Applied Anatomy of the Lymphatics
F. P. Millard, D.O.
         John H. Bailey, D. O. Philadelphia, Pa.
Lymphatics of the Nose

    Except in the olfactory area, the nasal mucous membrane is characterized by ciliated columnar epithelium, interspersed with goblet cells that secrete mucous.  Beneath the basement membrane of the epithelium is a layer of adenoid tissue that is particularly plentiful in children, and beneath this again is a layer of mucous and serous glands of variable sizes with ducts opening upon the surface.    The fibrous stroma is dense in the deeper parts and forms the periosteum which is not firmly attached to the bone, but is quite easily peeled off.  This must be guarded against.  The cilia or hairs of the columnar cells act as scavengers, sweeping away debris, dust, bacteria, etc., that have been trapped by the moist surfaces during the whirling of the inspired air.  When the columnar epithelium is destroyed by atrophy, accident, electricity, or operation, it does not form again, but is replaced by squamous epithelium which does not moisten and sweep away the debris, resulting in the constant forming of crusts within the nose.

    The mucous membrane of the nose is continuous anteriorly into the frontal, and maxillary sinuses and the anterior ethmoid cells, posteriorly into the posterior ethmoid cells and the sphenoid sinus, and it furthermore continues up through the lachrymal duct and is reflected over the eyelids and eyeballs as the conjunctiva.  Posteriorly, also, it is continuous with the mucous membrane of the pharynx, Eustachian tube, middle ear, inner lining of the tympanum, mastoid cells and accessory cavities of the ear; also into the larynx, trachea, bronchi and alveoli; also into the esophagus and on through the entire gastro-intestinal tract, the pancreatic duct, the common bile duct and into the pancreas, liver and other accessory gastro-intestinal glands, into the intestines, appendix, colon, and rectum.  Hence any infection of the mucous membrane of the nose can involve almost any organ in the body.

    The nasal lymphatics lie just beneath the epithelium, forming a diffuse adenoid tissue, infiltrated with lymph-corpuscles, which, no doubt, helps to account for the marvelous destruction of bacteria by the nasal mucous membrane.  The lymph is drained partly into the retro-pharyngeal glands in the upper lateral pharyngeal wall in front of the axis, and partly into one or two glands which lie near the great cornu of the hyoid bone, and from all of these into the upper deep cervical glands.  Obstruction to lymph drainage reduces the nasal immunizing power and leaves the body an easy prey to any air-borne infection.

Tuberculosis Prevented by Healthy Nose

    It has been shown by St. Clair, Thomson and Howlett, that whereas the front of the nose contains numerous microorganisms, none are to be found in the posterior regions of 80% of normal noses; or, more strictly, none which are capable of growth upon the ordinary laboratory media.  For practical purposes, at all events, one may say that inspired air which has passed through the nose is clean as well as moist, and that a healthy man possesses in that organ, a protective apparatus which relieves his lungs of all sources of danger, so far as the air inhaled through the nose is concerned.

    Air-borne bacteria gain entrance to the body by way of the respiratory tracts.  If the nose is normal there will be no tuberculosis.  If the public press would start now and educate the masses as to the proper use of the nose, and if in all schools of learning, public and private, time were devoted to educating the rising generation to the point of using the nose properly and thus keep it in good condition, we would have no great white plague, nor any other infectious diseases.  For years we have had it drilled into our heads by the medical profession of how important our lungs are and what to expect if tuberculosis enters them.  How can the lungs delop if the breathing apparatus, nose, etc., is not working properly?

    Catarrh, deafness, headache, bronchitis, gastritis, lack of development of body and mind, and a host of other abnormal conditions, are in the vast majority of cases primarily due to improper breathing.

    Every attack of smallpox, typhoid fever, acute articular rheumatism, epidemic influenza (la grippe), erysipelas, measles, diphtheria, infantile paralysis, cerebrospinal meningitis, tonsillitis, bronchitis, pneumonia, hay fever, catarrh and other acute infections, begins with a cold in the head.

    Tell your patients to bring their children in for treatment as soon as they have the first signs of a cold.  Nearly all acute infectious diseases begin with “a cold in the head,” and they never develop, if the “cold” is treated at once.  Medical men will laugh at this statement.  They cannot do anything for a cold.  Yet hundreds of cases are on record of children that have entirely escaped children’s diseases because the defensive mechanism of the nose is normal and hundreds of cases of children’s diseases are aborted every year when the nose is normalized and kept so.  The first appearance of a watery discharge from the nose is the danger signal.

Suppurative Rhinitis a Serious Symptom

    There is pus in the sinuses in the later stages of acute coryza; in chronic nasal catarrh; accompanying syphilitic, gonorrheal or tuberculous processes in the nose; during diphtheria, influenza, and the other specific exanthematous fevers; and in a number of rare conditions which it is well to look up in Ballenger and other authorities.  This pus is discharged into the nasal passages and it is essential that both nasal cavities be thoroughly examined in a direct light by means of a speculum and head mirror to determine the source of the pus, specimens being taken for bacteriological examination when necessary.

    The frontal sinus, maxillary sinus, and anterior ethmoidal cells open into the middle meatus through the infundibulum and semilunar hiatus and drain on to the upper surface of the inferior turbinate.

    The posterior ethmoidal cells open into the superior meatus and drain onto the upper surface of the middle turbinate.  The sphenoidal sinus opens into the upper, back corner of the olfactory fissure, between the septum and the superior turbinate.

    There may, however, be a closed empyema in any cavity, and there is also great variation in the drainage, from normal free drainage to closed cavity.  Closed pus cavities may demand operation.  Diagnosis is by transillumination, or X-ray.  There is danger of the infection spreading to the meninges and cranial cavity.  The accessory sinuses are usually found to be involved in chronic rhinitis, and are always involved in suppurative rhinitis.  The region beneath the Middle Turbinate is called the storm centre because the anterior group of nasal accessory sinuses drain into this region.

Wonderful Mechanism of Drainage in Normal Sinuses

    When normal the nasal accessory sinuses are capable of self-drainage in the following ways:

    1.  The lining mucous membrane is composed of ciliated columnar epithelium, the motion wave of the cilia being always directed to the ostium, or opening into the nasal fossa, and the quantity of secretion being just enough to keep the mucous membrane moist.

    2.  They all drain toward the median plane, so that in lying with the head turned to one side, the sinuses in the upper side drain more readily with aid of gravity and the sinuses on the lower side tend to drain more slowly.

    3.  Each sinus drains most readily when the position of the head is such that the lowest portion of the sinus is its ostium; namely:

        (a) In the erect position, standing or sitting, both frontal sinuses.

        (b) On lying down on the back, both maxillary sinuses.

        (c) On lying face down, forehead lower than chin, both sphenoidal sinuses.

        (d) The ethmoidal cells may drain directly into the nasal cavity, into the frontal sinus or into one another, and their drainage may therefore be simple as the frontal, or it may be very complicated.

    The Edwards technique is today proving its efficacy in the hands of osteopathic physicians all over the country, in a remarkable variety of eye, ear, nose and throat conditions.  Not only the profession but the public, owes Dr. Edwards a debt of gratitude for the wonderful work that he has done along this line.

    The connection between a “cold in the head” and the acute exanthemata, has never been properly brought to the attention of the public.  You should post yourself thoroughly on this point.  It will save you many a patient who would otherwise, perhaps, shift to an allopath with the advent of acute disease.  It will also establish you as an authority in the minds of your patient.  It will save many a child from serious disease, impairment of faculties, distressing sequelae, and even untimely death.  Your duty is plain.

A Normal Pharynx is to the Child What a Normal Nose is to the Adult

    (a) Adenoid tissue is connective tissue like that forming the lymphatic glands.  It consists of a network of fibres in the meshes of which lodge lymphoid cells.  Bear in mind, that in early years, up to the age of puberty and in some cases beyond that age, the child depends in great part on the adenoid tissue of the pharynx to protect it against the exanthemata, and other infections.

    (b) As the child approaches adult life the nose takes up the burden when the adenoid tissue in the pharynx atrophies.  It is, therefore, of prime importance in children that the arterial blood supply, the venous drainage and the lymph drainage of the pharynx be thoroughly free and unobstructed.  Any obstruction in the pharynx will obstruct the lymph drainage from the nose, will react on the vagus and other nerves and the superior cervical sympathetic glanglia and cause a variety of distressing symptoms in every organ of the body.  On the other hand, there is scarcely a disease of any consequence in which the pharynx is not involved.  It may be inflamed by all pathogenic organisms, whether borne by air, food, water, blood or lymph, may show mucous patches, gummata, cancer, tubercle, abscesses; is involved in all the exanthemata, in nasal condition, in nervous conditions, in heart disease, in kidney disease, in diabetes, in systemic toxemias, etc.

