SYMPTOMATOLOGY 41
Wickman, and subsequently Ed. Müller, Zappert, Spieler, and others have especially emphasized that neither the height of the fever, nor the severity of the other initial symptoms, foretell the nature of the subsequent course. After mild initial symptoms, some patients develop extensive and severe paralysis; some even die. Others, after an alarmingly severe onset, soon recover, with- out a trace of the affection they have undergone.
Rarely the disease is ushered in by a rigor.
Besides the fever, there are other initial symptoms, such as headache and malaise, which have no special characteristics, but which may sometimes awaken suspicion. Drowsiness, general tenderness, stiffness. of the neck and marked perspiration often appear. The drowsiness in most cases is very marked. Mothers frequently narrate that the patient has slept for several days and has awakened only to eat and to void. Spieler and several other observers have reported deeper disturbances of consciousness. Very rarely actual coma occurs; sub finem vitae, in lethal cases it may appear; complete unconsciousness may also arise, even in favorable cases. Zappert showed that coma may appear synchronously with the fever at the onset of the illness. Starr states that delirium generally accompanies the fever. Fürntratt recorded maniacal outbursts; and others reported delusions.
More characteristic than drowsiness is diffuse tenderness, which perhaps is the most noticeable symptom that in the initial stage directs our attention to the likelihood of Heine-Medin's disease. The mother notices that a mere touch is evidently painful to the child. Sometimes, if she only approaches the patient's bed, anxiety and protests are expressed by the little sufferer. The patient may hardly be able to tolerate either the pressure of the bed clothes or the same position for any length of time. In the early descriptions of the disease this tenderness which was known to Heine, Duchenne, and others, was scarcely mentioned. Medin emphasized its frequency and also its prominence in the clinical picture of the disease. Wickman, Starr, Zappert, Foerster, Ed. Miiller, Netter, and others, confirmed his observations. This hyperesthesia is in many instances the most marked symptom in the initial stage. It is usually increased by passive movements, especially in my experience, by movements of the vertebral column, such as rising. Spontaneous pains exist, in some cases,
