Our study relied on the memory of some of the 50 sword swallowers active in the English speaking world as well as some retired performers. Respondents could have exaggerated side effects, but it is more likely that details were overlooked. We did know of some incidents that involved non-respondents, and most serious events probably would have come to the attention of the association.
Some respondents swallowed a sword easily, but mastery for most required daily practice over months or years. The gag reflex is desensitised, sometimes by repeatedly putting fingers down the throat, but other objects are used including spoons, paint brushes, knitting needles, and plastic tubes before the swallower commonly progresses to a bent wire coat hanger. The performer must then learn to align a sword with the upper oesophageal sphincter with the neck hyper-extended. The next step requires relaxation of the pharynx and oesophagus and particularly the horizontal fibres of cricopharyngeus, which are not usually under voluntary control.3
Devgan et al have shown that one swallower was able to reduce voluntarily the resting pressure of this sphincter by 10-20 mm Hg.3
This swallower described having to “relax the muscles of his neck,” and several swallowers mentioned not being able to perform when they could not “relax” or the throat “closing up” when sore. Huizinga4
described a swallower who “sucked in” the sword, and a lateral radiograph in Huizinga's paper shows the pharynx filled with air, but preliminary air swallowing is not invariable. Force must not be used and the clean sword is usually lubricated at least with saliva. One performer used butter, and one had to retire because of a dry mouth caused by medication.
Once the swallower has got the sword past the cricopharyngeal sphincter and relaxed the oesophagus, he or she must learn to control retching so the sword can be passed down to the cardia. The cardia lies about 40 cm from the teeth and the sword straightens the flexible and distensible oesophagus. Further progress depends not only on the swallower learning to relax the lower oesophageal sphincter and controlling retching but also on the shape of the stomach. The angle of the gastro-oesophageal junction and lesser curve vary, being obtuse in the vertically oriented stomach, particularly when it is full, and more acute in the high horizontal stomach often present in thickset individuals (fig 2). A 220 cm giant is said to hold the record for the longest swallowed sword (82.5 cm) and body build should have a bearing on what length of sword can pass. Nevertheless, we did not find any correlation between the longest sword an individual could swallow and their size, suggesting other factors are important.
Fig 2 Barium radiographs showing the differing angle of the gastro-oesophageal junction in four individuals
Some experienced artistes add embellishments that increase danger. Some let the sword fall abruptly, a manoeuvre known as “the drop,” controlling the fall of the sword with the muscles of the pharynx, and some invite members of the audience to move the sword. One lies prone on a bed of nails; one sometimes performs on a unicycle; and another under water.
Sore throats—“sword throats”—occur when swallowers are learning, when performances are repeated frequently, or when odd shaped or multiple swords are used. Lower chest pains occur occasionally, most often after an obviously damaging swallow or when the “drop” is practised frequently. One performer described this pain after performing the drop 40 times a day in a state fair, and another described shoulder tip pain implying diaphragmatic irritation. Proprietary medicines are used for this problem, physicians are rarely consulted, and abstinence from swallowing swords is the main treatment.
Major injury is sometimes preceded by a previous painful performance, suggesting that minor injury may predispose to more serious damage. Occasionally a sword is difficult to advance or retract, presumably because of spasm or mucosal dryness related to nervousness or soreness. Overforceful efforts to move the sword may then cause trauma, and this resulted in oesophageal perforation in one performer. Several cases of perforation or severe haemorrhage occurred when swallowers used multiple or unusual swords or when a technical error was committed, often because of distraction. For example, one swallower lacerated his pharynx when trying to swallow a curved sabre, a second lacerated his oesophagus and developed pleurisy after being distracted by a misbehaving macaw on his shoulder, and a belly dancer suffered a major haemorrhage when a bystander pushed dollar bills into her belt causing three blades in her oesophagus to scissor. Of the 12 cases of probable perforation, including the two previously described in the literature, at least five involved the cervical or upper dorsal oesophagus with only one definite pharyngeal perforation. The other injuries were either lower down or the exact level of perforation was uncertain. All these patients survived, and no contacts of the association have died as a direct result of sword swallowing and no deaths have been reported in the medical literature. There is historical evidence elsewhere, however, and deaths from swallowing swords and other items such as neon tubes are described on the internet (www.swordswallow.com/halloffame.php
Comparison with endoscopic injury
The first endoscopy by Adolph Kussmaul in 1868 used mirrors and a gasoline lamp in a sword swallower,4
but rigid instruments, with their high rate of perforation, have largely been replaced.5
Patients injured during endoluminal procedures tend to be older and have pre-existing disease, the injuries usually complicating therapeutic manoeuvres.6
Iatrogenic perforation is sometimes not recognised until an instrument has passed well into the mediastinum of the patient, who is usually not fully conscious, and it tends to occur either adjacent to a lesion or where the pharynx narrows down to the oesophagus at or near Kilian's dehiscence.6
Most sword injuries were lower than this level, suggesting that the failure of a straight sword to negotiate the oesophageal lumen as it curves to fit the dorsal kyphosis may contribute to injury.
As in iatrogenic perforation, penetration is the main cause of injury but lacerations and scissoring injuries occur. A sword rarely passes out into the mediastinum and, although an injured swallower may realise that the performance has not proceeded smoothly, the injury may be recognised only when surgical emphysema, pain, or other symptoms develop, and there is often a delay before medical advice is sought.
Many factors, including delay and the size and site of the injury, have a bearing on outcomes. Mortality from iatrogenic perforation is quoted at 10-30%,7
but we did not find any deaths from sword swallowing.
Our 46 respondents collectively had swallowed over 2000 swords in the three months before we contacted them but the complications relate to their professional lifetimes. Although the risk of sustaining life threatening injury is low for an experienced swallower while relaxed and concentrating on swallowing a single sword, the risk over a career is high. The prognosis for a sword swallower who does sustain upper gastrointestinal injury seems better than for patients who suffer iatrogenic perforation.
What is already known on this topic
Two cases of perforation from sword swallowing have been reported in the English medical literature; other sources suggest deaths have occurred
What this study adds
Perforation or major haemorrhage occur infrequently
Pharyngeal problems are common particularly during the learning phase
Occasional chest pains are usually self treated
Many performers accept a financial as well as a physical risk