    When children are threatened with any of the exanthemata there is always congestion in the regions draining the pharynx, due to the increased activity of the phagocytes destroying the invading bodies, coupled with muscular contractures and bony lesions in the cervical area, the hyoid, mandible, clavicles, etc.  As long as the drainage is free, the child does not contract mumps, measles, scarlatina or any of the exanthematous fevers.  It is only when obstruction has provided the invading virus with a suitable culture medium, free from pure blood, that disease can gain ascendency in the child’s pharynx, nose, lungs, stomach, etc.  Always examine every patient for obstruction to the drainage of the pharynx and free it up when necessary.

Drainage of the Pharynx, Nose and Ear

    The retropharyngeal lymphatic glands on each side are placed in front of the atlas and axis, behind the upper back corner of the pharynx, upon the rectus capitis anticus major muscle.  They receive lymph from the nasal fossae and accessory cavities, the nasopharynx and Eustachian tube and probably the middle ear.  They drain into the internal group of upper deep cervical glands, which lie directly upon or close by the outer border of the internal jugular vein beneath the sternomastoid muscle forming a chain along the front, side and back of the internal jugular vein from the mastoid process of the temporal bone to the point where the omohyoid crosses the common carotid artery opposite the cricoid cartilage.  The glands of the internal group communicate freely with each other and with the external group which lies behind and external to the internal jugular vein in the same region, draining the external regions of the side and back of the head.  The internal group receives lymph from the retro-pharyngeal glands, mentioned above, and also from the parotid, subparotid, submental glands, the palatine tonsils and submaxillary glands, the superficial and deep anterior cervical and recurrent glands, and from the nasal fossae, nasopharynx, soft palate, roof of the mouth, tongue, larynx, thyroid gland, trachea and esophagus (cervical region); in a word, all the important structures on, within, or adjoining the mucous membrane of ear, nose, pharynx and cervical portions of the respiratory and digestive tracts.  This shows the extreme importance of free drainage.  The internal group terminates in the jugular trunk, which on the right side, helps to form the right lymphatic duct or empties directly into the junction of the internal jugular and subclavian veins, and on the right side into the junction of the veins or into the thoracic duct.

    Treatment to promote drainage consists in deep manipulation of the tissues beneath the mandible and the sternomastoid muscle.  Nearly every patient requires this treatment.  Glands may enlarge because of inflammation, injury, new growth, bacterial invasion, cancer, secondary syphilis, disease of any of the tissues drained or regurgitation, causing pressure on important nerves, arteries, veins, etc.
    There are eight tonsils: The two faucial or palatine tonsils, to which the word tonsils is frequently limited, though strictly it should include also the lingual tonsils, at the base of the tongue, (described in Gray under tongue), the adenoid or pharyngeal tonsils on the upper part of the posterolateral walls behind the fossae of Rosenmuller and the tubal tonsils surrounding the Eustachian orifices.

Osteopathy for School Children

    Ear, nose and throat affections would rarely occur if the colds and diseases of childhood and adolescence were properly looked after in the beginning.  Osteopathy gets astounding results in these even when of long-standing.  In nearly all cases when osteopathic treatment is given before great structural changes have taken place, the child is restored to a practically normal condition, is mentally and physically efficient, and is saved years of discomfort.

    Children should not be sick.  And they would not be sick if their noses, throats and mouths were kept normal, and due attention given to diet and hygiene.  All infectious diseases are propagated via the nasal, oral and pharyngeal secretions.  Therefore, (1) No child with “running nose” should be allowed to play with other children, because the nasal discharge may be charged with virulent disease; and (2) Any child with nasal discharge, hoarseness, or other symptoms of sore throat should receive expert attention at once.  A child can readily be trained to do its breathing exercises, take the nasal douche and gargle the throat, by simply making sport of it as if it were a game.  Care must be taken not to frighten the child.

Normal and Abnormal Adenoid Tissue

    With the anatomy of the pharynx well in mind we will briefly review the function of the lymphoid tissue forming the tonsillar ring.  Formed by a special development of the mucous membrane, and characterized by an infolding of the epithelium into pockets or crypts, this tissue has engaged the attention of many investigators without definite determination of its exact function.  However, we know that it is always there normally, and presumably it is there for a good purpose.  Other vital organs whose function is not definitely known are the spleen, thyroid, thymus, pituitary and adrenal glands.  These adenoid or tonsillar masses do not look like remnants of ancestral organs, such as the appendix, which is also rich in lymphoid tissue.

    They probably have a function during childhood in some way similar to the thymus gland, which atrophies after a few years as do the tonsils.  From their location and structure, I believe it is safe to assume that in infancy and childhood this tissue helps to warm, moisten and clean the inspired air, catching and holding the microorganisms inhaled.  The nose and mouth are the only open portals through which disease germs may enter easily.  Surrounding these open passages we find the adenoid or tonsillar tissue standing ready to receive these germs into its crypts, holding them there and not allowing them to penetrate any farther.  The presence of a disease germ stimulates phagocytosis and other auto-protective reactions enabling the body to make an antidote for that disease. The tonsil may either secrete an antitoxin, or permit the necessary phagocytic action to render the microorganisms inactiave.  Or it may in some undetermined manner use the disease germs to elaborate serums or antibodies to protect the individual from the germs that surround it, particularly those to which children are susceptible.

Normal Tonsils Closely Related to Immunity

    If this hypothesis should prove to be true or partly true, it would follow that the adenoid or tonsillar tissue is the natural protection of the body against the exanthematous fevers and other infections.  Therefore a child with a pharynx normal in structure and function would be immune to the common diseases of childhood.  Hence the tonsils and adenoids, when doing no harm, should be let alone.

    It is fair to assume that the adenoid or pharyngeal tonsil is a most important organ of defense against bacterial invasion.  It produces phagocytes which attack and ingest the bacteria which gain entrance through the nose.  Long-continued phagocytosis produces chronic hypertrophy of adenoid tissue in response to functional demand.  To remove the adenoid while thus engaged in killing bacteria, is to lay the body open to bacterial invasion.  When the blood and nerve supply and drainage both venous and lymphatic, to nose, sinuses and pharynx are normal, the adenoid tonsil is not overtaxed and does not hypertrophy.  The logical cure for adenoids is to correct the lesions and other conditions which permit too many bacteria to reach the adenoid.  Merely taking out the adenoid tonsils, does not remove the cause of the hypertrophy.  As a result of removal the body is laid open to invasion and in its struggle to protect itself goes right on building up adenoid tissue and in a very short while has it back where it was before operation.  The adenoid tonsil is particularly connected with the prevention of cerebrospinal meningitis.  When it fails in this task, the microorganisms overcome the phagocytes on the pharyngeal tonsil, and then pass along the blood vessels and lymph vessels and involve the sphenoidal sinus and sella turcica, thence spreading to the meninges.

    Any interference with nasal space, such as deviated septum, polypi, hypertrophied turbinates, etc., affects nasal respiration, which in turn affects the nasopharynx and the respiratory tract.  When nose-breathing is prevented or reduced by obstruction, the nose does not do its share of bactericidal work, overtaxing the pharyngeal tonsils.  Furthermore, since the child now breathes through its mouth, the faucial tonsils also receive more bacteria than they should and they too enlarge in response to the functional demand.  In a number of cases, I have noticed that after intranasal technique in adults to correct nasal obstructions there occurred a marked atrophy of the previously enlarged tonsils.

    Normally, a large number of tonsillar masses are found imbedded in the mucous membrane of the side and back of the pharynx.  They range from the size of a pinhead to a small pea.  The true adenoid or pharyngeal tonsil is present at birth and increases in size with the growth of the child up to the seventh year.  It remains at that size for a few years and then diminishes, is quite small at fifteen, and has almost disappeared by twenty.


When to Suspect “Adenoids”

    “Adenoids” were discovered about thirty years ago in Denmark and the operation for their removal then began.  When removed they grow again.  The term “adenoids” or “adenoid vegetations” means in a child that the pharyngeal tonsil is larger than normal or has grown in such a way as to obstruct breathing.  In an adult it means that the lymphoid tissue of the nasopharynx has not properly atrophied.

