ver the
hiatal constriction moderately firm pressure continued for a short
time will cause it to yield. Then the tube, maintaining this same
direction will, without further trouble glide into and through the
abdominal esophagus. The cardia will not be noticed as a constriction,
but its appearance will be announced by the rolling in of reddish
gastric mucosal folds, and by a gush of fluid from the stomach.

[FIG. 70.--Schematic illustration of the author's "high-low" method of
esophagoscopy, fourth stage. Passing the hiatus. The head is dropped
from the position of the 1st and 2nd stages, CL, to the position T,
and at the same time the head and shoulders are moved to the right
(without rotation) which gives the necessary direction for passing the
hiatus.]

[FIG. 71.--Esophagoscopy by the author's "high-low" method. Stage 4.
Passing the hiatus The patient's vertex is about 5 cm. below the top
of the table.]

_Normal esophageal mucosa_ under proper illumination is glistening and
of a yellowish or bluish pink. The folds are soft and velvety,
rendering infiltration quickly noticeable. The cricoid cartilage shows
white through the mucosa. The gastric mucosa is a darker pink than
that of the esophagus and when actively secreting, its color in some
cases tends toward crimson.

_Secretions_ in the esophagus are readily aspirated through the
drainage canal by a negative pressure pump. Food particles are best
removed by "sponge pumping," or with forceps. Should the drainage
canal become obstructed positive pressure from the pump will clear the
canal.

_Difficulties of Esophagoscopy_.--The beginner may find the
esophagoscope seemingly rigidly fixed, so that it can be neither
introduced nor withdrawn. This usually results from a wedging of the
tube in the dental angle, and is overcome by a wider opening of the
jaws, or perhaps by easing up of the bite block, but most often by
correcting the position of the patient's head. If the beginner cannot
start the tube into the pyriform sinus in an adult, it is a good plan
to expose the arytenoid eminence with the laryngoscope and then to
insert the 7 mm. esophagoscope into the right pyriform sinus by direct
vision. Passing the cricopharyngeal and hiatal spasmodically
contracted narrowings will prove the most trying part of
esophagoscopy; but with the head properly held, and the tube properly
placed and directed, patient waiting for relaxation of the spasm with
gentle continuous press