Direct /lutoscopv; Kirstein. 
WITH DEITONSTR AXIOM. 
BY 
ROBERT LEVY, M. D. 
DENVER, COLO. 
Professor of Laryngology, Rhinology and Physiology. 
Gross Medical College, Laryngologist to Arapahoe 
County, St. Luke’s and St. Anthony’s Hospitals, 
President Colorado State Medical So- 
ciety, etc. 
REPRINTED FROM 
Gross Medical College Bulletin, 
July, 1896. DIRECT AUTOSCOPY; KIRSTEbN.—With Demonstration.* 
ROBERT LEVY, M. D. 
Professor of Laryngology, Rhinology and Physiology, Gross Medical College 
Laryngologist to Arapahoe County, St. Luke’s and St. Anthony’s 
Hospitals, President Colorado State Medical Society, etc. 
Allow me to consume a short time in showing you the direct 
method of examining the larynx by means of what is known as the 
method of Kirstein. 
I regret that the patient suffering from Laryngeal Papillomata 
has not presented himself, and as a consequence, I wish simply to 
show you the use of the instrument known as the Autoscope, and the 
larynx of a patient who is easily examined by this method. The 
Autoscope is an instrument consisting of a handle upon which is 
placed a hood and to which is attached cables connected with a ten 
volt battery. In the hood is an electric light of ten candle power, 
which is concentrated by a small bulls eyt upon a mirror. The 
mirror is so placed as to reflect the light through a slit in the hood 
and upon a long grooved tongue depressor. The tongue depressor is 
so introduced into the patient’s pharynx as to illuminate to a dis- 
tance below the vocal bands and even to the first bronchi. The 
object of the method is to do away with the laryngeal mirror, but this 
object has not, as yet, been accomplished. The great disadvantage 
of this means of examination is the difficulty that patients find in 
allowing the instrument to be passed far enough for a successful ex- 
amination. Some patients are more easily manipulated than others, 
and in the majority of instances it is necessary to anaesthetize the 
throat with a solution of cocaine. 
The photographs which are here presented show the patient in two 
positions in which the examination may be conducted. One position 
is that of the patient upon a table with his head thrown well down- 
ward over the edge, the other position is that of a patient sitting erect 
his head thrown back, the operator standing behind. A much simpler 
method and more comfortable position is that of the patient sitting 
erect in a chair, his body inclined slightly forward, his neck well 
extended, the operator standing in.front. 
Whatever position be assumed, the principle is simply that of 
bringing the mouth in as near a straight line with the larynx and 
trachea as possible, much as is done in the sword swallower’s act. 
Autoscopy is applied in three stages, namely: 
First. The simple examination of the pharynx is similar to 
ordinary pharyngoscopy, by means of the common tongue depressor 
* Presented at the meeting of the Colorado State Medical Society, June, 1896. Second. By slightly raising the handle of the instrument and 
slipping the tongue depressor backwards as far as the base of the 
tongue, the anterior suface of the epiglottis together with the 
adjacent regions is seen. 
Third. The examination of the interior of the larynx and 
trachea; this is the most important as well as the most difficult por- 
tion of the procedure. It is necessary, in order to accomplish the 
third position, that the handle of the instrument be well raised, the 
instrument gradually slipped well into the glosso-epiglottic space 
and firm pressure made downward and forwards; the epiglottis is 
thus raised and the interior of the larynx with more or less of the 
structures below brought into view. At times this is not accom- 
plished so easily on account of failure to raise the epiglottis suffic- 
iently; in these instances it is not difficult to pass the end of the 
tongue depressor over the epiglottis, drawing it well forward by 
gentle pressure upon its under surface. 
In regard to the practicability of this instrument, it is true this 
is as yet very limited. However, there are certain conditions which 
can undoubtedly be more successfully treated under the guidance of 
this method of examination. 
Intra-laryngeal operations upon children are with great difficulty 
performed with the laryngoscope, either under general anaesthesia 
or local. Von Bruns* has recently operated upon two cases of 
laryngeal papilloma in children, by placing them under complete 
anaesthesia and then using Kirstein’s Autoscope. We can readily 
appreciate the ease with which this method is applied during 
anaesthesia as compared with ics use in children under simple 
applications of cocaine. It is easy to appreciate also the advantages 
in such instances of this method over the almost impossible examin- 
ation by the laryngoscope. 
* Central blatt fur Kinderheilkunde.