    In most cases of adenoids, breathing is obstructed because the pharyngeal tonsil has grown so large that it takes up too much room in the nasopharynx and blocks the airway.  In any case where a child does not breathe easily through the nose, suspect adenoids unless breathing becomes normal in a few days.  In many cases the child can breathe through the nose when awake; but at night, when the soft palate is relaxed, the child breathes through the mouth.  If the obstruction is greater, the child has to breathe through the mouth at all times.

    The ventilation of the middle ear via the Eustachian tube may be interfered with by adenoids causing periodical or persistent deafness.  Persistent snoring at nights in children is often due to adenoids.

    Examination of nasopharynx may be made by palpation or by laryngoscopic mirror and nasopharyngoscope.  In digital examination the index finger (with nail filed down to cushion) is passed above the soft palate, and the mass of adenoids on the roof, posterior and lateral walls of the nasopharynx are felt through the tip, sides and nail of the finger.

    If the pharyngeal tonsil is normal, it is not to be disturbed.  When its drainage is interfered with, it may become diseased; when it is overtaxed and its blood supply is increased it hypertrophies.  When it hypertrophies, it reduces the airway through the nasopharynx, and it may become a serious obstruction.

    All obstructions to the free passage of air through the nose and nasopharynx must be removed and the airway restored to normal freedom.  Because of the obstruction to breathing, adenoids produce farreaching bad effects on the body, the reduction of oxygen intake resulting in loss of energy, both physical and mental, with consequent retarded development.  Locally, the obstruction results in mouth-breathing arrested development of the nasal cavities, hypertrophy of tonsils, irritation of the whole respiratory tract, because the air reaches it uncleaned, unwarmed, unmoistened.

    The condition is due primarily to vasoconstrictor paralysis or vagus autonomic hyperactivity, resulting from osteopathic lesions, errors of diet, or other injurious habits or environment.  Correction of lesions, nasal breathing, and normal diet and hygiene, potentially restore normality, and in cases seen before the breathway is much obstructed, may clear up the symptoms.  Usually, the condition passes unnoticed by the parents till the breathway is seriously obstructed.  The only thing to do at this stage of the condition is to have the adenoids removed if they obstruct the breathway.  The operation is usually neither dangerous nor difficult.  Up to the age of five, they can usually be removed in one treatment.  From five to eight or ten, they can be removed by five or six treatments.  After ten years of age the growth of fibrous tissue makes them too hard to remove digitally and they should be cleaned out with a curette.  The symptoms of adenoids and technique of the treatment are as follows:
Symptoms of Adenoids

    1.  Catch cold easily.
    2.  Recurring earache
    3.  Nose bleed.
    4.  Enuresis  (wets bed at night).
    5.  Restless and nervous.
    6.  Tires easily.
    7.  Mouth breathing.
    8.  Poor appetite.
    9.  Constipation.
    10.  Chronic nasal discharge from both nostrils.

    Examine pharynx digitally under anaesthesia to know if adenoids are obstructing the airway or interfering with the potency of the Eustachian tube.  If so, remove as follows:

Operation for Removal of Adenoids

    General anaesthesia.

    Use index finger: take all aseptic precautions as indicated in postnasal technique; file index fingernail down to cushion.  This is done by first making a knife-edge on nail as close as possible to cushion, moving the file away from you, afterward filing off the sharpness level with cushion and being careful to file off all corners and sharp points so that nail cannot tear the delicate mucous membrane of the pharynx.

    Insert finger in pharynx, entering at side of uvula.  Then crush adenoids with back of fingernail and remove shreds as much as possible.  A dull curette may be used for this purpose.  Head should be held so that nasopharynx is lower than larynx, to prevent blood from entering larynx.  If bleeding does not stop at once, it may be controlled by sufficient pressure upon the denuded surface.  For this purpose, a long, curved hemostat holding a piece of picked gauze may be introduced and pressed against the bleeding surface.  It may be removed in three or four minutes.  Patient should rest for twenty-four hours, and be placed on a light, bland, unstimulating diet for two days, gradually returning to normal diet.

    Adenoids are often a sequala of acute exanthemata.  The irritation of the nasal and nasopharyngeal mucous membrane and the increased numbers of bacteria cause overgrowth of the lymphoid tissue.  Much of this irritation is allayed by osteopathic treatment of these conditions as indicated.  I believe that adenoids will not occur following these diseases if proper osteopathic treatment is given as outlined.  The human race could be emancipated from most diseases if the nose and nasopharynx could be kept normal.  Moreover, I believe that children receiving regular osteopathic treatment will not easily contract any more “children’s diseases.”

    Another serious element of danger from adenoids is that they invade the fossa of Rossenmuller and even extend to the tubal tonsil and block the Eustachian tube.  In both these respects they interfere with the ventilation of the middle ear.  Many cases of middle ear deafness have more or less adenoid overgrowth, which should be removed and normal blood supply and drainage re-established.  The whole problem of adenoids, tonsils, etc., is well covered in Ballenger.  Study it well there.  But do so in the light of your own osteopathic viewpoint.  The adenotome, curette, forceps, etc., are well-illustrated and explained.

    Remember, that from the osteopathic viewpoint, the adenoids are overgrown glands, mostly lymphatic.  When normal they have an important function to perform.  When abnormal they are probably unable to perform their function normally.  The whole trouble may clear up when you normalize the nasal ventilation, the venous and lymphatic drainage and correct the lesions found, cervical and upper dorsal; if it does not clear up within a few weeks, the indications are to remove the adenoids and keep up the treatment to restore the nasopharynx to normal.  Simply removing adenoids without osteopathic treatment as indicated, is useless, for the tissue grows right back again, as long as the ventilation, blood supply and drainage remain abnormal.

The Lingual Tonsils

    The lingual tonsils, situated together at the base of the tongue, cause many coughs.  Manipulation of lingual tonsil, with index and middle finger at the base of the tongue gives relief and is diagnostic.  If permanent relief is not afforded by deep local manipulation and drainage of lymphatics and restoration of the blood and nerve supply by correcting lesions found, then lingual tonsil should be removed surgically.  The lingual tonsil sometimes overlaps and blends with the faucial tonsil.  The lingual tonsil atrophies at fourteen years of age, after which the base of the tongue becomes carpeted over with adenoid follicles.

The Faucial Tonsils

    The faucial tonsils are situated on both sides of throat in the pocket between the anterior and posterior pillars of the fauces.

    One thing, bear in mind: a tonsil which sticks out into the throat may look large and still be no larger than is normal for a person of that age and it is no more likely to do harm than is one out of sight.  Size has no great importance.  Are they healthy or not, is the important factor.  How many physicians who examine our school children daily in our public school know this?  Tonsils that are unhealthy often show repeated attacks of tonsillitis.

    Quinsy is a peritonsillar abscess or a collection of pus in the region just behind the capsule of the tonsil.

    The removal of tonsils has been done more or less for a century.  The operation appears to become popular at times and then go out of fashion.  It is now more frequent than ever before.

    The lymphatics draining the tonsil empty into the deep cervical chain beneath the sternomastoid muscle.  The lymph nodes that receive the tonsillar efferent lymphatics are situated near the tip of the great cornu of the hyoid bone overlapping the jugular vein.  They are almost invariably enlarged in tonsillar affections, and this enlarged mass is often mistaken for the tonsil.  The tonsil, however, corresponds to the angle of the jaw.  The swelling of these glands in scarlet fever has led some investigators to believe that scarlet fever finds its way into the system through the faucial tonsils.  These glands are also frequently the first to enlarge in tuberculous disease of the cervical glands, hence the tonsils may be the primary source of infection for tuberculosis.  The tonsils are usually inflamed at the onset of rheumatic fever.  Many other conditions also point to the faucial tonsil as the site of entry of virulent disease; and as a strong protection against disease when normal.

    The tonsillar crypts or fossulae, formerly called follicles, are tubular recesses or pockets in the tonsil (the faucial tonsil has about 20), lined with stratified pavement epithelium.  They are surrounded by follicular tissue and extend right through the follicular tissue to the capsule.  They may become filled with food, dead epithelium, bacteria, leucocytes and mucous, causing local congestion and (perhaps) constitutional disturbance.  When for any reason the crypts are clogged, or the nerve and blood supply to the tonsil, or the venous or lymphatic drainage from it, are interfered with, the tonsil may become the seat of inflammation.  The tonsil has been held responsible for rheumatism, endocarditis, insanity, and what not.  Streptococci lodged in the tonsil are supposed to be the active agent.  The toxins reach the blood-stream directly or by way of the lymphatics.  The toxins are supposed to cause insanity by reaching the brain via the sheath of the third division of the fifth cranial nerve which is in relation to the tonsil.  While the tonsil is not universally accepted as the cause of these conditions, it is well to bear this possibility in mind and consider the tonsil whenever such a case presents itself.  The crypts may also harbor acute infections, which may therefore be transmitted to other people.

