CHAPTER IV. GENERAL ENDO-NASAL, AURAL AND ALLIED TECHNIQUES.

The General Endo-nasal, Aural and Allied Techniques are a continuity of movements encompassing the whole body by areas, while the specific techniques take recognition of that portion of the body particularly afflicted. In the majority of cases, it is recommended that all the General Techniques be performed before the specific. However, the physician will have to be the judge of what is best to do under certain unusual circumstances. In cases of severe earache, mastoiditis, or highly inflamed and swollen tonsils, we do not recommend the general techniques until the acute symptoms have subsided. We proceed now to outline the anatomical areas of the general techniques, and to give a brief outline of the areal contents. The functional relationship of these areas to the intake and utilization of oxygen is explained with each step of the techniques. The arrangement of these areas is deliberate and largely at variance with the arrangement found in average textbooks.
 

Areas of General Techniques.

The lymphatic area consists of all the lymphatic vessels and nodes that can be directly or indirectly influenced by manipulation.

The neck area consists of occipital, cervical, lambdoidal and mastoidal sutures, the muscles of the neck, the carotid sinus contents, the meniscuses and the carotid glands, and the sponges between the vertebral bodies of the whole spine.

The nasal area, which we also call the trigger area, extends from the anterior nares up to the infundibulum, and includes the mucous membrane, septum, turbinates and all the air passages within the nares, also all the sinuses, and the ten sutures surrounding the frontal nasal area.

The pharyngeal area is sometimes called the trapdoor area. Included in this area are the soft palate, the contents of the Fossa of Rosenmuller, the pharyngeal walls, the tonsils, the trachea, the pharynx and larynx. Embedded in the branchial walls of the muscles of the neck are the thyroid, parathyroid and thymus tissues, also the remnants, if any, of the thyroglossal duct. 

The mediastinal area contains the vital organs of respiration and is also the pathway through which important structures pass.

The endo-navel area consists of that portion bounded by the diaphragm, and the diaphragm itself in relation to its functions on the organs above and beneath it.

We put the lymphatic area first, for the importance of having the general lymphatic, circulation in good condition cannot be overestimated, because of the many functions performed by the lymph.

The Lymphatic system consists of lymphatic vessels, lymphatic glands and lymphs. The lymphatics drain the lymphatic glands and extend to every portion of the body. Those in the abdomen and lower extremities unite to form the receptaculum chyli, which is situated on the second lumbar vertebra. This lymph space is drained by the thoracic duct, a vessel about eighteen inches in length, which duct originates at that point.

The Right Lymphatic Duct is a short vessel, from ¹/2 to ³/4 inch long, which, after receiving the lymphatics from the right side of the head and neck, the right upper extremity, and the right half of the thorax, ends at the confluence of the right internal jugular and subclavian veins.

Lymph originates in the lymph spaces that surround the blood vessels and unite to form the lymphatic vessels. It is derived from the blood, which contributes a modified plasma that has osmosed through the walls of the capillaries, and from the lymph glands, which contribute lymphocytes.

We will state here only a few of the functions of the lymphatic system.

1. It conveys fluid, and the products of digestion. 

2. It removes effete matter from the tissues.

3. It relieves the blood vascular system of an excess of fluid.

4. It acts as a powerful solvent to medication and hard foreign substances.

5. It is a reserve for the blood to draw on after hemorrhage or during starvation.

6. It is a lubricant in synovial and other fluids.

7. It takes part in the healing of wounds (glazing of the wound surface).

8. It affects special functions connected with the special senses (cerebrospinal fluid, lacrimal secretion, aqueous humor, etc.).

9. It acts as a reservoir of oxygen to the perivascular and extra vascular spaces.

10. It acts as a detoxitizer of toxins and poisons.

The lymph stream, therefore, is important to the Endo-nasalist, if for only four of its functions, namely, distributing of oxygen, carrying of waste matter, destroying toxins to some extent, and generally protecting the internal circulations. It is always well to remember that after treatment is given to the tonsils and the Fossa of Rosenmuller, there is considerable mucus seepage; some of this can be expectorated, but much of it goes down into the body. It is the action of the body lymphatics which disposes of this waste matter, thus preventing congestion.
 

General Techniques.   FIRST TECHNIQUE.
Lymphatic Drainage.

The first technique is to move any lymphatic congestion found by whatever methods known to the physician. For the method the writer uses, see Lymphatic Drainage Techniques in my book, "Treatment by Neuropathy and the Encyclopedia of Physical and Manipulative Therapeutics." Pages 152 to 165.

SECOND TECHNIQUE. The Lake Head Recoil Adjustment for the Basilar Sutures, Neck and Spine.

We call this the Lake Head Recoil Technique for want of another name. It accomplishes a great deal on many parts at one time. Let us see if we can explain the physiological purposes of this technique.

The sutures of the skull have expansile and contractional properties the same as any other tissues of the body. The skull and the contents of the skull are of the same material as all other parts of the body arranged differently in degree, and as to functions, but subject to the same nerve currents, pulsations, oscillations and vibrations. There is this distinction, however, that the brain can start nerve currents, pulsations, or oscillations without any external stimulus. These pulsations oscillate out through the nerves to all parts of the body by vibrations and the nerves of the body send impulses in the form of vibrations to the nerve centers of the brain. As these are pressure currents contents of the skull must have room for expansion according to the pressure. The sutures of the skull are for that purpose.

