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

Chapter 9

Mechanical Vibration in Relation to the Muscular System

    THE MUSCULAR SYSTEM occupies a most important position in relation to vibration, being vitally concerned in metabolism - the metabolism depending on muscle energy and circulatory activity.

    In the subject under discussion the voluntary, or skeletal, muscles most directly concern us.  The muscle fibres, 30 to 45 or even 120 mm. in length by 10 to 50 mm. in width, are liberally supplied with blood vessels, which are in close relation by means of capillary net works around each fibre.  These are extended when the muscle is at rest, but curved when the muscle is contracted.  According to Piersol, dilatations occur in the course of the blood vessels, which possibly give relief "to sudden temporary interference with the circulation during contractions." Distinct lymphatic vessels in striated muscles are limited "to the larger or looser masses of tissue of the perimysium" and are not found in many small muscles (Kolliker).

    MECHANICAL VIBRATION in the author's experience has demonstrated the removal or diminution of pain, tenderness and stiffness with a consequent relaxation of the muscular tissue involved.  It may by in-creasing circulatory activity develop an atrophied muscle, or lessen the flaccidity of a relaxed muscle.  It has a marked effect on the circulation as noted in the preceding chapter, and when we recall that it is estimated that the muscles contain about 25 per cent of the blood in the body we can understand their importance as factors in metabolism.  In many cases exercise, particularly passive exercise, has been found a useful adjunct to vibratory treatment, the two acting by regulating functional cellular activity.  They also assist in the elimination of toxic substances, consume reserve materials as fat, and increase nutritional activity.  Mechanical vibration increases the blood supply to the muscle, renders it firmer, more healthy and more elastic.  In cases following injury it rapidly diminishes the tense hardness due to local stasis so characteristic of the affected part.  After the first treatment properly administered, the part treated usually has a feeling of warmth and comfort.

    Vibratory effects on muscles as noted by others [Cyriax. Vibrations and Their Effects] are as follows:  "Rood found that vibration caused contraction of muscles; this was also noted by Lavalette, but only by Mesuard whenever very rapid vibrations were used.  Danilewsky found production of warmth in muscle, and Stenberg obtained reflex muscular contraction from vibration of the bony substance.  Ewer states that vibrations can sometimes cause contraction in muscles which will not react to electrical stimuli."

    THE NERVES SUPPLYING THE STRIATED MUSCLE consist of both sensory and motor fibres, the sensory ending as a "loose network, the fibrillae of which apparently terminate between the individual muscle fibres" and the motor ending in the end-plates.  There are also sensory end-plates in the tendon as studied by Golgi. [Piersol. Text-Book of Human Physiology] The trunk of a nerve generally enters the muscle at its "geometric center."  According to Landois and Stirling in triangular muscles, however, this point of entrance is more towards the apex of the triangle and in all muscles it is generally where the muscle substance is the least misplaced during contraction.  The motor nerves supplying nonstriated muscles end in a ground plexus, which forms the intermediate plexus, which in turn forms the intermuscular plexus "in the cement substance between the muscle cells, which ends in the vicinity of the nucleus (Lustig) or "nucleon of the nucleus" (Frankenhauser).

    A MUSCULAR CONTRACTION [Text-Book of Human Physiology. Landois and Stirling, 4th ed. Page 609] CONSISTS OF:

    "l.  A period of or stage of latent stimulation lasting from .004 to .01 second.

    "2. A period of increasing energy or contraction (from .03 to .04), in non-striated muscles for a few seconds.

    "3. A period of decreasing energy or more rapid relaxation (elongation) of a shorter duration than

    "4. A period of slow relaxation or the elastic after vibration.

    The latent period is lessened if the strength of the stimulus is increased, or if heated.  Cooling or fatigue will increase it.  The latent period is lengthened in "secondary degeneration of the cord after apoplexy, atrophic muscular anchylosis of the limbs, muscular ,atrophy, progressive ataxia, and paralysis agitans of long standing, and is shortened in the contracture of senile chorea and spastic tabes (Mendelsohn)."  "In chorea the curve is short."  In Thomsen's disease the contraction is lengthened.  The contraction varies as the stimulus, muscle excitability being shorter for a mild stimulus or if the muscle be not fatigued.  The latent period may be even from .0033 to .0025 second "if the muscle be still attached to the body, protected as much as possible from external influences and properly supplied with blood" state Landois and Stirling.  According to the same authorities "the latency of the individual muscular elements is shorter than that of the entire muscle (Gad, Tigerstedt)."

    The elongation stage varies with the stimulus, it being lengthened as the strength of the stimulus is increased.  The fourth stage is dependent upon muscular elasticity and its time is in proportion to the force of the contraction, being longest when the contraction is more powerful. It is worthy of notice also in this connection that "if the stimulus be applied to the motor nerve instead of to the muscle itself, the contraction is greater (Pfluger), and lasts longer (Wundt), the nearer to the spinal cord the stimulus is applied to the nerve."  It has been found by Cash and Kronecker that "individual muscles have a special form of muscle curve" which may shed some light on the value of the use of harmonic vibrations.

    "The pale muscles are more excitable, have a longer latent period, are more readily fatigued, and their contraction is of shorter duration than the red.  They also "produce more acid" during contraction (Gleiss) and "execute more rapid movements." "Muscles which are composed chiefly of pale fibres have a greater 'lift' and a considerably greater absolute force during a single contraction, but during tetanus they are second to the red" (Grutzner).  Non-striated muscles have a longer period of contraction.  When a muscle contracts and also as it relaxes heat is evolved, the amount being in proportion to the muscular tension.  Fatigue diminishes heat production.  The above physiological data are of importance in mechanical vibratory selection for the production of certain effects.

    MUSCULAR EXCITABILITY NORMALLY IS BEST MAINTAINED when the temperature of the body is normal.  It varies with the rise or fall of temperature.  This excitability is best induced by stimuli, although it has been demonstrated that muscles also possess "independent excitability," not depending on the excitability of nerves [Landois and Stirling. Text-Book of Human Physiology. 4th ed., page 600]. The points to which the administration of mechanical stimulation causes most energetic muscular contraction are those that best respond to the faradic current.  Within natural limits the contraction of a muscle is increased by tension or extension.  It is important in using vibratory stimulation that there be no interference with the blood supply as by bands, or strained positions, as it diminishes the energizing power of the muscles.  Another important point concerning the regulation of the strength of interrupted mechanical vibration as applied, is to remember that although a feeble stimulus will not induce a contraction, a second one may, as "the first one has increased the muscular excitability" (Fick).  Foster states that "a muscular contraction itself is essentially a translocation of molecules, a change of form, not of bulk."

    Sajous believes that the reaction in the contractile elements of muscles when different compounds, principally hydrocarbons are oxidized, results in chemical energy which is utilized as mechanical energy by passive living voluntary muscles.  When irritability is transformed into contractility by an "exacerbation of the activity of this mechanical process active work results.

