eper
location and could only be followed with the bronchoscope. Sudden
respiratory arrest might occur, from pathology or foreign body,
necessitating the inserting of the bronchoscope for breathing
purposes, and the insufflation of oxygen and amyl nitrite. Trachectomy
might be required for dyspnea or other reasons. It might be necessary
to explore the esophagus for conditions associated with laryngeal
lesions, as for instance a foreign body in the esophagus causing
dyspnea by pressure. In short, when planning for direct laryngoscopy,
bronchoscopy, or esophagoscopy, prepare for all three, and for
tracheotomy. A properly done direct laryngoscopy would never
precipitate a tracheotomy in an unanesthetized patient; but direct
laryngoscopy has to deal so frequently with laryngeal stenosis, that
routine preparation for tracheotomy a hundred unnecessary times is
fully compensated for by the certainty of preparedness when the rare
but urgent occasion arises.

_Direct Laryngoscopy in Children_.--The epiglottis in children is
usually strongly curled, often omega shaped, and is very elusive and
slippery. The larynx of a child is very freely movable in the neck
during respiration and deglutition, and has a strong tendency to
retreat downward during examination, and thus withdraw the epiglottis
after the arytenoids have been exposed. In following down with the
laryngoscope the speculum is prone to enter the hypopharynx. Lifting
in this location will expose the mouth of the esophagus and shut off
the larynx, and may cause respiratory arrest. Practice, however, will
soon develop a technic and ability to recognize the landmarks in state
of spasm, so that on exposing the approximated arytenoid eminences the
endoscopist will maintain his position and wait for the larynx to
open. The procedure should be done without any form of anesthesia for
the following reasons:
1. Anesthesia is unnecessary.
2. It is extremely dangerous in a dyspneic patient.
3. It is inadmissable in a patient with diphtheria.
4. If anesthesia is to be used, direct laryngoscopy will never reach
its full degree of usefulness, because anesthesia makes a major
procedure out of a minor one.
5. Cocain in children is dangerous, and its application more
annoying than the examination.

_Inducing a Child to Open its Mouth (Author's Method)_.--The wounding
of the child's mouth, gums, and lips, in the often inefficacious
methods with gags, hemostats, raspatories, etc