A 
CASE 
OF 
PERICARDITIS- 
WALTER CHANNING, M. D. 
A. B. aged five, had cough in June 1834, which was thought 
to resemble hooping-cough. This was very slight, and I was 
not requested to see him. Towards the latter part of the 
month he suddenly fell lame of the left knee. This was ascribed 
by his parents to a sprain, from a fall during exertion in play. 1 
was requested to examine his knee. There was neither swell- 
ing, nor increased pain on pressure. Care was taken in walk- 
ing to favor this limb, and when he stopped walking he inva- 
riably rested the left foot on the instep of the right, as patients 
acquire the habit of doing in those chronic affections of the 
joints in which stiffness exists, or in which a difference in 
length in the limbs is produced. Just before this affection 
of the knee, a very slight attack of something resembling in- 
cipient fever was noticed. A mild cathartic, abstinence, and 
rest, were followed in a day or two by relief. Before the 
first of July the knee was well, or no complaint was made of 
it, or lameness noticed. I was desired to see him the 4th, 
of July, as he seemed less well than usual, though no particu- 2 
Case of Pericarditis. 
lar complaint was made. 1 found him still with cough, though 
this was not severe. He was unquiet, with variable spirits, 
and a less healthful aspect than when I last saw him. His 
pulse was quicker than in health, but not more so than could 
be explained by his constant activity, and the debility, though 
slight, which had followed his previous confinement on account 
of lameness. 
It had been arranged by his family to leave the city for the 
remainder of the summer, and it being their purpose to leave 
on the 4th, I advised they should do so, as the country offer- 
ed in its healthful air, and freedom from causes of excitement, 
the best opportunities for the completion of the convalescence 
which seemed to be making progress. He therefore left 
town on the 4th, which was Friday. 
Early the Sunday following, July 6th, I was requested to 
visit him, being at the same time informed by note that he had 
the previous night, or rather at three in the morning, been taken 
more severely ill than at any time since he had manifested any 
appearance of disease. I should have said that the drive to 
the country had not annoyed him in the least, and that he had 
passed Saturday with unusual freedom from all unpleasant feel- 
ings or marks of disease. On my arrival I learnt that at three 
in the morning he had been restless, with great heat of the 
skin, more cough, and marks of general distress. His greatest 
trouble was referred to the lower part of the chest, though 
there was a decided extension of uneasiness or pain complain- 
ed of across the upper part of the abdomen. A fact of some 
interest in connection with this latter difficulty was now stated. 
I was told that it had been a very common thing, almost of 
daily occurrence with my patient, to complain of pain in some 
part of the abdomen, especially after eating. His pain was of 
short duration, and generally went off suddenly. It had been 
noticed by his parents for a year or two. 
I found the patient relieved from some of the earliest 
symptoms with which he had been seized, but was still some- 
what feverish — his countenance was pale and languid, — his 
pulse rapid, — the skin hot and dry,— his tongue slightly fur- 
red. Occasional dry cough. As my patient, was some miles 
from town, and now threatened with severe disease, 1 advised 
his immediate return to the city. The arrangements for this 
were soon made, and about noon he reached home. I now 
examined the chest with much care. By auscultation the res- 
piratory murmur was heard over all parts of the chest, it was 
louder than natural, and without rale. Percussion gave a Case of Pericarditis. 
3 
healthful sound every where, except over the region of the 
heart. Here was some flatness, but the murmur of respiration 
was sufficiently audible, in the whole neighborhood of the 
heart. The treatment directed consisted in a solution of tar- 
tarized antimony in such doses as the stomach would hear, at 
intervals of from three to four hours, — an alterative pill of 
submuriate of mercury, opium, and antimony at bed-time, mild 
laxatives, and demulcent drinks, with liquid farinaceous diet. 
Under this course the symptoms subsided. There were, how- 
ever, attacks of pain referred to various parts of the trunk of 
the body, but more frequently than elsewhere to the epigastri- 
um and a little below it, corresponding to the place of the arch 
of the colon. Sometimes this so nearly resembled the trouble 
produced by flatus, or other causes of annoyance in the large 
intestines that emollient enemata were used, and notunfrequently 
with relief. Sometimes the pain would as suddenly disappear 
as it came, and before anything was exhibited. Frequently 
relief followed the extensive application of a camphor embro- 
cation to the chest and abdomen, and in the course of the dis- 
ease this remedy was frequently called for by the patient, and 
became a very favorite application with him. 
