Download and Read online, DOWNLOAD EBOOK, [PDF EBOOK EPUB ], Ebooks

download, Read Ebook EPUB/KINDE, Download Book Format PDF

Working with Adults with Eating, Drinking and

Swallowing Needs: A Holistic Approach 1st Edition
Mackenzie

OR CLICK LINK
https://textbookfull.com/product/working-with-
adults-with-eating-drinking-and-swallowing-needs-
a-holistic-approach-1st-edition-mackenzie/

Read with Our Free App Audiobook Free Format PFD EBook, Ebooks dowload PDF
with Andible trial, Real book, online, KINDLE , Download[PDF] and Read and Read
Read book Format PDF Ebook, Dowload online, Read book Format PDF Ebook,
[PDF] and Real ONLINE Dowload [PDF] and Real ONLINE
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Working with Violence and Confrontation Using Solution

Focused Approaches Creative Practice with Children
Young People and Adults Judith Milner

https://textbookfull.com/product/working-with-violence-and-
confrontation-using-solution-focused-approaches-creative-
practice-with-children-young-people-and-adults-judith-milner/

Working with Traumatic Memories to Heal Adults with

Unresolved Childhood Trauma Neuroscience Attachment
Theory and Pesso Boyden System Psychomotor
Psychotherapy 1st Edition Jonathan Baylin
https://textbookfull.com/product/working-with-traumatic-memories-
to-heal-adults-with-unresolved-childhood-trauma-neuroscience-
attachment-theory-and-pesso-boyden-system-psychomotor-
psychotherapy-1st-edition-jonathan-baylin/

Teaching music to students with special needs : a

label-free approach Second Edition Hammel

https://textbookfull.com/product/teaching-music-to-students-with-
special-needs-a-label-free-approach-second-edition-hammel/

Working with Transgender Young People and their

Families: A Critical Developmental Approach Damien W.
Riggs

https://textbookfull.com/product/working-with-transgender-young-
people-and-their-families-a-critical-developmental-approach-
damien-w-riggs/
Working with High Risk Adolescents An Individualized
Family Therapy Approach 1st Edition Matthew D. Selekman

https://textbookfull.com/product/working-with-high-risk-
adolescents-an-individualized-family-therapy-approach-1st-
edition-matthew-d-selekman/

Biota Grow 2C gather 2C cook Loucas

https://textbookfull.com/product/biota-grow-2c-gather-2c-cook-
loucas/

Eating Drinking Surviving The International Year of

Global Understanding IYGU 1st Edition Peter Jackson

https://textbookfull.com/product/eating-drinking-surviving-the-
international-year-of-global-understanding-iygu-1st-edition-
peter-jackson/

Creating Procedural Artworks with Processing A Holistic

Guide 1st Edition Dr Penny De Byl

https://textbookfull.com/product/creating-procedural-artworks-
with-processing-a-holistic-guide-1st-edition-dr-penny-de-byl/

Cooking with Sol Brah - Your Complete Guide to Eating

with vitality 1st Edition Sol Brah

https://textbookfull.com/product/cooking-with-sol-brah-your-
complete-guide-to-eating-with-vitality-1st-edition-sol-brah/
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 soci-
etal 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 com-
pletion 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 pre-
registration 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 expres-
sive 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 ‘go-
to’ 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 diag-
nosis, management and treatment options.

Written in a fully accessible style, each book bridges theory and practice and offers ready-to-
use and well-rehearsed practical material, including guidance on interventions, management
advice, and therapeutic resources for the client, parent or carer. The series is an invalu-
able 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
A Holistic Approach

Sophie MacKenzie
with illustrations by Emily Olive
Cover image credit: © Getty Images

First published 2024

by Routledge
4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN

and by Routledge
605 Third Avenue, New York, NY 10158

Routledge is an imprint of the Taylor & Francis Group, an informa business

© 2024 Sophie MacKenzie

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.

All rights reserved. The purchase of this copyright material confers the right on the purchasing institution to photocopy
or download pages which bear the support material icon and a copyright line at the bottom of the page. No other parts of
this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system,
without permission in writing from the publishers.

Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for
identification and explanation without intent to infringe.

