Rubeola

BY W. A. HARDAWAY, M.D.

In the preparation of this article the writer has consulted the following works: Thomas, in Ziemssen's Cyclop. Pract. Med., vol. ii., N.Y., 1875, Am. edit.; Bohn, in Gerhardt's Handbuch der Kinderkrankh., Zweiter Band, Tübingen, 1877; Squire, in Quain's Dict. Med., N.Y., 1883; Ringer, in Reynolds's System Med., vol. i., Phila., 1879; Meigs and Pepper, Dis. of Children, Phila., 1882; J. Lewis Smith, Dis. of Children, Phila., 1882; Hebra, Dis. of Skin, London. 1866; Vogel, Dis. of Children, N.Y., 1871; Niemeyer, Handbook of Pract. Med., N.Y., 1869; Trousseau, Clinical Med., Phila., 1871. Other references will be found in the foot-notes to the text.

SYNONYMS.—Rubeola, Morbilli, Measles, Masern, Flecken, Rougeole.

DEFINITION.—Measles is an acute infectious disease involving the skin and mucous membranes, characterized by successive stages and a maculo-papular eruption, which terminates in a fine branny desquamation. In normal cases it runs a definite course, which from the date of invasion to the end of desquamation occupies about fourteen days. It is highly contagious, and occurs, as a rule, but once in the same person.

HISTORY.—The word rubeola is probably of Spanish origin and was formerly written rubiola or rubiolo. The designation morbilli is the diminutive of the Italian il morbo, the plague. Although it is doubtful, as claimed by Willan, that the Greek and Roman physicians were acquainted with measles, there is no question that Rhazes was one of the first to describe the affection correctly. Rubeola is said to have been distinguished from variola by the Arabians in the twelfth century; but, nevertheless, as late as the middle of the seventeenth century we find Sennertus discussing the question "why the disease in some constitutions assumed the form of small-pox, and in others that of measles;" and in a posthumous work of Diemerbroeck, published in 1687, it is asserted that small-pox and measles are only different degrees of the same affection. According to Mayr, the merit of having shown measles to be a distinct malady from scarlatina must be ascribed to Forestus and Sydenham. It is not clear, however, that the two diseases were accurately differentiated till the close of the last century, and notably by Withering in 1792.

Cyclop. Pract. Med., London, 1834, p. 625.

ETIOLOGY.—The exact nature of the measles contagium has never been satisfactorily established, although we are in possession of numerous researches in that direction, which, however, are to a great extent contradictory. A brief examination of these various observations will not prove uninteresting. Hallier found in the blood and sputa numbers of free cocci, which fructified upon various substrata, but was invariably the same fungus—mucor mucedo verus, Fres. In 1862, Salisbury published his observations on the relation of the straw fungus to measles. He recorded instances of inoculation with this organism that resulted, according to him, in the production of a modified form of rubeola, and, moreover, was protective against further attacks of the same disease. In an exhaustive paper bearing on this question H. C. Wood quotes certain experimental inoculations made by William Pepper, which showed conclusively that measles was not propagated in this way, and that where any symptoms were developed they were not those of true measles, nor did they protect the subjects from unquestioned measles. Salisbury also claimed that measles had occurred in camps where damp and mouldy straw had been employed for bedding. J. J. Woodward in his work on Camp Diseases points out that camp measles prevailed almost exclusively in regiments from the rural districts, while men enlisted in towns and cities were more or less completely exempt. The explanation was, that those from the country had hitherto escaped the disease, while townspeople had suffered from it at some previous time—a condition of affairs inconsistent with the theory of the straw fungus. Coxe and Felz found numerous bacteria in the blood of measles patients, especially in regions where the eruption was most pronounced. The nasal mucus also contained similar germs. Inoculation of the blood from the subjects of measles upon rabbits did not produce an analogous affection (Thomas). Klebs obtained micrococci from the trachea and from blood taken from the hearts of infant cadavers. "In the latter, collected in flattened capillary tubes, there developed balls of micrococci; in the trachea both micrococci and bacteria were present in large quantities. Under observation, pale, finely-granular micrococcus balls developed and changed very quickly to bacteria, which moved about very actively. These sought the periphery, about ½ mm. distant from the centre of development, and formed a zone, comparable with a hedge or fence that is composed of rods. From this were formed new masses of micrococci, but further no regular process of arrangement or development could be observed."

Am. Jour. Med. Sci., July and Oct., 1862.

Ibid., Oct., 1868, p. 333.

Würzbr. Verh., N. F., v., 1874, quoted by Forchheimer in Supplement to Ziemssen's Cyclopedia, W. T., 1881, p. 102.

Braidwood and Vacher, as the result of a number of experiments, believed that they had sufficient evidence for concluding that the most active mode of the transmission of measles was through the breath, and accordingly instituted a series of experiments by carefully examining the breath of children in the acute stage of the disease. With this object in view they coated over with glycerine the inside of several clean glass tubes of a diameter of a half to three-quarters of an inch. As soon as the nature of the eruption was manifest the patient was required to breathe through one or more of the tubes, and so on each day till the eruption had faded. Upon examination of the glycerine with an one-eighth objective every specimen showed numerous sparkling bodies, something like those found in vaccine, but larger. Some were spherical; others were elongated, with sharpened ends. They were most abundant during the first and second days of the eruption. Healthy children and patients suffering from typhoid and scarlet fevers were made to imitate these experiments, but no such bodies were to be seen in their specimens. They conclude from these observations that the small spherical elements discovered in the breath are perhaps the active agents in the propagation of measles. Upon post-mortem of patients who had died of rubeola these germs were found in the lungs and liver, and, particularly, close to the walls of the capillaries. They believe that the "lungs are the favorite breeding-ground of the contagium."

Brit. Med. Jour., Jan. 21, 1882.

Several years ago Ransome of Manchester obtained particles from the breath of two persons suffering from measles (Squire).

That inoculation of morbillous blood may convey the disease was first demonstrated by Home in 1757, which experiments were verified by Speranza in 1822 and by Katona in 1842. The inoculations of the latter are especially noteworthy, as they numbered more than a thousand. No person inoculated by him died, and only 7 per cent. of the inoculations failed. On the other hand, inoculations made by Mayr gave negative results. It is stated that Monro and Locke communicated measles by inoculating with the tears and saliva. Attempts of the same kind were fruitlessly made in Philadelphia in 1801, although the blood, the tears, the nasal and bronchial mucus, and the exfoliated lamellæ of the epidermis were successively employed in the trials.

Rayer, Diseases of the Skin, Phila., 1845.