Underneath the part covered by the occipital lambdoidal, temporoparietal and mastoidal sutures are the respiratory center, the mastoidal air cells, and the pathway of sensory nerve impulses from the carotid gland to the floor of the fourth ventricle in the medulla. Here also are found other nerves, air and vibration pathways. It is reasonable to expect quicker results if these sutures are opened and f reed of constant adherence, allowing the tissues underneath to expand and oscillate more freely.

Another result of the Lake Head Recoil Technique is the breaking up of a carotid sinus block or syndrome.

The carotid sinus is a dilation at the proximal end of the internal carotid artery and is situated at the angle of the jaw. It is supplied with sensory receptor nerves which are particularly rich in adventitia. This network of nerves leaves the carotid sinus and ends in a meniscus, forming what is known as the sinus nerve of Hering or the intra­carotid nerve of De Castro. It is associated with the glosso­pharyngeal and the hypoglossal.

These intracarotid nerves, and the aortic depressor nerves are very important in the reflex regulation of the blood pressure. The carotid sinus nerves also influence the vagal system, the cardio inhibitory portions of it, and the adrenal glands. Normally, the carotid sinus prevents an exceptional elevation of the blood pressure under stress.

Interference with the free flow of blood, lymph, and nerve currents here, is a serious matter. These interferences may come from diseases, from drugs and from the processes of gravity especially in old age. The meniscus may fall, creating a block from emotional states, or from subluxations of the cervical vertebrae, occipital and lambdoidal suture closure, unusual deposits of calcareous matter in the neck and shoulder regions, all creating a stiffness and tenseness of the muscles of those regions. Any or all of these may cause an irritation of the bundle of nerves in the carotid sinus, creating a squeeze which causes a fall of arterial blood pressure, which in turn results in a change of normal cerebral blood supply to the ischemic state with a consequent anogemia of the whole cranium.

Out of this fall of blood pressure and consequent anoxemia in the cranium may come such diseases as catalepsy, epilepsy, vertigo, heart irritations, palpitations, asthma, headaches, migraine, deafness and tinnitus. The next effect of the Lake Head Recoil Technique is the liberating of the carotid bodies. These are wheat-sized glands located slightly inward from the carotid sinus and according to Heyman of the Belgian School have important functions to perform, one of which is that when there is a lack of oxygen, the rise of carbonic gas creates a stimulation on the sensory nerve end fibers of these bodies which in turn sends impulses to the respiratory center in the floor of the fourth ventricle of the medulla. This in turn is stimulated as a result of these impulses, and thus is maintained the balance of intake of oxygen and the outgo of CO2. (See Fig. 4.)

The next effect of the Lake Recoil is the raising and leveling of the vertebrae superiorly and relieving the gravity of weight upon the spongy disks or snubbers between the vertebral bodies. The articular facets act as stabilizers of the whole spine. If the weight of the body is not carried evenly on the intervertebral disks, posterior and anterior, one portion of it will be crowded together. When this happens, the size of the intervertebral foramina is diminished more or less causing many disturbances such as subluxation of a part, interference with the vasomotor and constrictor dilator nerves with circulatory systems of the body resulting in some degree of anoxia and anoxemia. It also raises the diaphragm to some extent.
 

Instructions for Performing the Lake Head Recoil Adjustment.

Sit patient on a low stool. Stand on left of patient, put patient's arm back of him. The left hand of the doctor is then placed on the forehead of the patient with the heel of the hand on the frontal ridge of the nose, while the fingers rest lightly on forehead. No pressure should be exerted. The right arm encircles head all around, bringing the fingers to rest lightly on the wrist of the left hand. Now the adjustment emphasis is made just over the occipital, lambdoidal and mastoidal sutures, and in order for the fatty part of the forearm to fit snuggly on the skull, turn the head to the right three times very slowly, then bring head to dead center. To make sure it is in dead center, bend the head forward a little, then bring it back. Now put your feet in position for a proper body balance, so you will not slip. Next bring your chest over against the patient's head toward you. Now stretch the head of the patient upward slightly until all slack is taken out, then give a quick upward jerk, slightly raising the patient a little off the stool. Repeat on right side, reversing arms and contacts. (See Figs. 1, 2, 3.)
 

Cautions:

Do not hurry, make positive contacts first. Do not let encircling arm slip.

Do not press hard on forehead.

Watch that ear is not squeezed by encircling arm.

We all recognize that more blood must be poured into the affected regions. Massage of the neck muscles, with fingers digging deep into the muscles to squeeze the blood again into proper circulation, can follow the head adjustment. Heat applied in any form is helpful for this purpose.

THIRD TECHNIQUE. The External Carotid Sinus Adjustment.

This sinus is subject to the same types of collapse and block that affect the internal carotid sinus ; and it also presents syndromes.