    The decomposition of retained epithelial structures within these crypts produces the fetid breath found in some cases of enlarged tonsil, and probably plays a part in reducing the vitality of the tonsil and causing tonsillitis.  When calculi form in the crypts they irritate twigs of the glossopharyngeal nerve and cause a spasmodic cough.

    While Metchnikoff has shown that mucous taken from the surface of the tonsil, is rich in leucocytes and phagocytes filled with microorganisms, still the tonsil differs from lymphatic glands in its construction and in the possession of the fossulae or crypts.  There are no lymphatic sinuses around the tonsil.  When normal, the tonsils do not absorb liquid or solid particles from the oral cavity.  The lateral, or external deep surface of the faucial tonsil is encased in a firmly adherent, strong, fibrous capsule, into which are inserted muscular fibres derived from the superior constrictor of the pharynx.  The sheath is not perforated by lymphatics, nerves, arteries or veins.  It is firm and solid and prevents abscesses of the tonsil from opening into the maxillopharyngeal space.  The sheath sometimes sends a network of fibrous tissue into and between the folds of the mucous membrane and along the blood vessels of the tonsil which prevents the blood vessels from readily contracting when cut.  The severe hemorrhage thus produced is often wrongly attributed to hemophilia.  Hemophiliacs may be detected before operation by letting a few drops of blood and testing for clotting by passing needle through them.  The tonsil is only slightly vascular.  Its nerve supply is not clearly established.  The production of lymphocytes within the follicles has been observed.  These lymphocytes pass through the mucous membrane into the crypts and thence to the mouth where they are thought to be identical with the corpuscles of the saliva.

    It is difficult to define a normal tonsil.  The size, shape, consistency, color, weight and general appearance vary in different individuals, and from time to time in the same individual.  These characteristics undergo constant change from infancy to old age.  The faucial tonsils are largest from three to eighteen years, after which they diminish in size, have a smooth surface and a firm, cartilaginous consistency.  Although often large enough to annoy during childhood, they generally cease to annoy after puberty.  With advancing years the tonsil atrophies, gets harder and smaller and infections become less.

The Tonsil Has a Wide Range of Motion and is not Firmly Bound Down to the Sinus Tonsillaris

    The tonsil is loosely adherent to the sinus tonsillaris which is a pyramidal space bounded by the anterior faucial pillar, the posterior faucial pillar, and the superior constrictor of the pharynx.  The tonsil is moved inward by the superior constrictor muscle in swallowing, and outward by the stylopharyngeus.  The anterior pillar may be well-developed or poorly-developed.  The tonsil thus presents very different appearances within a few seconds, and the extent to which it projects beyond the level of the pillars gives no true idea of its size.  Above the tonsil is the tonsillar recess where the pillars meet the soft palate, and joining the pillars above is the plica supratonsillaris.  Below, the plica tonsillaris passes from the anterior pillar to end on the antero-inferior aspect of tonsil.  The plica is composed of a fold of the mucous membrane.

    The plica protects the tonsil during deglutition and prevents food from entering the crypts.  Under certain conditions the plica becomes atonic, allowing food to enter the crypts and set up inflammation.  If the plica then becomes adherent to the mucous membrane of the tonsil so that the crypts cannot empty, the crypts become packed with (1) the retained food particles; (2) desquamated epithelial cells from the lining mucous membrane; (3) the leucocytes that are continually being produced; (4) the mucous secretion of the lining mucous membrane of the crypt; and (5) bacteria.  In some cases there is no inflammation, but in many cases the clogging of the crypts leads to inflammation, reduced vitality and disease of the tonsil.  To relieve this obstruction some operators are advocating a resection of the plica triangularis, but we osteopaths contend that it is normal to every throat and has an important protective function and should be freed but not removed.

    Tonsils, clinically, may be divided into FREE and SUBMERGED, and may be large or small fibrous, hypertrophied, atrophied, infected, etc.

    Free tonsils have very little plica, and when large, extend prominently beyond the faucial pillars.  The surface is studded with crypts.  Submerged tonsils have a well-developed plica and may be either small or large.  Even when large they do not have a cryptic appearance over the entire pharyngeal aspect.
Tonsillectomy May be Avoided by Freeing the Plica and Draining the Crypts

    In some cases the plica may be freed from the tonsil by simply separating it with the index finger.  This technique saves the tonsils and avoids tonsillectomy in 90% of the cases among children and 75% of adult cases.  Dr. James D. Edwards of St. Louis, in May, 1915, in an article in the A. O. A. Journal on “Conservative Surgery of the Tonsil” advocated circumcision of the tonsil, by separating the pillars and loosening up the plica with the index finger.  This was followed by Dr. Murphy, an allopath of Mason City, Iowa, who advocated the same technique several months later, using blunt scissors to dissect the adhesions between the pillars and tonsils.  Osteopathy claims priority for this technique.  Dr. Edwards uses general anaesthesia and does the work in one treatment.  General anaesthesia is essential in children, but in adults it may also be done under local anaesthesia, the tonsils and pillars being desensitized with PROCAIN.

    When the plica is not adherent to the mucous membrane of the tonsil, or after it is freed as above, the retained material may be withdrawn either by suction, or by pressure from behind.  Dr. T. J. Ruddy of Los Angeles, uses a “Ruddy Tonsil Suction Cup” producing suction by means of a “Bulb.”  This aspirates the retained material from the crypts.  It is excellent technique to diagnose diseased tonsils, as the pus can be collected with ease for microscopic examination.  This instrument can be purchased from Sharp and Smith, Chicago.

    Dr. Edwards uses an instrument called “Edwards Tonsil Searcher” to explore the plica, crypts and tonsillar recess and to press the material from the crypts.  It is a blunt probe bent at a right angle and with it the anterior pillar of the fauces is pressed backward and outward, causing the tonsil to come forward into the throat.  This technique everts the tonsil and exposes the crypts and hidden pockets.  The gagging of the patient then squeezes or milks the tonsil so that the crypts are emptied from behind.  The extruded material escapes into the throat and is expectorated.

    The tonsil may then be sprayed with normal saline solution, and if it is suspected that the crypts still retain material, a bent trocar may be introduced into the crypts and the saline solution forced directly into them by a syringe.  In some cases, it is advisable to swab out the crypts with a cotton wound applicator dipped in iodine.  This is advisable before operation to help make the field of operation aseptic, and prevent possible infection that may arise from the otherwise unsuspected tonsil.  Ballenger points out that the pricky sensation in the throat accompanied by slight soreness that persists for several days is due in some cases to infection in the tonsil, and when present is an indication to use caution, and to make sure that the crypts are rendered aseptic before operation.

Relation of Tonsils to Deafness

    The tonsil cannot press the Eustachian tube, but it may disturb the soft palate and the tensor palati muscle which helps keep the tube patent.  The deafness in these cases is, however, more likely due to adenoids or to hypertrophy of the adenoid tissue within the mucous membrane of the Eustachian tube itself, or to extension of inflammation from the inflamed tonsil.  Many cases of deafness in which the tonsils have been removed, have not cleared up for a considerable time, indicating that usually the tube is not blocked by any mechanical interference, but is occluded or rendered less patulous by the same hypertrophic process which affected the tonsil.  The deafness was not due to pressure but to extension of the inflammatory process.  Moreover, the inflammatory process is due to osteopathic lesions interfering with blood and nerve supply and venous and lymphatic drainage; and when these are corrected, the tonsil and Eustachian tube soon return to normal; more quickly in fact than they do by removing the tonsil.  And when once returned to normal they do not easily become diseased again; and the answer to the argument that they are no use in and might just as well be out, is that in about 50% of the cases in which they are removed, one or other of the important palatal muscles is no longer able to work properly.  When the tensor palati is affected, the Eustachian tube tends to become more occluded resulting in increased deafness.

