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noticed in Europeans or Americans who have suffered from severe attacks 
of beriberi and who have returned to their native country during con- 
valescence, that the disease frequently assumes a protracted course, from 
which recovery is very slow. 
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 
In many ‘cases of beriberi occurring among the uneducated and ignorant 
Asiatics, the diagnosis must be made exclusively from the objective symp- 
toms, as an intelligible history is unobtainable. ‘The most important 
points to be emphasized are the following: The condition of the pulse 
while the patient is at rest and before he has been at all disturbed ; and 
the same after the patient has been subjected to some physical exertion. © 
If the patient is not too ill, he should be compelled to leave his bed and 
to walk up and down the room a few times. While so doing, the 
gait should be noted, in order to ascertain whether it presents the char- 
acteristic appearance. The pulse should then once more be counted 
because it is usually very excitable in beriberi, and its rapidity increases 
very markedly even on very slight exertion. ‘The percussion and auscul- 
tation of the heart are also of special value in the diagnosis of this disease. 
Particular importance attaches to the enlargement of the right ventricle, 
to the accentuation of the second pulmonic sound, and to a reduplication 
of the second mitral one. The presence of hydropericardium, hydro- 
thorax, and abdominal ascites is of considerable value in the diagnosis ; 
the increase of the patellar reflex in the early stages of the disease and 
the loss of it in the more advanced ones is also important. The fre- 
quency of pain in the muscles of the calf and of oedema in the legs and 
feet has already been referred to in the consideration of the symptoma- 
tology. The great decrease or even the suppression of the urine in the 
early stages of the cedematous form of the affection is also a very im- 
portant factor in the diagnosis; the disturbances of sensation and of 
locomotion and the paralysis and contractions have been sufficiently 
emphasized under the symptomatology. Scheube thinks that the diag- 
nosis of beriberi in a majority of the cases offers no particular difficulty, 
and that the most important symptoms to be looked for are hypesthesia 
in circumscribed places (particularly of the legs and feet), oedema of the 
legs and of the dorsum of the feet; pain on pressure in the muscles of 
the calf; absence or increase of the patellar reflexes, palpitation of heart, 
accelerated, easily excitable pulse, and increase of the number of pulse 
beats after slight exertion. 
Baelz and Miura** particularly mention the following among the 
diseases and their symptoms which might be confounded with beriberi : 
Spinal myelitis: Increased reflexes; ankle clonus; paralysis of the extremities 
without muscular atrophy; paralysis of the bladder and rectum; complete 
3 Baelz and Miura: Beriberi oder Kakke. Mense, Handb. d. Tropenkrankheiten, 
Leipzig (1905), 2, 140. 
