer] disinfects a vibration sound and introduces it.  "Braun makes use of 2-8 per cent menthol vaseline; others wrap cotton around the sound and dip it in a solution of cocain, potassium of iodide-glycerin (1 per cent iodin) for the atrophic, and 2 per cent solution of protargol for hypertrophic conditions." In atrophic conditions the diseased parts should first be cleansed.  The vibrations must be given cautiously and evenly... The time of treatment was short at first but was gradually lengthened.  Witthauer treated vasomotoric hypertrophy of the turbinates with a vibration-sound avoiding the alae nasi.  He vibrated each side for two minutes when he began treatment.  A pocket vibrator operated by a small pocket battery, a special vibratode being used, is to be preferred to the sound.

    NASAL CATARRH may be favorably affected by employing vibration in the nasal cavity or interrupted vibration over the motor points on each side of the nose with the cup-shaped vibratode, followed by stroking downward and outward from the bridge of the nose across the cheek.  A vibratory treatment of the neck will also assist in relieving the process.

    The following in respect to the NERVE SUPPLY OF THE LARYNX is of interest.  The superior laryngeal nerve divides behind the hyoid bone into its two terminal branches.  The external branch supplies the crico-thyroid and ramifies in the mucous membrane of the vocal cord.  The internal branch supplies all of the laryngeal mucous membrane.  The inferior recurrent laryngeal nerves, "the chief motor nerves of the larynx, supplying all its muscles, except the crico-thyroid, pass backwards into the furrow between the oesophagus and trachea.  They ascend in this furrow and divide at the level of the crico-thyroid articulation into two branches."

    IN MECHANICAL VIBRATORY TREATMENT OF CERTAIN CHRONIC AFFECTIONS OF THE LARYNX use the shortest stroke of the vibrator and the rubber-covered disc or cup-shaped vibratode.  Give light interrupted vibration alternately on both sides of the thyroid cartilage.

    Slow and gentle vibratory stroking or light vibratory friction centripetally when applied td the neck anteriorly and posteriorly is serviceable in catarrhal inflammations of the nose, pharynx and larynx as well as in oedema of the neck affecting respiration.

    Curtis reports success in the treatment of three ,cases of TONSILLITIS.  Application was made to the spinal nerves throughout the cervical region, using a ball vibratode and medium stroke.  The patient was then placed on his back and treatment applied to the cervical sympathetics, using a throat vibratode with firm pressure to thoroughly relax the muscles and allow the venous blood to more rapidly escape.  In addition the lymphatics in the axilla were stimulated with the multiple point vibratode.  Treatment was then applied to both the liver and spleen to increase the elimination of waste products.

    It is well to recall that many intermittent chronic sore throats" have their source from auto-intoxication due usually to a disordered stomach, or bowels which call for constitutional treatment and regulation of diet, the local throat treatment being of minor importance, for without the cause removed the after effects will resist unaided local treatment.

    MECHANICAL VIBRATION AFFECTS RESPIRATION (1) by increasing tissue combustion, and metabolism; and (2) by promoting the absorption of 0 [oxygen] and the removal of CO₂, which is induced principally by stimulation of the muscles affecting the oxidation of muscle glycogen.  This also causes increased activity of the lungs, diaphragm, and all parts affected by respiratory changes, the depth of respiratory movement being increased.

    Cyriax [Vibrations and Their Effects] notes that "Hasebroek and many others found that vibration improved respiration.  The effect of every mechanical stimulus to ciliated epithelium is to stimulate the cilia to increased waves of movement (Kraft, Verworn, Roth).  The vibrations in the lungs set up by "hackings" stimulate the lung and facilitate expectoration (Thieme, Freidlander, Erni, Cybulsky)." The same author states that Fleisch v. Marxow thought that the heart-beat imparted shocks or vibrations that "were necessary for the gaseous interchange."

    PERCUSSION of the lungs should yield a clear, pulmonary resonance, but if the patient is stout the resonance may Joe less clear.  The supraclavicular, infraclavicular, mammary, axillary, suprascapular and interscapular, scapular and infrascapular spaces should be percussed.