Mayr has shown that the nasal mucus is capable upon inoculation of propagating the disease. He performed the experiment upon two healthy children living at a distance from each other, at a time when the disease had ceased to be epidemic. Some nasal mucus taken from the patient during the stadium flavitionis, and kept fluid in a glass tube, was the same day placed upon the mucous membrane of each of these children. In one of them the first symptom of sneezing occurred after eight days, in the other at the expiration of nine days. Febrile symptoms set in two days later. In each child the rash appeared on the thirteenth day after infection. The inoculated disease was mild and regular in its course.

While it is perhaps true that the contagion of measles is not so tenacious as that of small-pox and scarlatina, it is a matter of observation that susceptible persons are liable to contract the disease, even if not directly exposed to its influence. There is incontestable evidence that it is conveyed by fomites—a fact well worth bearing in mind.

It is but just to say that so excellent an observer as Mayr taught that measles could not be conveyed by clothes, linen, etc. unless transferred immediately from one individual to another. Panum, however, showed that contagion could be carried many miles by an unaffected third person without losing its activity. Aitken has also pointed out the fact that children's clothes sent home in boxes from schools where the disease has raged communicated the disease, and that susceptible children who had slept in the same beds, in the same rooms, after they had been occupied by persons suffering from measles, have taken the malady. Squire observes that the contagium of measles, except in the catarrhal stage, is not far diffusible in the air, but clings to surfaces, and may be thus carried from place to place; on the other hand, children have been brought, while in full eruption, into a house among others, and nursed in a room apart, without any extension of the disease to the most susceptible.

Science and Pract. of Med., Phila., 1868.

Various circumstances render it probable that measles is most readily propagated during the stage of efflorescence; but that it is also highly infectious during the prodromal period is now universally acknowledged.

According to Niemeyer, the probability of infection during the prodromal stage is supported by the wonderful spread of measles through schools; for, while the strictest surveillance is established over children with any suspicious eruptions, and those known to have had the disease are not allowed to return till long past the stage of desquamation, no heed is paid to those exhibiting the premonitory cough and coryza. There is no reason for believing that measles can be propagated during the period of incubation; on the other hand, there is no satisfactory argument for the denial of its infectiousness in the desquamative stage. Although Panum is inclined to doubt its contagiousness at this time—and his observations are worthy of the greatest confidence—other good authorities differ from him materially, and extend the stage of personal infection to a period of from three weeks (Squire) to forty days (Hillairet).

Reasoning from analogy, we would naturally expect that the period of incubation in measles suffered a certain amount of variation; the result of numerous observations confirms this expectation. It is manifestly a difficult matter in densely populated communities to establish with accuracy the date of a given infection, but from a study of more or less carefully noted cases it will be found that the period of incubation may vary from three to thirty days. For the vast majority of cases the average time between the reception of the measles poison and the appearance of the characteristic eruption will be about from thirteen to fourteen days. Panum, under exceptionally favorable surroundings, found it more frequently fourteen than thirteen days. Therefore, deducting the three or four days occupied by the invasion stage, we shall find that the real incubation period is from nine to ten days from the date of exposure. Mayr's two cases of inoculation with nasal mucus showed no departure from this rule, but in the inoculations made by Katona with blood the prodromic symptoms made their appearance in seven days, the cutaneous lesions developing two, and at the most three, days afterward.

Minor epidemics of measles are said to occur every three to five years, more extensive and severe ones every seven or eight years. In the centres of population measles may be said to be endemic; in isolated regions the visitations of the disease may be widely separated. Measles is a less severe disease in warm than in cold climates, and, as a rule, we also find the affection more common and more intense in the fall, winter, and spring than in the summer months. Epidemics of measles are usually short, and it is thought that there is a definite relation between the severity of their onset and their duration, this being in general short in proportion as the given epidemic was at first severe (Mayr). Intestinal complications are more frequent in summer, and involvements of the respiratory organs more common in winter. The varying aspects of different epidemics—sthenic, asthenic, etc.—depend on changes in the weather, season of the year, the presence of complications, and other agencies not very clearly understood. Epidemics of whooping cough may precede, accompany, or follow in the wake of measles, and it has therefore been suggested that it stands in some peculiarly close connection with the latter; but, aside from this often-observed coincidence, we are not justified in our present state of knowledge in assuming any definite relation of cause and effect between the two diseases.

Aitken (op. cit., p. 295) declares that the mortality returns from England and Wales show that the influence of season is most trifling. Occasionally it has been found that the deaths in summer exceeded those in winter, but we believe that the statement made above is, in the main, correct. For instance, Parson's figures for Berlin for the years 1863-67, inclusive, are: spring, 11.9 per cent.; summer, 13.3; autumn, 33.4; winter, 41.4. Voit's statistics in an average of thirty years at the Children's Clinic at Würzburg establish the same general principles (Thomas).

There would seem to be neither geographical nor racial bar to the propagation of measles, for it has been observed in all countries and among all peoples. As in the case of other zymotic diseases, a tolerance is established for measles in countries where the disease is more or less constantly prevalent; but where the affection becomes epidemic for the first time, or reappears after many years, it rages with terrific violence. This fact was particularly exemplified in the epidemic in the Faroe Islands, and more especially in the recent (1877) visitation of the Fiji Islands, where one-fourth of the population succumbed in a comparatively short time.

It is quite probable, as asserted by Mayr, that children affected with scrofulous complaints, as well as those who are the subjects of diseases of the respiratory organs—pertussis, bronchitis, or tuberculosis—are eminently susceptible of measles; but his statement that sufferers from epilepsy, chorea, and paralysis exhibit an unusual power of resistance cannot be accepted without reservation. Acute diseases often appear to delay the outbreak of measles, so that the latter does not appear till convalescence from the former (Thomas). The development of vaccinia is occasionally interfered with by an attack of rubeola; on the other hand, the two diseases may be seen running their courses together. The emphatic statement made by Hebra, that measles is never seen to occupy a patient simultaneously with another acute exanthem, has not been confirmed by other observers. My own experience furnishes several examples. Measles may also occur during the course of other acute or chronic maladies. From a study of the literature of measles complicating pregnancy and parturition Underhill finds it to be quite uncommon, due probably to the fact that most adults are insusceptible of further attacks; but when it does occur in pregnancy he regards it as a very serious and frequently fatal complication. Underhill believes measles to be most fatal when it supervenes soon after delivery, while those who are confined during the course of the malady stand a better chance of recovering from it. That puerperal women are not always unfavorably affected by measles is well shown in two remarkable cases reported by Nelson of St. Louis and Chantier of Geneva, in which the mothers were safely delivered, though suffering from measles contracted at the end of their pregnancies.

