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AUTOSCOPY 
 
 OF THE 
 
 Larynx and the Trachea 
 
 (Direct Examixation AVithout Mireok.) 
 
 ALFRED KIRSTEIN, M.D., 
 
 Berlix. 
 
 Authorized Translateon (Altered, Enlarged, and 
 Revised by the Author) by 
 
 MAX THORNER, A.M., M.D., 
 
 Cincinnati, O., 
 
 Professor of Clinical Laryngology and Otology, Cincinnati College of Medicine 
 
 AND Surgery; LARYNcOLOGfST and Aurist, Cincinnati 
 
 Hospital, etc. 
 
 WITH TWEIiVe IIiIiUSTf^HTIOJlS. 
 
 PIIILADET.PHIA . 
 
 THE F. A. DAVIS CO., Publishers. 
 
 1897. 
 
 2859 
 

 COPYRIGHT, 1896, 
 
 BY 
 
 THE F. A. DAVIS COMPANY. 
 
 [Registered at Stationers' Hall. London, Eng.] 
 
 Philadelphia, Pa., U. S. A. : 
 
 The Medical Bulletin Printing- House, 
 1916 Cherry Street. 
 
TO 
 
 J. SOLIS-COHEN, M.D., 
 
 OF PHILADELPHIA, 
 
 THIS TRANSLATION IS DEDICATED, 
 
 IN 
 
 Grateful recognition of much personal 
 
 kindness, 
 
 BY 
 
 The Translator and 
 Editor. 
 
 (iii) 
 
PREFACE. 
 
 EvEE since the time when progressive minds 
 first endeavored to get a view of the interior of 
 the human larynx they have been under the im- 
 pression that the way from the mouth to the 
 vocal cords, according to existing anatomical 
 conditions, must of necessity form an angle. 
 Under the influence of this conception, the 
 truth of which no one ever seemed to doubt, 
 no plan could have been conceived other than 
 the one which finally, in the sixth decade of our 
 century, resulted in the discovery of laryngo- 
 scopy by Garcia, Turck, and Czermak, — namely, 
 to overcome this difficulty by means of a re- 
 flecting apparatus (a mirror) placed at the apex 
 of the angle, or the introduction, into medicine, 
 of the laryngoscope, the laryngological tech- 
 nique entered upon a path of development from 
 which it has hitherto not departed in the slight- 
 est degree. The introduction of endolaryngeal 
 surgery by Victor Bruns was the next brilliant 
 development of Turck's and Czermak's great 
 
 (V) 
 
VI PREFACE. 
 
 invention. Cocaine has freed laryngological 
 surgery from its many difficulties without at 
 all changing its method. Thus, there has been 
 but one creative thought which has hitherto 
 directed all our laryngological methods of ex- 
 amination and treatment. 
 
 It may appear a rash undertaking for me 
 to deviate from time-honored tradition, and to 
 open up an entirely new way for the examina- 
 tion and treatment of the larynx and the tra- 
 chea, by teaching that we can view the interior 
 of the air-passages directly, without the aid of 
 optical appliances, and operate with straight 
 (uncurved) instruments in the same manner. 
 Nevertheless, my undertaking is doubly justi- 
 fied. In the first place, because of the facts 
 themselves, which may be demonstrated at any 
 time, and which I have made known in a series 
 of publications entitled " Autoscopy of the Air- 
 Passages." * The fact that we have, up to this 
 time, never viewed the interior of the larynx 
 directly (without a mirror) is certainly not due 
 
 * Allgem. med. Centralzeitung, 1895, No. 34 ; Berl. klin. Woch- 
 enschrift, 1895, No. 22 ; Archiv f, Laryngologie mid Rhlnologie, Bd. 
 ii, 1,2; Therapeut. Monatshefte, July, 1895; Deutsche med. Woeh- 
 enschrift, 1895, No. 38. 
 
PREFACE. Vii 
 
 to logical reasoning, but because we had no 
 idea of such a possibility. Since, however, we 
 have discovered that it can be done, and how 
 we can do it, there can be no possible objection 
 raised to our making full use of our new knowl- 
 edge and ability. In the second place, this 
 method is not intended to replace the laryngo- 
 scopic method, but to add to it. I must decid- 
 edly deny any prejudice on my part toward the 
 laryngoscopic method ; the very fact that I my- 
 self have shown that my direct method cannot 
 render the indirect method superfluous throws 
 into strong light the value of the laryngeal mir- 
 ror. Of course, many a laryngologist is con- 
 vinced that the laryngological technique needs 
 no additions; others may think differently. 
 Only the future can decide this question. 
 
 KlESTEIN. 
 BERiiiN, January, 1896. 
 
 All the instruments described in this mono 
 graph are manufactured by W. A. Hirschmann, 
 Berlin, N. They may also be procured from 
 
 Messrs. Krohne & Sesemann, Duke Street, 
 8 Manchester Square, London, W. 
 
Vlll PREFACE. 
 
 Mayer & Meltzer, 71 Great Portland Street, 
 London, W. 
 
 Ottomar Carliczek, 56 Dearborn Street, Chi- 
 cago, 111. 
 
 Max Wocher & Son, 23 W. Sixth Street, 
 Cincinnati, 0. 
 
 Denyer Brothers, 272 Swanston Street (next 
 Lonsdale Street), Melbourne, Australia. 
 
PREFACE OF THE TRANSLATOR. 
 
 This translation, made at the request of the 
 author, is in reality a second edition of the 
 original German monograph. Dr. Kirstein has 
 placed so much new material at my disposal, 
 changing and adding to the original work to 
 such an extent that alterations will be notice- 
 able on almost every page. A number of illus- 
 trations are entirely new; others have been 
 improved. Several additions have become 
 necessary from time to time, as the transla- 
 tion progressed, in accordance with the im- 
 provements and modifications which were 
 gradually developed by the author. While 
 the translation was going through the press 
 the author published some very important 
 modifications of his method, simplifying the 
 technique and the instrumentarium to a con- 
 siderable degree. I have appended an abstract 
 of his article (page 63), bringing thus the 
 description of this method up to date. 
 
 It is needless to say that I consider the 
 
 (ix) 
 
X PREFACE OF THE TRANSLATOR. 
 
 autoscopic examination of the air -passages, as 
 developed by Kirstein, the most important 
 addition to our technical resources made since 
 the discovery of the laryngoscope by Garcia. 
 And I have no doubt that henceforth every 
 one, who wishes to master the technique of 
 laryngology, will have to familiarize himself 
 with this — after all, astonishingly simple — 
 method of laying the air-passages open to 
 direct inspection. 
 
 M. Thoener. 
 
 Cincinnati, O., December, 1896. 
 
CONTENTS. 
 
 
 PAGE 
 
 Preface, 
 
 V 
 
 Translator's Preface, 
 
 . ix 
 
 Definition and Theory, . 
 
 . . . . 1 
 
 The Technique, 
 
 . 8 
 
 I. Illumination, 
 
 . 8 
 
 II. The Autoscope, 
 
 . 15 
 
 III. AUTOSGOPY, .... 
 
 . 21 
 
 Individual Fitness for the Autoscopic Examination, 29 
 
 Comparison between Autoscopy and Laryngoscopy, . 35 
 
 I. Examination of Adults, . . . . .35 
 
 II. Examination of Children, 44 
 
 III. Operations, 47 
 
 Conclusion, . 55 
 
 Resume, 57 
 
 Appendix, 59 
 
 Additional Notes of the Translator, . . . .62 
 I. A Foreign Body Removed from the Larynx 
 
 BY THE Translator, .62 
 
 11. Latest Improvements in Autoscopy, . . 63 
 
 (xi) 
 
AUTOSCOPY. 
 
 DEFINITION AND THEORY. 
 
 By "autoscopy of the air-passages" I under- 
 stand the direct linear inspection, through the 
 mouth, of the lower pharynx, the larynx, the 
 trachea, and the entrances into the primary 
 bronchi. 
 
 The necessary conditions of such a complete 
 linear inspection can be stated a priori to be : — 
 
 1. The body must be placed in such a po- 
 sition that an imaginary continuation of the 
 laryngo- tracheal tube would fall within the 
 opening of the mouth. 
 
 2. This imaginary straight line must be 
 cleared of those parts of the body (epiglottis 
 and base of the tongue) which obstruct it. 
 
