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Recognizing and refuting the myth of tongue swallowing during a seizure

  • Author Footnotes
    1 Permanent Address: University of Massachusetts Medical School, Department of Neurology, Division of Epilepsy, 55 Lake Ave N, Worcester, MA 01655, USA.
    ,
    Author Footnotes
    2 These authors contributed equally to the manuscript.
    Kyle C. Rossi
    Correspondence
    Corresponding author at: University of Massachusetts Medical School, Department of Neurology, Division of Epilepsy, 55 Lake Ave N, Worcester, MA, 01655, USA.
    Footnotes
    1 Permanent Address: University of Massachusetts Medical School, Department of Neurology, Division of Epilepsy, 55 Lake Ave N, Worcester, MA 01655, USA.
    2 These authors contributed equally to the manuscript.
    Affiliations
    Beth Israel Deaconess Medical Center and Harvard Medical School, Department of Neurology, Division of Epilepsy, 330 Longwood Ave, Boston, MA, 02215, USA
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  • Author Footnotes
    2 These authors contributed equally to the manuscript.
    Alexander J. Baumgartner
    Footnotes
    2 These authors contributed equally to the manuscript.
    Affiliations
    Beth Israel Deaconess Medical Center and Harvard Medical School, Department of Neurology, Division of Epilepsy, 330 Longwood Ave, Boston, MA, 02215, USA
    Search for articles by this author
  • Shira R. Goldenholz
    Affiliations
    Beth Israel Deaconess Medical Center and Harvard Medical School, Department of Neurology, Division of Epilepsy, 330 Longwood Ave, Boston, MA, 02215, USA
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  • Daniel M. Goldenholz
    Affiliations
    Beth Israel Deaconess Medical Center and Harvard Medical School, Department of Neurology, Division of Epilepsy, 330 Longwood Ave, Boston, MA, 02215, USA
    Search for articles by this author
  • Author Footnotes
    1 Permanent Address: University of Massachusetts Medical School, Department of Neurology, Division of Epilepsy, 55 Lake Ave N, Worcester, MA 01655, USA.
    2 These authors contributed equally to the manuscript.
Open ArchivePublished:October 05, 2020DOI:https://doi.org/10.1016/j.seizure.2020.09.023

      Highlights

      • Many still believe that a person can swallow their tongue during a seizure.
      • This belief was spread in part by both medical and popular literature.
      • Many still believe that objects should be placed into a seizing patient’s mouth.
      • Some modern-day media continue to portray and perpetuate this practice.
      • Every modern expert guideline advises against this practice.

      Abstract

      Objective

      There is a harmful myth that persists in modern culture that one should place objects into a seizing person’s mouth to prevent “swallowing the tongue.” Despite expert guidelines against this, the idea remains alive in popular media and public belief. We aimed to investigate the myth’s origins and discredit it.

      Methods

      A medical and popular literature review was conducted for the allusions to “swallowing one’s tongue” and practice recommendations for and against placing objects into a seizing person’s mouth. Current prevalence of these beliefs and relevant anatomy and physiology were summarised.

      Results

      The first English language allusions to placing objects in a patient’s mouth occurred in the mid-19th century, and the first allusions to swallowing one’s tongue during a seizure occurred in the late 19th century. By the mid-20th century, it was clear that some were recommending against the practice of placing objects in a patient’s mouth to prevent harm. Relatively recent popular literature and film continue to portray incorrect seizure first aid through at least 2013. There is ample modern literature confirming the anatomical impossibility of swallowing one’s tongue and confirming the potential harm of putting objects in a patient’s mouth.

      Conclusion

      One cannot swallow their tongue during a seizure. Foreign objects should not be placed into a seizing person’s mouth. We must continue to disseminate these ideas to our patients and colleagues. As neurologists, we have an obligation to champion safe practices for our patients, especially when popular media and culture continue to propagate dangerous ones.

      Keywords

      1. Introduction

      There is a very harmful myth still prevalent in modern culture stating that one should place objects into a seizing person’s mouth to either prevent “swallowing the tongue” or prevent biting the tongue. Every modern expert guideline advises against this practice [
      • Chillemi S.
      • Devinsky O.
      What to do if someone near you is having a seizure.
      ,
      • Freeman A.
      • Li Nelson
      What to do when someone has a seizure.
      ,
      • Osborne-Shafer P.
      First aid for seizures - stay, safe, side.
      ]. Nevertheless, the idea persists in popular media and in public belief. In the medical literature, we find little devoted to this topic. The origin of the myth remains cryptic, and how it was originally disseminated is not clear. It is also unclear why this belief persists amongst the public and even some healthcare providers today despite many decades of expert recommendations to the contrary.
      In this article, we investigate the origins of the myth by surveying English language medical and popular literature for their first occurrence, and then track the spread of the idea over time through medical literature, books, TV, and film. We also examine surveys of modern beliefs, summarise the medical harms involved in placing object into a seizing person’s mouth, and review the pertinent anatomy involved to confirm the impossibility of “swallowing one’s tongue.”

