The ears are frequently the seat of catarrhal or purulent otitis media. This readily occurs in children suffering from adenoid vegeta tions, so soon as the rhinitis becomes severe, and the infection of the nose and nasopharynx extends into the Eustachian tube. The advent of otitis media is announced by a fresh rise of temperature, often of a high grade, and usually of an intermittent type. The child becomes restless, complains of the ears or of headache and puts its hands to its head. In younger children opisthotonos is frequent and mental dulness and convulsions commonly occur. These alarming symptoms disappear with the escape of the exudate through the drum-head into the outer ear. With protracted retention of the exudate, or if the suppuration becomes chronic, carious changes can occur in the bony structures of the ear, in the mastoid antrum or of the entire mastoid process. The objective signs of this extension are redness, swelling and (edema of the skin over the mastoid process, pain on pressure, and protrusion of the outer ear. If the otitis media be one-sided and there occur a swelling of the lymph-nodes of the same side (which often occurs with otitis) then the diagnosis is clear.
Moderate swelling of the lymph-nodes is often present during and after measles. This swelling may be general while the rash is present, but more frequently it is confined to the cervical groups. In tuberculous and scrofulous individuals,_ particularly as a result of eczema, excoria tions, etc., marked swelling of the lymph-nodes may occur in these groups, and even proceed to suppuration. The tendency to the prolif eration of adenoid tissue is likewise evident in the region of the pharynx and a persistent enlargement of the tonsils may be noted. More frequently we find an enlargement of the adenoid tissue of the naso pharynx, which plays an essential part in the development of the nasal and ear affections so prone to arise after measles.
Although the lymphatic apparatus of the intestine, mainly the mes enteric nodes and Pever's patches appear moderately enlarged, especially during the period of the rash, the part played by the intestinal tract is generally insignificant. Nausea, vomiting, and diarrhcea sometimes occur in the initial and exanthematous stages. The diarrhoea may con tinue until the disappearance of the rash if care be not taken. In young children the condition is more serious when the lower bowel is attacked, either alone, or in association with a former enteritis, and arises usually as the rash is fading or later. This lowers the resistance of the patient and forms a favorable basis for the development of other infections, especially pneumonia. The sharp outbreak of such an intestinal condi tion not infrequently leads to a fatal issue, by the marked exhaustion, intoxication and infection. The symptoms are at first those of a moderate intestinal catarrh, but soon the evacuations assume a mucopurulent character, which in turn give place to movements of pure pus with an admixture of blood; still later a frothy fermentation occurs, the stools have a curdled appearance, and a foul, sometimes putrid odor. The patient wastes rapidly, the color of the skin fades to a grayish tint, the eyes sink deep into their sockets, there is marked prostration, and finally collapse. With this there is a progressively lower temperature, some times the abdomen is much distended, very tender on pressure along the line of the descending colon, and particularly so over the sigmoid flexure.
The anatomical findings agree exactly with the clinical picture of a severe dysentery, in that the large intestine shows deep gangrenous, broken-down ulcers, often of great extent. The observations of Jehle as well as the gradually increasing study of these intestinal lesions point to the fact that we have to do with a secondary infection following upon measles, the latter favoring the sharp necrosis of the tissues.
The nervous system during the course of measles shows no particu lar disturbance apart from the general condition already depicted.
Exceptionally there may be mental dulness or convulsions in the initial period or at the time of the rash, especially in children under one year of age. Severe inflammatory changes though fortunately rare may even occur in the brain and its membranes. Considering the tendency to tuberculous new fofmations in association with measles, as has already been mentioned, the development of meningitis is to be feared. It may arise even after an interval of one month, but the other forms of men ingitis, encephalitis, and poliomyelitis are much less frequent.
The bones and joints are but seldom involved, and here again it is chiefly a tuberculous process that is to be considered. Rheumatic affections which are so frequently observed with scarlet fever are here of rare occurrence.
Diagnosis.—Xs a rule the recognition of measles presents no dif ficulty provided that the disease follows the stereotyped course, especially in the appearance of the rash. Difficulty can arise in the prodromal stage in the absence of any trace of rash. The existence of an epidemic, the points noted in the history, and suspicious early symptoms, such as attacks of sneezing, snuffling, coughing, conjunctivitis, and slight rise of temperature are presumptive as to the onset of measles. This is made a certainty when Koplik's spots or red patches are visible on the mu cous membrane of the cheeks or gums. The search for these must be continued for two or three days on account of their late appearance in some cases. The Koplik spots are the most important diagnostic signs in the early stage. They are best seen by diffused daylight, less dis tinctly by a glaring illumination such as direct sunlight or lamplight, on account of the lustre of the mucous membrane. Inflammation of the cheek, or particles of milk in young children, can give rise to error. These latter can be wiped away, and moreover the microscopic exam ination would show the existence of oil globules or fungi. Desquama tion of the epithelium of the buccal mucosa and gums can likewise give rise to mistakes, but the greater extent of these flakes and their occur rence mainly on the gums, make a differentiation from Koplik's spots less difficult even though they are on the mucous membrane of the cheek, and at the same time not as white in color. In German measles, sometimes punctiform papules as large as of the head of a pin are scat tered on the mucosa of the cheek which at first sight resemble the Kop lik spots, but they are distinguished from them by their regular rounded form, their sharp margins, their pale red color, and the deficiency in the centre, distinctly bluish white in color, the result of epithelial necro sis. In favor of measles, on the contrary, the Koplik spots, when they are present, are an excellent differentiating point, as they occur in the majority of cases of measles and arc wanting mostly in slight cases, and then particularly in the first year of life.