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Working with Adults with Eating, Drinking and Swallowing Needs: A Holistic Approach 1st Edition
Mackenzie
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Working with Adults with Eating, Drinking and Swallowing Needs
This practical guide encourages clinicians to treat eating, drinking and swallowing in a holistic way, keeping the client at the forefront of management by considering cultural, ethical and societal influences on the eating and drinking process. It draws on contemporary evidence to critically evaluate assessment and management strategies.
Closely aligning to the 20 RCSLT newly qualified practitioner eating, drinking and swallowing competencies, this book will provide clinicians with the theory that underpins the statutory completion of these standards, and the guidance to put that theory into practice. This book:
• Is clear and easy to follow with information broken down into a digestible format.
• Includes regular questions to help the reader consolidate their knowledge.
• Highlights in each chapter the knowledge required to achieve the RCSLT competencies.
• Contains a wealth of case studies SLTs may encounter in different settings, followed by suggested approaches.
• Provides helpful resources that can be downloaded and printed for use in daily practice.
Working with Adults with Eating, Drinking and Swallowing Needs provides an up-to-date, clinically relevant resource. With an emphasis on clinical decision-making, holistic practice and provision of practical materials, this is an essential text for both student and qualified SLT practitioners.
Sophie MacKenzie graduated from City, University of London in 1990 and has practised as a speech and language therapist in both acute and rehabilitation settings. She began her first academic role in 2007, combining clinical management of the acute SLT team at Maidstone and Tunbridge Wells NHS Trust with teaching at the University of Greenwich and Canterbury Christ Church University on their PGDip pre-registration programme. She moved into fulltime academia in 2010 and has taught eating, drinking and swallowing to both undergraduate and postgraduate preregistration students, as well-as post-registration Masters students at City, University of London.
In 2017 she completed her PhD which focussed on exploring spirituality with people with expressive aphasia. Person-centred and holistic care remain her passion, as well as the nurturing of future clinicians.
Sophie is currently a senior lecturer in SLT at AECC University College in Dorset, UK.
The Working With Series
The Working With series provides speech and language therapists with a range of ‘goto’ resources, full of well-sourced, up-to-date information regarding specific disorders. Underpinned by robust theoretical foundations and supported by intervention options and exercises, every book ensures that the reader has access to the latest thinking regarding diagnosis, management and treatment options
Written in a fully accessible style, each book bridges theory and practice and offers ready-touse and well-rehearsed practical material, including guidance on interventions, management advice, and therapeutic resources for the client, parent or carer. The series is an invaluable resource for practitioners, whether speech and language therapy students, or more experienced clinicians.
Books in the series include:
Working with Global Aphasia
Sharon Adjei-Nicol
2023 / pb: 9781032019437
Working with Trans Voice
Matthew Mills and Sean Pert
2023 / pb: 9781032012605
Working with Autistic Children and Young People
Sally Mordi
2023 / pb: 9780367723149
Working with Adults with Communication Difficulties in the Criminal Justice System
Jackie Learoyd and Karen Bryan
2023 / pb: 9781032265322
Working with Child and Adolescent Mental Health
Susan McCool
2024 / pb: 9781032192833
Working with Adults with Eating, Drinking and Swallowing Needs
Sophie MacKenzie
2024 / pb: 9781032311982
Working with Adults with Eating, Drinking and Swallowing Needs
The right of Sophie MacKenzie to be identified as author of this work has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
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A catalogue record for this book is available from the British Library
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A catalog record for this book has been requested
ISBN: 978-1-032-31199-9 (hbk)
ISBN: 978-1-032-31198-2 (pbk)
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DOI: 10.4324/9781003308560
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This book is dedicated to my amazing Mum, Christine, whose altruism, sense of community and kindness to others is inspirational, to Jacob and Kate, my chief supporters and encouragers and to John whose belief in me never seems to waver.
1 The typical swallow 3
Anatomy 5
Physiology 10
Airway protection 13
Neurological underpinnings of the swallow process 13
Positioning 16
Oral hygiene 17
2 Signs and consequences of an unsafe swallow 19
What is an unsafe swallow? 19
What happens to the lungs during aspiration? 21
Signs of an unsafe swallow 24
Aspiration pneumonia 25
What can go wrong at each stage of the swallow? 26
Oral hygiene and the compromised swallow 27
Psychosocial-spiritual consequences of a compromised swallow 27
3 Causes of adult eating, drinking and swallowing needs: aetiologies and symptoms 30
Neurological 31
Structural 40
Age-related 43
Related to learning disability 43
Related to congenital or acquired physical disability 43
Functional neurological disorder 44
Psychiatric disorder 44
Medication and dysphagia 45
4 Clinical assessment 47
Information-gathering 48
Observation 52
Cranial nerve assessment 52
Oral hygiene examination 56
Laryngeal palpation 56
Cough reflex testing 58
Water test 59
Oral trials 59
Mealtime observation 61
Assessing quality of life in EDS 64
Multidisciplinary input to the clinical EDS assessment 64
Telehealth and assessment of EDS 64
Cervical auscultation 64
5 Instrumental assessment 67
What is an instrumental assessment? 67
Why carry out an instrumental assessment? 68
Videofluoroscopy 69
Fibreoptic endoscopic evaluation of swallowing (FEES) 75
Ultrasonography 77
Pulse oximetry 77
Creating an eating, drinking and swallowing diagnosis 78
6 Management of eating, drinking and swallowing in adults 81
Direct therapy 83
Compensatory strategies 88
Support, advice and liaison 91
Training of others 92
Management and telehealth 92
Clinical decision-making and formulating management plans 92
Oral care 96
Nil by mouth 96
Enteral feeding 97
Eating, drinking and swallowing goal-setting and outcome measures 97
7 Psychosocial, spiritual and cultural aspects 101
Holistic care 102
Person-centred frameworks 102
Social considerations 104
Psychological considerations 105
Spiritual and religious considerations 106
Cultural considerations 109
How can we practise in a more spiritually and culturally competent way? 109
8 Ethical, legal, safety and professional considerations 112
Ethical considerations 113
Legal considerations 115
Safety considerations 117
Professional considerations 119
Creating a positive eating and drinking environment 122
9 The team around the client with EDS needs 127
Physiotherapist 128
Occupational therapist 129
Dietitian 129
Nurse 130
Healthcare assistant 131
Hospital doctor 131
General practitioner (GP) 132
Carer and support worker 133
Pharmacist 133
Radiographer 133
Chaplain 134
Clinical psychologist 134
Best interests meetings 134
Training 135
10 Advanced practice in working with adults with EDS needs 137
Working in the Intensive Therapy Unit 137
Tracheostomy 138
Ventilator-dependence 141
COVID-19 and long COVID 142
Coma and prolonged disorders of consciousness 142
Eating and drinking with acknowledged risk 143
End-of-life care 144
Multiple and complex needs 144
Case study 1: Mary – interpreting a clinical history 148
Case study 2: Charlie – acute stroke with neurological past medical history 149
Case study 3: Daniel – acute stroke with spiritual considerations 149
Case study 4: Arthur – traumatic brain injury 150
Case study 5: Shona – breast cancer with brain metastases 151
Case study 6: Peggy – head and neck cancer 151
Case study 7: Alec – laryngectomy 152
Case study 8: Romilly – learning disability 152
Case study 9: Hamza – Alzheimer’s disease 152
Case study 10: Vera – vascular dementia 152
Case study 11: Jamal – functional dysphagia 153
Case study 12: Josh – prolonged disorder of consciousness 153
Case study 13: Kehinde – on ITU (with tracheostomy) 153
Case study 14: Jim – Parkinson’s Disease 153
Case study 15: Marian – Motor Neurone Disease (MND) 154
Case study 16: Adam – end-of-life care 154
Case study 17: Rosie – eating and drinking with acknowledged risk (EDAR) 155
Acknowledgements
So many wonderful colleagues and friends have generously shared their expertise and experience in the creation of this book. My particular and heart-felt thanks go to:
• Fran Chandler for diligently experimenting with the templates and aides mémoire and providing the invaluable perspective of the NQP
• Penny Webster for cementing in me the notion that PT/SLT joint-working is not only essential for the client but also fun for the clinicians
• Debs Broadbent and Lucie Rochfort whose dysphagia know-how is incomparable
• all the SLTs of X (formally Twitter) who so generously told me their top five management strategies
• all my past clients with EDS needs who taught me so much about the resilience of the human spirit in adversity
• all the many students over the years who I’m pretty sure have taught me much more than I ever taught them
Lastly, I can’t thank enough Emily Olive who managed to create some wonderful diagrams whilst simultaneously completing a Masters – thank you for putting up with my endless emails which were invariably entitled “just one more thing…”
3.1
4.2 Potential results from information-gathering at the start of the clinical assessment process, what they can tell us, and possible next steps
4.3 Some suggested questions an SLT may wish to ask a client and the rationale behind them
4.4 Potential questions to ask the representative of a client who has speech, language or cognitive issues when taking a case history
4.5 Observations used in the assessment of EDS difficulties
4.6
4.7
4.8
4.9 What to look out for at each stage of the swallow process, what this may indicate and possible interventions
5.1 The Penetration-Aspiration Scale (PAS)
5.2
6.1
6.2
6.6
9.1
9.3 Specialisms of doctors
INTRODUCTION
For the last 30 or so years, assessment and management of dysphagia has been an integral component of many speech and language therapy (SLT) roles. The evidence base for SLT intervention has increased exponentially during that time, as has our remit; dysphagia is no longer just the preserve of a few specialist, adult therapists. In the twenty-first century, SLTs run videofluoroscopy and fibre optic endoscopic evaluation of swallowing clinics; manage clients with tracheostomies and those on ventilation; coordinate feeding clinics for children; and manage neonates who are struggling to feed. They are involved with end-of-life care, people with dementia, adults and children with learning and physical disabilities. We now refer to eating, drinking and swallowing (EDS) in order to reflect the breadth of our work. All this is important and specialist work and SLTs need to be rigorously trained for these roles and responsibilities.