The amendment was gradual and seemed to promise to be 
permanent. This was, however, not the case, for an increase of 
symptoms gradually took place marked by some new phenom- 
ena. This was about the 12th of the month. The new 
symptoms were increased flatness on percussion about the 
region of the heart, — increased frequency, with a diminished 
force of the circulation,— dyspnoea, or rather short and pant- 
ing breathing, of uncertain continuance at any time, and almost 
always produced by moral causes, though these last might be 
slight, a dry cough, and this rare, and without pain. Ausculta- 
tion discovered no difference in respiration from what was no- 
ticed on the examination of the sixth. Over the portion of 
the chest in which percussion gave a flat sound, bellows 
sound was not perceived in the slightest degree; the action of 
the heart was found to be strong, but not irregular, and no pain 
was complained of in its region. Along with this aggravation 
of the disease the pains before-mentioned, as occurring in the 
trunk in various parts returned ; they however, were still refer- 
red to their former seats. 
The case thus far described had from its commencement 
been obscure. There were symptoms, both local and general, 
quite grave enough to explain the enfeebled condition of the Case of Pericarditis. 
patient, but he had in a short time risen from much that seemed 
to be their natural effects, and without known cause was again 
ill, with symptoms more serious than at any other time of 
the complaint. The new phenomena shed much light on the 
pathology of the case. I had never lost sight of the affec- 
tion of the knee before-mentioned. I had never been satis- 
fied that its explanation by the parents was the true one, 
and I could not but remember that it was upon the disap- 
pearance of the pain in that joint that symptoms, apparently 
very trifling, were soon developed, and that the gravest of these 
now present were little other than an exaggeration of the 
earliest movements of the disease. The state of the patients 
mind was quite striking. Naturally very intelligent, he seemed 
to have suddenly acquired extraordinary acuteness, weighing 
everything that was said with great care, to be sure that he 
understood its full amount. His senses were exceedingly 
acute, especially his hearing, which frequently produced no 
small embarrassment. He manifested an unusual antipathy 
to everything in the nature of medicine, and an accidental 
allusion to the subject, however slight, always produced more or 
less alteration in breathing and in the action of the heart. 
This, at times, amounted to a paroxysm of extreme distress, 
making it questionable if these might not do more of harm 
by their temporary aggravations of symptoms, than medicines 
would of good by any present or more permanent operation. 
From all these circumstances both moral and physical, present- 
ed by this case, the diagnosis was cleared of obscurity. I 
believed the disease to be pericarditis, that it was rheumatic, 
and that it was closely related with the affection of the knee 
which had so distinctly preceded it. 
The treatment adopted under these circumstances consisted 
in the application of leeches to the left chest, counter-irritants 
afterwards, colchicum, and a laxative; quieting mixture of mag- 
nesia and assafoetida at bed-time and in the night, as might be 
indicated. Under this treatment very marked relief took 
place. It was greater than after the first attack. He slept well 
at night, and was happy in the day ; his pulse fell to nearly 
or quite their natural standard,— about eighty beats in the 
minute ; the breathing became calm ; the flatness over and 
about the heart diminished ; the bowels were regular; and 
some desire for food was manifested. I found him in his chair 
on the 17th, cutting pieces of wood, a favorite occupation ; 
drawing on his slate, and his whole countenance and manner Case of Pericarditis. 
5 
showing from how much of a very heavy weight his system 
had been relieved, and how happy it made him to express in 
a variety of ways his sense of relief. ‘ I feel very well to-day, 
Doctor,’ was his cheerful greeting of me at my morning visit. 
During my examination, 1 asked him to step out of his chair 
and walk to a bureau which was within a step or two. This 
he did, and returned to his chair without any other mark of 
disease than the apparent weakness which a fortnight’s illness 
might be expected to produce. I left him with easier feelings 
than after any previous visit, and indulged strong expectation 
that any farther active measures, would be wholly unneces- 
sary. It hardly seemed necessary to continue farther medical 
attendance. 