    The lower border of the lung is lower than normal in emphysema and bronchial asthma, and is higher than normal in "phthisical shrinking, collapse, a distended abdomen or paralysis of the diaphragm."

    Nerve stimulation is effected relatively, as the muscles are under the control of nerves or nerve centers. If a particular intercostal nerve be cut the action of the muscle which it supplies stops absolutely, and if the spinal cord is divided below the level of the fifth cervical nerve, that is, below the origin of the roots of the phrenic nerves, costal respiration will cease but the diaphragm will still move.  Gowers [Diseases of the Nervous System, page 231] states that the diaphragm is probably represented in the gray matter at the level of the phrenic nerve, the 4th cervical nerve which has its exit between the 4th and 5th cervical vertebrae.  When the cord is divided below the medulla all thoracic movements cease, but the respiratory action of the nostrils and glottis does not cease." The degree of excitability and the stimulation of the center depend upon the state of the blood, and chiefly upon the amount of blood gases, the 0 and CO2 (J.  Rosenthalt)."

    The respiratory center may be stimulated by (1) the will, (2) directly or (3) reflexly when afferent nerves are stimulated.  Stimulation of the pulmonary branches of the vagus, the auditory, the optic and cutaneous nerves affects the center reflexly resulting in increased activity, whereas stimulation of the superior laryngeal and the inferior laryngeal nerves lessens respiratory activity or causes its arrest in expiration.  Both inspiratory and expiratory fibres are found in the vagus in the neck.  Stimulation of the expiratory fibres reflexly arrests respiration during expiration.  "Stimulation of the central end of the sciatic nerve usually accelerates the respiration, more rarely reflex expiratory arrest." "According to Langendorff, direct electrical, mechanical, or chemical stimulation of the center may arrest respiration, perhaps in consequence of the stimulus affecting the central ends of these inhibitory nerves where they enter the ganglia of the respiratory center.  During the reflex inhibition of the respiration in the expiratory phase there is a suppression of the motor impulse in the inspiratory center (Wegele)." Stimulation of the nasal and ophthalmic branches of the trigemiuus, glossopharyngeal, and of the olfactory stops respiration in expiration. [The Internal Secretions and the Principles of Medicine, page 845]

    Special reference has been made to these various actions relative to stimuli, as such knowledge has a direct bearing on the application of vibration and in explanation of some of the various apparent phenomena that sometimes arise from treatment.  The vaso-motors (constrictors) of the blood vessels of the lungs come from the dorsal region of the spinal cord (2nd to 7th dorsal) through the first thoracic ganglion (Brown-Sequard, Fick and Badoud, Lichtheim), which is of prime importance when spinal stimulation for such control may be necessary.

    The following is a general review of the muscles of respiration from Landois and Stirling's "Textbook of Human Physiology, 4th ed.;"
 

A. INSPIRATION

    I. DURING ORDINARY INSPIRATION

    (1) Diaphragm supplied by the phrenic nerve from the 3rd, 4th, and 5th cervical and phrenic plexus of the sympathetic, which can be reached near the right supra-renal capsule or the solar plexus.  The phrenic nerve "passes behind the sterno--clavicular joint." (2) "Mm.  Levatores costarum longi et breves (Rami-posteriores Nn. dorsalium). (3) Mm. intercostales externi et intereartilaginei. (Nu. intercostales).

    "According to their action, the auxiliary musclesof forced inspiration, are those that elevate the ribs directly or indirectly, or fix the lower jaw, so that muscles attached to the hyoid bone can act
(Rutherford).

    "The hyoid bone is raised by the:

• Mylo-byoid.
• Genio-hyoid.
• Stylo-liyoid.
• Digastric.

• Sterno-mastoid.
• Sterno-hyoid.
• Sterno-thyroid.
• Thyro-hyoid.

• Scaleni.
• Cervicalis ascendens.
• Serratus posticus superior.

