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it reaches the pharynx. Push the catheter until it touches the posterior wall of the pharynx; withdraw the instrument about one half of an inch, and direct its point outward and slightly upward toward the corresponding ear, touching the side wall of the pharynx. A sensation, as if the catheter is grasped, is felt when its point engages in the orifice of the canal. Generally the opening is sought for too far posteriorly. The catheter may be passed from the opposite nostril, or from the mouth.

Confirm the introduction, if desirable, by using the otiscope, to hear the rush of air when forced through the catheter into the tympanum.

Probing of the Nasal Duct.-Pull down the lower lid to expose the punctum with the orifice of the lower canaliculus. Introduce a small silver probe perpendicularly, into the orifice and then turn its point horizontally inward, following the canal until it touches the inner bony wall of the lachrymal sac. The point is now directed downward almost perpendicularly, with a slight inclination backward and outward, and advanced until it appears in the inferior meatus of the corresponding nostril. The canal trav. ersed is about an inch in length.

Catheterism of the Larynx.The mouth is held open by means of a mouth-gag if necessary. With the left index-finger passed back to the root of the tongue, feel and hook forward the epiglottis. Pass the catheter, keeping its beak against the finger, until it reaches the epiglottis. Direct the beak of the cathe- . ter over the epiglottis, and down its posterior surface into the larynx.

Intubation of the Larynx.Direct O’Dwyer's tube of suitable size by the foregoing manipulations into the larynx. Push the tube loose from the obturator, and sink it down into the larynx until the epiglottis can close over its opening. A piece of thread passed through the opening in the anterior angle of the tube, and out of the mouth, prevents its descent into the @sophagus if the introduction has been faulty. Withdraw the thread, if the tube has been correctly introduced, holding the finger against the tube to prevent the thread drawing upon it.

To withdraw the tube, the extractor is guided into the opening in the tube, and its blades separated, to hold it firmly. It can now be removed, keeping the blades of the extractor separated during the removal.

Stomach-Tube, (Esophageal Probang, or Bougie. -Push the head of the subject back so as to make the canal to be traversed as straight as possible. Pass the tube, probang, or bougie, to the posterior wall of the pharynx. Place the left index-finger so as to protect the larynx, until the instrument has been directed down the cesophagus along the posterior pharyngeal wall for several inches. Remove the finger from the mouth. Bend the head forward to make a curve in the cervical region corresponding to the dorsal curve. Gently introduce about eighteen inches of tubing when the stomach will be entered.

The esophageal probang is introduced beyond the body to be removed, when the bristles are spread and the body drawn up.

If the tube is passed through the nostril, give it a slight bend downward, so that, when it meets the posterior wall of the pharynx, it will be directed downward.

Catheterization of the Urethra.To pass a catheter or sound through the male urethra, the body must be laid on the back, the shoulders elevated, and the hip-joints slightly flexed and rotated outward, the thighs being separated. Stand on the left side facing the head of the subject, and grasp the penis behind the corona glandis between the middle and ring fingers of the left hand with the palm turned upward. Separate the lips of the meatus with the left thumb and index-finger, and raise the penis. Hold lightly by its extremity the oiled catheter or sound between the right thumb and index and middle fingers. Enter the beak of the instrument into the meatus, keeping the handle depressed and the shaft horizontally lying over the left groin. By pulling the penis over the instrument thus held, with slight pressure, it will be “swallowed” until its beak is below the pubes. Revolve the shaft of the instrument horizontally until it occupies the median plane of the body lying on a line which would run from the umbilicus to the

symphysis pubis. The beak being fairly engaged under the symphysis, begin to raise the handle of the instrument, supporting more than its weight, so that the beak will follow the roof of the canal. The left index-finger can support the convexity of the instrument by pressure over it through the rectal wall or perinæum. The handle is made to revolve through a semicircle in the vertical plane running through the median line of the body. While the handle is being depressed between the thighs, the finger supporting the convexity makes the beak of the instrument continue to follow the roof of the canal. If the beak circles around the shaft when turned, the catheter is in the viscus.

On a fat subject the tour du maitre is convenient. The body is placed as before, but the operator stands on the right side facing the head of the subject. The handle of the instrument may be held between the thighs, or over the left thigh, with the shaft lying horizontally. The instrument is introduced as before until the beak reaches the bulb, when the handle is made to describe an arc toward the umbilicus, being continually raised until the median vertical plane is reached, when it is depressed as before between the thighs.

To introduce rubber catheters requires no manipulative skill.

Tunneled Sounds and Catheters. These are introduced upon a guide of rubber or whalebone. Inject so as to distend with oil the urethra. Introduce a filiform bougie, avoiding the lacunæ, on the roof of the urethra, for the first inch. If it is arrested, introduce another, and so on until six or eight are introduced. Alternate the ends introduced—first straight, then spiral and angular. By withdrawing and then advancing with a screwing motion, one of the bunch will enter the bladder; withdraw the others. The protruding end is now threaded through the tunnel of the catheter, and held firmly between the left thumb and index-finger. The sound is made to fol. low the same manœuvres as the ordinary sound, but is guided by the filiform bougie, without force, into the bladder.

To catheterize the female urethra, turn the subject on the back, semiflex the hip and knee joints, and separate the thighs. Stand on the right side, facing the head of the subject. Hold the oiled catheter near its beak between the right thumb and indexfinger, overlapping its end with the index-finger. Pass the hand holding the catheter under the right knee, and separate the labia with the index-finger from below upward, until the upper edge of the vagina is felt. Feel for the prominent urethral papilla, about one half of an inch above this, and place the pulp of the index-finger at its lower border. The catheter can now be easily guided over the pulp of the finger into the urethra and on into the bladder. It may be necessary to follow the cord-like urethra, felt through the anterior vaginal wall, up to the papilla.

If a soft catheter is used, pass the left hand over the thigh, to aid in its introduction.

Introduction of Rectal Bougies.Place the subject on the back with the knees and hip-joints flexed, and the buttock at the edge of the table; or on the side with the hip-joints and knees semiflexed. Gently enter the oiled point of the bougie into the anal orifice, inclining it slightly forward. Direct the point for the first inch and a half forward toward the bladder. Now introduce the bougie until five inches have entered the rectum with the point directed nearly horizontally toward the middle of the sacrum. If the bougie is to be further introduced, its point should be directed a little forward and to the left, as if to strike the abdominal wall two inches to the left of the umbilicus.

III. PLUGGING THE POSTERIOR NARES.

Place the subject on the back with the head slightly raised upon a block. Separate the jaws by

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