Articles On Manual Therapy
WHAT FINGER SURGERY IS, AND WHAT IT WILL DO
by M. L. Richardson, D.O., Norfolk, Va.
[Note: This paper was read before the Osteopathic Society of the
city of New York at the Waldorf Astoria Hotel, December 16, 1926]
The nose with the paranasal sinuses
and postnasal spaces appears to me an area of unusual anatomical
features and of compelling clinical interest to all practitioners,
for, from the cradle to the grave, the nasopharyngeal district
is subjected to recurrent severe inflammatory reactions which
for frequency and violence have no parallel in any other part
of the body.
It is a district surrounded by
highly important structures, some of which are submucous, some
separated only by thin porous partitions, and some communicating
by open passages.
Many of the anatomical features
I have in mind are self evident as soon as thought is turned to
them. Some others are perhaps not quite so generally known
as their importance deserves.
Although the nasal cavity is
of considerable size its parts are so arranged to provide broad
surface area, that the open spaces are mere slits and the opposing
surfaces all but touching. Into these narrow passages
the nasal accessory sinuses open all by small ostia. In
the cases of the sphenoid and maxillary sinuses the ostio are
so placed that these sinuses have no gravity drainage. The
prominence of the nose and its frail structure exposes it to early
and frequent injury. In fact its anterior septum is probably
dislocated from the pre-maxillary bones frequently in its course
through the birth canal, imposing deformity on these narrow passages
to complicate inflammatory reactions.
The mucous membrane lining of
the nose and sinuses is very closely applied to the periosteum,
exposing the periosteum and the bone to surface influence in a
manner not paralleled anywhere else in the body. This is
significant, for bone changes are a part of all chronic nasal
pathology. Elsewhere in the body the periosteum is covered
by loose connective tissues which acts as a barrier against considerable
inflammation in the surrounding tissues. The quantity and
distribution of the erectile tissues in different noses varies
About the pharynx I would particularly
mention that its back wall is applied to the anterior surfaces
of the first four cervical vertebrae; of the presence here of
the tonsillar or lymphatic ring, extending from the pharyngeal
tonsil downward on either side to meet again at the lingual tonsil,
surrounding the postnasal and oral spaces, and the only place
in the body where lymphoid tissue comes to the surface and is
directly exposed. I believe the arrangement of this lymphoid
tissue is clinically and pathologically important. The ring
arrangement is constant. In some heads the lymphoid tissue
is quite limited to the ring; in others there is in addition a
vast amount spread generously over the pharyngeal wall, inside
and outside of this ring. The Eustachian tube opens into
the pharynx in the band of this tonsillar ring.
This vast labyrinth extending
from the tip of the nose to the spine behind, from the roof of
the mouth to well above the orbits and laterally to the malar
bones, tympanic and mastoid cavities, lined throughout by one
continuous mucous membrane, and holding the record over all parts
of the body for the frequency and severity of its inflammatory
reactions, is by itself of the highest clinical importance.
This is magnified many times by important structures lying (according
to the text books) outside of its boundaries, and yet separated
from its cavities and pathologies by such thin porous partitions,
that only by miracle can they escape serious insult – in fact
they do not escape.
All of the cranial nerves leave
the base of the skull through close fitting bony foramina.
Of the first six some are constantly, and the others sometimes,
in contact with a sinus wall, separated from its mucous membrane
by a porous shell of bone of paper thinness. That these
nerves are accessible to influence from nasal and sinus disease
is established clinically and experimentally.
The sphenoid sinus often extends
laterally to completely surround the optic foramina, and it is
well established that sphenoidal bone disease has gradually closed
the foramina, strangled the nerve and caused blindness.
The maxillary nerve is in contact
with the wall of the same sinus, and a drop of cocaine dropped
into the sinus – not injected submucously – is quickly absorbed
through the thin partition
of bone and will completely paralyze the entire nerve trunk.
Like exposure of other cranial nerves and ganglia could be adduced
but time prohibits and these are illustrative.
