98 THE PHARYNX AND NASOPHARYNX noted, but size is not an indication of sepsis. The surface of the tonsils is examined to see whether the mouths of the crypts contain pus. In the adult the tonsil may be squeezed by the pressure of a spatula on the anterior pillar to see if pus or food particles are extruded from the crypts. Pus is fluid, but particles of food appear as solid yellowish pellets which have an unpleasant smell and taste, of which the patient often complains. The free edge of the anterior pillar is examined for a band of congestion in this area. The neck is then palpated for enlarged cervical lymph nodes. There are no absolute criteria of tonsillar sepsis on inspection, but the combination of palpable cervical glands, flushing along the free edge of the anterior pillar, and the presence of pus hi the tonsillar crypts is generally agreed to denote sepsis in the tonsil. Attention is then turned to the condition of the mucosa of the posterior pharyngeal wall. Dryness and glazing of the epithelium suggests an atrophic condition in the nose. Mucopus may be seen coming down from the naso- pharynx to suggest sinus infection. Dilated blood vessels may be seen on the pharyngeal wall or on the surface of the tonsil. In some cases there is a roughness of the mucosa, or small submucosal swellings due to discrete lymphoid nodules. An appearance suggesting an abnormal gland may be suspected in thin, long-necked people if they are examined with the head slightly rotated to one side. This swelling is due to the prominence of a cervical vertebra. EXAMINATION IN CHILDREN Most children can be coaxed to open their mouths sufficiently to allow an adequate examination of the pharynx without the use of a depressor. Indeed, most children resent having a spatula inserted into their mouths, and it is wise not to use one except in the case of the child who clamps his mouth tightly. The young child will be sat on his mother's knee, and she should hold his hands. Mothers should not be encouraged to hold their child's head, because they usually over-restrain the child who becomes fractious. Children over the age of 4 years will usually sit by themselves provided that the mother is close by. The child will open his mouth, and the older one will say ""aK which is sufficient to depress the tongue and expose the tonsils and pharynx. The younger child can generally be persuaded to put his tongue out, and this protrudes the anterior pillars so that the tonsils are swung into view. Difficulty is usually only experienced with frightened children. Those who howl will open their mouths sufficiently to allow an inspection. The child who clamps his jaws tightly must be examined with a tongue depressor which is of a suitably small size. It is inserted between the cheek and the teeth and the tip is turned medially behind the back teeth, and as this makes the child gag the pharynx is exposed, even if momentarily. Examination of the nasopharynx (posterior rhinoscopy) has been described on p. 13.