• Trapezius.
• Levator anguli scapulae.
• Rhomboideus major.
• Rhomboideus minor.

• Pectoralis major.
• Pectoralis minor.
• Subclavius.
• Serratus magnus.

B. EXPIRATION

    I. DURING ORDINARY EXPIRATION

    The thoracic cavity is diminished by the weight of the chest-wall, the elasticity of the lungs, costal cartilages, and abdominal wall and abdominal contents.

    Ordinary expiration, therefore, is non-muscular, and the act is a purely passive one.

    The abdominal contents are compressed and forced against the diaphragm by:

• Obliquus externus.
• Obliquus internus.
• Transversus abdominis.
• Levator ani.
• Rectus abdominis.

• Rectus abdominis.
• Quadratus lumborum.
• Serratus posticus inferior.
• Triangularis sterni.

    The innervation of the muscles of respiration appears to Sajous [The Internal Secretions and the Principles of Medicine, page 468] to be as follows:

    "The nervous supply of the respiratory muscles is composed of:

    "A. The divisions of the general motor system are (1) the phrenic (the internal respiratory nerve of Bell), distributed to the diaphragm; (2) the intercostals, distributed to the parietes of the thorax and abdomen; and (3) the posterior thoracic (the external respiratory nerve of Bell), distributed to the  serrate magni.

    "B. The divisions of the vagal system are (1) the hypoglossal, distributed to the diaphragm (conjoined to the phrenic) and to the intercostal and external respiratory muscles (instead of sympathetic); (2) the inferior laryngeal distributed to the muscles of the larynx (except the crico-thyroid) ; (3) the superior laryngeal, distributed to the crico-thyroid muscle."

    The control by the two systems is as follows:

    "The divisions of the general motor system maintain tonic vascular contraction in, and nutrition of 9 the respiratory muscles, while the divisions of the vagal system incite and govern their functional and co-ordinative activity.

    "The mechanical energy of the respiratory muscles is the result, as in all muscular tissues, of a chemical action of the oxidizing substance of the blood plasma upon the myosinogen of the musclecells.

    Bradford and Dean [Sajous. The Internal Secretions and the Principles of Medicine, page 481] found that PULMONARY PRESSURE is raised, and aortic pressure lowered, that is, there is pulmonary vaso-constriction, by stimulation of filaments which emerge from the cord from the 2nd to the 6th dorsal nerve.  These nerves have their origin from the lower border of the spine of the 6th cervical to the lower border of the spine of the 2nd thoracic or even just below the lower border of the spine of the 5th thoracic vertebra, their exits being from between the 2nd and 3rd dorsal vertebrae to where the 6th dorsal has its exit between the 6th and 7th dorsal vertebrae.  "On a level with the 3rd, 4th and 5th dorsal nerves maximum effects are obtained.

    The pulmonary vaso-constrictors ascend the chain up to the lst thoracic ganglion where they become detached, to reach t he pulmonary plexuses."

    "The following deductions" refer to the nervo-vovascular mechanism of the lungs and the respiratory [Sajous. The Internal Secretions and the Principles of Medicine, page 481]
process:

    "The nervo-vascular functional mechanism of the lungs consists of two autonomous, though correlated, systems.

    "A. The respiratory nervo-vascular system which is composed of:

    "(a) The pulmonary lobules, in the walls of which the blood is oxygenated.

    "(b) The pulmonary artery and its subdivisions, which bring venous blood, adrenal, secretion, and granules O to the capillaries of the lobules.

    "(c) The pulmonary venules and veins, which return the arterialized blood to the heart.

    "(d) The general motor nerves and plexuses (sympathetic) which govern the functions of the foregoing structures and the vaso-constriction of all vessels of the pneumo-respiratory system.

    "B. The bronchial nervo-vascular system which is composed of:

    "(a) The bronchial arteries, which, by their oxidizing substance, sustain functional energy and metabolism in: (I) the interlobular cellular, tissue and its lymphatic vessels and glands, the blood thus used passing to the venae azygos by the bronchial veins, thence to the superior vena cava; (III) the bronchi, the terminal ramifications of which only reach to the exterior of the 1obules, but anastomose with the pulmonary capillaries of the latter.

