Measles

(RUBEOLA; MORBILLI)

=Definition.=—Measles is an acute infectious, contagious, erythematous

disease, occurring in epidemics, characterized by an initial coryza,

bronchial catarrh and an eruption of a general maculopapular type; also

by the presence of Koplik’s buccal spots.

=Etiology.=—=Predisposing Influences=: The chief predisposing factor in

measles, as in all other contagious diseases, is a lowered resistance

in which some structural or functional change has taken place that

reduces the functional activity of the body’s inherent protective

agencies. These predisposing factors may be classed under three heads,

namely; (a) structural, (b) environmental, (c) dietetic. Under the

first we find structural disturbances in the upper cervical area

affecting the functional control of the nose, throat and head, as

well affecting the thyroid and its internal secretions: structural

disturbances in the upper and mid-dorsal areas affecting the vasomotor

control to the head, neck, and chest, thereby perverting nutrition

to all these structures and rendering them more susceptible to the

infective organisms; also the dorsal lesions disturb the functional

integrity of the lungs and heart, with the result of disturbed

respiration and circulation, both of which are vital factors in body

resistance: we also find structural lesions in the lower dorsal region,

affecting the function of the kidneys and their elimination and the

function of the adrenals and their internal secretions. Under the

second or environmental, we have unsanitary and unhygienic conditions,

exposure to sudden changes of temperature, wet clothing, fatigue, etc.,

all of which produce secondary structural lesions and the effects above

mentioned. Under the third or dietetic classification, we have the

errors of diet so common in children and adults as well; such as too

much candies and other sugars, also too much starches, as well as over

eating and unbalanced diet.

Measles prevails in all climates and attacks all races, the Negroes

appearing to suffer more severely than the whites and to be more

subject to complications. Outbreaks are more common in winter and

spring, but occur at all seasons. The disease is particularly a

children’s disease but adults may contract it if not protected by an

attack in early life, and with adults the disease frequently manifests

the more aggravated forms. It is more common after puberty than scarlet

fever.

=Exciting Cause.=—While the disease is probably produced by a

micro-organism, it has not yet been demonstrated. Inoculation

experiments upon human beings have shown the presence of the infecting

principle in the blood, in the tears, in the secretions of the nasal,

pharyngeal and bronchial mucous membranes, and in the contents of

vesicles occasionally present. Inoculation with the epithelial scales

thrown off at the end of the disease has been unsuccessful. Ordinarily

the transmission of the disease takes place through the breath or

the nasal and bronchial secretions. The disease may be carried by

a third person or by fomites. The infecting principle is intensely

active, but not so tenacious nor persistent as scarlet fever. Measles

is communicable throughout its entire course from the earliest

appearance of the coryza. The individual predisposition toward measles

is apparently so general that few, upon exposure, escape it, though

we have observed cases where children have been directly exposed and

who were immediately thereafter put under osteopathic care and did

not develop the disease. Second, or even third, attacks may occur

at intervals of some years, but these are unusual. Sporadic cases

do occur and are often the starting points for epidemics. Extensive

outbreaks occur at intervals of five or six years.

The incubation period is from seven to eighteen days, usually about ten

days.

=Symptoms.=—Prodromes are common, usually consisting of loss of

appetite, restless sleep, fretfulness, and often feverishness. There

are three stages, (a) Invasion, (b) Eruption, (c) Desquamation.

(a) Stage of Invasion. The prodromal symptoms are intensified. There

is often chilliness but seldom distinct chills. The temperature rises,

often reaching 102 to 104 degrees, upon the first and second day. It

then falls one degree or more to rise again upon the appearance of the

eruption. Nausea, vomiting and headache are often present. The tongue

is furred. With these symptoms coryza has developed and is sometimes

intense, often simulating severe influenza. Irritation and smarting of

the eyelids, lachrymation, photophobia, persistent sneezing, running

of the nose, sore throat, discomfort in swallowing, hoarseness, and

cough, at first of a croupy character, appear in rapid succession

and with varying intensity. These initial catarrhal symptoms are

characteristic and occur in the mildest cases in which chilliness,

fever and the associated signs of the reaction of the organism to

general infection are not observed. The vessels of the conjunctivæ are

injected, the eyelids swollen, the nasal mucosa tumid and reddened. The

mucous membrane of the mouth and throat is erythematous, while upon

the soft palate and the roof of the mouth, and particularly upon the

buccal mucous membrane, are to be seen pin head or split pea sized,

circumscribed, round or irregularly shaped reddish blotches slightly

or scarcely at all raised above the surrounding tissues, usually

discrete, but sometimes confluent. This eruption also shows itself in

the larynx and is undoubtedly the cause of the croupy cough and other

throat symptoms. In a strong light there may be seen upon some of the

spots on the mucous membrane of the cheeks and lips minute bright

whitish, or bluish-white flecks which are called Koplik’s Spots. These

spots appear early and soon disappear, and as they are not found in

any other disease they are of value in the early diagnosis of measles.

The duration of this stage is usually three or four days; rarely it is

shorter or it may be as long as a week.