SLTs are the lead clinician in dysphagia. Although many members of the multidisciplinary team are involved in dysphagia care, we are the clinicians with the most knowledge, skills and experience in this area. All SLTs need to be EDS-ready, particularly in this post-COVID-19 world; clinicians were routinely redeployed in the National Health Service (NHS) in Britain during the pandemic in order to deal with the rising numbers of COVID patients, many of whom developed dysphagia and voice difficulties. The cognitive, voice and swallowing difficulties relating to effects of long COVID (or post-COVID syndrome) are now also becoming apparent. The SLT workforce needs to be ready to cope with these increased needs, and to respond to further pandemics in the future.
As the role has developed, so professional bodies and higher education institutes have had to respond by developing guidelines and competencies and by honing their curricula. It is no longer enough for dysphagia management to be seen as an extra, tagged on to basic SLT training, or indeed an optional post-registration add-on.
In 2022, the UK’s Royal College of Speech and Language Therapists published their new EDS competencies and curriculum guidelines, with the aim of all graduates in the UK from all Universities
demonstrating the same level of knowledge and the same level of clinical competence on completion of their pre-registration courses.
At the end of each chapter of this book, I have outlined which areas of knowledge are addressed in that chapter, and which of the entry level clinical competencies the chapter may help equip the clinician to achieve. These are also summarised in Appendix 3. University lecturers may want to supplement their teaching with readings from this book.
I have also included some questions at the end of each chapter (with indicative answers at the end of the book), to help clinicians test and consolidate their knowledge. A glossary of terms and a list of common abbreviations are available in Appendix 2 to aid the clinician navigate EDS-specific terminology. Case studies provide the opportunity to synthesise theory with hypothetical practice.
I want this text to be practical and useful; a book for the clinician to pull off the shelf when planning intervention or when wanting to refresh their knowledge. Appendix 1 contains photocopiable templates and aides-mémoire, which I hope prove useful and time-saving for the busy clinician.
Treating clients in a holistic way is hugely important to me, so I have endeavoured to imbue the book with the respect and dignity for clients mandated by the NHS constitution. I therefore strive to use non-gendered language, and refer to the individual with EDS issues as either the client or simply the person. I have used person-first language throughout (for example, the person with dysphagia).
The language we use is powerful and as EDS clinicians we should be constantly mindful of the effect of the language we use on those with whom we interact. I would urge all SLTs working in this field to avoid the term feeding; this suggests passivity and lack of agency on the part of the client and in my opinion should be reserved for babies and animals. Let’s choose instead to talk about helping the individual to eat and drink. Let’s also stop using the rather pejorative word drooling and refer instead to anterior escape of saliva
Similarly, we should make every effort not to use victim language, but rather empower our clients by referring to wheelchair users (rather than someone confined to a wheelchair), people unable to transfer from their bed (rather than bedbound) and stroke survivors (rather than victims).
It is a privilege as a speech and language therapist to be able to meet people at their point of need and to journey with them through rehabilitation or through the progression of a disease. At the heart of this book is the desire to treat our clients with compassion, empathy and respect, in a way that keeps the client and their family and carers always at the heart of what we do.
1
THE TYPICAL SWALLOW
Anatomy
• Structures
• Musculature used in the swallowing process
o Facial muscles
o Muscles of mastication (chewing)
o Tongue muscles
o Pharyngeal muscles
o Laryngeal muscles
Physiology
• Oral preparatory stage
• Oral stage
• Pharyngeal stage
• Oesophageal stage
Airway protection
Neurological underpinnings of the swallow process
• The cranial nerves
Positioning
Oral hygiene
Summary
Test your knowledge!
Eating and drinking is an integral part of being human. Not only do we need nutrition and hydration to fuel our bodies and survive, but mealtimes are also imbued with social, cultural and sometimes even religious meaning. We celebrate by eating at a wedding and we mourn by eating at a wake. We can eat for comfort, for companionship or for networking. Religious festivals like Christmas, Eid, Purim and Diwali are all marked by feasting with friends and family. Our individual cultural and family narratives are all characterised by specific dishes and tastes.
4 The typical swallow
However, this intrinsic facet of what it means to be human is an incredibly complex process, involving many anatomical structures and governed by a complex system of neurones (a glossary of EDS terms and a list of common abbreviations can be found in Appendix 2 in order to help the clinician navigate this complexity). Small wonder, then, that this process can become disrupted through illness or disability and that the effects of this disruption can be physically, socially and spiritually devastating.
In this chapter, we will explore what the typical swallow process looks like; that is, the main principles involved. Of course, each individual is unique and what is typical for a young able-bodied person is different from what is typical for an elderly person, or for a young person with a learning disability. Sometimes people may need to face a new normal, where their swallow function is changed and strategies need to be employed.
Swallowing happens whether we are awake or asleep. It is estimated that we swallow at least 600 times during the day – more when we are actually eating and drinking and a bit less when we are asleep. It is an everyday function of the body; one we don’t necessarily think about until something goes wrong.
Swallow your saliva now, as you are reading. What do you notice? The first step to becoming a competent and knowledgeable therapist is to observe, take note of and reflect on things that you might previously not have considered.
Now have a sip of water or a bite of something to eat. What do you notice? The complexity of swallowing really becomes apparent when we concentrate on the process.
• What can you smell, see, taste or feel?
• What skills do you need in order to get the food or drink to your mouth?
• How do you prepare the food in your mouth before it is swallowed?
• Is your mouth open or closed when you swallow?
• What are your lips, tongue and jaw doing?
• Are you in control of the movements?
• Are you in control of your swallow?
It is a useful exercise when training others to ask them to focus on the swallowing process in this way. It is something that we do so unconsciously that encouraging others to become conscious of it allows for better understanding. By attempting to answer the questions above, we are already breaking down the swallow system, rendering it more understandable.