      2. Tracing the phrase “swallowing one’s tongue” in relation to seizures

      When considering the idea of swallowing one’s tongue, it would be remiss not to mention common idiomatic use of the phrase in various languages. The phrase even lends itself particularly well to idiomatic usage given that “tongue” is another word for “language” in many world languages. Table 1 shows a sample of world languages with idiomatic usage of the literal phrase, “to swallow one’s tongue” [
      • Henley W.E.
      Slang and its analogues past and present; a dictionary, historical and comparative, of the heterodox speech of all classes of society for more than three hundred years. With synonyms in English, French, German, Italian, etc.
      ,
      • Dubrovin M.I.
      A book of Russian idioms illustrated.
      ,
      • Todorova M.
      Morpho-syntactic properties of Bulgarian verbal idiomatic expressions.
      ,
      • Lobzhanidze I.
      Similar ways of forming idioms in Georgian, Udi and Russian.
      ,
      • Bas M.
      Conceptualization of emotion through body part idioms in Turkish: a cognitive linguistic study.
      ]. Intriguingly, many of these idiomatic usages of “swallowing one’s tongue” are things that may happen to a patient during a seizure: choking, becoming mute, or even dying. Perhaps the modern belief in the myth arose from a conflation of idiomatic usage of the phrase (perhaps meaning not speaking, choking, or dying) and the observation of presumed airway blockage from a relaxed tongue after the seizure.
      Table 1Various world languages’ idiomatic use of the literal phrase “to swallow one’s tongue”.
      LanguageIdiomatic meaning of “to swallow one’s tongue”
      French“To die” [
      • Henley W.E.
      Slang and its analogues past and present; a dictionary, historical and comparative, of the heterodox speech of all classes of society for more than three hundred years. With synonyms in English, French, German, Italian, etc.
      ] (1890, possibly archaic)
      Russian“To fall silent; to stop talking” [
      • Dubrovin M.I.
      A book of Russian idioms illustrated.
      ]
      Bulgarian“Lose ability to talk from great emotion” [
      • Todorova M.
      Morpho-syntactic properties of Bulgarian verbal idiomatic expressions.
      ]
      GeorgianA somatic idiomatic expression for “Fear” [
      • Lobzhanidze I.
      Similar ways of forming idioms in Georgian, Udi and Russian.
      ]
      Turkish“Not to be able to talk due to fear or excitement” [
      • Bas M.
      Conceptualization of emotion through body part idioms in Turkish: a cognitive linguistic study.
      ]
      An early English language medical reference to swallowing one’s tongue was found in an 1884 journal, The Medical News. In an article, Thomas describes the case of a physician treating “a fourteen-day old infant who, on being given for the first time a few drops of medicine from a spoon, not knowing what to do under the unusual circumstances, swallowed its tongue” [
      • Thomas R.H.
      Spasmodic retraction of the tongue.
      ]. There are even rare cases described in 1858 and 1933 where one has literally bitten off a piece of tongue and swallowed it during a seizure [
      • Sieveking E.H.
      On epilepsy and epileptiform seizures: their causes, pathology, and treatment.
      ,
      • Löwenstein O.
      Über klinisch-kinematographische Epilepsie-Beobachtung und die Prinzipien einer experimentellen „Anfalls"-Analyse.
      ]. Since then, there have been numerous allusions to “swallowing one’s tongue” in the medical and paramedical literature, nearly always in the context of epilepsy and seizures. The term was later used frequently and without clear figurative or idiomatic explanation in sources from various fields including police training [
      Daily Training Bulletin of Los Angeles Police Department.
      ], school health [
      • Anderson C.L.
      School health practice.
      ], psychiatry [
      Ohio division of mental hygiene.
      ], and even an epilepsy-specific publication [
      • Livingston S.
      Living with epileptic seizures.
      ].
      Interestingly, more nuanced language is used by the authors in The Management of Epilepsy in 1974, who write "tracheal obstruction from secretions, vomitus or ‘tongue swallowing’ may occur if prompt measures are not taken to maintain an adequate air passage” [
      • Aird R.B.
      • Woodbury D.M.
      The management of epilepsy.
      ], perhaps implying idiomatic or non-literal usage. In his 1975 book Understanding and Living with Brain Damage, Logue uses the term but later explains, “what seems to be a swallowed tongue is the air passing over the relaxed tongue of the individual and creating a disturbing rattle," again possibly implying non-literal usage [
      • Logue P.E.
      Understanding and living with brain damage.
      ]. Wright clearly states in 1975 that a patient swallowing one’s tongue is “of course anatomically impossible,” but goes on to describe the possibility for “the tongue to become limp and slide backward to obstruct the entrance to the trachea immediately after the attack” [
      • Wright G.N.
      Epilepsy rehabilitation.
      ]. Finally, in a 1988 article from the journal Health, it is explicitly stated that “the tongue can fall back and block the airway. That's what is meant by ‘swallowing your tongue.’ (See 'Myth of the Month')” [
      • Unknown
      Unknown. Health (Irvine Calif).
      ], indicating clear non-literal use of the term. They then pertinently go on to state, “Don't put anything into the person's mouth."
      More recent sources have continued to use the phrase “swallowing one’s tongue” instructively. For example, the 1990 book The Management of Chronic Disease advises, “if it is possible to lie [the victim] down in the lateral position (to prevent swallowing of the tongue or vomit) so much the better" [
      • Schofield T.
      Continuing care: the management of chronic disease.
      ]. Additionally, the 2010 edition of Guyton and Hall Textbook of Medical Physiology states that during a seizure, a patient "often the person bites or ‘swallows’ his or her tongue and may have difficulty breathing, sometimes to the extent that cyanosis occurs" [
      • Hall J.E.
      • Guyton A.C.
      Guyton and hall textbook of medical physiology.
      ], though their use of quotation marks may indicate a figurative or even historic usage of the phrase.