Hardaway, Essentials of Vaccination, p. 60.

Obstet. Jour. Great Britain and Ireland, July, 1880.

St. Louis Courier of Med., Sept., 1879.

Annales de Gynécologie, May, 1879.

All ages are susceptible to the measles poison, and the apparent exemption enjoyed by adults is due to the fact that most grown-up people have already suffered the disease in childhood; but in Panum's epidemic, mentioned above, it was discovered that nearly all who had not had measles elsewhere, or were not old enough to have been exposed at the last visitation, sixty-five years before, acquired the affection regardless of age. It is quite probable, however, that the law of decrease of susceptibility with age holds good for measles as well as for variola, etc., but to a less degree. It will therefore be seen that measles is not essentially a disease of childhood. Although there is no special limit to the susceptibility of rubeola at one extreme of life, it would seem to be quite well established that it is much modified at the other—namely, that infants under six months are rarely attacked. This latter fact is conceded by individual experience, by the records of epidemics, and by the testimony of most observers.

On the other hand, as quoted by Forchheimer (loc. cit.), H. C. Fox publishes some tables which show that for England and London a much larger number of young children are attacked by measles than other statistics would lead us to believe.

England. London.

Males. Females. Males. Females.

Under one year 3022 2530 3571 2987

One and under two years 6086 5825 8630 8050

Two and under three years 3178 3255 4683 4757

Three and under four years 1730 1851 2594 2620

Four and under five years 980 1028 1358 1466

Five and under ten years 255 278 301 316

Ten and under fifteen years 29 38 24 32

Fifteen and under twenty years 9 13 9 11

Twenty and under twenty-five years 7 9 5 7

Twenty-five and under thirty-five years 5 8 5 7

Thirty-five and under forty-five years 3 5 2 3

Even sucklings do not enjoy a complete immunity from measles. Steiner states that he has met with it in children only four or five weeks old. Monti has recorded ten cases of rubeola in children under two months of age. A case is reported by Kunze where a mother in the stage of efflorescence gave birth to a child, which contracted the disease five days afterward. Quite a number of cases of congenital measles have been put on record from time to time; but Thomas, after a careful investigation, says that he has been able to discover but six authentic accounts of such occurrences. That children born to mothers suffering at the time of parturition from measles may yet escape it themselves is proven by the cases of Nelson and Gautier mentioned above. Whether a pregnant woman attacked by measles transmits the disease to the foetus in utero, thereby securing immunity from it in after life, is a question difficult of decision, especially as we have not yet been able to decide this same inquiry, with infinitely better opportunities, for vaccinia.

Compendium of Children's Diseases, N.Y., 1875, p. 396.

I believe that, under certain circumstances, the erythema papulatum of the new-born is often mistaken for measles.

See experiments of Burckhardt, Rickett, Gart, and others, quoted in Hardaway's Essentials of Vaccination, p. 38.

There is no good reason to believe that sex is of much importance in establishing a predisposition to measles, although the statement has been repeatedly made that males are more frequently attacked than females. Fox's statistics show a slight preponderance in favor of the male sex; but a careful examination of accessible statistics proves, as would be expected, that this degree of susceptibility varies at different times in obedience to circumstances not readily understood.

By the older writers (Willan, Rosenstein, Fuchs) it was very dogmatically asserted that one attack of measles completely extinguished all future susceptibility to the disease. Of late years this dogma has met with much opposition, and numerous observations have been recorded which, if entirely trustworthy, would lead us to believe that rubeola may occur not only twice, but several times, in the same individual. While from analogy and actual experience we are quite sure that the recurrence of measles is not so uncommon an event as it was once held to be, a closer examination of the question in all its bearings clearly confirms us in the belief that subsequent attacks are much more infrequent than is now thought to be the case by many, and that other diseases, more or less resembling true measles, are largely responsible for errors of diagnosis in this regard. Panum found that all the old people who had measles during the epidemic on the Faroe Islands in 1781 escaped it in 1846. Both Rosenstein and Willan declared that they had never witnessed an instance of the true recurrence of measles. Among other facts, it may be stated in this connection that Woodward (loc. cit.) has shown that during our late war, while members of regiments recruited from the rural districts, who had never before had measles, largely took it when exposed to its influence, regiments from the cities, who had presumably acquired the disease in childhood, remained almost entirely exempt. Other arguments of a similar sort could be readily adduced. There is no question that mistakes in diagnosis have occurred from confounding rötheln, roseola, etc., which closely simulate measles, with that disease. Those particularly engaged in the treatment of cutaneous affections could multiply instances of such errors. It is quite significant that for certain analogous infectious diseases—e.g. variola and scarlatina—the same frequency of recurrence is not claimed, although as a matter of fact they do occur. The explanation would seem to lie in the fact that neither small-pox nor scarlet fever is so closely counterfeited by other skin affections, notably by rötheln, as is measles. But it would be entirely contrary to analogy and indubitable experience to go to the extreme of the older writers and absolutely deny the possibility of second, and even third, attacks of rubeola. The frequency of such cases is, however, as Henoch truly states, much overestimated.

These observations of Woodward were made without any reference to the question at issue.

Lectures on Diseases of Children, N.Y., 1882, p. 282.

Occupying quite a different position from the measles induced by reinfection from without are the so-called relapses of rubeola. These relapses, which may occur in from two to four weeks after the original invasion, are analogous to the similar occurrences in scarlatina and typhoid fever. I am cognizant of but a single case of this sort, but Steiner and other accurate observers record a number of such instances.

SYMPTOMS AND COURSE.—It is generally stated that the stage of incubation exhibits no symptoms whatever; but it is undoubtedly true that the patient will sometimes appear dull and listless, and, on occasion, even give evidence of some slight and ephemeral elevations of temperature. As a rule, however, this period is devoid of any marked indication of the presence of the measles poison in the system.

Some writers describe a much more marked train of symptoms as prevailing at this time than seems warranted by general experience, and Rehn has gone so far as to declare that the prodromal period, as usually understood, properly commences in the stage of incubation. Bohn is inclined to a similar view. The prodromic stage of authors is, then, to be looked upon as the "period of the mucous membrane exanthem."

The prodromal stage is usually ushered in by symptoms of general malaise, fretfulness, more or less frontal headache, shiverings, nausea, loss of appetite, excited sleep, and sometimes delirium. Vomiting is not so common in measles as in scarlatina, and may occur at any time previous to the appearance of the rash. The tongue is apt to be coated, although it may remain clean; the taste is bad, and pressure over the stomach and bowels occasionally elicits considerable pain; an aching pain over the sternum is also noted. As a general thing, at this time patients are drowsy and inclined to sleep much. Meigs and Pepper found this a very constant symptom, which they state is in no way alarming unless associated with other more serious symptoms of local or general disturbance. Constipation is present in some cases, or the bowels may be relaxed or remain in their natural state.