    He thinks [The Internal Secretions and the Principles of Medicine, page 237 and 247] that the chemical process to which muscular contractility is due is dependent on the oxidizing substance of the blood (of blood-plasma principally).  "The nerve impulses simply exciting and governing the function." The red corpuscles carry oxygen to "sustain the plasma's efficiency as an oxidizing body."

    The functional activity [Sajous. The Internal Secretions and the Principles of Medicine, page 261 and 262] of a voluntary muscle depends on:

    "(1) Nervous stimulus: An impulse wave transmitted from a cerebral center through motor nerves, which adjusts the muscle to a fixed degree of contraction.  As the vibratory rhythm of the impulse and that of the muscle always correspond, any variation of rhythm by the brain center correspondingly modifies the muscular contraction.

    "There are no independent vaso-constrictor or vaso-dilator nerves in voluntary muscles, both functions being fulfilled by the motor nerves through the filaments distributed to the muscular coat of the vessels of these muscles, and under the influence of the same impulse-wave that adjusts and fixes the latter's contraction or retraction.

    "In muscles [Sajous. The Internal Secretions and the Principles of Medicine, page 294] the excito-regulator branch of the general motor nerves subdivides into two branches: one of these, the 'excitor,' supplies filaments to the muscle-fibres and excites them to activity; the other, the 'intrinsic constrictor,' is distributed to the muscular arterioles that do not supply the muscular fibres with capillaries, constricts them during muscular contraction, and thus increases the blood-flow through those that do supply capillaries to the contractile elements.

    "An oxidation [Sajous. The Internal Secretions and the Principles of Medicine, page 262] process in the muscular contractile elements the chemical energy of which, after conversion into mechanical energy, supplies the muscle during any stage of contraction or retraction with the power-to-do-work required to sustain either of the latter.

    "This oxidation process is subject to fluctuations of activity, and occurs as the result of a reaction between two physiological compounds: first, myo-sinogen, - i.e., blood-plasma containing various carbohydrates and immanent in the muscle-fibre, - as a potential; second, an oxidizing substance, also contained in the blood-plasma, but in that of the arteries as reagent.

    "(2) Mechanical process: Variations in the calibre of the muscular vessels give rise to corresponding variations in the proportion of oxidizing substance admitted to the myosinogen in the muscular fibre and to correspondingly marked fluctuations in the activity of the oxidation process.

    "The myosinogen is stored in the contractile disks while the oxidizing plasma fills the interstitial disks, and an opening between the two probably exists through which the oxidizing plasma is forced when the impulse-wave adjusts the muscle to the required contraction, the quantity of energy produced being thus simultaneously adjusted to the needs of that contraction.

    MECHANICAL VIBRATORY STIMULI MAY BE DIRECT OR INDIRECT.  Contractions are generally best induced by the use of a ball vibratode or rubber-covered disc.  Reflex contractions are not always induced by mechanical vibration.  The static spark or sinusoidal current are better agents for the induction of muscular contraction unless they occur directly or reflexly through the vibration of a painful or sensitive area.  If a violent stimulus be applied to a fatigued muscle a local contraction of considerable duration will result, Schiff's "idio-muscular contraction," which may also be caused "when the blunt edge of an instrument is drawn transversely over the direction of muscular fibres." The degree of contraction varies according to the strength of the stimulus, the fatigue of the muscle and the temperature.  Schmulewitsch found by experimenting on a frog that with a "given strength of stimulus" and degree of fatigue, the contraction in the muscle of a frog was increased when heat was applied up to 350 C. but above this temperature the contraction diminished.

    MECHANICAL VIBRATION AS A STIMULUS, by inducing muscular contraction, causes increased heat production, diminished elasticity, increased extensibility, and possibly a muscular sound.  It increases the amount of CO2 given off, promotes the absorption of more oxygen, and increases the production of sarco-lactic acid.

    If two successive stimuli be applied the effect varies.  If each is capable of causing a maximal contraction, when the second follows the relaxation two maximal contractions result.  If the second is applied during muscular contraction or relaxation a new contraction follows.  If "both occur in the latent period, we obtain only one maximal contraction" (v.  Helmholtz).  If the stimuli are not maximal a summation of contractions result.  Sewall believes that the best time for the second stimulus to be applied is 1-20 of a second after the first.  This is important in vibratory therapeutics, for we are apt to employ too high a frequency and make too short intervals between repetitions.  In accordance with these views the number of movements of the vibratode should not exceed 1,200 per minute for muscle stimulation.  The number of stimuli to produce tetanus varies for different muscles.  Kronecker believes that very feeble stimuli, more than 20 per second, cause tetanus." Strong vibrations at a high rate of speed will cause tetanus.  Landois wrote the letters, n, n, and every contraction was "equal to about 3.5 vibrations (of a tuning fork) (vibration = .01613 second) = .0564 second.  When the right arm was tetanized 2 to 2.5 vibrations occurred = .0323 to .0403 second.

    According to Landois and Stirling a simple muscular twitch caused by a single induction shock, is shorter than a momentary voluntary single movement (v.  Kries), a point to be remembered in the treatment of local disease marked by involuntary twitchings.  Kellogg employs a vibratory apparatus, having a movement of 30 per second, for inducing muscular contractions.  He claims, in speaking of mechanical vibration relative to the large and old machines, that "vibratory movements forcibly communicated to the body at the rate of six per minute, have been shown to produce at first a distinct muscular contraction with each oscillation; but if the vibration is long continued, the individual contractions become generally less distinct, and after a time merge one into another, so that the contractions become continuous or tetanic.  Schafer finds that prolonged voluntary contraction in man is an incomplete tetanus produced by eight to thirteen successive nervous impulses per second.  About ten per second may be taken as the average." [Text-Book of Human Physiology. Landois and Stirling, page 618] Barbaker says that 2.5 to 4 stimulations per second cause a "most rapid voluntary contraction."

    If "induction shocks 224 to 360 per second be applied to a muscle, the tetanus after a so-called 'initial contraction' (Bernstein) may cease (Harless, Heidenhain).  This occurs most readily when the nerves are cooled.  Kronecker and Stirling, however, found that stimuli following each other at greater rapidity than 24,000 per second produced tetanus;" which demonstrates that a definite rate of speed is an important factor to be considered in the application of mechanical vibration.

    Herrman states that "the velocity of the contraction wave, in the voluntary muscles (not exercised) of a living man" is "10 to 13 metres" per second, which is diminished by conditions such as fatigue and cold; but strength of stimulus has no effect on the velocity of the wave.  According to Kirke the stimuli must be very rapid or the tetanus will be "in a condition of vibratory contraction and not of unvarying contraction."