5 The typical swallow
The upper respiratory tract of the human enables us to breathe and vocalise. However, this vital biological system is positioned close to the gastrointestinal system. It is essential, therefore, that our anatomy and physiology ensure that both breathing and eating, drinking and swallowing (EDS) can happen in a safe way. In Figure 1.1 below, you can see how close the trachea (part of the respiratory system) is to the oesophagus (part of the gastrointestinal system). The swallow process therefore needs to be coordinated and protective of the airway. We will discuss how both the anatomy and the physiology of the typical swallow process allow humans to eat and drink safely, without material entering the trachea or the lungs.
To develop your skills of assessment, you need a good understanding of the typical swallow, including the anatomy, physiology and underpinning neurology.
Anatomy
Essential to understanding the swallow process is a good working knowledge of the anatomical structures and musculature involved. This then also provides us with the vocabulary for explaining and understanding the concomitant physiological processes.
Structures
The following diagram (Figure 1.1) is a lateral representation showing the key structures of the head and neck in the sagittal plane. All of these structures have a function in EDS and these are listed in Table 1.1.
The faucial arches, velum and uvula in the oral cavity are more visible in the anterior-posterior (AP) plane (see Figure 1.2).
Musculature used in the swallowing process
A large number of muscle groups are involved in the process of swallowing, including facial, lingual, pharyngeal and laryngeal musculature and the muscles of mastication.
Facial muscles
Some of the muscles of the lower face are used in the EDS process, as well as in speech production. The buccinator is a large muscle in the cheek, which contracts to help contain food and fluid within the oral cavity in a process known as buccal tension. The orbicularis oris (as the Latin name suggests) is a muscle which surrounds the mouth and enables the lips to move and to close.
Table 1.1 Key structures of the head and neck and their prime eating, drinking and swallowing (EDS) functions
Anatomical structure Prime function in EDS
Alveolar ridge Tongue tip presses against this during the anterior-posterior propulsion of the bolus (chewed food)
Epiglottis Protects the airway during swallowing and directs the bolus towards the oesophagus
Faucial arches The swallow reflex is triggered when the head of the bolus hits this point
Hard palate Tongue presses against this during the anterior-posterior propulsion of the bolus
Hyoid bone During the swallow, the hyoid moves up and forwards and contributes to both laryngeal closure and opening of the upper oesophageal sphincter
Other information
The bumpy ridge posterior to the upper teeth
Curved structure made of cartilage
Mobile mucosal folds which can approximate (close together)
Arches of tissue at the back of the mouth, either side of the uvula Hard roof of the mouth
A small, u-shaped bone which sits above the larynx
Unlike any other bone in the human body, it is not directly attached to another bone –the hyoglossus muscle attaches it to the tongue superiorly and the thyrohyoid muscle attaches it to the larynx inferiorly
Figure 1.1 Lateral view of the head and neck.
Anatomical structure Prime function in EDS
Larynx The vocal folds form the glottis and are able to adduct (close) to protect the airway
False vocal folds sit just above the true vocal folds and can also approximate for protective reasons
Lips Provide a seal to the oral cavity
Mandible Allows for mouth-opening and mastication (chewing)
Maxilla
Top teeth (mastication) and hard palate (bolus propulsion) are housed here
Nasal cavities Should be closed off for swallowing Olfactory sensory neurones send messages to the cortex to identify smell – sense of smell also relates closely to taste
Oesophagus Allows passage of food and drink from the pharynx to the stomach
Oral cavity Contains the bolus ready for swallowing
Pharynx Bolus is squeezed through the pharynx towards the oesophagus
Pyriform fossae Food/fluid residue may accumulate / sinuses (see here Figure 1.3 for the location of the valleculae and pyriform sinuses)
Soft palate/velum Makes contact with the posterior pharyngeal wall to seal off the nasal cavity
Sulci (singular – Food may fall into the sulci and need sulcus) retrieving with the tongue
Teeth Used in biting and mastication
Tongue Used to manipulate the bolus in the oral cavity and to propel the bolus from the front to the back of the mouth Allows taste
Trachea Expiration post-swallow
Upper oesophageal A sphincter that is closed until food/ sphincter / fluid reaches it, when it opens to cricopharyngeal allow the material through into the sphincter oesophagus
The typical swallow
Other information
There are three subsections to the larynx –the supraglottic, glottic and subglottic regions The vocal folds are surrounded by the thyroid (shield-shaped) cartilage, with the cricoid (ring-shaped) cartilage just below
The supraglottic area (above the vocal folds) is also sometimes referred to as the laryngeal vestibule
Labial is the adjective related to the lips
Mobile, lower jaw which is joined to the maxilla by the temporomandibular joint (TMJ)
Fixed, upper part of jaw
The nose comprises the nasal septum (thin bone which divides the left and right nasal cavities) and the turbinates (small bony structures inside the nose which help to cleanse and humidify inspired air)
Hollow, collapsed, muscular tube, comprising striated muscle in the upper third and smooth muscle in the lower two-thirds
We sometimes refer to perioral (around the mouth) and intraoral (within the mouth)
Divided into three sections: oropharynx, nasopharynx, hypopharynx/ laryngopharynx
Pyriform means “pair-shaped” and refers to pockets within the pharynx, close to the entrance to the larynx, created by the aryepiglottic folds and the thyroid cartilage
The posterior part of the palate which contains muscle fibres and is therefore able to move when innervated
The spaces between the inner cheek and the teeth (lateral sulci at the sides and anterior sulcus in front)
Dentition refers to the teeth. Someone with no teeth is referred to as edentulous
Large muscular structure, which comprises the tip, blade (dorsal surface), back of tongue and tongue base
Fixed, open, cartilaginous tube, allowing air in and out during respiration
Sometimes you will see the abbreviation UES (upper esophageal sphincter)
(Continued)
8 The typical swallow
Table 1.1 (Continued)
Anatomical structure Prime function in EDS
Uvula Secretes saliva
Valleculae Food/fluid residue may accumulate
Other information
Means “little grape” in Latin and is the small dangling structure you can see at the back of your mouth which extends from the soft palate The uvula is composed of connective tissue
These are pockets in the pharynx, formed here where the base of tongue meets the epiglottis
1.2 Anterior-posterior
Muscles of mastication (chewing)
During the eating process, in order to create a cohesive mass which is ready to swallow (bolus), it is often necessary to masticate (chew) solid food as well as add saliva to it. The temporalis and masseter muscles elevate the mandible, allowing the mouth to close. The temporalis also allows for retraction of the mandible. Place your finger on your temple when you chew and you will feel your temporalis muscle. Place your finger on your cheek and you will feel the masseter muscle.
The muscles of mastication also comprise the pterygoids: the lateral pterygoids allow the jaw to move laterally, and the medial pterygoids enable elevation, protrusion and depression of the mandible.
Figure
view of the oral cavity.
Figure 1.3 Anterior-posterior view of the throat.
Tongue muscles
The tongue is a large, muscular structure which comprises both intrinsic and extrinsic muscles. Intrinsic muscles lie within the tongue itself and allow for intricate and small movements needed in both speech and swallowing. These muscles are referred to as either vertical, transverse or longitudinal (inferior and superior), depending on the direction of their fibres. The extrinsic muscles link the tongue to other structures. The names of these muscles are rather helpfully formed by linking together the Greek names for each structure involved. For example, the genioglossus links the mandible/chin (genio-) to the tongue (-glossus), the hyoglossus links the hyoid bone (hyo-) to the tongue, the palatoglossus links the palate (palato-) to the tongue and the styloglossus the styloid process (stylo-) to the tongue.
Pharyngeal muscles
The pharynx has to constrict to enable food and fluid to be pushed down towards the oesophagus. The pharyngeal constrictor muscles are divided into superior, middle and inferior, depending on their position.
The typical swallow
Laryngeal muscles
Laryngeal musculature can also be divided into extrinsic (which attach the larynx to something else – that something being the hyoid bone) and intrinsic (which attach to different parts of the laryngeal framework).