The prodromal fever of measles follows a peculiar course. It is remarkably remittent in character, and is rarely of such intensity as to threaten life, as is often the case in scarlet fever. The temperature will rise on the first day to 102°-104° F., and the height of the fever at this time will measurably foreshadow the character of the subsequent course. On the second day of the prodromal stage the fever suffers a marked remission, or may even entirely disappear, to again rise in the evening. Smith has observed two exacerbations in the day. Again, in some instances, after the high initiatory fever, the temperature may remain normal till just before the rash comes out (Bohn). It is this peculiar behavior of the fever, together with the fact that the child may regain its usual vivacity in the fever-free intervals, which so often misleads the physician into the diagnosis of malarial poisoning.

The most pronounced feature of this stage of the disease is, beyond all others, the catarrhal affection of the mucous membranes. The mucous membranes of the eyes, nose, mouth, and air-passages are all more or less involved, and the patient suffers in varying degrees from photophobia, coryza, hoarseness, cough, and pain in swallowing. Sneezing is frequent and annoying, and slight epistaxis is not uncommon. The cough usually appears on the first day, simultaneously with the fever. It is not very troublesome at first, but by the fourth day it becomes more frequent, assuming a hoarse, barking, paroxysmal character. Expectoration is scanty, and auscultation reveals a harsh vesicular murmur or else sibilant râles. Alarming but not dangerous attacks of false croup may come on during the night. Many observers have called attention to the red spots (papules) in the oral cavity, which make their appearance during the period of invasion. According to Bohn, usually on the second or third day from the beginning of the fever there appear upon the slightly hyperæmic mucous membrane of the soft palate, palatal arch, and uvula small or large, dark, red spots that spread to the mucous membrane of the cheeks, and sometimes to the hard palate, lips, and gums. Soon they become more defined, and are to be distinguished by shape and coloring from the membrane upon which they are situated. According to the same authority, they also afford an index to the intensity and extent of the coming cutaneous eruption. It is also stated that if the latter partakes of a hemorrhagic character, the spots on the mucous membrane may also become livid. This same punctate reddening has been demonstrated in the epiglottis, larynx, and trachea (Gerhardt), and upon the bronchi and small intestines of children who had died during this stage of the eruption. It is also to be noted on the conjunctivæ. It has been assumed that this period of this disease is not to be looked upon as the stadium prodromorum, but as the period of the "exanthem of the mucous membrane." This view of the pathology of measles seems to me most reasonable; but in whatever way we may look upon the question, the practical importance of this precutaneous eruptive stage is to be insisted upon for diagnostic purposes, just as is the analogous eruption upon the mucous membrane in small-pox.

In ordinary cases of measles we do not find such profound reaction of the nervous system as in scarlatina. I believe that convulsions in the prodromal stage are much more common than available statistics would have us believe; at least, this is my own experience. Meigs and Pepper met with convulsions but five times in 314 cases at the beginning of the eruption, while Rilliet and Barthez observed but one convulsion in 167 cases. Thomas says that convulsions are almost always absent. On the other hand, Trousseau and Bohn expressly declare that they are very common, the former stating that they occur with greater frequency than in scarlatina. I consider that convulsive seizures occurring in connection with marked catarrhal affection of the mucous membranes are very important aids in forecasting a probable attack of rubeola. Fortunately, convulsions at this stage are not very serious unless repeated or injudiciously treated.

The duration of the period of invasion in regular cases is from three to five days, with an average of about four, but in perfectly uncomplicated attacks this period may be extended to six or eight days, or even longer. But that the duration of this stage may be much shorter than the average is not sufficiently insisted upon by writers. Ringer, for instance, says that he had an opportunity of testing the earliest appearance of the rash in an epidemic of measles in a large public school for boys under twelve. In every case during the epidemic the rash appeared on the first day, the cases being severe, though of short duration, the temperature rising to 103° and to 104° F. In some instances the rash preceded (?) the fever. Thus, several of the boys feeling poorly, their temperature was carefully taken night and morning under the tongue, and in several cases the rash appeared in the morning about the face and collar-bone, while the temperature remained normal, and did not rise till the evening, when it ran up to 101°-103° F., and even higher. These cases certainly resemble rötheln more than measles. In two cases, which I observed under very favorable conditions, the eruption commenced to appear on the morning of the second day, and more or less similar experiences are recorded by others.

Handbook of Therapeutics, 6th ed., London, 1868—note to p. 26.

The skin eruption, which appears, as a rule, on the third, fourth, or fifth day of the attack, is ushered in with an increase in the general and local symptoms of the disease. It is particularly to be remarked that the fever does not subside at this time, as is the case in variola. The eruption appears first upon the face, about the cheeks and forehead, then on the chin and neck, and thence gradually overspreads the trunk, and finally reaches the extremities. When the eruption is intense no part of the body is free from it, the rash being found upon the palms and soles and upon the hairy scalp. The cutaneous lesions proper consist at first of hyperæmic spots of about a line in diameter, which gradually increase in size, until at their full development they may attain a diameter of from one-twentieth to a quarter of an inch. In the beginning they bear a very close resemblance to the sub-papular lesions of small-pox. The maculo-papules, when fully developed, are slightly elevated above the level of the skin, the elevation, however, being more appreciable to touch than sight, have a smooth velvety feel, and are so arranged as to enclose areas of healthy skin. In the individual spots we may frequently observe one or several minute, darker-colored papules, due to follicular congestion, which when more intense constitutes the morbilli papulari presently to be described. The maculæ are, as a rule, roundish, or they may be moon-shaped, or their borders may present an indented or notched appearance. Where the capillary circulation is active—on the cheeks, for example—or upon parts subjected to pressure, the eruption may become confluent; that is to say, the usually pale intervening skin becomes injected or the papules coalesce, and in this way produce a uniform redness over large single tracts of skin. This scarlatinoid rash, however, never occupies the whole surface of the body, but only limited regions, and in other situations may be detected the characteristic discrete papules of rubeola; the color is not uniform, but is broken here and there by the darker streaks and spots of the measly eruption. The rash, which disappears upon pressure to return when the pressure is removed, is of a more or less rosy red, with a tendency in some to deep red, and has occasionally a purplish hue. According to Mayr and Hebra, it is of the precise color which is obtained by adding a little yellow or brown to a red pigment.

