Signs and Symptoms of Oropharyngeal Dysphagia
Clinical Signs & Symptoms
Clinical signs and symptoms of dysphagia are varied, ranging from the obvious, such as choking, to the subtle, such as facial grimacing during mealtimes. The presence of a sign or symptom does not guarantee a swallow disorder or the presence of aspiration. However, specific signs and symptoms associated with dysphagia may be identified during effective screening for dysphagia. Box 2.1 provides examples of some commonly reported symptoms and their clinical signs.
Box 2.1: Signs and symptoms that may be observed during the dysphagia exam
Clinical Note
Symptoms are reported by the patient.
Signs are observed or measured during the clinical or instrumental exam.
Sensitivity is the percent of patients with a disease who test positive for that disease.
Specificity is the percent of patients without a disease who test negative for that disease.
To assess the predictability of a single sign or symptom to be a sensitive and specific indicator of the presence of dysphagia or aspiration, findings on clinical examinations are compared to instrumental findings. Box 2.2 summarizes sensitivity and specificity for various clinical signs and symptoms. Interpretation of this data should be considered with respect to: (1) the level of sensitivity and specificity, individually and combined, (2) the consistency of these variables across multiple investigations, and (3) the patient population used in the investigation. Box 2.2 is not exhaustive. Vomiting, throat clearing, presence of stridor, and eye tearing have also been reported to be linked to dysphagia (Benfer et al., 2015; DeMatteo, Matovich, & Hjartarson, 2005; Weir, McMahon, Barry, Masters, & Chang, 2009).
Box 2.2: Summary of sensitivity and specificity of various clinical signs and symptoms
Sensitivity or specificity greater than .75 is bolded.
Although clinical signs and symptoms can help us identify a risk of dysphagia, that information alone is insufficient to draw direct physiologic implications. Box 2.3 displays sensitivity versus specificity for individual signs and symptoms across the studies presented in Box 2.2. In Box 2.3 high specificity is indicated by the blue shading; high sensitivity is indicated by the pink shading. Overall, individual signs and symptoms lack consistent sensitivity and specificity across investigations. In fact, across the literature, sensitivity (the ability to identify people with a disease) and specificity (the ability to identify people without a disease) does not yield an obvious single clinical variable that consistently has both a high sensitivity and high specificity. Using a cut off of .75 in Box 2.3, the box that highlights the overlap of these two shaded segments indicates that while some variables come close, no single variable has both high sensitivity and specificity as a predictor for risk of dysphagia. Assessing the presence of multiple signs and symptoms, serves as a better predictor of risk than a single symptom alone.
Box 2.3: Summary of sensitivity and specificity across various signs and symptoms of swallowing
Clinical Note
Signs and symptoms associated with dysphagia include:protracted mandible, impaired oral sensation, oral incontinence or drooling, nasal regurgitation, weak voice, weak neck muscles, residue or stasis, oral or pharyngeal pain or globus sensation.
Presence or Absence of a Gag Reflex
The gag reflex is a brainstem reflex that may be elicited by a foreign or unwanted stimulus entering the oropharynx (Box 2.4). The result is a strong contraction with elevation of the velum, pharynx, and larynx. In patients with dysphagia, an abnormal gag reflex has a sensitivity ranging from 33-62% and a specificity ranging from 81-82%. In short, an abnormal gag reflex may be an indicator of dysphagia (Daniels et al., 1998). Yet, a healthy gag reflex is not required to produce a safe swallow. In fact, the gag reflex is absent in 4-13% of non-dysphagic individuals (Leder, 1996; Ramsey, Smithard, & Kalra, 2005). That is, the individual may not produce a gag response (CN X), despite feeling the stimulus (CN IX). In summary, an intact gag reflex does not imply a healthy swallow, nor does an abnormal gag reflex guarantee a swallow deficit. Although the presence of an abnormal gag reflex does indicate a higher likelihood of dysphagia. Consideration should be given to those individuals who not only have an absent gag response, but also deny feeling the stimulus.
Box 2.4 Video: Visualization of stimulated gag reflex
Click to play the video. Note that the velum elevates and the tongue protrudes.
Clinical Note
Recall that the gag reflex receives sensory input from CN IX and generates a motor response via CN V and X. Therefore, the lack of an observed gag reflex does not definitively define sensory status.
Clinical Note
In adults, the gag reflex should be tested on both the right and left side. Regardless, if intact, the soft palate should elevate symmetrically.
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Currently, there are no data comparing the strength of a healthy reflexive cough to a voluntary cough in healthy individuals (Magni, Chellini, Lavorini, Fontana, & Widdecombe, 2011).
Coughing
A cough is a brainstem reflex whose purpose is to protect the airway (Box 2.5). Specifically, if material penetrates the laryngeal vestibule, a cough will be reflexively triggered to expel material out of the airway entrance. A weak cough may render the individual unable to expel foreign material from the larynx. Coughing during mealtimes may be linked to penetration of material into the laryngeal vestibule (Daniels et al., 1998; Logemann, Veis, & Colangelo, 1999). In individuals with swallow disorders, the spontaneous cough may be weak or absent. If the penetrated material is not properly ejected and goes below the true vocal folds, it is considered aspiration. In the case of an absent cough, the individual is at risk for silent aspiration — entering below the vocal folds without a clinically observable physiologic response. In individuals with dysphagia, spontaneous coughing during mealtimes has a sensitivity for identifying dysphagia ranging from 57-78%. For individuals who are status post stroke, a weak voluntary cough has a specificity for dysphagia ranging from of 58-85%. In other words, individuals with a strong and functional voluntary cough are less likely to have dysphagia.
Box 2.5: Schematic of a cough reflex
Clinical Note
Spontaneous coughing does not always mean that an individual has dysphagia. Cough not associated with mealtimes may be related to medication (e.g., ACE inhibitors such as Lisinopril) or pulmonary disease (e.g., asthma). This symptom is also noted in frail and weak elderly individuals, but is not necessarily related to dysphagia
While a spontaneous cough during oral intake implies oropharyngeal swallow deficits, it is possible to have swallow deficits and not stimulate a spontaneous cough. When this happens, the clinician may ask the individual to produce a voluntary cough and use the strength of that cough to judge its potential effectiveness. A voluntary cough may provide insight into the strength of the structures used in the production of a reflexive cough. A weak voluntary cough has a sensitivity for the presence of dysphagia of 48-68% and a specificity of 82-94%.
General Dysphonia or Wet Vocal Quality
Individuals with dysphagia may have a wet or gurgly voice quality associated with swallowing, especially during and immediately after mealtimes. This is true in both adults and children (Weir et al., 2009) and is generally linked to moderate to severe penetration or aspiration (Weir et al., 2009; Irwin, 2006). (See Box 2.6 for a sample of a gurgly vocal quality.) The physiologic assumption is that if material collects in a supraglottic or pharyngeal space, and remains there after the swallow, then voice quality will be altered during phonation. Material in the supraglottic region implies that either the individual is lacking in sensory function (risk of silent aspiration), or motorically weak, such that a cough is inadequate to expel the laryngeal contents. Regardless, the end result is the risk of aspiration after the swallow. Overall, the sensitivity of a gurgly voice quality during or after oral intake ranges from 38-91%; specificity ranges from 40-92%. Dysphonia (with or without a gurgly vocal quality) is associated with dysphagia. The presence of dysphonia has a sensitivity of 48% and a specificity of 56% as a risk marker for dysphagia.
Box 2.6 External Link
Drooling
Drooling, or anterior loss of oral contents, can occur during mealtimes, as well as throughout the day. Although drooling is considered normal in infants and toddlers due to either immature muscle tone or increased salivation associated with tooth eruption, the presence of drooling may also indicate a deficit. Box 2.7 depicts common causes of drooling. Drooling may occur when there is a mismatch between the amount of saliva produced and the frequency or functionality of saliva swallows. Other causes of drooling include inadequate sensory or motor function of the lips, or poor nasal patency resulting in an open oral posture for breathing. Logemann and colleagues (1999) reported the sensitivity and specificity of drooling as an indicator of dysphagia to be 37% and 88%, respectively. When drooling is observed, an attempt should be made to (a) assess the cause, and (b) quantify the amount. The Drooling Severity Scale depicted in Box 2.8 (Rashnoo & Daniel, 2015) is one example of a way to quantify the extent of drooling.
Box 2.7: Common causes of drooling
Box 2.8: Drooling Severity & Frequency Scale
(Rashnoo & Daniel, 2015)
Dysarthria
Dysarthria and dysphagia have been shown to co-occur with neuromuscular diseases (Knuijt et al., 2014). Oral motor strength required for intelligible speech, at least with respect to the tongue, is much less than that required for a safe and efficient swallow (Neel & Palmer, 2012; Neel, Palmer, Sprouls, & Morrison, 2015). Thus, the presence of dysarthria may imply inadequate strength to produce a functional swallow. (Box 2.6 links to a YouTube video of a patient with dysarthria. Note the gurgly vocal quality.) Recall that the swallow is a pressure-driven event. If oropharyngeal muscle strength is reduced, then pressure generation may be impaired. The end result is an insufficient pressure to effectively and safely propel the bolus through the oral and pharyngeal cavities. Residue may occur, risking aspiration after the swallow. The sensitivity and specificity of dysarthria as an indicator of dysphagia ranges from 64-78% and 44-75%, respectively.
Complaint of Pain with Chewing or Swallowing (Odynophagia)
Odynophagia, pain while swallowing, may be reported by individuals with dysphagia. However, odynophagia is more often associated with an infection in the mouth or throat, such as candidiasis or herpes. Non-infectious causes, such as ulcers, tumors, or gastroesophageal reflux disease (GERD), should also be considered. If it is a young individual or someone with reduced cognitive function, consider the possibility of a foreign object in the throat, particularly if the caregiver reports a sudden onset (and a missing item). Odynophagia may be accompanied by difficulty breathing (dyspnea) and/or chest pain.
When pain with swallowing is reported, localization of pain should be assessed and may be as simple as asking the patient to point to the site that hurts. There are some caveats to consider when asking an individual to localize pain. First, localization skills may be limited in individuals with cognitive impairment or in the pediatric population. Second, pain or discomfort from the esophagus may be referred to the hypopharynx. For example, esophageal reflux is commonly associated with discomfort in the hypopharynx. In cases of referred pain, individuals may report that something is “stuck” in the hypopharynx, yet nothing is visualized on instrumental exam. This globus sensation, as it is sometimes called, is linked to reflux and may co-occur with chest pain associated with meal times (or just after mealtimes).
Clinical Note
While localization of pain may indicate the region in need of careful visual inspection, not all anatomic regions associated with swallow can be clinically visualized. Instrumental exam or referral to an ENT or GI physician may be required.