 Regarding No. 1. When the military po- 
 sition is assumed the continuation of the wind- 
 pipe would strike somewhere in the neighbor- 
 hood of the root of the nose ; when the head is 
 
 (1) 
 
2 AUTOscopr. 
 
 bent comfortably backward, as in looking aloft, 
 it would about strike the chin ; this can be 
 made clear by looking at any person in the 
 erect position, if we remember that the trachea, 
 the upper end of which in the neck lies quite 
 to the front, runs downward and backward 
 through the thorax, parallel to the spinal col- 
 umn, forming a considerable angle with the 
 sternum. The position adapted for " auto- 
 scopy" must therefore be somewhere between 
 the two positions just mentioned, and can be 
 easily obtained by gently tilting the head up- 
 ward until the axis of vision forms with the 
 axis of the trunk an angle of about 135 de- 
 grees. This theoretical consideration is fully 
 borne out by experience. (Fig. 1.) This tilting 
 movement of the head is a rotation on the 
 atlanto-occipital articulation. I do not believe 
 that the flexibility of the cervical spinal column 
 is to any extent called into requisition. The 
 fact that a small angle in the atlanto-occipital 
 joint will produce a sufficiently large excursion 
 of the superior maxilla is explained by the large 
 radius of the circle of rotation, about 12 centi- 
 metres. 
 
DEFINITION AND THEORY. 
 
 Eegarding No. 2. The base of the tongue 
 can, of course, be got out of the way of the pro- 
 longed trachea in but one direction, — namely, 
 
 Fig. 1.— Position for Autoscopy. 
 
 X ^ atlanto-occipital articulation. > = axis of vision. 
 
 forward and downward. To get this position 
 of the tongue a tongue-depressor is necessary, 
 — i.e., a spatula, — which, however, unlike the 
 ordinary spatula, must not be placed in front of 
 
4 AUTOSCOPY. 
 
 the circumvallate papillse, but must be applied 
 behind the same, to the root of the tongue. 
 The epiglottis can be elevated, as has been long 
 known, in one of two ways : (1) directly, by an 
 instrument which projects over the epiglottis 
 (thus, in our case, most easily by the spatula 
 itself, the tip of which must therefore be intro- 
 duced behind the epiglottis) ; (2) indirectly, by 
 a method the principle of which was described 
 by Reichert* in 1879 as follows : Pressure upon 
 the base of the tongue and the median glosso- 
 epiglottic ligament produces an elevation of the 
 epiglottis on account of its close attachment to 
 the tongue. As the first method requires pre- 
 vious cocainization, it should be reserved for 
 exceptional cases ; autoscopy must depend, in 
 general, on the principle enunciated by Eei- 
 chert, — a principle which is already involved in 
 the necessary instrumental depression of the 
 base of the tongue. 
 
 The patient tilts his head slightly upward and 
 opens his mouth; the physician presses the base 
 of the patienVs tongue forward with a spatula. 
 
 * " Eine neue Methode zur Aufrichtung des Kebldeckels bei lar- 
 yngoscopischeu Operatiouen," Arch. f. klin. Chirurgie, Bd. xxiv. 
 
DEFINITION AND THEORY. 5 
 
 These are the remarkably simple directions 
 which we deduct from our theoretical consider- 
 ations concerning the possibility of autoscopy. 
 Looking at the question from the stand-point 
 of our present knowledge, it is hard to see how 
 a discovery lying so near at hand should have 
 been so long overlooked. One would imagine 
 that an off -hand glance at any sagittal section 
 of the upper part of the body would have suf- 
 ficed to suggest the idea of autoscopy. The 
 stimuhts to such a discovery, however, was 
 apparently wanting, because the need of addi- 
 tions to our laryngological armamentarium was 
 nowhere felt. Whoever would conclude from 
 this that autoscopy even now, after it has be- 
 come established, fills no real need, might have 
 argued with the same logic that the laryngeal 
 mirror is superfluous because through all the 
 preceding centuries there was no demand for it 
 until, forty years ago, it was discovered by a 
 musician, and then had to be forced upon a 
 profession — whose duty it was to recognize and 
 treat disease — not by a practising physician, 
 but by a physiologist. 
 
 It seems to me even more remarkable that 
 
6 AUTOSCOPY. 
 
 chance, which has so often led to discoveries, 
 has left laryngology so completely in the lurch 
 in this particular. At present, during an ordi- 
 nary examination of the pharynx, in depressing 
 the tongue with the usual angular spatula, we 
 occasionally get, all of a sudden, a full view of 
 the whole arytenoid cartilages and part of the 
 vocal cords, sometimes even of the bifurcation ; 
 formerly this never occurred. I can only ex- 
 plain this fact by supposing that the diligent 
 use of the autoscope leads, in depressing the 
 tongue, to a special dexterity which formerly 
 was scarcely called for. By practising auto- 
 scopy we acquire an entirely new way of intro- 
 ducing the spatula. Our preconceptions re- 
 garding the awful reflex excitability of the 
 base of the tongue we soon relinquish ; we 
 lose our timidity; we place the patient in a 
 better position; we no longer look mainly in 
 an horizontal direction, but also now from 
 above downward. Those laryngologists who 
 are accustomed to make examinations while 
 standing were much more likely to make the 
 accidental discovery of direct laryngoscopy 
 than the majority who use the laryngoscope 
 
DEFINITION AND THEORY. 
 
 while seated. Time will show that autoseopy 
 will introduce into laryngological technique a 
 certain freedom of action which is of great 
 advantage, provided it is not overdone. 
 
THE TECHNIQUE. 
 
 I. ILLUMINATION. 
 
 Stationaby appliances of illumination {^^Sta- 
 tivspiegeV^) are of no value, not only for auto- 
 scopy proper, but also for the freer method of 
 laryngoscopy which has lately come into vogue. 
 The cone of light reflected into the throat must 
 come from a source attached to the observer 
 himself, so that it can readily follow his slight- 
 est movements, and thus render him inde- 
 pendent of the position of the reflector. The 
 forehead-mirror answers these requirements 
 essentially, though not quite completely. At 
 all events, it is the only favorable and thor- 
 oughly practical instrument for autoscopy, if 
 we use sunlight, or have to depend upon 
 lamplight, Argand burners, or the incandes- 
 cent gaslight, — the so-called Wellsbach light. 
 Only the electric light renders us entirely inde- 
 pendent, or, rather, can render us entirely inde- 
 pendent, if we avail ourselves of its possibil- 
 ities. If we simply substitute an incandescent 
 (8) 
 
THE TECHNIQUE. 9 
 
 lamp (with or without a condenser) for the gas- 
 light, and use a forehead-mirror according to 
 our old custom, we thereby sacrifice, for the 
 sake of a traditional method based upon entirely 
 different conditions, the special advantages of 
 the electric light. Two persons are necessary 
 for an examination of the throat : a patient and 
 a physician. The classical method of examina- 
 tion requires the addition of an entirely super- 
 fluous and troublesome element, — namely, the 
 lamp. This is stationary, and may not be dis- 
 turbed; the observer must regulate, according 
 to its position, the position of his own head, 
 which bears the forehead-mirror; and which 
 should be moved with no other considerations 
 than the position of the patient. Furthermore, 
 the lamp must be shifted when the patient 
 bends, and must be raised when the patient is 
 examined according to Killian's method; and 
 last, but not least, the physician, instead of 
 simply giving light, is himself constantly illu- 
 minated and blinded. At all events, this is at 
 least endurable, and without the electric light 
 there is no other way. But we need not make 
 a virtue of our necessity. We may at least 
 
10 AUTOSCOPY. 
 
 admit that all this is disagreeable and an im- 
 pediment, although custom has blunted us to 
 this fact. 
 
 The electric light resembles sunlight more 
 than the Wellsbach light does, but the latter 
 resembles sunlight sufficiently for all practical 
 purposes of laryngology. The pre-eminent 
 value of the incandescent lamp depends, in my 
 opinion, on something else, — namely, the fact 
 that it is free from limitations as to place and 
 position. The incandescent lamp weighs prac- 
 tically nothing; it can be placed obliquely or 
 upside down ; the observer may have the best 
 light without a lamp, as it were, for he attaches 
 the lamp simply to his own forehead and need 
 pay no further attention to it. Students must 
 acquire the use of the forehead-mirror ; and, 
 even could electric light be placed at their dis- 
 posal, the forehead-mirror would nevertheless 
 be in place, in my opinion. When, however, 
 it is not a question of acquiring, but of prac- 
 tising laryngoscopy, the forehead-lamp is the 
 rational instrument for electrical illumination. 
 The conducting-cords, which are needed to 
 connect the forehead-lamp with the battery. 
 
THE TECHNIQUE. 11 
 
 are certainly not a pleasant addition, and re- 
 quire a certain familiarity. But the connecting 
 and disconnecting with the battery is but little 
 trouble, and quite separate from the examina- 
 tion itself. It differs, therefore, decidedly from 
 those other inconveniences which we have 
 noted ; the long cords do not in any way inter- 
 fere with our movement ; the forehead-lamp 
 leaves us entirely unimi^eded as observers and 
 as operators. 
 
 A simple forehead-lamp which gives direct, 
 unreflected light meets all requirements as long 
 as we do not wish to examine the deeper por- 
 tions of comparatively narrow cavities; but it 
 is not well adapted to autoscopy or to anterior 
 rhinoscopy, because in these cases the axis of 
 our vision cannot coincide with the axis of 
 the rays of light ; so that either the one or the 
 other falls obliquely upon the parts to be illu- 
 minated, and thus a clear view of the deep por- 
 tions is impossible. 
 