Every Inflamed Tonsil Should be Accurately Diagnosed and Adequately Treated

    Follicular Tonsillitis (or acute fossulitis, as it is now called) may be distinguished from diphtheria by laboratory diagnosis and by inspection.  The Klebs-Loffler bacillus identifies diphtheria.  It is not found in follicular tonsillitis.  In diphtheria the membrane is a dirty white color, continuous, sharply defined, and leaves a raw surface when torn off; in follicular tonsillitis it is yellow, patchy, tears off without laceration, not continuous and has irregular sloping edges, and an exudate on surface of tonsil.  Scarlet fever is more violent in onset and the eruption comes out in 24 hours.  These three diseases must always be differentiated in any sore throat, and all precautions taken.  They occur most frequently in children, are quite acute, sudden in onset, and have temperature.

    Follicular tonsillitis is accompanied by enlargement of the tonsils making swallowing difficult.  Temperature may reach 103 or 104.  Anorexia, vomiting, constipation, pain in ear, thorough extension along Eustachian tube, and much inflamed throat.  Treatment: Rest in bed, if severe; fever diet, water and fruit juices for three days, then milk.  General spinal treatment to promote elimination.  Correct lesions in upper cervical, upper dorsal and ribs, etc.  Muscles over 1st and 2nd ribs are very sore.  Digastric is contracted.  Relax it.  Spring jaw.  Release supra and infrahyoid muscles.  In younger children clean out mouth with solution one-third liquor antisepticus U.S.P., or listerine in water.

    Coldpacks around throat are beneficial unless tonsil contains pus.  In suppurative conditions apply heat.  Thoroughly drain the lymphatics, especially around angle of jaw, as described in Lecture Thirteen.  Sweep the tonsil with the index finger and manipulate it between the index finger that is touching it within the mouth and the other index finger that is outside by the angle of the jaw.  Stretch the soft palate and do any corrective work needed in the nasopharynx, clean out fossae of Rosenmuller, etc.  Treat twice or three times daily during acute exacerbations.  During chronic inflammatory periods treat daily till drainage is established, then three times a week.  Recurrent tonsillitis can usually be controlled in one day by one general treatment to free up elimination followed by enema, etc., and then two other internal throat treatments.  Order gargle of Lugol’s solution, 10 drops to half a glass of water every two hours. Lugol’s solution is a “Compound Solution of Iodine.”  It is an aqueous solution of 5% of iodine and 10% of potassium iodide, and should be in the office of every physician who is doing nose and throat work.  Irrigate the throat with about two quarts of normal saline at a temperature of about 110, twice or three times daily, and irrigate the nose with same quantity of normal saline, morning and evening.  Give osteopathy a fair trial and the case will nearly always clear up.

    After attack subsides, with history of recurrent attacks, consider tonsillectomy.  After tonsillectomy, post-operative osteopathic treatment should be kept up for a long enough period to restore the pharynx to normal condition, otherwise the same trouble will recur, despite the absence of the tonsils.  The condition is due to vasomotor paralysis and vagus hyperirritability.  Therefore, osteopathic treatment is absolutely essential to restore vascular tone, and dietary and other habits must be corrected to remove irritation of vagus and sacral autonomics.  Reason out treatment for each case along lines laid down in Hay Fever and Asthma.  Each case is different, but the underlying principles apply to all cases in some degree.

    In acute tonsillitis, Edwards swabs tonsil with 90% of silver nitrate, being careful to touch the swab to a piece of gauze before applying to the tonsil (to avoid dripping).  This is allowed to remain three minutes (it blanches the tonsil) and is followed by swabbing the tonsil with saturated solution of sodium chloride, (table salt, chemically pure).  This neutralizes the caustic action of the silver nitrate.  Usually two applications together with osteopathic treatment to correct lesions and normalize the nose and throat, will cure a severe case of acute tonsillitis.

    Chronic tonsillitis is a chronic inflammation of the tonsils and other lymphoid tissue of the throat.  It follows repeated attacks of acute tonsillitis.  It is also a sequela of many of the infectious diseases.  The tonsils are permanently enlarged, but may be either free or submerged; are rough and pitted.  There is some difficulty in swallowing and breathing.  The child becomes a mouth-breather, dull and backward, does not develop as he should, and sometimes shows Rickety-rosary and Harrison’s groove.  Absorbed toxins produce headache, etc.  The cause of the trouble is often overlooked and you have a chance to make a spectacular cure because many of these cases clear up after removal of the adenoids, followed by correction of cervical and upper dorsal lesions and thorough osteopathic treatment till restored to normal.  If case is seen after tonsil is fibrous, have it out.  The condition will recur if osteopathic treatment is not given.

When to Advise Operation

    If adenoids are really obstructing nasal breathing, it is best to remove them, because their removal does very little damage compared to the serious effects of mouth-breathing.  But if the symptoms are trivial, the adenoids and tonsils should not be taken out merely because they look large.  Neither should tonsils be taken out at the same time as the adenoids are, just to have it over in one operation.  Before advising removal of tonsils, one should be absolutely certain that the disease that affects the tonsil cannot be cleared up by osteopahy or some other rational treatment.

    The abnormal condition of the tonsil may be primary, secondary, systemic, reflex, mechanical or hyperplastic.  If primary, it starts in the mouth and affects chiefly the crypts (fossulae).  Use Edwards’ method to free up the plica and pillars of the fauces.  Open the crypts to establish free drainage from the crypts.  Correct the lesions that affect the blood and nerve supply and drainage.  And squeeze or manipulate the tonsil between a finger in the fauces and finger beneath the ramus of the jaw.

    Secondary affection is via the lymph channels, chiefly from the nose.  When the nose and sinuses are restored to normal and kept clean the tonsil condition will clear up without operation.

    Systemic affection of the tonsil via the blood is quite common, and the tonsil is not to be removed simply because attacked.  Rather, the channels of elimination should be stimulated and the formation of antibodies in the spleen increased, so that the general bodily condition can be thrown off.

    Reflex affection of the tonsil may come from dental caries, gingivitis, pyorrhea, or other irritants to the fifth cranial nerve, as well as from spinal lesions and rib lesions from the fourth dorsal up to the occiput.  Hyoid and thyroid lesions may affect the drainage via the deep cervical lymphatics, and contractions of the cervical muscles may also interfere.

    The tonsil may be enlarged in response to mechnical stimuli from the faucial pillars and the constrictors of the pharynx and stylo-pharyngeus, also from misuse of the voice. Very tight biting contracts the pterygoids and forces the tonsils toward the median line of the fauces against the bolus of food, permitting food to enter the crypts with greater force than the delicate structure can stand.  These cases should be given the throat exercises as in Lecture Sixteen and should receive voice training in singing and elocution.

    When tonsils are hypertrophied or hyperplastic or diseased, the trouble is nearly always the effect of some derangement of function of some other part of the body.  If this is found and corrected, the tonsils will become healthy again.  Do not operate unless the tonsils are a menace to health.  In cases where you have definitely determined the nature of the disease of the tonsil (placed it in its proper group) and given it consistent osteopathic treatment without results, it is best to remove the tonsils.  But if the symptoms are trivial, the size of the tonsils is not an indication for removal.  If the nose were kept clean, few operations on the tonsils would be necessary.  By keeping the nose and mouth clean, and giving thorough osteopathic treatment to normalize all the structures related to the tonsil, we can save nearly all tonsils.  Faulkner, in his book “The Tonsils and the Voice,” 1913, states that Frederic Young found all prima donnas with extraordinary voices had big tonsils.  Also, that among 8,000 pupils examined by Neustaedter, tonsils were largest in the best pupils, and the best singers had fifty per cent more tonsils than the poorest.  Finally, competent authorities quoted by Faulkner differ as to the advisability, or even the possibility, of completely enucleating or removing the tonsil, and some of them even claim that the benefit of the operations is in proportion to the amount of tonsillar tissue which remains after the operation.  These views do not seem to agree with current practice.  In view of all the anatomical, physiological and pathological facts and probabilities, I think it is best to treat all tonsil cases without operation until we have proof that the tonsil in a given case is an actual menace to the health of the individual.  There are enough tonsils that have to come out without taking out tonsils that can be saved.