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging-in-Publication Data

A catalog record for this book has been requested

ISBN: 978-1-032-31199-9 (hbk)

ISBN: 978-1-032-31198-2 (pbk)
ISBN: 978-1-003-30856-0 (ebk)

DOI: 10.4324/9781003308560

Typeset in Galliard
by Apex CoVantage, LLC

Access the Support Material: https://resourcecentre.routledge.com/speechmark

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.
Contents

Acknowledgements xi
List of figures and tables xii

Introduction 1

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
viii Contents

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
 Contents ix

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
x Contents

11 Case studies 147

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
Indicative answers 156

References 166
Test your knowledge – indicative answers 170
Appendix 1: templates for photocopying and aides-mémoire 179
Appendix 2: glossary and abbreviations 192
Appendix 3: RSCLT competency mapping by chapter 201
Index 204
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 pro-
viding the invaluable perspective of the NQP
• Penny Webster for cementing in me the notion that PT/SLT joint-working is not only essen-
tial 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…”
Figures and tables

Figures

1.1 Lateral view of the head and neck 6

1.2 Anterior-posterior view of the oral cavity 8
1.3 Anterior-posterior view of the throat 9
1.4 Optimal position for safe swallowing 17
2.1 Aspiration of material into the trachea, below the level of the vocal folds 20
3.1 Someone with a right hemisphere stroke: (a) left orofacial weakness;
(b) left tongue weakness 37
4.1 Finger placement for laryngeal palpation 57
6.1 Goal-setting in EDS intervention 97
7.1 Facets of personhood 104
10.1 A tracheostomy tube in-situ 139

Tables

1.1 Key structures of the head and neck and their prime eating, drinking and
swallowing (EDS) functions 6
1.2 The cranial nerves used in swallowing with their UMN innervation 15
1.3 The primary functions of the cranial nerves in the eating, drinking
and swallowing process 16
2.1 Common potential issues at each stage of the swallow process 26
3.1 Cognitive problems and their effect on eating and drinking 34
3.2 Behavioural problems and their effect on eating and drinking 34
3.3 A summary of the common types of EDS issues in some
neurodegenerative conditions 35
3.4 Atypical oral reflexes and their effect on swallow 39
3.5 Side effects of common medications and their impact on the
swallow process 45
4.1 Information from medical notes which influences EDS assessment 49
 Figures and tables xiii

4.2 Potential results from information-gathering at the start of the

clinical assessment process, what they can tell us, and possible next steps 49
4.3 Some suggested questions an SLT may wish to ask a client and the
rationale behind them 51
4.4 Potential questions to ask the representative of a client who has speech,
language or cognitive issues when taking a case history 52
4.5 Observations used in the assessment of EDS difficulties 53
4.6 Cranial nerve deficits and their possible effects on the swallow 56
4.7 Observations from laryngeal palpation and what these tell us 58
4.8 Decision-making pathways in oral trials 60
4.9 What to look out for at each stage of the swallow process, what this
may indicate and possible interventions 62
5.1 The Penetration-Aspiration Scale (PAS) 72
5.2 Indicators that can be used to gauge the severity of dysphagia 78
6.1 A selection of oromotor exercises commonly used in clinical practice 84
6.2 Key reasons for recommending thickened fluids 88
6.3 Key reasons for recommending altered food textures 89
6.4 Suggested head and body positions to aid swallowing 90
6.5 Adaptive cutlery and crockery: how they facilitate eating and drinking 91
6.6 The various swallow manoeuvres which may be carried out with or
without oral intake 91
9.1 Types of team and their style of teamwork 128
9.2 The different grades of hospital doctor 132
9.3 Specialisms of doctors involved in the management of adult clients
with EDS needs 132
 INTRODUCTION

For the last 30 or so years, assessment and management of dysphagia has been an integral compo-
nent 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 com-
petencies and curriculum guidelines, with the aim of all graduates in the UK from all Universities

DOI: 10.4324/9781003308560-1
2 Introduction

demonstrating the same level of knowledge and the same level of clinical competence on comple-
tion 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 hydra-
tion to fuel our bodies and survive, but mealtimes are also imbued with social, cultural and some-
times 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.