    "(b) Vagal nerves and plexuses, which supply sensation to the bronchial mucous membrane, incite and govern its secretion and the vaso-constriction of all vessels of the bronchial system.  Vagus affects functions of bronchial tubes, etc., down to, but not including the pulmonary lobule."

    The following processes are of interest to the student of physiological activities:

    "1. The process through which functional energy is supplied to the lobular structures (epithelium, basement membrane, and vascular walls of the lobules) to compensate for the absence of oxygen in the blood brought to them by the pulmonary artery is as follows: The oxidizing substance in the blood of the bronchial terminal branches which anastomose with the lobular capillaries, meets the granules contained in the blood of the latter; oxidation of the granules ensuing, functional energy is liberated, as it is elsewhere in the organism.

    2. The functional oxidation process through which the right heart is supplied with mechanical energy is repeated in the pulmonary lobules, and there is some ground for the belief that the contractile effects of the adrenal secretion on the myocardium are reproduced in the pulmonary lobules, the abundant elastic fibres of the latter acting as contractile elements."

    3. The respiratory interchanges that occur in the lobules represent the end-result of a complicated process for which the reader is referred to Sajous' work..

    By applying interrupted vibration with moderate or fairly deep pressure with the, ball vibratode between the transverse processes on each side of the spine from the 2nd cervical to the 12th dorsal and over the solar plexus, the nutritional activity of all muscles in ordinary inspiration and some of the muscles in forced inspiration is increased.

    As before stated, the LUNG REFLEX OF CONTRACTION is elicited by vibrating over the spinous processes of the 4th and 5th cervical vertebrae or between their transverse processes, or directly over the lung.

    When vibration is applied to the lungs directly, if the patient is lying, the arms should be extended parallel to the sides of the head, thus elevating the ribs and favoring chest expansion.

    IN TREATING PULMONARY AFFECTIONS, a general vibratory massage of the chest is indicated with special directions as to specific indications.  In the early stage Of PHTHISIS, the blood pressure is usually high, in the later stages it is low.  Concussion of 10th dorsal spine is useful in early stage (Abrams).

    With the patient lying and holding his arms slightly outward and upward to straighten the pectorals without putting them on a tension , apply very light centripetal friction with the disc vibratode, going over each region about three times, from the insertion at the humerus of the pectoral muscles and from the clavicle toward the upper part of the sternum.  Below the pectoral muscles work from the sternum toward the axilla following the direction of the ribs and cartilages.  Avoid the breasts in women.  Interrupted vibration with the rubber-covered disc is used over the chest if there are painful spots, as are frequently found in asthma, use deep interrupted vibration lightly at first, gradually increasing the pressure until the pain lessens or disappears when it is applied.

    Movements may be used in connection with the vibratory treatment for assisting inspiration or expiration.  If it is desirable to assist expiration, make pressure on the sides of the thorax or draw the arms upward and outward.

    To help resist inspiration "Place one hand upon the abdomen, causing the patient to lift it upward by the inspiratory movement, making at the same time a degree of pressure variously adapted to the patient's condition."

    Stimulating the nose and larynx causes the bronchi to contract reflexly (Landois and Stirling).

    ASTHMA, SPASMODIC OR BRONCHIAL, is characterized by cough, difficulty of expectoration, and dyspnoea, the expiration being prolonged and wheezy.  According to Osler, "All writers agree that there is in a majority of cases of bronchial asthma a strong neurotic element," which has been the case with all cases under the writer's care.  The theories as to cause are (1) spasm of the bronchial muscles, (2) "swelling of the bronchial, mucous membrane, fluctionary hyperemia (Traube), vaso-motor turgesence (Weber), diffuse hyperemic swellings (Clark), (3) in special form of inflammation of the smaller bronchioles," (4) "spasm of the diaphragm or a reflex spasm of all the inspiratory muscles.  "Asthma may be cardiac, renal, vesical or sexual.

