Great apathy and .dulness of mind are in many cases associated with the cachectic stage of the disease. The child may be found to sleep almost constantly, his senses seem dulled, and his wants are so little pressing that he asks for nothing and makes no complaint. Indeed, sometimes it is most difficult to get him to speak at all. The urinary function is rarely interfered with, but sometimes blood is passed with the urine. In a case reported by Dr. Goodhart—a little girl aged ten months—the child's water towards the end of the disease became red with blood.
The anemia is usually extreme. The whole surface of the body is ex cessively pale, and the mucous membranes are singularly bloodless. Pur puric spots may be found on the body, face, and limbs, and sometimes larger dark purplish blotches are seen from more extended extravasation. Flushing of the face is a common symptom, and a redness of the cheeks at this time forms a curious contrast with the dead whiteness persisting round the mouth and eyes. A microscopic examination of the blood shows the diminution in the number of the red corpuscles which has been alreadj referred to. The white corpuscles are rarely in notable excess. As a con sequence of the anx:mia (=edema may occur in the limbs, and there may be ascites. Pressure of the enlarged glands upon the venous trunks may also aid in the production of serous effusion.
A good example of the more common form of the disease, where the general constitutional disturbance occurs subsequently to the primary glandular enlargement, was seen in the case of a little boy, aged thirteen years, who was under the care of my colleague, Dr. Donkin, in the East London Children's Hospital. The boy came of a healthy family and had himself been strong and healthy until the age of eight years, when he was laid up for three months in consequence of a fall on his head and spine. In this illness the lad could not rest on his back or side, but was obliged to lie on his face. Although he began to walk again iu two months' time, and was convalescent at the end of the third month, he never recovered his strength completely. Twelve months after his illness he was again laid up with pains in the chest and swelling of the face and arms. The swell ing soon subsided, but the boy remained weak and complaining and was often under medical treatment.
On admission the patient complained of lumps in his neck which he stated were of three years' duration. For three months he had been losing
flesh and his belly had been growing larger. His skin, he said, had been dry for some time. His legs had never swelled, but he had noticed a swell ing of his scrotum for three or four days. He was subject to cramp-like pains about the umbilicus which were often severe, and the belly at these times was tender. He had had a cough for a month without expectoration, and his bowels had been relaxed for a week.
On examination the boy was found to be very thin, and his skin was dry, rough, and furfuraceons, especially about the belly. The cervical and submaxillary glands were enlarged on both sides so as to form a collar round the neck. The axillary and inguinal glands were normal. No en largement of the liver or spleen was noticed. The abdomen was distended, with fulness of the superficial veins. There was some tenderness on pressure below the umbilicus, and the tension of the parieties was in creased. No growth could be felt in the belly, and there was at first no ascites. There was some cedema of the scrotum, but none of the arms or legs. The tongue was red and rather raw-looking, and some superficial ulceration was noticed at the angles of the mouth and inside the left cheek. The bowels were relaxed, the stools being loose and lightish yel low in colour. There were signs of consolidation of the right lung. The urine was pale; slightly alkaline, but contained no albumen. An examin ation of the blood showed the absence of any excess of white corpuscles.
After admission the boy remained in a very apathetic state, and whether up or in bed seemed to be always drowsy. He would be found asleep with his head on his arms or curled up on a sofa. His face was habitually very pale, but at times it would flush up irregularly. He coughed occa sionally, and expectorated tenacious mucus. His temperature was always, high, rising at night to 103° or 104°. He continued to waste and grow weaker. Death was hastened by a severe attack of vomiting which pro duced great prostration, and he died soon afterwards.
After death the cervical, bronchial, retro-peritoneal, and mesenteric glands were found to be' enormously enlarged, forming agglomerated masses in which, however, individual glands could still be made out. The enlarged glands were very tough. On section, the larger number were of yellowish tint and seemed fibrous. but a few were grayish and translucent.