(From deglutio, to swallow). The act of swallowing. In swallowing, the morsel is collected on the upper surface of the tongue, is squeezed against the bony palate, and then carries the palatum molle backward and upward; the pharynx meets it, the tongue keeps close to the palatum molle, and by this action the epiglottis closes the rimula of the larynx. The bolus is consequently forced down the oesophagus. When it is carried into the stomach, it is propelled by the sucessive action of the circular fibres of the pharynx, which contract from above downwards; and for this reason, when the continuity of these circles is destroyed by an ulcer, the action of the oesophagus is impeded or destroyed. General debility in a similar way will impede swallowing, and it is not uncommon in nurses, when the child's wants are disproportioned to the supply. Hysteric affections will equally occasion the disease, not only from debility, but from the distention of the stomach with wind, which the action of the muscular fibres cannot conquer. The latter cause we suspect to be much more frequent than physicians have supposed. Independent of these causes, incapability of swallowing, called acataposisor a difficulty, named dysphagia, orag-glutitio, may be occasioned by a thickening of the mucus in the oesophagus; indurations of the canal; a fungus in it; by spasms; foreign bodies sticking in their passage to the stomach; tumours pressing against the side of the oesophagus, either of the canal or neighbouring parts.
Mr. Warner relates a singular case of difficult swallowing, in which the oesophagus, besides being otherwise diseased, was ulcerated in its internal surface; which we shall relate to facilitate the distinction, and assist future practitioners in their prognostics. A young woman, aged twenty-five, had been afflicted with a difficulty in swallowing for some months; the sense of constriction was just below the back part of the cricoid cartilage. The part affected was easily discovered, by conveying down the throat a bit of sponge, fastened upon whale bone, which, though very small, could not be made to pass beyond it. She at length became incapable of taking any nourishment, and soon after died. After death, her neck was opened, and, upon taking out the oesophagus, it appeared considerably thickened, about an inch in length, just below the cricoid cartilage. Upon opening the oesophagus lengthways, its coats appeared so contracted in the diseased part, as to be only just capable of admitting a passage to a common probe. The internal coat of the oesophagus was in part ulcerated, and covered with matter. All the adjacent parts were sound.
When a bronchocele is the cause, there is no palliating the difficulty of swallowing caused by it, further than that of which the bronchocele admits, which we have found to be inconsiderable.
Hoffman observes, that mucus not unfrequently concretes, during the night, in the fauces and gullet, and is afterwards with difficulty brought up. This proceeds not from the aspera asteria, or the pharynx, or the pituitary tunic of the nose, but from the glands of the oesophagus itself, from a torpor in their vessels, from too violent and too frequent previous stimulus on the stomach. He recommends diluents and mineral waters as the principal remedies, and relates a case in which a cure was effected by abstinence from a more generous diet, and the use of a soft and slender one; drinking the Egra waters, omitting suppers, and taking a dose of a nitrous powder in a draught of cold water at bedtime.
Indurations happening in any part of the oesophagus are causes of a difficulty of swallowing, an instance of which is already noticed. These tumours rarely admit of relief. In the History of the Royal Medical Society in Paris, for the year 1776, we are told that a young lady, aged sixteen years, after being troubled for about three months with a spasmodic cough, began to have a difficulty of swallowing, which increased so fast, that after a very short time she was incapable of taking any nourishment by the mouth: so that, for the space of three months, life was supported solely by clysters. Mercurial and other frictions were employed without effect. At length M. Macquart, reflecting on the case, and conjecturing that an encysted tumour existed in the oesophagus, and that it might probably be now in a state of suppuration, he resolved to administer some substance, which, by its weight, might occasion a rupture of the sac. For this purpose he prescribed an ounce of crude mercury, mixed with the yolk of eggs, to be swallowed every three hours. This remedy was taken, and the patient, soon after she had swallowed the second dose, brought up a considerable quantity of pus. From this moment she was able to swallow broth, and by proper care recovered. When scrofulous indurations happen about the oesophagus, the ung. hydrargyri, rubbed on the neck over the induration, or small doses of calomel, have often been of singular efficacy, especially if used early after the attack of the disorder. If the case is of more considerable duration, the mercurials should be given so as to excite and support a moderate ptyalism for some time.