Improving the Drainage From the Tonsil

    The upper part of the tonsil is in front of the transverse process of the atlas.  The lateral side of the tonsil is in relation with the superior constrictor muscle, and is internal to the angle of the mandible.  It enlarges in the line of least resistance toward the median line of the pharynx, with but little effect in its relations laterally.  It can be palpated in the normal neck by placing the index finger as close to the front of the transverse process of the atlas and to the internal surface of the mandible as possible.  Steady drawing forward of the mandible with the index finger and of the tissues in relation to it with the middle finger is effective in draining the tonsil.  The lymphatic glands near the tip of the greater cornu of the hyoid receive the lymph from the tonsils and are nearly always enlarged if the tonsil is affected.  This mass is often mistaken for the tonsils.  The glands that receive the drainage from the tongue also tend to enlarge in any ear, nose or throat condition.  This congestion irritates the vagus and causes decreased heart action and general systemic depression.  This depression is a frequent symptom in ear, nose and throat conditions.  I get astonishing relief from the congestion and the consequent depression by the following technique.  Note that this technique is given after I have first freed up the kidney, bowel and skin elimination by such treatment as is indicated in the particular case; second, established normal activity of spleen, pancreas, liver, stomach and intestines by appropriate treatment; third, thoroughly relaxed the upper dorsal and cervical musulature and adjusted the vertebrae so as to insure normal secretory and vasomotor impulses to the lymphatics, veins and arteries from the neck up; and fourth, drained the lymphatics beneath the sternomastoid.  I then take a clean towel and with patient on back have patient open mouth wide and protrude tongue, I grasp the tip of the tongue in the towel and gently but firmly squeeze the entire tip of the tongue for about an inch between the thumb and index finger of both hands.  This presses the lymph against the lymph nodes and irritates them to activity.  Then draw the tongue forward, downward and lateralward to stretch the tissues.  With cotton rolls between lips and teeth to avoid cutting the lips on teeth, I now place one index finger in the mouth between the mandible and the index finger of the other hand on the outside between the mandible, and gently manipulate the tissues between the fingers, draining them toward the median line.  Then with the index finger beneath the tongue press the tongue toward the opposite side of the mouth, and with the outer finger reverse the motion.  These movements thoroughly stretch and drain the tissues of the tongue and tonsil.  Do the drainage from the ouside only, two or three times before you do any inside work to improve drainage.

    Osteopathic treatment saves practically all tonsils except those that are seriously diseased.  Some osteopathic physicians are inclined to claim that tonsillectomy is never justified, because so many brilliant results follow osteopathic treatment.  But I have seen a number of cases of large fibrous tonsils and seriously diseased tonsils, the removal of which was decidedly beneficial to the patient.  Choose the least evil in such cases.  It is bad to remove tonsils, but in cases where it is worse to leave them in, have them out.  In children they are rarely diseased, and normally they atrophy at puberty.  The operation is, therefore, in most cases, not indicated at once.  There is no hurry about operating and there is nearly always time enough to clear up the condition osteopathically, because these structures respond promptly.  But if the recurrent tonsillitis does not clear up under osteopathic treatment, it is best to remove the tonsils.  In some cases they are enlarged enough to interfere with the foodway, making swallowing difficult; or they may interfere with the tensor palati and indirectly interfere with normal ventilation of the middle ear through the Eustachian tube.  Such tonsils obviously are better out.

    The normal tonsil, especially during the first twnty years of life, is a useful part of the autoprotective mechanism of the body.  If in a given case it is found to be diseased, and is suspected of causing symptoms of infection in other parts of the body, such as tuberculosis of the cervical glands, osteomyelitis, acute articular rheumatism, endocarditis, nephritis, orchitis, adenitis, laryngitis, etc., and if it fails to respond to persistent osteopathic treatment over a period of several months; the question to be decided is then whether the tonsil has become so diseased that it is really a portal of infection rather than a barrier and defense.  Since in these cases the tonsil is not performing its function of protection, and is in effect a menace to the body, it should be completely removed, including the capsule.  If any part of the tonsil is left, it will regenerate.  When removed, the tonsil presents the appearance of a definite mass of lymphoid tissue enveloped in a smooth, glistening capsule on its outer, lateral, aspect, and mucous membrane on its inner, median, aspect.  If care is taken to avoid injuring the muscles in relation to the tonsil, there is very little hemorrhage in tonsillectomy.  The location of the ascending pharyngeal artery, of the pharyngeal venous plexus, and of the main arteries whose small branches supply the tonsil should be distinctly borne in mind.  The severe bleeding that occurs in some tonsillectomies is due to rupture of one or more of these vessels.  I have seen many surgeons remove tonsils.  Some of them were men of national reputation.  But never in my life have I seen such rapid and efficient tonsillectomies as those performed by Dr. Edwards at the 1920 Convention of the A.O.A. at Chicago.  In case after case he removed diseased tonsils from adults in the phenomenal time of four seconds for each tonsil.  The operation was practically bloodless and painless.  He anaesthetizes the tonsil by swabbing the parts with 10% cocaine in adrenalin chloride 1-1000, (48 grains of cocaine to 1 ounce of adrenalin chloride).  Swab every three minutes for ten minutes.  He used the new Sluder-Edwards technique, which is Edwards’ Finger Surgery plus Sluder guillotine, the tonsil being digitally dissected from the muscular walls of the sinus tonsillaris and removed completely with the capsule intact, without damaging the muscles of the faucial pillars or of the pharynx, and without cutting any bloodvessels except the relatively small vessels which supply the tonsil itself.  Edwards-Sluder technique is a decided improvement over the operations described in Ballenger.  Dr. Edwards has not made putlic this technique, but has given me the privilege of telling you about it in advance of publication.

Tensillar and Peritonsillar Abscess

    Peritonsillitis or quinsy is an inflammation of the tissue around the tonsil that rapidly becomes an acute abscess, calling for immediate draining to avoid serious complications such as edema of the larynx, strangulation, or ulceration of the great blood vessels in the neck.  Fortunately, it is rare in children, being most often found in young adults.

    Tonsillar abscess or phlegmonous tonsillitis is more rare than quinsy, the upper lobe of the tonsil being most usually affected.  In many of these cases, if free drainage is restored to the upper lobe the condition may be aborted.  Thoroughly free the drainage by sweeping out the supratonsillar fossa with the index finger.  (Nail filed down to cushion.)  Free the plica and clean out the crypts.  If this does not stop the progress of the inflammation, slit up the upper part of the tonsil, or lance the tonsil where the abscess points of this spot can be found.

    In quinsy find the point of fluctuation or pointing and let it out.  The essential thing to remember is that the pus is between the tonsil and the faucial pillars and pharyngeal constrictor, but not in the tonsil. In lancing to let out the pus, it is necessary to make sure that the peritonsillar space is drained; if this precaution is not taken the incision may be made into the tonsil without allowing the pus to drain.  Occasionally the pus can best be drained by making an incision right through the tonsil to the capsule.

    Fluctuation is usually felt in the upper third of the anterior pillar.  The finger feels a pumping or pulsating sensation.  When the pus is within the tonsil, the tonsil is swollen (as compared with its fellow of the opposite side) and extends out toward the median line.  When the pus is behind the capsule of the tonsil, the tonsil is pushed upward and may bulge the anterior pillar.  It has a certain consistency and resistance to the touch, whereas the place to lance is where the fluctuation is felt.  Use local anaesthesia.  Make the incision through the anterior pillar, far enough anteriorly to avoid incising the tonsil.  The incision should reach behind the capsule of the tonsil.  To lance, wrap adhesive tape around lance half an inch from the point and then make an incision at the place where the abscess points if this spot can be found.  Then insert hemostat and by spreading it enlarge the incision.  This releases the pus in nearly all cases.  If the pus is not found, it may be pointing posteriorly into the pharynx and may discharge into the larynx causing death.  It may be necessary to do Ballenger’s operation which consists in dissecting the capsule away from the superior constrictor muscle.  It is also sometimes necessary to lance the posterior pillar.

Treatment of Pyorrhea

    Dental caries may be evident on inspection of the teeth, or may be hidden by the adjoining tooth. Pus cavities may be located on the roots of teeth.  Pyorrhea alveolaris, also called suppurative gingivitis or Rigg’s disease, is characterized by a purulent discharge from between the teeth and the gums.

    There is a septic infection of the sockets, the teeth loosen, and the gums are eroded and recede.  These symptoms are accompanied by bleeding gums, foul breath, dyspepsia, anaemia, ill health, apathy, nervous disturbances, and sometimes general pyemia, synovitis, and arthritis, neurasthenia and depression.  Treatment consists in keeping the mouth clean, and freeing up the upper dorsal and cervical area so that a normal blood and nerve supply can reach the sockets of the teeth.  Also free up the drainage and general elimination, and stimulate the spleen to the formation of antibodies.  X-ray the teeth and have pus-pockets cleaned out.

