the child's size laryngoscope.

[FIG. 29.—The author's papilloma forceps. The broad blunt nose will scalp off the growths without any injury to the normal basal tissues. Voice-destroying and stenosing trauma are thus easily avoided.]

[FIG. 30.—The author's short mechanical spoon (30 cm. long).]

Papilloma Forceps.—Papillomata do not infiltrate; but superficial repullulations in many cases require repeated removals. If the basal tissues are traumatized, an impaired or ruined voice will result. The author designed these forceps (Fig. 29) to scalp off the growths without injury to the normal tissues.

[FIG. 31.—The author's laryngeal rotation forceps.]

[FIG. 32.—Enlarged view of the jaws of the author's vocal-nodule forceps. Larger cups are made for other purposes but these tiny cups permit of that extreme delicacy required in the excision of the nodules from the vocal cords of singers and other voice users.]

[FIG 33.-Extra large laryngeal tissue forceps. 30 cm. long, for removing entire growths or large specimens of tissue. A smaller size is made.]

Bronchial Dilators.—It is not uncommon to find a stricture of the bronchus superjacent to a foreign body that has been in situ for a period of months. In order to remove the foreign body, this stricture must be dilated, and for this the bronchial dilator shown in Fig. 25 was devised. The channel in each blade allows the closed dilator to be pushed down over the presenting point of such bodies as tacks, after which the blades are opened and the stricture stretched. A small and a large size are made. For enlarging the bronchial narrowing associated with pulmonary abscess and sometimes found above a bronchiectatic or foreign body cavity, the expanding dilator shown in Fig. 26 is perhaps less apt to cause injury than ordinary forceps used in the same way. The stretching is here produced by the spring of the blades of the forceps and not by manual force. The closed blades are to be inserted through the strictured area, opened, and then slowly withdrawn. For cicatricial stenoses of the trachea the metallic bougies, Fig. 40, are useful. For the larynx, those shown in Fig. 41 are needed.

[FIG. 34.—A, Mosher's laryngeal curette; B, author's flat blade cautery electrode; C, pointed cautery electrode; D, laryngeal knife. The electrodes are insulated with hard-rubber vulcanized onto the conducting wires.]

[FIG. 35.—Retrograde esophageal bougies in graduated sizes devised by Dr. Gabriel Tucker and the author for dilatation of cicatricial esophageal stenosis. They are drawn upward by an endless swallowed string, and are therefore only to be used in gastrostomized cases.]

[FIG. 36.—Author's bronchoscopic and esophagoscopic mechanical spoon, made in 40, 50 and 60 cm. lengths.]

[FIG. 37.—Schema illustrating the author's method of endoscopic closure of open safety pins lodged point upward The closer is passed down under ocular control until the ring, R, is below the pin. The ring is then erected to the position shown dotted at M, by moving the handle, H, downward to L and locking it there with the latch, Z. The fork, A, is then inserted and, engaging the pin at the spring loop, K, the pin is pushed into the ring, thus closing the pin. Slight rotation of the pin with the forceps may be necessary to get the point into the keeper. The upper instrument is sometimes useful as a mechanical spoon for removing large, smooth foreign bodies from the esophagus.]

Esophageal Dilators.—The dilatation of cicatricial stenosis of the esophagus can be done safely only by endoscopic methods. Blind esophageal bouginage is highly dangerous, for the lumen of the stricture is usually eccentric and the bougie is therefore apt to perforate the wall rather than find the small opening. Often there is present a pouching of the esophagus above a stricture, in which the bougie may lodge and perforate. Bougies should be introduced under visual guidance through the esophagoscope, which is so placed that the lumen of the stricture is in the center of the endoscopic field. The author's endoscopic bougies (Fig. 40) are made with a flexible silk-woven tip securely fastened to a steel shaft. This shaft lends rigidity to the instrument sufficient to permit its accurate placement, and its small size permits the eye to keep the silk-woven tip in view. These endoscopic bougies are made in sizes from 8 to 40, French scale. The larger sizes are used especially for the dilatation of laryngeal and tracheal stenoses. For the latter work it is essential that the bougies be inspected carefully before they are used, for should a defective tip come off while in the lower air passages a difficult foreign body problem would be created. Soft-rubber retrograde dilators to be drawn upward from the stomach by a swallowed string are useful in gastrostomized cases (Fig. 35).

[FIG 38.—Half curved hook, 45 cm. and 60 cm. Full curved patterns are made but caution is necessary to avoid them becoming anchored in the bronchi. Spiral forms avoid this. The author makes for himself steel probe-pointed rods out of which he bends hooks of any desired shape. The rod is held in a pin-vise to facilitate bending of the point, after heating in an alcohol or bunsen flame.]

Hooks.—No hook greater than a right angle should be used through endoscopic tubes; for should it become caught in some of the smaller bronchi its extraction might result in serious trauma. The half curved hook shown in Fig. 38 is the safest type; better still, a spiral twist to the hook will add to its uses, and by reversing the turning motion it may be "unscrewed" out if it becomes caught. Hooks may easily be made from rods of malleable steel by heating the end in a spirit lamp and shaping the curve as desired by means of a pin-vise and pliers. About 2 cm. of the proximal end of the rod should be bent in exactly the opposite direction from that of the hook so as to form a handle which will tell the position of the hook by touch as well as by sight. Coil-spring hooks for the upper-lobe-bronchus (Fig. 39) will reach around the corner into the ascending bronchus of the upper-lobe-bronchus, but the utmost skill and care are required to make their use justifiable.

[FIG. 39.—Author's coil-spring hook for the upper-lobe, bronchus]

Safety-pin Closer.—There are a number of methods for the endoscopic removal of open safety-pins when the point is up, one of which is by closing the pin with the instrument shown in Fig. 37 in the following manner. The oval ring is passed through the endoscope until it is beyond the spring of the safety-pin, the ring is then turned upward by depressing the handle, and by the aid of the prong the pin is pushed into the ring, which action approximates the point of the pin and the keeper and closes the pin. Removal is then less difficult and without danger. This instrument may also be used as a mechanical spoon, in which case it may be passed to the side of a difficultly grasped foreign body, such as a pebble, the ring elevated and the object withdrawn. Elsewhere will be found a description of the various safety-pin closers devised by various endoscopists. The author has used Arrowsmith's closer with much satisfaction.

Mechanical Spoon.—When soft, friable substances, such as a bolus of meat, become impacted in the upper esophagus, the short mechanical spoon (Fig. 30) used through the esophageal speculum is of great aid in their removal. The blade in this instrument, as the name suggests, is a spoon and is not fenestrated as is the safety-pin closer, which if used for friable substances would allow them to slip through the fenestration. A longer form for use through bronchoscopes and esophagoscopes is shown in Fig. 36.

A laryngeal curette, cautery electrodes,