    VOLUNTARY MUSCLES RESPOND MORE QUICKLY TO STIMULI than the involuntary. If any part which is supplied with unstriped muscular fibres, e.g., the intestine or bladder, is irritated, the resulting contraction develops more slowly, extends beyond the site of stimulation, and with alternate relaxation continues for some time after the stimulus has been withdrawn.  After a rectal mechanical vibratory treatment patients have said that they felt the vibratory sensation for five minutes after the withdrawal of the instrument.

    "The ureters [Baker and Harris. Kirke's Handbook of Physiology] and gall bladder are the parts least excited by stimuli; they do not act at all till the stimulus has been long applied, and then contract feebly, and to a small extent.

    "The contractions of the caecum and stomach are quicker and wider spread; still quicker those of the iris, and of the urinary bladder if it be not full.

    "The actions of the small and large intestines, of the vas deferens and pregnant uterus, are yet more vivid, more regular and more sustained; and they also require no more stimulus than that of varying temperatures of the air to excite them.  The heart, on account, doubtless, of its striated muscle, is the quickest and most vigorous of all the muscles of organic life in contracting upon irritation."

    The above principles are for a guide to the length and regulation of mechanical vibratory administrations when particular effects are sought.

    PROFESSOR MAGGIOR'S EXPERIMENTS demonstrated many valuable points.  He made the right and left middle fingers voluntarily raise six pounds every two seconds, twice in the morning, and twice in the afternoon, the fingers having been first massaged for three minutes.  The left middle finger without massage raised 4,252 kilos, whereas after massage 8, 019 kilos could be raised before extreme fatigue prevented further contractions.  Fatigue curves were also taken with Mosso's ergograph.  The results show that massage rightly applied will increase the working energy of a muscle or group of muscles.  Another experiment made was to test the effects of friction, kneading, and percussion to determine if the results had any fixed ratio of effect in respect to length of time.  He demonstrated that after employing massage for varying periods of two, five, ten and fifteen minutes, that five-minute administrations produced the best result.  Longer applications produced a slight difference above and below that of five minutes.  The third experiment to determine the relative effects of friction, percussion and kneading demonstrated but slight difference in the work done following five minutes of friction or five minutes of percussion.  The contractions representing work done were greatest in "force and duration" after kneading, but the best results were produced when the three movements alternated.  The fourth experiment showed that massage temporarily restored the working power of the muscles after fasting.

    From another experiment relative to the effects of massage after fatigue from an indirect cause, Dr. Douglas Graham claims that five minutes of massage equals two hours of rest.

    Yet another experiment demonstrated that ten minutes of massage could restore the muscles to such an extent that they would give a normal fatigue curve after a night's loss of sleep.  He also showed that ten minutes' massage following great intellectual effort after one-half hour, left the working energy "little less than natural;" that after ten hours of fever, massage recuperated weak muscles; and that it had a favorable effect even where the blood supply was cut off.

    MUSCULAR ELECTRO-EXCITABILITY may be increased by mechanical vibration.  It has been demonstrated by the writer that after vibration a contraction may be induced by a smaller number of milliamperes of the continuous electrical current than before.  In the case tried, a pad was held in the writer's left hand, which had not been vibrated, while make and break shocks were applied to the right thenar eminence which elicited contractions in the left wrist when nearly five milliamperes were indicated.  After a vibratory treatment between three and four milli-amperes caused such contractions.

    FATIGUE is a condition favorably affected by vibration.  La Grange [Ferdinand La Grange. Physiology of Bodily Exercise] divides fatigue into local and general, immediate and consecutive fatigue, caused by (1) Traumatic effects of work on the motor organs, (2) Auto-intoxication by the products of dissimilation, (3) Organic exhaustion through autophagy, (4) Dynamic exhaustion through expenditure of all the force at the disposal of the muscular and nervous elements."  Mechanical vibratory friction employing a rubber-covered disc vibratode, as well as interrupted vibration, greatly assists in lessening fatigue.

    A muscle that is fatigued has slower latent contractions, its latent period is longer, and its extensibility increases.  Mechanical vibration also lessens stiffness, probably by removing products of dissimilation, which La Grange thinks act as an auto-intoxicant, causing the "stiffness of fatigue," and which are found among the substances which go to form deposits of urates (fatigue toxins).  In the production of general consecutive fatigue these toxins are important factors.  If resistive movements be used as an adjunct, the contracted muscle not being allowed to shorten, there is an increased metabolism. Muscle fatigue is relieved by promoting absorption and stimulating peripheral circulation, but mental fatigue by increasing the peripheral circulation of the body, thereby relieving cerebral congestion.

    IN REGARD TO MUSCULAR FATIGUE, Sajous [The Internal Secretions and the Principles of Medicine, page 152] remarks that adrenal overactivity is characterized by "unusual muscular metabolism and consequent muscular fatigue - also due to excessive oxidation - as manifested by the fibrillary tremor similar to that of excitement, as well as exaggerated tendon reflex due to excessive muscular and spinal oxidation " and painful cramps in the extremities. Muscular twitchings are caused by "exacerbations of adrenal activity" according to the same authority.  He also believes that a small excess of thyroid secretion causes symptoms of suprarenal overactivity while a great excess causes symptoms of insufficiency.  Conditions demand treatment suitable to the disease, as the removal of the muscular twitchings of chorea by proper treatment of the disease.  Local twitchings are sometimes relieved by prolonged, mechanical vibration over the part involved.

    ATROPHY OF THE MUSCLES when slight may be due to disuse; if considerable with the reaction of degeneration, it means "a lesion of the lower motor neurons [Butler. Diagnostics of Internal Medicine]; if considerable, associated with no electrical reaction, "primary disease of the muscle or chronic disease of the joints is indicated."

    Atrophy of the muscles should be treated by mechanical vibratory friction, centripetal, with the rubber-covered disc vibratode applied over the muscle, or vibratory rolling, for both methods increase the blood supply and improve nutrition without using up the reserve force of the muscle.  The friction should be given quickly, and with but little pressure.  Go over each site about three times and make the application over the entire surface three times in said manner.  If atrophy is due to nerve disturbance, the nerve center should be stimulated.  Appropriate passive exercises may follow and active exercises may be introduced as soon as possible.

    Atrophy of the muscles associated with joint affections may be treated by spinal as well as local vibration.  Kellogg so aptly states in knee involvement "the quadriceps atrophies, in hip joint cases the glutei muscles are chiefly affected, in cases of the elbow the biceps and brachialis anticus, in those of the shoulder the deltoid and supra- and infra-spinatus." In these cases the nerve segment representing the muscle or the site of the vertebral exit of the involved nerve should be vibrated with the ball vibratode or the nerve affected may be vibrated with the disc vibratode.  The muscles involved are represented by the following segments, the quadriceps is represented by the 2nd and 3rd lumbar segment, the glutei by the 4th and 5th lumbar segments, biceps by 5th and 6th cervical segments, the brachialis anticus by the 6th and 7th cervical segments and the deltoid by the 5th, 6th and 7th cervical segments, and the supra-spinatus by the 4th and 5th cervical segments, the infra-spinatus by the 5th and 6th cervical segments.  As a rule when tenderness is present it is greatest over the exits of the involved nerves, in which case give interrupted vibration over their exits with the ball vibratode.