    Then, locally, press the gums between the thumb and forefinger and hold for a few seconds, repeating till the entire upper and lower gums have been treated.  Repeat the manipulation of the cervical deep lymphatics.  Repeat morning and evening, until tenderness is gone and blood supply and drainage is normal.  Try this technique on yourself and see whether your gums are normal.

    These patients should have three tooth-brushes and use a different one after each meal; allowing it to dry 24 hours before using again, otherwise they reinfect their gums with bacteria remaining on the damp brush.  A dry brush has very few bacteria on it.

    Edwards described the following technique which is very effective in the various forms of laryngitis, also in asthma and clergymen’s sore throat and voice affections.  It is essentially a SUSPENSION manipulation.  This is done by passing index and middle finger of right hand into the mouth, on the dorsum of the tongue to the larynx.  The index and middle finger then pick up the right and left cornua of the hyoid, rocking and rotating it, while the left hand is opposing on the outside of the throat, moving the thyroid cartilage in the opposite direction.  This drains the saccule and ventricle, releasing the passive congestion and the muscular and ligamentous contraction.

Edema of the Larynx

    In this form the inflammation is accompanied by exudation and infiltration of the tissues, as distinguished from the distinctly catarrhal laryngitis, or the spasmodic nervous laryngismus stridulus.  Most usually due to obstruction to the internal jugular veins.  Also due to errors in diet, such as too much salt, or too large a proportion of irritating substances, that overstimulate the kidneys, and irritate the vagus generally throughout the digestive apparatus and elsewhere.  The specific lesion must be corrected, and the diet and other habits regulated.  Thorough elimination must be secured through bowels, kidneys, skin and lungs, by osteopathic treatment, enemata, hot bath and fresh air.  In treating thoroughly relax the tissues of the neck and throat, raise the clavicle, and relax the deep anterior muscles and tissues of the root of the neck.  Drain the lymphatics.  Opening the mouth against resistance aids the circulation of the carotids.  Treat the vagus along the course of the sternomastoid and at the superior cervical region.  Treat the superior laryngeal nerve behind the superior cornua of the thyroid cartilage.  Treat the recurrent laryngeal nerve at the inner side of the sternomastoid at the level of the cricoid cartilage.  Treat deeply along the sides of the larynx and trachea, applying the fingers close along the sides of the trachea.  This relieves the huskiness and spasm, though the spasm often depends on the approximation of the hyoid to the thyroid or on some specific osteopathic lesion.

    Dropsy from kidney, heart or lung disease must be treated by removing the cause of the primary disease, if possible.  In dangerous cases of edematous laryngitis, great care must abe taken.  Intubation or tracheotomy may become necesssary to prevent suffocation, but ordinarily an operation can be obviated if the case is seen in time.  Hot footbaths, hot drinks, milk or seltzer-water may give relief.  The condition and operations are well described in Ballenger.  It is well to read up all there is about laryngitis in all the textbooks you have and have your treatment definitely in mind, because when you are called into any of these cases it is usually necessary to act AT ONCE.

    The lymphatics of the outer ear accompany the veins and empty into the posterior auricular and parotid lymph glands.  These in turn drain into the superior deep cervical chain.

    Any obstruction to venous or lymphatic drainage will cause a passive congestion of the meatus with hypersecretion of cerumen.

    The LYMPHATIC DRAINAGE of the membrana tympani is into the parotid and posterior auricular lymph glands superficially, and into the retropharyngeal lymph glands via the lymphatics along the Eustachian tube.  In myringitis or any other diseased condition of the membrana tympani, free up the lymphatic drainage of the superior and inferior deep cervical chain, then the parotid and posterior lymph glands, and then go behind the soft palate, clean out the fossa of Rosenmuller and drain the retropharyngeal glands by two or three strokes of the index finger in the upper back corner of the pharynx on the affected side.  If this is done early enough, and the lesions corrected and other sources of irritation cleared up, the condition will improve with surprising rapidity.

Mucous Membrane of the Tympanum or Middle Ear

    The mucous membrane of the middle ear is continuous with that of the pharynx, through the Eustachian tube.  It invests the ossicles, muscles and nerves contained in the tympanic cavity; forms the inner or medial layer of the membrana tympani, and the lateral or outer layer of the secondary tympanic membrane that closes the round window.  It is reflected into the tympanic antrum and mastoid cells which it lines throughout.  It also forms several vascular folds which give the interior of the tympanic cavity a honeycombed appearance.  In the tympanic cavity this mucous membrane is pale, thin, slightly vascular, and covered for the most part with columnar ciliated epithelium but over the pyramidal eminence, ossicles and membrana tympani, it possesses a flattened non-ciliated epithelium.  In the tympanic antrum and mastoid cells the epithelium is also non-ciliated.

    In the Eustachian tube the epithelium of the mucous membrane is columnar and ciliated.  In the osseous portion of the tube the mucous membrane is thin, but in the cartilaginous portion it is very thick, highly vascular and provided with numerous mucous glands.  These anatomical factors are important to remember in the treatment of tubal catarrh, tubal occlusion and middle ear conditions.

    LYMPHATIC DRAINAGE.  The majority of the lymphatics of the ear follow along the Eustachian tube and empty into the retropharyngeal glands.  They are drained by sweeping out the fossa of Rossenmuller.  Others reach the postauricular glands over the mastoid process, where they can be drained directly.  Both empty eventually into the Superior Deep Cervical Glands which must be thoroughly drained in any middle ear condition.

    LYMPHATIC DRAINAGE OF INNER EAR.  I have not found any lymphatic drainage described from the inner ear to the cervical lymphatic glands, but it is likely that some lymphatic drainage passes from the inner ear by way of lymph vessels accompanying the stylomastoid vein.  The perilymph is in communication with the subarachnoid space and, no doubt, drainage is dependent upon the difference in pressure between the fluid in the subarachnoid space, and the fluid in the labyrinth.
    Our problem of relieving ear symptoms due to nerve involvement resolves itself into one of establishing free drainage from the cranial cavity.  This is best facilitated by thorough osteopathic treatment, with special attention to upper cervical and mandibular lesions, restoring free motion to all vertebrae and dilating abdominal vessels.  The internal jugular vein must be relieved of back pressure, and no obstruction permitted to retard the escape of cerebrospinal fluid into the lymph spaces of the cranial and spinal nerve sheaths.  Also, all the emisssary veins and the anastomosing veins must be carefully treated, such as the anastomoses of the ophthalmic with the facial, in order that the freest possible escape may be afforded for the blood and cerebrospinal fluid from the cranial cavity.  Note particularly the vein connecting the lateral sinus with the posterior auricular or with an occipital vein.  Blisters or leeches have been applied here to facilitate cerebral drainage.  Note also the connection between the cranial veins and the lateral sinus via the diploic veins.  Note also that the veins within the cavities of the nose and middle ear communicate with those of the meninges.

Acute Otitis Media

    Acute otitis media is divided clinically into Acute Catarrhal or Non-Suppurative Otitis Media, and Acute Suppurative Otitis Media.  Inflammation of the middle ear usually begins by extension from the nasopharynx via the Eustachian tube, but it may occur directly from the blood stream.  The exudate is simply excessive mucous or it may be purulent.  The membrana tympani has a tendency to rupture at the point of greatest bulging, and should be incised before rupture occurs.  The simple catarrhal secretion rarely ruptures the membrana tympani.  All cases begin with chills, fever, vomiting and prostration.  Most cases terminate in resolution, but some go on to the purulent stage.  Thorough osteopathic drainage of the Eustachian tube, and the lymphatics, together with correction of mandibular, occipital, cervical, and dorsal lesions, usually control the case if seen early.  Opening the mouth against resistance should be done by the patients at intervals.  Scarlet fever and measles very often attack the mucous membrane of the middle ear.  In fact, EVERY CASE OF EXANTHEMATOUS DISEASE OR OTHER ACUTE INFECTION SHOULD SUGGEST CAREFUL EXAMINATION OF THE MEMBRANA TYMPANI AT EACH VISIT, TO FORESTALL TROUBLE.  Much of the chronic ear disease and deafness of middle life is due to neglect of this precaution.

    Treatment of mastoiditis is the same as for middle ear with the added caution to be on guard for indications that a mastoid operation is needed.  I have had two severe cases of mastoiditis where the patient appeared in imminent danger of death clear up by the persistent osteopathic treatment designed to improve drainage as explained.

