Diagnosis.—The chief difficulty in the diagnosis of tubercle of the pharynx lies in separating it from syphilitic ulceration of the same part. The distinction is, however, easier in the child than it is in the adult, for in young subjects the latter disease is almost invariably a congenital mal ady. If, then, by careful questioning of the parents, we can find no history of miscarriages on the part of the mother, or of syphilitic symptoms in the patient himself shortly after birth ; if the child bear about him no evidence of past syphilitic disease, such as flattened bridge of the nose, small pits, and linear cicatrices about the angles of the mouth, prominence of the fore head, opacity of the cornea, or enlargement of the spleen ; if, too, the per manent incisors have appeared and show no sign of malformation—in such a case we may exclude syphilis with tolerable certainty. If, on the other hand, a hereditary tendency to phthisis can be discovered, or if other chil dren of the family have .died with symptoms of tubercular meningitis, the evidence is in favour of tubercle. Still, a history of syphilis, although point ing strongly to this cause for the ulceration, does not make it certain that the pharyngeal disease is a result of the venereal taint, for a syphilitic child may fall a victim to tuberculosis. Nor, again, if signs of tubercle are to be discovered in other organs, can we, from this circumstance alone, positively exclude a syphilitic origin of the throat lesion, unless we are supported in this judgment by the family and personal history of the child. Fortunately, however, careful observations of the fauces itself furnishes sufficient evi dence. In syphilis, the ulcers have sharper edges, penetrate more deeply, tend to produce contractile scars, and have no gray nodules in their neigh bourhood. Tuberculous ulcers, as has been already remarked, are super ficial, as a rule, with irregular nodular, eroded, and undermined edges, and a cheesy floor. In their neighbourhood, gray miliary nodules are
seen underneath the epithelium. Moreover, in tuberculosis, the ulceration spreads very slowly, and the cervical glands are invariably enlarged. In syphilis, the extension is more rapid, and the glands of the neck are rarely indurated and swollen. Again, syphilitic ulceration is not accompanied by fever, while in tubercular pharyngitis the temperature is always elevated. The diagnosis will therefore rest upon the complete absence of all syphilitic history, either family or personal ; the appearance of the sores themselves, with the gray miliary nodules in their neighbourhood ; the enlargement of the superficial glands, and the presence of fever.
Prognosis.—The disease is always fatal ; and, indeed, the pharyngeal lesion tends to hasten the end by the rapid exhaustion it induces through the difficulty of supplying a sufficient quantity of nourishment. Death usually occurs in from two to six months.
Treatment.—Little can be done in the way of treatment in retarding the downward course of the illness. Nutritious food in small bulk, such as meat essence, pounded meat made liquid with gravy, yolks of egg, milk, etc., should be given ; and the strength of the patient may be also sup ported by doses of the brandy-and-egg mixture or port wine. If the child be unwilling or unable to swallow, nourishment must be administered by the stomach-tube passed through the nose.
We must endeavour to relieve the distress of the child by soothing ap plications. Brushing the affected part with glycerole of morphia is recom mended by Isambert. For a child of seven or eight years old, the strength of the application may be one grain in three drachms. Inhalations of steam also appear to relieve.