Part 89

Many other complications of measles have been recorded in literature (see Thomas, op. cit.); but it is no doubt true, as observed by Bohn, that very few of them have a real essential connection with that affection, and might as readily be associated with any other malady, especially in already vitiated constitutions. In the above sketch the endeavor has been made to indicate those disorders which from the nature of measles would seem to have a more or less close and definite relationship to it. It is certain that the more serious complications and sequelæ of measles are comparatively infrequent in private practice in America, although common enough in continental Europe, and to a certain extent in the children's asylums and foundling hospitals in this country.

SEQUELÆ.--It is a difficult matter to dissociate the complications and sequelæ of measles. Properly speaking, the sequelæ are to be looked upon as the complications which have continued in existence after the subsidence of the exanthem; but it is also customary to include under this head certain affections that are the result of the derangement of the system by the morbillous process.

As would be expected, among the most frequent sequelæ of measles are those diseases which have their seat in the mucous membranes. Thus, we may observe various grades of inflammation and ulceration of the larynx, trachea, and bronchial tubes. According to Loeri, follicular ulcers of the larynx always give a bad prognosis, for these cases usually succumb to tuberculosis. It is not uncommon to observe a bronchial catarrh, apparently simple in nature, which persists with frequent exacerbations for many months. The very frequent broncho-pneumonia, which occurs as a complication, always remains as a sequel, or it may develop after the morbillous process has come to an end. In favorable cases recovery may take place in two or three weeks, or, preceded by hectic and progressive emaciation, the disease may prove fatal after a number of months. But even here it is not impossible for affected persons to recover.

Chronic pulmonary tuberculosis is one of the most formidable and frequent sequelæ of measles. It is a not uncommon occurrence that, with the exception of some trivial bronchitis, a patient may apparently recover his health completely, and only after a lapse of time slight daily elevations of temperature, accompanied by loss of appetite and emaciation, {574} first give warning of the impending danger. This form of phthisis may follow either croupous or catarrhal pneumonia. Granular meningitis or general miliary tuberculosis also frequently follows in the wake of measles, connected in many cases with foci of caseous degeneration in the involved lymphatic glands or unabsorbed pneumonic exudation.

Various gangrenous affections, particularly of the oral cavity (noma) and genitals, but also of the skin, subcutaneous connective tissue, cartilages of the nose, ear, etc., are often to be observed after an attack of measles. Cancrum oris is to be especially noted.

Albuminuria is not an essential sequel of measles, although it may occasionally occur as the result of great exposure and neglect.

A large group of chronic affections may follow in the track of measles, either in the form of sequelæ to the complications which arise during the course of the disease or in the nature of secondary accidents. Some few, perhaps, are more common after measles than after any other complaint, but the majority are such as might arise in weakly children subsequent to any specific disturbance of the health. In addition to those already mentioned we may especially designate chronic intestinal disease, together with ulcerations and strictures of the bowel; chronic coryza, in varying degrees of obstinacy and severity; chronic ophthalmia, under which title may be included ciliary blepharitis, granulations, trachoma, phlyctenular conjunctivitis, ulcers of the cornea, etc. (Michel); aural affections in the form of chronic suppurative inflammation, and, more rarely, chronic catarrh of the middle ear (Spencer); certain cutaneous diseases, more especially in my experience furunculosis and pustular eczema; chronic bone and joint disorders (strumous), which, according to Gibney, may not only be evoked in the already hereditarily predisposed, but also induced when the diathesis has not heretofore existed; and, lastly, various derangements of the nervous system.

In Thomas's valuable and freely-quoted monograph on measles (op. cit.) it is stated that secondary measles can exert various influences upon the primary disturbance. In most instances when measles attacks a person already the subject of some other disease, particularly when the latter belongs to the common complications of the former, it usually is aggravated. This is a matter of common experience; but this author further declares--and supports his assertion with numerous references--that, on the other hand, should measles appear during the existence of a disease to which it does not usually give rise, it may favorably influence the course of the latter. In spite of the cases quoted in support of this view, such results would appear to be contrary to pathological laws.

