Dysphagia or difficulty of swallowing may result from simple debility, as in the moribund state; inflammation of the fauces, tonsils, or pharynx; stricture of the oesophagus; obstruction by a foreign body or by a cancerous or aneurismal tumor; retro-pharyngeal abscess; paralysis of the muscles of the throat, such as sometimes follows diphtheria. Soreness of the throat is present in some, but not in all of these examples of dysphagia, being most marked in the inflammatory condition of pharyngitis, tonsillitis, scarlet fever, and diphtheria. Ulceration of the throat should always be carefully looked for, and if present investigated to ascertain whether it is simple, diphtheritic, or syphilitic. We must be careful not to mistake a mere local accumulation of mucus, or aphthous vesicle, or the curd-like formation of thrush or muguet, either for ulceration or pseudo-membranous deposit. Aphthæ and thrush are most frequently met with in children, though small aphthous ulcers frequently appear toward the close of wasting, and especially cancerous, affections. If there be a doubt, pass a moistened hair pencil lightly over the apparent deposit, or allow the patient to gargle the throat with water, and then re-inspect it. Many causes may produce nausea and vomiting, which almost always occur together; that is, vomiting rarely takes place without previous nausea, although the latter may exist without the former. In the manner of vomiting there are some differences more or less characteristic, as the distressing retching of sea-sickness and of tartar emetic or other irritant poisoning, and the spasmodic out-spurting of rice-water fluid in malignant cholera. The matter vomited is often very important in diagnosis. In mere indigestion the food taken is apt to come up, and the same may happen in flatulent colic. When the liver is involved, as in bilious colic, bile also is ejected. Nothing peculiar exists in the ejecta of morning sickness in pregnancy. The ejecta contain mucus in gastritis, blood in ulcer and in cancer of the stomach, stercoraceous {163} material in obstruction of the bowels, black vomit in bad cases of yellow fever. Hysterical vomiting sometimes closely imitates the latter in appearance. Other affections attended by vomiting are cholera morbus, remittent fever, brain disease, Bright's disease of the kidney, etc. Spitting blood may be either hæmatemesis or hæmoptysis proper. If the former, nausea generally precedes the ejection of the blood by vomiting, and it is apt to be mingled with food partly digested. It is coughed up, bright red and frothy usually, when coming from the lungs or bronchial tubes. But blood may proceed from the gums or throat, or may run back through the posterior nares from the nose, and then it gives alarm by seeming to proceed from the chest. It is necessary to inquire very particularly into all such possibilities in every case of hemorrhage.