72 ANDREWS. 



but is muffled sometimes. In one or two cases I thought I ob- 

 tained a distinct heart murmur when the infant was sleeping. 

 This could not be located. 



Respiratory sytem. — As a rule dyspnoea is present, and this 

 increases in intensity the longer the condition exists, until at 

 the end it seems that all the accessory muscles of respiration 

 are called into play. While a certain amount of dyspnoea is 

 nearly always present, periodic attacks come on in which it 

 seems that the child will die the next minute. In one such 

 case the attack came on at 5 o'clock in the evening and lasted 

 until 9 o'clock that night. I watched the child during this time. 

 It was moaning and sighing and very restless and its face became 

 cyanotic. It seemed almost impossible for it to get any air. 

 Apparently all the accessory muscles of respiration were called 

 into play. The intercostal and abdominal muscles were de- 

 pressed with every inspiration. A slight manifestation of 

 Cheyne-Stokes' respiration was present. At 9 o'clock the attack 

 wore off and the child, exhausted, sank into peaceful slumber. 

 The next morning my assistant reported that the child was smil- 

 ing and apparently well. That evening shortly after 5 o'clock 

 another attack came on somewhat severer than the former. 

 I remained with the child from 5 o'clock until 11 that night. 

 Its suffering was intense. During these attacks the respirations 

 were 112 per minute and the pulse from 160 to 180. It re- 

 mained in this condition until 3 o'clock the next morning when 

 it died. Auscultation showed that considerable oedema was pres- 

 ent in both lungs and an increase of fluid in the pleural cavities. 

 Acute attacks of dyspnoea, which are apparently due to acute 

 attacks of heart failure, are not uncommon in these cases. They 

 may appear every few days, or weeks may intervene between 

 attacks. In some a form of Chejme-Stokes' respiration is pres- 

 ent ; coughing is never a marked symptom, but does occur. The 

 normal bronchial breathing is present and rales of any kind 

 are unusual, unless oedema of the lungs is marked. I have seen 

 one or two cases in which there was apparently little or no 

 dyspnoea. 



Fever. — There is no fever in an uncomplicated case. Indeed 

 the temperature is slightly subnormal. 



Digestive system. — The abdomen may be distended and tym- 

 panitic, or it may be flat. Constipation is present in the majority 

 of cases; in some, slight diarrhoea is present; in others, the 

 bowels are normal. The child has a normal appetite and takes 

 the nipple greedily. 



