The disappearance of the rash is followed by a fine desquamation of the spin. The peeling differs much from the shedding of the skin which is such a marked symptom in scarlatina. The epithelium falls in fine bran like scales which are often almost invisible to the naked eye, so that this stage not infrequently passes quite unnoticed by the attendants.
In an uncomplicated case of measles the chest symptoms are usually mild. The cough is at first hard and hacking, and during the eruptive period is often paroxysmal, with a loud barking character. After the eruption has begun to fade, the cough becomes looser and less frequent ; and if proper care be taken to avoid chills, it soon ceases to be heard. The physical signs about the chest are those of pulmonary catarrh. One con sequence of the irritation in the lungs set up by the catarrh is seldom absent, especially in scrofulous children. This is enlargement of the bronchial glands. If there be much throat affection, there may be a simi lar swelling of the glands at the angle of the lower jaw and at the sides of the neck.
The urine during the fever is high colored, with abundant urates. It may contain a trace of albumen.
In some epidemics cases are seen which present all the characters of the complaint with the one exception that the rash is absent. These are no doubt cases of irregular measles. Cases have been also described in which the rash is present, but the catarrhal symptoms are absent (morbili sine catarrho). It is very questionable if these latter are classed rightly under the head of measles.
There is a form of measles which is distinguished by great prostration. Here the complaint assumes from the first an asthenic type. The pulse is small, feeble, and very frequent ; the respirations are rapid ; the tongue is dry, brown, and thickly furred ; the temperature of the body is high, although the extremities feel cold to the touch ; and the child is dull and seems stupefied. When the rash comes out, it is imperfectly developed and of a dark red or violet hue. The skin is thickly spotted with pe techi. Soon the pulse becomes so rapid that it can only be counted with difficulty ; the muscles become tremulous ; there is muttering de lirium, and the patient dies comatose or convulsed. These cases, fortu
nately very rare, almost invariably prove fatal. They are generally accom panied by hemorrhages from the mucous membranes as well as into the skin. Epistaxis is often obstinate ; immaturia may occur ; and after death ecchymoses may be found in various internal organs.
In a healthy child an ordinary attack of measles is a mild disorder with little severity of the general symptoms. The sharpness of the illness appears to be determined to some extent by the constitutional tendencies of the patient. One of the pathological consequences of the specific fever being the active congestion of the mucous membranes, we might expect that a constitutional state in which there is already a predisposition to derangement of these membranes would determine more serious symp toms than are found in cases where there exists no such predisposition. Children who start in life weighted with a scrofulous diathesis are gener ally bad subjects for measles. It is in these patients that catarrhal symp toms assume such prominence, and that ophthalmia, otitis, and the other troubles referred to above are so liable to be met with. Even in the mildest cases a certain depression follows the subsidence of the fever. The temperature sinks to a subnormal level, and the pulse is very slow and intermittent.
Of all the eruptive fevers measles is, next to typhoid fever, the one most liable to return. Many children have it a second time, often after only a short interval ; and in some cases the second attack may occur at so early a period after the first as to constitute a true relapse. Cases are met with from time to time in which a child sickens with measles, passes through a more or less severe attack, recovers, and after a brief interval of convalescence sickens with it again—and all this within a month.
Complications.—The complications which may render an attack of mea sles troublesome or dangerous have been already in part referred to. As a rule, they are exaggerations of ordinary or extraordinary symptoms of the complaint, and are determined either by the character of the epidemic, or by the constitutional peculiarities of the patient.