    Mechanical vibration is also indicated in the treatment of RELAXED LIGAMENTS  and RELAXED AND ATROPHIED MUSCLES, such as are often present in rheumatoid arthritis and kindred affections.  Vibration should be applied both above and below the affected joint in the form of light vibratory friction centripetally with a rubber-covered disc vibratode.  Around the joint, however, interrupted vibration with varying degrees of pressure should be applied at first lightly and later with increased pressure.  This treatment should be followed by passive, active, assistive or resistive movements according to the indications of each particular case.  Time, patience, and perseverance are necessary.

    TROPHIC JOINT TROUBLES are classified by Peckham [The Classification and Treatment of Diseases Commonly Known as Rheumatism] as atrophic and hypertrophic arthritis.

    1. ATHROPHIC is characterized by a thick, spongy, "synovial membrane full of blood," fluctuation, with later involvement of cartilage which becomes, thin and atrophic.  When occurring in the knee, pressure causing a depressed patella "gives the sensation of stroking on rubber instead of the sharp click so easily sensed in a simple synovitis."  The thickened villi may "undergo fatty degeneration or calcification.  Calcified tips may break off and become floating cartilages.  On account of the villous arthritis and eroded surfaces the flexor muscles of these joints may contract.  The villi and erosions later cause grating and creaking.  Stiffness and fibrosis may characterize the beginning of some of these cases."  This type may be first noticed "in the smaller joints (fingers), later the larger joints (knees), and even the cervical vertebrae."

    It has been our experience that arthritis unless infectious is due primarily to auto-intoxication and it is of extreme importance that these patients be made to realize that diet and hygiene are factors of prime import in their trouble, for although it may be palliated by local treatment, it will return with renewed force if the underlying cause is not removed.  The condition of the teeth, mouth and gums should be noted and properly cared for.  A diet, devoid of auto-intoxicating foods as milk, curdled milk, whey, buttermilk, koumiss, kefir, zoolak, fresh cream cheese, the carbohydrates, the farinaceous foods as rice, farina, cooked vegetables, purees, cooked fruits and toast with little butter is demanded.  Later fresh fruit devoid of skins is permitted.  In severe cases, a diet of one or two of the following: milk, curdled milk, whey, buttermilk, koumiss, zoolak and six slices of toast or dry or old bread a day, or zweiback is advised.  Gradually cooked fruit and purees, are allowed.  High colonic flushings are given daily at first and later when indicated.

    In these cases promote metabolism.  Physical measures [Wm. Benham Snow. Currents of High Potential of High and Other Frequencies, also the Therapeutics of Radient Light and Heat and Convective Heat] form the treatment par excellence in joint troubles.  They include light from a 500 candle power lamp, or light baths, hot air, static wave current, static sparks, d'Darsonval current, and mechanical vibration.  Mechanical vibration is used as follows: Spinal vibration with the ball vibratode between the transverse processes for from five to ten seconds or twelve seconds for stimulation, but prolonged spinal vibration to relieve tension should be administered over the exits of involved nerves.  This vibratory treatment should be for five minutes over indicated sites.  Mechanical vibration with the disc over the liver, anteriorly and posteriorly, and over the stomach and abdomen is also indicated to promote elimination.  Prolonged local vibration with the disc over the affected joints and interrupted vibratory treatment over the tense muscles is also given.  "If villous arthritis is present," Peckham states "'the hard ball is a very efficient means of causing a contraction and slow disappearance of the condition" but the author prefers the rubber-covered disc vibratode for such treatment.

    2. THE HYPERTROPHIC TYPE OF ARTHRITIS is characterized by infiltration of the soft structures "later by overgrowth of bone or cartilage usually at the edges of the articular surface."  Actual hypertrophy occurs still later.  It may attack the spine causing pain on motion.  Before the stage of the deposition of bone salts, the prognosis is favorable for cure.  The 500 candle power incandescent light, the static wave current with fitted metal electrode, sparks, d'Arsonvalization, and mechanical vibration are employed.  This type of arthritis is due to auto-infection or auto-intoxication that calls for elimination and circulatory stimulation, consequently not only a local treatment is demanded, but the alimentary tract should be treated.  The liver should also receive vibratory treatment which helps the circulation, and the abdominal treatment stimulates the bowels and the promotion of the activity of the bowels lessens the danger of toxemia.  The quantity of poisonous gases is also diminished.  High colonic flushings are in order.  Watch the urine for indican and urates.

    IN TREATING INFECTIOUS ARTHRITIS baking of the joint is indicated before vibrating the affected joint.  The d'Arsonval current is also recommended.  Auto-intoxication and auto-infection and its cause should be considered and treated, and if a gonorrheal urethritis be present it should receive proper attention as outlined by Dr. Wm.  B. Snow. [Currents of High Potential of High and Other Frequencies, page 151]  In regard to vibration, Peckham [The Classification and Treatment of Disease Commonly Known as Rheumatism, page 54] says, "The hard ball on the spine stimulates the nerve centers.  The soft brush (multiple point vibratode) on the stomach and intestines and the hard ball on the abdominal lymphatics stimulate all these organs.  Let me also reiterate that the liver is an extremely important organ standing between the intestines and the general circulation to filter out the poisons.  This is stimulated in a wonderful way by the soft brush over the liver area, front and back.  This also stimulates the flow of bile. It is truly remarkable at times to see indigestion of both stomach and intestines which have been treated with no benefit by the best of medical men in probably the most careful (drug) manner slowly yield and get entirely well and also the joint trouble improve "pari passu." Stimulation applied in this manner results in an increased tone to the muscular walls of stomach and intestines and this in taking up of the slack to a certain extent and a stronger muscular activity in the digestive movements.  The various fluids are also in this way stimulated so that they are secreted more copiously and more rapidly.  In this way it is fairly easy to understand how a better and better "tone" is obtained and how a more and more physiological digestion takes place.  Hence it must also result in a diminution even to complete disappearance of fermentation and formation of bacteria and toxines.  In cases where constipation is a serious factor in the backing up of the intestinal stream, although drugs may be used to produce evacuations, the thing to be desired is to get the tone of the muscular walls so improved that they work once again from the stimuli which are provided in nature's own way.  This being the cause and the cause thus removed, the consequent joint trouble must disappear.  All of this takes time, - in many cases, months.  And at the same time that the treatment is begun, the joints themselves must receive attention in order to cause the swollen tissues (infiltration) to become contracted and restored to a normal physiological condition.  Elimination must also be promoted."

    PROGRESSIVE MUSCULAR ATROPHY may be benefited by mechanical vibration applied as massage, but it must be begun early and great patience is necessary.  Static electricity as a general tonic is also indicated in these cases.  Blood pressure should be regulated.