These nerve complications are
greatly increased by the situation submucous in the nasal wall
of the sphenopalatine or Meckel's ganglion. Sometimes only
2 mm and never more than 9 mm under the surface membrane.
And further by the otic ganglion in the close apposition to the
wall of the Eustachian tube.
These ganglia with their cranial
and sympathetic connections link up the first six with the rest
of the cranial nerves and with the cervical sympathetics, establishing
a network involving the special senses of sight, hearing, taste
and smell; the sensation of the head, face and neck; the motor
impulses of expression, voice, deglutition, hearing, and ocular
accommodation; and the entire sympathetic system of the head,
neck and thorax. In no other part of the body is such a
network of nerves and ganglia so exposed to surface influence.
The acute conditions of this
district first come to the general practitioner as is proper and
best. Your treatment is superior to any therapy for shortening
these inflammatory reactions and
preventing adhesive processes so likely to result from long continual
inflammation and which become permanent points of sympathetic
irritation, and mechanical embarrassment to subsequent inflammations.
Under your care these cases usually make uneventful recoveries.
The inflammation subsides, discharges disappear, the breathway
is open and the patients are all right until another infection.
Somewhere along the line chronic
processes start, we do not know just where; in fact the relationship
between the two, acute and chronic, is not clearly established.
We know quite certainly that pathology starts in the soft tissues
and later involves the bone.
The chronic conditions are largely
hypertrophies and hyperplasias, of both the soft tissues and of
the numerous and extensive paper-thin body partitions which support
them. When once established we know also that these chronic
conditions run their course quite independent of the inflammatory
attacks. Between the coryzas or other attacks when the inflammation,
swelling and discharge have completely cleared up, so far as the
patient is aware, the deeper chronic hyperplastic changes go on
This is an important point and
knocks in the head at least one popular notion. The freedom
from abnormal nasal or postnasal discharge is not a safe criterion
of health in this region. there are many conditions here
called collectively "catarrh" which have an excessive and modified
discharge, being surface or mucous membrane conditions they all
excite and modify the secretions. These conditions may,
and often do co-exist with deeper hyperplastic processes.
And these deeper conditions may, and often do exist without any
discharge of which the patient is aware.
Serious and disabling diseases
here develop and progress in patients who boast of never needing
a handkerchief, who will assure you that their breathway is always
free and open, and that they rarely have a head cold. A
searching history will usually reveal that they have had their
share of these in earlier life.
Local symptoms being wanting
or minor in many of these conditions, we are justified in ordering
a complete examination of the district in all cases which do or
may suggest involvement of the cranial nerves or ganglia or sympathetic
associations; including facial, cervical and brachial neuritis
and neuralgia. Tic douloureux, optic neuritis and atrophy,
headaches, especially the low grade unending type, the sub-occipital
type, migraine, vertigo, head-noises, deafness, hay-fever – seasonal
or perennial – bronchial and hay-asthma.
Many bold and ingenious surgical
procedures have been devised and executed in this region for the
relief of its many conditions. I pertinently remind you
that most of this has been executed in the nasal cavities and
its accessory sinuses; that beyond being confined to the pharyngeal
tonsil (adenoids) and the palatine tonsils, the gross pathology
of the rest of pharaynx, the epipharynx, and the tubotympanic
areas, although intimately known, has practically escaped the
pansurgical age, and, as a matter of fact before the advent of
Finger Surgery had never met with treatment that was any match
for its pathology.
That the surgery of this region
in competent hands has been a boon to the occasional sufferer
we cannot deny. That it has been unsatisfactory, and even
a complete failure, in the vast majority of cases you bear witness
to in your daily practices. Especially is this true of nasal
and paranasal surgery, where the progressive hyperplastic conditions
occur and which gradually involve the cranial and sympathetic
systems with such disabling results. Even the leading proponents
of that system admit it is only palliative, that it is not curative,
that the deeper pathology is inaccessible, that it is inoperable
even if it were accessible, that the best they can do is sacrifice
parts by removal to provide room for the remaining pathology to
develop outward and that the remaining pathology completely ignores
this surgical accommodation, will not back-up, and disports itself
after, just as before according to the laws of pathology.
