a IGN eae 
however one patient who was all skin and 
bones. 
SODRE and other Brazilian medical men 
mention the existence of muscular hypertro- 
phy. Evidently this is an error of interpreta- 
tion. The muscular hypertrophy could only 
be apparent, the dominant feature in the 
pathological course of the disease is 
atrophy. The illusory hypertrophy is a con- 
sequence of oedema which does not attain 
the muscular fibre, but the intersticial connec- 
tive tissue. In the first stages there may 
be a certain degree of hypertrophy ofthe 
‘heart, because it is the perypheric resistance 
(resulting from the vaso-motor alterations) 
which causes the modifications of the rhythm 
and the reduplicating of the sounds. In the 
motor-muscular system, the atrophic process 
is however the predominant lesion and as its 
consequence follows the functional disable. 
ment of the respective muscle. 
In the oedematous form, the oedema 
masks everything and the muscle in spite of 
having its fibres attacked seems hypertrophied, 
increasing in size because of the diffuse oede- 
ma. Hence the mistaken idea of the exis- 
tence of hypertrophy in beriberi. 
Abolition of tendon-reflexes. In the begin- 
ning of the disease the tendon-reflexes may 
appear exaggerated, but the general rule is 
the abolition of reflexes. The sign of 
WESTPHAL nearly always exists; the rotu- 
lar reflex is the first to weaken when the 
disease sets in, and with the progress of the 
symptoms it disappears altogether. 
Oedema. The perturbations of vaso-mo- 
tor innervation may be simultaneous with 
those of the nerves of motility and sensi- 
bility, or they may preceed or follow them. 
As a rule oedema appears at the same 
time aS numbness and anaesthesia. Someti- 
mes it is evident only after weakness of legs 
and difficulty in walking have set in. In 
the galloping form of beriberi, in which the 
disease takes immediate poesession of the 
whole of the sympathetic system, oedema, 
dyspnoea and asystolia predominate. 
Oedema nearly always begins on the 
says that one of the initial symptoms of 
beriberi is a slight tumefaction of the crest 
and anterior face. In some regions, oedema, 
is characteristic of beriberi. In the north 
of Brazil it is the most general. Dry or atro- 
phetic beriberi, as we have alreadv remarked, 
is rare, Such is the importance of oedema 
in the symptomatology of beriberi that SILVA 
LIMA divides the illness into three clinical 
forms: paralytic, oedematic and mixed. Here 
we may say that we do not approve of this 
division. In the pa ralytic form there is 
always oedema: in the oedematous form 
there is always paralysis. Indeed, modern ten- 
dency is not inclined to accept these clas- 
Sifications as separations of well-defined 
types. 
VEDDEK observes that some patients 
attacked by rudimentary forms of beriberi, 
surprise medical men by suddenly, showing 
cardiac affections, and dying almost suddenly. 
Cardiac insufficience may occur in all stages 
of this illness) VEDDER observed in the 
East, that the disease sometimes remains in 
the rudimentary stages during months or 
even years. It is interesting to register that 
AZEVEDO SODRE in 1898, before VED- 
DER, says: “the symptoms of beriberi may last 
weeks and months, being sometimes more, 
sometimes less accentuated; when they are bet- 
ter, the patients feel very well and take up their 
former occupations. In these cases it someti- 
mes happens that cardiac symptoms suddenly 
appear; acute and considerable dilatation of 
the righth cavity of the heart sets in and 
is almost immediately accompanied by asys- 
tolia, and death supervenes sometimes imme- 
diately and sometimes after some days. 
It is clear that the words of the two 
doctors coincide. They coincide also with the 
facts which came under my notice in the 
north. There is a superposition of symptoms 
in beriberi, according to the kind of nerves 
attacked. As long as the great sympathetic 
and the vagus are not attained the disease 
may have a comparatively benign course, but 
at a given moment the cardiac affections 
intervene, and all cases of beriberi end in 
crista tibiae; it is hará and elastic. SODRÉ | the same way, by an attack of acute asystolia. 