In this sinus is found the external carotid artery, the external jugular vein, the lymphatics and the nerves that follow the external carotid artery. Just a little below the angle of the jaw, they all bifurcate into many branches, forming a meniscus, by which we mean a concavoconvex blending of the various arterial, lymphatic and nervous systems. Gravity and shock will completely or partially close the pathway to the blood and nerve supply of the external portions of the head and face. We can easily judge the far-reaching effects of a block here by indicating the nine branches - the superior thyroid, the lingual, the facial maxillary, the ascending pharyngeal, the sternocleido­mastoid, the occipital, the posterior auricular, the superficial, temporal and internal maxillary arteries. With these arteries must be included all the nerves, veins, and lymphatics that accompany them. It is the arterial supply with which we are concerned here. Anoxia and anoxemia created by the block will present syndromes of twitching and shaking, pain and pallor in any part of the external facial and cranial tissues.
 

The Technique.

Instructions: - Put the thumb and middle finger on the tip of the chin, slide them all the way back to the angle of the jaw. Drop fingers down one-half inch, push them easily into the neckwalls, and feel the tissues underneath your fingers. Hold steady for an instant, then thrust the fingers quickly inward and upward with about a three-pound pressure, then withdraw the fingers quickly. Note: Pressure can be measured on any ordinary scale. (See Figs. 4, 5, 6.)

FOURTH TECHNIQUE. Opening the Pharyngeal Cavity.

In the general technique here, we will not outline the treatments for any particular tissues of this area. Tonsils, epiglottis, sinuses, and eustachian tube deformities or dysfunctions are treated under specific techniques. In this general technique, we must first learn to enter the pharyngeal cavity and the cavity of Rosenmuller before applying specific techniques, and we must attempt to do so without giving unnecessary distress or pain. A brief outline of the pharyngeal area will not be amiss here.

The pharynx is the upper portion of the digestive tube. It communicates with the mouth, larynx, nasal cavities, eustachian tubes, and esophagus. It extends from the base of the skull to the sixth cervical vertebra. It is divided into the nasal, oral, and laryngeal pharynx. The pharynx is a musculomembranous sac about four inches in length, broader transversely than anteroposteriorly. In the nasal pharynx are situated the pharyngeal tonsils and the orifices of the eustachian tubes; the space posteriorly to the tubes in the lateral wall is called the lateral recess or fossa of Rosenmuller. The oropharynx is the portion between the soft palate and the superior border of the larynx; it contains the faucial tonsil. The laryngeal pharynx is that portion situated behind the larynx; it contains the sinus pyriformis. The blood supply is derived from the internal maxillary and facial arteries. Nerve supply is derived from the ninth and tenth nerves and the sympathetic system. (See Fig. 32.) 
 

The Technique.

Instructions: - Sit patient on stool and stand on right side of patient. Encircle the head of the patient with left arm, allowing tip of middle finger to rest lightly on the superior crest of the fronto nasal suture. Lock patient's head between left arm and thorax. Cover the finger of right hand with which you can reach the farthest and use most dexterously, with a finger cot, moistened with water, or some volatile soothing substance. Now hook this finger slightly and slide it along the side of the mouth until you touch the uvula. Tell the patient to cough, and to keep on coughing easily. While the coughing is going on, slide the finger, without any force, into the pharyngeal cavity a little past the first joint. Beginners should stop there without any further moves, until they have learned by practice the strategy of approach to that point without any difficulty. Some pharyngeal cavities and soft palate are so constricted that at first it seems to be impossible to open them. In all our years of practice we have found only one patient whose pharyngeal cavity we could not open. This patient, in childhood, had an operation which required suturing the soft palate in place. We succeeded in making an opening large enough to give some relief from the symptoms of puffiness and dyspnea of which the patient had complained. The first step then is to learn the strategy of approach. After this is done, the next step is to turn the finger from side to side very easily, noting the feel of semi-solid-like jelly substance, which is mucus. Note the septum. Is it regular in contour or bent? Feel for anything like strings of tissue or lumps that may be adhesions or adenoids. Do not attempt to operate yet. Wait until you have this technique as near perfection as possible.

The next step is to learn how to control your dilators and constrictors. If you find the cavity too moist with discharge from the membranous cells, you will press against the posterior wall where the vaso constrictors are located. If very dry, as in hay fever, sinusitis, asthma and some forms of headache, you will pull outward on the anterior wall where the vasodilators are located. It is of especial interest to the doctor to know that while he is giving this technique, though not specifically treating any portion, the patient will breathe and feel better, even from the beginning.
 

Some Ideas to Bear in Mind:

Do not struggle with the patient. If entrance cannot be made after the second attempt, then the matter should be given up for that day. Before the attempt is made, the philosophy should be briefly explained to the patient. Never forget you are after a healing crisis. Patients will complain that after the pharyngeal cavity has been cleaned out they have more "dropping in the throat than before." That proves your method is a success. You have established drainage; but to have a healing crisis, the treatments must continue for at least once a week until the drainage is no longer noticeable. If the soft palate adheres to the boundary ring of the posterior nares, have the patient hold some hot water in the mouth for a minute. If it still resists opening, turn a tonsil suction tube upside down and press the bulb five times. (See Figs. 7 and 8.)
 

FIFTH TECHNIQUE. Fixation Adjustment for the External and Middle Ear.