(b) Stage of Eruption. On about the fourth day the temperature again

rises, increasing as the rash develops, often to 104 or 105 degrees

and reaching its maximum about the sixth day when it usually falls by

crisis; followed on the seventh or eighth day by normal temperature.

The pulse-rate increases with the fever, often reaching 140 or higher.

The eruption usually appears on the fourth day, and shows first about

the hair line on the forehead, spreading to the face, chest, trunk and

the arms and legs. The eruption is attended by itching and burning, and

completely develops in from twelve to thirty-six hours, the catarrhal

symptoms persisting during this time. During this time, in the more

severe cases, delirium or stupor may be present, and the patient

complains of sore throat and general discomfort, and is restless and

wakeful. Usually upon the second or third day of the eruption, great

and rapid amelioration of all these symptoms takes place and the fever

falls to normal or subnormal. When the eruption is fully developed

the individual spots are irregularly circular or oval, and differ

greatly in size, averaging about the size of a split pea. The eruption

is unevenly set, but usually close together and sometimes confluent,

especially on the face, buttocks, hands and feet. Frequently they

take on a crescentic arrangement and the spots are circumscribed, the

intervening skin being normal or slightly hyperemic.

About the ninth day the rash begins to disappear, on the face first,

then the neck and the rest of the body in about the same order as the

eruption appeared. The skin takes on a yellowish discoloration and

the rash disappears in a bran-like desquamation which lasts several

days to a week. In the beginning of the stage of eruption, and in many

cases throughout its course, the skin is moist and often bathed in free

perspiration. At the height of the eruption the superficial lymphnodes

of the neck, and elsewhere, are often slightly swollen and tender.

(c) Stage of Desquamation. The fine branny scales of desquamation

are often so fine as to be easily overlooked. This process occupies

about a week. The catarrhal symptoms in uncomplicated cases gradually

disappear, so that, by the end of the second week from the initial

coryza, convalescence is fully established. The cough frequently

persists and is of a bronchial nature. Epistaxis is common at the

height of the attack. Relapses of measles are extremely rare. Diarrhea

is apt to occur at some time during the attack, without any particular

significance.

=Varieties.=—Atypical cases may occur but are not common. They are as

follows: (1) Morbilli Papulosi, development of distinct papules, hard

to the touch but not extending deeply into the skin. (2) M. Vesicular;

a vesicular form. (3) M. Sine Exanthema, cases in which the eruption

does not appear, but general symptoms and coryza are present. (4) M.

Sine Exanthema, in which the mucous membranes are not involved.

=Variations in constitutional symptoms.=—(1) M. Afebriles, rare cases

in which there is no rise of temperature. (2) M. Hemorrhagica. This

is the malignant form and in it the organism is unable to withstand

the intensity of the infection and death takes place in the course of

two or three days after sustained hyperpyrexia, profound adynamia, or

hemorrhages into the skin and mucous membranes. These malignant forms

are very rare in private practice, but they occasionally occur in

asylums and in the fierce epidemics of camps, and were common in the

first outbreaks among the natives of the Fiji Islands, where measles

prevailed as a scourge. Death may occur before the rash appears or a

few papules may show themselves upon the forehead and wrists. This is

also known as =black measles=, and it is characterized by convulsions,

delirium and coma, petechiæ, bleeding from the mucous surfaces and

profound constitutional depression. The patient is rapidly exhausted,

the pulse frequent and thready, the skin pale and cold, and death

occurs. (3) Adynamic measles is a serious type in which the symptoms

are grave from the onset but without hemorrhages and a typhoid status

is early present.

=Complications.=—In the absence of complications, measles is

comparatively a benign disease, but these complications are frequently

enough present to place measles among the more serious diseases of

childhood. The ordinary complications are due to the extension or

intensification of the catarrhal processes peculiar to the disease.

(1) Otitis media is quite common, and may result in perforation

of the tympanic membrane and permanent impairment of the hearing;

or lead to sinus thrombosis, meningitis, or abscess of the brain.

(2) Bronchopneumonia is the most common complication. (3) Purulent

conjunctivitis may occur and in neglected cases infiltration and

ulceration of the cornea. (4) Catarrhal laryngitis is a frequent

complication. (5) Pseudo-membranous type is very uncommon but very

dangerous. (6) Edema of the glottis is not common but does occur. (7)

Diphtheria is much less common in measles than in scarlet fever. The

high death rate of measles is due to the bronchopneumonia complication

in which the lesions become extensive, the symptoms become urgent and

a large proportion of these cases die. (8) Acute enterocolitis is a

frequent and serious complication. (9) Gangrenous stomatitis occurs in

young and debilitated children, and in girls gangrene of the pudenda

occur during convalescence with greater frequency than in other

infectious diseases.

=Sequelæ.=—The more common sequelæ are chronic local inflammations,

conjunctivitis, otitis, nasal catarrh, laryngitis, and bronchitis.

Tuberculosis is a common sequel.

=Diagnosis.=—During an epidemic, coryza, persistent sneezing and fever

are suspicious. The appearance of the eruption on the third or fourth

day upon the mucous membrane of the mouth and throat, and Koplik’s

spots are positive.