 All the demands of laryngological and rhi- 
 nological technique, inclusive of autoscopy, are 
 met by a forehead-lamp for reflected light in- 
 vented by me (Fig. 2), in which the rays of the 
 
12 
 
 AUT03C0PY. 
 
 electric light, after they have been collected by 
 a convex lens, are deflected at a right angle, 
 immediately on issuing from the lens, by a 
 small plain mirror (8) placed at an angle of 
 45 degrees to it. The mirror is perforated ob- 
 liquely through its centre for the eye of the 
 observer. The latter need pay no attention to 
 
 Fig. 2.— Forehead-Lamp for Reflected Light. 
 
 the angle at which the mirror is placed, but is 
 guided solely by a longitudinal disc of tin (0) 
 placed vertically behind the mirror (between it 
 and the eye), and which is also perforated. 
 When one can look through both perforations, 
 the axis of vision coincides, of necessity, with 
 the centre of the bundle of light-rays, — an ideal 
 
THE TECHNIQUE. 13 
 
 condition for the purposes of vision. The lamp 
 {L) is attached to the head-band by means of 
 two joints {h and a) in such a way that any de- 
 sired motion within the widest possible limits 
 can be carried out with the least amount of 
 force, and so that the lamp remains fixed in 
 any given position. The lamp is moved from 
 one position to another by grasping the lower 
 border of the perforated tin disc. This latter 
 serves also to protect the observer from the 
 heat of the lamp. A current interrupter {A E) 
 is attached to the cord. 
 
 For the special purposes of autoscopy, in 
 addition to the forehead-lamp, another electrical 
 appliance for illumination must be considered, 
 — one which, I think, will gain the favor of lar- 
 yngologists. This is the so-called electroscope^ 
 — an excellent instrument originally devised by 
 Casper for examining the urethra, and which 
 has been unessentially modified by me for the 
 purposes of autoscopy. It (Fig. 3, page 16) 
 consists of an electrical hand-lamp, the rays of 
 which are collected by a lens and deflected 90 
 degrees by a prism. This hand-lamp is used as 
 a handle ; to it the spatula {S) of the autoscope 
 
14 AUTOSCOPY. 
 
 is fastened at a right angle by means of a 
 set-screw (a), so that the rays of the light are 
 reflected along the spatula, — an ideal optical 
 condition which can thus not be disturbed. 
 Therefore, we need be at no special pains to 
 direct the light ; we have simply to direct the 
 spatula, and the light must follow of itself. 
 Verily, a more convenient method of exami- 
 nation cannot be thought of. The observer 
 looks immediately above the edge of the prism, 
 so that he can get a complete view of the field 
 brilliantly illuminated by the diverging rays of 
 light. Autoscopy can hardly be demonstrated to 
 others without the use of this electroscope. 
 
THE TECHNIQUE. 
 
 II. THE AUTOSCOPE. 
 
 The autoscope consists of three parts : a 
 spatula, a hood, and a handle. When the 
 spatula {S, Fig. 3) is pressed upon the pos- 
 terior part of the tougue the middle of the 
 tongue is depressed more than the more fixed, 
 lateral portions, so that a groove is formed 
 between the palato-glossal arches ; it follows, 
 therefore, that the spatula, as used in auto- 
 scopy, should have the shape of a groove. The 
 narrower the groove, the less it infringes upon 
 the lateral, more fixed portions of the tongue, 
 and the more deeply therefore can it be pressed 
 into the middle portion of the tougue. The 
 spatula may not be too narrow, however, be- 
 cause the tongue would at times rise up on both 
 sides of it, and thus shut out the light. As not 
 only the tongue, but also the superior maxilla, 
 must be kept out of the way of the straight line 
 of vision, the spatula for autoscopy must form 
 a straight line from before backward ; only at 
 
 (15) 
 
16 
 
 AUTOSCOPY. 
 
 the end, where it has akeady passed the con- 
 vexity of the tongue, the ordinary (prelaryn- 
 geal) spatula is given a downward curve, so 
 that it can elevate the epiglottis by exercising 
 
 Fig. 3.— Standard Spatula (S) attached to the Elec- 
 
 TKOSCOPE, AND InTRA-DAKYNGEAL SPATULA (>S'), BOTH 
 
 WITH Hoods Omitted. 
 
 the proper pressure upon the base of the tongue 
 (and thus also upon the body of the hyoid bone, 
 which can always be easily felt in the valleculae) 
 and upon the median glosso-epiglottidean liga- 
 ment. The tip {d, Fig. 3) of the spatula, which 
 
THE TECHNIQUE. 17 
 
 must be thickened and well rounded, in order 
 to avoid injury to the mucous membranes, must 
 also be notched to receive this latter ligament. 
 The spatula for adults is 14 centimetres long ; at 
 the tii3 it is about 2 centimetres wide, and it is 
 about li centimetres wide where it passes the 
 convexity of the tongue. It is made of nickel- 
 plated Grerman silver, is exceedingly easy to 
 clean, and can be readily sterilized in boiling 
 water. The tip of the ordinarily used standard 
 spatula is bent downward so that its free border 
 is 1 centimetre below the level of the bottom of 
 the grooved portion. Yet, it is desirable to 
 have two spatulas in addition, — one with a 
 larger curve, but especially one with a smaller 
 curve, to be used in special cases, as experience 
 will soon indicate. 
 
 In cocainized patients, especially for oper- 
 ative puiposes, the intra-laryngeal spatula can 
 be used. This is introduced behind the epiglot- 
 tis, presses it against the root of the tongue, 
 and thus hides it from view. This intra-laryn- 
 geal spatula (see S\ Fig. 3) forms a perfectly 
 straight groove, which ends anteriorly in a thin, 
 convex border. It is by no means always easy 
 
18 AUToscopy. 
 
 to introduce this spatula, as soft and very yield- 
 ing epigiottides readily escape its grasp. If 
 occasion demand, one might try to introduce 
 the prelaryngeal spatula with the slight curve 
 behind the cocainized epiglottis. All the dif- 
 ferent forms of spatulas have lateral ribs (r), 
 to which the hoods are attached. 
 
 The hood, which is 6 centimetres long and 
 3 centimetres wide, is also made of nickel- 
 plated metal. It serves to keep the passage 
 clear for light and vision, which would other- 
 wise be obstructed by the close contact of the 
 upper teeth, or by the upper lip, and possibly 
 the moustache. By withdrawing the hood a 
 little it is possible to lengthen the autoscope 
 in examining very large people ; in the same 
 way the nose of the patient can be protected 
 from contact with the electroscope, the upper 
 end of which sometimes becomes heated. In 
 certain cases the hood may be dispensed with. 
 I have had hoods made of three different 
 heights, — about 3, 6, and 9 millimetres; the 
 medium -sized {''''standard hood'''') is the one 
 most commonly used ; the largest-sized allows 
 the introduction of large instruments (forceps, 
 
THE TECHNIQUE. 19 
 
 etc.) for operative purposes; the small -sized 
 one is also occasionally useful. It is astonish- 
 ing through what a narrow slit we can get an 
 unhindered view in autoscopy ; a slit 3 milli- 
 metres high is amply sufficient, though usually 
 we grant ourselves a greater allowance. 
 
 Instruments of unusual thickness cannot be 
 
 Fig. 4.— PijAix Hajtdle. 
 
 introduced even through the largest hoods if we 
 employ the electroscope, which certainly is very 
 convenient as an illuminating handle, but which 
 covers up, with its prism, the entrance into the 
 grooves, and leaves free only the passage-way 
 through the hood. Much space can be gained 
 (though this is very seldom necessary) by at- 
 
20 
 
 AUTOSCOPY. 
 
 taching tlae spatula to a simple metallic handle 
 (Fig. 4) which is used in connection with the 
 forehead-lamp (or the forehead-mirror). 
 
 I have of late,* however, succeeded in dis- 
 pensing with the hood by substituting a simple 
 plate for it (P, Fig. 5), which is fastened, on 
 
 Fig. 5.— Autoscope with Plate (P) instead of Hood. 
 
 its left side, to the spatula by means of a me- 
 tallic bar (b) and a set-screw (x) ; consequently, 
 the lateral ribs of the autoscopic spatula (S) 
 are omitted and the autoscope is entirely open 
 on both sides. By this means the introduction 
 of surgical instruments is greatly facilitated. 
 
 * March. 1896. 
 
THE TECHNIQUE. 
 