The extrinsic laryngeal muscles comprise the suprahyoid and the infrahyoid. The suprahyoid links the hyoid bone to the mandible, and the infrahyoid links the hyoid to the larynx. In Chapter 4, we will explore one assessment technique known as laryngeal palpation, where the clinician places their fingers on the laryngeal cartilages and the hyoid bone in order to feel the upward and forward movement of the larynx during swallowing.
Abduction (opening) and adduction (closing) of the vocal folds is an important element of the safe swallow. The airway is protected by closure of the vocal folds at the point of swallow, and abrupt abduction of the vocal folds (in the form of a cough) helps expel foreign bodies which may inadvertently penetrate the larynx. These functions all utilise the intrinsic muscles of the larynx. The posterior cricoarytenoid muscles abduct the vocal folds. The lateral cricoarytenoid and interarytenoid muscles adduct the vocal folds. The cricothyroid and thyroarytenoid muscles help alter the length, tension and thickness of the vocal folds, which is of course of particular importance in voicing.
Physiology
Now we have an understanding of the structures and the musculature involved in the swallow process, we can start to think about how, why and when they move in order to create a safe and efficient swallow. The swallow process is typically divided into four stages or phases. These stages are not separate from each other, and aspects of one stage may influence another, but this way of dividing up the process helps us to understand the physiology; it also enables us to pinpoint where difficulties may be arising. The four stages are normally referred to as:
• Oral preparatory
• Oral
• Pharyngeal
• Oesophageal
Sometimes you will see the oral preparatory and oral stages combined into one stage, but I think it is helpful to split them, especially when we start to learn how to diagnose different swallowing problems. You will notice that the names of the stages give us a clue as to what happens – and where.
The typical swallow 11
Oral preparatory stage
The first stage of the swallow process is all about getting ready to eat and drink; it involves sensory, cognitive and physical processes. This part of the swallow process is under our voluntary control.
From a cognitive perspective, we judge what sort of food we want to eat, we remember what we like and dislike, and what certain things taste like. We are able to plan a meal and carry out the preparations in the right order. When we sit down to a meal, we are able to recognise, see and smell the food in front of us. If we pick up a samosa with our fingers, we can feel, too. Already the swallow process is beginning; sensory messages are being sent to the brain to inform the cortex that we are about to eat. Smelling and seeing food (or even just thinking about it) can also start the process of salivation, whereby saliva is added to the food before we swallow.
At the oral preparatory stage, physical processes also occur; gross motor skills enable us to bring a cup to our mouth, fine motor control enables us to use cutlery and our mouth opens to receive the food.
Once the food is in the mouth, we can taste it; saliva is added and mastication (chewing) may take place so as to break the food down into a cohesive mass. The food is now referred to as a bolus. Fine tongue movements then help to manipulate the bolus within the oral cavity – including scooping up any residue which has slipped into the sulci - eventually bringing it into midline ready for the oral stage. Sensory receptors throughout the oral cavity allow us to gauge the size, shape, viscosity and location of the bolus.
Buccal tension (tension of the buccinator muscle) is maintained to keep the bolus within the oral cavity and to prevent it from slipping into the sulci. At this point, lip seal may occur to assist with maintaining the bolus in the oral cavity. However, lip seal at this stage is not essential from a physiologic perspective; it is possible (though perhaps not socially acceptable!) to chew and manipulate a bolus with your mouth open.
During the oral preparatory phase, the airway is open and nasal breathing continues.
The duration of the oral preparatory stage depends very much on the initial consistency of the food; a piece of crusty bread will take much longer to chew, manipulate and add saliva to than a spoonful of yoghurt.
Oral stage
By contrast, the initial consistency of the food has no effect on the oral stage, which takes on average 1 second (this is known as the oral transit time). In this phase, the bolus is pushed from the front to the back of the mouth in what is sometimes referred to as a stripping motion. The dorsal blade of the tongue presses up against the hard palate, thereby squeezing the bolus towards the back of the oral cavity. The sides and front of the tongue remain firmly fixed against the alveolar ridge, so that a central channel is formed along the blade of the tongue. This anterior-posterior movement is vital in order for the bolus to be in the correct place for the swallow reflex to trigger. Oral pressure within the mouth (intraoral pressure) also ensures that the bolus is sent to the back of the mouth ready to be swallowed; this is achieved through maintaining lip seal. Try swallowing your saliva without closing your lips together – notice how much harder it is to initiate a swallow.
Like the oral preparatory stage, the oral stage is also under voluntary control and the airway is open.
Pharyngeal stage
The swallow reflex triggers as the head of the bolus makes contact with the faucial arches. In older adults, the trigger may occur when the bolus has travelled slightly further to the point where the tongue base crosses the lower base of the mandible. Note that this is the point in the swallow process when actions become involuntary. At the point of swallow, a number of physiological processes occur simultaneously. The velum (soft palate) rises up to make contact with the posterior pharyngeal wall, and the wall itself pushes forward to meet it, creating a small bulge in the superior constrictor muscle known as Passavant’s Ridge. This creates a seal which means the bolus is unable to enter the nasal cavity. Velopharyngeal closure also helps to maintain the pressure which sends the bolus down into the oropharynx and hypopharynx. The epiglottis is pushed down by the bolus (epiglottic retroversion), thereby helping to seal off and protect the airway. The larynx rises up and forwards (laryngeal excursion) and the vocal folds and false vocal folds close. The tongue base retracts and the pharyngeal constrictors push the bolus downwards. As the bolus goes down through the pharynx, approximately half will progress on either side through the pyriform fossae. The cricopharyngeal sphincter (or upper oesophageal sphincter) at the top of the oesophagus relaxes, and allows the bolus to enter.
At the point of swallow, there is a period of apnoea – that is, respiration ceases as the vocal folds adduct (close).
Pharyngeal transit time (from the point of the swallow triggering to the bolus passing through the cricopharyngeal sphincter) is normally 1 second or less.
The typical swallow 13
Oesophageal stage
As the bolus enters through the cricopharyngeal sphincter, the oesophageal stage begins. At rest, the oesophagus is a collapsed, muscular tube. When food or fluid enters, it dilates and a series of regular muscular contractions (peristalsis) pushes the bolus towards the lower oesophageal sphincter and, ultimately, to the stomach.
Oesophageal transit time (from the opening of the cricopharyngeal sphincter to the opening of the lower oesophageal sphincter) is between 8 and 20 seconds.
The oesophageal stage is not under voluntary control.
Airway protection
Crucial to the safety of the swallow is protection of the airway. The typical swallow has four ways to ensure material does not enter the respiratory system: closure of the true vocal folds, approximation of the false vocal folds, epiglottic retroversion and forward movement of the arytenoids. This sequence normally occurs from bottom to top, ensuring any residual material in the laryngeal vestibule is squeezed upwards, away from the airway.
Even in typically developing and aging people, material may inadvertently venture into the laryngeal vestibule. In this instance, a strong cough reflex is usually triggered which expels the food or fluid. Very occasionally, and sometimes tragically, both children and adults may aspirate a large particle of food which occludes (or blocks) the airway; this is a choking episode and constitutes a medical emergency. We will discuss what constitutes an unsafe swallow further in Chapter 2.
Neurological underpinnings of the swallow process
Both the motor components and sensory components of the swallow process are governed by the neurological system, which comprises the central nervous system (CNS – brain and upper motor neurones) and the peripheral nervous system (PNS – lower motor neurones). The autonomic nervous system is a component of the PNS, and regulates some involuntary physiological processes (such as smooth muscle and glands). Both the sensory and motor aspects are important; we need to feel and taste the bolus, as well as activate muscles to manipulate and ultimately swallow the bolus.
Neural control of swallowing is in the cortex itself and in the brainstem (comprising the pons, medulla and midbrain), located just below. Subcortical structures (such as the cerebellum and basal ganglia) are involved in coordination and control of movements for swallowing.
