e indicated by the dotted line may be dropped or not, but
the back of the head must never go lower than here shown, for direct
laryngoscopy; and it is better to have it at least 10 cm. above the
level of the table. The table may be used as a rest for the operator's
left elbow to take the weight of the head. (Note that in bronchoscopy
and esophagoscopy the head section of the table must be dropped, so as
to leave the head and neck of the patient out in the air, supported by
the second assistant.)]

[FIG. 56.--Endoscopic view at the end of the second stage of direct
laryngoscopy. Recumbent patient. Larynx exposed waiting for larynx to
relax its spasmodic contraction.]

RULES FOR DIRECT LARYNGOSCOPY
1. The laryngoscope must always be held in the left hand, never in
the right.
2. The operator's right index finger (never the left) should be used
to retract the patient's upper lip so that there is no danger of
pinching the lip between the instrument and the teeth.
3. The patient's head must always be exactly in the middle line, not
rotated to the right or left, nor bent over sidewise; and the entire
head must be forward with extension at the occipitoatloid joint only.
4. The laryngoscope is inserted to the right side of the anterior
two-thirds of the tongue, the tip of the spatula being directed toward
the midline when the posterior third of the tongue is reached.
5. The epiglottis must always be identified before any attempt is
made to expose the larynx.
6. When first inserting the laryngoscope to find the epiglottis,
great care should be taken not to insert too deeply lest the
epiglottis be overridden and thus hidden.
7. After identification of the epiglottis, too deep insertion of the
laryngoscope must be carefully avoided lest the spatula be inserted
back of the arytenoids into the hypo-pharynx.
8. Exposure of the larynx is accomplished by pulling forward the
epiglottis and the tissues attached to the hyoid bone, and not by
prying these tissues forward with the upper teeth as a fulcrum.
9. Care must be taken to avoid mistaking the ary-epiglottic fold for
the epiglottis itself. (Most likely to occur as the result of rotation
of the patient's head.)
10. The tube should not be retained too long in place, but should be
removed and the patient permitted to swallow the accumulated saliva,
which, if the laryngoscope is too long in place, will trickle down the
trachea and cause cough. (Swallowing is almos