DOI: 10.4324/9781003308560-2
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 com-
petent 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.
 The typical swallow 5

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 respira-
tory system) is to the oesophagus (part of the gastrointestinal system). The swallow process there-
fore 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 produc-
tion. 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.
6 The typical swallow
Figure 1.1 Lateral view of the head and neck.
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
False vocal folds Airway protection
(vestibular folds)
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
 The typical swallow 7

Anatomical structure Prime function in EDS Other information

Larynx The vocal folds form the glottis and There are three subsections to the larynx –
are able to adduct (close) to protect the supraglottic, glottic and subglottic
the airway regions The vocal folds are surrounded
False vocal folds sit just above the true by the thyroid (shield-shaped) cartilage,
vocal folds and can also approximate with the cricoid (ring-shaped) cartilage
for protective reasons just below
The supraglottic area (above the vocal
folds) is also sometimes referred to as the
laryngeal vestibule
Lips Provide a seal to the oral cavity Labial is the adjective related to the lips
Mandible Allows for mouth-opening and Mobile, lower jaw which is joined to the
mastication (chewing) maxilla by the temporomandibular joint
(TMJ)
Maxilla Top teeth (mastication) and hard Fixed, upper part of jaw
palate (bolus propulsion) are housed
here
Nasal cavities Should be closed off for swallowing The nose comprises the nasal septum (thin
Olfactory sensory neurones send bone which divides the left and right
messages to the cortex to identify nasal cavities) and the turbinates (small
smell – sense of smell also relates bony structures inside the nose which
closely to taste help to cleanse and humidify inspired air)
Oesophagus Allows passage of food and drink from Hollow, collapsed, muscular tube,
the pharynx to the stomach comprising striated muscle in the upper
third and smooth muscle in the lower
two-thirds
Oral cavity Contains the bolus ready for We sometimes refer to perioral (around the
swallowing mouth) and intraoral (within the mouth)
Pharynx Bolus is squeezed through the pharynx Divided into three sections: oropharynx,
towards the oesophagus nasopharynx, hypopharynx/
laryngopharynx
Pyriform fossae Food/fluid residue may accumulate Pyriform means “pair-shaped” and refers
/ sinuses (see here to pockets within the pharynx, close to
Figure 1.3 for the entrance to the larynx, created by
the location of the aryepiglottic folds and the thyroid
the valleculae and cartilage
pyriform sinuses)
Soft palate/velum Makes contact with the posterior The posterior part of the palate which
pharyngeal wall to seal off the nasal contains muscle fibres and is therefore
cavity able to move when innervated
Sulci (singular – Food may fall into the sulci and need The spaces between the inner cheek and
sulcus) retrieving with the tongue the teeth (lateral sulci at the sides and
anterior sulcus in front)
Teeth Used in biting and mastication Dentition refers to the teeth. Someone with
no teeth is referred to as edentulous
Tongue Used to manipulate the bolus in the oral Large muscular structure, which comprises
cavity and to propel the bolus from the tip, blade (dorsal surface), back of
the front to the back of the mouth tongue and tongue base
Allows taste
Trachea Expiration post-swallow Fixed, open, cartilaginous tube, allowing
air in and out during respiration
Upper oesophageal A sphincter that is closed until food/ Sometimes you will see the abbreviation
sphincter / fluid reaches it, when it opens to UES (upper esophageal sphincter)
cricopharyngeal allow the material through into the
sphincter oesophagus

(Continued)
8 The typical swallow

Table 1.1 (Continued)

Anatomical structure Prime function in EDS Other information

Uvula Secretes saliva 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
Valleculae Food/fluid residue may accumulate These are pockets in the pharynx, formed
here where the base of tongue meets the
epiglottis

Figure 1.2 Anterior-posterior view of the oral cavity.