The typical swallow
As we saw in the physiology section above, there are both voluntary and involuntary aspects to the swallow process. Areas in the pre-frontal cortex govern the voluntary oral preparatory and oral stages, with some of the cognitive and sense aspects being controlled by other areas of the cortex (for example, the visual cortex for seeing food). The involuntary aspect of the pharyngeal stage is thought to be governed by areas of the sensorimotor cortex of the parietal lobe. Both voluntary and reflexive swallowing also involve the primary sensory and motor cortices, for sensation and movement of the articulators, respectively.
Upper motor neurones (UMNs) travel from the motor cortex, synapsing with the lower motor neurones (LMNs) in the brainstem (the pons and medulla). The LMNs involved in the EDS process are the cranial nerves.
Afferent (sensory) messages are received in the nucleus tractus solitarius – sensory input is received from the tongue, lips, pharynx etc by the trigeminal, glossopharyngeal or vagal nerves.
Efferent (motor) messages are sent from the nucleus ambiguus to the relevant muscles. The nucleus ambiguus comprises the motor nuclei of the trigeminal, facial, vagal and hypoglossal nerves.
The cranial nerves
Although there are 12 cranial nerves (CNs), these are the main five implicated in the swallow process (by convention, cranial nerves are referred to using Roman numerals):
V trigeminal
VII facial
IX glossopharyngeal
X vagus
XII hypoglossal
However, we also need to see our food (II optic), smell our food (I olfactory) and hold our head in a good position for safe swallowing (IX accessory).
The CNs are lower motor neurones which originate in the brainstem (pons and medulla). Most of them carry both efferent (motor) messages to the muscles, as well as afferent (sensory) messages back to the cortex.
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Then there is an “author” who writes the poorest short stories I ever read—I have only a magazine knowledge of his work—but he belongs to the “set.” Mr. Chenoweth is his intimate friend and his wealth enables him to give his chosen circle such entertainment as quite reconciles them to the poverty of his literary dower. Still, I cannot quite see why the public should be inflicted with him. He is quite bright to talk to, a very agreeable dinner companion, I fancy. I should like him rather if he were more honest with himself—and did not make epigrams.
Take them all in all they are as distinguished-looking—or should I have said “refined?”—as they feel it their duty to be, and quite as agreeable as I would have them—which is more to the point.
There is a Mr. Nugent, a guest, at the Club House, of Mr. Rogers, who rather interests me the most. I think on the whole I must tell you a little experience. He is about forty and a “brilliantly successful” lawyer. He has argued famous cases before the Supreme Court, amassed a fortune, and his admirers—not this set—want him to go into politics. He is very striking in appearance, tall, thin, nervous, with a lean, clever, hard, mobile face, an eye that burns and penetrates, a mouth that looks as if it had conquered everything but his passions, and a quick nervous grip of the hand which suggests that what he does he does quickly and wastes no time arguing about. Next to Mr. Rogers Bertie likes him better than any one up here, and I must confess he rather fascinates me. I am wicked enough to want to see a man like that go off his head about me. But I fancy I’d have my hands full if he ever did let go. Mr. Rogers—he is getting rather devoted, my dear—I always could manage, because he would be so afraid of making himself ridiculous that he hardly would allow his voice to tremble unless I almost proposed to him. He burst out one day: “You white English rose!” I fear I used my eyelashes rather wickedly, and my upper lip, for he drew a step nearer and the colour came into his grey face. Then I felt my eyes twinkle and he recovered himself in a manner that would have done credit to a woman of the world in her fourteenth flirtation; men are usually so clumsy about these things; he smiled quickly and added in the light tone of any man complimenting any woman: “You are really unique
here, you know, Lady Helen. Perhaps lily is rather your prototype in the floral world than rose. You make my countrywomen seem like hot-house flowers—if there were a floral heaven they would all be beautiful orchids in the next world.”
But to return to Mr. Nugent. One warm evening when he was calling on us and we were sitting on the piazza I asked him if he intended to go into politics. It is very difficult to make him talk of anything consecutively, by the way, and that makes him resemble us in one particular, at least. There are no semi-colons in his conversation, mostly dashes.
“I have not made up my mind, Lady Helen. It is an alluring prospect in one way, but I should be obliged to give up—those are wonderful clouds.”
They were, Polly. Above the mountain behind the Club House were two enormous masses of cloud that looked like colossal blue dishes piled to the heavens with whipped cream. They were almost alike and you cannot imagine anything more perfect than that cream whipped into form by a giant hand. I thought out loud and Mr. Nugent said hastily:
“Oh, call it sea foam, not cream.”
“But sea foam looks like yeast,” I objected. “I don’t think you are a bit more poetical than I am.”
He laughed heartily (these Americans can flatter so with their laugh).
“I am quite discomfited,” he said, “and I can only add that I have far more reason to be poetical than yourself.”
“Very neat,” said Bertie. I can imagine my beloved brother thinking it worth while to say the charming things these men do.
“Now tell me some more of your politics,” I persisted. “Mr. Rogers thinks politics are not respectable, but if the stables can be cleaned in one country they can in another.”
“Exactly, but if I went in for cleaning, in other words for reform—I should sacrifice a great deal. I am lawyer for one of the greatest Trusts in the United States, and as I could not consistently as a
reformer—in the present exaggerated state of public opinion— remain in such a position,—that would mean the sacrifice of a large slice of my income.”
“I must say I admire your frankness, but how can you be counsel for a Trust?”
“Why not?—so long as I have not taken a stand.”
“How can an honest lawyer work for dishonest men?”
“The word dishonest, dear Lady Helen, is usually applied to Trusts by men who are not in them. Trusts are an evolution, nothing more, a combination effected that some may live rather than that all shall die. I am not going into sordid details, but I will add that the question never arose that did not have two sides, and that one side is as entitled to able legal counsel as the other. There is no reason in the world why this particular Trust, which is open and above board, should not have the best it can pay for, and as it has done me the honour to select me, I in return have given it the very best of my ability—which should salve any conscience. I feel the same way when defending a man against the combined prejudices of the community. He is entitled to the best defence he can command, and being a human being, is as worthy of it as his more approved opponent.”
This was the longest speech I had ever heard him make, and I understood it as a defence of himself out of deference to me. So, I smiled at him in appreciation of the compliment, but replied:
“Still, I don’t see why you value the money more than the public honour you might win.”
“Money is a very good thing, Lady Helen, to a man with expensive tastes and a passion for travelling. If I went into politics I should not touch its money bags, for political money is invariably dirty; moreover, I should be obliged to sacrifice more or less of my general practice—and the result would be that I should be a comparatively poor man once more.”
“Are you self-made?” I asked eagerly.
Once more he laughed heartily, and his remarkable eyes expressed that I might say anything I chose.
“In a way, yes, in another, no. My father was a prominent lawyer, but given to speculation in Wall Street.—He left little or nothing—I went into his office as soon as I left college—and although I was helped in the beginning I have made my own way—Ah! we are going to have a thunder-storm. Not in our whipped cream. That has been eaten by the gods. This cloud is full of energy and would interfere with the most immortal digestion. May I sit it out, or must I run?”
“Stay,” said Bertie quickly, “I can’t sleep in that infernal racket. Have some Scotch whiskey? Do you take it neat, or with soda? Nell, ring the bell, that’s a good girl.”
They refreshed themselves, and then we concluded to watch the storm till the rain came. The great cloud was a long time approaching and the thunder only a distant angry rumble. But the lightning? It never seemed to play on the surface, but leapt constantly from the deep caverns of the purple cloud, flashing into relief tortuous convolutions that looked heavy and flat when the fire played elsewhere. Sometimes it was only that volcanic flame, at other times the cloud seemed torn asunder, and down the rift ran the zig-zag thunder bolt. Now and again the forked lightning assumed strange shapes, like the fiery skeleton of a man’s hand or of a gigantic leaf. Sometimes it leaped from peak to peak of that moving mountain, then suddenly darted hissing down a gorge as if in search of prey. What nervous impatient terrible energy, and what a tyrannical perversion of beauty!
