to use as the protected, double aperture tubes.]

[FIG. 10.—The author's malleable tracheotomic aspirating tube for removal of secretions, exudates, crusts, etc., from the tracheobronchial tree through the tracheotomic wound without a bronchoscope. The tube is made of copper so that it can be bent to any curve, and the copper wire stylet prevents kinking. The stylet is removed before using the tube for aspiration.]

[28] Aspirators.—The various electric aspirators so universally used in throat operations should be utilized to withdraw secretions in the tubes fitted with drainage canals. They, however, have the disadvantages of not being easily transported, and of occasionally being out of order. The hand aspirator shown in Fig. 11 is, therefore, a necessary part of the instrumental equipment. It never fails to work, is portable, and affords both positive and negative pressures. The positive pressure is sometimes useful in clearing the drainage canal of any particles of food, tissue, clots, or secretion which may obstruct it; and it also serves to fill the stomach or esophagus with air when the ballooning procedure is used. The mechanical aspirator (Fig. 12) is highly efficient and is the one used in the Bronchoscopic Clinic. The positive pressure will quickly clear obstructed drainage canals, and may be used while the esophagoscope is in situ, by simply detaching the minus pressure tube and attaching the plus pressure. In the lungs, however, high plus pressures are so dangerous that the pressure valve must be lowered.

[Fig. 11—Portable aspirator for endoscopy with additional tube connected with the plus pressure side for use in case of occlusion of the drainage canal. This aspirator has the advantage of great power with portability. Where portability is not required the electrically operated aspirator is better.]

[FIG. 12.—Robinson mechanical aspirator adapted for bronchoscopic and esophagoscopic aspiration by the author. The positive pressure is used for clearing obstructed drainage canals and tubes.]

[FIG. 13.—Apparatus for insufflation of ether or chloroform during bronchoscopy, for those who may desire to use general anesthesia. The mechanical methods of intratracheal insufflation anesthesia subsequently developed by Meltzer and Auer, Elsberg, Geo. P. Muller and others have rightly superseded this apparatus for all general surgical purposes.]

Sponge-pumping.—While the usually thin, watery esophageal and gastric secretions, if free from food, are readily aspirated through a drainage canal, the secretions of the bronchi are often thick and mucilaginous and aspirated with difficulty. Further-more, bronchial secretions as a rule are not collected in pools, but are distributed over the walls of the larger bronchi and continuously well up from smaller bronchi during cough. The aspirating bronchoscopes should be used whenever their very slight additional area of cross-section is unobjectionable. In most cases, however, the most advantageous way to remove bronchial secretion has been found to be by introducing a gauze swab on a long sponge carrier (Fig. 14), so that the sponge extends beyond the distal end of the bronchoscope, causing cough. Then withdrawal of the sponge carrier will remove all of the secretion in the tube just as the plunger in a pump will lift all of the water above it. By this maneuver the walls of the bronchus are wiped free from secretions, and the lamp itself is cleansed.

[FIG. 14.—Sponge carrier with long collar for carrying the small sponges shown in Fig. 15. The collar screws down as in the Coolidge cotton carrier. About a dozen of these are needed and they should all be small enough to go through the 4 mm. (diameter) bronchoscope and long enough to reach through the 53 cm. (length) esophagoscope, so that one set will do for all tubes. The schema shows method of sponging. The carrier C, armed with the sponge, S, when rotated as shown by the dart, D, wipes the field, P, at the same time wiping the lamp, L. The lamp does not need ever to be withdrawn for cleaning during bronchoscopy. It is protected in a recess so that it does not catch in the sponges.]

[FIG 15.—Exact size to which the bandage-gauze is cut to make endoscopic sponges. Each rectangle is the size for the tubal diameter given. The dimensions of the respective rectangles are not given because it is easier for the nurse or any one to cut a cardboard pattern of each size directly from this drawing. The gauze rectangles are folded up endwise as shown at A, then once in the middle as at B, then strung one dozen on a safety pin. In America gauze bandages run about 16 threads to the centimeter. Different material might require a slightly different size and the pattern could be made to suit.]

[32] The gauze sponges are made by the instrument nurse as directed in Fig. 15, and are strung on safety pins, wrapped in paper, the size indicated by a figure on the wrapper, and then sterilized in an autoclave. The sterile packages are opened only as needed. These "bronchoscopic sponges" are also made by Johnston and Johnston, of New Brunswick, N. J. and are sold in the shops.

Mouth-gag.—Wide gagging prevents proper exposure of the larynx by forcing the mandible down on the hyoid bone. The mouth should be gently opened and a bite block (Fig. 16) inserted between the teeth on the left side of the patient's mouth, to prevent closing of the jaws on the delicate bronchoscope or esophagoscope.

[FIG. 16.—Bite block to be inserted between the teeth to prevent closure of the jaws on the endoscopic tube. This is the McKee-McCready modification of the Boyce thimble with the omission of the etherizing tube, which is no longer needed. The block has been improved by Dr. W. F. Moore of the Bronchoscopic Clinic.]

Forceps.—Delicacy of touch and manipulation are an absolute necessity if the endoscopist is to avoid mortality; therefore, heavily built and spring-opposed forceps are dangerous as well as useless. For foreign-body work in the larynx, and for the removal of benign laryngeal growths, the alligator forceps with roughened jaws shown in Fig. 17 serve every purpose.

[FIG. 17.—Laryngeal grasping forceps designed by Mosher. For my own use I have taken off the ratchet-locking device for all general work, to be reapplied on the rare occasions when it is required.]

Bronchoscopic and esophagoscopic grasping forceps are of the tubular type, that is, a stylet carrying the jaws works in a slender tube so that traction on the stylet draws the V of the open jaws into the lumen of the tube, thus causing the blades to approximate. They are very delicate and light, yet have great grasping power and will sustain any degree of traction that it is safe to exert. They permit of the delicacy of touch of a violin bow. The two types of jaws most frequently used, are those with the forward-grasping blades shown in Fig. 18, and those having side-grasping blades shown in Fig. 19. The side-curved forceps are perhaps the most generally useful of all the endoscopic forceps; the side projection of the jaws makes them readily visible during their closure on an object; their broader grasp is also an advantage., The projection of the blades in the side-curved grasping forceps should always be directed toward the left. If it is desired that they open in another direction this should be accomplished by turning the handle and not by adjusting the blade itself. If this rule be followed it will always be possible to tell by the position of the handle exactly where the blades are situated; whereas, if the jaws themselves are turned, confusion is sure to result. The forward-grasping forceps are always so adjusted that the jaws open in an up-and-down direction. On rare occasions it may be deemed desirable to turn the stylet of either forceps in some other direction relative