DYSPHAGIA 229 GLOBUS HYSTERICUS This is a descriptive term applied to cases usually complaining of a feeling of a lump in the throat which is brought on or made worse by anxiety and in which no other organic cause can be found. Some cases are easy and safe to diagnose as globus—if there is an obvious emotional precipitating cause. The difficult cases are those in which there is no obvious psychological cause. Great care must be taken not to miss an early carcinoma. In this latter group oesophagoscopy must be done in spite of a negative barium examination. Globus is diagnosed much less now than formerly, because it has been realized that oesophagitis and reflex spasm of cricopharyngeus can mimic the symptoms. In these cases antacids will help the 'globus' symptoms. In the true globus cases, reassurance that no organic disease or cancer is present helps the patient to accommodate to the symptoms which will usually be self-limiting. Another cause of globus-type symptoms is the presence of cervical osteo- phytes indenting the posterior wall of the pharynx. These can be removed by exposing them using the same approach as for a pharyngeal pouch. ACHALASIA AETIOLOGY. This is also called *cardiospasm\ and is due to a defect in the intramural vagal supply (Auerbach's myenteric plexus). During swallowing, there is a loss of tone due to a lack of integrated parasympathetic stimulation and non-propulsive motility in the body of the oesophagus. There is also a failure of relaxation at the cardia. The lower area acts as a stricture and the oesophagus above this becomes very dilated and usually full of food debris. SYMPTOMS. There are few symptoms until the condition is advanced. The main symptoms are then intermittent difficulty in swallowing associated with discomfort and attacks of regurgitation. As the condition progresses and dilatation occurs, food entering the stomach does not initiate peristalsis, and so large quantities of food collect in the oesophagus. This causes an upset hi the swallowing mechanism and the condition becomes progressively worse. On barium swallow the oesophagus is very dilated, lengthened and occasionally sigmoid in shape (Fig. 117). When the patient is screened the barium will be seen to be held up for a considerable time and to pass into the stomach only when the pressure reaches a certain level. At the point of delay there is no irregularity and the barium emerges centrally as distinct from neoplasm. TREATMENT. In mild cases treatment with anticholinergic drugs is successful, but most cases will come to surgery, when a Heller's operation is done, CORROSIVE BURNS OF THE OESOPHAGUS This injury is not as common in this country as in America, Africa and Scandinavia. It usually occurs in children or potential suicides and the substances swallowed are strong acids or alkalis. High concentration or large volumes of the substance are the most damaging.