Measles.

Synonyms.—Moribilli; Rubeoli.

Definition.—An acute, infectious, and contagious fever, characterized by a general papular eruption, usually appearing the fourth day, and preceded by a catarrh of the mucous membranes of the bronchi, larynx, nose, and eyes.

Etiology.—The infectious material, whatever it may be, is found in the blood, in the secretions of the mucous membranes, and in the epidermic scales which are cast off. It is exceedingly volatile, and the presence of the unprotected in the near neighborhood is sufficient for the contraction of the disease. When once it enters the home, it usually infects all children who have not previously suffered from an attack. Unlike scarlet fever, the older the patient, the more severe the disease.

It usually occurs in epidemic form, though sporadic cases may occur. In the larger cities it may be found more or less at all seasons of the year, and may therefore be said to be endemic. While a single attack is generally supposed to confer immunity, a second or third attack is not uncommon, the soil not being exhausted as in other exanthemata.

The attempt to isolate a specific germ which will produce the disease has thus far failed, though many micrococci have been found in the secretions.

Pathology.—There are no characteristic lesions in measles, save the catarrhal conditions of the respiratory apparatus. Where death occurs, it is usually the result of complications, capillary bronchitis, and broncho-pneumonia being the most frequent. The other changes are common to those of grave fevers, such as lack of coagulability of the blood, which is dark in color. The internal organs are congested and softened. The lesion of the skin, consists of an acute hyperemia, with exudation in the vascular papillas of the corium, the sebaceous and sweat glands.

Symptoms.—The symptoms vary, being so mild some seasons that the child does not take to its bed. At other times the malignant character is manifest from the beginning", as seen by the characteristic septic symptoms.

Incubation.—From seven to fourteen days elapse from the time of exposure to the infection, to the first evidence of the disease, and is regarded as the period of incubation. During the time when the poison is at work upon the blood, multiplying itself a thousand-fold, the patient may manifest no symptoms of its presence.

Invasion.—The first manifestation of the disease is the presence of catarrhal symptoms. The child seems to have taken cold, and sneezes frequently. There is a watering of the eyes, stuffing up of the nose, with increased secretion and discharge of mucus. There is increased sensibility to light, hoarseness, and a dry bronchial cough. These symptoms may precede the chill twenty-four or forty-eight hours, or occur simultaneously in the cold stage.

Following the chill, febrile reaction comes up, but varies greatly, in mild cases scarcely noticeable, while in others the temperature reaches 103°, 104°, or even 105°. The skin is hot, flushed, and dry, the pulse hard and wiry, with marked irritation of the nervous system. The child is sensitive to the light, and intuitively screens its eyes from the glare. The cough is a constant factor, and is hoarse or metallic and irritating. The fever is generally remittent in character, and increases to the third or fourth day, then, as the eruption makes its appearance, gradually declines.

The eruption first appears upon the face, forehead, neck, and chest, gradually extending over the entire body. The single point of the eruption is a flat or slightly conical papule (much the color of a mosquito-bite), growing quite irregular as it develops, while the color gradually shades to the sound tissue. They are inclined to coalesce in patches, though, where the eruption is profuse, it is confluent, every part being- affected. In these cases the face and tissues are puffy and swollen, the eyes are red and watery, the tongue is covered with a dirty, moist, pasty coating, and there is a peculiar and characteristic odor.

The eruption requires from forty-eight to seventy-two hours for its full development, remains from one to three days, and then gradually disappears, the surface being clear by the sixth or eighth day, though the skin may present a mottled appearance for several days after the disappearance of the eruption.

During the one, two, or three days the eruption is coming to the surface, the child will be quite sick, the fever active, the skin dry, the cough hard, dry, and almost incessant, attended by more or less dyspnea; with the full development of the eruption, however, the fever rapidly subsides.

Koplik's Spots.—For a day or two before the skin eruption, there frequently appears on the buccal and labial mucous membrane, small red spots with a bluish-white center, Koplik's spots, and are pathognomonic. Their value in diagnosis, however, has been overestimated as they are frequently absent.