 III. AUTOSCOPY. 
 
 AuTOSCOPY is an art, to begin witli. Who- 
 ever believes tliat simply by reading this book 
 and by procuring an autoscope he will be able 
 to use it successfully is sadly mistaken. Auto- 
 scopy is a difficult art, until one has acquired a 
 certain, hard-to-define knack in introducing the 
 spatula. He who has once mastered the use of 
 the autoscope will seldom meet special diffi- 
 culties which he cannot easily overcome. 
 
 We have seen, in the chapter devoted to the 
 theory, that the axis of vision of the patient 
 should in general form a more obtuse angle 
 with the trunk than it does in military position. 
 If the patient who is sitting perfectly straight 
 should bend his head somewhat backward, the 
 continuation of his trachea, though somewhat 
 inclined toward the vertical, would project so 
 steeply upward that the examination would 
 become inconvenient for the physician. We 
 therefore tell the patient to bend the whole 
 
 (21) 
 
22 
 
 AUTOSCOPY. 
 
 upper part of his body slightly forward, as 
 illustrated in FigSo 6 and 9 (page 49). This 
 forward inclination of the body has the further 
 advantage that the muscles of the neck thereby 
 
 Fig. 6.— Position for Autoscopy. 
 
 This photograph was taken from a partly stripped patient in order to show 
 distinctly the position of head and neck during examination. 
 
 become somewhat relaxed, of which fact one 
 can easily convince one's self by palpating the 
 sterno-cleido-mastoid muscles. 
 
 For the purpose of examination the patient 
 need not undress, but might remove his necker- 
 
THE TECHNIQUE. 23 
 
 chief or a very tight collar. False teeth should/ 
 he removed. The physician stands in front oi 
 the patient, who is seated. The autoscope is 
 grasped with the whole hand — it is best to 
 practise from the beginning with the left hand 
 — and is introduced ivell illuminated^ — under no 
 circumstances without the guidance of the eye. If 
 the electroscope is used, — which will probably 
 be the rule, — the electric contact is closed for 
 the purpose of illumination before the introduc- 
 tion of the instrument. The spatula is intro- 
 duced in such a manner that its tip catches in 
 the groove between the tongue and the epi- 
 glottis. (The beginner is liable to rest the 
 spatula on the tongue, or he may inadvertently 
 hook it behind the epiglottis!) The handle is 
 now raised until the hood touches the upper 
 incisors, care being taken not to include the 
 upper lip between the hood and the teeth 
 (avoiding this, if necessary, with the other 
 hand), and the base of the tongue drawn evenly 
 and steadily downward and forward as far as 
 possible without exercising any force. During 
 all this time the physician looks through the 
 hood, using his better eye, and, if possible^ 
 
24 ACToscopy. 
 
 without glasses. The autoscope may come in 
 contact with the upper teeth, but must never 
 exert painful pressure against them. 
 
 If the autoscope is properly introduced, the 
 physician may take his time and examine at his 
 leisure, while the patient breathes and phonates 
 quite at his ease. In withdrawing the instru- 
 ment care must naturally be taken to raise the 
 hook-like tip by lowering the handle of the 
 instrument, thereby avoiding the danger of 
 pulling the tongue forward. Should the patient 
 attempt to grasp the instrument, it must be 
 instantly removed. 
 
 The proper manipulation of the autoscope 
 requires, as already stated, a great deal of prac- 
 tice ; only those will succeed in completely mas- 
 tering this method who, from the beginning, lay 
 the blame for all their failures in the introduc- 
 tion of the instrument upon themselves. The 
 expert autoscopist can be known by two char- 
 acteristics: he very seldom excites reflex move- 
 ments (retching) in the patient, and very rarely 
 pain. To attain this end the physician must 
 work accurately and rapidly, but not brusquely; 
 he must be careful, considerate, and must have 
 
THE TECHNIQUE. 25 
 
 a gentle and skillful touch. One should always 
 bear the following maxim in mind : " The auto- 
 scope is an instrument in using which the phy- 
 sician can hurt every patient, but should hurt 
 noneP It is true that most patients, even in 
 the hands of the most expert autoscopists, will 
 suffer some inconvenience from the first exami- 
 nation. But this sensation is not painful; it 
 depends primarily upon the fact that the base 
 of the tongue is subjected to contact with a 
 hard, smooth, and cold instrument,— something 
 to which it is not accustomed, and which is 
 opposed to its natural functions. If the phy- 
 sician has self-assurance and tact, he can easily 
 reconcile the patient to manipulations which 
 are not altogether agreeable; some physicians 
 succeed better than others in allaying the fears 
 of timid patients, and in preparing them for 
 examination. Individuality plays a large role 
 in such matters. Certainly the method should 
 not be blamed for what is due to unskillful 
 manipulation. As a rule, the method is pain- 
 less and easily borne. It stands to reason that 
 certain persons with exaggerated sensitiveness 
 to pain may be an exception to the rule, and 
 
 / 
 
26 AtJTOSCOPY. 
 
 may suffer real pain from even gentle pressure. 
 Comparing the two methods of examination, 
 laryngoscopy is, on the whole, the more elegant 
 and gentle method, though there are not a few 
 patients who prefer the autoscope to the mirror. 
 In the worst cases the mucous membranes may 
 be anaBsthetized with cocaine. 
 
 Certain little knacks — such as changing the 
 position of the patient, holding the autoscope 
 obliquely, or even looking past it, which are 
 sometimes of advantage — can be picked up by 
 everybody as occasion demands. 
 
 Autoscopy occasions the physician certain 
 annoyances and inconveniences, which may be 
 summed up as follows : — 
 
 1. The expense of the armamentarium and 
 the trouble of acquiring the technique. 
 
 2. The dependence on an available and reli- 
 able source of electricity (storage battery or 
 connection with the street- current). Auto- 
 scopy can, of course, as stated before, be car- 
 ried on by means of any sort of illumination, 
 but the electric light is best adapted for freely 
 realizing all the advantages of this method. 
 
THE TECHNIQUE. 27 
 
 3. The physician is closer to the breath of 
 the patient, and glasses become thus more eas- 
 ily clouded, and he is also more exposed to any 
 violent coughing spells of the patient, provided 
 he is not careful ; but the disturbance caused 
 by the coughing against the laryngeal mirror is 
 thereby avoided. There is, however, a simple 
 remedy for the clouding of spectacles by the 
 breath of the patient. The physician puts on a 
 forehead- njirror (intended, in this case, only as 
 a protecting diaphragm) and looks through its 
 central perforation ; by this means the moisture 
 exhaled by the patient against the eye of the 
 physician is almost entirely condensed upon the 
 forehead -mirror, thus leaving the spectacles 
 clear. 
 
 I am acquainted with no other disadvant- 
 ages of the autoscopic method to the physician. 
 That there may be certain disadvantages, how- 
 ever, to the patient, arising from autoscopy, 
 cannot be denied, — if the instrument is poor 
 or if the physician is a bungler ; but under 
 no other conditions. On the other hand, the 
 act of autoscopy may occasionally exert a cer- 
 tain therapeutic effect (be it by pressure on the 
 
28 AUTOSCOPT. 
 
 base of the tongue or through suggestion), in 
 certain forms of parsesthesia, neuralgia, or hys- 
 teria ; so that a few patients even demand the 
 application of the autoscope again and again. 
 
 The only contra-indication to autoscopy will 
 be mentioned hereafter. 
 
INDIVIDUAL FITXESS FOR THE AUTO- 
 SCOPIC EXAMINATION. 
 
 As is well known, the examination of the 
 air-passages by means of the laryngeal mirror 
 is possible, in the great majority of cases, to a 
 rather uniform degree. The aidoscope, on the 
 other hand, gives us, in some instances, a perfect 
 picture of the larynx and of the trachea; in others, 
 an incomplete picture ; while in still others no view 
 at all is obtainable. The causes of these individ- 
 ual differences may be stated as follows: A 
 projection of the anterior wall of the tracheo- 
 laryngeal tube forms a tangential plane (Fig. 7, 
 p. 30), from which we must remove the upper 
 jaw backward and the tongue (with the epiglot- 
 tis) forward in order to obtain a complete auto- 
 scopic view. The former can be accomplished 
 easily, as we know, in all people by a slight 
 tilting backward of the head (a physiological 
 rotation on the atlanto-occipital articulation). 
 An explanation of the difference must therefore 
 be sought in the second factor, — namely, in the 
 
 (29) 
 
30 
 
 AUTOSCOPY. 
 
 possibility of depressing the tongue. While the 
 tongue is being depressed by the illuminating 
 autoscope, the light, like a radius vector, at 
 first sweeps over the posterior wall of the phar- 
 ynx from above downward, then passes over 
 
 Fig. 7.— Tangential Plane. 
 
 the arytenoid cartilages, and lights up success- 
 ively the air-passages from behind forward till 
 it reaches the anterior angle of the glottis. 
 During this procedure the spatula of the auto- 
 scope overcomes the elastic resistance of the 
 
