n6 APPLIED ANATOMY. 



Enucleation is performed by grasping the tonsil with toothed forceps, drawing it 

 out, and cutting it loose with knife or scissors from its attachments to the pillars and 

 aponeurosis beneath. Sometimes after loosening its attachments above it is torn 

 loose or shelled out, from above downward, by the finger or a blunt instrument. On 

 account of the capsule sending prolongations into the tonsil, it cannot readily be 

 ' ' shelled out ' ' and portions may remain and require to be removed with the forceps 

 and scissors or tonsillar punch. It is a disagreeable and bloody procedure and is 

 usually done under a general anaesthetic. 



Retropharyngeal abscess may arise from any one of three causes, cervical 

 caries, suppuration of lymphatic nodes, or extension of pus from the middle ear 

 through the canal for the tensor tympani muscle. The pharyngeal aponeurosis lies 

 under the mucous membrane and between it and the constrictor muscle. It is thick 

 above and fades away below. It fills up the gap above between the superior constric- 

 tor and the base of the skull and is attached to the pharyngeal spine on the under surface 

 of the basilar process. It is lined with the mucous membrane and covered by the 

 constrictor muscles. Over all is the buccopharyngeal fascia, a thin layer continu- 

 ous forward over the buccinator muscle and separated from the prevertebral fascia 



FIG. 145. Cervical caries with retropharyngeal abscess opening just posterior to the sternonMistoid muscle. 



by very loose connective tissue. The space between these two layers of fascia 

 is known as the retropharyngeal space and pus can follow it downward behind the 

 pharynx and oesophagus into the posterior mediastinum. Retropharyngeal abscesses 

 occur beneath the pharyngeal aponeurosis and bulge into the throat. On account 

 of the looseness of this aponeurosis and its lack of firm attachments, these abscesses 

 may not bulge forward as a distinct circumscribed swelling as abscesses do elsewhere, 

 but are more apt to gravitate downward and hang in a loose bag-like manner opposite 

 the base of the tongue. They are not easily felt, being so soft, and to see them prop- 

 erly the tongue should be held down with a tongue depressor. In looking for their 

 origin, a careful examination of the spine should be made to detect the possible 

 existence of spinal caries or Pott's disease, and the ear should be examined for suppur- 

 ative otitis media. The lymph-nodes, which sometimes give rise to these abscesses, 

 are one or two lying on the anterior surface of the vertebral column between it and the 

 pharyngeal aponeurosis and constrictor muscles. In evacuating these abscesses the 

 safest way is to place the child on its back with the head hanging, the pus then gravi- 

 tates toward the roof of the pharynx. The tongue is held out of the way with a tongue 

 depressor and the abscess can be well seen and incised. If the flow of pus is free, as 

 soon as the incision is made, if in a child, the feet may be grasped and elevated, the 

 head hanging downward, and the pus will flow out of the mouth. 