Clinical Note
Do not confuse odynophagia (pain with swallowing) with globus sensation (a sensation of tightness in the throat).
Multiple Swallows per Bolus
Individuals with oropharyngeal dysphagia may swallow multiple times for a single bolus. Although a large bolus may necessitate a piecemeal approach, it is possible that an inefficient and weak swallow may result in reduced bolus clearance with a single swallow per bolus. The remaining bolus residue may require multiple swallow attempts to complete the transport of the entire bolus through the oral and pharyngeal cavities, even with small bolus amounts. Multiple swallows are common in patients with neuromuscular disease when pharyngeal function is weak (Palmer, 2010; Palmer, Neel, Sprouls, & Morrison, 2010). Multiple swallows as an indicator of dysphagia has a sensitivity and specificity of 58 and 57%, respectively.
Changes in Oral Intake, Weight Loss, or Inadequate Weight Gain
Oral intake is the food and liquid taken in by mouth and not lost anteriorly. Insufficient oral intake increases the risk of: (1) inadequate weight gain or growth in infants and children, or (2) weight loss and malnutrition in adults. While adequate growth and weight gain for infants and toddlers are well defined in commonly-used growth charts, clinically relevant weight loss in adults is not as easily determined. As a general rule, weight loss is considered clinically relevant if there is a loss of more than 5% of the body weight across a 6 month period (Gaddey & Holder, 2014). Reductions in oral intake or progressive unintentional weight loss may indicate the presence of dysphagia. Clinically relevant weight loss, or reductions in oral intake that threaten weight maintenance, should result in a referral to a nutritionist or other appropriate medical professional. If oral intake is deemed unsafe, or if oral intake does not provide adequate nutrition, then alternate means of nutrition (such as tube feedings) may be used as a supplement to feedings or in place of oral feeding.
Failure to Thrive
Failure to thrive (FTT) is a term that can refer to either infants or toddlers who fail to achieve anticipated growth, or adults who experience a state of decline that leads to weight loss and malnutrition. Common causes of FTT are indicated in Box 2.9. FTT in infants may be the result of inadequate oral intake or poor absorption of oral intake. In the latter scenario, an illness or medical condition may alter the gut’s ability to extract nutrients, thus reducing growth. When FTT is a result of poor oral intake, this may indicate poor feeding ability or food intolerance. FTT is common in preterm infants; approximately 40% of preterm infants exhibit abnormal or immature feeding patterns (Hawdon, Beauregard, Slattery, & Kennedy, 2000; Mercado-Deane et al., 2001). This may be related to: (1) reduced in-utero sucking practice, and (2) reduced oral-motor development and muscle tone. Further, preterm babies may have medical complications that interfere with adequate feeding or limit the ability to coordinate the suck-swallow-breathe pattern. FTT may have long-term consequences on growth and development. However, early treatment and support may minimize developmental and cognitive differences between kids with FTT and their healthy peers.
Box 2.9: Common causes of failure to thrive
FTT in adults describes a state of decline whose cause is related to multiple variables and may include concurrent chronic illnesses in combination with functional alterations to the swallow. Whether or not dysphagia is associated with adult FTT, weight loss, reduced appetite, reduced activity level, and poor nutrition are noted in these individuals. Some individuals may be identified as cachexic, which implies severe muscles wasting (much greater than age-related sarcopenia) due to chronic illness.
Congenital Anomalies
Congenital anomalies, especially those associated with the oropharyngeal cavity or airway, may contribute to feeding and swallowing deficits. Box 2.10 lists the consequences of various head and neck anomalies on swallow function. An infant with a cleft lip and palate may have difficulty generating the needed pressure to adequately draw liquid from a nipple without excess work, negating the nutritional benefits of feeding. An infant with a laryngeal cleft or tracheo-esophageal fistula may have an increased risk of aspiration. These typically require surgical intervention before oral intake and feeding development can be encouraged (Ha, Wertz, Driver, Zopf, & Ha, 2018).
Box 2.10: Incidence of congenital anomalies of the head and neck with their impact on feeding
For adults, changes in oral intake that results in unintentional weight loss may be related to dysphagia. Consideration should be given to changes in medical or mental status, changes in oral or pharyngeal function, or cognitive decline. Not all changes in oral intake are related to swallowing disorders. Identifying the cause of reduced oral intake will aid in selecting the proper referrals, as well as inform dysphagia treatment, if needed.
Clinical Note
Regardless of the etiology of poor growth, when a child is already small, dropping a growth curve (e.g., from 10% to 5%) is detrimental to their health and growth at a time when important growth is taking place.
Supplemental and Alternate Means of Nutrition
The presence of alternate means of nutrition may indicate that an individual has an underlying swallow or feeding disorder. Alternate means of nutrition may be used for full nutritional intake or for supplemental feeding, and may be employed for individuals who have clinically relevant weight loss, FTT, or inadequate cognition, anatomy or physiology to safely take food and liquid orally. Alternate means of nutrition can be divided into enteral and parenteral nutrition (Box 2.11). When alternate nutrition is required, enteral nutrition is the usual, and by far, the preferred mode of nutrition. Enteral nutrition allows nutrients to be absorbed by way of the gastrointestinal tract. This approach may be used when the oropharyngeal and/or esophageal aspects of the alimentary canal need to be bypassed for safety or to ensure adequate weight gain.
Box 2.11: Alternate means of nutrition
When enteral nutrition is employed, nutritional material is introduced to the stomach or gastrointestinal tract through the use of a tube (Box 2.12). Various routes include placing a feeding tube through a nostril (i.e., a naso-gastric tube or NG tube) or oral cavity (i.e., oro-gastric tube), or piercing through the abdominal skin directly into the stomach (i.e., a gastrostomy tube or G-tube, percutaneous endoscopic gastrostomy or PEG) or intestines (i.e., jejunostomy or J-tube).
Box 2.12: Alternate means of enteral nutrition
| NG-Tube | PEG | J-Tube |
By Cancer Research UK –(Original email from CRUK) [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia
Parenteral nutrition bypasses the alimentary canal and directly introduces needed nutrients into the bloodstream. When total parenteral nutrition (TPN) is used, hypertonic solutions are delivered by a central intravenous (CIV) line. A peripheral IV (PIV) line can be used to deliver partial parenteral nutrition (PPN). Parenteral nutrition is typically reserved for patients with significant gut problems (such as an obstructed bowel or short bowel syndrome), or when there is a short-term immediate need (such as dehydration due to illness). To protect the gut, parenteral nutrition is converted to enteral routes as soon as medically feasible.
Clinical Note
PEG tubes may be used prophylactically in patients where you anticipate swallow deficits, such as patients who will undergo radiation or chemo therapy (Shaw et al., 2015).
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Although the speech-language pathologist (SLP) does not aid in the selection of alternate nutrition, the SLP may provide the evidence for the need of such an approach by diagnosing a level of dysphagia that denotes reduced safety with oral intake. Note that alternate routes for nutrition do not eliminate the risk of aspiration; aspiration may still occur on oral saliva or refluxed material. In fact, the presence of the feeding tube may increase the risk of oropharyngeal deficits. Further, extended use of feeding tubes may hinder swallow ability (Langmore, Krisciunas, Miloro, Evans, & Cheng, 2012).
Clinical Note
Enteral nutrition may be associated with increased risk of GERD, as well as aspiration (Ferrer, Bauer, Torres, Hernández, & Piera, 1999; Schallom, Orr, Metheny, & Pierce, 2013).
Poor Oral Care
Good oral care has been linked to better general health and a reduced risk of illness. Conversely, poor oral care is linked to increased health risks. Oral health can be achieved with routine oral care including brushing and flossing. For individuals with dysphagia or sensory deficits, the cleansing routine should also include checking oral pockets in order to remove any bolus residue and debris. If left unattended, bolus residue after the swallow may putrefy and build bacteria resulting in notable halitosis (bad breath). Visual inspection of the oral cavity can provide evidence of the adequacy of oral care. If poor oral care is present and aspiration of saliva occurs, the individual is at higher risk for pneumonia. In the event of micro-aspiration (aspiration of small amounts of material), the dense and concentrated bacterial load imposed by poor oral care increases the risk of aspiration pneumonia (Langmore et al., 1998). Additionally, poor oral health is associated with an increased risk of cardiovascular disease, heart attacks, and strokes (Dai et al., 2015).
Clinical Note
In at-risk populations for poor oral care, such as toddlers, or motorically or cognitively impaired adults, oral care should be delivered by trained personnel who understand the importance of good oral care.
The variables that lead to poor oral care may be age-dependent. At an early age, oral care may be limited with respect to frequency (number of times per day that the teeth are brushed and the mouth is rinsed) and number of teeth contacted (the thoroughness of oral cleaning events). In the geriatric population, oral care may decline due to limited motor function and strength, reduced vision, and perhaps even reduced cognitive function. When an individual can not adequately perform oral care, the task maybe completed by a caregiver. Risks associated with poor oral care may be related to the skill of the person administering the oral care. In some cases, the connection between poor oral care and aspiration pneumonia is related to the dependence on a caregiver for oral care (Langmore et al., 1998). However, evidence suggests that when oral care is performed by a trained health care professional, the oral contents have a reduced bacterial load (Yoshino, Ebihara, Ebihara, Fuji, & Sasaki, 2001; Matsuo et al., 2016). This is likely due to differences in the quality of the oral care. Regardless, when thorough oral care is performed on a routine basis, it reduces the risk of aspiration pneumonia (Müller, 2015).
Oral care may not be the only culprit when dealing with oral bacterial load. Dental decay, gum disease, and reduced saliva may encourage bacterial buildup in the oral cavity. In summary, good oral care not only provides protection against the consequences of micro-aspiration, but it may also stimulate the physiologic system resulting in improved swallow physiology (Yoshino et al., 2001; Watando et al., 2004; Poisson, Laffond, Campos, Dupuis, & Bourdel-Marchasson, 2016).
Frailty
Frailty, commonly noted in the very elderly population, refers to increased vulnerability or a decline in functional reserve across multiple physical systems (Xue, 2011; Lee, Auyeung, Leung, Kwok, & Woo, 2014; Morley et al., 2013). Frailty may be an outcome from dysphagia (van der Maarel-Wierink, Vanobbergen, Bronkhorst, Schols, & de Baat, 2011). Specifically, frailty has been associated with impaired tongue strength and propulsion, as well as poor airway protection. Frail individuals are more likely to have trouble with swallowing when new foods or textures are introduced. Further, frail individuals are more likely to have a negative response to even small amounts of aspiration.
Clinical Note