    PARALYSIS may be treated by vibratory friction.  It has a soothing effect, and at the same time improves the nutrition of the affected muscles and prevents atrophy.  Appropriate passive with a few active exercises are beneficial adjuncts.  Blood pressure should be lowered and elimination promoted.

    PSEUDO-HYPERTROPHY characterized by an increase in size but a lessening of power must be distinguished from hypertrophy represented by an increase in size and strength caused by use.  In pseudo-hypertrophy of the muscles, "a chronic myositis" accompanied by interstitial hyperplasia of the connective tissue, the early use of vibration and hydrotherapy is indicated.

    IN MYOSITIS, whether traumatic or spontaneous mechanical vibratory treatment is applicable.  In fibrous or interstitial myositis "where proliferation and induration of the connective tissues have taken place with secondary atrophy of muscular fibres and consequent interference with motion, circulation, and innervation, " interrupted vibration may be successfully used, observing the principles governing the relief of inflammatory conditions.  Its effects are to relieve local stasis, promote absorption, induce a freer circulation, and relieve pain.  If the myositis is not traumatic, elimination should be promoted by the use of light baths, and colonic flushings.  A restricted non auto-intoxicating diet is essential.

    IN CHRONIC MYOSITIS characterized by indurations within the bodies of the muscles, causing pains in the neck, and interference with motion, circulation, and innervation associated with indurative headache, Abrams [Spondylotherapy, page 90] effects a cure with vibration and galvano-therapy although he prefers massage.  The author uses prolonged vibration with the disc vibratode with few interruptions over the sites for five minutes at a time.  Interrupted vibration is then given over the muscles affected.  With the ball vibratode, interrupted vibration is applied over the segment or segments representing the muscles, or over the sites of the vertebral exits of the nerves supplying them, in each case the ball being placed between the transverse processes of the vertebrae.

    INDURATED MUSCLES are most often found in the neck or head.  The cause seems to be exposure, injuries, strains, infections, or adenitis.  Prolonged interrupted vibration with the rubber-covered disc vibratode and ball as indicated above is employed.  The static wave current applied with a metal electrode fitted over the surface for twenty minutes and static sparks are beneficial.

    THE TONE OF A MUSCLE is increased by vibratory treatment, centripetal friction with the disc vibratode, and special vibration of the segment representing the affected muscle, or over the site of exit of the involved nerve alternately on each side of the spine with the ball vibratode.  Much must not be expected where there is an abnormal laxness or flaccidity, usually with atrophy of paralyzed muscles denoting lesions involving the lower neurons.  For testing the motor power the reader is referred to Butler's Diagnostics of Internal Medicine.

    MUSCULAR RELAXATION, due to atony, is effectively treated by mechanical vibration and exercise.  In such cases, centripetal vibratory friction is applied below and above the origin and insertion of the muscle As well as over it.  The application of interrupted vibration with light or moderate pressure with the rubber-covered disc at the joints involved, will also assist in improving the general tone.  The distal part is treated first.  In these cases mechanical vibratory applications with moderate pressure should be made to the nerve centers as well.

    MUSCULAR WEAKNESS may be found in insufficiency of the adrenals or in intoxication from venoma, and vegetable and mineral poisons.  The cause should be removed, elimination promoted by light baths and static electricity, and as otherwise indicated.  The low blood pressure calls for mechanical vibration to raise it, and the weak heart should be stimulated.  Locally the muscles may be vibrated with the disc vibratode, centripetal friction being used to Promote the blood flow.

    MUSCULAR CONTRACTIONS are relieved by mechanical vibration applied to the joints affording attachments for the involved muscles, with vibratory compression over the contraction in combination with appropriate exercises.  Static sparks are useful.

    Spinal vibration over the source of the nerve supply of the affected muscles often lessens the contraction.  The vibration should be given with the ball vibratode for five or ten minutes alternately on each side of the spine over the vertebral exit or origin if necessary of the nerve involved with a few intervals of rest, moderate but firm pressure being used.  But little can be expected other than to affect the blood supply in cases where there is "an increased tonus usually without atrophy of muscles paralyzed so far as voluntary effort is concerned," which is significant of disease of the upper neurons.

    CONTRACTURES, "tonic muscular spasms of long standing, may be functional, - disappearing during sleep as in hysteria, - or organic characterized by not being affected by sleep, as in haemiplegia.  Contractures when functional may be treated by prolonged local vibration with the disc vibratode over the affected muscles and by spinal vibration with the ball vibratode between the vertebrae of the segments representing the muscles involved or over the site of exit of the affected nerve.  Sherrington demonstrated that by exciting its antagonistic muscle, the tonus of a voluntary muscle can be inhibited.  If this method is used in treating contractures use the disc vibratode over the antagonistic muscle or use the ball vibratode in the intervertebral space corresponding to the segment representing the antagonistic muscle or over the exit of the nerve involved.  The X-ray is of value in treating contractures following burns.

    IN TREATING SCOLIOSIS the cause should be sought and treated.  A thorough examination of the different organs locally should be made for diseased organs sometimes affecting the spine reflexly.  Employ interrupted vibratory pressure with the ball on opposite sides of the spine, using deeper pressure. on the side where the contractions are.  If necessary the nerve segments representing the contracted muscles or over the vertebral exits of the involved nerves may be given prolonged interrupted vibration with the ball vibratode.  Inhibit the contracted, and stimulate the relaxed muscles by interrupted vibration with the rubber-covered disc vibratode.  Carefully graded suitable exercises should follow.  Trunk stretching may be combined with short vibratory interruptions over the weak muscles on the convex side.  In some cases Abbott's method of straightening the spine is of great value.  These cases require a devotion of considerable patience and time, both to the treatment and exercise; for such exercises must be carefully directed and suited to the requirements of each case.

    WHERE THE MUSCULAR SYSTEM IS AFFECTED IN DISEASES OF THE NERVOUS SYSTEM, mechanical vibration oftentimes will be most effectively applied in combination with the auxiliary forms of treatment.  If the affection be such that the part under treatment has no power of motion, use passive motion as an adjunct. If there be slight but not complete motion use assistive movements.  If there be a superfluity of muscular force, as in spasmodic conditions, employ resistive movements, but not forcibly.  If stimulation of sensation, motion or circulation is necessary, employ interrupted vibration.

    SPASMODIC AFFECTIONS, as chorea, blepharo-spasm, wry-neck and abdominal muscular spasms, some of which are of nervous origin and are considered in the chapter devoted to the nervous system, are greatly relieved by vibration alone, or vibration in combination with corrected diet, hygiene, exercise, light, or electricity, particularly static electricity.  Spasms of the muscles near the spine may be connected with visceral affections.  A peripheral spasm may be independent of a spinal spasm.  The two are more apt to be found together when the affection is of long standing.

