SYMPTOM A TOLOGY 



1301 



is suffering from alternate attacks of diarrhoea and constipation ; but 

 this is not always so, and some observers have recorded anorexia. 

 The motions may be very foul, containing undigested food, and at 

 times blood and mucus. Ulcerative stomatitis, and even noma, 

 may occur, and the last may appear on the face or on the genitalia. 

 Noma appears to be not uncommon in Greece. 



The spleen, as stated above, is always enlarged from the time 

 of the full establishment of the symptoms, but this enlargement is 

 not stationary. On the contrary, it steadily increases until an enor- 

 mous size is sometimes reached, so that it fills the left side of the 

 abdomen and projects across the median line into the right half, 

 causing the abdomen to bulge and become prominent. On palpa- 

 tion it is found to move, and notches may be felt through the 

 attenuated abdominal wall. It moves with the respiratory move- 

 ments, and may be altered in position from side to side, and up and 

 down by manipulation. There is not, however, any constant rela- 

 tionship between the progress of the disease and the size of the spleen. 

 Jemma, Di Cristina, and Critien state that it diminishes with a 

 persistent and profuse diarrhoea, especially during the last few days 

 of hfe. 



There is not always a concord between the temperature and the 

 pulse-rate; on the contrary, the latter is almost constantly rapid, 

 even during the apyrexial intervals, but may rise to 150 to 160 beats 

 per minute during attacks of fever. Hsemic murmurs may occur 

 over the heart, but are rare. The blood is pale, and shows a decrease 

 in the number of erythrocytes (1,500,000 to 3,000,000), and in 

 the haemoglobin (below 50 per cent.), which, however, is reduced 

 in proportion to the red corpuscles; and also in the leucocytes 

 (1,500 to 3,000), though the leucocytic formula is mononuclear (70 

 to 80 per cent.), being especially composed of medium-sized cells. 

 The mononuclears are increased at the expense of the polymorpho- 

 nuclear cells, which make up the remaining 20 to 30 per cent. 

 There is usually some poikilocytosis and anisocytosis, but nucleated 

 cells are rare or absent. The opsonic index is diminished below 

 that which is normal for a healthy child, and is especially low for 

 Bacillus coli communis, which is held to be responsible for the 

 frequency of the intestinal symptoms. (Edemas of the face, hands, 

 genitalia, and feet, coming on suddenly and disappearing suddenly, 

 are not unusual; they have a tendency to bilateral symmetry, but 

 are influenced by the position of the patient, and may occur at any 

 stage of the disease. At times they are painful and may show signs 

 of inflammation. 



The liver is very generally enlarged, but to a much less extent than 

 the spleen. On palpation, its edge is felt to be smooth and hard, 

 and is not tender. 



As the spleen and liver enlarge, the abdomen also enlarges and 

 becomes prominent, while the superficial veins may stand out 

 distinctly, and there may be a slight degree of ascites at times. 



The urine is usually normal, but there may be slight signs of albu- 



