[FIG. 47.--Schematic illustration of normal position of the intra-thoracic trachea and esophagus and also of the entire trachea when the patient is in the correct position for peroral bronchoscopy. When the head is thrown backward (as in the Rose position) the anterior convexity of the cervical spine is transmitted to the trachea and esophagus and their axes deviated. The anterior deviation of the lower third of the esophagus shows the anatomical basis for the "high low" position for esophagoscopy] [FIG. 48.--Correct position of the cervical spine for esophagoscopy and bronchoscopy. (_Illustration reproduced from author's article Jour. Am. Med. Assoc., Sept. 25, 1909_)] [FIG. 49.--Curved position of the cervical spine, with anterior convexity, in the Rose position, rendering esophagoscopy and bronchoscopy difficult or impossible. The devious course of the pharynx, larynx and trachea are plainly visible. The extension is incorrectly imparted to the whole cervical spine instead of only to the occipito-atloid joint. This is the usual and very faulty conception of the extended position. (_Illustration reproduced from author's article, Jour. Am. Med. Assoc., Sept. 25, 1909._)] [76] For _direct laryngoscopy_ the patient's head is raised above the plane of the table by the first assistant, who stands to the right of the patient, holding the bite block on his right thumb inserted in the left corner of the patient's mouth, while his extended right hand lies along the left side of the patient's cheek and head, and prevents rotation. His left hand, placed under the patient's occiput, elevates the head and maintains the desired degree of extension at the occipito-atloid joint (Fig. 50). [FIG 50.--Direct laryngoscopy, recumbent patient. The second assistant is sitting holding the head in the Boyce position, his left forearm on his left thigh his left foot on a stool whose top is 65 cm. lower than the table-top. His left hand is on the patient's sterile-covered scalp, the thumb on the forehead, the fingers under the occiput, making forced extension. The right forearm passes under the neck of the patient, so that the index finger of the right hand holds the bite-block in the left corner of the patient's mouth. The fingers of the operator's right hand pulls the upper lip out of all danger of getting pinched between the teeth and the laryngoscope. This is a precaution of the utmost importance and the trained habit of doing it must be developed by the peroral endoscopist.]