Measles.
Synonyms:—Rubeola; morbilli.
Definition:—Measles is an acute, infectious, self-limiting disease of childhood, usually epidemic, seldom endemic. It is ushered in by coryza, with lacrimation, general catarrhal symptoms and mild fever. Subsequently an eruption of a peculiar character appears, which is pathognomonic of the disease.
Etiology:—This disease is of frequent occurrence in epidemic form, but the cause of its occurrence is not determined. A child must be exposed by coming into the presence of one affected, or who has come in contact with another individual having the disease. It is doubtful if immediate contact is necessary, as it is probably conveyed for a short distance through the air, and may be conveyed for a short period and for short distances in the clothes (fomites). Children not rendered immune by a previous attack—and individuals are seldom attacked but once—are very susceptible to it. Probably ninety per cent will contract it under favorable conditions. When it occurs in any family in a neighborhood it immediately spreads throughout the entire locality, but few escaping who have not been previously attacked.
No specific germ of measles has been found. During the initial stage the breath of the patient is especially infectious, but that which in the breath conveys the disease has not been discovered. The patient will convey the disease during the entire period of illness, but it is more actively infectious in the early stage, and there is no danger usually three weeks after the first appearance of the disease. The disease occurs very rarely in sporadic form, or in patients above twenty years of age, however severe the epidemic. While one attack usually renders the patient immune, it is not uncommon for a patient to have the disease twice or even three times.
Symptomatology:—After exposure a period of about nine days elapses before the patient is attacked. It varies from seven to twelve or fourteen days. The first symptoms are those of a mild coryza, with some fever and chilliness, with flushed face and reddened watery eyes. There is a dry, hoarse, metallic cough and frequent sneezing. The fever rapidly increases, the evening temperature being from one to two degrees higher than that of the morning, and by the second clay the patient is acutely ill. The throat is irritable, red and hyperaemic, but not distinctly sore. There is usually some headache. Laryngeal and bronchial irritation are pronounced and rapidly increase, the incessant cough being an important symptom. Upon the hard palate can be seen a dotted rash, composed of distinct papules, which appear perhaps twenty-four hours before the rash appears upon the skin.
The characteristic eruption appears usually at the end of the third or upon the fourth day. Its first appearance is upon the sides of the neck and back of the ears; then upon the forehead and face. Within twenty-four hours it has extended to the shoulders, chest and arms. It then soon covers the whole body. The eruption is at first macular, upon a slightly raised, reddened base, on the surrounding white skin. It soon becomes papular and can be felt under the finger. The reddened spots then coalesce in crescentric masses, covered with groups of papules, forming at first red-dotted areas with white, unaffected skin between and surrounding them. In severe cases these groups coalesce until there is a uniform eruption over the entire surface of the body. When it has appeared upon the face, the face is swollen and distorted, and the physiognomy of the patient is altered in a characteristic manner, easily distinguishable from that induced by the eruption of any other disease. With the appearance of the eruption the fever increases and there is usually a marked increase in the bronchial symptoms. The eruption begins to disappear in the order in which it appeared, first on the neck and face, usually within forty-eight hours of its appearance. It disappears quite rapidly, and is gone by the eighth day. It leaves the skin rough, dull, of a pale bluish, mottled appearance, and a fine bran like desquamation takes place, which continues from three to five days after the eruption has disappeared.
Occasionally an epidemic of measles will assume an unusually severe form, sometimes described as malignant. The initial symptoms are severe, with marked chill and high temperature. There is a mental involvement and delirium from the first, with suppressed secretions, dry tongue and dry mucous membranes. The patient is greatly prostrated, and convulsions are common. The eruption appears very slowly, is vesicular in character or petechial and hemorrhagic. Other passive hemorrhages are apt to occur also.
Complications:—Devoid of complications, this disease has no terrors, and is quite amenable to treatment. It is the author's opinion, however, from many years' experience, that no common disorder is more liable to severe and intractable complications and sequelae than this, and none should be watched more assiduously to avert such a termination. In a single mild epidemic, in addition to the fact that a majority of the cases were followed by unpleasant symptoms of a more or less severe character, I saw one case of convulsions; one case of immediate locomotor ataxia in a young man, from which the patient never recovered ; one case of purulent infection, with multiple, deep, severe and intractable abscesses, and one case of double broncho-pneumonia, complicated with both endocarditis and pericarditis, in a boy twenty years of age.