According to the researches of Thomas, Squire, and Wunderlich, as abstracted by Seguin, the fever of the eruptive period is divided into a moderately febrile stage and the fastigium or acme. The moderately febrile stage averages thirty-six to thirty-eight hours, and is made up of one or two exacerbations of 100.4° to 102.2° F., but not quite so high as the initial fever. If there are two exacerbations, the second one is the higher; the intervening remissions are not so low as those of the prodromal stage, yet even now the norm may be noted on a single occasion. The fastigium commences early in the day or in the evening; if the rise should occur in the morning, the evening temperature rises still higher, with or without a slight remission the following morning, and the next evening attains the maximum. If the acme begins in the evening, the remission on the next morning is either absent or very slight. The greatest height of the fever in normal cases corresponds to the greatest intensity and development of the eruption. This rule is not invariable, however, for sometimes the fever is higher soon after the eruption appears, and has fallen when the exanthem has reached its highest point. The whole fastigium lasts from one and a half to two and a half days, so that the complete eruptive fever occupies from three to four and one-half days. The pulse in general preserves a proportionate correspondence to the temperature, and never attains the great frequency to be observed in scarlatina.

According to Ringer, the highest temperature reached in normal cases is 103° F. Thomas places it as high as 104° F., but states that it may go up to 105° F. without the intervention of any complication.

The general symptoms, with the exception of the fever, do not greatly differ from those common to the prodromal stage. The skin is hot and more or less swollen, particularly about the face; there are anorexia, photophobia, lachrymation, and sometimes epistaxis; the cough continues, and is generally frequent and harassing, and attended with little or no expectoration; the voice is hoarse. The tongue is coated, principally in the middle, through which the swollen papillæ protrude, while the tip and sides are red. The blotchy redness of the oral cavity is visible for some days, and finally becomes indistinguishable from the surrounding congestion. The tonsils sometimes become considerably enlarged, though suppuration must be rare. Enlargement of the glands behind the jaw and in the neck and groin are to be observed. At the outset of the eruption a profuse diarrhoea supervenes in most cases—a symptom which Trousseau rightly insists to be an essential feature of measles. This occurrence is interpreted by some writers as an evidence of the implication of the mucous membranes in the specific exanthem of the disease. This flux, which is sometimes accompanied by a little blood and tenesmus, rarely continues long, and may be succeeded by a degree of constipation. The respiration is generally somewhat accelerated, mostly in correspondence to the amount of fever present. Some degree of deafness is not uncommon, owing to the extension of inflammation along the Eustachian tubes. The urine is scanty and high colored; there is sometimes scalding in urination and vesical tenesmus, and at the acme of the fever traces of albumen may be detected.

The eruption, in fact, generally occupies the skin an average of four days, and, although this period may be shortened materially, it is less apt to be lengthened. The duration of the eruption at its maximum of development over the whole surface is about half a day, more or less, and, as a rule, corresponds with the greatest elevation of the temperature. The retrocession of the rash takes place in the order of its appearance—viz. first from the face, then from the trunk and upper parts of the extremities, and last from about the feet and hands, where, indeed, it may remain vivid, or even progress for a short time longer, after the eruption has begun to subside in other situations. Sometimes the almost faded spots will be temporarily renewed by an abnormal rise in the temperature.

With the decline of the eruption the other symptoms begin to subside. The cough loses its hacking, paroxysmal character, and becomes less and less frequent, and gradually disappears. The voice regains its normal tone, the tongue loses its fur, cleaning up in patches, and expectoration, which was absent or scanty and viscid in the beginning, increases and is free, the masses coughed up being coin-shaped and floating in a clear watery mucus—a symptom much dwelt upon by the older writers. The behavior of the temperature at this period—the stage of decline—is quite characteristic. The fall usually begins at night, and generally the next morning it has reached the norm or else fallen below it. On the other hand, the descent may be less precipitate, and the fall continues less rapidly all through the day; or there may be a slight rise again in the evening, the norm being reached the following morning. The termination by lysis—that is, slight elevations in the evening for several days—is much rarer, and while it may occur in perfectly regular cases, it should put the medical attendant on his guard against complications.

The comparatively normal course of measles portrayed in the preceding paragraphs does not always occur, but, on the contrary, the disease may depart from the more usual type in one or more particulars, either in especial stages of its progress or in the greater or less intensity of the malady as a whole.

In addition to those cases of measles where the eruptive and catarrhal symptoms are so slight as to almost escape observation, except for the existence of other cases in the same house or family, there are to be recognized two other trivial varieties of the disease—namely, measles without the catarrh, and measles without the rash.

That the eruption of measles should occur upon the skin without implication of the mucous membranes seems to be much more doubtful than that the catarrh should appear without the eruption. It is quite probable, at any rate, that many so-called cases of rubeola sine catarrho are merely instances of rötheln, which we know may occur without any reference to an existing epidemic of measles. But that this form of measles does exist is admitted by trustworthy observers, although its diagnosis under any circumstances must be a matter of great difficulty. Measles without the eruption (rubeola sine eruptione) is more readily recognized, especially and only, however, when a susceptible person is exposed, and as a result acquires the characteristic catarrhal symptoms. Since in recent years more attention has been paid to the eruption on the mucous membranes, it may be that its discovery in these situations may lend positive assistance to the diagnosis in such cases. It is hard to understand how this variety of measles, which presents no inflammatory changes in the skin, should be followed by desquamation; yet this observation has been made. The assertion that these anomalous forms of the affection afford no protection against subsequent attacks seems to be founded in error, and is undoubtedly due to the confusion existing between measles and rötheln or other exanthems.

Continental writers, especially, describe a form of measles called by them inflammatory or synochal. It is simply an exaggeration of the symptoms, particularly those appertaining to the mucous membranes, found in ordinary measles (morbilli vulgaris). The prodromal stage is much more violent, the nervous symptoms more threatening, the implication of the mucous membranes more pronounced and persistent, the febrile movement is of a higher inflammatory character, and the eruption, which instantly covers the whole body (Vogel), is made up of dark-red or purplish spots which fade slowly. It is this form of measles, according to Niemeyer, which is chiefly attended by croupous instead of catarrhal laryngitis, in which the inflammation of the air-passages often extends to the alveoli of the lungs, and in which the gastric and intestinal coats are often affected with catarrh.