    Salter and Bergson believe that bronchial asthma is due to "stimulation of the pulmonary plexus, causing spasmodic contraction of the bronchial muscle.  If this condition is really spasmodic in its nature ( 7 of the vessels), it must be usually of a reflex character; the afferent nerves may be those of the lung, skin, or genitals (in hysteria).  Perhaps however, it is due to a temporary paralysis of the pulmonary nerves (afferent), which excite the respiratory center (excito-respiratory)." Reflex asthma is due to "irritated surfaces of parts besides the lungs exciting the, oversensitive vagal center."

    Sajous' [The Internal Secretions and the Principles of Medicine, page 1700] explanation in respect to asthma is worthy of note.  He believes bronchial asthma to be "a form of paroxysmal dyspnoea due to the concurrence of two pathogenic factors: (1) hyperexcitability of the general vagal center (2) the presence within or upon the bronchial mucosa, of endogenous or exogenous irritants as products of hypocatabolism.  The mucosa requiring for the expulsion of these irritants, reflex impulses derived from the general vagal center, the hyperexcitability of the latter causes it to project unusually violent impulses, to all the elements of the bronchi, including their muscles, and these in turn being inordinately contracted, they reduce the calibre of the bronchi and thus provoke asthma." He believes an attack to be due "to vagal stricto-dilation of the bronchial arterioles" which means that the vasa vasorum of the arterioles that supply muscles (as well as any other organ), are constricted and consequently there is an arrest or diminished flow of blood to the blood vessels' walls, and therefore less nourishment is furnished which in turn causes lowered metabolism and heat in the blood vessels and consequently their spiral muscular elements relax and dilatation follows.  The calibre of the bronchi is lessened "by (1) contraction of their muscles, (2) congestive swelling of the bronchial mucous membrane." The lumen may become so small that the air cannot escape from the alveoli in consequence of which the thorax and diaphragm cannot contract and cyanosis occurs.  If the vasomotor center was stimulated, general vaso-conscriction would follow with a resultant rise of pressure.  Brodie aiad Dixon [Sajous. The Internal Secretions and the Principles of Medicine, page 1702] confirmed experimentally "that stimulation of the vagus causes a marked diminution of the volume of air entering and leaving the corresponding lung, owing to contraction of the bronchial muscles.  Kingscote [Sajous. The Internal Secretions and the Principles of Medicine, page 1702] states moreover, that this procedure causes simultaneously spasmodic contraction of the diaphragmatic muscle." According to "Lefevre, [Sajous. The Internal Secretions and the Principles of Medicine, page 1703] Salter, Trousseau, C. J. B. Williams, and many others, the spasmodic contraction of the bronchial muscles by greatly narrowing the calibre of the bronchi, provokes the asthma." Stricto-dilation of bronchial arterioles causes congestion of all the bronchial elements and hyperemic swelling.  Sajous also notes that researches show the absence of venous trunks in the bronchial mucosa, so it is supplied only with capillaries.  In an attack these capillaries become hyperaemic.  An attack is relieved by depleting them.  They "can be depleted as soon as the excess of blood supplied to them is reduced."  Sajous believes that "a hypersensitiveness of the vagal center in the posterior pituitary body is a predisposing cause of asthma.  Poisons act on the bronchial sensory end-organs of the vagus."  These cause afferent impulses which are  transmitted to the vagal center.  Normally they would cause "periodical contractions of the bronchi, but being hypersensitive the center projects violent stimuli to the bronchial muscles and mucosa," which causes broncho-stenosis, which in turn causes the asthma.  Since broncho-stenosis is due principally to contraction of the bronchial muscles and congestive swelling of the bronchial mucous membrane, and the swelling is due to stricto-dilation of the arterioles the first indication is to contract the arterioles and lessen the quantity of blood sent to them.  Constriction of the arterioles is by means of the sympathetic fibres.