It is because of this and of
other considerations about to be mentioned that I ask your serious
attention to Finger Surgery.
Finger surgery is not the ju-jutsu
of grabbing the world by the throat and trying to choke a living
out of it. In a few words it is the application of lesion
osteopathy to the base of the cranium, to the twenty-four cranial
nerves which leave its base through close fitting bony foramina,
which twenty-four nerves with their ganglia and sympathetic associations
represents a vast part of the human physiology. Carries
lesion osteopathy, through its only avenue of approach, to an
important system of nerves whose trunks are independent of, and
remote from the spinal intervertebral foramina, reaches them here
directly whereas from the spine they can be reached only reflexly.
The course pursued by pathology
in this district is quite different from that generally accepted
for the spinal district. Around the spine we are agreed
that the pathology of the lesion starts at or near the intervertebral
foramina. If this were so of the basal foramina of the skull the
cranial nerves would perhaps be hopelessly involved. It
is well established that head pathology begins as a surface condition,
penetrates deeper and deeper to finally involve the basal foramina.
Likely the earliest attacks upon the cranial nerves is by absorbed
toxins or products of inflammation, next by the pressure of swollen
parts, or by inflammation, and lastly by the encroachment of hyperplastic
The starting point in the surface
elements is not so well agreed upon. It is my opinion, based
upon study and clinical experience, that the lymphatic ring surrounding
the post nasal and oral cavities takes the primary and oft repeated
insults. That the varied clinical and pathological courses
from then on is determined somewhat by the arrangement of this
lymphoid tissue. I have reminded you that the ring arrangement
is constant, that in some heads, the lymphoid tissue is limited
to the ring, while in others there is considerable lymphoid tissue
widely diffused throughout the pharynx both inside and outside
of the ring, and that there remain all gradations between these
From these anatomical variations
it appears to me that in those cases where the lymphoid tissue
is limited to the ring, future developments depend upon lymph
stagnation, while in those cases having considerable lymphoid
masses beyond the confines of this ring there is more low grade
inflammation of soft tissues with venous stagnation, that the
district is then flooded by a combination lymph and venous stasis.
I note but do not explain this. Every important structure
in the head drains through this lymphatic ring and the veins adjacent
Clearly then I recognize the
lymphatic ring as the key to the restoration of nose, throat and
ear health. I attribute much of the success of Finger Surgery
to the fact that in the majority of cases it can completely restore
this ring structurally and functionally. In the upper half
of the ring by the use of the fingers only, which by well regulated
and directed force will destroy hypertrophied tissues without
injury to the healthy, the devitalized tissue disappears, leaving
a clean healthy mucous membrane. It is very rare that this
is not completely successful in competent hands. The rare
exceptions in my experience are old adenoid masses which have
degenerated into a resistant fibrous mass, and a few times I have
found them seemingly cartilaginous – these I have clipped with
an adenotome and crushed the stump to prevent scar formation.
Of course the complete ring must
be restored at the same time. The lower half comprises the
palatine and lingual tonsils. The palatine tonsils become
chronically involved because of peculiar anatomical relations.
Wedged in between the faucial pillars, and with its oral face
partly covered by a plica which may be anything from a mere linear
suggestion to a complete annular collar. Normally the tonsil
is freely movable in this muscular pocket, the actions of which
in swallowing express the contents of the crypts. Repeated
inflammations cause adhesions to form between the tonsil and the
plica and faucial pillars. It is no longer freely movable,
the crypts are blocked and the normal cleaning motions no longer
act. These adhesions can be severed, the tonsil completely
freed, and the cryptic matter aspirated out. If kept clean
and the adhesions prevented from reforming until healing is complete,
the tonsil will shrink to normal size quickly or slowly depending
on whether the enlargement was lymphoedema, inflammatory, or hypertrophic.