I suddenly became aware that Mr. Nugent was watching me instead of the storm, and as I felt embarrassed I told him hurriedly what I had been thinking. Bertie had gone inside, as the lightning hurt his eyes.
“In a way that thunder cloud reminds me of you,” I added, rather naughtily. “I don’t mean that you are beautiful, but you seem full of that same nervous energy and you suggest that you might direct it rather cruelly.”
“I don’t think I should strike at random,” he replied, still with his eyes on my face. “And at present I am in far more danger of being hit first.”
It seemed to me that I felt something vibrate. Perhaps it was only the electricity in the air. At all events, I replied as placidly as if my breath had not shortened. “One of the rules of prize-fighting is to strike first, and the weaker should always keep that in mind, don’t you think so?”
“Will you kindly tell me whom you consider the weaker?”
“Well—the woman—naturally.”
“I should sleep much easier if I thought you did not know your power.”
“Oh, sometimes my sex——”
“I am not talking of your sex but yourself.”
The lightning flashed just then and I saw more than his eyes. His whole face was eager and set. I could not help going a little further.
“I used to fancy I had some power over men—at least a good many seemed to love me—but during the last two years I have got out of practice rather. Positively I have not had the tiniest flirtation.”
“No wonder you are so distractingly complete—I am afraid your life has been a sad one these two years,” he added hurriedly, and, actually, his nervous peremptory voice softened. “Tell me something of it—But—pardon me—let me lift your shawl. The wind is coming and it will be very strong.” He folded the shawl about me, and at the same time I heard Agatha reading to Bertie so I felt off duty for the present. And, Polly, I actually talked to him as I never talked to any but the oldest and dearest friend before. But he drew it out of me. I could no more resist that determined concentrated force beside me in the dark than I could push the electric carnival over the mountain. The man seemed magnetism incarnate, and every time the lightning flashed across his face I could see that sympathy which comes not from a soft heart but an intense personal interest. But perhaps that interest is the most highly prized of all by women, and whatever the mainspring, it was sweet to me, after all these months of terrible
anxiety and suffering. I never talk things over with Agatha; I have avoided exchanging a glance of alarm with her; that would be too dreadful; and until now I never have felt sufficiently free from care to become interested enough in any one for confidences. But—and I am not the least bit in love with him, Polly—I felt that I could talk to this man all night. The thunder cloud moved down the lake, carrying its rain with it, and I sat there for an hour and talked to him, while Bertie slept on a sofa just beyond the open window and Agatha read on.
“I don’t think you like listening,” I said breaking off abruptly. “I don’t believe you ever listened so long to any one before.”
“That is quite true. I am not a patient man and I am usually thinking about several things at once—But—I am not going to pay you any idle compliments. I will only say that I have great powers of realisation and that I have absolutely understood all you have felt and suffered during the last two years. I have felt it all so keenly that I wish I could do something to help you. I am going to be your friend,” he added in his quick peremptory tones. “I will be your best friend in this country which must be so strange to you. I don’t care a hang about Rogers’ rights of priority. He isn’t capable of understanding you as I do.”
He took my hand suddenly in his warm magnetic clasp, and I had an odd feeling that he never intended to let it go. “This is only by way of pledging friendship,” he said. “I am not going to disturb you by making love to you—not yet. I make no promises for the future. You have roused and bewildered and enthralled me. Whether it is love or not I don’t know. Nor do I know what I can rouse in you. There is heaven and madness for some man. I am sure of that—but I—well, let all that go for the present. In the mean time I am your friend, remember that, and Rogers is to take a back seat.”
I will admit, Polly, that I lay awake a long time that night thinking of him and reliving that peculiar sense of being encircled with warm magnetism. After all, I suppose that what we women want more than anything else is sympathy and a feeling of belonging to some one exclusively. And when a man has the passion to stir and warm and
blind us how easily we can persuade ourselves that we are in love. But the grande passion—that is another thing. Of course you are in the throes of that and I rather envy you. Good night.
H .
Letter VI
From the Lady H P to the Countess of E and R .
Boulder Lake, July 17th
Dear Polly:
THIS afternoon I went over to Mrs. Laurence’s “camp” for tea. She wrote me the most graceful little note with two witticisms in it, and as I had no excuse to offer, I went. Agatha and Bertie were also invited but A. had a headache and B. went fishing, saying the most uncomplimentary things about teas. Mr. Rogers and Mr. Nugent, who went with him, attempted no defence.
Mrs. Laurence has quite the most attractive camp. It is exactly like a doll’s house, tiny but perfect, with two verandas, and it is full of dainty crétonnes and frills and bric-à-brac that no one could have selected but herself. She writes every morning in a doll’s study, fitted up much like a boudoir, in blue the exact shade of her eyes; but in the afternoon she is always rustling about, and you hear her petulant voice and swishing skirts, with only short intervals of relief till bedtime.
She received us in a little clearing between the leafy maples on the right of her camp, and wore the most fetching gown of grass green lawn with a flopping white leghorn trimmed with green feathers. The others were all in the most charming white and flowered muslins and I was glad I had put on a soft white mull myself—Henriette has made me some charming hot weather frocks since we came—and by chance I too have a white leghorn, which I wore. It was trimmed with blue flowers, and my frock with blue ribbons. I did not look as original as Mrs. Laurence but—now I am going to say something nasty—I can stand a strong light and she cannot. To tell you the truth most of these women look rather passée in the sun. Their skins are so very thin and delicate that they line quickly, and so many of them have grey in their hair. However, they made a very charming picture under the trees and I must say for them that they appear to get on together delightfully.
They all greeted me with the utmost cordiality, but Mrs. Laurence rose from behind the tea table and offered me her cold hand with rather a forced smile.
“Please forgive me, dear Lady Helen, if I am thoroughly unamiable for a few moments,” she pouted. “But I have been so annoyed.” She swept her hand dramatically in the direction of a newspaper which evidently had been flung into the bushes. I recognised the New York ——.[A]
“That has a picture of me, a large libellous photograph, procured, heaven knows how, certainly not from a friend! Why should they use my picture? Why should they mention my name? What possible interest can their readers—their million vulgar sensational readers— take in me? I don’t suppose they ever heard my name before. It is hard when you have striven to belong to the aristocracy of letters to be flung into a cowshed.”
I could not resist the temptation, although I trembled at my temerity: “I read the ——[A] every morning,” I said. “Now, had I not met you, I should have been quite keen on seeing your picture.”
“How sweet of you—but—Lady Helen—you don’t read the ——.[A] You surely don’t take it?”
I nodded, perfectly delighted at the twelve expressions of shocked amazement. “How is a stranger to master all your subtle distinctions at once? It seems to me very jolly and interesting. My brother is quite devoted to it.”
“Well, I don’t suppose it will do you any actual harm,” said Mrs. Hammond, with an anxious expression, “but I assure you that if you were an American you never would admit that you read it—would not, indeed, have the least desire to read it—and I should really rejoice if you would reprove them by writing and withdrawing your subscription.”
“Oh, I couldn’t think of doing that,” I said lightly “My brother and I are studying your country, and you have nothing more representative.”
“Representative?” Those carefully modulated voices were quite shrill.
I was in misery and my knees were shaking, but I determined to stand my ground.
“Do not you call a newspaper that a million people read every day, representative?” I answered. “What is it if not representative?”
“Of a certain class—yes,” said Mrs. Chenoweth disgustedly “But what a class!”
“A million people are not to be despised anywhere.” I longed to ask Mrs. Laurence if she would prohibit—if she could—the ——’s[A] million readers from buying her books, but I didn’t dare. I changed the subject instead by asking for a cup of tea.
But that conversation was nothing to one I took part in later.