    WRY NECK, a tonic or clonic spasm of the muscles of the neck usually characterized by a "tonic contraction of the flexors of the head" may be greatly benefited by the application of interrupted vibration.  If the head moves "with each clonic spasm," the branch of the spinal accessory nerve which supplies the sterno-mastoid muscle is affected.  The sterno-mastoid and trapezium are represented in the medulla, second, third and fourth cervical segment.  "In spasms of the trapezium the head is drawn backward and to the side.  Stimulation of the outer branch of the spinal accessory (which communicates with the first and sometimes with the second cervical nerves) causes tonic or clonic spasms of the above named muscles (sterno-mastoid and trapezium) usually on one side."  Butler believes that the third cervical nerve is most apt to be involved when the upper cervical nerves are affected.

    Wry neck or torticollis may be:

    1. Congenital characterized by a drawing of the neck to one side and absence of spasm.

    2. Symptomatic characterized by tenderness and pain.

    3. Pseudo characterized by real or pseudo-spasm of the neck muscles, spinal caries being the common cause.

    4. Spasmodic which is of nervous origin, the upper cervical nerves or spinal accessory being
involved.  This may be due to a sudden chilling.

    A twisting of the head associated with contracture of the sterno-mastoid or of other groups of muscles concerned in the maintenance of the head in an erect position may produce a symptomatic [Goldthwait, Painter and Osgood. Diseases of the Bones and Joints, page 50] torticollis.

    The causes of torticollis may also be inflammation of the cervical or mediastinal glands, carious teeth suppurating middle ear, pediculi capitis, ocular defects, facial asymmetry, congenital contracture of the sterno-mastoids, vertebral disease, local syphilis, or tumors of the neck.

    The treatment should be directed first to the removal or palliation of the cause.  The fourth class as classified above, is sometimes amenable to vibratory treatment.  A very severe case that I had the pleasure of curing was of this type.  It was caused by sitting by an open window all night.  The arms were even jerked up spasmodically, so severe were the spasms.

    The method of treatment consists of the application of interrupted vibration on each side of the upper portion of the spine employing the ball vibratode in the interspaces from the occiput as low as the insertion of the trapezium.  Notice which points elicit muscular spasm and apply prolonged interrupted vibration with the ball vibratode to such parts.  It may be found necessary, if the spasm is not sufficiently controlled, to apply prolonged interrupted vibration over the involved muscles with the rubber-covered disc vibratode.  With a fair rate of speed and a stroke adapted to the parts treated apply interrupted vibration over the painful sites and over the motor points of the affected muscles of the neck.  In these cases painful spots are often found in the vicinity of the sixth and seventh cervical and first few upper dorsal vertebrae, as well as in the region of the first and second cervical.  Movements are often a useful adjunct to vibration.  Mitchell's [Cohen's System of Physiologic Therapeutics] movements which are as follows are recommended: "The ordinary movements of rotation, forward bending, and extension of the head are the needed procedures.  These are opposed by the attendant, who stands in front or behind the seated patient and places his hands on the sides of the head or clasps them over the frontal region, according to the action to be resisted, whether rotation or forward bending.  In attempting extension of the neck, which perhaps would be better described as simple elongation of the neck, the patient's effort is, while keeping the chin level or a little drawn in, to elevate the head as if he were trying to make himself taller.  Lateral bending of the head without rotation may be needed in certain cases (which the writer has found to be extremely useful as a passive and later as an active exercise).  The face must be kept directed forward, while the effort is made to bring the cheek down to the shoulder; and the attendant opposes either the depression or the return of the head according to the effect sought for."  Each movement should be repeated three to seven or even ten times, morning and evening, the number of repeated movements depending on the indications of the case, muscular irritability and fatigue.  Passive movements followed by active ones may be directed instead of the resistive movements.

    LOCALIZED MUSCULAR SPASMS, cramps, usually affecting the muscles of the calf of the leg, are best treated by prolonged mechanical vibration with the disc vibratode over the motor points of the affected muscles.  The interruptions should be few.  Care must be exercised that phlebitis is not the cause of the trouble, when the use of the 500 candle power incandescent light and the static brush discharge is indicated.

    LUXATIONS are best treated by the static wave current and the static brush discharge.  The result is the relief of pain and diminution of swelling, a rendering of the tissues soft which were tense and the gradual removal of ecchymoses, and prevention of stiffness and the consequent atrophy of disuse.  Mechanical vibratory treatment with the disc vibratode as an auxiliary measure assists in the prevention of stiffness and atrophy.  The combined treatment is very satisfactory.  Adapted and regulated movements may also be employed.  Mechanical vibration applied to a joint increases circulatory activity in the structures and lessens local stasis.  If vibratory friction be also applied centripetally above the joint the circulatory flow will be assisted.  If vibratory friction is applied above and below the joint, the flow of blood will be lessened in the joint and increased in the other parts vibrated.  The shoulder and hip joints, owing to their inaccessible relations are the most difficult to treat.  Dr. John Hilton has very aptly summarized the nervous supply of joint structures as follows: "The same trunks of nerves whose branches supply the groups of muscles moving a joint furnish also a distribution of nerves to the skin over the insertion of the same muscles, and the interior of the joint receives its nerves from the same source.  This implies an accurate and consentaneous physiological harmony in these various co-operating structures."  Vibrate the segment affected.

    A SPRAIN OR SWOLLEN AND PAINFUL JOINT is best treated by the static wave current and the static brush discharge as outlined by Snow [Currrents of High Potential of High and Other Frequencies, page 111] but if these measures are not at hand and mechanical vibration is used the method of treatment is as follows: Employ vibratory stroking centripetally above the joint, gradually beginning the strokes nearer and nearer to the joint.  Great care must be taken not to injure the tissues.  At first also use centrifugal stroking over the tissues beyond the joint in each case.  After applying vibratory friction with a rubber-covered disc vibratode above and below the joint, use superficial interrupted vibration on the joint.  Day by day as conditions warrant the vibrations may be gradually increased in strength, the pressure being slightly more.  Gentleness must always be exercised.  If the joint is very sensitive, derivative vibration should be used, the affected joint being gradually approached, day by day.  In this manner, local stasis and compression of vessels due to exudates may be relieved by promoting elimination of the exudates.

    The following movements, which have been successfully used by Graham, are suggested.  When no contraindications exist "in order to gradually increase the strength of the muscles, as well as the confidence of the patient to use them, there is nothing better than resistive motion, alternately resisting flexion and extension or other natural movements of the affected joint, while keeping the resistance less than the strength of the contracting muscles, so that the patient may not recognize any weakness."  Mechanical vibration may be used simultaneously with passive movements, combined with traction.  These movements should be given slowly and as the patient forcibly exhales air from the lungs.  Absolute rest should be prohibited.  The patient should be encouraged to use the joint after the first treatment, a Crepe Velpeau bandage or one of similar make is recommended for the support of the joint and the comfort of the patient in the earlier stages of the treatment.

