Chronic carditis in a child of nineteen months.

A.N., a boy and the only child, was stated to have been a fortnight premature and to have weighed 5j lb. at birth. Breast fed for one month, he was then given bottle feeds as his mother had insufficient milk. On this he thrived, and subsequent progress was normal with no history of any illness until his last. At 16 months he weighed 21 lb., and at 18 months he had 12 teeth and could walk and speak a few words. Both parents were healthy, and there was no history of illness during the mother's pregnancy. Three weeks before admission, at the age of 19 months, the child became fractious and appeared unwell. The only abnormal physical sign was stiff and painful middle fingers, but the general condition deteriorated and he was eventually sent to hospital. Clinical Examination. On admission the child was lying quietly, but resented disturbances. The cheeks and mucous membranes were pale, the limbs hypotonic, and the nails spoon-shaped. There was sweating and apparent recent loss of weight, the actual weight being 18 lb. 3 oz. The skull circumference was 191 in. (normal average at this age, 18 in.), and the anterior fontanelle admitted a finger tip, indicating delay in closing, which is normally complete at 18 months. The middle finger of each hand was semi-flexed and painful and slight oedema of the feet and lumbar region was noticed. The temperature was 990 F., respiration 40, and pulse 135 per minute. The blood pressure was 75/40. Scattered r'ales were noted. The apex beat was not localized on palpation, but on percussion the area of cardiac dullness extended three finger breadths to the left of the sternum in the fourth intercostal space and one finger breadth to the right in the third space. On auscultation a blowing apical systolic murmur,