The word fixation means the putting of the bones and tissues in place, so that they can oscillate and carry sound vibrations. In addition to putting the bones and tissues in place, the technique creates a hyperemia, flooding the whole ear apparatus with the lubricants and nourishment they need. There are a number of theories relative to the transport of sound waves, but we have always accepted the vibrational resonant theory. This theory is built on the findings of anatomists that the basilar membranes of the ear are composed of transverse fibers that grow in thickness and length the deeper the ear is penetrated by sound, and each has an individual frequency of its own.  As the sound approaches the delicate analytical center in the brain, the fibers break down the tensity of sound. The other mechanisms are for the transport of sound waves.

A brief outline of the conveyance of sound vibrations, would be as follows : When the sound vibrations have reached the internal meatus of the ear, they are reflected so as to strike the cone or center of the membrana tympani or drumhead which divides the meatus from the middle ear. Vibrations set up in the drumhead create oscillations in the malleus which is attached to the drumhead at the manubrium or handle. The oscillations of the malleus are then reflected on the incus and in turn on the stapes. All of these can be said to be attached to each other by little tissue levers. The stapes, being in close relation to the oval window as it oscillates, strike the egg-shaped opening to the vestibule of the membranous labyrinth of the cochlea and stirs up the liquid named perilymph in the first two chambers of the cochlea known as the scala vestibule and the scala tympani. As this perilymph moves forward, it carries the sound impulses into contact with the third chamber known as the scala media where vibrations are set up in the endolymph. Then the vibrations in the endolymph are transmitted to the organs of Corti, which are the terminal acoustic apparatus in the cochlea. At the terminal of these organs of Corti begin the tendrons leading to the formation of the cochlear branch of the auditory nerve over which the vibrations are carried to the oliva of the medulla oblongata, then on to and through the lateral fillet to the posterior quadrigeminal bodies, to the auditory center in the superior temporal convolution.

The time of the reception of sound vibrations, its transport, analysis or interpretation and reaction differs in persons according to temperature, position and anatomical relationship of the structures over which the vibrations must pass, and also the pitch of the vibrations themselves. It is understood that the volume of vibrations capable of stimulating the human ear and producing reactions are from 16,000 to 20,000 vibrations per second, that below or above those figures man cannot perceive sounds, but that certain animals can. This may be due to the animal's having so many hair cells on its body which are sound conducting. The only possible standard that can be set for what can be termed normal reception and reaction to sound vibrations, is that of ordinary conversation, and the judge of this is the individual patient. Tests can be made by instruments but it is the patient who must report the reactions.

Deafness or slight deafness, impaired acuteness of hearing, are classified as (1) transmission or conductive deafness, due to interference with the conducting apparatus on its way to the inner ear, (2) perceptive deafness where the organs of Corti or the auditory nerve is affected and central deafness where there are perversions of the central nervous system in the brain. We are here concerned largely with the first, the apparatus. Should the air pressure on both sides of the tympanic membrane become unequal and remain that way for any length of time, the tympanum will either bulge inward or outward too far. A fixation of all the apparatus may occur. There may be some symptoms of tinnitus, but the main symptom is a fullness and dullness in all the area of the ear, with a lack of alertness in reception and consequently of reaction. The appearance of a certain degree of stupidity is noticeable, and the patient complains of being tired. The lack of oscillations in the apparatus for a long length of time can lead to a drying up process, then to ankylosis of the bones and tissues of the whole apparatus.
 

The Technique.

Instructions: - First, put the forefinger up to the second joint straight under the lobule of the pinna. Second, put the thumb on the antitragus. Do not use much pressure with the fingers, enough to make sure that the fingers will not slip. After contact has been made, hesitate for a few seconds, then give three three-pound jerks, downward, outward and upward, at about a fifty degree angle. Then quickly lay the knuckle of the fingers back of the ear with some pressure to aid in reducing the force of the vibrations set in motion. (See Fig. 18b for angles; also Fig. 9.)

Should the pinna of the ear be moist, it is best to wipe it off with fine tissue paper to avoid slipping,
 

SIXTH TECHNIQUE. Nasal Dilation and Drainage Technique.

No matter what the conditions may be, this technique will open the air passages and make the breathing easier.
 

Diseases of the Nose. Effect of Diseases of the Nasal Passages on Other Parts of the Body.

Because of the continuity of structure, nasal disease may extend to the pharynx or affect the other respiratory organs by abeyance of the functions of warming, moistening, and filtering the inspired air, so that it enters the pharynx cold, dry and dust-laden. Chronic pharyngitis and laryngitis frequently result from this cause. Nasal disease often induces certain reflex phenomena, viz., nasal cough, nasal asthma, nasal vertigo, nasal epilepsy, nasal chorea, hay-fever, paresis of the palate and larynx, neuralgia and headache, affections of the eye, suppuration of the orbit and meningitis by infection from suppurating accessory nasal sinuses.

The reflexes which originate in nasal or naso­pharyngeal irritation and terminate in cough, laryngeal spasm, or asthma, follow much the same pathway as the reflex known as sneezing. The nasal branches of the ophthalmic division of the fifth nerve and the nasal branches of the anterior palatine descending from Meckel's ganglion, which is in connection with the superior maxillary division of the fifth nerve, conduct the sensory impressions to the medulla. It is there reflected to the respiratory, pneumogastric and other centers; so what is termed a sneeze is the forced expiration, and the coincident spasm of the pharyngeal and laryngeal muscles.

