S.KEY561]	CLINICAL PICTURE	563
which entirely disappears as the infection passes. Severe constipation is
sometimes a feature of an attack and may be due to this cause.
The spleen becomes enlarged in at least half the cases, but it is rarely Spleen and
more than just palpable beneath the costal margin. The condition usually ^lmr
develops towards the end of the attack and may persist for long periods,
even up to a year or more. The liver is less commonly enlarged but is
occasionally distinctly tender.
There is usually some complaint of sore-throat for a day or two at the Fauces
onset, but on examination little can be seen except a general redden-
ing of the fauces and pharynx. Exudation is present only in subjects
of previous tonsillitis. As Pfeiffer pointed out, the enlargement of the
glands is out of proportion to the changes in the pharynx.
The temperature is usually slightly raised during the prodromal period Temperature
and then rises sharply with the enlargement of the glands. The degree of
pyrexia varies fairly closely with the amount of glandular enlargement,
and the temperature tends to fall in the course of a few days as the
main mass of the glands subsides. The temperature rises again with any
recrudescence of enlargement of glands.
The constitutional symptoms are characteristically slight, even when Constitutional
the temperature is high and the glands are greatly enlarged. The patient symptoms
does not look or feel so ill as the size of the glands would suggest. Con-
stipation is apt to be troublesome, and vomiting occasionally occurs.
Epistaxis is not uncommon in growing children and may be sufficiently
severe to cause anaemia and temporary anxiety.
The main mass of the glands usually diminishes rapidly in the course
of three or four days, the temperature and constitutional symptoms
subsiding at the same time. In most cases this is the end of the acute
infection, although some glands may be palpable for several months
subsequently, but recrudescences are by no means uncommon either Recrud-
on the same or on the opposite side. Usually these are less severe than ^escences
the initial attack, but occasionally the first attack is mild and the second
the most severe. Recurrences occasionally extend over several weeks or
even months. There is a tendency for an attack to be followed by a
troublesome degree of debility which may last for six to twelve months, Ultimate
but there are not any permanent ill effects, and the prognosis is uni- P^r°s^nosis
formly good except in the event of the rare septic complications.
(2)—Anginose Type
This type is much rarer than the glandular, and it is doubtful whether
it should be described as a separate type or as a complication. The
disease does not appear to spread in the anginose form, and it is possible
that infectivity has passed before it develops. It is commonest between
the ages of fifteen and thirty years, although it may occur at younger
ages, but in small children it rarely attains the severity seen in young
adults.
There is usually a recognizable prodromal period of one to three weeks Prodromal
during which constitutional symptoms gradually increase in severity, ^penod