The definition of frailty is usually associated with the following criteria: weight loss, self-reported exhaustion, a low level of physical activity, slow walking speed, and motor weakness (typically assessed via hand grip).
Instrumental Signs
While some clinical signs and symptoms can be easily linked to swallow physiology during the clinical exam, clinical signs that imply pharyngeal deficits are best assessed through the use of instrumental exams that visualize the oral and pharyngeal system during the dynamic act of swallowing.
Oropharyngeal Bolus Transfer
Typically, in a healthy individual, a cohesive bolus is transported from the horizontal to the vertical pathway in a single event. When this does not occur, the dysphagia clinician will assess the contribution of piecemeal deglutition, premature spillage of bolus from the oral cavity into the pharynx, or delayed pharyngeal trigger of the bolus (Box 2.13). Differentiation of piecemeal deglutition, premature spillage, and delayed or absent trigger can be performed by observing the bolus flow characteristics with respect to the amount of bolus and the level of coordination in the transfer from the horizontal to the vertical bolus trajectory, as well as the onset of hyo-laryngeal elevation associated with a swallow.
Box 2.13: Comparison of oral-pharyngal bolus transfer mechanisms
Piecemeal Deglutition
At times, particularly if the bolus is large, the bolus will be parsed into segments, where each individual segment is transported to the pharynx and swallowed, while the remaining bolus is purposefully and safely retained in the oral cavity. This process of piecemeal deglutition is controlled by the individual and occurs without incident. In healthy individuals, piecemeal deglutition may occur in boluses greater than 20ml. When this pattern is noted in smaller bolus sizes, the individual may have dysphagia (Ertekin, Aydoğdu, & Yüceyar, 1996).
Clinical Note
Premature spillage may be within normal limits in spontaneous swallows in elderly individuals. When premature spillage is observed consider the following swallow deficits: poor oral preparation or bolus control, poor oral transport, or delayed pharyngeal trigger.
Premature Spillage
Premature spillage is the unintentional entrance of a portion of the oral bolus into the pharyngal cavity during the oral preparation or transport (Box 2.14). This is typically the result of poor bolus control in the oral cavity, combined with poor lingual-velar valving (base of tongue and velar contact during the oral phase of the swallow). Because the stray piece of bolus falls into the pharynx before the pharyngeal phase has been readied, the swallow trigger may not occur in a timely fashion (or at all), placing the individual at risk for penetration into the airway before the initiation of the pharyngeal swallow.
Box 2.14 Video: VFES example of premature spillage and delayed trigger
Delayed or Absent Swallow Trigger
At times the bolus is intentionally transported to the pharynx, either as a single cohesive bolus or in pieces, yet the pharyngeal swallow is not triggered in a timely fashion (Box 2.14 and 2.15). This is referred to as a delayed trigger. Although a delayed or absent trigger may indicate dysphagia, a delayed trigger has been correlated with healthy aging. An impaired swallow trigger may be related to: (1) reduced sensory systems with inadequate information transported to the swallow CPG, (2) inadequate motor systems to carry out commands from the swallow central pattern generator, or (3) neurological involvement altering the capabilities of the central pattern generator. Because a timely swallow trigger correlates with the initiation of hyo-laryngeal elevation, and therefore airway protection, when the trigger is delayed or absent, there is an increased risk of penetration and/or aspiration of the bolus before the swallow.
Box 2.15 Video: Absent swallow trigger
Oral & Pharyngeal Residue
Oropharyngeal residue is a common occurrence in patients with dysphagia. Residue may be localized to one area or multiple discrete areas, or distributed throughout the oropharyngeal system. The location(s) of bolus residue may implicate the swallow deficit(s). Box 2.16 lists common residue sites with linkage to potential swallow deficits. In the oral cavity, residue is typically linked to poor bolus control, reduced lingual propulsion, or poor oral pressure generation. Localized oral residue can occur in the anterior or lateral sulci in the oral cavity, on the floor of mouth (under tongue), or coating the palate.
Box 2.16: Location of oropharyngeal residue and probably deficit
In the pharyngeal cavity, residue may be isolated to a region or distributed throughout. When evaluating the cause of the pharyngeal residue, the contribution of reduced hyo-laryngeal elevation and pressure generation should be considered. Coating of structures or pooling of the bolus can occur in the vallecula space, pyriform sinus, base of tongue, or posterior pharyngeal wall. Judgements of pharyngeal residue are impacted by the instrumentation used. Residue noted during FEES is judged to be greater than residue noted during VFES (Kelly, Leslie, Beale, Payten, & Drinnan, 2006). Box 2.17 and 2.18 reveal distributed pharyngeal residue.
Box 2.17: Endoscopic images of secretions in the pharynx
Box 2.18: Patient with distributed pharyngeal residue as observed on VFES.
Isolated vallecula residue may suggest that epiglottic down-folding was incomplete or inadequate. Recall that the down-folding of the epiglottis (a cartilage) is achieved through activation of attached muscles combined with passive forces from pressure and mechanical alterations related to the superior-anterior hyo-laryngeal excursion. The trajectory of epiglottic down-folding can be sub-divided into 2 components—(1) from upright to horizontal and (2) inversion. The movement from upright to horizontal is accomplished by a combination of passive forces introduced by laryngeal elevation with limited assistance from contraction of the small aryepiglottic muscle fibers. Complete inversion is highly dependent on the pharyngeal driving pressures as the bolus traverses the pharynx. Reductions in laryngeal trajectory or pharyngeal pressure may result in inadequate epiglottic inversion limiting valleculae clearance.
Isolated residue in the pyriform sinus is more likely related to alterations in UES opening, either with respect to extent of opening or duration of opening. Recall that adequate UES opening is a function of input from pharyngeal pressure, relaxation of CP muscle, and passive opening from the trajectory of the hyo-laryngeal complex, particularly the anterior aspect of the trajectory. UES opening may be impacted by age due to a reduction in the number of elastin and collagen fibers which can alter the passive abilities of the UES in response to the hyo-laryngeal excursion. Pyriform sinus residue may implicate any or all of the mechanisms of UES opening.
Trace residue may adhere to and outline pharyngeal structures such as base of tongue or pharyngeal wall. Recall that adequate pharyngeal clearance is related to both the pharyngeal pressure generated from base of the tongue to pharyngeal wall contact and pharyngeal stripping from sequential constrictor activity. When coating exists along the pharyngeal wall, the pharyngeal pressure is suspected to be insufficient. At times, residue may be unilateral–located on one side or the other. In this case, unilateral deficits should be considered.
Velar Deficits
The velum serves as a valve that aids functional swallowing in two ways: (1) during the horizontal bolus path, the velum may contact with the base of tongue, thus preventing premature spillage, and (2) during the vertical bolus path, the velum actively closes off the nasal cavity, thus preventing nasal penetration.
When functioning as a lingual-velar valve (i.e., engaged with the base of tongue), the velum may help prevent leakage of oral contents into the pharynx during the development of the oral bolus and movement of the bolus from the anterior to the posterior oral cavity. Observation of premature spillage of oral contents into the pharynx before completion of bolus development may implicate inadequate oral function or dysfunction (sensory, motor, and/or coordination) of the lingual-velar valve.
As the bolus transfers from the horizontal to the vertical direction, the velum makes contact with the pharyngeal wall (velar-pharyngeal valve) to close off the naso-pharynx and prevent penetration of material into the nasal cavity. Additionally, the closing of this valve helps maintain adequate pharyngeal pressure to encourage downward propulsion. When nasal penetration is noted (as seen in Box 2.19), the strength, timing, and adequacy of the velar-pharyngeal valve should be assessed.
Box 2.19 Video: Nasal penetration as observed on VFES
Reduced Airway Protection
Poor airway protection can result in penetration or aspiration of material. (See examples of penetration and aspiration from VFES in Box 2.20.) During the swallow, airway protection occurs as a result of several actions. First, as a result of supraglottic muscular activation of the hyo-laryngeal complex, the airway is lifted in a superior-anterior position. The result is that the larynx is tucked under the jaw and out of the way of the bolus flow pathway. This trajectory can be manually palpated or visualized on VFES or FEES. Reduced hyo-laryngeal trajectory can be discussed with respect to inadequate superior and/or anterior aspects of the trajectory.
Box 2.20 Video: Airway invasion observed during VFES
Second, internal laryngeal closure, which includes vocal fold contact, prevents penetration from being aspirated into the airway. Laryngeal closure is further supported by aryepiglottic tightening and epiglottic down-folding which collectively serve to reduce the size of and cover the the laryngeal aditus.
Airway protection may be compromised before or after the swallow or at times other than mealtime. Poor oral control can lead to material falling into the airway before the swallow has been triggered (premature spillage), rendering the airway unready and unprotected. When pharyngeal residue remains in the oro-pharynx after the swallow, it may enter into the airway once the protective actions have ceased. Further, when oral care is lacking, even when an individual is not eating or drinking, remaining material or excessive secretions may be aspirated. Box 2.21 shows an endoscopic visualization of an impaired larynx where copious secretions enter below the vocal folds without obvious reaction from the individual.
Box 2.21 Video: Aspiration of secretions observed endoscopically
Poor UES Opening
The UES (a.k.a. the pharyngo-esophageal segment) is composed of elastin fibers and muscle fibers. During the swallow, this region opens to allow passage of the bolus from the pharynx to the esophagus. Optimal UES opening is achieved through a combination of passive and active forces. Due to the attachment of the UES to the posterior cricoid, movement of the larynx passively manipulates the UES opening. That is, upon contraction of the supraglottic musculature, the hyo-laryngeal complex is pulled in a superior-anterior direction. The attachment of the UES to the posterior larynx pulls the anterior fibers, thus stretching open the UES region.
The muscular (or active) component of UES opening is dictated by the cricopharyngeus muscle. This muscle is tonically active (closed) during most actions to provide redundant protection of the airway by blocking esophageal contents from entering into the pharynx. The cricopharyngeus muscle activity relaxes during the swallow allowing for easy opening of the UES region.
When the active and passive forces are well timed and supported by the driving pressure of the bolus, adequate opening is achieved. When inadequate opening is observed, it may be a result of an individual mechanism or a combination of impairments across the various opening mechanisms — active or passive forces, or bolus driving pressure. Box 2.22 displays images of the UES region before and during swallowing.
Box 2.22: UES opening under various swallow conditions and diseases
|
UES region BEFORE Swallow |
UES during 5 ml thin (s/p CVA) |
UES duing 5ml thin |
UES during 5ml nectar (note CP Bar) |


