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[3] published {558} 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[4] 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[5]
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 1/2 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."
[Footnote 3: _Am. Jour. Med. Sci._, July and Oct., 1862.]
[Footnote 4: _Ibid._, Oct., 1868, p. 333.]
[Footnote 5: _Würzbr. Verh._, N. F., v., 1874, quoted by Forchheimer
in Supplement to _Ziemssen's Cyclopedia_, W. T., 1881, p. 102.]
Braidwood and Vacher,[6] 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.[7] 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 {559}
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."
[Footnote 6: _Brit. Med. Jour._, Jan. 21, 1882.]
[Footnote 7: 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.[8]
[Footnote 8: 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[9] 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.
[Footnote 9: _Science and Pract. of Med._, Phila., 1868.]
{560} 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.[10] 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 {561}
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.
[Footnote 10: 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.[11] 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[12] 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[13] of St. Louis and Chantier[14] of Geneva, in which the
mothers were safely delivered, though suffering from measles
contracted at the end of their pregnancies.
[Footnote 11: Hardaway, _Essentials of Vaccination_, p. 60.]
[Footnote 12: _Obstet. Jour. Great Britain and Ireland_, July, 1880.]
[Footnote 13: _St. Louis Courier of Med._, Sept., 1879.]
[Footnote 14: _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 {562} 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.[15]
[Footnote 15: 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. |
+------+------+------+------+
| | Fem- | | Fem- |
|Males.| ales.|Males.| ales.|
---------------------------------------+------+------+------+------+
Under one year | 3022 | 2530 | 3571 | 2987 |
One and under two years | 6086 | 5825 | 8630 | 8050 |
Two " " three " | 3178 | 3255 | 4683 | 4757 |
Three " " four " | 1730 | 1851 | 2594 | 2620 |
Four " " five " | 980 | 1028 | 1358 | 1466 |
|------+------+------+------|
|------+------+------+------|
Five and under ten years | 255 | 278 | 301 | 316 |
Ten " " fifteen " | 29 | 38 | 24 | 32 |
Fifteen " " twenty " | 9 | 13 | 9 | 11 |
Twenty " " twenty-five " | 7 | 9 | 5 | 7 |
Twenty-five " " thirty-five " | 5 | 8 | 5 | 7 |
Thirty-five " " forty-five " | 3 | 5 | 2 | 3 |
---------------------------------------+------+------+------+------+
Even sucklings do not enjoy a complete immunity from measles.
Steiner[16] 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.[17] 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.[18]
[Footnote 16: _Compendium of Children's Diseases_, N.Y., 1875, p.
396.]
[Footnote 17: I believe that, under certain circumstances, the
erythema papulatum of the new-born is often mistaken for measles.]
[Footnote 18: 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. {563} 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.[19] 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[20]
truly states, much overestimated.
[Footnote 19: These observations of Woodward were made without any
reference to the question at issue.]
[Footnote 20: _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. {564} As a rule, however, this period is devoid of any
marked indication of the presence of the measles poison in the
system.[21]
[Footnote 21: 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.