After involution has taken place, the depth of the crypts has
shrunk to half or less and they become self draining – any that
do not can be incised and obliterated. Occasionally a large
plica, and particularly an annular one must be partly trimmed
away. I have treated very few tonsils that this technique
had not been completely successful with. One case was examined
by an old school specialist (out of curiosity) two years later,
while examining the patient for glasses, and he informed the lady
I had taken her tonsils out whether she knew it or not.
While restoring to the structural
integrity of the lymphatic ring it is urgent that the lymphatic
and venous drainage be mechanically helped by manipulation of
the main trunks in the anterior neck and by stimulation of the
With the functions of the lymphatic
ring reestablished by lymphoedema congestion and swelling of everything
above – the nose, epipharynx and tubotympanic region - is much
reduced and Finger Surgery of the upper spaces thereby simplified.
Hypertrophied tissues in these parts is then destroyed again by
digital pressure which will not harm healthy tissue, turbinates
and septums which have been displaced by soft tissue pathology
or traumatic injury are adjusted, adhesions severed, and the patency
of the Eustachian tube restored, ventilation and drainage to the
paranasal spaces and middle ear recovered and a gradual and permanent
improvement to the entire head results.
I have not cut a turbinate in
three years and do not expect to again. Acute polypi of
the nasal chambers will vanish under this treatment, the chronic
polypi in my experience must be snared or cut away. I have
never found the extirpation, or removal of the whole ethmoid region,
as practiced by old school rhinologists necessary.
The deep hyperplastic bone conditions
which are so disastrous, and which, as I have said, admittedly
do not yield to any medical or surgical procedure, I have watched
under Finger Surgery very carefully and I believe they are yielding.
I base my belief on clinical and experimental evidence, rather
than on microscopic tissue specimens. The thin nasal bones
are elastic and bend to moderate pressure much as would a fresh
piece of celluloid. When hyperplastic changes have taken
place they become as rigid and unyielding as glass. I have
many times seen this elasticity return several months after clearing
up the soft tissue pathology of the nasopharyngeal district.
One case particularly astonished me. He was 77 years old
when I operated for catarrhal deafness and hay fever. In
about a year a fair amount of elasticity was palpable in the nasal
septum and turbinates, and has remained to this day - four years
later. I take this, and the experience in other cases to indicate
that with circulation, ventilation and drainage normalized, the
conditions on which hyperplastic processes feed are gone and that
the progress is not only stopped but that Nature by involution
has absorbed the excess bone salts. This to me is the most
convincing vindication of the osteopathic concept that it has
ever been my pleasure and privilege to witness.
Finger Surgery is a moderated
surgery. For its successful practice one must know his anatomy
surgically, be equipped to examine parts as thoroughly as up to
date methods permit, realize that he has made of his fingers surgical
instruments and that he must use them with the same care and precision
as he would the sharpest scalpel, and be surgically clean in all
operative and treatment procedures.
By its own nature it imposes
certain limitations to its practice and which are beyond individual
control: A No. 10 finger should never enter a No. 5 nares
or a No. 5 tube. Even hands that are adaptable cannot reach
digitally the nasal attack, the paranasal cells or the upper end
of the Eustachian tube, unless the Finger Surgery of the larger
and lower spaces, and which has corrected the grosser pathologies,
is supplemented in these higher and smaller spaces by accurate
and nontraumatic instrumental and applicator technique its best
efforts will give only partial or negative results. It must
also in occasional instances have some support from minor surgical
In proper and qualified hands
Finger Surgery is safe. Can be depended upon to give results
in the conditions mentioned, results that are permanent.
Without the danger of hemorrhage, without the production of scar
tissue which so often is the source of new reflex disturbance,
and without the sacrifice of parts which are so essential to healthy
functioning of the nose, throat and ears.