MORBID ANATOMY.--The normal rash of measles is not to be observed on the dead body, and the only lesions of the skin to be noted are those resulting from extravasation of blood into that tissue. Examination of the skin removed during life from a patient with measles reveals the following anatomical changes, according to Morris. In the earliest stages are found usually slight hyperæmia around the orifice of a sebaceous follicle, with slight swelling from effusion of plasma. Occasionally swelling alone is present, and more rarely hyperæmia only. Round the small hyperæmic papule thus developed--often pierced by a hair--a roseolar patch, due to congestion of the papillary body, soon makes its appearance. Slight exudation of plasma, with a few corpuscles, usually follows, and produces elevation of the papule itself. As most of the deaths in measles are due to the presence of some complication, the post-mortem changes will be found to correspond to the lesions produced by these diseases, principally affections of the respiratory organs and intestinal tract.

DIAGNOSIS.--As a rule, the diagnosis of measles offers no great difficulties, especially if a correct clinical picture of the disease has been thoroughly impressed upon the mind. The salient points may be thus summarized: A period of incubation of about fourteen days--i.e. from the date of infection to the commencement of the eruption; a prodromic stage of about four days, ushered in with fever and marked implication of the mucous tract, notably cough, coryza, epistaxis, and photophobia; in this stage may also be noted the punctated redness of the conjunctivæ and of the palatal mucous membrane, which is to be regarded as a diagnostic sign of great value and importance; finally, there appears at the conclusion of the stage of invasion, simultaneously with increase of the febrile movement, a characteristic eruption upon the cutaneous surface, this eruption coming out first upon the face, and composed of large maculo-papules of brownish-red color, arranged in a crescentic form with tracts of normal integument intervening. Of all the symptoms of measles, the catarrh of the mucous membranes is undoubtedly the most pathognomonic. In the colored races, where the recognition of the skin lesion is often a matter of difficulty, this combination of symptoms should be borne in mind.

In the way of conjectural diagnosis, the presence of an epidemic of measles in the community should be taken into account. Although measles possesses features so characteristic and pronounced, there are a number of other diseases with which it may be confounded, especially in its earlier stages.

There is no other disease which presents so close a resemblance to measles as does rötheln, and it must be confessed that under certain circumstances the question of diagnosis is a perplexing one. In rötheln the appearance of the eruption is often the first symptom of the affection, whereas in measles there is a prodromic period, having a peculiar remittent type of fever, which continues for three or four days. According to Liveing, the short duration of the febrile attack before the eruption appears is one of the most constant and distinctive features wherein rötheln differs from ordinary measles. In some instances, in rötheln the premonitory fever is not at all appreciable. The catarrhal involvement of the mucous membranes is not nearly so marked as in measles, while the very frequent sore throat bears more resemblance to the angina of scarlet fever. In many instances, although by no means constantly, the eruption of rötheln first appears on the chest, and not on the face, as is the rule in measles. It is quite evident that the eruptive spots of rötheln have presented different physical features in different epidemics; but, as a general thing, it may be said that they are smaller than those in measles, of a paler color, and, according to Thomas, not so angular, less indented, and not so often provided with processes, therefore less apt to assume the crescentic arrangement so often seen in measles. The incubation period is longer in rötheln than in measles.

In scarlet fever the incubation stage is shorter than in measles, and the constitutional symptoms are apt to be more pronounced; the temperature is higher, the pulse more rapid, and vomiting more frequent. The stage of invasion in scarlatina is but twenty-four hours; in measles, seventy-two. There is absence of the characteristic catarrh of measles, and the presence of severe sore throat, strawberry tongue, and swelling of the lymphatics at the angle of the jaws. In measles the rash begins on the face; in scarlatina, on the neck and chest. In measles the eruption consists of large papules arranged somewhat crescentically, with intervening normal skin, followed by bran-like desquamation; in scarlatina the rash is made up of large patches formed of minute red spots on a bright red, hyperæmic base, and is followed by desquamation in large lamellæ. In measles the rash is brightest on exposed parts; in scarlatina, most vivid on covered regions. The sequelæ of the two diseases are quite different.

