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40 ACUTE POLIOMYELITIS (a) Heine-Medin's disease usually attacks those in perfect health and begins acutely with fever and malaise, speedily followed by paralysis. Many earlier observers have asserted that the paralysis develops without preceding symptoms. Occasionally mothers make similar assertions and allege that the child, having been well when put to bed in the evening, awoke the next morning with a paralyzed leg or arm. West created for those particular cases a special name, "morning paralysis." The wide experience of re- cent years has shown the extreme rarity of such cases. Careful inquiry reveals that most of those children present prodromal symptoms, which sometimes, however, are so slight as to evade notice till the attention of the relatives is specially directed to them. The cases in which sudden paralysis is alleged to happen occur chiefly among the very young. Older children and adults rarely give such a history. But veridical examples can be cited in which the initial symptoms were extremely slight.

Occasionally the disease begins so insidiously that a vague unwellness, without any positively localized signs, gradually develops. But, as a rule, after this ill-defined prodromal period, acute symptoms arise.

Occasionally, as the disease develops, an intermission occurs. The patient recovers more or less completely from the first attack, only to be re-attacked. This second invasion must be considered as a relapse, if in the interval the patient were quite well. Even when paralysis has been established, relapses have occurred.

The most constant symptom of the initial stage certainly is the fever. Simultaneous with the acute onset, the temperature, as a rule, rises rapidly. It usually reaches 38°-39°; according to Ed. ft Killer a temperature of 40°-41° Celsius may rarely occur. Generally, the fever is maintained for a few days or even a week, and it falls, either gradually with marked occasional oscillations, or rapidly, as in a crisis. Ed. Muller observed that the subsiding temperature did not reach merely a normal, but sometimes even a subnormal level, which persisted for a certain period. In some cases he noticed, almost always after four days, a second rise, which, in general, was associated with evident increase of the paralysis. Zappert reported cases in which the temperature persisted at about 40° for 8-14 days. I have rarely observed prolonged fever.