Malignant Measles.—This is the so-called black measles, the surface presenting a dusky or dark purplish hue. This variety differs from the more simple form in the toxic character of the infection. Some seasons nearly every case partakes of this character, though why this difference the profession has not been able to explain, and we only know that the infectious material, having attained a high septic character, has the property of transmitting the same intense character to all infected. In one class of cases the eruption is tardy in its appearance.

The fever runs a pretty active course, with considerable bronchial disturbance, the fourth, fifth, or sixth day passes without its full appearance. The surface becomes swollen and of a dusky hue, while the eruption can be seen indistinctly beneath the surface. The pulse is oppressed, the temperature 104° or 105°; the tongue is broad and thick, with a dirty, pasty coating; while the breath is peculiarly fetid; in fact, so characteristic is the odor that the physician could almost diagnose the disease, in the dark, by the odor alone.

The patient is dull, with the pupils of the eye dilated. The cough is hoarse and frequent, with more or less dyspnea. The eruption is darker in color than in the simple form, and the tissues seem edematous as though infiltrated.

'"In another class of cases, the symptoms of malignancy are manifested early in the disease. The pulse is smaller and faster, the skin is flushed, but dry and dusky, and the tongue is covered with a dirty fur, with a tinge of brown. The nervous system suffers especially in these cases. In some there is great excitement for the first day or two, even delirium and sometimes convulsions, afterward coma. In the majority of cases, however, dullness and hebetude are marked symptoms; the child dozes with its eyes partly open, the coma gradually increases till the child can not be aroused. In all these cases the eruption is more or less dusky, or it may occur as petechial patches, and hemorrhage may occur from the various orifices of the body.

"Retrocession.—There may be retrocession of the eruption of measles at any time after it has appeared. In the milder form of the disease this increases the fever and the bronchial irritation, and, though unpleasant, is not dangerous. In other cases we will find the nervous system suffering severely from the retrocession, and, if it continues, the blood also becomes impaired. In these cases dullness, stupor, and coma follow one another rapidly; the skin is dusky, the temperature increased, the tongue becomes brown, and sordes appear upon the teeth. These symptoms are of a grave character, and unless prompt means are employed to bring the eruption again to the surface, it may terminate fatally in a short time." (Scudder.)

Irregular Course.—While measles usually presents a uniform course and is readily diagnosed, we are not to forget that occasionally a case will present itself which is somewhat puzzling to the practitioner, owing to the absence of some one of the prominent stages. Thus, there may be an absence of the catarrhal symptoms, "Moribilli sine catarrho," the eruption appearing without the customary announcement; or these earlier symptoms may be present, suggesting measles, and yet no eruption appear, though the cough and catarrhal symptoms point to measles. This has been termed Moribilli sine exanthemate.

Complications and Sequelae.—Perhaps the most frequent and also most severe complication is that of some part of the respiratory apparatus. While a certain degree of bronchitis attends every case of measles, yet there may be an extension to the smaller bronchioles and a broncho-pneumonia result, or, in delicate children. a capillary bronchitis develop.

These complications usually occur among- debilitated children, and are recognized by the adventitious sounds; viz., the crepitant, followed by the subcrepitant rales. These complications, of course, add to the gravity of the disease.

Conjunctivitis.—This is not an uncommon complication. There is marked congestion of the conjunctiva, a high grade of inflammation is set up, suppuration occurs, giving rise to purulent ophthalmia. Granular ophthalmia tarsi is apt to result from this complication.

Catarrhal inflammation of the middle ear is one of the distressing complications, as it leaves a serious lesion behind. The inflammation is followed by suppuration and perforation of the membrane, deafness being a result.

Catarrh of the intestine is not an infrequent result, especially if an injudicious use of cathartics has been made in the beginning of the disease. Stomatitis is somewhat rare, though occasionally present, the inflammation extending to the throat.

Following measles, the child, debilitated by the combined forces which have been at work, falls an easy prey to the ravages of tuberculosis. The soil is ready for the phthisical germs, and their further development speedily follows.

Diagnosis.—The diagnosis of measles is usually readily made. It is recognized from scarlet fever by the longer period before the eruption, by the irregular and blotchy character of the eruption, the absence of sore throat, the presence of the bronchial cough, and the initiatory catarrhal symptoms.

From rubella, by the absence of the enlarged post-cervical lymphatics, the congested fauces, and the short prodromal stage and slight fever of the latter. From variola, by the shotlike character of the papules of the latter and their subsequent evolution.