FITNESS FOR AUTOSCOPIC EXAMINATION. 31 
 
 tongue, using successively two fulcrums, — the 
 first a dorsal one (i.e., the root of the tongue, be- 
 tween the palato-glossal arches) and the second 
 a basal one (i.e., the hyoid bone itself or imme- 
 diately above it). A thorough and unhindered 
 use of the autoscope depends, therefore, mainly 
 upon the thickness and consistency of the 
 tongue and the resistance of its lateral attach- 
 ments, and secondarily upon the mobility of 
 the hyoid bone. Furthermore, it is evident 
 that the possibility of pressing the tongue for- 
 ward and downward must be taken more or 
 less advantage of, according to the varying 
 forms of the head and neck. Let us imagine 
 the patient in a position adapted to autoscopy, 
 the tongue at rest, just before pressure is made 
 upon it (Fig. 8, p. 32). Let us now join with 
 straight lines the point on the back of the 
 tongue where the pressure is made (Z), the 
 middle of the free border of the upper jaw (0), 
 and the anterior commissure of the vocal cords 
 (C). The form and size of the triangle Z C 
 will thus become the index of the amount of dis- 
 location to which the tongue must be subjected 
 to render autoscopy jjossible in a given indi- 
 
32 
 
 AUTOSCOPY. 
 
 viclual. For a perfect autoscopic examination 
 (A) the radius vector mnst be carried forward 
 through the angle Z C (A)', if the condition 
 of the patient's tongue allow a movement only 
 
 through a smaller angle (r^), then A = 
 
 A 
 
 Fig. 8.— DISPLACE3IENT OF TOMGUE IN AUTOSCOPY. 
 
 Fitness for autoscojDic examination varies, 
 therefore, with each individual. To determine 
 this empirically requires a willing assistance on 
 the part of the patient, which can easily be ob- 
 
FITNESS FOR AUTOSCOPIC EXAMINATION. 33 
 
 tained in the vast majority of cases. This fit- 
 ness would appear less than it really is should 
 the patient retch or put his muscles on the 
 stretch through anxiety. Should he be able to 
 relax his muscles the examination may, never- 
 theless, be rendered difficult at times by a rigid 
 epiglottis, or one with too large a curve, or one 
 which is so loosely attached to the toDgue that 
 it cannot be sufficiently raised, and thus blocks 
 the view into the laryngo-tracheal tube, which 
 would otherwise be in the direct line of vision. 
 Such cases are more adapted to the intra-laryn- 
 geal autoscopic spatula, which requires the use 
 of cocaine, and which should, therefore, be re- 
 stricted to special indications only. 
 
 In examining a patient with the autoscope 
 we accomplish two things : (1) we determine 
 his special fitness for the examination with the 
 autoscope, and (2) we learn the condition of 
 the parts open to inspection; both results are 
 achieved by one and the same act. According 
 to my estimate, in about one-fourth of all adults 
 the whole larynx and the whole trachea can be 
 conveniently examined autoscopically («5 = A ), 
 with this limitation : that the extreme apex of 
 
34 AUTOSCOPT. 
 
 the anterior commissure cannot be seen nearly 
 so often (possibly in about one-tenth of all 
 cases). About one-half of all people can be 
 fairly well examined with the autoscope, so 
 that the posterior region of the larynx, includ- 
 ing sometimes a more or less extensive portion 
 of the trachea, is exposed to view. The remain- 
 ing cases include those in whom one cannot see 
 beyond the tips of the arytenoid cartilages, or 
 not even so far, and those who, owing to their 
 abnormal irritability, cannot be examined at all 
 without cocaine. By pressure applied with the 
 thumb upon the middle of the thyroid cartilage 
 the autoscopic field of vision toward the front 
 can be considerably enlarged in many, espe- 
 cially in the young. By means of this manip- 
 ulation — which may in operations be left to 
 an assistant — the anterior commissure can be 
 brought into view rather frequently. Most 
 patients stand this manipulation well. Men 
 and women, so far as I have been able to see, 
 are equally adapted to autoscopic examination. 
 Should any one wish to make a statistical 
 investigation of these statements, let him not 
 begin to count until he has fully mastered the 
 entire technique of autoscopic examination. 
 
COMPARISON BETWEEN AUTOSCOPY 
 AND LARYNGOSCOPY. 
 
 After having recognized and demonstrated 
 the possibility of examining the mucous mem- 
 brane of the larynx and the trachea autoscop- 
 ically; after having developed and tested a 
 thousandfold a simple and uncomplicated tech- 
 nique; after having determined the limits of its 
 usefulness, and having completed the requisite 
 diagnostic and therapeutic armamentarium; 
 after having, furthermore, performed auto- 
 scopic operations in all parts of the larynx, 
 even up to the anterior commissure, I feel that 
 all of these experiences are sufficient to justify 
 me in trying to specify the position which 
 autoscopy may occupy among the methods of 
 laryngological examination and therapy, and 
 in comparing it with laryngoscopy. 
 
 I. EXAMINATION OF ADULTS. 
 
 It is the investigator who is responsible for 
 the discovery and the correct estimation of 
 
 (35) 
 
36 AUTOSCOPY. 
 
 facts ; the physician is responsible for the most 
 useful and skillful application of these facts; 
 but no one is responsible for the facts them- 
 selves. It cannot be laid to our door that the 
 throats of many people are so formed by nature 
 that we cannot get a good view of their deeper 
 portions. Just as little can it be placed to our 
 credit that the necks of many other people are 
 shaped differently, and allow us to see directly 
 down to the sixth ring of a bronchus without 
 difficulty. If we add to our art a new method 
 by the aid of which we can see and touch with- 
 out the use of a mirror the trachea of one 
 person, we ought certainly not to be blamed if 
 this method is not applicable to every other 
 person. It is simply our duty to draw the 
 logical conclusions from such actual objective 
 experiences which we have recorded in our 
 studies. The first of these conclusions is this : 
 We must continue using the laryngoscopic mirror 
 now as formerly. This truth is easily estab- 
 lished. 
 
 In our consideration of the individual fit- 
 ness for autoscopic examination we saw that 
 the mirror could be dispensed with in only a 
 
AUTOSCOPY AND LARYNGOSCOPY. 37 
 
 certain number of cases, as regards the exami- 
 nation of the larynx and the trachea. If we 
 bear in mind that the root of the tongue (be- 
 hind the papillae circumvallata^) can ordinarily 
 be seen only by means of the mirror (the auto- 
 scope covers this portion), it is clear that the 
 laryngoscopic mirror can he hardly ever ivliolly 
 dispensed with for a complete examination of the 
 throat. The only contra-indication to the use 
 of the autoscope is a morbid condition of the 
 base of the tongue or of the valleculae, — a con- 
 dition which is rarely encountered ; this can be 
 recognized only by means of the laryngoscopic 
 mirror. It would therefore be proj)er, under 
 ordinary circumstances, to examine the throat 
 first with the laryngoscope, and not till then 
 with the autoscope; but not much importance 
 need be attached to this order of procedure. 
 
 My statement — " We must continue using 
 the laryngoscopic mirror now as formerly" — 
 might lead some one to say : I acknowledge 
 that the discovery of the autoscope has en- 
 riched our theoretical knowledge ; I admit also 
 that in certain rare cases autoscopy may have 
 some special value ; on the whole, however, I 
 
38 AUTOSCOPY. 
 
 consider this innovation as useless for practical 
 purposes, for we continue using the laryngo- 
 scope, and things are as they were before. But 
 this would be an error. We continue using the 
 mirror, now as before, but things are neverthe- 
 less not what they were before ; on the contrary, 
 a good many things will be changed, although 
 this may not take place at once, nor every- 
 where. Everybody certainly has the privilege 
 of refusing to become acquainted with auto- 
 scopy ; but whoever has once grown accus- 
 tomed to its use will soon no longer be willing 
 to do without it. The weakness of autoscopy 
 lies in the limitation of its applicability, as just 
 explained ; but within the field of its applicabil- 
 ity it is, in almost every respect^ superior to lar- 
 yngoscopy. In comparing the two methods we 
 must, once for all, bear in mind, in speaking of 
 autoscopy, the phrase, " within the limits of its 
 applicability in the given individual." 
 