Let the contagion of measles be a grade more virulent, or perhaps the resisting power of the patient more feeble, and the case will assume the features of the septic, typhous, or hemorrhagic variety (rubeola nigra). It is said that the hemorrhagic measles is most apt to occur in epidemics; certain it is that the dreaded black measles of former times is very infrequent now-a-days, due, no doubt, to a more rational treatment and a better hygiene. Isolated cases, however, are occasionally encountered. As a rule, from the beginning all the symptoms evidence an overwhelming of the system by the virulence of the poison—a condition of things much more common in scarlatina. The pulse becomes weak, thready, and frequent; the temperature lacks the typical remittent character of normal measles; there is unusual prostration; and the nervous centres are profoundly concerned, as shown by delirium, convulsions, and coma. The eruption lags, and finally makes its appearance in an imperfect or irregular manner. The spots are of a livid hue, interspersed with larger or smaller ecchymoses. Hemorrhages from the mucous cavities take place, and the patient dies in convulsions or sinks into fatal coma. It has been said that the grave constitutional symptoms do not generally make their appearance till the eruptive stage, but I know from experience that the patient may be overwhelmed quite early, as in purpura variolosa.

Too much stress should not be laid on these different types of the disease, whether mild or grave, since they depend upon a common cause, however much modified in one way or another; but they may be allowed to stand for the sake of clinical convenience.

Measles may also present certain irregularities in its various stages without necessarily departing from the otherwise benign character of the disease.

As stated elsewhere, it is believed by some writers that a greater part of the period of incubation is occupied by symptoms which already indicate the activity of the measles poison in the system, and that, therefore, this stadium in reality lasts but a few days. This opinion does not seem to be generally accepted; at any rate, I think we are quite safe in saying that in the majority of cases no departure from the usual latency is observed. The deviations in the stage of invasion have been considered above, and mostly concern its duration and the character of the temperature. Evanescent rashes, which have nothing in common with the specific exanthem, are sometimes observed at this period. The eruption of measles may present certain peculiarities. First, as to localization. Instead of coming out on the face first, it may primarily develop on other parts of the body, provoked into existence, as it were, by local exciting causes; thus, where ointments or plasters have been applied or upon a part subjected to constant pressure. It may affect only one-half of the body, or entirely spare paralyzed extremities (Mayr). In some instances the papules are so sparse, indistinct, and short-lived as to be scarcely appreciable.

Second, as to the physical characters of the eruption. Hebra and Mayr recognize the following modifications:

Morbilli lævis. The efflorescence is smooth and flat, and the individual lesions are separated from each other by normal integument. This is the common form of measles.

Morbilli papulosi. The papules are dark red and more elevated, are about the size of hempseeds, and situated at the mouths of the hair-follicles.

Morbilli vesiculosi. In this variety the mouths of the hair-follicles are filled with fluid and produce delicate transparent vesicles.

Morbilli confluentes. The maculæ are here so crowded together that no healthy skin intervenes.

Morbilli hæmorrhagici. The efflorescence consists of maculæ or papulæ of a dark-red color, due to extravasations of blood, and do not fade on pressure. It is well to mention in this connection the fact, particularly noted by Meigs and Pepper in this country, that hemorrhages into the skin may occur in cases which otherwise run a benign course. They are best seen after the eruption has faded. In some cases the efflorescence of measles may remain visible for a week or ten days.

As heretofore observed, there may be a relapse of the measles eruption after some weeks, accompanied by fever. It is said that the spots appear on parts of the skin hitherto normal (Thomas). So far as I know, Hebra was one of the first to point out the fact that the so-called striking-in of the eruption was the result, and not the cause, of some complication in the disease; for, as this author states, before the rash fades or disappears the internal disease is always present. It is well known, for instance, that syphilitic eruptions will sometimes disappear upon the supervention of some acute intercurrent affection, such as pneumonia, acute rheumatism, etc.; but no one will suppose for a moment that the retrocession of the syphilides was the cause of these affections. The pathological explanation seems obvious.

See Bumstead and Taylor on Venereal Diseases, 4th edit., p. 513.

COMPLICATIONS.—The complications of measles consist, as a rule, in the exaggerated morbid action of organs or parts that are essentially implicated in the disease; therefore we are most apt to encounter such affections as laryngitis, bronchitis, pneumonia, etc. Inflammation of serous membranes, on the other hand, are rare; thus, pleurisy is infrequent unless in connection with a lobar pneumonia.

The exact causes of the complications are not always obvious, but in many instances can be traced to the previous bad health of the patient, to the influence of insanitation, or, finally, to certain ill-understood features attendant upon some epidemics.

Simple bleeding from the nose, not associated with the hemorrhagic diathesis, is not an uncommon accompaniment of the prodromal stage, and is rarely a dangerous symptom—rather the contrary. It may also arise after the development of the rash, and occasionally proves a complication of serious import.

The aural complications, unlike those in scarlatina, are generally not sufficiently prominent at first to attract attention. The symptoms, particularly pain and deafness, are apt to be masked. Purulent processes and consequent perforation may occur during the eruption, but are more frequent at the stage of desquamation (Spencer).

Oral communication.

Various disorders of the skin have been observed during the course of measles—viz. miliary vesicles, and even pustules, as already described; herpes facialis, zoster femoralis (Thomas), and erythematous rashes, which may precede, accompany, or, it is said, follow the eruption. Of considerably more importance is the pemphigoid eruption mentioned by several observers. In Henoch's case, a girl of four years, the usual remission of the fever on the evening of the second day was absent, and from the third day there appeared over nearly the whole surface blebs filled with a limpid fluid, which varied in size from a hazel-nut to a thaler, and even larger. The cheeks and the backs of the hands were each covered with a single bleb. The exanthem was of a hemorrhagic character, and the intervening skin was red and the face swollen. The bullæ appeared not only where the eruption existed, but also on parts of the body free from it. The fever remained at the same height till the fifth day, when, upon the cessation of the bullous eruption, it fell to 100° F. A.M., and 101° F. P.M. The child died on the eighth day of a pneumonia which developed between the sixth and seventh days. Other cases have been reported by Steiner, Klüppel, and Löschner. Henoch rejects the theory that the bullæ are the result of the morbillous dermatitis, but thinks that they are merely instances of the coincidence of a contagious pemphigus.

Berl. klin. Woch., No. 13, 1882.

The severe affections of the eye described by continental writers—blennorrhoea, keratitis, iritis, etc.—are certainly very rare in this country as complications of measles. Various so-called strumous disorders of this organ, as will be seen hereafter, not uncommonly, however, come under the care of the ophthalmologist as sequelæ of the disease.

The tonsils and the mucous membrane of the pharynx may become severely inflamed. The tonsils are sometimes very much enlarged, but suppuration, if it occur, is certainly rare. Slight ulceration of the gums close to the teeth is occasionally noted, also aphthous ulcerations on the lips, tongue, and gums (Ringer).

