Respirations

Day of

Direare

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Death

very weak, a moderate dilatation of the heart occurs; there is no vomiting. There were three such cases in our series, all fatal. These are so unusual that the charts are appended and a brief description given.

The first two illustrate the usual course in this type. In each case the disease was severe and treatment had been delayed for four or five days. The drop in the pulse rate was sudden and not accompanied by subjective symptoms until the rate was below 40; after this time a gradual dilatation of the heart occurred which continued until death. There was pallor, slight tibial oedema, marked diminution in the amount of urine which contained albumen in each case. Vomiting and epigastric pain and tenderness were not presThe patient failed gradually and death occurred a few days after the development of the bradycardia. The third case is of especial interest. varied between 30 and 40 for four days.

ent.

Here the pulse Three days later

it was 120 and a well marked gallop rhythm was present, which lasted for seven days.

From this time the patient slowly improved until the sixth week, when paralysis of extremities, palate, and muscles of deglutition and respiration developed which caused his death. The striking feature of this case is the fact that the patient survived the period of bradycardia and gallop rhythm, only to die of late paralyses.

We will now outline a brief clinical picture of the group of heart cases characterized by such symptoms as gallop rhythm, vomiting, epigastric pain and tenderness.

The appearance of gallop rhythm is usually indicated by an increase in the pulse rate. The pulse may increase in frequency for a day or so, often reaching 140 or more, when the gallop appears. In other cases it appears in comparatively few hours; usually the more rapid its appearance the more serious the outlook. By the time it is well marked the pulse is 140 to 160 or more, weak and thready and often

irregular at the wrist. The gallop may continue several days and the child be apparently not much affected except for a little pallor, loss of appetite and restlessness. Rapidly increasing prostration however soon follows, and the child becomes blanched and vomiting occurs.

Vomiting is apparently unattended by nausea, anything taken by mouth is almost immediately returned, and even if no food is taken vomiting in small amounts occurs. First, yellow fluid with mucus, and later brownish material containing altered blood. About the time that vomiting occurs the child complains of epigastric pain and tenderness, and on examination well marked spasm is found. These signs are not transitory but continue until death occurs or recovery begins. Very little urine is secreted; it nearly always contains albumen. There is often slight oedema over the shins, but no general edema. The respiration may be a little hurried but there is no dyspnoea. The heart is usually

moderately dilated.

The duration of life after these symptoms have developed is usually short, one to three days. The heart is dilated, the pallor becomes extreme, vomiting becomes more frequent, the vomitus running from the child's mouth, the pulse becomes more and more rapid, the child is restless and continually cries for water which if given is immediately returned mixed with altered blood. The pulse is finally lost at the wrist and death occurs in from 12 to 48 hours. Cyanosis is absent.

In other cases the gallop rhythm continues without much effect upon the child's condition. The pulse is rapid and weak and the heart may be dilated. There is no vomiting and no epigastric pain and tenderness, the gallop gradually grows less marked and finally disappears leaving the heart weak, irregular and rapid. Exertion may cause the gallop to reappear. This condition may last from a few days to several weeks. After recovery the heart is usually rapid, weak and irregular for weeks or months.