      3. Tracing the rise and fall of the standard practice of placing objects in a patient’s mouth

      Early sources regarding the treatment of epilepsy were notable for their relative lack of prescribed action to take during a seizure. In his 1796 dissertation for the degree of Doctor of Medicine, John Otto writes, “instead of danger and misery exciting our attention in proportion to their degree, we remain idle spectators, and leave the patient to his fate” [
      • Otto J.C.
      Inaugural essay on epilepsy.
      ]. Similarly, in the 1872 novel Poor Miss Finch, a physician watching a patient during a seizure only “loosened his cravat and moved away the furniture that was near him…looking at the writhing figure on the floor.” When asked "Can you do nothing more?" he answered, "Nothing more" [
      • Collins W.
      Poor miss finch.
      ]. The first clear English language references to placing objects in a patient mouth during a seizure we found were by John Comfort in 1850 who notes that, "patients are apt to injure the tongue during the paroxysm of epilepsy, unless prevented by the insertion of a piece of wood or cork, between their teeth" [
      • Comfort J.W.
      The practice of medicine on Thomsonian principles.
      ], and Gowers in 1881 writing, “little treatment is needed during the attacks of epilepsy. In patients who bite the tongue, a cork, or better, a small piece of India rubber, should be forced between the teeth, and thus the tongue-biting may often be prevented” [
      • Gowers W.R.
      Epilepsy and other chronic convulsive diseases.
      ]. Finally, Thomas’ 1884 case report describes a physician who saved the infant who “swallowed its tongue” by manually “drawing the tongue forward” [
      • Thomas R.H.
      Spasmodic retraction of the tongue.
      ].
      The practice of placing objects into a seizing patient’s mouth has been given credence and perpetuated through various sources over time, though it is important to note that the justification varies between prevention of tongue swallowing and concern about potential tongue injury. Between 1945–1991, many sources continued to recommend practices including using the hand or an object to pull the tongue forward to prevent swallowing the tongue or placing an object between the teeth to prevent tongue or lip injury. These sources were again from a broad range of fields including police training [
      Daily Training Bulletin of Los Angeles Police Department.
      ], school health [
      • Anderson C.L.
      School health practice.
      ], nursing [
      • Eliason E.L.
      Surgical nursing.
      ,
      ,
      • Black R.B.
      • Hermann B.P.
      • Shope J.T.
      Nursing management of epilepsy.
      ], psychiatry [
      Ohio division of mental hygiene.
      ], preventive medicine [
      • Butler K.
      • Rayner L.
      The best medicine: the complete health and preventive medicine handbook.
      ], oral maxillofacial surgery [
      • Davis K.
      Training manual for oral and maxillofacial surgery assistants.
      ], and even epilepsy-specific publications [
      • Livingston S.
      Living with epileptic seizures.
      ,
      • Aird R.B.
      • Woodbury D.M.
      The management of epilepsy.
      ] (Table 2).
      Table 2Various 20th Century nonfiction references to “swallowing one’s tongue” during a seizure or placing objects into a seizing person’s mouth.
      YearTitlePractice RecommendationJustificationQuote
      Prevention of tongue swallowing
      1954Daily Training Bulletin of Los Angeles Police Department [
      Daily Training Bulletin of Los Angeles Police Department.
      ]
      Manually pull tongue forwardPrevent tongue swallowing"…swallowed his tongue. If he has, pull his tongue back into his mouth so that he will not strangle, using care to avoid being bitten…"
      1955Psychiatric Aide Manual [
      Ohio division of mental hygiene.
      ]
      Manually pull tongue forwardPrevent tongue swallowing"Prevent swallowing of the tongue by grasping it and pulling it forward if necessary."
      1963Living with epileptic seizures [
      • Livingston S.
      Living with epileptic seizures.
      ]
      Placing object between the teethPrevent tongue swallowing"…that extreme vigilance should be exercised during an epileptic seizure to prevent the patient from swallowing his tongue."