33 The Tragedy of Julius Caesar, Act II
ACT II
SCENE I. Rome. Brutus’ orchard.
Enter Brutus.
BRUTUS.
What, Lucius, ho!
I cannot, by the progress of the stars,
Give guess how near to day.—Lucius, I say!
I would it were my fault to sleep so soundly.
When, Lucius, when? Awake, I say! What, Lucius!
Enter Lucius.
LUCIUS.
Call’d you, my lord?
BRUTUS.
Get me a taper in my study, Lucius:
When it is lighted, come and call me here.
LUCIUS.
I will, my lord.
[Exit.]
BRUTUS.
It must be by his death: and for my part,
I know no personal cause to spurn at him,
But for the general. He would be crown’d:
How that might change his nature, there’s the question.
It is the bright day that brings forth the adder,
And that craves wary walking. Crown him?—that;
And then, I grant, we put a sting in him,
That at his will he may do danger with.
Th’ abuse of greatness is, when it disjoins
Remorse from power; and, to speak truth of Caesar,
I have not known when his affections sway’d
More than his reason. But ’tis a common proof,
That lowliness is young ambition’s ladder,
Whereto the climber-upward turns his face;
But when he once attains the upmost round,
He then unto the ladder turns his back,
Looks in the clouds, scorning the base degrees
By which he did ascend. So Caesar may;
Then lest he may, prevent.
Enter Lucius.
LUCIUS.
The taper burneth in your closet, sir.
Searching the window for a flint, I found
This paper, thus seal’d up, and I am sure
It did not lie there when I went to bed.
[Gives him the letter.]
BRUTUS.
Get you to bed again; it is not day.
Is not tomorrow, boy, the Ides of March?
LUCIUS.
I know not, sir.
BRUTUS.
Look in the calendar, and bring me word.
LUCIUS.
I will, sir.
[Exit.]
BRUTUS.
The exhalations, whizzing in the air
Give so much light that I may read by them.
[Opens the letter and reads.]
Brutus, thou sleep’st: awake and see thyself.
Shall Rome, &c. Speak, strike, redress!
“Brutus, thou sleep’st: awake!”
Such instigations have been often dropp’d
Where I have took them up.
“Shall Rome, &c.” Thus must I piece it out:
Shall Rome stand under one man’s awe? What, Rome?
My ancestors did from the streets of Rome
The Tarquin drive, when he was call’d a king.
“Speak, strike, redress!” Am I entreated
To speak and strike? O Rome, I make thee promise,
If the redress will follow, thou receivest
Thy full petition at the hand of Brutus.
Enter Lucius.
LUCIUS.
Sir, March is wasted fifteen days.
[Knock within.]
BRUTUS.
’Tis good. Go to the gate, somebody knocks.
[Exit Lucius.]
Since Cassius first did whet me against Caesar,
I have not slept.
Between the acting of a dreadful thing
And the first motion, all the interim is
Like a phantasma, or a hideous dream:
The genius and the mortal instruments
Are then in council; and the state of man,
Like to a little kingdom, suffers then
The nature of an insurrection.
Enter Lucius.
LUCIUS.
Sir, ’tis your brother Cassius at the door,
Who doth desire to see you.
BRUTUS.
Is he alone?
LUCIUS.
No, sir, there are moe with him.
BRUTUS.
Do you know them?
LUCIUS.
No, sir, their hats are pluck’d about their ears,
And half their faces buried in their cloaks,
That by no means I may discover them
By any mark of favour.
BRUTUS.
Let ’em enter.
[Exit Lucius.]
They are the faction. O conspiracy,
Sham’st thou to show thy dangerous brow by night,
When evils are most free? O, then, by day
Where wilt thou find a cavern dark enough
To mask thy monstrous visage? Seek none, conspiracy;
Hide it in smiles and affability:
For if thou path, thy native semblance on,
Not Erebus itself were dim enough
To hide thee from prevention.
Enter Cassius, Casca, Decius, Cinna, Metellus
Cimber and Trebonius.
CASSIUS.
I think we are too bold upon your rest:
Good morrow, Brutus; do we trouble you?
BRUTUS.
I have been up this hour, awake all night.
Know I these men that come along with you?
CASSIUS.
Yes, every man of them; and no man here
But honours you; and everyone doth wish
You had but that opinion of yourself
Which every noble Roman bears of you.
This is Trebonius.
BRUTUS.
He is welcome hither.
CASSIUS.
This Decius Brutus.
BRUTUS.
He is welcome too.
CASSIUS.
This, Casca; this, Cinna; and this, Metellus Cimber.
BRUTUS.
They are all welcome.
What watchful cares do interpose themselves
Betwixt your eyes and night?
CASSIUS.
Shall I entreat a word?
[They whisper.]
DECIUS.
Here lies the east: doth not the day break here?
CASCA.
No.
CINNA.
O, pardon, sir, it doth; and yon grey lines
That fret the clouds are messengers of day.
CASCA.
You shall confess that you are both deceiv’d.
Here, as I point my sword, the Sun arises;
Which is a great way growing on the South,
Weighing the youthful season of the year.
Some two months hence, up higher toward the North
He first presents his fire; and the high East
Stands, as the Capitol, directly here.
BRUTUS.
Give me your hands all over, one by one.
CASSIUS.
And let us swear our resolution.
BRUTUS.
No, not an oath. If not the face of men,
The sufferance of our souls, the time’s abuse—
If these be motives weak, break off betimes,
And every man hence to his idle bed.
So let high-sighted tyranny range on,
Till each man drop by lottery. But if these,
As I am sure they do, bear fire enough
To kindle cowards, and to steel with valour
The melting spirits of women; then, countrymen,
What need we any spur but our own cause
To prick us to redress? what other bond
Than secret Romans, that have spoke the word,
And will not palter? and what other oath
Than honesty to honesty engag’d,
That this shall be, or we will fall for it?
Swear priests and cowards, and men cautelous,
Old feeble carrions, and such suffering souls
That welcome wrongs; unto bad causes swear
Such creatures as men doubt; but do not stain
The even virtue of our enterprise,
Nor th’ insuppressive mettle of our spirits,
To think that or our cause or our performance
Did need an oath; when every drop of blood
That every Roman bears, and nobly bears,
Is guilty of a several bastardy,
If he do break the smallest particle
Of any promise that hath pass’d from him.
CASSIUS.
But what of Cicero? Shall we sound him?
I think he will stand very strong with us.
CASCA.
Let us not leave him out.
CINNA.
No, by no means.
METELLUS.
O, let us have him, for his silver hairs
Will purchase us a good opinion,
And buy men’s voices to commend our deeds.
It shall be said, his judgement rul’d our hands;
Our youths and wildness shall no whit appear,
But all be buried in his gravity.
BRUTUS.
O, name him not; let us not break with him;
For he will never follow anything
That other men begin.
CASSIUS.
Then leave him out.
CASCA.
Indeed, he is not fit.
DECIUS.
Shall no man else be touch’d but only Caesar?
CASSIUS.
Decius, well urg’d. I think it is not meet,
Mark Antony, so well belov’d of Caesar,
Should outlive Caesar: we shall find of him
A shrewd contriver; and you know, his means,
If he improve them, may well stretch so far
As to annoy us all; which to prevent,
Let Antony and Caesar fall together.
BRUTUS.
Our course will seem too bloody, Caius Cassius,
To cut the head off, and then hack the limbs,
Like wrath in death, and envy afterwards;
For Antony is but a limb of Caesar.
Let us be sacrificers, but not butchers, Caius.
We all stand up against the spirit of Caesar,
And in the spirit of men there is no blood.
O, that we then could come by Caesar’s spirit,
And not dismember Caesar! But, alas,
Caesar must bleed for it!
And let our hearts, as subtle masters do,
Stir up their servants to an act of rage,
And after seem to chide ’em. This shall mark
Our purpose necessary, and not envious;
Which so appearing to the common eyes,
We shall be call’d purgers, not murderers.
And for Mark Antony, think not of him;
For he can do no more than Caesar’s arm
When Caesar’s head is off.
CASSIUS.
Yet I fear him;
For in the ingrafted love he bears to Caesar—
BRUTUS.
Alas, good Cassius, do not think of him:
If he love Caesar, all that he can do
Is to himself; take thought and die for Caesar.
And that were much he should; for he is given
To sports, to wildness, and much company.
TREBONIUS.
There is no fear in him; let him not die;
For he will live, and laugh at this hereafter.
[Clock strikes.]
BRUTUS.
Peace! count the clock.
CASSIUS.
The clock hath stricken three.
TREBONIUS.
’Tis time to part.
CASSIUS.
But it is doubtful yet
Whether Caesar will come forth today or no;
For he is superstitious grown of late,
Quite from the main opinion he held once
Of fantasy, of dreams, and ceremonies.
It may be these apparent prodigies,
The unaccustom’d terror of this night,
And the persuasion of his augurers,
May hold him from the Capitol today.
DECIUS.
Never fear that: if he be so resolved,
I can o’ersway him, for he loves to hear
That unicorns may be betray’d with trees,
And bears with glasses, elephants with holes,
Lions with toils, and men with flatterers.
But when I tell him he hates flatterers,
He says he does, being then most flattered.
Let me work;
For I can give his humour the true bent,
And I will bring him to the Capitol.
CASSIUS.
Nay, we will all of us be there to fetch him.
BRUTUS.
By the eighth hour: is that the uttermost?
CINNA.
Be that the uttermost; and fail not then.
METELLUS.
Caius Ligarius doth bear Caesar hard,
Who rated him for speaking well of Pompey;
I wonder none of you have thought of him.
BRUTUS.
Now, good Metellus, go along by him:
He loves me well, and I have given him reason;
Send him but hither, and I’ll fashion him.
CASSIUS.
The morning comes upon’s. We’ll leave you, Brutus.
And, friends, disperse yourselves; but all remember
What you have said, and show yourselves true Romans.
BRUTUS.
Good gentlemen, look fresh and merrily;
Let not our looks put on our purposes,
But bear it as our Roman actors do,
With untired spirits and formal constancy.
And so, good morrow to you everyone.
[Exeunt all but Brutus.]
Boy! Lucius! Fast asleep? It is no matter;
Enjoy the honey-heavy dew of slumber:
Thou hast no figures nor no fantasies,
Which busy care draws in the brains of men;
Therefore thou sleep’st so sound.
Enter Portia.
PORTIA.
Brutus, my lord.
BRUTUS.
Portia, what mean you? Wherefore rise you now?
It is not for your health thus to commit
Your weak condition to the raw cold morning.
PORTIA.
Nor for yours neither. Y’ have ungently, Brutus,
Stole from my bed; and yesternight at supper,
You suddenly arose, and walk’d about,
Musing and sighing, with your arms across;
And when I ask’d you what the matter was,
You star’d upon me with ungentle looks.
 So I did,
Fearing to strengthen that impatience
Which seem’d too much enkindled; and withal
Hoping it was but an effect of humour,
Which sometime hath his hour with every man.
It will not let you eat, nor talk, nor sleep;
And could it work so much upon your shape
As it hath much prevail’d on your condition,
I should not know you, Brutus. Dear my lord,
Make me acquainted with your cause of grief.
BRUTUS.
I am not well in health, and that is all.
PORTIA.
Brutus is wise, and, were he not in health,
He would embrace the means to come by it.
BRUTUS.
Why, so I do. Good Portia, go to bed.
PORTIA.
 What, is Brutus sick,
And will he steal out of his wholesome bed
To dare the vile contagion of the night,
And tempt the rheumy and unpurged air
To add unto his sickness? No, my Brutus;
You have some sick offence within your mind,
Which, by the right and virtue of my place,
I ought to know of: and, upon my knees,
I charm you, by my once commended beauty,
By all your vows of love, and that great vow
Which did incorporate and make us one,
That you unfold to me, your self, your half,
Why you are heavy, and what men tonight
Have had resort to you; for here have been
Some six or seven, who did hide their faces
Even from darkness.
BRUTUS.
Kneel not, gentle Portia.
PORTIA.
I should not need, if you were gentle Brutus.
Within the bond of marriage, tell me, Brutus,
Is it excepted I should know no secrets
That appertain to you? Am I your self
But, as it were, in sort or limitation,
To keep with you at meals, comfort your bed,
And talk to you sometimes? Dwell I but in the suburbs
Of your good pleasure? If it be no more,
Portia is Brutus’ harlot, not his wife.
BRUTUS.
You are my true and honourable wife,
As dear to me as are the ruddy drops
That visit my sad heart.
PORTIA.
If this were true, then should I know this secret.
I grant I am a woman; but withal
A woman that Lord Brutus took to wife;
I grant I am a woman; but withal
A woman well reputed, Cato’s daughter.
Think you I am no stronger than my sex,
Being so father’d and so husbanded?
Tell me your counsels, I will not disclose ’em.
I have made strong proof of my constancy,
Giving myself a voluntary wound
Here, in the thigh: can I bear that with patience
And not my husband’s secrets?
BRUTUS.

