found, if attention be given to the point, using our saliva instead for furnishing a physical stimulus to the parts. A few repetitions of the act, if continued in rapid succession, is, however, all that can be effected through the exercise of the will; the parts becoming then fatigued, and refusing to respond to the call that may be made upon them. With the stimulus. of foreign matter, on the other hand, to act, as in swallowing in the ordinary way, deglutition may be rapidly repeated over and over again without the slightest difficulty or sense of fatigue being experienced.

Everyday experience shows that when all the parts belonging to deglutition are in a state of structural and functional integrity, the security our air-passages enjoy from the intrusion of foreign matter is exceedingly complete; and it is well for our safety that it is So. It is true, it has sometimes happened, through the parts being taken as it were by surprise, that foreign bodies, as pieces of coin and so on, have dropped down towards the lungs; and the most serious consequences have in some cases arisen therefrom. The convulsive paroxysm of coughing which is sometimes brought on at the meal-table by "something going the wrong way," is usually, if not almost invariably, attributable to an attempt at laughing, coughing, or talking being made whilst there is food or fluid in the mouth. By the effort at inspiration, a small particle of food (a light crumb of bread is a particularly favorable substance for the purpose) or a little fluid shall happen to be drawn into the air-passages, or against the laryngeal surface of the epiglottis; and, although it may be immediately afterwards expelled, an urgent state of temporary dis

composure is the result, on account of the exquisite sensibility with which the surface touched is endowed.

Should the energy of the nervous system have become blunted, as it is observed to do under approaching death, an impression upon the fauces may fail to excite that quick and perfect respondence of the muscles of deglutition which is required for the ensurance of our personal safety. Thus, a portion of what has been introduced into the mouth may chance to get into the respiratory passages and excite a fit of choking which is sufficient to extinguish the flickering spark of life. Persons, it should be remembered, in a dying state swallow but imperfectly; and, therefore, the utmost caution is required in giving them medicine and drink, lest a sudden issue be brought about by something that is being administered passing the wrong way.

DIFFICULTY OF SWALLOWING, OR
DYSPHAGIA.

ALTHOUGH the object attained by the process of deglutition is an exceedingly simple one-namely, the transit of our food and drink from the mouth to the stomach-yet difficulties connected with its performance are not of uncommon occurrence, and these difficulties in some cases give rise to the most urgent and serious consequences. Dysphagia is the term applied to difficult deglutition; aphagia, when the condition amounts to an impossibility of swallowing. The seat of complaint may be located in the mouth, fauces, pharynx, or œsophagus; and the obstruction may be either partial or complete, and temporary or permanent. A permanent and complete obstruction cannot be long before it leads to death by inanition, unless, by operative means, an opening can be established direct into the stomach through which the sustenance required can be received. A variety of causes contribute to the production of dysphagia. They may be divided into mechanical and dynamic.

The mechanical causes are such as-congenital malformations of the mouth, throat, and oesophagus; inflammation of or structural changes in the tongue, fauces, pharynx, larynx and epiglottis, and oesophagus; obstruction of the passage by the projection of a

tumour, or the presence of a foreign body within; and its occlusion by pressure from without, as from the existence of a tumour, abscess, or aneurism in the neighbourhood.

Malignant disease, and the contraction following inflammatory action produced by swallowing a corrosive material, constitute, it may be said, the most common causes of mechanical dysphagia.

A remarkable case of obstruction of the passage by a growth projecting within is mentioned by Monro.* A polypoid excrescence grew from the upper part of the oesophagus, and extended down within the canal to the orifice of the stomach. On vomiting being excited, this growth was thrown up into the mouth, and reached as far as the front teeth; but it could hardly be retained for half a minute in this position, on account of the opening of the larynx being covered by it, and the breathing thereby stopped.

In the dynamic form of dysphagia, a perverted action-spasm or paralysis-of some portion or other of the muscular apparatus belonging to deglutition, constitutes the immediate source of the disorder. The perverted action, however, is dependent on a variety of pathological states, which may be either local or remote, as will be seen from what follows.

Difficulty of swallowing is one of the phenomena of hydrophobia and tetanus. Here the dysphagia depends upon a morbid functional condition of the nervous apparatus. Such a state of irritability exists, that an impression, which, under natural circumstances, would have led to an ordinary performance of the act of

* The Morbid Anatomy of the Human Gullet, Stomach, and Intestines,' by Alex. Monro, M.D., Edinburgh, 1811.

swallowing, throws the muscles, instead, into a violent and continued state of spasmodic contraction.

In structural disease of the medulla oblongata, the centre presiding over deglutition, as well as in structural disease of the neighbouring parts-whether consisting of central nervous matter, the enveloping membranes, or bone-more or less irregularity in the performance of swallowing may be looked for as a concomitant; and the occurrence of this symptom, in conjunction with other evidence of such disease existing, must be regarded as in the highest degree ominous of danger. Besides other modes of unfavorable termination, a patient so affected is under daily risk of being choked by a morsel of food becoming impacted in the throat from the imperfect manner in which deglutition is performed. A patient, for instance to give a sketch from an actual caseshall be complaining of symptoms suggestive of disease about the base of the brain. An occasional difficulty in the proper performance of swallowing, an alteration of the voice, and some disturbance of the breathing, lead to the presumption that the medulla oblongata is in some way or other implicated. The patient is sitting at dinner, and is all of a sudden seized with a fit of suffocation, and dies before there is time for professional aid to be procured. At the post-mortem examination, a piece of meat is found lodged in the entrance to the larynx, and this by stopping the breathing has been the immediate cause of death. Cerebral disease is also found sufficient to account for the phenomena that transpired.

In a case that not long since fell under my observation, a paralysed condition of the muscles of the fauces, apparently resulting from cold, formed the cause of a