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.
 The typical swallow 9

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 longitu-
dinal (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.
10 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 inadvert-
ently penetrate the larynx. These functions all utilise the intrinsic muscles of the larynx. The pos-
terior 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.
Another random document with
no related content on Scribd:
English birth and parentage. Soon after his marriage, he engaged in
the restaurant business and continued in this business until
September, 1862, when he enlisted in the One Hundred and Twenty-
fourth Regiment of Illinois Volunteer Infantry. He was mustered into
the service at Springfield, Illinois, went into action first at Jackson,
Tenn., participated in the siege of Vicksburg and in successive
campaigns, being mustered out of service at the end of three years
days from the date of his enlistment.
Immediately after his retirement from the military service, he
returned to his old business in Aurora. Enterprising, shrewd and
capable, his business expanded and he became the proprietor and
then owner of the leading hotel of the city, and one of its most
enterprising and public spirited citizens. He became largely
interested in real estate, laying out several large additions to the city,
and realizing handsome profits from his investments. In 1882, he
organized the Aurora Street Railroad Company, took charge of the
construction of the road, and pushed to completion, an enterprise
which has since been developed into one of the most perfect electric
railroad systems in the West. He was also the projector of the Joliet
and Aurora Northern Railroad, an enterprise with which he was most
actively identified up to the date of its going into operation, and at a
late date as one of its leading officials. In everything calculated to
contribute in any way to the growth and prosperity of Aurora he has
taken a most active interest, and as a natural consequence of this,
coupled with a cheering geniality, he has always enjoyed great
popularity.
His political life began in 1876, when he was elected an Alderman
for one of the wards of Aurora. In the fall of the same year he was
elected a member of the State Legislature. After serving one term in
the House of Representatives, he was elected, in 1880, a member of
the State Senate, and has been twice re-elected since that time. As
a member of the General Assembly, he has become recognized as a
careful and conscientious legislator, with a large stock of practical
ideas, and a capacity for energetic and persistent efforts, which have
made his services peculiarly valuable to his constituents. While
serving his first term in the Legislature he introduced and succeeded
in having enacted into a law, the bill providing for the establishment
of a State Soldier’s Home in Illinois—an institution which does great
credit to the State.
He was also the author of the law under which the National Guard
is now organized, a measure which met with determined opposition
at the time of its introduction. Despite the opposition however, it
became a law, and the wisdom of the act has since been
demonstrated on numerous occasions.
In recognition of his services in perfecting the organization of and
rendering effective the State Militia, Governor Shelby M. Cullom
made him a member of his military staff, with the rank of colonel. He
was appointed to the same position on the staff of Governor
Hamilton and Governor Oglesby, and is now serving on the staff of
Governor Fifer.
The Police Pension bill was another of the important measures
which had his successful advocacy.
The life of Col. Evans strikingly emphasizes the marvelous
industry, tireless energy, and broad spirit of enterprise that are to-day
so characteristic of the American man of affairs.
W. H. Maguire.
EDITORIAL AND HISTORICAL NOTES.
The present (November) number of the Magazine of Western
History, which is the first number of the new volume (Vol. XV)
appears under a new name which will more adequately describe its
present character.
The title chosen—“THE NATIONAL MAGAZINE—A Journal
Devoted to American History—” is in keeping with the enlarged
scope and purpose of the publication. When it first came into
existence, its proposed mission was to gather and preserve the
history of that great West which lies beyond the Alleghanies, and
while that labor has been pursued with results that have enriched
American history, the boundaries have been gradually enlarged until
the whole country has become its field of research, and readers and
contributors are found in every State and territory.
The Magazine has become National, and it is believed that the
present name will be accepted as more appropriate than the one that
has been outgrown.

The new name defines, perhaps with sufficient fullness, both

scope and purpose, but for the sake of clearness we add that it is
proposed to confine our interest exclusively to the field of American
History, and whatever directly illustrates it. By this we mean not
alone or chiefly the history of our remote past with its discoveries, its
early settlers, and its struggling colonies, but the history as well of
the present century—the planting of colonies by railroads, the
evolution of States, the founding of cities, the building up of a
literature, the history of politics, and of all that unexampled material
progress that makes America the wonder and admiration of the
world.
 The great civil war has served necessarily as an extraordinary
stimulus to historical writing and research concerning its antecedent
causes, the tremendous conflict itself, and its far reaching and still
potent consequences. It is plain however, that the history of the war
has yet been written only in outline. The historical material which
when gathered and sifted would give it completeness and fullness is
as yet largely unwritten. This exists in the recollections of men yet
living—actors and witnesses—in their letters, journals and other
written memoranda, and in the traditions carefully cherished by
families and friends of those that are gone. We propose to collect
such material as far as possible, and give it a permanent record in
our pages.

One of the interesting features of our national life is the growth of

societies for the encouragement of historical studies as well as the
preservation of valuable historical material which would otherwise be
lost. The historical societies having permanent homes, number
nearly or quite two hundred and fifty, and while some of the largest
support intermittent publications of their own, we believe there is no
general organ devoted to their interests and furnishing a medium of
intercourse between them. The National Magazine proposes, as far
as possible, to supply this want and will conduct a separate
department giving all notes of interest regarding the Historical
Societies of the United States which we may be able to obtain.