[Knock.]
Hark, hark, one knocks. Portia, go in awhile;
And by and by thy bosom shall partake
The secrets of my heart.
All my engagements I will construe to thee,
All the charactery of my sad brows.
Leave me with haste.
[Exit Portia.]
Enter Lucius with Ligarius.
Lucius, who’s that knocks?
LUCIUS.

BRUTUS.
Caius Ligarius, that Metellus spake of.
Boy, stand aside. Caius Ligarius, how?
LIGARIUS.
Vouchsafe good-morrow from a feeble tongue.
BRUTUS.
O, what a time have you chose out, brave Caius,
To wear a kerchief! Would you were not sick!
LIGARIUS.
I am not sick, if Brutus have in hand
Any exploit worthy the name of honour.
BRUTUS.
Such an exploit have I in hand, Ligarius,
Had you a healthful ear to hear of it.
LIGARIUS.
By all the gods that Romans bow before,
I here discard my sickness. Soul of Rome!
Brave son, derived from honourable loins!
Thou, like an exorcist, hast conjur’d up
My mortified spirit. Now bid me run,
And I will strive with things impossible,
Yea, get the better of them. What’s to do?
BRUTUS.

LIGARIUS.
But are not some whole that we must make sick?
BRUTUS.
That must we also. What it is, my Caius,
I shall unfold to thee, as we are going,
To whom it must be done.
LIGARIUS.
Set on your foot,
And with a heart new-fir’d I follow you,
To do I know not what; but it sufficeth
That Brutus leads me on.
[Thunder.]
BRUTUS.
Follow me then.
[Exeunt.]
SCENE II. A room in Caesar’s palace.
Thunder and lightning. Enter Caesar, in his
nightgown.
CAESAR.
Nor heaven nor earth have been at peace tonight:
Thrice hath Calphurnia in her sleep cried out,
“Help, ho! They murder Caesar!” Who’s within?
Enter a Servant.
SERVANT.
My lord?
CAESAR.
Go bid the priests do present sacrifice,
And bring me their opinions of success.
SERVANT.
I will, my lord.
[Exit.]
Enter Calphurnia.
CALPHURNIA.
What mean you, Caesar? Think you to walk forth?

CAESAR.
Caesar shall forth. The things that threaten’d me
Ne’er look’d but on my back; when they shall see
The face of Caesar, they are vanished.
CALPHURNIA.
Caesar, I never stood on ceremonies,
Yet now they fright me. There is one within,
Besides the things that we have heard and seen,
Recounts most horrid sights seen by the watch.
A lioness hath whelped in the streets,
And graves have yawn’d, and yielded up their dead;
Fierce fiery warriors fight upon the clouds
In ranks and squadrons and right form of war,
Which drizzled blood upon the Capitol;
The noise of battle hurtled in the air,
Horses did neigh, and dying men did groan,
And ghosts did shriek and squeal about the streets.
O Caesar, these things are beyond all use,
And I do fear them!
CAESAR.
What can be avoided
Whose end is purpos’d by the mighty gods?
Yet Caesar shall go forth; for these predictions
Are to the world in general as to Caesar.
CALPHURNIA.
When beggars die, there are no comets seen;
The heavens themselves blaze forth the death of princes.
CAESAR.

Of all the wonders that I yet have heard,
It seems to me most strange that men should fear,
Seeing that death, a necessary end,
Will come when it will come.
Enter Servant.
What say the augurers?
SERVANT.
They would not have you to stir forth today.
Plucking the entrails of an offering forth,
They could not find a heart within the beast.
CAESAR.
The gods do this in shame of cowardice:
Caesar should be a beast without a heart
If he should stay at home today for fear.
No, Caesar shall not. Danger knows full well
That Caesar is more dangerous than he.
We are two lions litter’d in one day,
And I the elder and more terrible,
And Caesar shall go forth.
CALPHURNIA.
Alas, my lord,
Your wisdom is consum’d in confidence.

We’ll send Mark Antony to the Senate-house,
And he shall say you are not well today.
Let me upon my knee prevail in this.
CAESAR.
Mark Antony shall say I am not well,
And for thy humour, I will stay at home.
Enter Decius.
Here’s Decius Brutus, he shall tell them so.
DECIUS.
Caesar, all hail! Good morrow, worthy Caesar.
I come to fetch you to the Senate-house.
CAESAR.
And you are come in very happy time
To bear my greeting to the Senators,
And tell them that I will not come today.
Cannot, is false; and that I dare not, falser:
I will not come today. Tell them so, Decius.
CALPHURNIA.
Say he is sick.
CAESAR.
Shall Caesar send a lie?
Have I in conquest stretch’d mine arm so far,
To be afeard to tell grey-beards the truth?
Decius, go tell them Caesar will not come.
DECIUS.
Most mighty Caesar, let me know some cause,
Lest I be laugh’d at when I tell them so.
CAESAR.
The cause is in my will; I will not come.
That is enough to satisfy the Senate.
But for your private satisfaction,
Because I love you, I will let you know:
Calphurnia here, my wife, stays me at home.
She dreamt tonight she saw my statue,
Which like a fountain with an hundred spouts
Did run pure blood; and many lusty Romans
Came smiling, and did bathe their hands in it.
And these does she apply for warnings and portents
And evils imminent; and on her knee
Hath begg’d that I will stay at home today.
DECIUS.
This dream is all amiss interpreted:
It was a vision fair and fortunate.

This by Calphurnia’s dream is signified.
CAESAR.
And this way have you well expounded it.
DECIUS.
I have, when you have heard what I can say;
And know it now. The Senate have concluded
To give this day a crown to mighty Caesar.
If you shall send them word you will not come,
Their minds may change. Besides, it were a mock
Apt to be render’d, for someone to say,
“Break up the Senate till another time,
When Caesar’s wife shall meet with better dreams.”
If Caesar hide himself, shall they not whisper
“Lo, Caesar is afraid”?
Pardon me, Caesar; for my dear dear love
To your proceeding bids me tell you this,
And reason to my love is liable.
CAESAR.