There is no great difference in the duration of the invasion stages of variola and rubeola; but in the former disease we have the marked lumbar and sacral pains and vomiting, while in the latter the catarrhal symptoms and photophobia are pathognomonic. When the eruption of {577} small-pox appears there is subsidence of fever; in measles, an exacerbation. A point of great importance in the diagnosis of variola is found in an examination of the mouth and pharynx, for in these situations on the fourth day we will often find the vesicles fully developed, while on the skin they are still in the stage of papulation. When measles assumes the papular form (morbilli papulosi, rougeole bouttoneuse), it is often confounded with the papular stage of small-pox. I have seen a number of such mistakes made. Attention to the general symptoms of the two diseases, however, and particularly an examination of the mucous membranes, will generally clear up any doubt. At any rate, the question will generally settle itself in the next twenty-four hours, for if it be variola the papules will have undergone their specific development and the rubeolous elevations will have become more decidedly macular.

Typhus sometimes offers a certain resemblance to measles. According to Buchanan, the eruption of typhus is occasionally, though not commonly, a good deal like that of measles, and appears about the same time after invasion. Coryza, when present and distinct, points to measles. The eruption of typhus is of a smaller pattern, discrete, and not raised; that of measles, often coalescent, crescentic, and elevated. Subcuticular mottling is present in typhus, and absent in measles. The palatal mucous membrane should always be examined in suspected measles.

As I have never been able to convince myself of the existence of an independent disease called roseola, I am at a loss to give the points of differential diagnosis; on the other hand, the various forms of symptomatic erythema, occurring either as the result of numerous slight derangements of the system, or in connection with grave constitutional disease, should be carefully considered. In the first group of cases the absence of premonitory symptoms, catarrh, etc., and the presence of the smooth, rose-colored macules, mostly on the trunk, and in the latter the existence of symptoms belonging to the primary disease, should prove of assistance. The erythema papulatum of new-born children I have seen mistaken for measles, but the fact that rubeola is exceedingly rare in sucklings, and the absence of fever and catarrhal disturbances, are sufficient grounds for a differential diagnosis.

The erythematous syphilide (roseola syphilitica), particularly when accompanied by fever, may bear some resemblance to the rash of measles; but the history of the case, the circumscribed, indolent character of the syphilide, in many instances sparing the face, the absence of pathognomonic catarrhal symptoms of measles, and the coexistence of other features of syphilis, are quite distinctive.

PROGNOSIS.--The prognosis of normal uncomplicated measles is very favorable. Thus, of 257 cases observed by Meigs and Pepper (op. cit.), all terminated favorably. But in coming to any conclusion in regard to prognosis a number of different factors must be taken into consideration. Among the more important are--the hygienic surroundings of the patient, the age, the nature of the complications, whether the measles be primary or secondary, and the character of the epidemic. In the first place, rubeola in foundling hospitals and among the poorer classes in large cities gives a larger ratio of deaths than among the well-to-do members of the community. For instance, Bartels has shown that catarrhal pneumonia, one {578} of the most frequent causes of mortality in this disease, is particularly prone to occur among those dwelling in crowded, poorly-ventilated houses. Then, again, the asylums and hospitals for children are peopled in many instances with the victims of depraved constitutions, who readily succumb to intercurrent maladies.

Leaving out of consideration sucklings under six months of age, in whom measles is rare and said to be slight, most deaths from the disease occur among very young children, from their greater liability to complications. According to Beddoes, the mortality from measles is, beyond all comparison, greatest in the second year of life, and by the tenth has become quite trifling. An examination of the statistics bearing on this question coincides with this general statement; but Fox's tables, already quoted, would show that more infants under one year of age die of measles than has hitherto been supposed. The susceptibility to measles decreases with years, perhaps on account of the fact that most adults have already contracted the disease; but when it does attack the unprotected adult it may prove fatal. This statement is borne out by the large death-rate in the so-called camp measles of our late war. The ravages of measles in virgin communities have been referred to in preceding pages. The general temper of the epidemic must also be considered, since it is well recognized that the essential character of epidemics differs much as to severity.