      "insertion of object between teeth"
      1968School Health Practice [
      • Anderson C.L.
      School health practice.
      ]
      Use object to guide the tongue forwardPrevent tongue swallowing"If the subject is swallowing his tongue, there will be an audible gurgling in the throat.”

      "…necessary to hold the tongue forward for several minutes. If a wooden stick is not available, something else, such as rubber, may be used to hold the mouth open."
      1974The Management of Epilepsy [
      • Aird R.B.
      • Woodbury D.M.
      The management of epilepsy.
      ]
      Use object to guide the tongue forwardPrevent tongue swallowing"Tracheal obstruction from secretions, vomitus or "tongue swallowing" may occur if prompt measures are not taken to maintain an adequate air passage. Turning the patient over so that the tongue will fall forward rather than backwards, the use of a throat stick to guide the tongue forward if necessary…"
      1991Abnormal Psychology [
      • Holmes D.S.
      Abnormal psychology.
      ]
      Placing object between the teethPrevent tongue swallowing“During the convulsion, it is necessary to put something in the patient's mouth to prevent swallowing of the tongue."
      Prevention of tongue biting or lip injury
      1945Public Health Nursing [
      ]
      Placing object between the teethPrevent tongue or lip injury"…if it can be slipped between his teeth easily enough, will keep him from biting his tongue."
      1955Surgical Nursing [
      • Eliason E.L.
      Surgical nursing.
      ]
      Placing padded tongue blade between the teethPrevent tongue or lip injury“A padded tongue depressor should be placed between the molar teeth to prevent the tongue from being bitten”
      1979Training Manual for Oral and Maxillofacial Surgery Assistants [
      • Davis K.
      Training manual for oral and maxillofacial surgery assistants.
      ]
      Placing padded tongue blade between the teethPrevent tongue or lip injury"If feasible, a padded tongue blade or gag should be placed between the patient's teeth to prevent injury to the lips and tongue."
      1982Nursing Management of Epilepsy [
      • Black R.B.
      • Hermann B.P.
      • Shope J.T.
      Nursing management of epilepsy.
      ]
      Placing soft object between the teethPrevent tongue or lip injury"A soft object may be placed between the teeth to prevent tongue biting, but one should wait until the clonic phase when the mouth opens."
      1985The Best Medicine: The Complete Health and Preventive Medicine Handbook [
      • Butler K.
      • Rayner L.
      The best medicine: the complete health and preventive medicine handbook.
      ]
      Placing soft object between the teethPrevent tongue or lip injury"Tongue biting may be prevented by placing a pad between the teeth, but be sure it is too large to swallow, like a folded handkerchief."
      As early as 1948, in a Control of Communicable Diseases report from California, authorities recommended to "avoid use of any metal objects between teeth, since patients frequently break their teeth on them” [
      Control of communicable diseases in California.
      ]. In 1965, Nemir astutely notes in a school health textbook that, "more epileptic individuals' teeth and gums have been injured by well-intentioned but misguided efforts to prevent biting than by the biting itself" [
      • Nemir A.
      The school health program: a textbook for teachers, school nurses, and school administrators, and others who are concerned with the health of school-age youth.
      ]. Finally, in a 1971 book on Maternal and Child Health nursing, the authors state that, "the Epilepsy Society does not advise the general public to place anything into the patient's mouth" [
      • Ingalls A.J.
      • Salerno M.C.
      Maternal & child health nursing.
      ]. Despite these early and clear recommendations against the practice, relatively late sources have continued to recommend the practice of placing objects in the seizing patient’s mouth. For example, the 1991 edition of Abnormal Psychology states, “during the convulsion, it is necessary to put something in the patient's mouth to prevent swallowing of the tongue" [
      • Holmes D.S.
      Abnormal psychology.
      ].
      It bears mentioning that various biteguards and oral protection techniques are still used today during electroconvulsive therapy to prevent tongue and lip injury [
      • Muzyka B.C.
      • Glass M.
      • Glass O.M.
      Oral health in electroconvulsive therapy.
      ,
      • Minneman S.A.
      A history of oral protection for the ECT patient: past, present, and future.