I am ashamed I did yield to them.
Give me my robe, for I will go.
Enter Brutus, Ligarius, Metellus, Casca, Trebonius,
Cinna and Publius.
And look where Publius is come to fetch me.
PUBLIUS.
Good morrow, Caesar.
CAESAR.
Welcome, Publius.
What, Brutus, are you stirr’d so early too?
Good morrow, Casca. Caius Ligarius,
Caesar was ne’er so much your enemy
As that same ague which hath made you lean.
What is’t o’clock?
BRUTUS.
Caesar, ’tis strucken eight.
CAESAR.
I thank you for your pains and courtesy.
Enter Antony.
See! Antony, that revels long a-nights,
Is notwithstanding up. Good morrow, Antony.
ANTONY.
So to most noble Caesar.
CAESAR.
Bid them prepare within.
I am to blame to be thus waited for.
Now, Cinna; now, Metellus; what, Trebonius!
I have an hour’s talk in store for you:
Remember that you call on me today;
Be near me, that I may remember you.
TREBONIUS.
Caesar, I will. [Aside.] and so near will I be,
That your best friends shall wish I had been further.
CAESAR.
Good friends, go in, and taste some wine with me;
And we, like friends, will straightway go together.
BRUTUS.
[Aside.] That every like is not the same, O Caesar,
The heart of Brutus yearns to think upon.
[Exeunt.]
SCENE III. A street near the
Capitol.
Enter Artemidorus, reading a paper.
ARTEMIDORUS.
“Caesar, beware of Brutus; take heed of Cassius; come not near Casca; have
an eye to Cinna; trust not Trebonius; mark well Metellus Cimber; Decius Brutus
loves thee not; thou hast wrong’d Caius Ligarius. There is but one mind in all
these men, and it is bent against Caesar. If thou be’st not immortal, look
about you: security gives way to conspiracy. The mighty gods defend thee!
Thy lover, Artemidorus.”
Here will I stand till Caesar pass along,
And as a suitor will I give him this.
My heart laments that virtue
cannot live
Out of the teeth of emulation.
If thou read this, O
Caesar, thou mayest live;
If not, the Fates with traitors do contrive.
[Exit.]
SCENE IV. Another part of the same street,
before the house of Brutus.
Enter Portia and Lucius.
PORTIA.
I pr’ythee, boy, run to the Senate-house;
Stay not to answer me, but get thee gone.
Why dost thou stay?
LUCIUS.
To know my errand, madam.
PORTIA.
I would have had thee there and here again,
Ere I can tell thee what thou shouldst do there.
[Aside.] O constancy, be strong upon my side,
Set a huge mountain ’tween my heart and tongue!
I have a man’s mind, but a woman’s might.
How hard it is for women to keep counsel!
Art thou here yet?
LUCIUS.
Madam, what should I do?
Run to the Capitol, and nothing else?
And so return to you, and nothing else?
PORTIA.
Yes, bring me word, boy, if thy lord look well,
For he went sickly forth: and take good note
What Caesar doth, what suitors press to him.
Hark, boy, what noise is that?
LUCIUS.
I hear none, madam.
PORTIA.
Pr’ythee, listen well.
I heard a bustling rumour, like a fray,
And the wind brings it from the Capitol.
LUCIUS.
Sooth, madam, I hear nothing.
Enter the Soothsayer.
PORTIA.
Come hither, fellow:
Which way hast thou been?
SOOTHSAYER.
At mine own house, good lady.
PORTIA.
What is’t o’clock?
SOOTHSAYER.
About the ninth hour, lady.
PORTIA.
Is Caesar yet gone to the Capitol?
SOOTHSAYER.
Madam, not yet. I go to take my stand,
To see him pass on to the Capitol.
PORTIA.
Thou hast some suit to Caesar, hast thou not?
SOOTHSAYER.
That I have, lady, if it will please Caesar
To be so good to Caesar as to hear me,
I shall beseech him to befriend himself.
PORTIA.
Why, know’st thou any harm’s intended towards him?
SOOTHSAYER.
None that I know will be, much that I fear may chance.
Good morrow to you. Here the street is narrow.
The throng that follows Caesar at the heels,
Of Senators, of Praetors, common suitors,
Will crowd a feeble man almost to death:
I’ll get me to a place more void, and there
Speak to great Caesar as he comes along.
[Exit.]
PORTIA.
I must go in.
[Aside.] Ay me, how weak a thing
The heart of woman is! O Brutus,
The heavens speed thee in thine enterprise!
Sure, the boy heard me. Brutus hath a suit
That Caesar will not grant. O, I grow faint.
Run, Lucius, and commend me to my lord;
Say I am merry; come to me again,
And bring me word what he doth say to thee.
[Exeunt.]


11.6 Chapter Summary
Kelly Szott
Drug use is often mistakenly identified as a social problem in and of itself. This chapter has shown that it is the consequences of some forms of drug use (and often by certain groups of people) that can be constructed as problems. The problems that arise from drug use must be solved collectively because they have structural roots.
Structural racism and class inequality drive different outcomes for people who use drugs. White rich people are more likely to be perceived as having a medical condition that needs treatment. They are also more likely to access effective treatment. People of Color and poor people are more likely to be seen as criminals and receive punishment. They are much less likely to have access to effective treatment. It’s not the use of drugs that’s the social problem—it’s the deep injustice in the consequences of the behavior that is the social problem.
What is considered a harmful drug, and thus, must be outlawed, is constantly changing. This is demonstrated by the recent decriminalization of the possession of small amounts of drugs in Oregon. We must wrestle with defining drug use as legal or illegal, moral or immoral, individual or social.
Structural inequality combined with drug policy that creates avoidable harm from drug use. Social justice for people who have substance use disorder includes changing the laws, policies and practices related to harmful drug use. It includes increasing funding for effective community and inpatient treatment and services, particularly in rural communities. And it includes addressing the generational problems of racism and poverty reflected in the disproportionality of both the assignment of criminality and access to treatment.
Essential Ideas
Learning Objective 1: How can we describe drug use and misuse as a social problem?
Harmful drug use is a social problem because it affects different groups of people in different ways. People differ on whether they consider drug use a moral, psychological or structural problem. They disagree on what to do, reflecting a conflict in values. Our ideas about legal and illegal drug use, and the consequences of that harmful drug use are socially constructed. Finally, taking action to expand justice requires individuals to take action to pursue recovery and collective action by people in our society to change drug laws, support harm reduction programs, fund drug treatment, and fight racism. These interdependent actions increase social justice for people who use drugs in harmful ways.
Learning Objective 2: How does social location impact the experience of harmful drug use?
We see disproportionality and disparity when we examine the outcomes of harmful drug use based on race and ethnicity. Whites are disproportionately less represented in prison and jail populations. Black, Brown, and Indigenous people are disproportionately more represented in prison and jail populations. The reasons for this disparity include racist policing and disparate mandatory sentencing, among other practices. Generally, White people are perceived as needing treatment, and they more often have access to it. People of Color are more often seen as criminals and get punished.
Learning Objective 3: How do the five models of addiction differ in how they explain the causes and consequences of harmful drug use?
The five models of addiction are moral, disease, public health, sociological, and intersectional. The moral model focuses on the failings of an individual. While most sociologists don’t use this approach, it can be effective in peer-led recovery groups. The disease model focuses on substance use as a medical disorder, often based on neurological explanations. This approach is helpful in developing medical treatment but often minimizes the social determinants of health, which influence the differential outcomes of harmful drug use. The public health model focuses on minimizing the harm that occurs related to harmful drug use. This approach focuses on harm reduction strategies. The sociological approach focuses on how structural inequalities like racism or economic inequalities influence the consequences of harmful drug use. Finally, the intersectional approach looks at how historical and generational trauma is uniquely experienced in communities of color. Scholars examine how the deep roots of colonization continue to create unequal access to treatment resources. Finally, in this model, researchers look at how cultural capital can be used to make a difference.
Learning Objective 4: Which interdependent actions increase social justice related to problematic drug use?
Radical justice for drug use and misuse will take federal, state, community, and individual action to transform our society. Among the options are harm reduction, decriminalization of small amounts of substances, increased access to treatment options, and community collaborations. Recovery is social justice.
Key Terms Review
[H5P56]
[H5P57]
[H5P58]
[H5P59]
Key Terms List
addiction: a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences.
criminalization: the act of making something illegal.
decriminalization: the act of reducing penalties for possession/use of small amounts from criminal sanctions to fines or civil penalties
disparity: the unequal outcomes of one group compared with outcomes for another group. Disparity can be used to compare any groups with different social locations.
drug use: the imbibing of substances, which can happen without addiction or physical dependence but may lead to those outcomes.
five models of addiction: five ways to understand drug use that are dominant in US society—the moral view, the disease model, the public health perspective, a sociological approach, and an intersectional approach.
harm reduction: a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs.
harmful drug use: a person’s drug use negatively impacts their health, their livelihood, their family, their freedom, or any other aspect of their life that they deem important.
legalization: to make the possession and use of a drug legal
mass incarceration: the overwhelming size and scale of the US prison population
New Jim Crow: the network of laws and practices that disproportionately funnel Black Americans into the criminal justice system, stripping them of their constitutional rights as a punishment for their offenses in the same way that Jim Crow laws did in previous eras.
opioid crisis: a surge of drug overdoses and suicides, both linked to the use of opioid drugs
private prisons: for-profit incarceration facilities run by private companies that contract with local, state, and federal governments.
risk environment: the space—whether social or physical—in which a variety of factors interact to increase the chances of drug-related harm.
social capital: the social networks or connections that an individual has available to them due to group membership.
substance use disorder (SUD): a condition in which there is uncontrolled use of a substance despite harmful consequences. People with SUD have an intense focus on using a certain substance(s), such as alcohol, tobacco, or illicit drugs, to the point where the person’s ability to function in day-to-day life becomes impaired.
War on Drugs: The War on Drugs is an effort in the United States since the 1970s to combat illegal drug use by greatly increasing penalties, enforcement, and incarceration for drug offenders.
Discuss and Do
- Harmful Drug Use as a Social Problem: What’s the difference between illegal and legal drugs? Does everyone in society agree on these categories? Why or why not?
- Causes and Consequences: Which of the five models of addiction best explains the opioid crisis?
- Conflict in Society: What are the advantages and disadvantages of legalizing any currently illegal drug? Feel free to use an example from the textbook, or from your community.
- Mass Incarceration: How can we see mass incarceration as a social problem related to the racialization of drug use?
- Social Construction of Drug Use: Please find a video, print, or social media ad that is selling or against selling a mind-altering substance. This could be prohibition, smoking in old movies, medical cannabis today, or other substances. How did this ad capture the beliefs or opinions of the drug at the time? How have the views changed over time?
- Community Action: What drug treatment services are available in your community? Are they community-based, medical, or carceral? How might you access them? Are they effective?
Licenses and Attributions for Chapter Summary
Open Content, Original
“Chapter Summary” by Kelly Szott is licensed under CC BY 4.0.
a social condition or pattern of behavior that has negative consequences for individuals, our social world, or our physical world
the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care and criminal justice
a group who shares a common social status based on factors like wealth, income, education, and occupation
the act of reducing penalties for possession/use of small amounts from criminal sanctions to fines or civil penalties
a person’s drug use negatively impacts their health, their livelihood, their family, their freedom, or any other aspect of their life that they deem important
areas are sparsely populated, have low housing density, and are far from urban centers.
the state of lacking the material and social resources an individual requires to live a healthy life.
The overrepresentation or underrepresentation of a racial or ethnic group compared with its percentage in the total population.
the actions taken by a collection or group of people, acting based on a collective decision
a group of people who live in a defined geographic area, who interact with one another, and who share a common culture
a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs.
full and equal participation of of all groups in a society that is mutually shaped to meet their needs
the combination of factors including gender, race, social class, age, ability, religion, sexual orientation, and geographic location that define an individual or group in relationship to power and privilege
the unequal outcomes of one group compared with outcomes for another group. Disparity can be used to compare any groups with different social locations.
a socially constructed category with political, social, and cultural consequences, based on incorrect distinctions of physical difference
a group of people who share a cultural background, including language, location, or religion.
five ways to understand drug use that are dominant in U.S. society—the moral view, the disease model, the public health perspective, a sociological approach, and an intersectional approach
a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences.
a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.
a person (or group) response to a deeply distressing or disturbing event that overwhelms one's ability to cope, causes feelings of helplessness, diminishes self esteem and the ability to feel a full range of emotions and experiences.


