of the rhythm is rarer; I have never met 
with it. SCHEUBE often observed it, espe- 
cially some hours before death. The palpi- 
taticns also cause the precardiacal pain, 
which in slight cases is only a feeling of 
oppression, though in very acute cases it 
assumes the proportions of angina pectoris. 
FRANCISCO DE CASTRO was the 
first to describe the beriberi angina pectoris 
«with excruciating retro-sternal pains, which 
extend to the neck, back of the neck and 
left arm». PEKELHARING and WINKLER 
describe similar observations. In the cases 
that came under my notice, I saw that the 
pains were far more excruciating than those 
of simple angina pectoris. The attendant dys- 
pnoea, pains, the livid countenance contras- 
ting with the cyanotic lips, the groans, the 
anxiety, the wild look of the patient together 
form a picture of as dramatic and pun- 
gent intensity, as the worst attack of angina 
pectoris. Under such conditions of well-de- 
fined asystolya it is impossible to obtain 
any clear account of his feelings from the 
half-unconscious patient. 
Ausculation reveals other most impor- 
tant signs of heart affection. One cannot 
deny that SILVA LIMA deserves all the ho- 
nour of the discovery of the predominance 
and gravity of the cardiac phenomenona in 
beriberi. He calls attention to the per- 
turbations of rhythm: “a complete disorder 
in the succession and frequence of the systolic 
and diastolic movements, which render it im- 
possible to count the cardiac revolutions and 
the pulse”. He also called attention to the 
reduplicating of the second sound, “thus gi- 
ving rise to three distinct sounds; the iirst is 
the ventricular systole and after a short in- 
terval, in comes the diastole sound which 
is re duplicated and followed by a long 
pause”. Reduplication of the first sound, 
although mentioned by SILVA LIMA, 
TORRES HOMEM and FRANCISCO DE 
CASTRO, is almost denied by PEDRO DE 
ALMEIDA MAGALHAES and SAMPAIO 
VIANNA. The reduplication of the second 
sound has been met with and well described 
by all the Brazilian medical men who studied 
beriberi cardiopathy, from SILVA LIMA down 
to the present day. AZEVEDO SODRE and 
PEKELHARING say the point cf the heart 
is the best place for hearing the doubled 
sound; ALMEIDA MAGALHAES and SAM- 
PAIO think that the best point for ausculta- 
tion of the second sound is the focus of the 
pulmonary artery. 
There is no doubt that these latter ob- 
servers are right. MAGALHÃES says that 
of the two sounds, the aortic precedes the 
pulmonary. SODRÉ denies this invariability. 
However all brazilian pathologists agree that 
there is accentuation and reinforcement oi the 
pulmonary sound, a factto which FRANCISCO 
DE CASTRO called attention for the first 
time, and which was confirmed by SCHEU- 
BE, PEKELHARING and WINKLER, AZE- 
VEDO SODRÉ, PEDRO DE MAGALHÃES 
and SAMPAIO VIANNA. 
Galloping sound. This sound was first 
mentioned by PEDRO ALMEIDA DE MA- 
GALHÃES, SAMPAIO VIANNA noticed 
that the adiventitious sound, whose addition 
to the normal sounds, causes the sound, of 
galloping is localised in the epigastric region 
and is sometimes more distinctly heard at a 
certain distance from the left margin of the 
sternum (margin of the right ventricle). 
Murmurs. The murmurs are according to 
P. A. MAGALHÃES and SAMPAIO VIAN- 
NA generally mezzo-systolic, rarely systolic. 
“These sounds are soft, superficial, varia- 
ble and not lasting.’ SAMPAIO VIANNA 
heard them distinctly in 24 patients out of 
24. 
Pathogeny of the cardiac alterations. 
SCHEUBE says they ensue from the altera- 
tion of the vagus. AZEVEDO SODRE and 
LACERDA attribute then to the alterations 
of the sympathetic system. NINA RODRI- 
GUES, without denying the influence ofthe 
alterations of the vagi, is of opinion that the 
lesion of the sympathetic is the chief factor 
in the cardiopathy observed in beriberi. 
PEDRO DE MAGALHÃES thinks that 
the cardiac alterations ensue from the vaso- 
motor disorders in the pulmonary circulation 
“the constriction of the pulmonary network 