In the London Medical Observations and Inquiries, vol. iii. p. 85, is the history, etc. of a case, in which deglutition was obstructed, from a preternatural dilatation of a bag formed in the pharynx. This instance was produced by a cherry stone lodging in the throat, which was returned three days afterwards by a fit of coughing; the part where it had lodged gradually expanded, and retained a part of the food taken at each meal. At last all the aliment returned, without causing either pain or sickness. It is proposed in a similar case to pass a tube into the oesophagus, and through it, to inject a due quantity of broth; by which life may be continued many years, and the enlargement of the sac will be thus prevented.
Deglutition prevented by spasms. See (Esophagus.
When debility occasions difficult deglutition, bark, port wine, and a generous diet, assisted by drawing electrical sparks from the neck, will often succeed. A blister on the back part of the neck has sometimes been effectual; and even the irritation of introducing the pro-bang we have thought useful, in exciting the action of the languid fibres.
Foreign bodies sticking in the passage to the stomach are no unfrequent cause of this disorder. Many are the contrivances for removing them; but it would often be better to leave the case to nature, than to irritate so tender a part, which must be the effect of such attempts. If the substance can be reached with the fingers, or with the forceps, the extraction is easy. When pins, fish bones, or similar bodies, stick across the gullet, some recommend a wire with its end turned up like a hook to be passed below these bodies, and then turned so as to bring them up. Pins, and other sharp bodies, when they have stuck in the throat, have been returned by swallowing a piece of tough meat tied to a strong thread, and then pulled up again. If the detained body-may more safely be pushed down, the probang, a flexible piece of whalebone, with a piece of sponge secured to its end, is a safe instrument. It hath frequently happened, that though indigestible bodies have been swallowed, no inconvenience hath arisen from them. If the bodies cannot be easily moved up or down, endeavours should not be continued long, lest inflammation come on. If the patient can swallow some softening liquid, barley water, or milk and water, may be taken; and if he cannot swallow, an assistant may inject some similar fluid into the gullet, which will not only abate inflammation, but will sometimes loosen the impacted body. When endeavours fail, the patient must be treated as if labouring under an inflammatory disease; and the same treatment will be required if an inflammation take place in the part, after the obstructing body is removed. A proper degree of agitation hath sometimes succeeded in removing the obstructing body, better than instruments. Thus a blow- on the back hath often forced up a substance that stuck in the gullet or windpipe. Pins, which have stuck in the gullet, have been discharged by riding on a horse or in a carriage. If the gullet is strongly contracted, so that the patient cannot swallow, he may be supported by means of clysters until relief is obtained. If there is danger of suffocation, the operation of bronchotomy will be necessary; but sometimes the obstructing cause is seated below the part where the trachea can be opened. If an indigestible substance is forced into the stomach, the patient should live on a mild smooth diet, consisting chiefly of farinaceous matters, as puddings, soups, etc. carefully avoiding whatever will irritate or heat.
In the London Medical Observations and Inquiries, vol. iii. p. 7, is an account of a small fibre of a feather being swallowed, and extracted by means of a probang, with a thread or two passing from one end to the other, and fastened to the sponges which were connected with each end of this instrument.
In the Medical Museum, vol. ii. are several instances related of different bodies sticking in the oesophagus, and the methods by which patients were relieved. In the same volume it is observed, that many bodies are not much to be dreaded when they arrive at the stomach, though they have passed the oesophagus with difficulty. Pieces of money of various sizes have passed by the anus in a few days: pieces of lead, as bullets, have at last been discharged, though sometimes they have been detained for years.
In the London Medical Transactions, vol. iii. p. 30, is an account of a crown-piece which a man swallowed., An emetic was given, but without discharging the piece, which, after twenty months, was brought up by a spontaneous vomiting.
See Warner's Cases in Surgery. Medical Museum, vol. ii. Haller's Physiology. London Medical Transactions, vol. i. p. 165. ii. p. 90. iii. p. 30. Percivaps Essays, vol. ii. p. 141. Gooch's Cases, vol. ii. p. 108. Lewis's Translation of Hoffman, vol. ii. p. 147, etc. London Medical Observations and Inquiries, vol. iii. p. 7, etc. 85, etc. Med. Communications, vol. i. p. 157, 242. White's Surgery, 296.