of this constricted lumen at the level of the
cricopharyngeus and the subjacent orbicular esophageal fibers.

[109] [FIG. 67.--Schematic illustration of the author's "high-low"
method of esophagoscopy. In the first and second stages the patient's
head fully extended is held high so as to bring it in line with the
thoracic esophagus, as shown above. The Rose position is shown by way
of accentuation.]

[FIG. 68.--Schematic illustration of the anatomic basis for difficulty
in introduction of the esophagoscope. The cricoid cartilage is pulled
backward against the cervical spine, by the cricopharyngeus, so
strongly that it is difficult to realize that the cricopharyngeus is
not inserted into the vertebral periosteum instead of into the median
raphe.]

[FIG. 69.--The upper illustration shows movements necessary for
passing the cricopharyngeus.

The lower illustration shows schematically the method of finding the
pyriform sinus in the author's method of esophagoscopy. The large
circle represents the cricoid cartilage. G, Glottic chink,
spasmodically closed; VB, ventricular band; A, right arytenoid
eminence; P, right pyriform sinus, through which the tube is passed in
the recumbent posture. The pyriform sinuses are the normal food
passages.]

_Stage 3. Passing Through the Thoracic Esophagus_.--The thoracic
esophagus will be seen to expand during inspiration and contract
during expiration, due to the change in thoracic pressure. The
esophagoscope usually glides easily through the thoracic esophagus if
the patient's position is correct. After the levels of the aorta and
left bronchus are passed the lumen of the esophagus seems to have a
tendency to disappear anteriorly. The lumen must be kept in axial view
and the head lowered as required for this purpose.

_Stage 4. Passing Through the Hiatus Esophageus_.--When the head is
dropped, it must at the same time be moved horizontally to the right
in order that the axis of the tube shall correspond to the axis of the
lower third of the esophagus, which deviates to the left and turns
anteriorly. The head and shoulders at this time will be found to be
considerably below the plane of the table top (Fig. 71). The hiatal
constriction may assume the form of a slit or rosette. If the rosette
or slit cannot be promptly found, as may be the case in various
degrees of diffuse dilatation, the tube mouth must be shifted farther
to the left and anteriorly. When the tube mouth is centered o