favorable. Thus, of 257 cases observed by Meigs and Pepper (_op.
cit._), all terminated favorably. But in coming to any conclusion in
regard to prognosis a number of different factors must be taken into
consideration. Among the more important are--the hygienic surroundings
of the patient, the age, the nature of the complications, whether the
measles be primary or secondary, and the character of the epidemic. In
the first place, rubeola in foundling hospitals and among the poorer
classes in large cities gives a larger ratio of deaths than among the
well-to-do members of the community. For instance, Bartels has shown
that catarrhal pneumonia, one {578} of the most frequent causes of
mortality in this disease, is particularly prone to occur among those
dwelling in crowded, poorly-ventilated houses. Then, again, the
asylums and hospitals for children are peopled in many instances with
the victims of depraved constitutions, who readily succumb to
intercurrent maladies.
Leaving out of consideration sucklings under six months of age, in
whom measles is rare and said to be slight, most deaths from the
disease occur among very young children, from their greater liability
to complications. According to Beddoes,[39] the mortality from measles
is, beyond all comparison, greatest in the second year of life, and by
the tenth has become quite trifling. An examination of the statistics
bearing on this question coincides with this general statement; but
Fox's tables, already quoted, would show that more infants under one
year of age die of measles than has hitherto been supposed. The
susceptibility to measles decreases with years, perhaps on account of
the fact that most adults have already contracted the disease; but
when it does attack the unprotected adult it may prove fatal. This
statement is borne out by the large death-rate in the so-called camp
measles of our late war.[40] The ravages of measles in virgin
communities have been referred to in preceding pages. The general
temper of the epidemic must also be considered, since it is well
recognized that the essential character of epidemics differs much as
to severity.
[Footnote 39: Art. "Mortality" in _Quain's Dictionary Med._, p. 1002.]
[Footnote 40: In the general field hospital at Chattanooga the
death-rate was 22.4 in 100 cases. In General Hospital No. 1, at
Nashville, it was 19.6 in 100, or nearly 1 in 5. Many died or became
permanently disabled from the sequelæ (Bartholow).]
Such complications as diphtheria, catarrhal pneumonia, diarrhoea,
convulsions, etc. necessarily affect the prognosis of measles most
seriously. More patients die of measles in the second than in the
first week of the disease. The careful studies of temperature made by
Thomas, Bohn, and others show that an unusually high and increasing
fever in the prodromal stage is of ill omen, particularly on the
second and third days, and a fever heat measuring over 105° F. at any
stage should be considered as very unfavorable.[41] Particularly to be
feared is continuation of the fever after the subsidence of the
eruption, or a sudden elevation after the normal curve has been
reached. In fact, it is a safe rule to look upon all anomalies of the
curve with suspicion. Secondary measles, or measles grafted upon some
serious existing affection, is particularly fatal.
[Footnote 41: In adolescence a body heat of 107° F. has been safely
passed during the decline of measles with no marked complication
(Squire).]
TREATMENT.--There is no remedy which will destroy the susceptibility
to measles. The future may develop some form of vaccination against
rubeola, for, certainly, the hopes held out by the inoculation of
measles upon the healthy subject have not been realized, as this
procedure merely reproduces the original complaint, without any
diminution in its intensity, and does not lessen the probability of
complications (Mayr). The matter of carrying out a practical and
efficient quarantine in measles is one of unusual difficulty, for the
reason that the disease is capable of active propagation at a
time--the prodromal stage--when it is not yet sufficiently
characteristic for positive diagnosis. But, as measles is by no means
as trivial a disease as would seem to be the common impression, I hold
it as a well-established principle of preventive medicine that a {579}
strict isolation should be enforced whenever, from the nature of the
case, it is at all possible; certainly, very young children and those
suffering from or showing a tendency to other diseases should be
jealously shielded from exposure.
