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A CORRECT diagnosis lies at the foundation of all treatment of disease. The therapeutic advance of the last decade is valueless, unless we have kept pace with it in the differentiation of symptoms and proper relegation of effect to cause.

I will place upon the records of this Section the history of two cases which may help to show the necessity of careful scrutiny, even when the source of the symptoms seems to be plainly indicated. In both of these cases, which were cases of hemorrhage, the bleeding seemed to come from the lungs, and there were local evidences of pulmonary disease to sustain this verdict. In neither of them was this found to be true.

Miss D., æt. 22, teacher in one of the St. Louis public schools, consulted me last October, after having several hemorrhages of slight duration, at intervals of a week. Both father and mother had died of phthisis, and she had been the only child. This, with the fact that for some months she had had a hacking cough, at times pain iv the right infra-clavicular region, and some loss of flesh, suggested at once a careful examination of the chest. At the right apex, the site of the pain, I found dullness and prolonged expiratory murmur. However, the pain was not so great since the last hemorrhage. The opinion already expressed by her attendant physician, that the bleeding had been from a pulmonary lesion, seemed to be confirmed.

A few days after, it was my good fortune to see Miss D. during another attack of supposed hemoptysis. Noticing that the blood was unmixed with air, not very copious, and that there were no rales in any part of the chest, an examination of the throat was made. Blood was seen slowly trickling down

from behind the left tonsil; a cotton-covered probe holding a strong solution of Monsel’s-salt was pressed against the bleeding point, and soon the hemorrhage ceased. The tonsil being slightly enlarged, in a few days I cut away the projecting part, and made a few astringent applications to the base and surrounding tissues. Eight months have passed, and there has been no return of the bleeding. More than this, the young lady being relieved from the fear of progressive disease, and encouraged to persevere in right conduct of her case, has greatly gained in general health. The hemorrhage evidently came from the tonsilar artery, or possibly from a branch of the ascending palatine, for these anastomose.

A second case I saw in January of the present year. Mr. T., of Kansas, a merchant, æt. 35, tall, finely developed, and of good family in respect to phthisis. For several years he had been having slight hemorrhages at intervals of six or eight weeks, the last one, which occurred a fortnight prior to my seeing him, being considerable in amount. His physician, a most excellent practitioner, found evidences of disease of the right lung, and located the source of the hemorrhage there. Upon examination, I also found slight dullness and prolonged expiratory murmur at the right apex. He had been using nutrients for some months, and had gained flesh. There was no cough or other subjective evidence of phthisis. I was willing to accept the diagnosis already made, but, fortunately, in this case also a hemorrhage occurred soon after, and during the bleeding I saw him.

Remembering the case of Miss D., I examined the pharynx, and found blood coming from the upper pharyngeal region. Free use of the post-nasal syringe and an astringent solution soon caused the bleeding to cease. The next day, with the rhinoscope, I found a deep ulcer on the posterior surface of the soft palate. Touching this with the probe, hemorrhage recommenced. Under treatment, the ulcer soon healed, and there has been no return of the hemorrhage.

In this instance the lesion probably affected one of the divisions of the pharyngeal branch of the ascending pharyngeal artery, which supplies this surface in part, or it may have come from a branch of the palatine artery itself.

A fair deduction from these histories is, that in all cases of supposed hemoptysis, the larynx and pharynx should be exam

ined, especially if the pulmonary disease be incipient. If there be no physical evidence of lung lesion, such an examination is all the more important, especially if the hemorrhage be recurrent. In each of these cases the chest condition was such as to almost warrant the earlier diagnosis, had not the pharyngeal injury been discovered.

In conclusion, let me add that a great amount of ulceration in the pharynx is not necessary in order that hemorrhage should be induced. Here, as elsewhere, infarction of a bloodvessel may be the cause of rupture. Fatty degeneration may also destroy the epithelial cells and walls of the capillaries, with the same result. Laryngeal hemorrhage has been demonstrated by Hartman and others. That pharyngeal hemorrhage may occur repeatedly, and under such circumstances as to simulate hemoptysis, is also true.






By J. M. TONER, M. D.

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