The arteries of the nasal fossae are the anterior and posterior ethmoidal from the ophthalmic, the sphenopalatine branch of the internal maxillary, and the alveolar branch of the internal maxillary to the antrum.

The nerves of the nasal fossae are the nasal branch of the ophthalmic to the septum and outer wall, anterior branch of the superior maxillary to the inferior turbinated body, and the floor of the nose. The sphenopalatine ganglion gives off the Vidian nerve to the septum and superior turbinated body and the superior nasal branch to the same regions, the nasopalatine to the middle of the septum, and the anterior palatine to the middle and lower turbinates.

The olfactory or first cranial nerves from the olfactory bulb enter the nose through twelve or more openings in each side of the cribriform plate. They are distributed to the specialized nerve-endings in the mucous membrane of the superior turbinate nerve endings and a corresponding small region of the septum. 

The lymphatics of the nose are numerous. The more anterior terminate in the submaxillary glands, the posterior communicate with the pharyngeal glands. Hence the not uncommon slight inflammation of the tonsils and cervical lymphatics after nasal operations.
 

Physiology and Pathology of Mucous Membranes.

During respiration through a normal nose, the bulk of the air passes along the septum above the inferior, turbinated body, describing a semi-circle over and around each turbinate, smaller currents extend upward nearly to the roof of the nose, and then it spreads out like a fan in its passage through the nose. It is understood that the respiratory path changes with the shape of the nasal chambers. Abnormal dryness of the nasal mucous membrane, or nasal obstructions of any kind interfere with the free access of air.

The nose also serves as a resonant cavity during vocalizations, so that obstruction of the nasal chambers produces a peculiar nasal intonation during speech. Perhaps the most important function of the nose is to warm, moisten, and free from the dust inspired air. In health, exhaled air has a temperature of 98.5 degrees F., and it has been proved experimentally that most of the heat supplied to inhaled air comes from the nose, the turbinated bodies being well adapted not only to warm the inspired air, but to moisten it and free it from particles of dust which adhere to its moist, sticky surface.

The normal secretion of the nasal mucous membrane, is over 16 ounces of clear water mucus in twenty-four hours, a part of which in health passes unnoticed through the nasopharynx down into the esophagus and stomach. But obstructions cause this mucus to congest and become infected and inflamed, creating anoxia and anoxemia.
 

The Techniques.

There are seven moves to the sixth technique. The fact that they dilate and create a hyperemia in the nasal passages can be ascertained by the much easier breathing of the patient. It is also evidenced by the insertion of a nasal dilator before and after the treatment.

Instructions: - Move 1. Have patient sit on stool. Stand on right side of patient. Place your left hand just above the fronto-zygomatic suture, the heel of your right thumb at the pisiform process, just below the fronto suture. Hesitate for a moment, then give a thrust downward. Beginners should start giving easy thrusts at first. Move 2. Stay on right side. Put left hand over the fronto-nasal suture. Place dorsal portion of thumb and hand on bony bridge of nose. Hesitate. Give thrust downward. Move 3. Go to left of patient and repeat technique on the right fronto-zygomatic suture, reversing hands. Move 4. Stay on left side and feel for the naso-maxillary suture on the right side. Having found it, place the two middle fingers of both hands on opposite sides of suture. Press deeply without hurting. With back of fingers of each hand touching the other, cup the hands around the face. Using the face as a brace, hesitate for a moment, then give a quick jerk in opposite direction with the fingers only. Move 5. Go to the right side of the patient to adjust the left naso­maxillary suture and repeat as directed above. Move 6. Stay on right side of patient. Encircle head with right arm. Put pisiform portion or heel of thumb of left hand on the malar bone prominence. Press in deeply, hesitate, turn the hand downward slowly while pressing, then give a quick downward thrust. Move 7. Go to left side of patient, reversing hands to adjust right malar bone and repeat as directed in Move 6.

The Second Method. Go through all seven of the above moves. Stand on left side of patient with little finger of left hand in right nostril, right hand on malar prominence. With quick jerks on the malar bone by the right hand to open sutures, let the little finger slip up into the nostril. Do not push hard on the little finger or you will cause pain and bleeding which are not necessary if technique is performed correctly. (See Figs. 10, 11, 12, 13, 14, 15, 16, 17, 18, 19.)
 

SEVENTH TECHNIQUE. The Tonsil Technique.

We have always maintained that the tonsils should be preserved if at all possible. They exercise a protective function and destroy or lessen infections. They are formed by lymphatic tissue and make what is called the tonsillar ring completely around the throat; everything that enters the body, whether air, liquid, or solids must pass through this tonsillar ring. (Techniques for the various specific conditions of the tonsils are given in the next chapter.)

Functions o f the Tonsils:

1. To destroy anything of an infectious nature; 

2. To assist in the formation of white cells; 

3. To act as a lubricator to the throat.

It has been stated that the tonsils have a selective stimulative power; that is, that if an excessive amount of one type of food is ingested, impulses are sent to certain nerve centers which in turn send a strong reflex action to stimulate to a greater degree of activity the secretory glands in the organ in which that type of food is digested. We are not in a position to deny or affirm this theory, but another theory that we have some possibility of proving is that most people over seventy years of age still have their tonsils, or have never had them removed entirely.