    FLABBINESS OF THE MUSCLES AND A RELAXED JOINT with no marked symptoms may be treated by applying deep interrupted vibration with varying degrees of pressure around the joint and vibratory friction with a rubber-covered disc vibratode centripetally above and below the joint.  Then use active movements, followed by proper bandaging of the joint.  Resistive movements may also be found valuable but care must be exercised that resistive motion is not carried so far as to cause fatigue.

    IN CASES OF PERIARTICULAR AND CAPSULAR INDURATION AND THICKENING use deep interrupted vibration with a rubber-covered disc vibratode to the joint and vibratory stroking, followed by vibratory friction centripetally above and below the joint, particularly in conjunction with passive movements.  Tense muscles call for prolonged vibration with the disc vibratode.

    "Massage, " [Graham. Reference Handbook of the Medical Sciences, vol. IV] and better still mechanical vibration, "disintegrates newly-formed granulation tissue, removes the stasis which it has occasioned and presses the white corpuscles and transuded plasma into the lymph current: at the same time the newly-formed capillaries that feed this granulation tissue are ruptured and undergo retrograde metamorphosis, as well as the crushed mass, and thus the formation of connective tissue, and the subsequent change of this into cicatricial tissue which often
causes pernicious retraction, is prevented or limited.

    HYPERPLASTIC TISSUE, firmly organized and solid, like India rubber, and not sensitive to pressure, is probably non-vascular, owing to its pressure upon and obliteration of the blood vessels which formerly nourished it.  Dr. Graham regards the treatment of hyperplastic tissues unfavorably, but Billroth, Gottlieb and others claim that by "vigorous perseverance in manipulation, impervious blood- and lymph-vessels may be reopened and absorption of the adventitious tissue promoted."  Mechanical vibration, like massage, is contraindicated when solutions of continuity or anchylosis are present, or where there is danger of scattering infection.

    PERI-ARTHRITIS, particularly of the shoulder-joint, a subacute or chronic inflammation of the sub-acromial bursa and of the loose areolar tissue under the deltoid, with thickening and the formation of adhesions" resulting in or associated with neuritis with muscular spasm and limited motion, and also sometimes complicated with myositis, may be advantageously treated by the static wave current, static sparks, mechanical vibration and applied movements.

    MECHANICAL VIBRATION OF THE SHOULDER JOINT should include a spinal vibration with the ball vibra-tode applied between the vertebrae where the nerves representing the affected muscles have their exits as well as over their sites of origin.  Sometimes the inferior part of the trapezium muscle is contracted, in which case spinal vibration with the ball vibratode should also be applied in the intervertebral spaces of the lower dorsal region.  Spinal vibration when employed to overcome muscular tension should be continued for five minutes or longer with one or two short intervals of rest.  The trapezium for example, is supplied by the spinal accessory represented in the medulla and 2nd, 3rd and 4th cervical segments.  These nerves have their exits between the posterior arch of the atlas and the lamina of the axis, and between the 2nd and 3rd cervical vertebrae.  Interrupted vibration using the disc vibratode may be applied over the motor points of the involved muscles when necessary.  Attention must also be given to the muscles of the upper part of the arm as the triceps and the deltoid.  A most useful exercise in cases where there is difficulty in elevating the arm is to direct the patient to stand with both shoulders against the wall, and then the well arm should be raised until it is against the wall horizontally.  The attendant with one hand on the affected shoulder to prevent it from rising, should support the arm of the affected side at the elbow and gradually raise it and simultaneously bear the forearm back to the wall to correspond as nearly as possible to the position of the well arm.  This should be as far as the nurse is able to move it within the limits of the patient's endurance.  The arm should be so held until the nurse counts ten or fifteen, or twenty, according to the patient's strength.

    If the patient exhales air from the lungs as the arm is raised, the pain is lessened.  A second exercise includes shoulder lifting or circling with arms down, the shoulder being brought forward, upward, backward and to the initial position.  Passive motion in early cases should soon be followed by active movements.  In chronic cases, break up the adhesions under an anaesthetic, and treat the condition the same as a sprain or fracture, using vibratory treatment with the static current and sparks.  In using passive motion care should be taken that it is done very slowly and cautiously.  Painful movements are best performed during deep exhalations.  X-ray is used for adhesions.

    RHEUMATOID ARTHRITIS first demands an inquiry into the cause which is usually auto-intoxication associated with constipation and intestinal putrefaction.  High colonic flushings, daily at first, and later at intervals, are indicated with a restricted diet, limited principally to milk, buttermilk, zoolak, koumiss, toast and purees.  Later stewed or fresh fruits devoid of skins, and vegetables, except onions and cabbage, are allowed, animal food being excluded.

    Rheumatoid arthritis is best treated by radiant light and heat and the static modalities [Wm. Benham Snow. Currents of High Potential of High and Other Frequencies], - the wave current and sparks, in conjunction with mechanical vibration.  On days when light baths are not given hot or warm baths of five minutes' duration should be taken by the patient, preferably in the mornings.  In these baths Epsom salt may be used two or three times a week.  About two or three pounds of the salt should be used for twelve gallons of water.  The patient should be told to gently bathe the parts constantly while in the water to prevent a stickiness of the skin which sometimes occurs, causing a rash.  A sponge-off with warm water should follow.  These salt baths may be of ten or fifteen minutes' duration.  A local bath, in which is Epsom salt, of an ankle or knee is often beneficial.  The additional use of dry hot air is also often of benefit.  The combined method increases nutrition and the activity of the metabolic processes and removes pathological obstructions, - which are the local indications in rheumatoid arthritis.  Sometimes when the deformities cannot be removed the soft structures may be made to accommodate themselves to the changed condition.  The writer has followed this line of treatment in connection with the static treatment with marked results.

    Examine for spinal tenderness applying the ball vibratode on each side of the spine alternately.  The sites of tenderness usually correspond to the segments representing muscles, rendered tense by the joint involvement, or to the exits of the nerves of the affected muscles.  These painful sites should be vibrated with the ball vibratode for a number of minutes, it sometimes requiring five minutes to lessen the tension or contraction.  If the neck muscles are involved, vibrate especially between the 2nd and 3rd cervical vertebrae to affect the third cervical nerve.  Above and below the affected joints of the extremities employ deep interrupted vibration as well as about and on the affected joints, with stimulation of the next set of lymphatic glands nearest the trunk preferably with the rubber-covered disc vibratode.  The tense muscles about the joint should receive prolonged interrupted vibration with the disc vibratode.  If the hand is affected, the treatment is the same as for stiffness of the hand and the muscles of the arm and forearm as well as of the elbow joint should be vibrated.  In the beginning cases, mild interrupted vibrations of long duration with a rubber-covered disc or cup-shaped vibratode applied over affected joints of the hand, it being closed, and over the wrist and forearm and elbow joint afford considerable relief by relieving the muscular tension.  Care must be taken to steady the vibratode in order to avoid too great friction on the skin.  Passive closing of the hand should be followed by prolonged active closing with short active opening of the hand.  If the knee is affected, the muscles of the thigh and leg should be similarly vibrated.  Follow this with passive and later resistive and active movements.  If the pain resulting from motion gradually disappears within half an hour, such exercise is not contra-indicated.  If, however, the pain persists, the movements should be diminished in number and extent, or they may be stopped for a time.  Passive and active exercises, consisting of opening and closing the mouth, following the application of mechanical vibration with a rubber-covered disc vibratode to the temporo-maxillary articulation, are effective for overcoming contractions of the temporal, pterygoid and masseter muscles.  A limited amount of exercise out doors if the weather permits, is essential to the welfare of these
patients.  Absolute rest means fixation of joints, atrophy of the muscles, and eventually a helpless patient.  Fresh air and sunshine in a dry climate are beneficial, but they will not care the disease.