I was called at noon to see my patient. He had been sud- 
denly seized at that time with a paroxysm more distressing 
than either of the others. His distress was universal. His 
breathing, seventy respirations in the minute, was accompanied 
by a grunt, a groan, or a shrill cry, occasionally accompanied 
by a short quick cough. The pulse was 160 in the minute; 
the skin pale, dry, but not strikingly hot. He lay on his back, 
shoulders but little elevated, with the feet drawn up, and 
thighs strongly bent on the trunk. Respiratory murmur heard 
everywhere, loud as before ; beating of heart strong and heard 
in the right chest. Dulness on percussion as before. My 
friend, Dr Bigelow, saw him in the course of this paroxysm, 
and continued in occasional attendance during the remainder 
of the patient’s life. Leeches were directed about the 
heart, and such other means as promised relief from present 
and extreme distress. Partial relief only was procured until 
the middle of the second day from the attack. On the lStli 
it was perceived that swelling had taken place extending from 
between the second and fifth ribs, the swelling being most 
obvious at its upper part. Percussion discovered increased 
flatness about the region of the heart. Its extent was 
very easily made out. Its limit in front was the middle 
of the sternum ; from above, downward, it extended from the 
space between the second and third rib to beyond the sixth; 
laterally, it spread but little beyond a line drawn from above, 
downwards, in the direction of and near to the left side of the 
heart. Everywhere else the chest resounded well, and the 
respiratory murmur was fully heard. It should be added 
here, that such was the distress produced by the least motion, 
that the patient was never moved unless it was very important 
that he should be. This circumstance has not been mentioned Case of Pericarditis. 
before, but it was so striking that it deserves a distinct place in 
the history. It was not that the limbs were in any way affected 
as by rheumatism, nor was it owing to the ordinary soreness 
or tenderness of the surface from severe previous disease, or 
from long lying in the same position; distress; hurried res- 
piration ; a cough, or cry ; increased rapidity of pulse ; these 
were among the effects of even slight motion, All this pre- 
vented any sufficient examination of the back, to ascertain 
how far morbid changes had taken place in other portions of 
the thoracic viscera than those which allowed of easy investi- 
gation laterally and in front. But both sides resounded so well, 
and the breathing was heard so distinctly in both these regions 
that it was not thought that important disease existed else- 
where, or that it was desirable to distress the patient by ex- 
aminations which were not likely to lead to any useful practi- 
cal results. 
After this attack the system never rallied as completely as 
before. The appetite for a time failed entirely. So little was 
the thirst and desire for food, that for one twentyfour hours, 
not more than an ounce was swallowed, of cold water, and 
this not from desire of the patient, but at the intreaties of 
the attendants. The flesh rapidly disappeared ; languor more 
or less strongly marked was present. Respiration wras more 
easily affected, at times louder cough than at any other time 
occurred, with either the sound of mucus in the air passages, or 
that which accompanies the relaxed state of the vocal organs, 
which not unfrequently is ascribed to loose mucus in those pas- 
sages. The bowels were easily moved by mild enemata, and 
the discharges were not morbid. The urine was small in quan- 
tity at times, but frequently not naturally altered from healthy. 
The suffering in the upper part of the abdomen, and in the last 
days of life in the hypogastric region, and distress under the ster- 
num continued to harass the patient, though for some hours he 
would he perfectly free from these troubles. The skin under- 
went change. He became exceedingly white, of a marble 
whiteness, — oedema took place in the face, particularly in the 
cheeks, — not excessive, hut the face had the fulness which 
would accompany an increase of flesh after disease, — slight 
oedema occurred in the feet, more remarkably in the spaces 
between the instep and toes. Wherever this existed the 
whiteness was most declared. The expression of the coun- 
tenance was rarely much altered from health, perhaps never 
in the degree observed by writers on acute pericarditis. 
It was said that after the last paroxysm there was obvious Case of Pericarditis. 
7 
fulness in the upper part of the left chest. This did not con- 
tinue, or was certainly less noticeable on the third day from 
its first appearance, 1 thought that there was less flatness on 
percussion in the upper part of the chest here than before the 
swelling, but what was very certain at the same time was, that 
this flatness could now be distinctly felt in the right chest, it 
extended, in other words, across the sternum, into the right 
side, and almost as far in every direction there as it had ever 
existed in the left. With this extent of flatness there was not 
a corresponding increase of symptoms. There was on the 
contrary much relief from some of them. Thus the pulse fell 
from one hundred and sixty, to one hundred and sixteen or 
twenty; the respirations to forty, to thirty, and at length 
when the patient was perfectly tranquil, the number was not 
much above health. But he was still entirely without appe- 
tite,— at times his distress was as great as ever — his nights, 
though he might sleep, were distressing ; his sleep short, and 
generally accompanied with groaning or a distinct forcing grunt. 
