Part 91

In the greatest number of cases in my own experience the exanthem is composed of ill-defined, roundish, punctate macules, without special grouping. These are usually discrete, but in certain situations they may coalesce. The color is of a pale rosy red, quite difficult to describe, but less purplish than in measles, and not so livid a red as in scarlatina. I have occasionally observed large irregular spots not unlike those of measles.

Thomas distinguishes three types of eruption--one with large spots, which is rare; one with medium-sized spots; and one with small spots. Emminghaus describes a discrete and a more confluent variety. I have observed one case where the maculæ on the back had undergone a vesicular transformation. Others have mentioned this occurrence. Itching of the skin is marked in some cases, and a fine desquamation is observed after the rash, but by no means invariably.

The mucous membranes are implicated to a slight degree in rötheln, but the amount of involvement varies considerably. In some cases that I have observed the catarrh of the mucous membranes has been barely appreciable. As a rule, however, the eyes are somewhat suffused, and there is slight lachrymation and photophobia. Sneezing may be noted, but there is little discharge from the nose. Sore throat is not uncommon, perhaps the most constant feature, and, according to Liveing, is apt to persist after the subsidence of the rash. The fauces are injected, and the tonsils are red and swollen, but with no evidence of ulceration. J. Lewis Smith and others state that the buccal mucous membrane shows a more or less diffuse patchy and spotted redness. The tongue may be, and usually is, covered by a white fur, through which protrude a few enlarged red papillæ. There may be slight cough. Loeri describes the mucous membranes of the pharynx, larynx, and trachea as presenting a spotted or uniform hyperæmia. There is no marked participation of the intestines in the catarrh. Some few writers have noted a transient albuminuria, but it is safe to say that such cases are entirely anomalous, if not, indeed, in some instances, examples of mistaken diagnosis.

A very constant feature is the swelling of the lymphatic glands of the neck, especially those back of the sterno-mastoid; the swellings may come on before the rash appears. In all the cases that have fallen under my notice this symptom has not been absent in a single instance. Less constantly, and it would seem in proportion to the development of the rash, engorgement of the glands may be noted elsewhere.

{587} There is but slight disturbance of the temperature in rötheln, and when it does occur it is usually limited to the first few hours of the eruption. This has been the rule in my observation, and certainly holds good for the majority of cases. In a minority, varying degrees of fever may be present; thus, the temperature may reach 102° F. or 103° F., and then rapidly sink by the second day of the disease, or, having fallen a degree, it may continue at this point till the subsidence of the rash, or, it is said, may retain its initial height till the end of the disease. During the following week Squire states that the temperature may be readily disturbed--either elevated by exertion or depressed by fatigue or chill. A relapse or recrudescence of the rash may be looked for at this time.

COMPLICATIONS AND SEQUELÆ.--In the vast majority of cases neither complications nor sequelæ have been observed in connection with rötheln. J. Lewis Smith has recorded instances of diphtheritic inflammation as a complication, which, however, as he justly remarks, may, when prevalent, attack any inflamed surface. Pneumonia and bronchitis have been occasionally reported as complicating or following rötheln. Liveing and Duckworth mention albuminuria, but, so far as I know, they are alone in this experience. I have known otorrhoea and ciliary blepharitis to occur as sequelæ. It would not be a matter of surprise that in weakly children various chronic ailments should be set up by rötheln, as by any other disturbance of the general health.

DIAGNOSIS.--There is no other disease which so much resembles rötheln as measles. Especially is this true of atypical cases occurring sporadically. In rötheln the whole course of the disease is much milder than in measles, the incubation is longer as a rule, and the fact of a previous attack of rubeola is of much importance, since we know that recurrences are very rare. In measles there is a prodromic period, having a characteristic temperature curve, and presenting pathognomonic catarrhal symptoms, which precedes the eruption for three or four days; in rötheln the appearance of the rash is often the first sign of the affection. The sore throat of rötheln resembles that seen in scarlatina more than the angina of measles, and the general catarrhal implication of the mucous membranes, so marked a feature of measles, is either absent in rötheln or exists to a very trivial extent. Measles is essentially a febrile disease, having a peculiar type of fever; rötheln may run its whole course without appreciable rise of temperature. As will be seen in the preceding pages, the development and progress of the exanthem of measles differs materially from that witnessed in rötheln. In measles the lesions are larger, more vivid, more angular and indented, more frequently provided with processes, and therefore more apt to assume the crescentic arrangement, than in rötheln. Finally, it must be urged that the tout ensemble of the case should be taken into consideration, and not some special feature of the skin eruption.