      ], which is a very different situation than unexpected seizures given that the biteguard can be placed properly prior to the anticipated seizure. Similarly, some clinicians have recommended that a tongue wedge or soft flexible mouth guard can safely be used during seizures in specific scenarios such as when patients have prolonged auras [
      • Wyllie E.
      Treatment of epilepsy.
      ]. Our recommendation, consistent with guidelines [
      • Chillemi S.
      • Devinsky O.
      What to do if someone near you is having a seizure.
      ,
      • Freeman A.
      • Li Nelson
      What to do when someone has a seizure.
      ,
      • Osborne-Shafer P.
      First aid for seizures - stay, safe, side.
      ], is to avoid placing ALL objects in the mouth in order to maintain a simple, uniform message to the public; we have seen there are numerous ways the public has misunderstood the medical recommendations on this issue .
      Table 3Comparison of opinions on prevention of oral trauma and/or tongue swallowing in seizing patients. Shown is the percentage of those surveyed who felt it was appropriate to place an object in the patient’s mouth, and the exact phrasing used by the survey. Studies are divided as to whether the purported aim of inserting an object into the patient’s mouth was to prevent tongue swallowing, prevent tongue biting, or the purpose was not explicitly stated.
      CountryRespondents (n)% Responding PositivelyPhrasing
      Prevention of tongue swallowing
      Long et al. [
      • Long L.
      • Reeves A.L.
      • Moore J.L.
      • Roach J.
      • Pickering C.T.
      An assessment of epilepsy patients’ knowledge of their disorder.
      ]
      United StatesPatients with epilepsy (175)41.0“To stop me from swallowing my tongue, an object should be placed in my mouth”
      Prevention of tongue biting
      Martino et al. [
      • Martino T.
      • Lalla A.
      • Carapelle E.
      • Di Claudio M.T.
      • Avolio C.
      • d’Orsi G.
      • et al.
      First-aid management of tonic-clonic seizures among healthcare personnel: a survey by the Apulian section of the Italian League Against Epilepsy.
      ]
      ItalyPhysicians (81)45.7“Put immediately something in the mouth to avoid tongue bite”
      Other healthcare workers (67)64.2
      Baxendale & O’Toole [
      • Baxendale S.
      • O’Toole A.
      Epilepsy myths: alive and foaming in the 21st century.
      ]
      United KingdomUniversity staff & students (4605)32.9“Put something in their mouth to stop them from biting their tongue”
      Huang et al. [
      • Huang M.C.
      • Liu C.C.
      • Huang M.C.
      • Thomas K.
      Parental responses to first and recurrent febrile convulsions.
      ]
      TaiwanParents of children with febrile seizures (216)37.6“Put protective devices into mouth to prevent tongue injury during convulsion”
      Reason not explicitly stated
      Alkhotani et al. [
      • Alkhotani A.M.
      • Almalki W.M.
      • Alkhotani A.M.
      • Turkistani M.A.
      Makkah female teachers’ knowledge of seizure first aid.
      ]
      Saudi ArabiaSchool teachers (426)55.2“Open mouth and insert object”
      Nishina & Yoshioka (2018) [
      • Nishina Y.
      • Yoshioka S.I.
      A survey of epilepsy-related knowledge, attitudes and practices of home healthcare nurses in the San-in region of Japan.
      ]
      JapanHome healthcare nurses (285)29.8“Place something inside the mouth”
      Kolahi et al. [
      • Kolahi A.A.
      • Ghorbanpur-Valukolaei M.
      • Abbasi-Kangevari M.
      • Farsar A.R.
      Knowledge, attitudes, and first-aid measures about epilepsy among primary school teachers in northern Iran.
      ]
      IranPrimary school teachers (342)73.7“Attempt to open the mouth to put something between jaws”
      Ekeh et al. [
      • Ekeh B.C.
      • Ekrikpo U.E.
      The knowledge, attitude, and perception towards epilepsy amongst medical students in Uyo, Southern Nigeria.
      ]
      NigeriaMedical students (232)31.0“Put something in his mouth”
      Eze et al. [
      • Eze C.N.
      • Ebuehi O.M.
      • Brigo F.
      • Otte W.M.
      • Igwe S.C.
      Effect of health education on trainee teachers’ knowledge, attitudes, and first aid management of epilepsy: an interventional study.
      ]
      NigeriaUniversity students (226)62.2“Insert spoon/object into his mouth”
      Chomba et al. [
      • Chomba E.N.
      • Haworth A.
      • Atadzhanov M.
      • Mbewe E.
      • Birbeck G.L.
      Zambian health care workers’ knowledge, attitudes, beliefs, and practices regarding epilepsy.
      ]
      ZambiaPhysicians & nurses (276)58.8“Put something hard in his or her mouth”