The usual precautions as to disinfection and purification of the room,
bedding, and utensils used by patients should be observed, as in other
infectious diseases. Squire is of opinion that there is danger of
personal infection for perhaps a month, and Hillairet that isolation
for forty days should be enjoined. It is quite certain that inunction
lessens the danger of infection, and Kaposi[42] is authority for the
statement that a warm bath administered after the completion of
desquamation, or about fourteen days from the beginning of the attack,
will effectually prevent contagiousness.
[Footnote 42: _Pathologie u. Therapie der Hautkrankh._, Wien, 1880.]
The apartment occupied by a patient suffering from measles should be
kept at a uniform temperature of from 66° to 70° F., and free
ventilation, at the same time avoiding draughts, should be enforced.
The room should be kept moderately dark. The bed-clothing should be
light, yet sufficiently warm, and the old notion of keeping the
patient in a profuse sweat the better to bring out the eruption should
be discouraged. The diet should be bland and nutritious, and may
preferably consist of milk, gruel, tapioca, and such like substances.
As convalescence progresses there may be a gradual return to more
substantial food. The patient may be allowed cool water in moderation,
as it is cruel and useless, and even harmful, to restrict one
suffering with fever to warm or sweetened drink. The patient should be
confined to his room until convalescence has been fully established,
and should not be allowed to leave the house, both on his own account
and that of others, until the usual health has been regained. Any of
the lingering results of the disease, such as bronchitis, otorrhoea,
conjunctivitis, etc., should receive prompt attention; iron and
cod-liver oil should be prescribed for the weakly and strumous, and
regular hours of sleep, careful diet, and appropriate bathing and
exercise should be advised. It may be said, without exaggeration, that
neglect of the after-care of measles patients is, in some instances,
more to be deprecated than a similar neglect in the actual treatment
of the disease itself.
Since we are powerless to cut short an attack of measles by any
remedial agents at present known to therapeutics, the intervention of
the physician is limited to assisting the cases through to a safe
termination. Quite a number of cases, as seen in private practice,
require no special medicinal treatment, or at most one that is merely
symptomatic. The value of the so-called specific treatment, such as by
carbonate of ammonium, etc., has not been verified by experience.
In ordinary uncomplicated attacks, if the temperature should run high,
in addition to the general rules as to diet and hygiene referred to
before it will usually be found advisable to put the patient on some
diaphoretic mixture, to which may be added a mild opiate. I know of
nothing better than the formula found in the work of Meigs and Pepper
on the _Diseases of Children_:
Rx. Potass. Citrat. drachm i;
Spt. Ætheris Nit. fl. drachm ii; {580}
Tr. Opii Deodorat. minim xii vel xxiv;
Syrupi fl. drachm ii;
Aquæ fl. oz. ii. M.
S. A teaspoonful every two or three hours for a child of five years of
age.
Aconite in small doses has been well spoken of in this connection, but
I have no personal experience in its use. Bromide of potassium,
together with a few drops of syrup of ipecac., dissolved in syrup of
wild cherry, acts pleasantly both on the cough and the nervous system.
The inunction of fatty substances, as originally proposed by
Schonemann, and recently urged by Milton,[43] is an excellent routine
practice, and in addition to adding very much to the patient's
comfort, has, perhaps, the merit of lessening somewhat the danger of
infection to others. For this purpose one may use leaf lard, cold
cream, or vaseline, to each ounce of which it is well to add a few
minims of carbolic acid.
[Footnote 43: _Archives of Dermatology_.]
Stimulants are rarely needed in uncomplicated measles, but Squire very
wisely calls attention to the great value of wine in the depression
following upon the crisis.
In spite of some excellent authority to the contrary, I cannot see
that any benefit is to be derived from using severe measures to bring
out an eruption that has undergone retrocession. As stated in another
part of this article, the so-called striking-in of the rash is the
result of the supervention of some complication, and not the cause of
it; therefore, a rational course of action would be to ascertain the
nature of the complicating trouble, and to endeavor to correct it,
which, at the same time, would be the very best means of restoring the
normal course of the disease.