Such complications as diphtheria, catarrhal pneumonia, diarrhoea, convulsions, etc. necessarily affect the prognosis of measles most seriously. More patients die of measles in the second than in the first week of the disease. The careful studies of temperature made by Thomas, Bohn, and others show that an unusually high and increasing fever in the prodromal stage is of ill omen, particularly on the second and third days, and a fever heat measuring over 105° F. at any stage should be considered as very unfavorable. Particularly to be feared is continuation of the fever after the subsidence of the eruption, or a sudden elevation after the normal curve has been reached. In fact, it is a safe rule to look upon all anomalies of the curve with suspicion. Secondary measles, or measles grafted upon some serious existing affection, is particularly fatal.

TREATMENT.--There is no remedy which will destroy the susceptibility to measles. The future may develop some form of vaccination against rubeola, for, certainly, the hopes held out by the inoculation of measles upon the healthy subject have not been realized, as this procedure merely reproduces the original complaint, without any diminution in its intensity, and does not lessen the probability of complications (Mayr). The matter of carrying out a practical and efficient quarantine in measles is one of unusual difficulty, for the reason that the disease is capable of active propagation at a time--the prodromal stage--when it is not yet sufficiently characteristic for positive diagnosis. But, as measles is by no means as trivial a disease as would seem to be the common impression, I hold it as a well-established principle of preventive medicine that a {579} strict isolation should be enforced whenever, from the nature of the case, it is at all possible; certainly, very young children and those suffering from or showing a tendency to other diseases should be jealously shielded from exposure.

The usual precautions as to disinfection and purification of the room, bedding, and utensils used by patients should be observed, as in other infectious diseases. Squire is of opinion that there is danger of personal infection for perhaps a month, and Hillairet that isolation for forty days should be enjoined. It is quite certain that inunction lessens the danger of infection, and Kaposi is authority for the statement that a warm bath administered after the completion of desquamation, or about fourteen days from the beginning of the attack, will effectually prevent contagiousness.

The apartment occupied by a patient suffering from measles should be kept at a uniform temperature of from 66° to 70° F., and free ventilation, at the same time avoiding draughts, should be enforced. The room should be kept moderately dark. The bed-clothing should be light, yet sufficiently warm, and the old notion of keeping the patient in a profuse sweat the better to bring out the eruption should be discouraged. The diet should be bland and nutritious, and may preferably consist of milk, gruel, tapioca, and such like substances. As convalescence progresses there may be a gradual return to more substantial food. The patient may be allowed cool water in moderation, as it is cruel and useless, and even harmful, to restrict one suffering with fever to warm or sweetened drink. The patient should be confined to his room until convalescence has been fully established, and should not be allowed to leave the house, both on his own account and that of others, until the usual health has been regained. Any of the lingering results of the disease, such as bronchitis, otorrhoea, conjunctivitis, etc., should receive prompt attention; iron and cod-liver oil should be prescribed for the weakly and strumous, and regular hours of sleep, careful diet, and appropriate bathing and exercise should be advised. It may be said, without exaggeration, that neglect of the after-care of measles patients is, in some instances, more to be deprecated than a similar neglect in the actual treatment of the disease itself.

Since we are powerless to cut short an attack of measles by any remedial agents at present known to therapeutics, the intervention of the physician is limited to assisting the cases through to a safe termination. Quite a number of cases, as seen in private practice, require no special medicinal treatment, or at most one that is merely symptomatic. The value of the so-called specific treatment, such as by carbonate of ammonium, etc., has not been verified by experience.

In ordinary uncomplicated attacks, if the temperature should run high, in addition to the general rules as to diet and hygiene referred to before it will usually be found advisable to put the patient on some diaphoretic mixture, to which may be added a mild opiate. I know of nothing better than the formula found in the work of Meigs and Pepper on the Diseases of Children:

Rx. Potass. Citrat. drachm i; Spt. Ætheris Nit. fl. drachm ii; {580} Tr. Opii Deodorat. minim xii vel xxiv; Syrupi fl. drachm ii; Aquæ fl. oz. ii. M.

S. A teaspoonful every two or three hours for a child of five years of age.

Aconite in small doses has been well spoken of in this connection, but I have no personal experience in its use. Bromide of potassium, together with a few drops of syrup of ipecac., dissolved in syrup of wild cherry, acts pleasantly both on the cough and the nervous system.