 Under ordinary circumstances the vocal 
 cords are seen at a shorter range with the auto- 
 scope than with the mirror ; and, furthermore, 
 with my method the object itself is seen with 
 undiminished distinctness, with all its natural 
 
AUTOSCOPY AND LARYNGOSCOPY. 39 
 
 colors and shades of light; with the method of 
 Oarcia, Tiirck, and Czermak, however, only the 
 reflected image of the object is seen,— an ex- 
 cellent substitute, but at best only a substitute of 
 direct vision. It is a matter of no practical im- 
 portance that the mirror permits of binocular 
 vision, while autoscopy allows of only monoc- 
 ular vision (just like anterior rhinoscopy). 
 Every anatomical detail (such as slight irregu- 
 larities of the surface, small erosions, etc.) can 
 be recognized and appreciated far better with 
 the autoscope. It is only in the diagnosis of 
 disturbances of mobility that the laryngoscope 
 is more appropriate, as the autoscope slightly 
 immobilizes the larynx ; in every other respect 
 autoscopy is the better method. The auto- 
 scopic picture has all the vivid freshness and 
 warmth of actual life ; the reflected image is 
 duller and colder, it is a beautiful art-product, 
 and comes to us at second-hand. How often, 
 during the past few months, have I heard the 
 exclamation: "The larynx looks entirely dif- 
 ferent /" — which remark did not refer to the no- 
 longer-present reversal of the image. Strictly 
 interpreted, this would prove that hitherto we 
 
40 AUTOSCOPY. 
 
 have not really known liow the larynx actually 
 does look. 
 
 In the beginning of our experience in auto- 
 scopy it was rather painful to feel that the re- 
 flected image was so much less beautiful than 
 the autoscopic picture, and that we, neverthe- 
 less, could not dispense with it ; autoscopy thus 
 awakens a desire which it cannot fully satisfy. 
 Autoscopy is, therefore, a difficult morsel ; un- 
 til it is thoroughly absorbed into 'the life-blood 
 of laryngology it will cause many a digestive 
 disturbance. 
 
 For the purposes of scientific demonstra- 
 tion autoscopy is just the thing; a number of 
 spectators can look, one after another, through 
 the autoscope and note the conditions. In 
 persons well adapted to autoscopy it is easy to 
 demonstrate to any layman the movements of 
 the vocal cord, the physiological pulsation of 
 the wall of the trachea, the systolic beating 
 of the bifurcation-spur, and quite as easily a 
 carcinoma of the larynx. 
 
 The special triumph of autoscopy lies in the 
 possibility it affords of obtaining, in many 
 cases, an incomparably complete view of the 
 
AtJTOSCOPY AND LARYNGOSCOPY. 41 
 
 posterior wall of the larynx and tlie entire inner 
 surface of the trachea, as well as of the entrance 
 of the bronchi. There is no special need of 
 discussing these important points in detail. 
 Whoever has once obtained a good autoscopic 
 view of these parts requires no verbal explana- 
 tion of the advantages it offers to the eye, and 
 mere words can give no adequate idea to him 
 who has never seen it. I therefore refer the 
 reader to the ■ testimony of his own eyes, and 
 limit myself here to the expression of my con- 
 viction, corroborated by extensive experience, 
 that autoscopy has considerably advanced our 
 ability to diagnosticate, and especially to treat, 
 pathological conditions of the posterior laryn- 
 geal wall, the trachea, and the primary bronchi. 
 Given a patient suffering from chronic tracheo- 
 bronchitis, stenosis of the bronchi, or something 
 similar, the cardinal question concerning the 
 local treatment is : Can he be readily examined 
 with the autoscope or not 1 In principle and in 
 theory we can see and accomplish nothing by 
 means of the autoscope that we cannot do as 
 well by means of the laryngoscope ; but the 
 difference in our practical results is, neverthe- 
 
42 AUTOSCOPY. 
 
 less, very great. The posterior wall of the lar- 
 ynx, as is well known, forms in different people 
 a varying angle with the longitudinal axis of 
 the trachea ; according to this variation the 
 angle at which it apjDears in the autoscope also 
 varies. The nearer it approaches to a right 
 angle, the better is the view obtained ; a perfect 
 surface-view can be obtained, in many cases, 
 only when the patient departs from the normal 
 position and lowers his head toward his breast. 
 I think that I am able to get a sufficiently good 
 autoscopic view of the posterior wall of the 
 larynx in about two-thirds of all cases. 
 
 In practice it is certainly not necessary to 
 exhaust all of our means in every case, and 
 thus we need not use the autoscope in every 
 patient ; but experience will soon teach any 
 unbiased observer that autoscopy is necessary 
 to a complete and thorough examination of the 
 throat in many cases. The more familiar we 
 become with the autoscope, the more we shall 
 learn to regret that the possibility of being ex- 
 amined thoroughly and satisfactorily with this 
 instrument is not a universal characteristic of 
 the human race. 
 
AUTOSCOPY AND LARYNGOSCOPY. 43 
 
 There is no theoretical objection to the 
 employment of magnifying instruments in auto- 
 scopy, to the use of OerteVs stroboscope (stro- 
 bantoscopy of the larynx). 
 
 I can also recommend to snch of my col- 
 leagues as have experience in photography 
 to try to photograph the larynx through the 
 autoscope. 
 
 In this connection I may mention a proced- 
 ure not strictly autoscopic, but made possible 
 by means of autoscopy, which consists in the 
 inspection of the under surface of the vocal 
 cords by means of a small, round mirror 8 mil- 
 limetres in diameter ; this mirror is introduced, 
 through the autoscope, beneath the glottis of 
 the cocainized patient. The subglottic mirror 
 is fastened to a very thin, nickel-plated rod of 
 copper, which may be bent to suit the require- 
 ments of the case. Hitherto the view of the 
 under surface of the vocal cords (first obtained, 
 as far as I know, by Eauchfuss) could be 
 gained only as a twice-reflected image, for the 
 lower image had to be reflected once more by a 
 mirror higher up ; thus the picture was, so to 
 speak, " third-hand " ! 
 
COMPARISON BETWEEN AUTOSCOPY 
 AND LAEYNGOSCOPY. 
 
 II. EXAMINATION OF CHILDKEN. 
 
 Childeen are examined with the antoscope 
 in the same manner as adults, but the spatulas 
 used are shorter (12 centimetres) and narrower. 
 Though the shape of the epiglottis in children 
 is not well adapted to laryngoscopy, it does 
 not offer so great an obstacle to autoscopy, in 
 which the epiglottis is raised. The success of 
 autoscopy in children depends more or less 
 upon circumstances. Obstreperous children, 
 who will not allow any manipulation, can be 
 made to submit to the examination by force. 
 It is obvious that this is a dangerous procedure 
 in inexperienced hands. I do not at all recom- 
 mend it, but simply wish to state that it can 
 easily be done. In struggling children the 
 entrance to the larynx appears contracted ; the 
 epiglottis, the arytenoid cartilages, and the ary- 
 epiglottic folds are readily seen, and this is 
 often sufficient for a diagnosis in children. 
 (44) 
 
AUTOSCOPr AND LARYNGOSCOPr. 45 
 
 I have frequently made autoscopic examina- 
 tions of children under the influence of an an- 
 aesthetic ; this was accomplished with the great- 
 est ease and to the fullest extent ; in fact, I 
 
 have come to the opinion that the equation — 
 
 is comparatively favorable in children. The 
 head of the chloroformed child is drawn over 
 the edge of the table and is held by an assist- 
 ant. The autoscope is now introduced with 
 the left hand, the spatula directed downward, 
 and the base of the tongue is then pressed for- 
 ward in the usual manner with the spatula ; the 
 head of the child is now gradually raised or 
 lowered until the correct position is obtained. 
 In this attitude a bougie can be pushed readily 
 into the larynx, or intubation may be per- 
 formed under favorable circumstances. Should 
 one desire to use the intra-laryngeal spatula, 
 cocaine could probably not be dispensed with, 
 even though chloroform were employed. I 
 would be loath, however, to use cocaine during 
 anaesthesia, not so much from fear of intoxica- 
 tion, but on account of the danger of aspiration 
 when the entrance of the larynx is completely 
 anaesthetized. 
 
46 AUTOSCOPY. 
 
 In all probability autoscopy will assume an 
 important role in the examination of children, 
 — on an equal footing with laryngoscopy ; but in 
 preference to laryngoscopy in very young chil- 
 dren. Even infants can be examined with the 
 autoscope ; they are most easily examined in 
 the dorsal position, as just described, naturally, 
 without the use of an anaesthetic. 
 
COMPARISON BETWEEN AUTOSCOPY 
 AND LARYNGOSCOPY. 
 
 III. OPERATIONS. 
 
 We now come to the consideration of anto- 
 scopy in its relations to the technique of local 
 treatment. It is immaterial whether we carry 
 out such common procedures as iDJections, in- 
 sufflations, applications with the brush, etc., 
 according to the old or the new plan, in patients 
 well adapted to autoscopy. I will therefore 
 confine myself to the consideration of operative 
 procedures. Autoscopy is veritaUy a surgical 
 method; it exposes the larynx in the depth of 
 the throat with a speculum, in about the same 
 way as the portio vaginalis uteri is exposed by 
 the distension of the vagina. When I have once 
 brought a tumor to view through the autoscope, 
 I simply have to attack it straightway with for- 
 ceps, knife, or snare, in whatever manner is 
 most suitable. For this purpose I control the 
 autoscope with my left hand and introduce the 
 instrument with my right hand between the 
 
 (47) 
 
48 AUTOSCOPY. 
 
 hood and the spatula, along its right side. The 
 handle of the surgical instrument can be held, 
 according to the requirements of the case, 
 parallel with the handle of the autoscope or at 
 any desired angle to it. There is no room in 
 the autoscope for extensive lateral movements 
 of the surgical instrument ; but this is no loss, 
 for we can seize nothing that we do not dis- 
 tinctly see, and we can see only that distinctly 
 which is brought well into view through the 
 autoscope. With our left hand we must closely 
 control the position of the autoscope ; our right 
 hand remains free for the more delicate manip- 
 ulations. (Fig. 9.) 
 
