Articles On Manual Therapy

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 considerably.

    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 progressively.

    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 bone production.

    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 extremes.

    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 to it.

    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 cervical sympathetics.

    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 procedures.

    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.