I have not told you of Miss Shephard, for she did not come up with the others. She is the editor of a literary monthly magazine, issued by Mr. Rogers’ publishing house. It is charmingly got up and quite a smart readable affair, but, Bertie and I had agreed, rather light and vague in criticism—although very pretentious—as compared with our literary weeklies; in fact, not to be taken seriously as criticism at all. The half dozen numbers Mr. Rogers sent us left no impression on my mind whatever beyond a great many pages of clever writing by people who fancied their own opinions mightily. But when Mrs. Hammond told me that Miss Shephard was expected, she added that she was the brilliant editor of The ——,[A] and that probably no one living had a more exact knowledge of what constituted literature, including matter, form, style and perfect English than Miss Shephard. I cannot say that I was very keen to meet her, I am so tired of perfection, but when I saw her I was rather interested, for she does not appear to be more than one—or two-and-thirty. When I expressed some surprise at the position accorded her, I was assured that she had “genius” for criticism, and had, moreover, enjoyed the rare advantage of being the daughter of a Harvard professor and scholar who had been intimate with all the great literary lights of his time. She is a tall thin girl with dark hair, mal coiffée, thoughtful grey
eyes, a very refined nose and a thin ascetic mouth. Her skin looks worn, and there is an affected—so it strikes me—severity about her dress. But she has a thin sweet voice, and a very nice, if too serene, manner.
She did not sit near me during the tea, which was quite lively. Mrs. Laurence was brilliant as usual and moved about a good deal, particularly after Mr. Rolfs “dropped in” unexpectedly and some of his admirers showed a disposition to hang upon the words which a large piece of cake made even more weighty. Finally he did talk—to make her more jealous, I think—and gave them quite a lecture on celestial botany, as it were. Mrs. Laurence could only get the better of him by capping his melodious paragraphs with scintillating epigrams, which annoyed him excessively. I sincerely wish they would murder each other. Finally I became so bored that I wandered down to the edge of the lake, and in a moment Miss Shephard joined me.
“Like all great writers,” she said apologetically, “he puts his best in his books, and sometimes lacks magnetism and fresh thought in talking.”
For some reason Miss S. antagonises me. Perhaps it is a certain air of omniscience, the result of being a factor in the destinies of so many great and brilliant authors. So I answered with some pleasure:
“I think Mr. Rolfs’ books as dull as his speech. He has his points, but he is not a born author, therefore you see the little glittering implements and smell the oil all the time, and of course his stories do not go.”
“There is some truth in what you say,” she answered sweetly, “but then don’t you think that a man with so great and beautiful a mind should be above being a good story-teller?”
“Shakespeare was not.”
“True, dear Lady Helen, but I need not remind you that we are in neither the times nor the country of Shakespeare. Have you observed how non-imitative, how independent we are? There was a time, of course, when American writers slavishly imitated, and in consequence burlesqued, English literature; the only exceptions
were Hawthorne and Poe, and, later, Mark Twain and Bret Harte; but the literature of the last twenty years, which includes so many illustrious names—surely there never has been anything like it in the world.”
“There never has! I suppose I am old-fashioned but it wearies and irritates me—I do not wish to be rude—but—really—I like to read about men and women with human passions.”
“Oh, a discussion without frankness is a poor affair. I am sure that yours is merely a first impression and that our literature will fascinate you in time. Will you permit me a brief explanation? It is our object to produce a literature which shall demonstrate in what ways we are different from all other nations—those differences, peculiarities and so forth which our new and in all things unique country has evolved. Why should we demonstrate—and encourage—the worn out passions that are common to all countries? The refined of ours prefer to forget that such things exist. All well-brought up American girls are taught to ignore this lamentable side of human nature, and never voluntarily to think of it. Without boasting I think I can say that this is the most refined country the world has ever known, and that our literature proves it.”
“But occasionally you develop an author of irrepressible virility who gives the world to understand that a certain percentage at least of the United States are very much like the old accepted idea of human nature.”
“They do not count,” she said emphatically, “because we will not admit them to the ranks of literature, and they must go to the wall in time. The literary pages of the high-class newspapers, and the weekly and monthly bulletins never paragraph them, never refer to them, except in the reviews which advertising exigencies compel. Then we kill them by sneers, not abuse—which always excites a lamentable current in human nature. They are quietly brushed aside, and the real jewels of American literature forced into even greater prominence.”
“Suppose one of these outsiders equals the elect in literary quality?”
“He cannot, because matter and manner are really one. They are too strong, too bold and unpleasant, therefore they shatter and deface that fine exquisite thing called style.”
“Your style. Cannot you conceive the possibility of any other standard being as correct?”
“Certainly not. It is a subject to which we have given years of earnest and analytical thought.”
“What of the very different standards of England, France, Germany, Russia? The novels of all countries seem to be issued by your American firms—and, presumably, read.”
“Oh, we are quite willing that each country should have its own standard. Those old states, indeed, could not imitate us, for they have not the same material. Therefore when a successful European novel treats of things that no well-bred American will discuss, we are generous enough not to be hyper-critical of a race which differs from us in every particular. The older nations are naturally coarse, and allowance should be made for them. But there is not one of our elected authors who would dare or care to treat a subject in the same way. And why should he deal with nasty passion? He has the brilliant kaleidoscopic surface of American life to treat.”
“And you cannot conceive of a day when the standard will change?”
“Certainly not.”
“The minority of one generation is usually the majority of the next,” I said, now warmed to the theme. “Your people of the world—and I know that you have that class—have chosen as their favourites the very authors you have tabooed, and whose works do not reach, I am told, the great public you instruct. As these few authors set their faces against emasculation they offend your aristocratic middleclass, and as they are not erotic your unspeakable sub-stratum will have none of them; but they deal truthfully with that world which those of your country who have enjoyed superior advantages can stand reading about.”
I had hit her at last. She coloured and drew herself up. “I do not understand your term ‘aristocratic middle-class,’” she said icily. “And
I can only assert definitely that we who give our brains and time and culture to the subject are setting and maintaining a standard that always will prevail.”
I turned to go and say good-bye to Mrs. Laurence, but I could not forbear a parting shot. I waved my hand at the company.
“I wonder they marry,” I said. “And I think it positively indecent of them to have children.”
20th July
I am very much alone these days. Bertie is so much better that he spends the entire day fishing or at the Club House, and frequently dines and spends the evening there as well. Agatha has discovered at least twenty neglected correspondents and writes as hard as Mrs. Laurence or Mr. Rolfs, all the morning. I do not mind that, for it keeps her in the house and I can receive any of the men who care to call; but every afternoon, Polly, she goes to Mrs. Chenoweth’s and plays whist, and I either have to shut myself up like a nun or walk in the wood alone. Of course I could defy the dear old soul, but that would be the end of an ideal domestic harmony, and as for Bertie he would be furious. Mr. Rogers is the only person privileged to walk alone with me, and I do not know whether he is flattered or not. I had heard a good deal about the liberty of American girls, but Mrs. Chenoweth assures me that that is all a mistake as far as the upper classes are concerned. Still, I have had a good many conversations with Mr Nugent, and some day perhaps I’ll relate them to you. He calls in the evening and we wander off the veranda to the edge of the lake and stand there for an hour or so admiring the sunset, and once or twice we have met quite accidentally in the forest. After all, I do not own the trail down the mountain even if it is my favourite one. He certainly is interesting, Polly, although in so different a way from all the men I have ever known or read about that I really do not know whether I like him or not. He fascinates me, but that is his magnetism, the concentration of his preternaturally clever mind upon myself, the brilliant and unexpected things he says, and the truly delightful little attentions he pays me, when I know that he is full of restlessness and hardness, and ambition and nervous contempt of the details of
life. But the moment he comes near me I feel protected and surrounded; I am possessed immediately to drop my shawl or handkerchief or worry about the punkies—dreadful little beasts that he keeps off very effectively with a fan or his hat. Once I made him go down on his knees and tie my shoe, merely because I wanted him to see that my foot was as small as any of his countrywomen’s, in spite of my five ft. seven, and much better shod. On another day I had a headache, and instead of remaining in bed I had Henriette arrange me luxuriously on a divan in the living-room, and received him when he called. I had an uncontrollable desire to see how he would act when I was ill. He was charming, in an abrupt, sincere, and wholly tactless way. I think if I had known others like him or had known him about five years I should almost fall in love with him; but how we cling to our ideals! Independence of thought! We are all creatures of traditions.