It is generally accepted that the tonsils have a protective quality, and if so, have something to do with longevity.

The size of the tonsils depends on the amount of work they have to do. If the infection is too powerful, they have to work harder, which requires a greater blood supply; thus they sometimes become engorged and enlarged. This, however, is no reason for their removal.

Sometimes the infection is so severe that the tonsillar tissue itself is injured and pus forms in the crypts, but if the blood stream is healthy, nature will soon take care of the pus.

The problem before us, then, is to reduce the size of the tonsils by removing the cause of the enlargement, rather than to remove the tonsils. Again, the tonsils, like every other organ in the body, depend for their ability to function on normal conditions - a good blood stream founded on right living, right dietary and sedentary habits, right breathing and exercise, and freedom from retention of excessive waste matter and obstructions.
 

The Technique.

The general technique here is very simple, and if practiced sufficiently one becomes expert in handling emergencies of serious character in that locality.

Instructions: - Have patient sit on stool in front of the physician. Put left hand on head of patient; let finger slide down side of mouth to root of the tongue. Slide finger to center of tongue. Curve the finger, then using slight pressure, let it slide into the top of the right tonsil, press a little, then massage from left to right. The time for performing this technique by the beginner should be about half a minute. (See Figs. 20 and 21.)

EIGHTH TECHNIQUE. Massage and Dilation o f the Pharynx and Larynx.

There are so many abnormal conditions that take place in the larynx that we will pass them on to specific techniques, and give here the general technique which we have found useful in all laryngeal conditions.

This technique is especially beneficial to public speakers, singers and for loss of voice in general. With a special astringent on the finger cot, the affected points should be massaged and pressed. If there is an acute condition with pain, ice pellets in the mouth and heat applied to the neck for a time will reduce the acute symptoms enough to permit manipulation.
 

The Technique.

Instructions: - After washing hands thoroughly, dip finger covered by finger cot into cold water; now slide the finger down the side of the mouth until it reaches the root or base of the tongue, then quickly slide finger over to the middle of the tongue. (Get one pressure on finger and maintain it all through the operation; if air gets under finger, patient will gag.) Now, with your finger in middle of the tongue, move the finger backward until you reach the epiglottis. Your finger is now in the valleculae, one on either side of the glossoepiglottic fold. Now massage right and left and up and down five or six times. When you are withdrawing your finger, pull the tongue upward and outward. Many abnormal conditions in the larynx are due to ptosis of the tongue.

For anemia, enervation or congestion, this operation puts the tissues in place, and creates a freer circulation of blood fluids around the area. Some authorities have suggested using two fingers to perform this operation, one on each side of the mouth. We leave this to the discretion of the individual practitioner. (See Fig. 22.)
 

NINTH TECHNIQUE. The Tracheal Adjustment Technique.

Dr. J. Everett Clark has written a delightful little essay on this technique, and we are using excerpts of it here, and also his techniques, by his kind permission.

Anatomy and Physiology.

The trachea or wind pipe, a wide tube, is kept permanently patented by a series of bent cartilaginous bars embedded in its wall. These bars are deficient dorsally and consequently the tube is not completely cylindrical. Its dorsal wall is flattened. The trachea begins at the inferior border, the cricoid and trichoid cartilage opposite the inferior margin of the Sixth cervical vertebra. It is about 4 1/2 inches long in the male and 32 inches long in the female, when relaxed. This is controlled through the action of the lower cervical and upper dorsal vertebra.

The upper part is the beginning of the thyroid cartilage and is practically surrounded by the thyroid gland. It is an anterior protection for the esophagus while the spine protects it posteriorly. The rings or bars that surround the wall of the trachea are the part of the anatomical structure in which we are particularly interested at this time. The trachea helps to protect the subclavian artery, and is also a protector for the mouth of the aorta. It also controls the bronchus and bronchii. Very briefly, it protects, also assists or controls to some extent, the vagus nerve and several very important glands such as the thyroid, parathyroid, thoracic duct, and entrance to the pleura; it reacts to the intercostal artery and also the innominate artery. Indirectly it has many contacts. It affects and is affected by the sixth and seventh cervical, and the first, second, third, fourth and fifth dorsal vertebra. Its reflex operations are innumerable.
 

INSTRUCTIONS BY DR. CLARK TO PERFORM THE TECHNIQUE.

1. Have the patient sit on a stool so that you, the doctor and operator can stand directly behind him. 2. Place the right or left leg directly at patient's back and the other leg just behind the other to give you support. 3. Ask patient to relax as much as possible. 4. Place the thumbs of each hand on the point of the jaw most prominent, and the little fingers of each hand on the superior point of the collar bone. The positions assumed by the thumbs and fingers are for balance and control of the amount of pressure to be used in the adjustments. 5. With thumbs and little fingers in position, palpate with the other three fingers of each hand both sides of the trachea. Some of the rings will probably be out of line in the majority of people examined. Laterality is the greatest cause of distress in the tracheal area. 6. Having found by palpation a distortion of one or more rings of the trachea, the physician proceeds as follows: The patient is asked to breathe deeply, and while in the act of doing so, a light thrust is given on the body of the ring at the greatest point of laterality. 

