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The left ventricle with its enormous strain is perhaps the first part to dilate, thus enlarging the opening of the defective mitral valve. The left auricle is then unable to cope with the increased amount of regurgitant blood, and there is in consequence congestion in the lungs, and the right ventricle finds the pressure ahead in the lungs greater than it can well overcome.
An old mitral regurgitant murmur is useful for this purpose. It is not flattering to one's vanity to overlook a case of malingering, but should this occur little harm is done. It is a much more serious matter to accuse a person of malingering when in reality he may be suffering from an organic disease.
The pulse, however, will always show the quickly lost arterial pressure of every beat on account of the aorta losing its pressure through the regurgitant flow of blood. Sooner or later, from the impaired aortic tension causing a diminished or imperfect flow of blood through the coronary arteries, impaired nutrition of the heart muscle occurs.
He began the interview by unbuttoning his waistcoat and asking me to listen at his fifth intercostal space, two inches from the left sternal line. I did so, and was shocked to hear a well-marked mitral regurgitant murmur. "It is of old standing," said he, "but of late I have had a puffiness about the ankles and some renal symptoms which show me that it is beginning to tell."
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