He wrould breathe in this way, and with great and increasing 
rapidity, and at length awake from sleep as if awakened by 
the effort and distress which breathing required or produced. 
In the last week in July, appetite returned, and it soon be- 
came very strong, producing much trouble as it would not have 
been safe under any circumstances, even of fair convalescence 
to have fully satisfied it. Food was, however, allowed. Rice 
with the red gravy of roast beef was a favorite at first and con- 
tinued so even when meat was strongly demanded. Meat 
was at length given, and such other articles as would not obvi- 
ously injure by their quantity or quality. There was no de- 
sire for fruit, even peaches and grapes of the finest kinds were 
hardly noticed, and were never allowed to take the place of 
more substantial food. Emaciation went on, the dejections 
were perfectly natural and abundant. I could not but think 
that suppuration had taken place in some organ. I said so to 
the friends. But with the single exception of the voracious- 
ness of appetite, there was no symptom present of the exis- 
tence of such a process. There were neither chills, heats, 
nor sweats, —the countenance had not the appearance of such 
lesion as attends suppuration, — there was no diarrhoea, nor 
no remarkable frequency of pulse. There existed, however, 
the same pathological state of the organs within the chest as had 
marked the case from the last paroxysm, the same evidence, 
and this increasing, of pericarditis with effusion within the 
pericardium. 8 
Case of Pericarditis. 
This patient died on the 5th of August. About a week 
before his death, I noticed a remarkable change in the appear- 
ance of the tongue. This had never discovered anything 
strikingly morbid. It had, on the contrary, been very uniformly 
clean and moist. If coated at any time, this seemed to be 
an accidental thing, for the coat soon disappeared. But at 
the time referred to, on examining the tongue, I was surprised 
to find that it was quite black over its whole surface. It looked, 
as one said, as if he had been swallowing charcoal powder. 
This perfect blackness did not continue to the end of life, but 
was always present more or less, and where it was wanting, a 
brown, dark brown color had taken its place. There was no 
marked change in the symptoms accompanying this state of 
tongue. He gradually failed, respiration becoming more and 
more difficult, the pulse increasing in frequency, — the strength 
failing. The stomach and bowels continued to perform their 
functions as in health. The appetite was as craving, and more 
so than when it first occurred. The sleep became very distress- 
ing with the night symptoms already given. There was no 
increase of oedema. That of the face was less than when first 
noticed. A very common action with him was to raise the 
arms along the sides of the head, and to clasp the hands above 
it. He always, or almost always lay on his back, and never 
required his shoulders or head to be much raised, a single pil- 
low or two thin ones being all he desired. 
I was called to see him on the morning of the 5th, at an 
earlier hour than customary for some days. I found him on a 
long chair to which he had been occasionally removed, his 
countenance altered, sunken, — his eyes and mouth open, 
breathing with much difficulty, — his skin was cold and damp, 
and pulse scarcely perceptible. I asked how long since 
these changes had taken place, and learnt that it was but a few 
minutes only. He was obviously in much distress, but too fee- 
ble to give to it full expression. His mind was perfectly clear, 
and bis senses had all the acuteness which had marked his 
disease. He spoke to me frequently, said he was very faint, 
and this was many times repeated. He would rise with much 
apparent force, bend his head and body forward, and stretch 
forth his hands. These motions were often repeated. I saw 
him several times in the morning, and found him at each time 
more sunken, and at about eleven in the morning he died, 
with no apparent increase of distress. The countenance im- 
mediately after death assumed the sweetest expression of his Case oj Pericarditis. 
9 
ordinary health. This return of the countenance to the nat- 
ural and healthful, soon after death, from acute disease, espe- 
cially when accompanied by much suffering, has been often 
observed, but in this case it was so striking that I have thought 
it worthy notice. 
