tage
of the tongue is reached, the tip of the laryngoscope is directed
toward the midline and the dorsum of the tongue is elevated by a
lifting motion imparted to the laryngoscope. The epiglottis will then
be seen to project into the endoscopic field, as seen in Fig. 54.

[FIG. 54.--End of the first of direct laryngoscopy, recumbent adult
patient. The epiglottis is exposed by a lifting motion of the spatular
tip on the tongue anterior to the epiglottis.]

_Second Stage_.--The spatular end of the laryngoscope should now be
tipped back toward the posterior wall of the pharynx, passed posterior
to the epiglottis, and advanced about 1 cm. The larynx is now exposed
by a motion that is best described as a suspension of the head and all
the structures attached to the hyoid bone on the tip of the spatular
end of the laryngoscope (Fig. 55). Particular care must be taken at
this stage not to pry on the upper teeth; but rather to impart a
lifting motion with the tip of the speculum without depressing the
proximal tubular orifice. It is to be emphasized that while some
pressure is necessary in the lifting motion, great force should never
be used; the art is a gentle one. The first view is apt to find the
larynx in state of spasm, and affords an excellent demonstration of
the fact that the larynx can he completely closed without the aid of
the epiglottis. Usually little more is seen than the two rounded
arytenoid masses, and, anterior to them, the ventricular bands in more
or less close apposition hiding the cords (Fig. 56). With deep
general anesthesia or thorough local anesthesia the spasm may not be
present. By asking the patient to take a deep breath and maintain
steady breathing, or perhaps by requesting a phonatory effort, the
larynx will open widely and the cords be revealed. If the anterior
commissure of the larynx is not readily seen, the lifting motion and
elevation of the head should be increased, and if there is still
difficulty in exposing the anterior commissure the assistant holding
the head should with the index finger externally on the neck depress
the thyroid cartilage. If by this technic the larynx fails to be
revealed the endoscopist should ask himself which of the following
rules he has violated.

[FIG. 55.--Schema illustrating the technic of direct laryngoscopy on
the recumbent patient. The motion is imparted to the tip of the
laryngoscope as if to lift the patient by his hyoid hone. The portion
of the tabl