Every patient should be examined by indirect, mirror laryngoscopy as a preliminary to peroral endoscopy for any purpose whatsoever. This becomes doubly necessary in cases that are to be anesthetized. [65] CHAPTER IV--ANESTHESIA FOR PERORAL ENDOSCOPY A dyspneic patient should never be given a general anesthetic. Cocaine should not be used on children under ten years of age because of its extreme toxicity. To these two postulates always in mind, a third one, applicable to both general and local anesthesia, is to be added--total abolition of the cough-reflex should be for short periods only. General anesthesia is never used in the Bronchoscopic Clinic for endoscopic procedures. The choice for each operator must, however, be a matter for individual decision, and will depend upon the personal equation, and degree of skill of the operator, and his ability to quiet the apprehensions of the patient. In other words, the operator must decide what is best for his particular patient under the conditions then existing. _Children_ in the Bronchoscopic Clinic receive neither local nor general anesthesia, nor sedative, for laryngoscopic operations or esophagoscopy. Bronchoscopy in the older children when no dyspnea is present has in recent years, at the suggestion of Prof. Hare, been preceded by a full dose of morphin sulphate (i.e., 1/8 grain for a child of six years) or a full physiologic dose of sodium bromide. The apprehension is thus somewhat allayed and the excessive cough-reflex quieted. The morphine should be given not less than an hour and a half before bronchoscopy to allow time for the onset of the soporific and antispasmodic effects which are the desiderata, not the analgesic effects. Dosage is more dependent on temperament than on age or body weight. Atropine is advantageously added to morphine in bronchoscopy for foreign bodies, not only for the usual reasons but for its effect as an antispasmodic, and especially for its diminution of endobronchial secretions. True, it does not diminish pus, but by diminishing the outpouring of normal secretions that dilute the pus the total quantity of fluid encountered is less than it otherwise would be. In cases of large quantities of pus, as in pulmonary abscess and bronchiectasis, however, no diminution is noticeable. No food or water is allowed for 5 hours prior to any endoscopic procedure, whether sedatives or anesthetics are to be given or not. If the stomach is not empty vomiting from contact of the tube in the pharynx will interfere with work. With _adults_ no anesthesia, general or local, is given for esophagoscopy. For laryngeal operation and bronchoscopy the following technic is used: