752 
very common occurrence in beriberi to find changes in the voice, such 
as hoarseness and more or less complete aphonia. Paresis of the facial 
nerves and of the nervus abducens has occasionally been observed, as 
have also disturbances of the optic nerves, manifesting themselves by 
central scotoma, and in rare cases by amblyopia. Among the late symp- 
toms of beriberi, which in the advanced disease frequently become quite 
prominent, are contractions of the muscles, particularly of the gastroc- 
nemius. 
If an early examination, both in the hypertrophic and in the atrophic 
dry types, be made, the following symptomatology may be elicited; 
the pulse is generally rapid, somewhat irregular, rather weak, and 
easily compressible. Upon exertion, which may even be so slight as the 
act of sitting up in bed for examination, the pulse rate increases 20 to 30 
beats a minute. At times, quite early in the course of the disease and 
frequently later, after if has existed for several days, the apex of the 
heart is found to be displaced upward and outward and the area of 
visible heart beat to be enlarged. Percussion shows an extension of the 
area of heart dullness toward the right and frequently even to the right 
of the sternum. Where there is hypertrophy of the left ventricle the 
area of dullness is also increased to the left. Auscultation at the apex 
of the heart frequently reveals some changes in the systolic sound, but 
the most common alteration observed in beriberi generally is a marked 
accentuation of the second pulmonic sound. At times a definite, systolic 
bruit may be heard at the apex; frequently a reduplication of the 
second sound both at the apex and at the pulmonary valves exists. A 
considerable number of cases of beriberi also reveal a musical sound 
which may be heard over the crural arteries as was first prominently 
pointed out by M. Miura.*° This observer in some cases reported the 
sound to be audible even at a distance of several feet from the vessel. 
In the early stages of beriberi, sometimes up to the sixth or seventh day 
of the disease, the patellar reflex is increased ; then a diminution develops, 
and finally it becomes entirely absent. Even in cases which terminate 
favorably, the absence of the patellar reflex may last for a long time and 
may still be noticeable after the disturbances of locomotion have dis- 
appeared. When the knee jerk begins to reappear, it then generally once 
more becomes temporarily accentuated, finally returning to the normal. 
Durham makes the following statements with reference to the patellar 
reflex in beriberi: 
Too little notice is, I think, taken in most books of the preliminary exagger- 
ation of the knee jerk, which so commonly precedes the loss thereof. Whether 
the knee jerk is ever lost without a previous stage of increase I am not able 
“M. Miura: Der diastalische Arterienton. Zeitschr. d. Mediz. Ges. zu Tokyo, 
Jan. (1891), and Mittheil. d. mediz. Fakultit, Univ. zu Tokyo (1898), No. 2, 
C1; 