Traveling waves
18 Wave basics
Wave analogy
Scientists have found that waves provide an excellent analogy for understanding many of the behaviors of sound (and light and other things). Before getting into the details about how sound is like a wave, it is useful to look at waves we can visualize- like water waves and waves on slinkies.
Mechanical waves
Waves on a slinky are an example of a mechanical wave. As you wiggle up and down on a slinky, pulses move away from your hand, travel through the slinky and are eventually felt at the other end of the slinky. Careful observation of a slinky yields some important conclusions about mechanical waves. First, vibrations cause waves. Second, mechanical waves need a material to travel through (called the medium).
There are two primary types of waves- transverse waves and longitudinal waves. In transverse waves, vibrations move perpendicular to the wave itself. The “wave” at the football stadium is an example of a transverse wave. People stand up and sit down, but the wave moves around the stadium. You can also make T-waves easily on a slinky- stretch the slinky along the floor and wiggle the end of the slinky side to side. The coils on the spring move left and right while the wave travels away from you. In longitudinal waves, the vibrations move parallel to the wave itself. To make a L-wave in the classroom, you form a conga line, with one person holding the shoulders of the person in front of them. The person at the back of the line pushes forward on the next person to start the wave. Each person moves forward and backward as the wave travels to the front of the line. To make an L-wave with the slinky, you must push and pull in and out on the end of the slinky. L-waves are sometimes called compression waves.
This short (0:24) youtube video [1] shows the difference between L- and T-waves on a slinky. The two pictures in this section are screen shots from that video.
Sound is a longitudinal wave
Sound is a longitudinal wave. Sources of a sound move in and out, compressing and stretching the material in front of them. This wave motion animation [2] on Daniel Russell’s website at Penn State shows how air molecules move in a sound wave (in air).
What moves in a wave?
A close look at waves in a slinky reveals something important about mechanical waves- particles in the medium vibrate, but they do not move along with the wave. Send a pulse along a slinky and you’ll notice that individual coils of the spring move up and down but never stray far from their original location. It’s like “the wave” at the football stadium. People stand up and sit down, never leaving their seat, but the wave travels around the stadium. This is an important feature for all mechanical waves- individual molecules in the medium vibrate, but never travel very far from their original location. The vibration travels long distances- individual particles don’t. This explains, for instance, why ducks on a pond bob up and down as waves go by, rather than move along with the crests. The same thing happens in a sound wave. Look at the highlighted air particles on Dan Russell’s wave motion animation– notice that the highlighted particles vibrate in place as the wave crosses the screen.
Some people think of sound as being like wind- a group of air particles moving from place to place. The idea is illustrated in a famous 1980s era commercial for Maxell brand audio tape. A man sits in a chair as loud music plays through a speaker near the left side of the picture. As the music plays, the man’s hair (tie, drink, and pretty much everything else) are all blown to the right across the screen. We’re supposed to believe the speaker creates a wind. This idea is wrong: the air molecules in a sound wave do not travel along with the sound! Each air molecule in the room vibrates, but stays in essentially the same place. Each air molecule disturbs its neighbor and it is the disturbance that crosses the room- not the air. The wind in the commercial is, in fact, caused by a large fan just off screen. If sound worked like a wind, we might expect to be able to spread perfume faster by putting an open bottle in front of a speaker with loud music. It simply doesn’t work. Perfume spreads just as slowly with the music as without it.
Stop to think
A loudspeaker is on stage in a quiet auditorium. Joe sits at the back of the auditorium. Suzy sits about halfway between Joe and the speaker. A particle of dust is in the air somewhere close to Suzy’s ear when the speaker blasts a short blast of 400 Hz tone.
- How does the dust particle move while Suzy hears the sound?
- How does the dust particle move after Suzy hears the sound?
- Where is the dust particle when Joe hears the sound?
Stop to think answer
While Suzy hears the sound, the dust particle wiggles back and forth along the line of travel of the sound (towards and then away from the stage). The particle’s oscillation is pretty quick (400 oscillations per second). Once the sound passes, the particle stops moving, ending up essentially where it started (near Suzy’s ear). So, when Joe hears the sound a short time later, the particle is still very close to Suzy’s ear. It is the sound that moves from place to place- not the air.
Online resources
Watch What does sound look like? [3] (2:31 youTube video). This short piece produced for NPR shows high speed video of several common sounds and explains the technique used to produce the videos.
Image credits
- Transverse wave on a slinky. (Screenshot from [1]; original is CC-BY-NC)
- Longitudinal wave on a slinky. (Screenshot from [1]; original is CC-BY-NC).
- Animations for Physics and Astronomy. (2012, February 7). Longitudinal and Transverse Waves. Retrieved from https://youtu.be/UHcse1jJAto ↵
- Russell, D. (1988, August 5). Wave Motion. Retrieved from http://www.acs.psu.edu/drussell/Demos/waves/wavemotion.html ↵
- SkunkBear (2014, April 9). What does sound look like? Retrieved from https://youtu.be/px3oVGXr4mo. ↵


John Witt dies; funeral services on Saturday
John Witt, 85, a lifetime Nebraskan, died about 6:15 a.m. today’ at his home, 2110 17th street. In failing health for several years, he was seriously ill the last three months.
Funeral services will be at 3 p.m. Saturday at the Federated church with the Rev. Harold B. Taylor, pastor, officiating and burial will be in Roselawn Memorial cemetery.
The body will lie in state at the Gass Funeral chapel from 11 a.m Friday until the hour of the service.
Mr. Witt, son of the late John H. and Sophie Mavis Witt, was born Dec. 24, 1873 at Scribner, one of a family of 11 children. After attending rural schools and Fedmont Normal, he took up the milling trade, an occupation he followed for 50 years, operating mills at Scribner, Leigh and Potter. Later he pursued his hobby of cabinet making until retiring about three years ago.
He married Friedricka Brunken on Oct. 20, 1898 at her home northwest of Columbus and’ they observed their 60th wedding anniversary last fall. Mr. and Mrs. Witt have resided in Columbus for 17 years. He was a member of the Federated church, was affiliated. with the Oddfellows lodge for 46 years and had a life membership in the Macabees lodge.
Survivors include his wife; six children, Mrs, M. D. (Clara) Miur of Fremont, George of Los Angeles, Mrs. Jacob (Anna) Glur at Columbus. Harry of Los Angeles, Leroy of Bonners Ferry, Ida., Clifford of Planada, Calif; 25 grandchildren and 18 great grandchildren; one sister,Mrs/ Pete Diedrickson of Scribner; four brothers, Dr. Bernard Witt and Reinhold Witt of Scribner, Ewald Witt of Washington,’ D.C. and Arnold Witt of West Point.
He was preceded’ in death by a son, Melvin, three sisters and two brothers.
Choice of ‘memorials may be designated by the donors.
SOURCE: 2 April 1959
- RELATION TO COUSINS: Husband of great-aunt • Fredericka Mary Brunken
- BIRTH: 24 Dec 1873 • Scribner, Dodge County, Nebraska, USA
- DEATH: 2 Apr 1959 • Columbus, Platte County, Nebraska, USA
- BURIAL: Roselawn Memorial Park • Columbus, Platte County, Nebraska, USA
- FIND A GRAVE MEMORIAL ID: 20603053


Work Cited
Blanke, T., Bryant, M., & Hedges, M. (2020). Understanding memories of the Holocaust—A new approach to neural networks in the digital humanities. Digital Scholarship in the Humanities, 35(1), 17–33.
Drobac, S., & Lindén, K. (2020). Optical character recognition with neural networks and post-correction with finite state methods. International Journal on Document Analysis and Recognition (IJDAR), 23(4), 279–295.
Li, H. (2017). Deep learning for natural language processing: advantages and challenges. National Science Review.
Salami, D., & Momtazi, S. (2021). Recurrent convolutional neural networks for poet identification. Digital Scholarship in the Humanities, 36(2), 472–481.
Suissa, O., Elmalech, A., & Zhitomirsky-Geffet, M. (2021). Text analysis using deep neural networks in digital humanities and information science. Journal of the Association for Information Science and Technology.
Wevers, M., & Smits, T. (2020). The visual digital turn: Using neural networks to study historical images. Digital Scholarship in the Humanities, 35(1), 194–207.
Ying, L., & Huidi, L. (2020). Review of Text analysis Based on Deep Learning. 2020 International Conference on Intelligent Computing and Human-Computer Interaction (ICHCI), 384–388.


