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 {565} 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,[22] 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.
[Footnote 22: _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 {566} 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 {567} and a half days, so that the complete
eruptive fever occupies from three to four and one-half days.[23] The
pulse in general preserves a proportionate correspondence to the
temperature, and never attains the great frequency to be observed in
scarlatina.
[Footnote 23: 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 {568} 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.
{569} 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.
{570} 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.[24] The pathological
explanation seems obvious.
[Footnote 24: 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).[25]
[Footnote 25: 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 {571} 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[26]
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.
[Footnote 26: _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).