    Landois [Text-Book of Human Physiology, page 719] says "the cervical sympathetic cord contains centripetal fibres that stimulate the vaso-motor center in the medulla oblongata."  It is possible that the sympathetics are reached by vibration over the 4th and 5th cervical spines which gives temporary or permanent relief.

    Pressor fibres [Landois. Text-Book of Human Physiology, page 764] are represented by fibres of centripetal nerves, "irritation of which influences the vaso-motor center.  They increase blood pressure.  Aubert and Roever discovered pressor fibres in the cervical sympathetic."

    THE TREATMENT indicated is to first control the paroxysm as by a drug stimulating the sympathetic center as belladonna which raises blood pressure and gives better oxygenation. [Sajous. The Internal Secretions and the Principles of Medicine, page 1214]  This can be accomplished by mechanical vibratory treatment so applied as to increase the vascular tension.  The second indication for treatment is the removal of the cause.

    The causes are local disorders or foci of irritation arising from the toxins or endotoxins of diseases following successively or from the constant irritation of toxic products resulting from the effects of hypocatabolism on the central neurons.  Measures should be employed to care for and remove the causes as they present themselves.  In the latter cases there is an excess of waste products requiring elimination.  Metabolism must, therefore, be promoted by means which will awaken tissue activity, such as the application of general or local mechanical vibration or the high potential electrical currents, radiant light and heat, or by stimulating the adrenal center which may, according to Sajous, cause an increase of auto-antitoxin in the blood.  Diet is of the utmost importance.  A diet largely of milk is to be preferred.

    The induction of the LUNG REFLEX OF CONTRACTION (Abrams) is effected by a five or ten-minute seance of interrupted vibration with the ball vibratode applied between the 4th and 5th cervical vertebrae.  The patient may sit erect or lie face down during the treatment.  This will relieve the rales in a remarkable manner.  If conditions call for a longer vibration, it may be applied for an additional five minutes.  If the rales have not then fully disappeared, an interrupted vibration over the region between the clavicle and breast and over the sternum with the disc vibratode may be applied, a half stroke and moderate speed being used.  The parts are vibrated interruptedly two or three times.  Abrams advises forcible concussion over. any area of the lungs (by means of a plexor and pleximeter) as a method of inducing the lung reflex of contraction.  When not entirely relieved, an administration of the static wave current with a small metal electrode (1 by 3 inches) covering the intervertebral space between the 4th and 5th cervical vertebrae for fifteen minutes is often followed with good results.  Blowing exercises are also practiced to advantage.

    Another method is as follows: The patient first removes all clothing about the waist and chest except the undervest.  Then use the ball vibratode with medium stroke for the cervical region if necessary, otherwise with full stroke and regulated pressure with a moderate rate of speed.  Apply deep interrupted spinal vibration on each side alternately between the transverse processes from the lst cervical vertebra to the waist line noting the painful sites.  This application should be made to each interspace from above downward, two or three times.  When sensitive spots are found, as they will be in most cases to the right of the 6th cervical vertebra, and often in the interscapular region, apply interrupted vibration for six or seven times, i.e., interruptedly each time increasing the pressure, according to the effect produced.  Apply the vibratode lightly at first, gradually increasing the pressure with each application as the pain diminishes.  The disc vibratode is afterwards used for applying interrupted vibration to the tense muscles of the back, then the patient is allowed to rest for a short time, after which he should lie upon his back with a pillow beneath the thorax to elevate the chest, and the arms should be extended upward along the sides of his head.  Then apply vibratory friction to the neck with the rubber-covered disc vibratode, employing a short stroke.

