It has been the chagrin of skilled surgeons to find the diverticulum present functionally and roentgenographically precisely the same as before the performance of the very trying and difficult operation. The time of operation may be shortened at least by one-half by the aid of the esophagoscopist in the Gaub-Jackson operation. Intratracheally insufflated ether is the anesthesia of choice. After the surgeon has exposed the esophagus by dissection, the endoscopist introduces the esophagoscope into the sac, and delivers it into the wound, while the surgeon frees it from adhesions. The esophagoscope is now withdrawn from the pouch and entered into the esophagus proper, below the diverticulum, while the surgeon cuts off the hernial sac and sutures the esophagopharyngeal wound over the esophagoscope. The presence of the esophagoscope prevents too tight suture and possible narrowing of the lumen (Fig. 102). [FIG. 102.--Schematic representation of esophagoscopic aid in the excision of a diverticulum in the Gaub-Jackson operation. At A the esophagoscope is represented in the bottom of the pouch after the surgeon has cut down to where he can feel the esophagoscope. Then the esophagoscopist causes the pouch to protrude as shown by the dotted line at B. After the surgeon has dissected the sac entirely loose from its surroundings, traction is made upon the sac as shown at H and the esophagoscope is inserted down the lumen of the esophagus as shown at C. The esophagoscope now occupies the lumen which the patient will need for swallowing. It only remains for the surgeon to remove the redundancy, without risk of removing any of the normal wall. The esophagoscope here shown is of the form squarely cut off at the end. The standard form of instrument with slanted end will serve as well.] _After-care_.--Feeding may be carried on by the placing of a small nasal feeding tube into the stomach at the time of operation. Gastrostomy for feeding as a preliminary to the esophageal operation has been suggested, and is certainly ideal from the viewpoint of nutrition and esophageal rest. The decision of its performance may perhaps be best made by the patient himself. Should leakage through the neck occur, the fistula should be flushed by the intake of sterile water by mouth. Oral sepsis should, of course, be treated before operation and combated after operation by frequent brushing of the teeth and rinsing of the mouth with Dakin's solution, one part, to ten parts of peppermint water. A postoperative barium roentgenogram should be made in every case as a matter of record and to make certain the proper functioning of the esophagus. [268] CHAPTER XXXIV--DISEASES OF THE ESOPHAGUS (_Continued_) PARALYSIS OF THE ESOPHAGUS