It is believed that a large amount of historical material of great

interest both to the general reader and the historical student exists in
the shape of papers prepared by members of these various
Historical Societies for the interest and instruction of their particular
organizations.
 Such papers as we refer to are prepared for the most part by
members who have both leisure and taste for historical research, or
who find in such work a grateful relief from the exacting cares of
successful professional and business careers, and although
addressed to a limited circle, have frequently a value and interest
that entitles them to a larger audience and to preservation in more
permanent form.
It is proposed to present in the pages of the Magazine, in
pursuance of our general purpose to broaden the field of its interest
and usefulness, a selection from such papers. It is believed that the
literature of American History would be greatly enriched from this
source. Papers of even local interest are not without value to the
student of history in any portion of the country, and all these various
efforts at writing history are building up that great body of historical
material from which American History at least in the nineteenth
century is to be exhaustively and philosophically written.

“In lighter vein” we propose to touch on the picturesque side of

historical research, and to seek material in the legends and traditions
that attach to certain localities. The very fact that a certain headland,
valley, mountain or river has a legendary interest is not undeserving
the attention of the scholar and is a matter of legitimate historical
interest if not value. A country as new as ours can well afford to
jealously preserve whatever of such legendary and historical lore it
may have. It at least serves to “adorn the tale” which has a more
solid basis. Other changes are contemplated that will add value, and
interest to the pages of the Magazine.

The present number contains the first installment of a series of

articles from the advance sheets of the forthcoming Memorial History
of New York, edited by Gen. James Grant Wilson. It is the intention
to select for publication in the Magazine such parts of this work as
will in our judgment be of great interest to its readers, and as far as
possible present a continuous narrative. These articles will be amply
illustrated from the plates prepared and selected for the original work
with great care. The exhaustive character of the work, the time given
to its preparation, the staff of contributors each pre-eminent in his
special field, are fully set forth on the cover of the present number.

In the August number of this Magazine we remarked upon the fact

that the historic property of Valley Forge was in danger of being sold
and divided among individual purchasers and that in this event the
ancient ramparts of Fort Washington, the site of the forge, the cold
spring, and the Headquarters of Washington, Lafayette and Knox
would be obliterated. It is a pleasure to learn that the march of such
“improvement” will probably be arrested. A meeting of the members
of the National Society of the Daughters of the Revolution residing in
Washington was held on Oct. 13th, and a plan was considered for
purchasing and preserving this property. The Illinois chapter of the
same organization has also held a meeting to advance the same
cause. With the patriotic ardor of women thoroughly awakened there
should be no question about preserving to the nation the field of
Valley Forge with all its “visible history.”

A monument to the great Indian Chief Red Jacket, Chief of the

Senecas and the renowned orator of the six nations was dedicated
at Waterloo, N. Y. on Oct. 14th. President Welles of the Waterloo
Historical Society under whose auspices the monument is erected
presided. The Hon. W. C. Bryant of Buffalo delivered an historical
address. The monument is unique in design, being carved from a
block of granite to represent the trunk of an oak tree, and stands on
the west shore of Cayuga Lake near the spot where Red Jacket was
born. The base bears four descriptive bronze tablets, and around the
base are clustered six small bowlders bearing the names of the six
nations of the Iroquois. Red Jacket was one of the unique figures of
his time, his character a peculiar mixture of the noble and the
ignoble, a sagacious statesman, a cunning demagogue, but always
an Indian.

A gathering both important and unique was held in Independence

Hall, Philadelphia, on the 12th of October. The occasion was the
reunion of a committee which has undertaken to organize a Pan-
Republic Congress and Human Freedom League, and to arrange an
international meeting in connection with the anniversary ceremonies
of 1892. The leaders of the movement claim that their ideas have
been gradually disseminated through organized societies in all
civilized countries. Their meaning and purpose they broadly state to
be: That the four hundredth anniversary of the discovery of this
continent should be celebrated by a convocation, first of the
representatives of all governments based on an acknowledgment of
the rights of man, and secondly, of representatives of the people of
high purpose everywhere, independent of the form of government
under which they live. That these two bodies acting in concert on the
soil of the greatest of the governments founded upon freedom,
should consult together on the means of widening the domain in
which the earth’s dwellers may enjoy the rights claimed for us by our
immortal Declaration of Independence.

