Concurrently with the coryza, irritation of the larynx and bronchial mucous membrane become evident, the early cough is short and dry, and the severe paroxysms are annoying. With involvement of the lar ynx the cough assumes a barking character, and with still greater swell ing of the subglottie laryngeal mucous membrane takes on the character of a pseudocroup, which with the diagnostic barking cough denotes a greater or less amount of laryngeal stenosis. This may be sufficiently great. to produce slight attacks of dyspnom. These laryngeal changes of the prodromal stage are however without danger to life, in contrast to those of pseudocroup, and croupy changes which sometimes occur in the period of convalescence and which may prove a serious complica tion.
Now and then in small children, or those weakly or tuberculous, the bronchitis of the early stage with its short dry cough extends to the smallest bronchi and gives rise to foci of bronchopneumonia, which in its further course is of bad prognosis. Usually the bronchitis is charac terized on auscultation mostly by dry riles, and where there is expec toration it is invariably scanty and mucoid. With the outbreak of the rash there is a great increase of the cough, the frequency and dryness of which is distressing alike to the patient. and those about him. The frequency of respiration which is the result of lessened blood aeration and of the high temperature, is increased to a distressing dyspncPa. This is made still more harassing by the increased bronchial secretion, and numerous and various forms of rides. With the fading of the rash all these respiratory signs subside, either at the same time or shortly afterwards.
The temperature in measles shows a fairly characteristic curve as the accompanying Chart I, (Fig. will show. Frequently in the early stage the elevation of the temperature may exceed 39° C. (102° F.). It is usually not of long duration and gives way to normal or subnormal temperature for one or several days. With the first appearance of the rash the fever rises rapidly often to -10° C. (10-1° F.) or over, and usually assumes a continuous or remittent type until the fifth or sixth day of the disease when it falls by crisis. It goes without saying that this tempera ture curve is subject to many variations depending as it does upon the severity of the infection, the individual predisposition to temperature changes, and the occurrence of complications. It may be therefore,
that this two pinnacle type of curve in measles may, according to the height of fever in one stage, take on another form of curve; usually however this particular type ill be recognizable in it to a grea ter or less degree. A glance over the accompanying temperature charts should make the individual variations of the temperature course clear.
Charts II and III show- the as sociation of Koplik spots and high temperature. There can be a still earlier appearance of the fever in relation to the Koplik efflorescence, so that the other prodromal signs appear first, and then the »leaning of the rise of temperature is difficult for the physician to interpret; in any case a careful inspection of the mouth should always be made. With a more protracted initial stage the interval between the two rises of temperature will naturally be increased, sometimes the rise of temperature occurs first with the out break of the rash. Elevations of temperature after the normal defer vescence and after the subsidence of the rash are mostly associated with complications (otitis, stomatitis, pneumonia, tuberculosis, etc.). A late fever of short duration, such as is shown in Chart IV for instance, may show no pathological reason for it. In slight cases, as also in nursing infants, I have often seen a striking afebrile course in undoubted measles.
When the early stage has run its course with the symptoms de scribed, the eruption follows as the diagnostic appearance of measles. Simultaneously in severe cases the catarrhal manifestations and the fever make their appearance in the most intense form. The patient shows great lassitude, is dull and delirious, and in small children there may be convulsions. The general condition, and the other symptoms usually bear the closest relationship to the severity of the rash, the intensity of which is an index of the severity of the entire course. Very rarely there appears a slight transient erythema on the face, and particularly on the neck, two or three days before the general outbreak of the rash, but only three instances of this rash have come under my observation. The rash spreads according to definite rule over the skin, from the thirteenth to the fourteenth day from the beginning of the incubation. Exceptions from the typical spread or extension of the rash are found only in the milder eases.