      4. Perpetuation of these ideas in popular media

      Further perpetuating the myth of tongue swallowing during seizures has been the popular literature and media. Several novels have described passages involving placing objects in a patient’s mouth during a seizure. For instance, in Muriel Sparks’ The Bachelors (1961), while observing a seizure taking place, one of the characters states that, "he [another character] could bite his tongue in the meantime…I'd shove in the wedge if I were you." In Ken Kesey’s novel One Flew Over the Cuckoo’s Nest (1962), two seizures are managed when a character pries a seizing patient’s “mouth open and shoves the stick between his teeth,” and later “put a wallet between his teeth to keep him from chewing his tongue” [
      • Kesey K.
      One flew over the cuckoo’s nest.
      ]. The myth has made its way into children’s literature as well: in Madeline L’Engle’s A Ring of Endless Light (1980), for example, a character states after witnessing a seizure, "she had a convulsion…I put the shawl in her mouth to keep her from swallowing her tongue…" Ironically, the nurse’s reply only serves to reinforce the myth. L’Engle, likely thinking that she was simply reflecting the thinking of the times, has the nurse praise the girl’s actions by saying, “good girl” [
      • L’Engle M.
      A ring of endless light.
      ]. Even nearly two decades later, popular literature continues to make reference, even obliquely, to the potential for tongue injury. In Sylvia Nassar’s A Beautiful Mind (1998), the narrator, after experiencing a seizure describes, “…the taste of blood in my mouth, my tongue is raw. The gag must have slipped today” [
      • Nasar S.A.
      Beautiful mind.
      ].
      Disturbingly, the perpetuation of the myth of the swallowed tongue does not end with literary examples. Scenes of incorrect or improper seizure first aid can be seen in movies ranging from One Flew Over the Cuckoo’s Nest (1975), to A Beautiful Mind (2001), and Black Hawk Down (2001). All of these films clearly show a seizing patient having something placed in his or her mouth. With regard to the portrayal of seizures on television, in 2011, Moeller et al. systematically rated the seizure management in seizures on television programs, and reported that first aid management was deemed appropriate in 21 (32.3 %) seizures, inappropriate in 28 (43.1 %), and indeterminate in 16 (24.6 %). More specifically, 11 (16.9 %) television seizures depicted a character putting something in the seizing person's mouth [
      • Moeller A.D.
      • Moeller J.J.
      • Rahey S.R.
      • Sadler R.M.
      Depiction of seizure first aid management in medical television dramas.
      ]. Since then, in the popular series Game of Thrones episode “The Climb,” a character has a vision which causes a seizure, during which another character promptly plugs his mouth with a leather strap [
      • Sakharov A.
      • Benioff D.
      • Weiss D.B.
      • Katznelson D.
      • Ottey O.N.
      Game of thrones: “the climb”.
      ]. Of note, these examples from film and television media may be particularly powerful in reinforcing the myth today given their typically much larger audience, and the potential for higher staying power from “seeing” rather than reading the act.