Youngest among the sisterhood of the States of our Union stands

Washington, on the borders of the far Pacific. It is very gratifying to
observe the citizens of a community of such regent origin, amid the
eager competitions of life and the pressure of material interests,
turning aside from these practical pursuits to secure for future
generations a record not only of their own achievements, but of the
humbler and more heroic doings of the pioneers of their State. Such
is the aim and purpose of the Washington State Historical Society,
organized during the present month in the city of Tacoma, and the
latest to join the ever widening circle of these societies. In the words
of its president, the Hon. Elwood Evans, “the State of Washington
has reached a time when the need of collecting original historical
material has become imperative since the history of the State and
Territory runs back 38 years, and most of the early settlers are dead.
The hardships and heroism of the pioneers should be handed down
and recorded as material for the historian of later years.”
 NOTES FROM THE HISTORICAL
SOCIETIES.
The quarterly meeting of the Chicago Historical Society, (Illinois,)
was held on Tuesday evening, Oct. 20. A paper was read prepared
by Samuel C. Clarke of Marietta, Ga., entitled “Some recollections of
Chicago in the Forties.”

The Pejepscot Historical Society (Brunswick), Maine, are

considering the erection of a fireproof building.

The Maryland Historical Society (Baltimore), are discussing with

active interest the successor to John H. B. Latrobe, Esq., late
President of the Society, S. Teakle Wallis, Esq., and Gen. Bradley T.
Johnson are the most prominent names mentioned.

The Wakefield Historical Society, Mass., at its monthly meeting in

October, received some valuable donations, the most interesting of
which was the diary of Capt. Natl. Cowdrey, kept by him during the
campaign in New York which included Arnold’s treason and the
attempt to capture West Point.
 The annual meeting of the Beverly Mass., Historical Society was
held on the evening of Oct. 14th. The occasion was the 223rd
anniversary of the settlement of the Town of Beverly.

The Old Colony Historical Society, (Taunton) Mass., held a large

meeting on Thursday, Oct. 15. Geo. Fox Tucker, Esq. of New
Bedford, gave an elaborate address on the Quaker element in New
England, and the Old Colony life in the middle of the seventeenth
century.

The Cape Ann Historical Society (Gloucester) Mass., was formed

on the evening of Oct. 7th. Joseph L. Stevens was elected president
and Alfred F. Stickney corresponding secretary.

The Suffolk County Historical Society N. Y., held its annual

meeting at Riverhead on Oct. 6th. A committee was appointed to
consider the erection of a suitable fireproof building for the use of the
society and the preservation of its treasures, many of which are
original parchments and manuscripts which could not be replaced.

The Westchester County Historical Society, N. Y. held its annual

meeting on Wednesday, Oct. 28th—the anniversary of the battle of
White Plains—Judge J. O. Dykman gave an address on County
Affairs during the Revolutionary War.
 Waterloo Historical Society N. Y.—See Editorial Notes.

The Dauphin County Historical Society, (Harrisburgh) Pa., held an

interesting meeting on Oct. 8th, and received many valuable
documents connected with the war. A paper on “Historic Localities”
by Mr. E. J. Stackpole was read.

The Ohio Historical Society (Columbus), with characteristic

enterprise and timeliness has appointed a committee of three into
whose hands will be placed the arrangements for the historical and
archeological display of Ohio at the Columbian Fair.

The October meeting of the Rhode Island Soldiers and Sailors

Historical Society (Providence), was held on Oct. 20. Several
interesting historical donations were received. Gen. Viall read a
paper entitled “Sketch of the 14th R. I. Heavy Artillery.”

The Rhode Island Veteran Citizens Historical Association

(Providence) held one of their regular meetings on Oct. 20th. It was
announced that Noah J. Arnold, Esq., was preparing a paper on
“Adrien Block and Block Island” which should prove very interesting.

The Tennessee Historical Society (Nashville), held its monthly

meeting in the Watkins Institute on Oct. 13th. The noteworthy event
of the meeting was their action in formally requesting their senators
and members in Congress to lend their aid to the erection of the
proposed national gallery of history and art in commemoration of our
400th anniversary. It is hoped that other societies will support the
Tennessee Historical Society in this object.
The Vermont Historical Society (Montpelier), held their annual
meeting at their rooms in the State House on Oct. 20th. President
Hiram Carleton, presided. The old officers were re-elected.

