THE MOUTH AND THROAT. 



121 



catheter in a vertical position and then change to a horizontal one as soon as the beak 

 passes over the elevation which marks the separation of the vestibule of the nose from 

 the interior. If this method is used, care should be taken to keep the tip of the catheter 

 on the floor of the nose and not pass it up in the region of the middle turbinate bone. 



There are three ways of introducing the beak of the catheter into the mouth of 

 the tube after it is felt touching the posterior pharyngeal wall. The first is to with- 

 draw the beak about 2 cm. away from the 

 wall of the pharynx and then turn it upward 

 and outward, pushing it a trifle onward. 

 The second way is to turn the beak directly 

 outward and draw it forward, when it can 

 be felt passing over the cartilaginous open- 

 ing of the tube. The third way is to turn 

 the beak inward and draw it forward until 

 it catches behind the septum. This is op- 

 posite the anterior edge of the mouth of 

 the tube. The beak is then rotated down- 

 ward and then upward and outward into 

 the tube. 



Liquids and sprays are sometimes in- 

 jected into the ear through the catheter; 

 bougies are also passed into the tube in the 

 same manner as the catheter or, if flexible 

 bougies are used, they are passed through 

 the catheter. As the tip of the bougie 

 passes into the bony portion of the canal, 

 the constriction of the isthmus can be felt 

 2.5 cm. up from its mouth. The bougie 

 should not be passed farther than 3 cm. 

 into the tube, otherwise, if the tympanum is entered, the ossicles are apt to be injured. 



Openings of the Mouth, Larynx, and CEsophagus. The opening of the 

 mouth into the pharynx is sometimes narrowed from cicatricial contractions, resulting 



FIG. 152. Introducing the Eustachian catheter, first 

 step. 



FIG. 153. Introducing the Eustachian catheter, 

 second step. 



FIG. 154. Introducing the Eustachian catheter, 

 third step. 



from ulcerative processes due to syphilis, caustics, etc. There is rarely obstruction 

 downward, so that these patients can usually swallow, but the cicatrices contract the 

 opening upward, and the soft palate, its arches, and the walls of the pharynx may be 

 all bound together in one cicatricial mass, preventing, as I have seen, all respiration 

 through the nose. This condition is an exceedingly difficult one to remedy, as the 

 contraction tends to recur even after the most radical operations. 



The opening into the larynx is more accessible than is often supposed. On 

 drawing the tongue well forward, the tip of the epiglottis can be seen. If a long 