      5. Current beliefs regarding the practice of placing objects in the patient’s mouth

      The belief that an object should be inserted into the mouth of an actively seizing patient remains highly prevalent among healthcare workers, patients, and the general public. This belief stems not only from a perceived need to prevent tongue biting or oral trauma, but also to prevent swallowing of the tongue and maintain patency of the airway. Several surveys from around the globe have repeatedly demonstrated that a substantial proportion of both healthcare professionals and the general public believe that it is advisable to insert something into the mouth of a seizing patient (Table 3). Though the exact phrasing is varies regarding whether this should be done to prevent tongue swallowing, oral trauma, or both, it is clear that the belief remains highly prevalent. This is, of course, in direct opposition to recommendations for seizure first aid from several organizations including the Epilepsy Foundation, Epilepsy Action, and the American Academy of Neurology [
      • Chillemi S.
      • Devinsky O.
      What to do if someone near you is having a seizure.
      ,
      • Freeman A.
      • Li Nelson
      What to do when someone has a seizure.
      ,
      • Osborne-Shafer P.
      First aid for seizures - stay, safe, side.
      ].

      6. Associated harms

      Data on the frequency of oral trauma resulting from insertion of an object into a seizing patient’s mouth are generally lacking. One series of 75 children in Nigeria presenting with febrile seizures found that 35 (47 %) had a spoon inserted into their mouth by a caregiver [
      • Ndukwe K.C.
      • Folayan M.O.
      • Ugboko V.I.
      • Elusiyan J.B.E.
      • Laja O.O.
      Orofacial injuries associated with prehospital management of febrile convulsion in Nigerian children.
      ]. Of these, 26 (75 %) sustained an injury, including laceration, bruising, or dental subluxation or avulsion [
      • Ndukwe K.C.
      • Folayan M.O.
      • Ugboko V.I.
      • Elusiyan J.B.E.
      • Laja O.O.
      Orofacial injuries associated with prehospital management of febrile convulsion in Nigerian children.
      ]. Notably, these injuries far exceeded the number of orofacial injuries in patients who did not have anything inserted into the mouth; there was only one such injury reported in this group [
      • Ndukwe K.C.
      • Folayan M.O.
      • Ugboko V.I.
      • Elusiyan J.B.E.
      • Laja O.O.
      Orofacial injuries associated with prehospital management of febrile convulsion in Nigerian children.
      ]. Coincidentally, another series of 257 Nigerian children presenting with seizure found that all of the orofacial injuries (13) occurred in those who had a hard object inserted into the mouth; there were no injuries in children who did not have anything inserted into the mouth [
      • Adeyemo W.L.
      • Fajolu I.B.
      • Temiye E.O.
      • Adeyemi M.O.
      • Adepoju A.A.
      Orofacial and dental injuries associate dwith seizures in paediatric patients in Lagos University Teaching Hospital.
      ].

