be tided over for a time by feeding through a rubber
tube, but it is to be remembered that, in children, struggling in
resisting the passage of the tube may seriously strain a heart that is
already threatened by the toxins of diphtheria.

#Diverticula or Pouches of the Gullet.#--A diverticulum consists in
the protrusion of the mucous and submucous coats through a defect or
weak part in the muscular tunic; it is therefore of the nature of a
hernia and not a localised dilatation of the tube as a whole.
Anatomically, there is such a weak spot in the posterior wall opposite
the cricoid cartilage, known as the _pharyngeal dimple_, between the
circular and oblique fibres of the crico-pharyngeus muscle. As the
pouch increases in size by pressure from within, it usually extends
downwards and to the left. This pouch is described as a _pressure or
pulsion diverticulum_ because the hernial protrusion is ascribed to
increased pressure within the pharynx, not only the normal increase
caused by the act of swallowing, but an abnormal pressure from the too
rapid swallowing or bolting of imperfectly masticated food materials.

[Illustration: FIG. 285.--Radiogram, after swallowing an opaque meal,
in a man suffering from malignant stricture of lower end of Gullet.]

The _clinical features_ are not so characteristic of difficulty in
swallowing as might be expected. The patient, usually a man over forty
years of age, complains of dryness in the throat and of a sensation as
of a foreign body; later there is regurgitation of saliva and of food
with occasional choking. In about one-third of the cases, there is a
fullness, or a palpable tumour in the neck, about three times more
often on the left than on the right side, which may increase in size
after a meal, and pressure on which may cause a gurgling sound and, it
may be, regurgitation of food.

It is suggestive of a pouch, if the patient regurgitates food
materials which can be identified as having been swallowed several
days before, currants perhaps being those most easily recognised and
remembered.

Diverticula are also met with at a lower level, springing from the
gullet at or below the upper opening of the thorax; the distension of
the pouch with food materials presses upon the gullet with more
serious effect, even to the extent of complete obstruction and
consequent rapid emaciation. In men over fifty, the resemblance to
carcinoma may be very close.

In this, as in all cases of