The incubation period of scarlet fever is much shorter than in rötheln, and all of the constitutional symptoms are, as a rule, infinitely graver. In scarlatina there is a febrile invasion stage of twenty-four hours; in rötheln, if fever is present at all, it is most generally simultaneous with {588} the rash, and rapidly disappears, while in the former it persists for a number of days longer. Vomiting is common in scarlet fever, rare in rötheln. In scarlet fever the lymphatic glands are notably involved at the angles of the jaw, in rötheln at the sides and back of the neck. Sore throat is a feature common to both scarlet fever and rötheln, but it is very much less marked in the latter. Thomas says that in scarlatina only the posterior parts, the uvula, the arches of the palate and their vicinity are affected, while in rötheln the anterior parts are also affected, and both in much the same degree. In scarlet fever the rash, which mostly begins on the neck and chest, is made up of large patches formed of minute red spots on a bright-red hyperæmic base; in rötheln the eruption is composed of roundish pea-sized macules, with normal integument intervening. In cases of doubt--for example, when the rash of rötheln consists of very small spots which have become confluent--the further development and persistence of the scarlatinal efflorescence, the temperature, the pulse, the angina, and the character of the desquamation must be taken into consideration. The complications and sequelæ are very different in the two diseases.

The symptomatic eruptions of the skin which pass under the name of roseola bear no resemblance to rötheln. They usually occur as the result of some trivial derangement of the system or in the course of some primary affection. They are not contagious, the lymphatic glands and the mucous membranes are not involved, and the rash is quite different in character.

PROGNOSIS.--The prognosis of simple uncomplicated rötheln is invariably good. Complications arising in delicate children necessarily affect the prognosis, as would any other disturbance of the general health.

TREATMENT.--Simple cases of rötheln require no treatment, as the patients are rarely sick enough to be confined to bed. Graver forms of the disease must be met by such measures as are indicated by the symptoms present. The after-management must be conducted on general principles having reference to the previous and present condition of the person attacked.

{589}

MALARIAL FEVERS.

BY SAMUEL M. BEMISS, M.D.

In the medical nomenclature of this country the term malaria is synonymous with swamp or ague poison.

Malarial affections, therefore, comprise all those diseases or morbid manifestations which the swamp poison produces in the human organism.

This article is not designed to notice in a systematic manner any of these disorders which are not properly classifiable under the head of malarial fevers. It will, however, be necessary to make such references to the pathology of chronic malarial toxæmia as may serve to explain the influence this condition exerts in occasioning departures from type in the febrile attacks.

When a poison generated outside the human system obtains admission to it, and produces deleterious effects, three questions naturally arise: What is the essential character and natural history of this noxious agent? How does it obtain access to the human system? What is its mode of action when received?

In reference to the first of these questions, it must be admitted that the substantive essentiality of the malarial poison remains as yet undemonstrated. It is true, however, that the attempts at an objective study of this poison by means of the microscope and the cultivating retort point to the conclusion that it is an organism.

Its subjective or analogical study affords quite incontestable evidence in support of this conclusion. The leading features in the natural history of malaria are closely coincident with those of certain known organisms. It requires for its production suitable conditions of moisture, temperature, and a properly circumstanced breeding-place. Within certain bounds these conditions are requisite to the life and perpetuity of all organisms.

Again, when all the above-enumerated conditions correspond apparently in the most favorable degree, their continuous concurrence for a lapse of time is necessary before the poison manifests its presence. It is not improbable that this period of development may differ in different climates, but in this country we assume it to be about thirty days. If these facts related to some noxious organism visible to the eye, no doubt would be entertained that the presence of its germs in the places where it appeared was the indispensable condition. It would then follow that the concurrence of suitable meteorologic and telluric conditions with sufficient time for its growth and maturity were merely accessories to its perfect development. According to this theory, the coincidence of five circumstances is necessary before malaria can be fully matured--viz.: Its own {590} specific germ; suitable soil or pabulum; suitable moisture; suitable temperature; sufficient time for its growth and development.

Certain physical qualities which pertain to the malarial poison can also be profitably made points of subjective study. These are very closely connected with the answer to the second question, or "How the malarial poison obtains access to the human system." They will therefore be briefly noticed in relation to the instrumentality of each in conveying malaria into the system.

The first to be mentioned is ponderability, which the following facts prove that malaria possesses:

Those different atmospheric states which affect the range of diffusion of known air-borne yet ponderable substances exert similar influences upon the malarial poison.

Altitude illustrates the ponderability of malaria by powerfully retarding its diffusion.

High readings of the barometer favor its aërial dissemination.

Fogs, smoke, dust, or floating particles presumably more buoyant than this poison may exert greater or less influence in overcoming the obstacle which ponderability attaches to malaria as an air-borne agent.

Currents of air passing continuously and steadily in one direction over the breeding-places of malaria increase the limits and intensity of toxic range.