Prognosis.—Measles is generally regarded by the laity as of little consequence, and something which every one must undergo, and the physician who has never passed through an epidemic of the malignant variety, or seen a serious complication, is prone to regard the disease of minor importance.

In all mild or uncomplicated cases, the prognosis should be favorable, but where the child is delicate, or has a feeble vitality, and the disease is attended by respiratory complication, or if it is of the malignant type, the prognosis must be guarded, though even here, if skillfully treated, the mortality should not be very large.

Treatment.—There are no prophylactic measures which can be said to be successful when an epidemic of measles makes its appearance in a community, and there are no means of hedging it in. It permeates the air, and the children contract the disease, though not necessarily exposed directly to a patient suffering from it; and while a few may escape by isolation, they are the exception.

To limit it as far as possible, the same precautions should be taken as in other diseases of infectious character; viz., the thorough disinfection of all the excretions, perfect cleanliness in the sick-room, a thorough disinfection of the sick quarters, together with the clothing of the nurse, upon the recovery of the patient.

The medicinal treatment of measles, unless complicated, is very simple. The child should be put to bed, even in mild cases, to avoid dangers which would arise from exposure. Sponge the surface with warm soda-water, and give the child a hot foot-bath. Internally, the small dose of aconite and asclepias will modify the fever and favor the eruption. Where there is restlessness and inability to sleep, or where the child cries out in the sleep, rhus tox. will replace the asclepias. For the initiative cough, drosera will be called for, drops ten to twenty in a half glass of water and given in teaspoonful doses every hour.

The emetic powder on a larded cloth over the chest will be found beneficial, not only in relieving the respiratory irritation, but also in hastening the eruption. Where the cough seems to arise from the larynx, as indicated by a tickling sensation in the throat, nitrate of sanguinary will prove efficient—a fourth or half grain of the nitrate to half a glass of water; or a small powder of the third trituration given hourly brings relief. Where the child has difficulty in breathing, and there is oppression of the pulse, give ten drops of lobelia to half a glass of water in teaspoonful doses every hour. If there be pain of a sharp character in the chest, bryonia will be the remedy, four drops to a half glass of water. Tartar emetic 2x or 3x is highly recommended by Dr. Webster.

In the severer form of measles, the child will need more careful attention. Specific medication, however, promises the best results, for though sepsis will be the chief condition with which we have to deal, experience has proven that every case can not be successfully treated by the same prescription. There seem to be different kinds or manifestations of the toxin, and by careful study we may meet these conditions with appropriate antiseptics.

When the eruption is tardy in making- its appearance, and the child's face is flushed and dusky, pupils dilated, the child is dull and passive, belladonna, ten drops to half a glass of water, will be the remedy. The older Eclectics obtained good results from the lobelia emetic, and it would be difficult to convince one who had succeeded by this means to trust the specific action of the small dose.

Where there is a broad, pallid tongue, with a dirty, white, moist, pasty coating upon it, nothing equals sodium sulphite given in from one to three grain doses every two or three hours. If the tongue presents a dry, sleek or glossy appearance, with redness of the mucous membrane, muriatic acid takes the place of the alkali. Where the breath is foul and the tongue is moist, with a yellowish coating, chlorate of potassium with hydrastine will be more effective than either of the above-mentioned remedies. Where the face is dusky, the tongue is full and thick, with duskiness of the mucous membranes, echinacea will be one of the best antiseptics. If there be any cerebro-spinal complication, the indications for that remedy will be all the more marked.

Where there is intestinal complications attended by diarrhea, aconite and ipecac, five drops of each to half a glass of water, in teaspoonful doses, will be useful, or ipecac and subnitrate of bismuth in mint-water may be called for.

The diet should be bland and nourishing. Hot milk is preferable, but if the patient objects, matted milk, either as a drink or prepared as a broth, will be readily appropriated. Meat broths should not be allowed till the convalescent stage has been reached. Tepid baths should be used daily, and the patient kept in a darkened room to protect the eyes.

During the convalescent period the child must be carefully watched; for it is during this stage, when the skin is peculiarly sensitive, that the danger from unpleasant sequelae arises.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.