 The instruments for autoscopic operations 
 are shaped like nasal instruments; they 
 measure 20 centimetres from the knee to the 
 tip, and are correspondingly longer for the 
 windpipe. We are not under the necessity of 
 devising new instruments; we simply trans- 
 form our ordinary into an autoscopic armamen- 
 tarium (Fig. 10, page 50) by having our laryn- 
 goscopic models lengthened and bent, and the 
 rhinological ones simply lengthened. 
 
 Endolaryngeal operations are comparatively 
 
AUTOSCOPY AND LARYNGOSCOPY. 
 
 49 
 
 easy with the autoscope and comparatively 
 difficult with the laryngoscope. This fact 
 might cause dissensions among laryngologists. 
 
 Fig. 9.— Atjtoscopic Opekation. 
 
 To some it will appear self-evident that we 
 should not make a difficult operation out of an 
 easy one, that we should not construct obstacles 
 just for the pleasure of overcoming them, and 
 
50 
 
 AUTOSCOPY. 
 
 that we should not seek to exercise the excep- 
 tional skill of a specialist when ordinary surg- 
 
 FiG. 10 —Types of Instruments for Atttoscoptc Operations. 
 
 ery is wholly adequate. On the other hand, 
 there are teachers who will warn their pupils 
 against spoiling themselves by practising auto- 
 
AUTOSCOPY AND LARYNGOSCOPY. 51 
 
 scopy, instead of using every opportunity to 
 operate under the guidance of the mirror; 
 arguing that operators will have to use the 
 laryngoscope in the future just as in the past, 
 as there always will be many patients requiring 
 operations who are poor subjects for autoscopy. 
 We can imagine a laryngological parliament the 
 radical wing of which, as a matter of principle, 
 would operate with the aid of the laryngoscope 
 only in those cases not adapted to autoscopy, 
 while the conservatives would tolerate auto- 
 scopic manipulations only under exceptional 
 circumstances; the centre, however, would 
 decide each case on its merits. In my opinion, 
 the question does not justify a position either 
 on the extreme right or left. To make a battle- 
 cry of the autoscope, on the one hand, or the 
 laryngoscope, on the other, would be folly. 
 Where two ways are open, some for many 
 reasons will prefer one, while others prefer the 
 other; we can ask no more of any operator 
 than that he should perform any necessary 
 operation with nicety and care. How he does 
 it is a matter of taste. If, in spite of this, I 
 nevertheless believe that finally, in the course 
 
52 AUTOSCOPY. 
 
 of years, autoscopy will be generally accepted 
 — of course, not as a matter of dogma — as the 
 standard method for endolaryngeal and endo- 
 tracheal surgery in those cases in which it 
 can be easily used, I base this conclusion on 
 human nature, which does not obstinately hold 
 on to a complicated procedure when a simple 
 one is at its disposal. Whatever resistance 
 arises from custom (and this I by no means 
 undervalue) will of itself grow weaker with 
 time, and the argument that we have got along 
 so far without autoscopy will lose its force after 
 awhile. Autoscopic operations on the posterior 
 wall of the larynx will become common prop- 
 erty of laryngologists more quickly (or, rather, 
 less slowly) than the other autoscopic pro- 
 cedures. 
 
 Autoscopy comes in competition with 
 general surgery in only one class of cases, 
 —namely, in foreign bodies in the air-passages ; 
 here it will render tracheotomy unnecessary in 
 some cases. 
 
 Concerning endotracheal local therapeutics-^ 
 which can now reach a development whiqh was 
 denied to it in the pre-autoscopic era, I should 
 
AUTOSCOPY AND LARYNGOSCOPY. 53 
 
 like to raise a finger of warning, as a result not 
 of unfortunate experiences of my own, but of 
 observation and reflection. The lower half of 
 the trachea is a region of great danger! The 
 rhythmical bulging of its wall, especially the 
 tracheal aortic pulse, which can be easily ssen 
 toward the left and somewhat anteriorly, and 
 readily counted, is a constant and impressive 
 phenomenon in people well adapted to auto- 
 scopy, which should lead to the greatest caution 
 in the introduction of rigid instruments. The 
 aorta lies almost in as close contact with the 
 'wall of the windpipe as the radial artery does 
 with the surface at the wrist (reference is made 
 only to the aorta distended with blood, as it is 
 during life, and not to the conditions existing 
 after death). During the examination of a 
 number of healthy people the aortic arch has 
 often seemed to protrude like a hump, as it 
 were, into the trachea ; so that the beginner in 
 autoscopy would be tempted to diagnosticate 
 an aneurism where none exists. I have seen 
 the most enormous pulsations in patients suf- 
 fering from aortic insufficiency, in whom, how- 
 ever, there was no evidence of actual aneu- 
 
54 AUTOSCOPY. 
 
 rismal changes ; in such cases I have seen very 
 marked undulations over an area about 6 to 8 
 centimetres long and 3 centimetres wide. 
 
CONCLUSION. 
 
 Whoever believes in uninterrupted progress, 
 in small things as well as in large, may nurture 
 the hope that in the future autoscopy will be 
 developed to such an extent that it can ulti- 
 mately be applied to every individual. This 
 hope, however, I cannot share. The problems 
 of aiitoscopy are confined within exceedingly 
 narrow limits; their determining factors are 
 well known, and I have expounded them suf- 
 ficiently in this monograph. The limitations 
 of autoscopy are of an anatomical nature, and 
 the structure of our bodies will scarcely accom- 
 modate itself to our wishes. If we cannot get 
 the tongue out of the way toward the front, we 
 shall have to look over it, — that is, around a 
 curve, — and for this purpose a mirror or a 
 prism is absolutely indispensable ; thus, we 
 come back to where we started. I know of but 
 one way in which any special advance over the 
 results already achieved is possible. By draw- 
 ing the angle of the patient's mouth sideways 
 
 (55) 
 
56 AUTOSCOPY. 
 
 toward his ear with a retractor, applying the 
 spatula over the lower molars to the base of the 
 tongue, and pressing the corresponding half of 
 the tongue forward, we sometimes obtain a 
 very good side-view of the larynx, even in 
 persons who are poor subjects for ordinary 
 autoscopy. This lateral autoscopy is worth 
 further attention. In this connection I can 
 also recommend, as a useful aid in the exami- 
 nation of the lateral portions of the pharynx, the 
 tonsillar region, etc., the drawing back of the 
 angle of the mouth on the opposite side ; this is 
 done by the physician or by the patient himself, 
 either with a finger or with a retractor. In 
 other respects I now consider the problems of 
 autoscopy definitely settled^ — until, at least, an 
 entirely new creative thought arises to open up a 
 new path. 
 
EESUME. 
 
 1. The human larynx and trachea can be 
 examined autoscopically ; that is, they are 
 accessible to direct inspection; the means to 
 this end is pressure on the tongue. 
 
 2. The individual adaptability to autoscopy 
 varies within wide limits ; the reasons are of an 
 anatomical nature. 
 
 3. Laryngoscopy is no longer the only 
 method of examining the air-passages as 
 hitherto ; but it will continue to be the 
 standard method and the one to be used above 
 all others for the purpose of diagnosis. 
 
 4. Autoscopy is an important addition to 
 laryngoscopy, especially for examining the pos- 
 terior wall of the larynx and the trachea. 
 
 5. In the examination of children autoscopy 
 is indispensable in some cases ; especially with 
 the aid of chloroform anaesthesia, it can be car- 
 ried out without any great difficulty. 
 
 6. In endolaryngeal and endotrachecd surgery 
 
 (57) 
 
58 AUTOSCOPY. 
 
 autoscopy will take the front rank as the standard 
 method; of course, within its anatomical limits. 
 
 7. The technique of laryngoscopic oper- 
 ations remains the same, and must continue to 
 be used in those patients who are ill-adapted to 
 autoscopy. 
 
APPENDIX. 
 
 THE FIRST AUTOSCOPIC OPERATION ON A 
 TUMOR OF THE VOCAL CORD. 
 