I may just as well tell you first as last, Polly, that I am sure both Mr. Rogers and Mr. Nugent have made up their minds to marry me. Agatha is blind and Bertie amused, for he cannot imagine me falling in love with anything un-English and new. You see, I look so—well, traditional, few know or suspect that I am impetuous and full of curiosity and love of novelty inside. Of course, as I said, I am in a way as traditional as I look, but in another I’m not. I don’t know if I have expressed myself clearly.
I am sure that Mr. Rogers and all of them think that he has the better chance, because he is so cold and calm and correct. He really is charming in his way and I think I might have had rather a jolly little flirtation with him if Mr. Nugent had not happened to be a guest of the Club. But he talks to me about things that interest me so much more, and he has made me talk to him about myself as I never talked before—even to you. If I could remember all of the nonsense we have talked I’d write it to you, but you know I never did have any memory.
The other day a year-old doe mysteriously appeared in our icehouse with my name printed on a card lying on its chest. I know that either Mr. R. or Mr. N. shot it for me, but I do not dare thank one or the other or even hint the subject: the game laws are so severe that
it would be like a breach of confidence. But it has made all other meat insipid and we enjoyed it quite enough to compensate the offender for the risk he ran. It was one evening when both were calling that I regretted being obliged to wait till September for the game I like best.
Mr. N’s first name is Luke.
22nd July
Well, I will tell you of one conversation at least between Mr. Nugent and myself. A very celebrated—you may be sure he is in the superlative class—lung specialist came up the other day to visit the Chenoweths. Although Bertie is apparently so much better, the moment this doctor appeared I felt that I must have a verdict. At first I thought of appealing to Mr. Rogers, but finally concluded that as I had talked so much to Mr. Nugent it would be positively unkind to pass him over; besides it is so much easier to speak to him about anything. The one thing that keeps me from feeling the perfect freedom of friendship when I am alone with him is the fear that he suddenly will lose his head and take me in his arms and kiss me. He looks passion incarnate and I know that if he ever did let go he would be like one of these alarming electrical storms that visit us every two or three days. However, I have managed him rather well, so far
Well, I confided in him, and he engaged to persuade Dr. Soulé and Bertie to meet for examination, and pledged himself to get the truth out of the doctor and tell me every word of it. It was finally agreed— Bertie was a long time being persuaded—that they were to meet this morning in Mr. Nugent’s room and that at four this afternoon Mr. N. and I would meet at a certain spot in the forest, where I should hear the fateful truth—I thought the appointment was justifiable in the circumstances.
By three I was so nervous that I could not stay in the house and I plunged into the forest, praying that I would meet no one else. Fortunately our camp is alone on our side of the lake and the others prefer the trails behind the Club House and at the north end. I walked far down the mountain to quiet my nerves a little, then returned to the place where we had agreed to meet. It was the rocky
brook I told you of, but some distance below the boulder The opposite bank sloped up gently, its gloom hung with scattered leaves and sun-flecks. I sat down on a rock among the alders, still nervous, my hand, indeed, pressed against my heart, but—what strange tricks the mind plays us—my terrible anxiety crossed by imaginings of what Mr. N. would do and say should he bring me the worst. In a moment, too, my mind was diverted by the dearest sight. A chipmunk—a tiny thing no longer than my finger with a snow white breast and reddish brown back striped with grey and ivory—sat on his hind legs on a stone opposite me eating a nut which he held in his front paws. His black restless eyes never left my face as he tore that nut apart with teeth and nail, and he seemed to have made up his little mind that I was quite stationary—he did seem to enjoy that nut so much. His bushy tail stood straight up behind and curled back from his head. It was quite an inch longer than himself, and not a bit of him moved but those tight little arms and those crunching teeth. He ate the entire nut, and when he had finished and dropped the shell, he still sat there on his hind legs, glancing about, his eyes never wandering far from my face, and absorbing my attention so completely that I quite forgot the apprehension that had torn me for the past four hours. But our mutual interest was shattered by a footstep. I sprang to my feet and he scampered into the ferns.
The moment I saw Mr. N.’s face I knew that I was not to hear the worst, at all events; and then, for the life of me, I could not let the subject be broached. I hurriedly commenced to tell him about the chipmunk and he sat down on the stone it had deserted and listened as if he never had heard of a chipmunk before.
“I’ll try and get you one,” he said. “I think one might be tamed.”
“Oh, I should love it!” I exclaimed. “It would be company for hours at a time. I am sure it has intelligence.”
“I am afraid you have many lonely hours,” he said. “I think you do not like our people here.”
“No,” I said, “they fidget me. I really admire them and I never in all my life believed that so many clever people could be got together in one place. But—that is it—they are not my own sort.”
“No, they are not, and I have a plan to propose to you, that I think might be carried out now that your brother is so much better. I have a number of friends at another lake about ten miles from here. They are very different from these—far more like what you have been used to. They belong to one of the worldly sets in New York, and, while they are quite as clever as our friends here, cleverness is not their métier and they are not so self-conscious about it. They bought Chipmunk Lake and built cottages there that they might go into camp whenever they felt that they needed rest more than Europe or Newport—Should you like to visit there?”
“Yes, but how?”
“I should have said that my married sister is there and that I have written to her about you. She would be delighted if you would pay her a visit. Of course Lady Agatha will go with you, and the Duke can transfer himself to the Club House for a time.”
“He is there always, anyhow,” I said, and I suspect I pouted. At all events he smiled sympathetically and said,
“I am afraid you have learned already something of the selfishness and ingratitude of man.”
“It is a good preparation for matrimony,” I remarked drily.
“Are you contemplating matrimony?” It is interesting rather to bring some colour into the face of an American.
“I am always afraid I might marry some time when I am unusually bored.”
“It is not so great a risk to bore you, then?”
“Oh, I mean by Circumstances. I should expect the man to descend suddenly into them with the wings of an archangel and bear me off.”
“Are you very much bored here? Have I come too soon?”
“I never have enjoyed myself so much.”
“Nevertheless you are not averse to a change.”
“Oh, as my time is short in the United States and as human nature is the most interesting study in the world, I want to meet as many of your interesting types as possible.”
“Your stay may be longer than you think. Soulé says that the Duke must not think of leaving the Adirondacks for two years.”
He had me at last. “Two years!” I gasped. “Must we stay up here for two years?” The place has lost some of its charm since these people came.
“Not here, for you would be snowed in in winter and uncomfortable in every way. I have suggested to the Duke that he endeavour at once to lease a house at Lake Placid. There you would be close to an express train to New York—which you could visit frequently—and undoubtedly could find a house with golf links, tennis court, etc., to say nothing of good trails where you could have daily rides. I know you are longing to be on a horse again.”
“Oh, I am! How did you guess it? That does not sound so hopeless. I suppose our friends would visit us occasionally.”
“I can assert positively that some of them would come as often as they were asked.”
“It would be charity, of course. How kind you and Mr. Rogers have been to think of everything for us.”
Again I had managed to bring the colour into his face. “Rogers is a kind fatherly soul,” he said, tartly. “I don’t pretend to be philanthropic.”
Here I was afraid he would propose to me so I said hurriedly:
“We have forgotten all about Chipmunk Lake. I should like to see some other lakes and some other people. But it is a great deal to ask of your sister.”
“My sister is undoubtedly pining for a new acquaintance. There are only four families at the lake and they soon get talked out. Will you go? I may as well confess that I have already written to and heard from her. Here is her note to you.”