Laryngitis, bronchitis and broncho-pneumonia, ophthalmia, otitis and diarrhea are direct complications, due to the eruption. Those complications, caused indirectly or by infection, are glandular involvement, pyemia, nephritis and diseases of the nervous system—neurasthenia, paralysis and locomotor ataxia.
Diagnosis:—If the symptoms of the occurrence of the disease are typical the diagnosis is not difficult. But there is a variation so wide in epidemics, and especially in sporadic cases, as to often render diagnosis difficult. The acute catarrhal symptoms, with watery eyes and persistent sneezing, are suggestive, and if the eruption appears duly, the diagnosis is certain. The distinct, raised, reddened and papular areas are easily distinguishable from the uniformly bright red skin of scarlet fever. The redness is not eliminated by pressure, as it is in scarlet fever. Eruptions occurring without premonitory or constitutional symptoms should never be mistaken for measles. This rule applies to very many eruptions of sudden occurrence, which disappear within a few days, or assume a chronic form. Measles always has the premonitory acute catarrhal symptoms.
Koplik described small reddish spots with a white-tipped speck in the center, which, if they occur on the buccal and labial mucous membranes from one to three days before other symptoms, are pathognomonic of measles. Their absence does not prove that measles does not exist, however.
Prognosis:—But few patients in previous good health, with proper care and environment, die from measles. With children debilitated from any cause, acute or chronic, and especially when it follows other infectious diseases, the mortality is high. A very large percentage of the complicated cases die.
Treatment:—The practice, as often advised, of giving no medicine, because the disease is self-limiting, is radically wrong. The rule to treat every indication with its specifically indicated remedy, whatever the name of the disease, is certainly applicable in measles, as I am convinced by long observation that complications and sequelae are averted and that aggravated phases of this disorder are relieved, the patient rendered comfortable and the disease shortened by specific treatment.
If the initial fever is accompanied by irritation of the nasal, laryngeal and pharyngeal mucous membranes, aconite is of the first importance, but should be given in small doses. If the nerve centers be irritated and the pupils contracted, with bright eyes, gelsemium will be of great service. Euphrasia will quickly soothe the irritability in the post-nasal membranes, and ipecac is indicated for that within the bronchial tubes and pharynx. From three to five drops of ipecac and two or three drops of aconite in four ounces of water, a teaspoonful every half hour or hour, for the first twelve hours, will render the symptoms mild and hasten the appearance of the eruption. This condition is brought about satisfactorily with belladonna in one-fourth drop doses prepared as above. This is an especially serviceable remedy if the skin be cool, the circulation sluggish and the eruption retarded, and petechial in character, and the skin be dark colored. Also if the eyes are dull and the patient dull and stupid.
If euphrasia is not at hand for the nasal symptoms, from ten to twenty grains of the salicylate of sodium, dissolved in four ounces of water, and the aconite added to this, may be all the medication indicated. The patient kept very clean and quiet, in a well ventilated and particularly darkened room, with the above treatment, should pass through all the phases of the disease rapidly without complications.
Severe bronchial irritation is met with bryonia, and five-drop doses every two hours of the syrup of ipecac. If an open vessel of water, to which a few drops of the oil of eucalyptus be added, be kept simmering in the room it will afford great relief to this irritation.
The skin should have a bath twice daily, and should be anointed with olive oil, cocoa butter, lanolin or other unctuous substance. The patient should be kept in bed during the entire period of desquamation, and should be watched for weeks afterward and protected against chill and sudden cold to prevent lung, bronchial or other complications.
The food must be light and easily digestible and is best taken warm. Cold diet should not be administered. Milk and eggnog in small quantities, frequently, and light broth and soup, with fruit juices, will satisfy the patient and be well received.
The appearance of any complication must have prompt attention in accordance with its specific indications. Tonics should be administered as needed. The simpler iron tonics, with nux vomica or hydrastis, or the glycerophosphates, or syrup of the phosphates, or if lung or bronchial irritation persist free phosphorus are of much service. Strychnin arsenate in minute doses is of much value. In cases of inanition cod liver oil or malt preparations will be needed.