    After a few minutes' rest, apply interrupted vibration with the disc vibratode from the insertion at the humerus of the pectoral muscles toward the sternum, and below the pectorals vibrate from the sternum to the axilla.  If there are any particularly sensitive spots, apply interrupted vibration very lightly at first, gradually increasing the pressure at each impulse until the pain is lessened or disappears.  Also apply interrupted vibration with the rubber-covered disc vibratode over the solar plexus to affect the phrenic nerve and thus affect the action of the diaphragm.  In addition the writer sometimes applies interrupted vibration over the region of soreness, which may form a girdle around the waist line in men, or be in the abdominal region in women, probably due to their manner of breathing and mode of dress.  Treatments should be given daily at first, and later the intervals may be lengthened as the condition improves.  If possible, give the treatments early in the day for the comfort of the patient.  Sometimes forced breathing exercises are useful while the patient lies in, a prone position, the head and chest being below the level of the pelvis, to assist in getting rid of the secretion.  If the patient's general condition is poor, the static wave current may be administered with advantage, employing a spinal electrode.

    Theoretically the induction of THE REFLEX LUNG CONTRACTION is indicated in CHRONIC BRONCHITIS where "bronchial dilatations are not uncommon and emphysema is a constant accompaniment, in BRONCHIECTASIS when not congenital or an anomaly, in later stages Of PHTHISIS, and in all conditions where there is overexpansion.

    IN ACUTE BRONCHITIS, CHRONIC BRONCHITIS AND PHTHISIS PULMONUM, Cyriax [Elements of Kellgren's Manual Treatment, page 164] has always found an interscapular tenderness which he believes is due to the posterior pulmonary plexus being "largely formed of sympathetic fibres from the second to and including the fourth thoracic sympathetic ganglia." He also often noted tenderness in the nerves supplying the intercostal spaces that lie over any affected area.

    EMPHYSEMA, the most marked form of which is hypertrophic emphysema is "characterized by enlargement of the lungs due to distension of the air cells and atrophy of their walls, and clinically by imperfect aeration of the blood and more or less marked dyspnoea."  The treatment should aim [Sajous. The Internal Secretions and the Principles of Medicine, page 1859] to "increase the blood supplied to what normal alveoli remain, by causing dilation of the arterioles or by increasing their propulsive activity, and simultaneously the power of the blood to absorb oxygen."  Hence stimulate [Abrams. Spondylotherapy, page 303] the sympathetic and the adrenal systems.  Induce a rise of blood pressure.  The treatment is practically the same as for asthma, but the prognosis is not so good.

    THE LUNG REFLEX OF DILATATION is elicited (Abrams) by concussing from the 3rd to the 8th dorsal vertebral or by vibrating between the transverse processes of the 3rd and 4th, 4th and 5th, 5th and 6th, 6th and 7th, 7th and 8th dorsal vertebrae [Abrams. Spondylotherapy, page 303], when the same effect has been produced by the writer.  The effect is recognized by hyper-resonance and the "extension of the pulmonary percussion note and obliteration of the cardiac and splenic areas of dulness." [Abrams. Spondylotherapy, page 295]

    Theoretically the lung reflex of dilatation may be employed in PULMONARY ATELECTASIS when the lessened expansion is not due to causes of obstruction or compression which are not removable as tonsillar enlargement, adenoids, growths, kypho-scoliosis.

    Absorption is assisted by stimulating the lymphatics communicating with the axillary glands.  To accomplish this apply vibratory friction centripetally.

    "Poliakow reports most excellent results in the treatment of cases of PLEURISY WITH EXUDATION," by the employment of thoracic massage.  The manipulations were made in the direction of the lymphatics of the affected region.  The treatment was begun with light stroking, and soon brisk, deep massage was employed, and this was followed by percussion all consuming from ten to twenty minutes daily.  Vibratory friction may be supplemented by interrupted vibration.  Vibration applied to produce the vibratory effect of "hacking" is useful in UNRESOLVED PNEUMONIA, CHRONIC PLEURISY, and where there is an effusion of a serous character.  According to Graham, Dr. Emil Schliegel accelerated absorption in some cases of pleuritic effusion by manual massage "in the form of percussion, employing only the ulnar border of the hand, striking at a rate of two blows a second, or six hundred in five minutes, which made a sitting and two of these were given daily." Properly applied vibration will accomplish the same results and with greater facility.  The number of percussions per second given by Schliegel will suggest to the operator the importance of employing a definite control of speed.