difficulty in swallowing, chief stress
should be laid on the X-ray appearances after the administration of an
opaque meal; a pouch shows as a uniform, spherical shadow of from one
to two inches in circumference.

_Treatment_ is influenced by the manner in which the patient may have
learned to overcome the difficulty of getting food into his
stomach--Lord Jeffrey, who was the possessor of the pharyngeal pouch
shown in Fig. 286, was in the habit of emptying it, after a meal, by
means of a long silver spoon. Some patients learn to feed themselves
through a soft rubber tube.

[Illustration: FIG. 286.--Diverticulum of the Oesophagus at its
junction with the Pharynx.

(Anatomical Museum, University of Edinburgh.)]

If an _operation_ is decided upon, and for this it is essential that
the pouch should be accessible from the neck, the general condition is
improved by feeding through a stomach tube and by rectal and
subcutaneous salines. The operation consists in exposing and isolating
the pouch by a dissection on the left side of the neck, and either
excising it as if it were a tumour or cyst, or if the risk of
infection of the deeper planes of cellular tissue is regarded with
apprehension, the pouch may be _infolded_ into the lumen of the
gullet, or the excision be carried out in two _stages_. At the first
stage, the pouch is isolated and rotated on its pedicle, in which
condition it is fixed by sutures; after an interval of from ten to
fourteen days it is excised.

Should the diverticulum be inaccessible from the neck, and the
difficulty of swallowing be attended with progressive emaciation,
_gastrostomy_ may be required to avert death by starvation.

_Traction diverticula_ are due to the contraction of scar tissue
outside the gullet, as for example that resulting from tuberculous
glands in the posterior mediastinum; they are rarely attended with
symptoms, and are rather of pathological than surgical interest.

#Innocent Stricture or Cicatricial Stenosis of the Gullet.#--The
innocent or fibrous stricture follows upon the swallowing of corrosive
substances, usually by inadvertence, sometimes with suicidal intent.
Having recovered from the initial effects of the corrosive agent, the
patient suffers from gradually increasing difficulty in swallowing,
first with solids and later with fluids. There is the usual variation
or intermittence of symptoms that attend upon all conditions causing
difficulty of swallowing, the exac