The rash first at tacks the head and re gion of the face, where the earliest appearance is at the margin of the hairy scalp, and the region behind the ears, and from there it spreads rapidly over the face particularly the temples and the region of the chin. It extends over the neck and downwards over the upper arm and trunk, its further course is over the fore arms, hands, the thighs, and finally the legs and feet. It fades in the same order as it comes. The rash usually requires for its develop ment and disappearance from three to five days according to its inten sity, and leaves behind it a pigmentation of the skin which is visible for fourteen days or more. The rash at its height can cover the greater part of the skin surface at one time, particularly on the second and third days of eruption, both the fading and freshly appearing rash being from pale to bright red in color, occasionally of a livid tint. This latter coloring occurs in the more severe infections, with the onset of pneumonia, failing heart with lack of compensation, and other complications damaging to the heart and lung functions, such as myocarditis, croup, etc.
The rash often has a pale appearance in nursing infants, and in weakly, debilitated or crippled children. Usually the eruption varies in size and form, from the size of a pin head to that of a cent, mostly irreg ular, and never exactly circular as one often observes in German measles. The rash does not begin on the surface of the skin, and in its further development is usually of a maculopapular character, which may easily be felt by passing the finger over it. The edges are not abrupt but fall away gradually. In young children we sometimes find, as a result of greater infiltration, that the individual spots are raised, map-like in form and with abrupt edges which can easily be confused with other forms of urticarial eruption. The single spots may run together into larger spots or patches, always leaving however greater or smaller areas of healthy skin between them, so that a mottled, even checkered appearance of the skin always occurs, and the designation in the lay mind of "spots" or "spotted sickness" is appropriate. When the finger is pressed upon an old erythema the skin remains a yellow or brownish color, especially in those forms of measles in which the rash shows blood infiltration and takes on a livid character. Effusion of blood into the skin is not uncommon and is absolutely no criterion as to the severity of the case. This can be produced artificially by raising a fold of the skin diagonally to its usual con l'Se and pinching it. This increased permea bility of the vessels of the skin also exists in parts free from the rash. 'hemorrhages occurring at the outset of measles in sickly, or tuberculous children, are of had omen. They occur in points or patches and often
involve the whole of the abdominal surface. Some instances are re corded in the literature of measles without an eruption and the existence of such cases cannot be doubted, even if we question the diagnosis and the want of knowledge of the observer. Heubner was able to obtain the best possible opportunity to follow up this matter in observations upon brothers and sisters. Undoubtedly the best field for clearing up such caprices of the rash is that of private practice.
In close relation to the rash stands the desquamation of the shin, which in measles is an evanescent and slight matter and often entirely wanting. Exceptionally, however, it may appear in a very marked form and similar to that of scarlet fever. It differs from this in the fact that the hands and feet remain free, while on the face, neck, trunk, arms, and legs it is most evident. The face is chiefly involved and shows a marked peeling. The desquamation is usually fine and bran-like in character, but in severer cases it may occur in small flakes.
As a result of the measles poison, and the skin changes induced thereby, there is frequently a swelling of the lymph-nodes, chiefly those of the cervical region. Sometimes this swelling while only slight, attacks the whole lymphatic apparatus. The liver and spleen are not affected and show no appreciable enlargement. Fairly regularly there is a dimin ution of the leucocytes, but in the incubation stage a leucocytosis is observed.
The general condition produced by the grade of infection and combination of individual symptoms is dependant not only upon the severity of the illness but also upon individual peculiarity. The marked cerebral disturbances (convulsions, drowsiness, delirium) which appear in many febrile diseases in infants, fortunately are rarely seen in measles. Even the initial stage shows certain disturbances of the general condi tion, such as lassitude, prostration, apathy, headache, a sense of press ure in the eyes, subjective sensation of light, irritation in the throat, a sense of stoppage in the ears, symptoms all connected with the infec tion and the early catarrhal condition. With the progress of the disease the drowsiness is augmented and marked jactitation may appear. Pains in the joints, and lumbar pain is common particularly in adults. Loss of appetite, and at the same time rapidly increasing thirst are the common accompaniments of the period of eruption. The general con dition usually improves rapidly as the exanthem fades, only the lassi tude and swelling of the face are seen in this stage, just as peevishness is the common accompaniment of the stage of convalescence.