Some degree of laryngitis is an accompaniment of all cases of measles. It has already been stated that catarrhal or false croup is frequently observed during the stage of invasion. Inflammation of the larynx may be present in all grades of severity. Rilliet and Barthez found ulcerations and erosions, especially of the vocal cords, upon post-mortem examination of a large proportion of measles subjects; and Gerhardt, both during life and by autopsy, has verified these observations. Loeri states that inflammatory changes are more marked in the larynx and trachea than in the pharynx. According to his examinations, hemorrhages or ecchymoses seldom occur, but more frequently superficial or even deep catarrhal ulcers, especially on the anterior aspect of the posterior wall of the larynx at the apices of the cartilages of Santorini, or on the posterior portion of the vocal cords. The physical condition of these parts readily accounts for the frequent and harassing cough and attacks of spasmodic laryngitis which are such frequent complications of the invasion and eruptive stages of measles.

Jahrb. f. Kinderheilk., xix. B., 1 H.

There may be an extension of the tracheo-bronchitis to the finer bronchial tubes, thus producing capillary bronchitis (suffocative catarrh). It is apt to prove fatal to very young children. It occurs more generally during or after the eruption.

Pneumonia is one of the most frequent and, directly and indirectly, most dangerous complications of measles. Catarrhal pneumonia (broncho-pneumonia) is, for obvious reasons, more common than the lobar or croupous variety. Pneumonia may develop at almost any stage of measles, but experience does not confirm the statement occasionally made that it is most frequent in the initial stage. Most observers will agree as to its greater frequency just at the end of the eruption or during the desquamative period. The occurrence of epileptoid convulsions, or an untoward increase of the fever, or an unexplained continuance of the same, should direct the attention of the attendant to the chest, if his anxiety have not already been aroused by a change in the character of the respiration or other symptoms. It may be mistaken for meningitis (Squire). In estimating the prognosis it should be remembered that croupous and catarrhal pneumonias run quite different courses. The influence of inflammation of the lungs upon the rash is quite decided. If an intense pneumonia should develop in the initial stage, the eruption will be pale and sparse, or else absent; if the eruption is already out at the time of the attack, it may become temporarily more vivid, to rapidly fade later.

A scanty rash by no means indicates an unfavorable course of the disease; this symptom is only serious when evidently due to some complication.

Chadbourne has the merit of calling attention to the occurrence of heart-clot and subsequent pulmonary oedema as a fatal complication of measles. In a number of autopsies he found that in each case the heart contained clear gelatinous clots of a very firm consistence, which in most instances extended to the pulmonary arteries, and in some to the extent of one and one-fourth inches. In the series of cases observed by him pneumonic consolidation was mostly absent, and there was very little evidence of collapse, but the lungs were exceedingly oedematous. But Keating has also found heart-clot to be the cause of death in some cases, and believes, as the result of his investigations, that the presence of large numbers of micrococci in the blood and in the white blood-corpuscles is responsible for this condition.

Am. Jour. Obstet., Oct., 1880.

Phila. Med. Times, Aug. 12, 1882.

There is a strong tendency in measles to intestinal catarrh. As already stated, a quite sharp diarrhoea is not uncommon at the beginning of the eruptive stage; but, unless it should prove very profuse and long-continued, it is not to be looked upon as of very serious import, especially if the other general symptoms of the disease are following a normal course. In other instances the bowel affection may be much more severe, giving rise to tenesmus, bloody stools, and the other phenomena of colitis. In weakly children the early diarrhoea may persist in spite of treatment for many days; indeed, under the influence of high temperatures it may take on a true choleraic character. Diarrhoea is a very frequent and grave complication of the broncho-pneumonia of measles.

Acute miliary tuberculosis as an immediate concomitant of measles is rare. According to Thomas, the disease at times immediately follows the exanthem, and reaches a fatal issue in a few days or weeks. The tubercles are more particularly to be found in the lungs and in the membranes of the brain.

Among the more common disturbances of the nervous system convulsions play an important rôle. The epileptoid seizures of the prodromal stage generally terminate favorably, but in some cases of a malignant character the onset of the disease may be ushered in with fatal convulsions. Convulsions in the later stages are apt to have a lethal termination, as they usually occur in connection with some grave complication, particularly of the thoracic organs.

Diphtheria is an exceedingly grave complication of measles, although not necessarily a fatal one. It is of less frequent occurrence than in scarlatina. It may attack any of the usual oral, nasal, or laryngeal regions, sometimes extending into the bronchi, but suffers no modifications in its symptoms and course from the primary disease. It may also rarely involve other parts—e.g. genitals, eyelids, etc. There is reason to believe that it is most prone to attack those cases in which the mucous membranes have undergone the greatest inflammatory alterations.

Loeri (loc. cit.) says that diphtheria may appear at any stage of measles, and commences generally in the larynx, and sometimes in the trachea simultaneously; seldom in the pharynx, as in primary diphtheria or in that complicating other diseases than measles.

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, 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.

Oral communication.

See valuable statistical article in N.Y. Med. Record, June 3, 1882.

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.

Thus, while Thomas seems to be without personal experience in the matter, he quotes without dissent a number of observations in support of his assertion—viz.: Behrend saw a chronic eczema of the scalp permanently disappear after measles; Rilliet found that a chronic coxitis improved noticeably after measles; various chronic skin symptoms, and also chorea, epilepsy, incontinence of urine, mania, worms, dropsy, joint diseases, ophthalmia, gonorrhoea, etc., have been known to recover under the same influence. Gibney (loc. cit.) in his valuable paper states that he can readily believe that, occasionally, any acute disease, occurring in the course of a chronic one, will prove beneficial to the other, but that he is far from considering this to be anything more than an exception to a very general rule to the contrary. Chronic joint disease, he continues, is especially a disease of exacerbations, and any one not familiar with their natural history may interpret the post hoc as a propter hoc. Gibney has collected 24 cases of chronic bone disease in children, 21 of whom were under ten years of age and all under thirteen. On analysis he found that 12 of these came out of the intercurrent disease in a worse condition, 11 were unaffected, and 1 only seemed a little better. In my personal experience I have invariably seen the eczemas of children made worse by measles. I have no wish to dispute the trustworthiness of the statistics quoted by Thomas; indeed, I regard them as mostly thoroughly reliable instances of exceptions to a general pathological law; but I wish it to be clearly understood that they are such, and that measles is not a disease to be slightly regarded as to its effects upon the system.

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.

Skin Diseases, Phila., 1880, p. 57.

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.