66 Leslie Marmon Silko
Leslie Marmon Silko (1948- )
“Yellow Woman”
Native American
Contemporary Literature
Leslie Marmon Silko was born in Albuquerque, New Mexico, but was raised in Laguna Pueblo. She is a talented poet and prose writer, whose work incorporates elements of Native American storytelling traditions. She studied English at the University of New Mexico, and graduated with honors. After her graduation, she published her first story, “Tony’s Song.” She briefly studied law, but left the program to pursue a graduate degree in English. In 1974, she published several stories in Kenneth Rosen’s anthology, The Man to Send Rain Clouds: Contemporary Stories by American Indians. Her first novel, Ceremony, a World War II veteran’s attempts to find peace after the war, was published in 1977, to critical acclaim. The novel led to Silko being awarded a MacArthur Fellowship in 1981. In her writing, Silko commonly addresses ideas of healing and reconciling conflicts (cultural, spiritual, internal). “Yellow Woman” was first published in The Man to Send Rain Clouds: Contemporary Stories by American Indians. It is one of her most commonly anthologized pieces. In the story, Silko explores the Laguna tradition of Yellow Woman, who is often abducted, taken to the spirit world, and later returns with a great power that helps her people. Whether or not the characters from the story are Yellow Woman and other spirits is something that Silko does not clarify. The uncertainty is a compelling aspect of the story.
Consider while reading:
- How does Silko’s work draw from the storytelling traditions of the Laguna Pueblo people?
- What commentary is Silko making about identity?
- Discuss Silko’s symbolic use of color in the story.
- What is the significance of geography in the text?
Written by Laura Ng


G02, G03 Four Questions
Code Practice
OBJECTIVE
After completing this unit, you should be able to:
- Use four questions to write a code to cut an arc
Terminology
- Arc: A curve. A round angle. A part of a circumference of a circle.
E.g., An arc can go around the outside (profile) of a part.
An arc can go into a part. It might look like someone took a bite out of a part. - Mode: This is the root word for modal. Remember that a CNC code stays active when it is modal.  The program is in the G00 mode.
G01 is the modal command for cutting. The machine is in the G01 mode.
G90 and G91 are modal. The machine can only be in one mode. - Equidistant: At equal distance to a point.
E.g., Any point on a radius is equidistant to the center point.
G02 and G03 Circular Motion are modes for the CNC Machine.
G02 establishes a mode for clockwise circular arcs.
G03 establishes a mode for counter-clockwise circular arcs.
Like the G01 command, G02 and G03 require a feed rate (F). The feed rate will default to the previous feed rate in the code.
Also like G01, the G02 and G03 codes need coordinates (X, Y, and/or Z). However, the CNC code uses different letters to identify the center of an arc.
X = I
Y = J
Z = K
I, J, or K identifies the center of the arc from the starting point of the arc.
There are two different ways to program a G02 or G03. For this class, we will only talk about and practice one of them, which is the I, J, K Method.
I, J, K Method
Only two of I, J, and K will be used.
The I, J, and K codes identify the DISTANCE from the ARC START POINT to the CENTER POINT of the arc. This distance from the start point to the center point is called “offset.”
EXAMPLE OF CLOCKWISE ARC:
This arc starts at X0 Y2.
It finishes at X2 Y0.
Its center is at X0 Y0.
We could specify it in G-code like this:
G02 (Set up the clockwise arc mode) X2 Y0 I0 J-2.0
Four Questions
Another Example:
Assume the machine is currently at X0.0 Y0.0 and G90 is enabled in the header.
G01 Y1.0 F8.0;
G02 X1.2803 Y1.5303 I.750;
The code above will produce the following toolpath. Notice the value for J (the distance in the Y axis) would be zero. It can be omitted.
Four Questions
When the G02 or G03 mode is in the code, arcs are defined by identifying their two endpoints. The endpoints are easy. In the program, the first point (location or position) where GO2 or G03 is used identifies the first endpoint. The first point begins the circular cut to make the arc on the part. The second endpoint uses XYZ coordinates. The second endpoint is where the arc stops.
The center point must be equidistant from each endpoint. The center is identified by using I, J, or K to establish measurements (a.k.a. “relative offsets”) from the starting point of the arc to the center. The computer will calculate the starting point to the center. It will compare the center point to the endpoint coordinates. The computer will calculate if those two measurements are equidistant.
Questions
Adapted from 1) “CNC Language and Structure ” by LamNgeun Virasak, Manufacturing Processes 4-5 is licensed under CC BY-SA 4.0; and 2) “CNC G Code: G02 and G03” by ManufacturingET is licensed under CC BY-SA 4.0


9 April 2011: Rossini, Le Comte Ory
Metropolitan Opera Live in HD. Count Ory: Juan Diego Flórez; Countess Adèle: Diana Damrau; Isolier: Joyce DiDonato. Conductor: Maurizio Benini
A wonderful romp of a comic opera, in which Juan Diego Flórez masquerades as a nun (with a very noticeable five o’clock shadow), and ends up in bed with two women at the same time, to hilarious conclusions. Isolier is a trousers role, as the page of the Count, whose only object in life is to seduce the most beautiful women he comes into contact with. Isolier is in training for this sort of thing, and both receive in due course the tongue-in-cheek, lightly moralized, turn-about ending that is part of the frothy truth of comic opera ethos. Both are magnificently abetted in this by Rossinni’s magical music, played and sung at a pace that defies the workings of even the stoutest metronome.


Concision and Precision Defined
Concision and Precision are two important business communication goals.
- To be concise is to communicate information in as few words as possible.
- To be precise is to communicate all required information.
To achieve concision and precision in writing, writers need to be cognizant of word choice and sentence structure.
Precision
Include clear subjects in sentences. Avoid the following.
Avoid using ambiguous “they”, “it”, “you” pronouns.
| Ambiguous – to be avoided | They need the costing information by the afternoon. | When you use the costing application, you sometimes get an error message because you haven’t saved the most recent input. | It will mean that management may have to lay off some employees. |
|---|---|---|---|
| Improved | The controller needs the costing information by this afternoon. | Users sometimes get error messages when using the costing application because they haven’t saved their most recent input. | The merger will mean that management will have to lay off some employees. |
Present facts clearly.
Use precise language.
| Ambiguous – to be avoided | A while ago we received some complaints about our sauces. | A lot of union members indicated that they would ratify the agreement. |
|---|---|---|
| Improved | In April, we received about 15 complaints about the re-heating instructions on our Ole Mole sauce label. | About 65 percent of union members indicated that they would ratify the agreement. |
Use Plain English: Avoid overly formal words, foreign words, cliches, and slang.
| Overly formal words, foreign words, cliches, and slang – to be avoided | Hank Fuchs apprised me of the poorly performing Facebook shares. | The conference will commence at 10 a.m. | We are really going to have to tighten our belts this quarter. | Critics argue that Google’s raison d’etre is to provide businesses with an endless stream of customers. | Ian bounced as soon as the meeting was over. |
|---|---|---|---|---|---|
| Improved | Hank Fuchs told me about the poorly performing Facebook shares. | The conference will start at 10 a.m. | We are going to have to reduce spending by 10% this quarter. | Critics argue that Google’s goal is to provide businesses with an endless stream of customers. | Ian left as soon as the meeting was over. |
Use job-related jargon only if your audience is familiar with the jargon.
The sentences below are effective only if the reader understands the italicized terms.
- The PAC was pleased with the improvement in prospective employees’ communication skills.
- The HR department is completing its bi-annual CPQR report.
- Edalat began the content curation for our webpage yesterday.
- The bounce rate on our Twitter account is almost 76%.
Concision
Eliminate wordy or redundant phrases
Avoid unnecessary words such as “true fact” of “refer back”. A fact is true, so “true fact” is redundant. Refer means to go back, so “refer back” is redundant.
Click on the following link to see a list 50 common redundant phrases 50 Redundant Phrases to Avoid. Do you use any of them?
Avoid nominalizations.
A nominalization is a grammatical term used to describe the process of turning a verb into a noun.
| Weak – to be avoided | Clifford made the conclusion that we need to improve efficiencies in product transport. | We made the assumption that we would have received the vegan leather from our suppliers by last week. | The Health and Safety Team conducted an investigation on air quality in our 5th floor offices. | Our IT team had a discussion on how to enhance cyber security. | Our IT team made a recommendation that we should increase our firewall. |
|---|---|---|---|---|---|
| Improved | Clifford concluded that we need to improve efficiencies in product transport. | We assumed that we would have received the vegan leather from our suppliers by last week. | The Health and Safety Team investigated air quality in our 5th floor offices. | Our IT team discussed how to enhance cyber security. | Our IT team recommended increasing our firewall. |
Exercises
Part 1
Eliminate the unnecessary words in the following sentences.
- How basically comfortable are you working on Easy Money spreadsheets?
- Recent graduates need to have earned high marks in accounting class in order to participate in our Recent Grad Program.
- Please refer back to the warranty clause to see if the default is actually covered.
- At this point in time, Sweet Sylvie’s Baked Goods is focusing on developing a line of vegan options.
- Jennifer Fong was recommended for the promotion by each and every person on her team.
Part 2
Rewrite the following sentences to eliminate unnecessary nominalization.
- They completed the renovation with great efficiency and with great speed.
- She made the suggestion that we consider piloting four-day work weeks.
- Arash Gaspar, our finance principal, has an impressive collection of coins from around the world.
- Our researchers carried out interviews with several people who work in the hospitality industry.
- I would like to offer my congratulations to all the managers who participated in and completed the diversity training program.
- Barry Hoffman made the recommendation that all storage rooms be equipped with upgraded fire detectors.
Part 3
Rewrite the following sentences to correct errors in slang or outdated language.
- Michael Power really needs to step up his game since his sales quotas are not up to par.
- Please be advised that all supervisors are expected to attend the meeting on June 2 at 10 a.m.
- The document attached herewith is in requirement of your signature. We look forward to its timely reception.
- We pulled an all-nighter and carefully re-checked the addition because we did not want to screw up on the numbers.


27 Virtual Field Trip: Coming of Age Ceremonies
Where do you want to go?
Virtual Field Trip: Coming of Age Ceremonies
How did you know when you were an ‘adult?’
Explore this great overview of coming of age ceremonies in cultures around the world 13 Amazing Coming of Age Ceremonies Around the World as the transition from childhood to adulthood is marked and celebrated as a community.
Then, choose one of the two ceremonies below for your Field Trip, to explore a coming of age ceremony more deeply!
Your Field Guide
Explore the Required Resources
- Article: 13 Amazing Coming of Age Ceremonies Around the World, Global Citizen
Choose A Topic and Explore More Deeply
Choose ONE of these two topics.
Use the suggested links below to explore your topic more deeply or select your own scholarly resources:
Apache Nai’es Ceremony (Woman’s Coming of Age Ceremony)
- Article: Apache Puberty Rites: 6 Girls Attain Womanhood Indian Country Today
- Website: White Mountain Apache Tribe
- Article: An Apache dance into Womanhood, AZ Central
- Website: Mescalero Apache Tribe, Culture
- Website: Yavapai Apache Nation: History
- Website: Fort Sill Apache Tribe, Oklahoma
Kaningara Skin Cutting Ritual (Man’s Coming of Age Ceremony)
- Article: Making Boys Into Men: Kaningara Skin-Cutting Ritual
- Video: Crocodile Scars National Geographic (contains graphic images)