Measles is often confused with 1. Rubella or German measles, 2.

Variola, 3. Typhus Fever and 4. Scarlet Fever, which see. Occasionally

=drug exanthems= are confused with measles. These may be caused by

salicylates, antipyrin, quinine, turpentine or copaiba. These rashes

are not accompanied by fever or throat symptoms unless they have been

given to allay these very conditions.

=Treatment.=—Measles is so often a serious disease that it should

not be attended with carelessness as it so often is, but the best of

care and attention given. Parents should be informed of the danger

of complications and of the absolute necessity of proper care and

attention.

As soon as a susceptible individual is exposed to the measles, he

should be immediately isolated, watched and corrections made of any

dietetic errors, unsanitary conditions or structural lesions that may

exist. He should be protected from sudden atmospheric changes and

carefully watched for the first symptoms of the prodromal coryza.

On the appearance of the prodromal, or invasion symptoms the patient

should be put to bed in an isolated, well ventilated room of as nearly

constant temperature as is possible, from which all hangings, rugs and

unnecessary furniture have been removed. The windows must be shaded to

protect the eyes from direct or strong light, and any artificial lights

in the room must also be well shaded.

The cases can usually be easily handled by careful, well-directed

osteopathic treatments. In the manipulative treatment we must pay

especial attention to the muscular and other soft tissue conditions in

the suboccipital region, over the transverse processes of the upper

four or five cervical vertebræ, under the angle of the lower maxilla

and the lateral cervical tissues to remove any obstructions to the

circulation and nerve control of the head and throat; see that the

muscles in the lower cervical and upper dorsal areas are kept well

relaxed, and articulation of these vertebræ, the upper three ribs and

the clavicles are kept free; remove all lesions in the mid-dorsal area,

whether muscular or otherwise, to prevent involvement of the lungs

or heart, and to keep up function of the respiratory and circulatory

systems; treat and keep normal the tissues and the articulations at

the kidney and adrenal center, 11th and 12th dorsal; raise the ribs

and keep them freely movable, this especially for the bronchial cough.

Painful manipulations should be avoided and are not necessary. Dr.

Still said, “The arms must be raised and the axillary region freed and

kept so.” During the acute stage two or three treatments per day are

advisable. Do not treat severely or to cause discomfort to the patient.

Best results are obtained in the gentle, but thorough, treatments.

In the beginning of the case have the bowels cleansed with an enema,

and then careful attention must be constantly given to the bowels and

kidneys. The bowels can be kept open by manipulations and diet. The

diet should be light and easily digested; during the fever it is best

to withhold all food but give plenty of water. Follow fast with fruit

juices and then the light diet.

The temperature is usually controlled by treatment, but if it remains

high for some time and if the physician cannot reach the patient, the

nurse should be directed to give a tepid sponge bath of ten to twenty

minutes duration, and repeated at intervals of two or three hours. Also

the tepid enema will often reduce the temperature.

For the itching of the skin, a tepid bath with water at 100 degrees

given twice daily should be used, the patient dried carefully, and an

application of olive oil, cold cream, liquid albolene, or a two per

cent menthol salve, rubbed over the entire body will give relief.

The cough is best relieved by thorough treatment of the anterior

thoracic regions and the correction of any upper rib or clavicular

lesions. Keeping the air of the room moist with vapor is agreeable to

the mucous membranes. The dropping of a few drops of eucalyptus oil in

the boiling water produces a very soothing vapor.

If the eyes are much involved, they should be bathed every hour or two

with a three per cent solution of boric acid, using cotton which is

immediately destroyed after use. Dark glasses in a well ventilated room

is better than an unaired darkened room.

The nose and mouth should be carefully cleansed at regular intervals

and the cloths burned. The throat should be carefully examined daily

at first, and at least every other day later, until the case is

discharged. The conditions of the lungs must be observed by daily

examinations, and the lung and bronchial areas should be daily treated

to prevent the possibility of respiratory involvement.

If rash is slow in appearing and the temperature is high, a hot bath

(105 to 110 degrees) for three to five minutes will often bring out

the rash and relieve the more serious symptoms. During convalescence

the patient must be protected against cold. Recovery is hastened by

the continuation of treatment during convalescence and treatment given

should be indicated by the symptoms present.

=Prognosis.=—Practically all uncomplicated cases recover. In the

hemorrhagic and adynamic types, the majority succumb. One attack

usually confers immunity. Sequelæ are frequent under the “old school”

treatment, but are infrequent under careful, conscientious osteopathic

treatment and careful nursing.

“In and of itself measles is usually not particularly serious, but

the after effects are so far-reaching and so serious that students of

the history of medicine rank measles third among infectious diseases

for causing death. During recovery from measles the patient stands in

special danger from pneumonia, and pneumonia following measles is more

dangerous than uncomplicated pneumonia. There is a considerable length

of time during which he is particularly susceptible to tubercular

infection. This is so often insidious, and its evidences are so

obscure, that by the time the disease has fully developed, one may have

forgotten the mild attack of measles which really paved the way for the

serious malady.”—C. A. WHITING.