DIAGNOSIS AND TREATMENT OF BERIBERI 893 



accentuated and sharp, and may be reduplicated. These changes are 

 not due to stenosis or insufficiency of the valves as shown by post mortem 

 examination. 



The body temperature is usually normal, but slight fever has been 

 observed in some cases. The right heart dilates, and on account of in- 

 sufficient heart action the urine is diminished and the edema rapidly 

 increases. Sometimes effusions into the pericardium, pleura and peri- 

 toneum occur. Marked motor disturbances now manifest themselves, 

 first in the gait of the patient, which is generally of the "high-stepping" 

 type, the foot being raised with difficulty, brought forward with a jerk 

 and lowered abruptly. There is a tendency to walk with the legs spread 

 apart. The sensory abnormalities increase in severity and the patient 

 complains of cramps, burning, and the sensation of pins and needles, this 

 being especially noticeable in the anterior tibial and peroneal muscles. 

 The paralysis may extend in severe cases to the abdomen, diaphragm, the 

 intercostals, and also to the arms so as to produce wrist drop, and some- 

 times complete loss of motor control of the upper extremities. In chronic 

 cases this paralysis leads to extreme muscular atrophy which, however, at 

 first glance may not be easily recognized on account of the coexistence of 

 edema. There may be anesthesia and paresthesia with loss of sense for 

 heat, cold and pain. Little has drawn attention to the presence of 

 night-blindness in beriberi. Aphonia is also sometimes observed, 

 especially in infants, and is probably caused by the paralysis of the 

 muscles of the larynx, which are supplied by the pneumogastric nerve. 

 Painful cramps of certain muscles are not uncommon in marked cases, 

 and fibrillary muscular twitchings and tonic convulsions are sometimes 

 seen in the advanced stages of the disease. Spasticity has been noted 

 during convalescence by numerous observers, causing a gait similar to 

 that characteristic of spastic spinal paralysis. 



Voegtlin and Lake (1919) have described similar motor disturbances 

 in polyneuritic cats. In polyneuritis gallinarum the principal symptoms 

 consist of a progressive paralysis of the legs and wings which in the 

 early stages is recognized by unsteadiness of the gait and inability of 

 the birds to roost and fly. A convulsive type is frequently seen which 

 some writers attribute to cerebellar lesions (Richter, 1913) ; others ex- 

 plain the convulsions by assuming the existence of an unequal degenera- 

 tion of the nerves innervating flexor and extensor muscle groups. 



Diagnosis. The diagnosis depends largely on the symptoms of per- 

 ipheral neuritis, the cardiac insufficiency and the generalized tendency to 

 edema, the absence of fever and marked albuminuria. Several other 

 diseases have to be distinguished from beriberi, such as the various 

 common peripheral neuritides caused by alcohol, arsenic, lead and malaria. 

 Alcoholic neuritis may be ruled out by the history, arsenic poisoning by 

 the absence of abdominal pains and diarrhea, lead poisoning by the 