Corre (La Mère et l'Enfant dans les races humaines, Paris, 1882) states that measles and scarlatina exist in all climates and among all races; however, they are less frequent in warm than in cold climates. This relative rarity may be only apparent, and has only been established by reason of the difficulty of recognizing exanthems among dark-skinned peoples. In the negro the eruption (of measles) often escapes observation, but the general symptoms, the angina, coryza, and bronchitis, and the special coloration of the bucco-pharyngeal membranes, permit the establishment of the diagnosis. The skin appears more tense, and the face especially is puffed and glossy; in passing the hand over the different regions of the body slight elevations are felt—a difference in the level of the skin exists in the affected and unaffected portions. On examining the surface of the body obliquely at a well-pronounced angle of incidence, these elevations can be perceived by the eye. Desquamation, which is very manifest in the negro, also confirms the diagnosis; this desquamation is formed of epidermic débris; it gives rise to a white dust, which is well defined against the black skin. The skin itself seems to have lost its gloss; it is completely dry, and no longer gives the abundant and odoriferous secretion characteristic of the subjects of that race.

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.

According to Curtman (St. Louis Courier Med., June, 1882), the eruption of rötheln consists, when not confluent, of single papules, each separated by a distinct small red areola. Not infrequently the papules are large, and sometimes a few pass into vesicles or pustules. In measles the papules are very small, mostly confluent, from four to six landing on a single areola, which is larger than that of rötheln.

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 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.

Art. "Typhus" in Reynolds's System Med., Am. ed., p. 262.

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 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.

Art. "Mortality" in Quain's Dictionary Med., p. 1002.

In the general field hospital at Chattanooga the death-rate was 22.4 in 100 cases. In General Hospital No. 1, at Nashville, it was 19.6 in 100, or nearly 1 in 5. Many died or became permanently disabled from the sequelæ (Bartholow).

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.

In adolescence a body heat of 107° F. has been safely passed during the decline of measles with no marked complication (Squire).

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 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.

Pathologie u. Therapie der Hautkrankh., Wien, 1880.

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;

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.

The inunction of fatty substances, as originally proposed by Schonemann, and recently urged by Milton, is an excellent routine practice, and in addition to adding very much to the patient's comfort, has, perhaps, the merit of lessening somewhat the danger of infection to others. For this purpose one may use leaf lard, cold cream, or vaseline, to each ounce of which it is well to add a few minims of carbolic acid.

Archives of Dermatology.

Stimulants are rarely needed in uncomplicated measles, but Squire very wisely calls attention to the great value of wine in the depression following upon the crisis.

In spite of some excellent authority to the contrary, I cannot see that any benefit is to be derived from using severe measures to bring out an eruption that has undergone retrocession. As stated in another part of this article, the so-called striking-in of the rash is the result of the supervention of some complication, and not the cause of it; therefore, a rational course of action would be to ascertain the nature of the complicating trouble, and to endeavor to correct it, which, at the same time, would be the very best means of restoring the normal course of the disease.

Quinia is of great value in controlling the excessively high temperature which is sometimes observed either in connection with, or independent of, complications. If the quinia should prove ineffectual or else be rejected by the patient, the physician should not hesitate to abstract heat by cold water in the shape of the wet pack or the general bath. I think the latter method is to be preferred. It is but to employ the gradually cooled bath of Ziemssen, perhaps, commencing at 90° F. and going to 80° or 70° F. The condition of the patient, as ascertained by the thermometer and also the state of the pulse, must be the guide as to the duration and repetition of the baths. In Germany excellent results are claimed for the treatment of hyperpyrexia in measles by the cold pack, even when the excessive temperature is due to such a complication as broncho-pneumonia.

There is little hope from therapeutical interference in malignant forms of measles, but the medical attendant should endeavor to reduce temperature and support the strength by free stimulation and nourishing food.

It will now be advisable, at the risk of some repetition, to call attention to the treatment of some of the more prominent disturbances and complications of measles.

Epistaxis, if severe, should be checked by cold applications and astringents. Plugging will rarely be found necessary. Trousseau recommends the injection of water as hot as can be borne. Ergotine by the mouth or hypodermically will sometimes prove highly valuable.

The lids should be anointed with vaseline or cold cream to prevent their sticking together, and it is well to occasionally evert them to see that no serious mischief has happened to the eye. If the conjunctivitis is intense, the discharges should be removed and cold compresses applied.

Since aural complications are due to extension of inflammation from the oral and nasal cavities, Spencer urges the importance of early and systematic treatment of these parts. He advises astringent applications (Monsell's solution 1 to 4 of glycerine) to the pharyngeal mucous membrane. Ointments of boracic acid, zinc, or iodoform are likewise useful when introduced through the nostril. Earache will require warm opiated poultices and inflation. Otorrhoea is best treated after the dry method.

For sickness of the stomach a spice poultice may be applied and small bits of ice given to suck. If constipation exist, a little oil or syrup of rhubarb or some stewed prunes, or an enema, may be ordered. Active purgation should be withheld.

The early diarrhoea need give little concern, as it usually soon ceases; but if it should persist, recourse must be had to more energetic measures, such as the use of opium by mouth or enema, given cautiously in the case of children, vegetable and metallic astringents, and the application of hot poultices to the abdomen. The diet should be carefully guarded.

The cough, even in mild cases, generally requires some slight palliative, such as syrup of ipecac., and an occasional small dose of Dover's powder. Loeri very properly advises against the use of irritating expectorants. I think it advisable to keep the chest well smeared with camphorated oil, over which should be worn an oil-silk jacket. These simple measures, perhaps, diminish the tendency to thoracic complications. The sometimes violent paroxysms of false croup are very satisfactorily managed, after the manner of Graves, by gently pressing a sponge, soaked in very hot water, under the chin and over the front of the neck. When the dyspnoea is alarming, emetics, and the general warm bath should be brought into requisition.

Convulsions in the early stage require little treatment other than the warm bath and appropriate doses of the bromide of potassium; occurring later, they are very fatal under any treatment, as they generally supervene in connection with some of the grave complications of the disease. Chloral, preferably by enema, and chloroform may be tried. The management of the severe bronchitis and pneumonia of measles requires great care and circumspection on the part of the physician. The application of a well-made flaxseed poultice, which should be neither too heavy nor too hot, is to be regarded as invaluable. To the flaxseed may be added a small quantity of mustard. Over the whole is to be placed an oil-silk jacket. Alcoholic stimulants, nourishing, easily-digested food, and expectorants containing carbonate of ammonium are to be recommended.

For the treatment of the other complications and sequelæ of measles the reader is referred to the appropriate sections of this work.