stretches his feet wide apart, to have a fir- 
mer support; at the same time, he feels 
bound to keep his attention fixed on the 
ground, which seems to him, judging from 
the sensation in the soles of his feet, to be 
elastic and flexible. He can only keep his 
equilibrium by the aid of his sight, as the 
muscles of his legs do not seem to him to 
obey his will. (SILVA LIMA, MIGUEL 
COUTO, AZEVEDO SODRÉ). 
Later on, the gait becomes even more 
irregular. The patient lifts his heels very high, 
implanting the outside border of the footon 
the ground. The paralysis of the extensors 
of the toes causes the point of the foot to 
sink to the ground, and in order to prevent 
this, the leg must be lifted very high. FRAN- 
CISCO DE CASTRO calis this way of wal- 
king “high stepping”. Birds suffering from 
beriberi, also show this characteristic “high 
stepping”. After this simple difficulty in walk- 
ing, comes an almost complete paralysis be- 
ginning in the extensory muscles of the low- 
er extremities, the anterior tibial, the ex- 
tensory hallucis and the commum extensors 
of the toes and finally the flexors of the foot. 
etc. etc. 
In the beginning paresis is incomplete 
but it becomes more and more intense and 
gradually invades a greater number of mus- 
cular groups; after the muscles of the leg, 
it attacks those of the thigh, then of the 
fore-arm, the arm, the hand, the abdomen 
and the thorax. In the upper extremities the 
extensory muscles are also the first attacked. 
PEKELHARING observed that the biceps 
and the great pectoral are the last involved. 
SODRÉ says that he never saw the sterno- 
cleido-mastoidian attacked. SILVA LIMA re- 
cords a case where the paralysis was total 
and the patient moved only his head. 
Complete motor paralysis is very rare. I 
never saw it. Often, the movements are quite 
incoordinate. SILVA LIMA says that in his 
observation VIII «the patient moved his 
arms and legs, but his movements were limited, 
incoordinate and jerky. For instance, if he 
wanted to lift his finger to his mouth or his 
forehead, he never got it to the right place, 
85 
nor could he calculate the muscular force 
necessary for these movements. Abrupt mo- 
vements of the fingers and hands, due to 
sudden contraction of the flexors were 
added to these symptoms on the ninth day.» 
Paralysis may also attain other muscles, 
for example those of the pharynx, as obser- 
ved by SILVA LIMA and SODRÉ, and also 
the muscles of the larynx. In experimental 
beriberi, I observed paralysis of the pharynx 
and of the oesophagus. Birds in this and at 
last stage of the disease swallow with the 
utmost difficulty. 
Perturbations of the voice were obser- 
ved by SILVA LIMA as comparatively fre- 
queut phenomena. In his observation VII he 
noticed a difference in the tone of the voice 
and has described cases of aphonia. SODRÉ 
says that paralysis of the larynx may cause 
sudden death. TORRES HOMEM and 
MIGUEL COUTO call attention to paralysis 
of the bladder. In these latter cases miction 
is slow and requires great efforts on the 
part of the patients. SILVA LIMA never no- 
ticed paralysis of the bladder. 
Myalgia. I is constant phenomenon 
in beriberi be it spontaneous or pro- 
voked. SILVA LIMA, as we have already 
seen, observed that the pain is seated in the 
paralysed muscles. In the confirmed cases 
of the disease the patients cannot bear pres- 
sure on the muscles of the legs and of the 
fore-arm. “It is this hyper-sensitiveness which 
renders walking difficult, when the paralysis 
of the muscles is not very great”. SILVA 
LIMA also noticed neuralgic pains varying, 
as to seat, intensity and duration. 
It was the neuralgic pains which certain- 
ly led to the theory of rheumatism in beriberi, 
in vogue at the time of JULIO DE MOURA. 
Pain on pressing of the gastrocnemius is a 
first-class and well-known diagnostic sign; 
the same also refers to the muscles of the 
thigh and the forearm. 
Muscular atrophy. In beriberi the mus- 
cles are always attacked. Muscular atrophy 
is recognised by the naked eye when it takes 
the dry form. This is the rarest form in the 
north and I seldom met with it. | remember 