    IN THE AFTER TREATMENT OF JUXTA-ARTICULAR FRACTURES, mechanical vibration with appropriate exercise, followed later by active exercise, applied immediately after the removal of the plaster cast, will remove oedema, relieve stiffness and lessen sensory disturbances.  Prolonged interrupted vibration with the ball vibratode should be applied between the transverse processes of the spine where the nerves of the involved muscles have their exit-S.  Interrupted vibration with the disc vibratode is also applied about the joint where motion has been limited by the fracture, to the contracted muscles should also be applied prolonged vibration especially over their motor points.  Radiant light and heat when used should precede the vibratory treatment.  The static wave current and well-directed sparks are as a rule indispensable in most cases of arthritis.

    The earlier the institution of treatment, the quicker and better the result.  Vibratory treatment diminishes the swelling, increases the nutrition of the muscles, prevents the adhesion of inactive tendons in their sheaths, and shortens the period of repair.  The relief of pain or the discomfort of fatigue occasioned by the treatment should govern the length of each treatment.  Following fractures, particularly, exercise is used as an adjunct, both passive and active, but should not be brought into service until a good union has taken place.  The aim as in massage should be "to move the neighboring parts but to keep the broken bone still" while enhancing its nutrition.  We should base our employment of mechanical vibration on what has been done by noted surgeons, such as Mm. Championniere, Tripier, Rafin, Marevery, Landerer, Franks, Tilanus and Wagner.  Manual massage was used in intra- and para-articular fractures.

    Mechanical vibration is indicated over the site of fractures and over the centers controlling the blood supply in cases of INCOMPLETE OR DELAYED UNION.  Apply mechanical vibration to induce hyperemia in cases of FIBROUS UNION where "absorption and attenuation of the ends of the fragments, or eburnation has not occurred, and where there is no constitutional dyscrasia."

OEDEMA FOLLOWING FRACTURES may be promptly relieved by vibratory friction centripetally applied over the muscles and interrupted vibration with, moderate or heavy pressure about the joint and over the glands.  In such cases elevate the limb, the hand or foot being the highest.  Dust the surface to be treated with talcum powder to facilitate the administration of vibratory friction.  First vibrate the lymphatic glands nearest the trunk.  Centripetal vibratory friction of the muscles of the part beyond should follow.  Interrupted vibration of the joint below is then given.  This method is followed, the parts being treated from the trunk to the extremity in order, until the entire limb has been vibrated when a short vibratory friction from the extremity to the trunk may be given if deemed necessary.

    The rubber-covered disc vibratode is the best for such cases.  Vibratory treatment will also relieve other oedemas temporarily or permanently, depending on their cause.  In oedemas resulting from kidney, heart or liver affections, or thrombosis, the relief will be but temporary.  Care must be taken in relieving oedema that the removal of the local infiltration does not overtax the heart, kidneys or lungs.

    AFTER BREAKING UP ADHESIONS the indications are vibratory and static electrical treatment, at first associated with passive movements, later to be followed by gradually increasing active exercise.

    IN STRUMOUS SYNOVITIS apply interrupted vibration over involved muscles, the joint being treated by light and d'Arsonvalization.  Passive motion should be begun with the cessation of inflammation, but should be used with care.  An indurated condition of the swelling, shown by pain and tenderness, any considerable amount of degeneration, infection, shooting pains and tenderness of the joint surfaces contra-indicate passive motion.  More rapid progress can be made in using passive motion, when the joint has a certain fixedness, if the movement be then made gradually and tentatively, directing the patient to take deep breaths and making the increased movement when he exhales.

    HICCOUGHS - SINGULTUS - are "due to a spasmodic contraction of the diaphragm, causing an inspiration, which is arrested by the sudden closure of the glottis so that a characteristic sound is emitted.  Not infrequently it is due to irritation of the gastric membrane and sometimes it is a very troublesome symptom in uraemic poisoning."  It occurs in visceral disease of the abdomen as gastritis, in some diseases of the nervous system as epilepsy, and hysteria, and apparently in some constitutional conditions, as typhoid fever, gout, nephritis, diabetes and diaphragmatic pleurisy.  Mechanical vibratory treatment is oftentimes of great value in some forms of hiccoughs.  A case worthy of special mention is that of a patient who had had hiccoughs for a year, and was finally successfully treated by Dr. House.  In this case there was "pain in the epigastrium along the costal arch, especially over the right side."  Drugs and other treatment had proved of no value.  An examination of the patient previous to the institution of vibratory treatment showed "marked irritation at the right sacroiliac synchondrosis, causing marked contraction of the quadratus lumborum muscle (a muscle of inspiration).  Following up the. course of the muscle to its attachment to the last rib, it was found that irritation of the diaphragm was conveyed reflexly through this means.  The other points of reflex irritation were at the twelfth dorsal and fifth lumbar spinal nerves."  The brush (multiple point vibratode) was used "over the affected areas, and also over the diaphragm" with success.  The author has had a similar case.  The nervous supply of the diaphragm is the phrenic which Gowers believes can be reached at the 4th cervical vertebra where prolonged infrequently interrupted vibration with the ball vibratode may be given.

    OBESITY [Sajous. The Internal Secretions and the Principles of Medicine, page 1867] BEING "due to deficiency of adrenoxidase and pancreatic ferments in the blood owing to functional debility of the adrenal system, the carbohydrates being inadequately broken down, fat accumulates in the subcutaneous and subserous and other tissues."  The indications are to increase catabolism.  Diet is restrained especially as to quantity.  Small doses of thyroid extract, 2 to 3 grains t.i.d., may be used if deemed necessary.  Saline catharties or flushings are often essential to the treatment.  A general vibratory treatment including an abdominal vibratory treatment, using heavy vibration, in combination with d'Arsonvalization, prescribed exercises, and walks of definite distances to meet conditions, usually give results.  The static induced current or Nagelschmidt's high frequency apparatus are sometimes used.  In any treatment involving tissue combustion, such combustion provoked must not be too rapid as toxaemia results from the throwing off of the wastes into the circulatory system.  This must be provided for by keeping open the bowels and all channels of elimination.