Post mortem appearances. Thorax. The body was ex- 
amined in the afternoon of the day on which he died. Per- 
cussion was followed by the same sounds as during life. The 
body was everywhere of the same marble whiteness ; no in- 
crease of oedema was noticed. The sternum being raised the 
pericardium presented itself filling both sides of the chest as 
far as this could be seen, and entirely covering and shutting 
back the lungs. The appearance of the pericardium was that 
of a dense, opaque membrane, in parts of it the texture looked 
white, shining, very exactly resembling a fascia. It felt thick 
and firm, and being tapped upon by the finger the undulation 
of fluid was very apparent. As it was determined to take 
out the organs of the chest entire, the abdomen was opened, 
and a pint of a light yellow serum removed. The diaphragm 
was now separated from all its adhesions, the blood vessels and 
oesophagus divided, and the lungs, heart, and costal pleura care- 
fully raised without the least wound to the organs or pericar- 
dium. The trachea and oesophagus were then divided. It 
was found that the left lower lobe of the lungs was spread 
over in a very thin layer, and adherent to the pericardium, 
about half way over. Before opening the pericardium, its 
size was carefully ascertained, and found to be in its greatest 
circumference thirteen inches and ten lines ; measured as it 
lay in the chest before removal, the extent of surface which 
presented on removing the sternum, with the cartilages of the 
ribs was across just seven inches. The pericardium was 
next opened, and twelve ounces of dense, heavy pus at 
once escaped. The pericardium was found preternaturally 
red, thickened, and lined with a light greenish yellow colored 
lymph, from two to three lines in thickness. This was gelati- 
nous in its texture, but sufficiently firm to preserve its shape 
and connections with the pericardium. The heart was covered 
with a similar incrustation of lymph, somewhat irregular on its 
surface ; this was owing probably to the contraction of the heart. 
It adhered firmly to the heart. Upon examining the ventricles 
the left was found much larger, and firmer, and thicker than 
the right, and very closely contracted. The heart was every- 
where very pale in its texture, and contained but little blood. 10 
Case o f Pericarditis. 
The lungs were but slightly altered from health. The right 
lobes were healthful, perfectly so. There was a small adhe- 
sion of the back part of the upper right lobe to the ribs. The 
lower lobe of the left lung was hepatized in a portion at its 
posterior part. At least its cut surfaces were perfectly smooth. 
It was firmer here than in health, and contained no air. Slight 
oedema was noticed in both lobes of this side. The anterior por- 
tion of the left lower lobe adhered to the pericardium as before 
related. This was very thin, being expanded over the sac. The 
lungs were very small, compressed into a very narrow compass 
by the distended pericardium. But except the portion of the 
left lower lobe and the oedema above-named, these organs 
were healthful. They were examined with much care that it 
might be ascertained if tubercles existed ; but none were 
found. They were remarkably free from the post mortuary 
congestions in their lowest portions, which are so commonly 
noticed, and which may sometimes pass for disease, where 
symptoms have given us reason to suspect it, but of which 
no other mark is discovered on dissection. 
Abdomen. A pint of straw colored fluid, it was said, was 
taken from the abdomen, at the beginning of the examination. 
Other effects of disease were subsequently found. Much 
lymph, similar to that which lined the loose pericardium, was 
found in and about the pelvis, more especially about the coe- 
cum, by which this gut was slightly glued to the surrounding 
peritoneum. Its attachment was very slight to the parts upon 
which it was effused, and the peritoneum itself here was not 
noticably altered from its ordinary healthful, smooth, translucent 
condition. The intestines were healthful, and contained very 
little foecal matter. The kidneys were large. The liver 
showed much disease. The change from its natural condition 
consisted in extreme hardness, increased size, its peritoneal 
covering being opaque, and in spots thickened, and of a fascia- 
like firmness. The spleen was natural, but the pancreas was 
large, and of a hardness which, when the knife passed through 
it, wras semi-cartilaginous. The peritoneum everywhere, with 
the exceptions above given, presented its most healthful aspect, 
and there was nowhere either in the mesentery, nor intestines 
any marks of disease. The effusion was obviously recent, 
and had taken place a few days before death. It should 
have been remarked that much fulness of the abdomen marked 
its occurrence. 
The above history is a long one. It w7as preferred to give 
it in a general way, that the more important points should Case of Pericarditis. 
