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[27] 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.
[Footnote 27: _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 {572} 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.[28]
[Footnote 28: 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[29] 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.[30]
[Footnote 29: _Am. Jour. Obstet._, Oct., 1880.]
[Footnote 30: _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 {573}
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.[31]
[Footnote 31: 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, {574} 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[32]); 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,[33] 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.
[Footnote 32: Oral communication.]
[Footnote 33: 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.[34]
[Footnote 34: 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 {575}
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.[35] 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.
[Footnote 35: _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.[36]
[Footnote 36: 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 {576}
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.[37] The incubation period is longer in rötheln than in
measles.
[Footnote 37: 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 {577} 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,[38] 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.
[Footnote 38: 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.