    IN THESE CASES, REMEMBER THAT YOU HAVE AT YOUR DISPOSAL THERAPEUTIC MEANS THAT ARE INFINITELY MORE EFFECTIVE THAN ANY MEDICINAL MEASURES AVAILABLE TO THE ALLOPATHIC AURIST.   If the stage is reached where mastoid operation is needed have it done by the most competent ear surgeon or brain surgeon available, BUT KEEP RIGHT ON TREATING THE PATIENT, because the osteopathic treatment is fully as important as the operation.  The operation only helps drain one part.  Remember, pure blood and plenty of it is needed in the mastoid, middle ear and inner ear, and the way to get it there is to establish free drainage as explained.  Know this part of the work IN DETAIL so that you can use it when the time comes.

The Nose and Sinuses in Eye Conditions
    Each orbit is bounded medially by the frontal, ethmoidal and sphenoidal sinuses and below by the maxillary sinus, and separated from these sinuses by only a very thin plate of bone with only a thin mucous membrane within the sinus.  Thus, a closed empyema of any sinus may be fraught with serious danger to the orbital structures.  And this is further accentuated by blood and nerve supply being distributed from practically the same arteries and nerve trunks.  Correction of nasal and sinus conditions results in marked improvement in vision, which, with supportive treatment in the upper dorsal and cervical regions, is permanent.

    A similar thin plate of bone is all that separates the sphenoidal, ethmoidal and frontal sinuses from the cranial cavity.  The cribriform plate of the ethmoid upon which rests the olfactory bulb, is extremely thin and perforated by numerous foramina for passage of the olfactory nerves, and through these, infection is frequently carried from the nasal cavities to the cerebral meninges as the nasal mucosa is continuous with the dura mater at the foramina.  Swelling of the middle turbinate can close the olfactory fissure in such a way as to prevent ventilation and drainage, making it a fertile culture medium for any pathogenic micro-organisms that may lodge there.  In this way the optic nerve may be affected within the cranial cavity.

    The cornea has no trace of blood vessels except at its extreme margin.  A fine network of lymphatic spaces serves to nourish it.  When inflamed it becomes opaque, and the blood vessels, which encroach on it give a “salmon” tinge to it.  In pannus, the continued irritation causes blood vessels to pass over the cornea just beneath the epithelial covering, but the cornea proper remains bloodless.

    Blood to all eye structures is almost entirely from branches of the ophthalmic artery which arises from the internal carotid artery, just as that vessel is emerging from the cavernous sinus.  In the orbit this artery is in relation with the lower border of the obliquus superior, rectus superior and levator palpebrae.  Some of its branches go to the nose and accessory sinuses.  Any irritation in the nose and sinuses to visceral afferent nerves is therefore reflected in dilatation of the ophthalmic artery and its branches.  Lymphatic drainage of the nose and sinuses is largely through the retropharyngeal glands.  Therefore, the first thing to do, to normalize the blood supply to the eye, is to thoroughly restore a normal healthy condition to the nose, sinuses, pharynx and neck, as well as to correct any upper dorsal or cervical lesions that might affect the sympathetic nerves in the grey lateral horn or in the superior or inferior cervical sympathetic ganglia.

Manipulation of the Eyeball and Adjacent Structures

    Venous drainage of the eye is three-fold: into the cavernous sinus, pterygoid plexus, and anterior facial vein.

    The lymphatic vessels of the eyelids and conjunctiva empty into the facial glands, thence into the parotid and submaxillary glands, which, in turn, empty into the upper deep cervical lymphatic glands.  It is also to be borne in mind that the lymph spaces around the eyeball and within the fascia bulbi communicate with the subdural and subarachnoid spaces in the brain, and that any disturbance of the drainage of the cerebrospinal fluid will affect this drainage, notably brain tumor or meningitis.  Gentle manipulation of the various glands will stimulate their activity.

    Conjunctivitis is materially helped by gently stroking the lids along the orginal margins toward the inner canthus, as the conjunctival arteries, veins and lymphatics are all stimulated in this way.

    Granulations are crushed between the index finger and thumb, the finger being aseptically clean and inserted beneath the lid, or with the lid everted.  Dr. A. T. Silll held that many eye conditions were due to hypertonicity of the orbicularis muscle, which he relieved by stretching the eyelid by inserting his finger beneath the lid and gently pulling.  The lids may also be pulled from side to side.

    The drainage of the eyeball and orbit can be improved by pressing the outer side of the tip of the little finger deep into the orbit and pushing the eyeball as far as possinble in every direction.  Dr. T. J. Ruddy, of Los Angeles, has devised the “Ruddy Eye Finger” to facilitate eye manipulation.

    Treatment of conjunctivitis is mainly osteopathic.  Drain and manipulate as described above.  The conjunctiva cannot stand strong antiseptics.  Even 25% argyrol when used for several months permanently discolors the sclera brown, known as argyria.  Alkalol 50%, normal saline, saturated solution of boric acid, pure water, are usually the best eye-washes, to be applied by winking the eye in an eye cup.  They should be ice-cold if given at the first stage of inflammation, otherwise as hot as can be borne.  Cold compresses wrung out in ice-water, or just off the ice, may be also applied at the begining of conjunctivitis, but ice should not be applied.  Later in the conjunctivitis, hot compresses should be applied.  A weak solution of zinc sulphate, (1/2 to 2%) is very effective in destroying the Morax-Axenfeld bacillus which is present in angular conjunctivitis and causes a tenacious grey discharge that glues the lid.

    Always wear protective glasses whenever examining an eye that is glued shut, as the pent-up secretions may squirt into your own eye when you succeed in getting the lids separated a little.

    Considering the various causes given by medical authors for cataract, glaucoma and other eye diseases which do not yield to medicinal therapy, it is easy to see how osteopathic lesions affecting the blood supply, nerve supply, venous drainage and lymphatic drainage re responsible for most of these cases.  Many of these cases can be cured by osteopathy, plus hygiene.  It is the duty of every osteopath to know enough about them to give the patient the right treatment or at least to refer him to the right specialist.

    Dr. J. D. Edwards of St. Louis, Mo., in the May, 1920, A.O.A. Journal, described his original technique under the title of “Finger Surgery of the Orbital Cavity in the Treatment of Glaucoma.”  He states that “the results of this local manipulation in glaucoma in many instances were very gratifying.  Museac Volitantes, synechia of the iris, staphyloma, asthenopia, strabismus, incipient cataracts, retinal detachment choroiditis, iritis, simple retinitis, refractive errors, uveitis, dacrocystitis, epiphora, blepharitis, conjunctivitis, optic nerve atrophy, have responded to this technique, and with the exception of the specific and malignant diseases, which should be carefully differentiated, almost every morbid condition of the orbital cavity can be benefitted if not entirely cured.”  Dr. Curtis H. Muncie, of New York, in the October, 1921 A.O.A. Journal described additional finger surgery technique to correct errors of refraction by controlling drainage.

    As a matter of fact, this technique secures far better results than any of the ordinary methods, such as eye-drops, eye-glasses, rest in dark rooms, etc.  The discovery of Dr. Bates of New York is really osteopathic.  Let’s make the most of it.  His medical confreres are as slow to take it up as they were to take up osteopathy.  And osteopaths for forty years have been taking off peoples’ glasses by simply normalizing the spine, whereupon the underlying cause of the strain was removed and the errors of refraction cleared up.

    The circulation to the brain is interfered with by any lesion, bony, ligamentous, muscular, etc., which narrows the lumen of the spinal canal at the foramen magnum or further down.  Such a lesion reduces the normal interchange of cerebrospinal fluid between the ventricles and the spinal canal at each heart-beat.  Owing to the rigidity of the cranium, cerebrospinal fluid must leave the ventricles at systole as the arteries within the cranium dilate. If it does not, cerebral ischaemia, increased intracranial pressure, or congestion will occur.  This tends to irritate the vagus and autonomic fibres to hyperactivity, and to set up an irritability of instability reflexly from the cerebral cortex in every cell, tissue and organ in the body.  Occipital or cervical lesions causing this condition must be corrected.  Cerebral ischaemia may also result from insufficient heart action due to vasoconstrictor paralysis and lack of accelerator and augmentor impulses, caused by upper dorsal lesions, or to inhibition of sympathetic impulses over the vertebral and internal carotid arteries.  The headaches, depression, and emotional instability of hay feverites are all markedly improved after correction of lesions in these regions.