      7. Tongue anatomy and function: the impossibility of swallowing one’s tongue

      The human tongue is not one single muscle but is rather composed of several skeletal muscles. These include the genioglossus, styloglossus, hyoglossus, palatoglossus, transverse muscle, vertical muscle, and the superior and inferior longitudinal muscles [
      • Abd-El-Malek S.
      Observations on the morphology of the human tongue.
      ,
      • Berkovitz B.K.
      • Moxham B.J.
      Head and neck anatomy: a clinical reference.
      ]. Anatomically, these muscles are divided into two groups: intrinsic and extrinsic. Intrinsic muscles have both their origin and insertion within the tongue, whereas extrinsic muscles have one bony attachment and one insertion in the tongue [
      • Abd-El-Malek S.
      Observations on the morphology of the human tongue.
      ]. The intrinsic muscles (transverse, vertical, superior longitudinal, and inferior longitudinal) serve in general to alter the shape of the tongue, while the extrinsic muscles (genioglossus, styloglossus, hyoglossus, and palatoglossus) move the whole tongue [
      • Berkovitz B.K.
      • Moxham B.J.
      Head and neck anatomy: a clinical reference.
      ,
      • Sanders I.
      • Mu L.
      A 3-dimensional atlas of human tongue muscles.
      ]; though this dichotomy has been debated by some [
      • Gilbert R.J.
      • Napadow V.J.
      • Gaige T.A.
      • Wedeen V.J.
      Anatomical basis of lingual hydrostatic deformation.
      ]. A complex array of interdigitated muscle fibers allows for an essentially limitless number of conformations of the tongue in a variety of directions [
      • Gilbert R.J.
      • Napadow V.J.
      • Gaige T.A.
      • Wedeen V.J.
      Anatomical basis of lingual hydrostatic deformation.
      ].
      The tongue’s anterior attachment to the floor of the mouth via the lingual frenulum is an often cited reason why tongue swallowing during a seizure is impossible [
      • O’Connor A.
      The claim: during a seizure, you can swallow your tongue.
      ]. However, a more detailed exploration of tongue movements, particularly as they pertain to retrusion (posterior movement of the tongue towards the pharynx), will explain why occlusion of the airway by the posterior tongue is also not possible. Hypothetically, it is this retrusive motion of the tongue that could result in “swallowing” the tongue during a seizure. During swallowing, a food bolus is swept posteriorly by a sequential squeezing of the tongue against the hard palate that moves in an anterior-to-posterior direction and forces the bolus towards the pharynx (Fig. 1) [
      • Matsuo K.
      • Palmer J.B.
      Anatomy and physiology of feeding and swallowing – normal and abnormal.
      ]. This retrograde propulsion of the tongue is accomplished by synergistic contraction of the genioglossus, hyoglossus, styloglossus, and inferior longitudinal muscles [
      • Gilbert R.J.
      • Napadow V.J.
      • Gaige T.A.
      • Wedeen V.J.
      Anatomical basis of lingual hydrostatic deformation.
      ]. However, this coactivation of both protrusors (genioglossus) and retrusors (styloglossus, hyoglossus) has been shown to dilate and stiffen the airway, thereby preventing airway occlusion by the tongue [
      • Oliven A.
      • Odeh M.
      • Geitini L.
      • Oliven R.
      • Steinfeld U.
      • Schwartz A.R.
      • et al.
      Effect of coactivation of tongue protrusor and retractor muscles on pharyngeal lumen and airflow in sleep apnea patients.
      ]. Furthermore, experimental stimulation of muscles that produce tongue retrusion (either isolated stimulation of the retrusors or co-stimulation of retrusors and protrusors) not only causes stiffening and depression of the tongue, but in fact leads to a less collapsible airway with improved pharyngeal airflow [
      • Fuller D.D.
      • Williams J.S.
      • Janssen P.L.
      • Fregosi R.F.
      Effect of co-activation of tongue protrudor and retractor muscles on tongue movements and pharyngeal airflow mechanics in the rat.
      ,
      • Eisele D.W.
      • Smith P.L.
      • Alam D.S.
      • Schwartz A.
      Direct hypoglossal nerve stimulation in obstructive sleep apnea.
      ]. Thus, airway patency is maintained even when the tongue is displaced posteriorly and downwards.
      Fig. 1
      Fig. 1MOVEMENT OF THE TONGUE DURING NORMAL SWALLOWING.
      Legend: Drawings based on a videofluorographic recording. The body of the tongue is indicated by the crosshatch pattern. (A, B) The bolus is held between the anterior tongue and hard palate, then is propelled backwards by the tongue. (C) The soft palate then elevates, and the bolus is moved further by the tongue making contact with the palate. (D) The upper esophageal sphincter opens, and the tongue retracts towards the pharyngeal wall. (E) The soft palate descends, the pharynx and larynx re-open, and the esophageal sphincter returns to its closed position.
      Modified from Phys Med Rehabil Clin N Am, 19(4), Matsuo K, Palmer JB, Anatomy and physiology of feeding and swallowing - Normal and abnormal, 691–707, Copyright (2008), with permission from Elsevier.

      8. Conclusions

      Consistent with the recommendations of the past several decades, there is ample evidence warning against the practice of placing objects into a seizing person’s mouth. However, though the reason cited for doing this varies, people still state they believe one can “swallow their tongue” during a seizure. In some primary sources, how literal the author or speaker is being when they say this is not always clear. What is clear, however, is that this was not always the recommended treatment method during a seizure, and the belief may have arisen and grown due to well-intended but factually incorrect literature, folk tales, or even misinterpreted metaphor. Additionally, much public education work is needed to reverse the popular belief in these ideas, which may prove to be a “mythic” challenge. We advise against using of the phrase “tongue swallowing” in the context of seizures, and we emphasise recommendations against placing objects into a seizing person’s mouth. Moreover, we believe it is the duty of neurologists to speak out against misinformation about this issue, as continuing this myth will only harm more of our patients.

      Funding sources

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Financial disclosures

      Kyle Rossi – Reports no disclosures.
      Alexander Baumgartner – Reports no disclosures.
      Shira Goldenholz – Reports no disclosures.
      Daniel Goldenholz – Received grants from NIH, a BIDMC departmental grant, and is an advisor for Magic Leap and Epilepsy AI, none of which are relevant to the present manuscript.

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