As an illustration, suppose the third ring was right: Place palmar surface of third finger of right hand on the posterior lateral point and let the other fingers rest gently against the rest of the trachea.

On the left side place all fingers against the posterior rings, laterally, and hold gently for position. Thrust gently from right laterally to the left. You will hear it snap into alignment. If 4 is out on the left, move both hands down and thrust with third palmar finger from left to right. Most of the work is done_. with the third finger, palmar surface.

There are many conditions that will be helped by the technique; namely, bronchial, cardiac and thyroid disorders, vagus reflexes, common nerve reflexes, stomach and intestinal conditions, general nervousness and many others.
 

TENTH TECHNIQUE. Releasing and Raising the Glands of the Neck Area.

Any deformities in or around the thyroid, parathyroid or thymus glands will, if enlarged, contracted or displaced, interfere with the intake of oxygen and air. The interference is direct by pressure and indirect by the malfunctioning of the glands themselves.
 

Parathyroid Glands.

These are four small glands about the size of a pea, two on each side of the back of, and at the lower edge of, the thyroid gland. They control the calcium phosphate balance of the body with the aid of the adrenal glands. They reduce the calcium in bones while the adrenals increase the calcium in bones. The loss of calcium promotes excitability, muscular contractions, and probably is the basis of some types of epilepsy and pseudo epilepsy.

A second function of the parathyroid glands is the neutralization of certain toxic wastes generated in the gastro intestinal tract as a result of proteolytic bacteria.

Specific abnormal conditions of the thyroglossal duct, parathyroids, thyroid and thymus glands are treated in the next chapter. In many cases we have found the general technique given here, as a supplement to our other treatments, sufficient to bring about very beneficial results in diseases of those glands.
 

The Techniques.

First: Breaking adhesions. 

Second: Raising the Glands.

The first step is to make sure of the location of the glands. This is accomplished by massing the muscles of the neck between the fingers until a semi-solid like substance is felt in the shape of the little finger. Take it for granted that if the thyroid glands are down and out of position, all the others are also. After finding the gland on one side, press the fingers easily but deeply in between the trachea and the gland, and feel for adhesions. They are string-like tissue. They may be single or in clusters of two to five. Now release that side and dig deep into the other side of the gland to ascertain if adhesions are binding the gland to the anterior, lateral or posterior branchial walls. We have found it best to try and count these adhesions and not to break more than two at a sitting, or to give more than two operations a week unless the acute condition makes the complete operation imperative at one sitting.

Instructions: - Patient sits on a low stool. He should be made to relax - tell him a funny story if necessary. Place the fingers of one hand between the trachea and the gland, then go deep without hurting, sliding fingers up and, down. Adhesions are stringlike; sometimes they are in clusters of three to five, but more often they are individual adhesions. Having located one, slide the finger over tightly against its origin in the gland. With the finger of the other hand, cover its insertion into the tracheal tissue. Let the finger tips touch, with hands raised so back of hands almost touch. Then, holding position, bring hands around neck, after a few seconds of pause, quickly snap the fingers inward and outward. Never hurry. Take time to make sure of your diagnosis and contacts. This same process is used to break adhesions in the. external lateral portion of the gland where it is embedded in the branchial walls. (See Figs. 23 and 24.)
 

THYMUS GLAND.  

To find adhesions of the thymus gland, run fingers along the clavicle bone. The adhesions here must not be mistaken for normal tissues that have pathways upward and downward. It would be well for the student to review the anatomy of this whole section before attempting diagnosis. We can be assured, however, that with the small force needed to break adhesions here, only good can come of the treatment to all the tissues. This technique is repeated on the other side if deemed necessary.

Instruction: - Patient sits on stool, the doctor standing on the right side of him. Put left thumb on clavicle bone over adhesion. Bend patient's head until it rests lightly on chest of the doctor. Put right hand cuffed just under angle of the jaw of patient. Hold firm with left thumb over adhesion, then with the right hand fitting snugly so it will not slip, give an upward recoil jerk. The first time the doctor performs this technique, his jerk should be very light, but always quickly, as in a recoil. Repeat on other side of neck. (See Fig. 25.)
 

Raising All the Glands.

Instructions: - To raise all the glands of the neck, have patient sit on stool. The doctor stands on right side a little behind patient, patient's head resting on doctor's chest. Cup one hand, with the ulnar border of the hand pressed into the neck tissue. The other hand is then cupped equally over the other hand. Hesitate a moment. Now give a jerk upward with the right hand only. Using both hands to give the adjustment will cause the left hand to slip. Three of these adjustments at a sitting is sufficient; one just above the clavicle bone, one in the middle of the neck, and the other just below the ear. It must be done on both sides of the neck, reversing the hands and position of the doctor. (See Fig. 26.)

ELEVENTH TECHNIQUE. Raising of the Diaphragm Techniques.

The diaphragm can be called the second heart of the body. Its importance has been overlooked. We had intended to give here a complete outline of its anatomical structure and functions, but found it would have enlarged the size of this volume considerably. We have, therefore, just briefly outlined some essential points.