11 
have a distinct notice, rather than after the more common 
manner of a daily record of events. This case had for me 
interests aside from, or additional to, those which are strictly 
professional. I saw the patient very often and carefully noted 
all the circumstances which were presented. It has been 
seen that it was marked by three periods, two of them very 
distinct. These were so many paroxysms, with remarkable 
intermission of the symptoms : after the second paroxysm the 
relief was so great, the symptoms so much wanting, that it 
almost seemed that convalesence was taking place. The ap- 
pearances, on dissection, confirm the diagnosis, and explain all 
the symptoms. Percussion discovered flatness about the 
heart; then there was circumscribed fulness ; next, a dis- 
appearance of this fulness, with an extension of flatness 
across the sternum into, and at length over, the greater part 
of the right side. The breathing, its difficulty, its characters 
by auscultation, are also explained. The lungs were greatly 
compressed. The effort to overcome this characterised the 
breathing in a remarkable manner. It was a distinct forcing 
effort — a grunt — such as so commonly marks in children 
attempts to evacuate the bowels when costiveness exists. 
The sounds were transmitted by the distended pericardium. 
The swelling of the abdomen, and the pains there, especially 
in the last days of life, are explained by the effusions discov- 
ered after death, and by the morbid processes wdiich produced 
them. 
A question may arise, if so slight an affection of the knee, if 
rheumatic, (as has been supposed,) could have produced so 
grave and distinctive a disease of the pericardium as above 
described ? It was slight, but sufficiently severe to render 
the patient lame, and to impose upon him partial rest for some 
days. It disappeared perfectly, and without the occurrence 
of pain in any other joint. Upon this ceasing of lameness, 
however, did the other troubles of the patient arise. The 
identity of the affection of the pericardium with that which 
at times is produced by or along with rheumatism, may be 
inferred by a striking fact in our history, viz., the recurrence 
of the disease in paroxysms, after intervals of remarkable 
freedom from symptoms. To be sure, this absence of cardiac 
symptoms was not accompanied by the appearance of the 
disease elsewhere, as in the joints. But this does not neces- 
sarily happen in the unequivocal disease. It has been observed 
that the succeeding paroxysms are rarely, if ever so severe, as 
the earliest. They generally grow milder and milder, we are 12 
Case of Pericarditis. 
told, with increasing intervals, until they disappear entirely. 
This was not, in any sense, true in the above case. The 
intervals were indeed short, but in one of more than a week’s 
continuance, the marks of amendment were the most satisfac- 
tory, and still the succeeding paroxysm was the severest. 
Finally, pericarditis does not seem to have its violence or 
danger determined by the severity of the rheumatism which 
may have preceded it; the mildest forms having been ac- 
companied or followed by as severe cardiac disease as the 
most violent. 
This article has extended too far already to be lengthened 
by the recital of other cases. But I may add that I have not 
seen pericarditis before at so early an age. Two years ago 
a case came under my care, in a delicate female, about twelve 
years of age. This patient was in the first place seized early 
in the winter with common inflammatory rheumatism, rheu- 
matic fever, so called, in its severest forms. I do not recollect 
a case in which the affection of the limbs, and all of them, 
was so distressing, or so violent. Every characteristic of the 
disease was present. Such was the irritability of the intestinal 
mucous tissue, that the smallest doses of the remedies most 
depended on in acute rheumatism, produced the greatest dis- 
tress. This was especially true of colchicum, calomel, and 
antimony, in all modes of exhibiting them. Griping, diarrhoea, 
bloody and mucous dejections were produced by them, however 
cautiously employed, and however combined with opium, 
&c, to diminish these effects. They were at length laid aside, 
and opium alone trusted to. The vinegar of opium was exceed- 
ingly grateful in its effects. Months passed before recovery. 
Pericarditis occurred during this attack, with its usual symp- 
toms. She went to the sea-shore early in the next summer 
to recruit. Here she was again attacked with rheumatism, 
much less severe than in the first seizure, and during this, 
pericarditis soon became the leading disease. The rheuma- 
tism troubled her in a mild degree of it, for some weeks ; the 
cardiac disease has yielded, gradually, to remedies and time ; 
and now, at the end of nearly two years, she is very little 
annoyed by it, or rather by its effects. She walks freely, as 
much as three miles at a time without dyspnoea, or increased 
palpitation, and seems perfectly well. A dry, harassing 
cough accompanied the disease during almost all its active 
periods. In this case the dulness on percussion was very 
extensive, with an obvious enlargement of the left side, and 
the bellows murmur was unusually loud, and uninterrupted.