 Mrs. Wilhelmine Konig, set. 39, small, 
 slender, ill-nourished; had been coughing for 
 three years; had haemoptysis two years ago; 
 had been hoarse since August, 1895. Dullness 
 
 Fig. 11.— Tumor of Vocal Cord. 
 
 over the right apex down to the second rib; 
 respiratory murmur weak; no rales. Sputum 
 not obtainable. Upper teeth carious and partly 
 lost. Marked hoarseness. Examination with 
 the laryngoscope revealed a condition repro- 
 duced in the illustration. (Fig. 11.) The right 
 arytenoid cartilage was tipped considerably 
 
 (59) 
 
60 AUTOSCOPY. 
 
 forward; the right vocal cord was immovable 
 in the cadaveric position and its free edge was 
 concave. The left vocal cord possessed normal 
 mobility, and during phonation extended only 
 to the median line. In its anterior portion, 
 close to the anterior commissure, was a pink, 
 round tumor, the size of a millet-seed, and 
 dotted on its apex with a small, red point. The 
 tumor was attached to the edge of the vocal 
 cord, and was movable. The patient could be 
 examined with the autoscope so well that the 
 tumor, notwithstanding its unfavorable local- 
 ity, could be readily seen as the autoscope was 
 introduced. 
 
 Operation. — On October 26, 1895, the larynx 
 was cocainized by instillation of a 20-per-cent. 
 solution of cocaine (without the aid of a 
 mirror). The autoscopic intra-laryngeal spatula 
 fastened to the electroscope was passed behind 
 the epiglottis and controlled with the left hand. 
 The tumor was seized and removed with the 
 greatest ease with a small, cutting, double 
 curette (in the straight tube and handle of 
 Krause). The patient was not aware of the 
 operation, which lasted but a few seconds. 
 
APPENDIX. 61 
 
 Result of the operation: The left vocal cord 
 is now normal. The hoarseness was little im- 
 proved at first, as was to be expected in a case 
 of paralysis of the recurrens on the right side. 
 Four weeks after the operation the left vocal 
 cord began to approach the paralyzed cord dur- 
 ing phonation. Since the beginning of Decem- 
 ber, 1895, return of the voice, notwithstanding 
 the continuance of the paralysis of the recur- 
 rens. During phonation the left vocal cord 
 now comes in contact with the right cord. 
 By the middle of January, 1896, the paralysis 
 had disappeared and the patient was entirely 
 restored. 
 
ADDITIONAL NOTES OF THE TRANS- 
 
 LATOE. 
 
 I. A FOKEIGN BODY EEMOVED FROM THE LARYNX 
 BY THE TRANSLATOR. 
 
 Mr. C. F. B., ast. 24, consulted me on March 
 25, 1896. He stated that while eating some 
 stewed chicken, two days before, he suddenly 
 felt something " go the wrong way." He had 
 subsequently a severe coughing spell and some 
 choking sensations, which, however, soon sub- 
 sided. In order to remove the foreign body 
 an emetic had been taken, but without avail. 
 Since that time he had had occasional coughing 
 spells, but felt otherwise well. He was sure, he 
 stated, that a foreign body, probably a bone, 
 was somewhere lodged in his throat, although 
 there was no difficulty in swallowing, nor any 
 pain worth mentioning. 
 
 The patient was a strong, young man, of 
 more than average size. No signs of distress 
 were noticeable. There was no dyspnoea, nor 
 (62) 
 
ADDITIONAL NOTES. 63 
 
 any tenderness of the neck on pressure. The 
 voice was slightly husky. Laryngoscopic ex- 
 amination revealed, in the extremely large 
 larynx, a longitudinal piece of bone, the one 
 end of which seemed to be imbedded in the 
 right ventricle, while the other end leaned 
 against the left ary-epiglottic ligament. The 
 upper end seemed not to be impacted. It was 
 evident that this patient's larynx was not very 
 irritable. The autoscope was introduced with 
 the medium-sized hood attached. No cocaine 
 was deemed necessary. It was possible to 
 grasp the foreign body readily with a slender, 
 serrated forceps in Krause's straight tube and 
 universal handle, and to lift it out of the larynx 
 and remove it together with the autoscope. 
 The removed piece of bone was nearly four 
 centimetres long. The whole operation took 
 but a few seconds. 
 
 II. LATEST IMPKOVEMENTS IN AUTOSCOPY. 
 
 While the preceding pages were going 
 through the press Dr. Kirstein published some 
 modifications of his method,* which I append, 
 
 * Therapeutische Monatshefte, July, 1896. 
 
64 AUTOSCOPY. 
 
 in abstract, in order to bring this essay up to 
 date : — 
 
 The main impediments to a thorough ex- 
 amination of the deeper portions of the throat 
 are, as has been previously pointed out, the 
 tongue and the epiglottis. If we were able to 
 remove these impediments there would be noth- 
 ing to prevent an inspection (and possibly a 
 palpation), through the mouth, of the laryngo- 
 tracheal tract. Kirstein has now fully demon- 
 strated that this principal impediment — the 
 tongue — can be removed from the pathway 
 of straight rays of light, thrown directly into 
 the laryngo-tracheal tube, a great deal farther 
 than we had ever suspected. The amount of 
 displacement, it is true, varies greatly in differ- 
 ent subjects. 
 
 It has lately been found that for ordinary 
 examination a complicated appliance is not 
 necessary. A tongue-depressor, constructed 
 on the lines of the one shown on next page, will, 
 in most cases, be sufficient. The patient should 
 be seated, should tilt the head slightly back- 
 ward (as described on page 21 ; see also Figs. 
 6 and 9), and the physician stands before the 
 
ADDITIONAL NOTES. 65 
 
 patient. The spatula is then placed far Lack 
 upon the tongue, — as far as possible, — and 
 a firm pressure in a downward and forward 
 direction is exercised upon the root of the 
 tongue, whereby a deep and slanting groove 
 is formed along the back of the tongue, thus 
 allowing the rays of light to fall in line with 
 
 Fig. 12.— Tongue-Depressor for Phaeyngoscopy and 
 Direct Laryngo-Tracheoscopy. 
 
 Side-view and surface-view of the anterior portion. In some cases an instrument with a 
 larger curve of the anterior portion is more practicable. 
 
 an imaginary laryngo-tracheal axis. With 
 proper illumination we are now enabled to 
 get a good view of the air-passages. The ex- 
 tent of this view depends, of course, upon the 
 individuality of the patient, as stated in a pre- 
 vious chapter (page 29), and upon the skill of 
 the examiner. Many apparently unsurmount- 
 
66 AUTOSCOPY. 
 
 able difficulties may be overcome by patience 
 and practice. 
 
 There are, however, some tongues which are 
 so " stubborn," as it were, that it is well-nigh 
 impossible to completely overcome their resist- 
 ance to this manipulation. As the source of 
 illumination we may use an ordinary forehead- 
 reflector, or, still better, Kirstein's electric fore- 
 head-lamp (Fig. 2). If during this examination 
 the upper lip or a moustache should obstruct 
 the vision, the other hand will readily remove 
 this obstacle. 
 
 In this way we shall be enabled to see, in 
 the vast majority of cases, the posterior wall 
 of the larynx; in a good many cases the pos- 
 terior two-thirds of the vocal cords can be seen, 
 and, although rarely, the whole interior of the 
 larynx, including the anterior commissure of 
 the vocal cords, is exposed to a thorough in- 
 spection. 
 
 The extent to which the trachea may be 
 seen is larger or smaller in proportion to the 
 view obtained of the interior of the larynx. 
 There are, however, — and we must not forget 
 it, — certain limitations to this method which 
 
ADDITIONAL NOTES. 67 
 
 we cannot overcome, also not by brusquely 
 increasing the i)ressure upon the tongue; al- 
 though we may, in cocainized patients, during 
 operations, be a little more energetic. 
 
 For simple autoscoj^ic examination the spat- 
 ula, or tongue-depressor, alone will be sufficient. 
 As this tongue-depressor is available also for 
 ordinary pharyngoscopy, there is, in reality, 
 nothing needed for autoscopy which we do not 
 already possess in our armamentarium. The 
 more complicated instrument described on page 
 15 will henceforth be used more especially for 
 operations, clinical demonstrations, and in the 
 examination of children. 
 
 In this connection it may be repeated 
 that the laryngological examination of chil- 
 dren will immeasurably be aided by the auto- 
 scopie method. The larynx and trachea can 
 be examined, in children who are anaesthetized, 
 with such thoroughness as was never before 
 possible. 
 
 It is frequently feasible, especially in young 
 children, to dispense altogether with the an- 
 aesthesia, and yet to get a good view of the 
 laryngo-tracheal tube. 
 
68 AUTOSCOPY. 
 
 In conclusion, it must be repeated that auto- 
 scopy is an art that requires study and practice : 
 the art of pressing into the tongue with a mini- 
 mal amount of irritation a longitudinal groove, 
 reaching backward and downward as far as pos- 
 sible, and approximating in direction to the axis 
 of the laryngo-tracheal tract. 
 
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