The diaphragm is a muscular organ composed on each side of two parts, which are different in origin and nerve supply. These two parts are the spinal and sternocostal. The first arises from the lumbar vertebrae and curves upward and forward, and as it expands is inserted into the central tendon. The second, the sternocostal, is composed (1) a rather short pair of narrow muscles that arise from the back of the xiphoid process, and curve backward and slightly upward to be inserted into the tip of the central tendon; (2) a broad flat muscular sheet that arises on each side by several fascicles from the lower fifth and sixth costal cartilages. This muscle invests the whole of the thoracic cavity and is a tough fibrous membrane. The central tendon is situated near the sternum. It makes up one third of the diaphragmic surface.
 

Functions.

There is no muscle or organ in the body that performs so many functions as the diaphragm because of its many contacts. It is in intimate contact with the pleural, pericardial and peritoneal sacs, liver, spleen, stomach, parts of the intestines, adrenals, pancreas and kidneys. It is in close contact with important structures that pass through the diaphragm; namely, the esophagus, the vena cava, aorta, thoracic duct in addition to some smaller vessels and important nerves that pierce the diaphragm. All of these contract or expand with every diaphragmic action, and disturbances of the diaphragm as explained by Sir Arthur Keith in his book "The Engines of the Human Body" are quite intriguing. He has likened the diaphragm to a piston working in a cone-shaped cylinder, the thorax. Contraction of the crural parts of the diaphragm causes the piston to descend. At the same time, the dome-shaped sternocostal parts contract and flatten, pushing the abdominal viscera downward and forward, and aid in the elevation of the lower ribs. Thus the descent of the diaphragm increases the volume of the thorax and compresses the abdominal viscera; the pressure in the abdomen rises as that in the thorax falls. The piston is then pushed up passively through contraction of the strong abdominal muscles, which press the viscera against the now related diaphragm; with its ascent, the reciprocal pressure relation between abdomen and thorax is reversed.

The muscular activity of the diaphragm may be regarded as rhythmic fluctuations of tonus; ordinarily, only some of its fibers, and not always the same ones, are active. This fact explains the absence of fatigue.

The actual functions of the diaphragm then are as follows:

1. Of vital importance in proper respiration.

2. Buffer between the thoracic and abdominal cavities. 

3. Important effect upon the circulation of the blood.

It is now becoming more and more apparent that the pumping action of the diaphragm is of almost as much importance as the pumping action of the heart. The right side of the heart receives more blood on every inspiration. The liver is like a sponge, which to be kept resilient must have something to continually squeeze it out. If the diaphragm is in proper working order, the liver is compressed directly between the diaphragm and the abdominal wall, the blood is squeezed out, then on relaxation of the diaphragm, an inflow of blood takes place. This in and out movement is also the action upon all of the fluids of the tissues and organs in the whole abdominal cavity. Many conditions of illness are due to a ptosed or misplaced diaphragm, which creates first anoxia and then anoxemia, followed by stasis and congestions or anemias of certain organs. The ptosing of the diaphragm is responsible in a large measure for the excessive rise of carbonic gases which create disturbances in the cranial cavity, and downward create constipation, hernias, and hemorrhoids. Because of its intimate relationship with the respiratory apparatus, its malfunction will ultimately have a serious effect on the production of asthma, dyspnoea and other abnormalities of the respiratory system. Furthermore, because of its intimate relationship to the pericardial sac, we are led to believe that the heart is sometimes injured severely by the ptosis. We have seen pain around the heart and left arm disappear almost instantly by correction of a football bulge in the lower abdomen.
 

The Technique.

There are two efforts that can be made by the doctor, and one by the patient to raise the diaphragm. The first is the "Rolling Method."

Instructions: - Patient lies in the dorsal position with knees flexed; the doctor stands on one side of the patient. Doctor places his hands straight upward on the abdomen, on a line straight across from the angle of the ribs. The doctor pushes his fingers deep into the tissues holding for a second; then as they are released, the thumbs go in deep under the fold the fingers have made, and the thumbs push the mass upward. The fingers are pressed in behind the mass where the thumbs are holding. The thumbs are released and the rolling up movement is continued until a straight line is reached from the crest of one ilium to the other. Then if the doctor has an assistant, he can stretch a piece of adhesive tape across from one ilium to the other, or the doctor can ask the patient to hold the abdomen up while he puts the adhesive on. The adhesive need not be more than two inches wide. This will hold the whole mass up until a belt can be procured. The adhesive should be kept on only until patient can procure an abdominal belt. For obvious reasons, the adhesive should not be left on more than a few days.
 

The second method is as follows:

Instructions: - Patient sits straight up on a stool with arms upstretched. Doctor puts arms around patient with the ulnar portion of hands pressed into the fascia over the inguinal ring. After contact is made, five quick jerks are made upward, spacing them equally between the inguinal ring and the lateral angle of the lower ribs. If the doctor desires he can instruct the patient to do this technique at home. However, we have always found it best to have the patient wear a belt for awhile, and we do the relaxing technique at the office. Patients are usually too busy, too lazy or too worried to carry out the instructions properly. (See Figs. 27, 28.)