The Washington State Historical Society was organized at Tacoma

on Oct. 8th. Hon. Elwood Evans was made President and C. H.
Hobart, Secretary.
 RECENT HISTORICAL
PUBLICATIONS.
“Historical Essays.” By Henry Adams. Chas. Scribners’ Sons.
In this volume are gathered a number of essays, chiefly on
historical subjects, which have appeared at various times in
magazines. They are characterized, as might be expected, by the
clear and attractive style and the incisive thought that belongs to all
of Mr. Adams’ literary work.
Some of the essays are of pronounced value and interest. Notably
the essay on the Gold Conspiracy, which to any one who is at all
familiar with the details of one of the most remarkable episodes in
American financial history, will prove absorbingly interesting. It
contains a sketch of Jay Gould, which, in the light of recent
occurrences, has a peculiar interest.
In no field of investigation at the present time is the skeptical spirit
more active than in the historical, and the essay on Capt. John Smith
will provoke some criticism and more regret, as it is an effort to cut
away the historic basis from the beautiful story of Pocahontas. As Dr.
Schliemann has lifted Troy and its legends to the dignity of history,
perhaps some historical explorer may be inspired to undertake the
same task for the Pocahontas incident.

We have received in pamphlet form, as one of the published

collections of the Minnesota Historical Society for 1891, the account
of the ceremonies of the two hundredth anniversary of the discovery
of the Falls of St. Anthony by Father Hennepin in 1680, and the
different papers read on that interesting occasion. This “Part” is a
continuation of the series of short sketches and papers which had
been interrupted, and makes a valuable addition to the data for
Western History. It is a real pleasure to praise the beautiful
typographical appearance of this pamphlet.

“Beginnings of Literary Culture in the Ohio Valley.” By W. H.

Venable, L.L.D. Robert Clarke & Co., 1891.
Dr. Venable has been very successful in his undertaking to show
the progress of literature, education, art, politics and religion in the
Ohio Valley, from the days of the early settlers until the present time.
He has done this by sketching the careers of those who have been
conspicuous in these fields of culture and practical interest, and has
gathered a great fund of information, anecdote and biographical
detail, which has made his narrative very interesting as well as full.

“James Freeman Clarke. Autobiography, Diary and

Correspondence.” Edited by Edward Everett Hale. Houghton,
Mifflin & Co., 1891.
A book on James Freeman Clarke, by Edward Everett Hale,
encourages “great expectations,” and these expectations are not
disappointed.
It is a delightful mixture of the handiwork of two bright thinkers and
recognized lights in our native literature. After a modest account of
himself, the subject of the sketch is delineated still further by a fond
and appreciative friend. The man, broad and free and catholic in his
thinking and in his feeling, opens his heart to us in diary and letters.
And what he fails to tell, as eminently improper for himself to tell, Dr.
Hale gives to us, so that the picture may be complete. The keynote
to the book, and the real use of it, are indicated on the first page by
Dr. Clarke himself: “I have lived in an important period; have known
many eminent men and distinguished women; have seen great
changes in social life, in religious opinion, in private morals and
public manners. If I can succeed in making a few suggestive
pictures, or memory sketches, it may be a gratification to my children
and friends, and possibly contribute matter for the future historian of
this period.”

“Historical Collection of Ohio.” By Henry Howe, L.L.D.

The two concluding volumes of the Historical Collections of Ohio
are now published together, and complete a monumental work. Dr.
Howe has given many years to this undertaking, and is said to have
personally visited every locality of which he treats, and collected his
facts from the lips of living men and women as well as from written
records. The work is more than a formal history. It unfolds before the
reader the whole life and annals of Ohio, from the earliest
settlements to the present day. Geography and statistics go hand in
hand with narration, reminiscence and details of social life and
customs.

“Ohio Archæological and Historical Society, vol. III.”

We have received the third volume of the publications of The Ohio
Archæological and Historical Society. This volume is mainly
concerned with the anniversary exercises connected with the
centennial of the settlement of Gallipolis. Exhaustive papers on “The
French Settlement and Settlers of Gallipolis,” “The Scioto Company
and its Purchase,” and the “Early Judiciary of Ohio,” attest the
historical value of this volume. It also contains a report of the sixth
annual meeting of the society, February 19th and 20th, 1891. The
secretary (Mr. A. A. Graham), very pertinently says in his preface,
“The State is now indebted to the Ohio Archæological and Historical
Society for three valuable historical volumes, and if the society had
done nothing else, its existence is more than justified.”
*** END OF THE PROJECT GUTENBERG EBOOK THE NATIONAL
MAGAZINE, VOL. XV, NO. 1, NOVEMBER 1891 ***

Updated editions will replace the previous one—the old editions

will be renamed.

Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States copyright
in these works, so the Foundation (and you!) can copy and
distribute it in the United States without permission and without
paying copyright royalties. Special rules, set forth in the General
Terms of Use part of this license, apply to copying and
distributing Project Gutenberg™ electronic works to protect the
PROJECT GUTENBERG™ concept and trademark. Project
Gutenberg is a registered trademark, and may not be used if
you charge for an eBook, except by following the terms of the
trademark license, including paying royalties for use of the
Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is
very easy. You may use this eBook for nearly any purpose such
as creation of derivative works, reports, performances and
research. Project Gutenberg eBooks may be modified and
printed and given away—you may do practically ANYTHING in
the United States with eBooks not protected by U.S. copyright
law. Redistribution is subject to the trademark license, especially
commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
 PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the

free distribution of electronic works, by using or distributing this
work (or any other work associated in any way with the phrase
“Project Gutenberg”), you agree to comply with all the terms of
the Full Project Gutenberg™ License available with this file or
online at www.gutenberg.org/license.

Section 1. General Terms of Use and

Redistributing Project Gutenberg™
electronic works
1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand,
agree to and accept all the terms of this license and intellectual
property (trademark/copyright) agreement. If you do not agree to
abide by all the terms of this agreement, you must cease using
and return or destroy all copies of Project Gutenberg™
electronic works in your possession. If you paid a fee for
obtaining a copy of or access to a Project Gutenberg™
electronic work and you do not agree to be bound by the terms
of this agreement, you may obtain a refund from the person or
entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only

be used on or associated in any way with an electronic work by
people who agree to be bound by the terms of this agreement.
There are a few things that you can do with most Project
Gutenberg™ electronic works even without complying with the
full terms of this agreement. See paragraph 1.C below. There
are a lot of things you can do with Project Gutenberg™
electronic works if you follow the terms of this agreement and
help preserve free future access to Project Gutenberg™
electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the
collection of Project Gutenberg™ electronic works. Nearly all the
individual works in the collection are in the public domain in the
United States. If an individual work is unprotected by copyright
law in the United States and you are located in the United
States, we do not claim a right to prevent you from copying,
distributing, performing, displaying or creating derivative works
based on the work as long as all references to Project
Gutenberg are removed. Of course, we hope that you will
support the Project Gutenberg™ mission of promoting free
access to electronic works by freely sharing Project
Gutenberg™ works in compliance with the terms of this
agreement for keeping the Project Gutenberg™ name
associated with the work. You can easily comply with the terms
of this agreement by keeping this work in the same format with
its attached full Project Gutenberg™ License when you share it
without charge with others.

1.D. The copyright laws of the place where you are located also
govern what you can do with this work. Copyright laws in most
countries are in a constant state of change. If you are outside
the United States, check the laws of your country in addition to
the terms of this agreement before downloading, copying,
displaying, performing, distributing or creating derivative works
based on this work or any other Project Gutenberg™ work. The
Foundation makes no representations concerning the copyright
status of any work in any country other than the United States.

1.E. Unless you have removed all references to Project

Gutenberg:

1.E.1. The following sentence, with active links to, or other

immediate access to, the full Project Gutenberg™ License must
appear prominently whenever any copy of a Project
Gutenberg™ work (any work on which the phrase “Project
Gutenberg” appears, or with which the phrase “Project
Gutenberg” is associated) is accessed, displayed, performed,
viewed, copied or distributed:

This eBook is for the use of anyone anywhere in the United

States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it
away or re-use it under the terms of the Project Gutenberg
License included with this eBook or online at
www.gutenberg.org. If you are not located in the United
States, you will have to check the laws of the country where
you are located before using this eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is

derived from texts not protected by U.S. copyright law (does not
contain a notice indicating that it is posted with permission of the
copyright holder), the work can be copied and distributed to
anyone in the United States without paying any fees or charges.
If you are redistributing or providing access to a work with the
phrase “Project Gutenberg” associated with or appearing on the
work, you must comply either with the requirements of
paragraphs 1.E.1 through 1.E.7 or obtain permission for the use
of the work and the Project Gutenberg™ trademark as set forth
in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is

posted with the permission of the copyright holder, your use and
distribution must comply with both paragraphs 1.E.1 through
1.E.7 and any additional terms imposed by the copyright holder.
Additional terms will be linked to the Project Gutenberg™
License for all works posted with the permission of the copyright
holder found at the beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project

Gutenberg™ License terms from this work, or any files
containing a part of this work or any other work associated with
Project Gutenberg™.