Symptoms.—The illness begins insidiously. Sometimes at first the general health alone seems to be impaired ; sometimes even from the be ginning the belly is noticed to be large. The child loses his sprightliness and begins to look pale and to droop. His appetite fails and he slowly wastes. There is almost always more or less fever, but this is at first slight and occurs irregularly. Afterwards it becomes more continuous and the temperature rises to a higher level.
Enlargement of the spleen, although not always noticed at an early period of the disease, is usually to be detected on careful examination. The limits of the organ should be always estimated by percussion as well as palpation. The degree of enlargement varies. In neither of my cases did the lower edge reach more than three fingers' breadths below the ribs, and there did not seem to be any great upward extension. In many cases, however, the increase in size is much greater. Some enlargement of the liver may also be noticed.
When the disease is fully developed, the child is pale and weakly look ing. His complexion is very white round the mouth and eyes, and at the sides of the nose ; but often there is a flush on the cheeks, which at times is noticed suddenly to disappear, leaving the face ghastly pale from the contrast. Often, especially when the disease is advanced, there is a pecu liar sallow, half-jaundiced tint of the skin. This has been attributed to the anemia, the altered blood being unable to destroy the bile pigment absorbed into it from the intestine. The belly is usually swollen from flatu, lent accumulation, as well as from enlargement of the liver and spleen. No tenderness is noticed on pressure of the abdomen, but if the bone medulla is diseased, pains in the limbs may be complained of in walking. There is no loss of elasticity of the skin. The is furred and the bowels are often capricious. Sometimes the stools are loose and slimy ; at other times there is constipation. The child may cough, and his breath ing may be short ; but unless a complication be present, examination of the chest discovers merely a little large-bubbling rhonchus at the bases of the lungs. The•pulse is quickened, especially at night. It is usually over 100, sometimes considerably so. In one of my cases—a little boy aged
two years and a quarter—the urine was high-coloured and offensive, and contained bile, but no albumen. There was some difficulty in holding it at night.
The temperature rises in the evening to between and 103°, sink ing to 99° in the morning. The fever, however, is very irregular, and on some days is much higher than it is on others. The skin may be moist at night, and sometimes there is copious perspiration. An examination of the blood discovers a great excess in the number of the white corpuscles.
As the disease goes on the child remains very fretful and pining. He sleeps badly at night and continues to lose flesh. His expression is verb distressed, and his face is white and haggard. He is thirsty, but cares little for food. Often 'hemorrhages come on, and these effusions form a very characteristic symptom. The nose may bleed, or blood may be dis charged by the mouth or by stool. Although usually a late symptom, hremorrhage is not always delayed until near the close of the illness. Epistaxis is sometimes noticed quite early in the disease.
Enlargement of lymphatic glands may occur, but this is rarely con siderable in a case of pure splenic leucocythemia, and pressure signs from this cause are rarely noticed. Towards the end of the disease cedema and dropsical effusions are common. There may be ascites or hydrothorax or oedema of the lung, and the lower limbs may swell and pit on pressure.
The fever usually perseveres to the end, and the child grows thinner and weaker. Various complications occur before the close, especially croupous pneumonia and pleurisy. Death is often preceded by an attack of convul sions, due, probably, to obstruction of the cerebral capillaries by masses of leucocytes, as described by Bastian.
Diagnosis.—The symptoms of leucocythemia are sufficiently character istic of the disease. Irregular pyrexia and general impairment of nutri tion, combined with a distressed, pallid face, a sallow complexion, a swollen abdomen, an enlarged spleen and liver, and the occurrence of epistaxis or inelna, point very distinctly to leucocythenaia ; and the diagnosis is at once confirmed by a microscopical examination of the blood.