Quinia is of great value in controlling the excessively high
temperature which is sometimes observed either in connection with, or
independent of, complications. If the quinia should prove ineffectual
or else be rejected by the patient, the physician should not hesitate
to abstract heat by cold water in the shape of the wet pack or the
general bath. I think the latter method is to be preferred. It is but
to employ the gradually cooled bath of Ziemssen, perhaps, commencing
at 90° F. and going to 80° or 70° F. The condition of the patient, as
ascertained by the thermometer and also the state of the pulse, must
be the guide as to the duration and repetition of the baths. In
Germany excellent results are claimed for the treatment of
hyperpyrexia in measles by the cold pack, even when the excessive
temperature is due to such a complication as broncho-pneumonia.
There is little hope from therapeutical interference in malignant
forms of measles, but the medical attendant should endeavor to reduce
temperature and support the strength by free stimulation and
nourishing food.
It will now be advisable, at the risk of some repetition, to call
attention to the treatment of some of the more prominent disturbances
and complications of measles.
Epistaxis, if severe, should be checked by cold applications and
astringents. Plugging will rarely be found necessary. Trousseau
recommends the injection of water as hot as can be borne. Ergotine by
the mouth or hypodermically will sometimes prove highly valuable.
The lids should be anointed with vaseline or cold cream to prevent
their sticking together, and it is well to occasionally evert them to
see that no {581} serious mischief has happened to the eye. If the
conjunctivitis is intense, the discharges should be removed and cold
compresses applied.
Since aural complications are due to extension of inflammation from
the oral and nasal cavities, Spencer urges the importance of early and
systematic treatment of these parts. He advises astringent
applications (Monsell's solution 1 to 4 of glycerine) to the
pharyngeal mucous membrane. Ointments of boracic acid, zinc, or
iodoform are likewise useful when introduced through the nostril.
Earache will require warm opiated poultices and inflation. Otorrhoea
is best treated after the dry method.
For sickness of the stomach a spice poultice may be applied and small
bits of ice given to suck. If constipation exist, a little oil or
syrup of rhubarb or some stewed prunes, or an enema, may be ordered.
Active purgation should be withheld.
The early diarrhoea need give little concern, as it usually soon
ceases; but if it should persist, recourse must be had to more
energetic measures, such as the use of opium by mouth or enema, given
cautiously in the case of children, vegetable and metallic
astringents, and the application of hot poultices to the abdomen. The
diet should be carefully guarded.
The cough, even in mild cases, generally requires some slight
palliative, such as syrup of ipecac., and an occasional small dose of
Dover's powder. Loeri very properly advises against the use of
irritating expectorants. I think it advisable to keep the chest well
smeared with camphorated oil, over which should be worn an oil-silk
jacket. These simple measures, perhaps, diminish the tendency to
thoracic complications. The sometimes violent paroxysms of false croup
are very satisfactorily managed, after the manner of Graves, by gently
pressing a sponge, soaked in very hot water, under the chin and over
the front of the neck. When the dyspnoea is alarming, emetics, and the
general warm bath should be brought into requisition.
Convulsions in the early stage require little treatment other than the
warm bath and appropriate doses of the bromide of potassium; occurring
later, they are very fatal under any treatment, as they generally
supervene in connection with some of the grave complications of the
disease. Chloral, preferably by enema, and chloroform may be tried.
The management of the severe bronchitis and pneumonia of measles
requires great care and circumspection on the part of the physician.
The application of a well-made flaxseed poultice, which should be
neither too heavy nor too hot, is to be regarded as invaluable. To the
flaxseed may be added a small quantity of mustard. Over the whole is
to be placed an oil-silk jacket. Alcoholic stimulants, nourishing,
easily-digested food, and expectorants containing carbonate of
ammonium are to be recommended.
For the treatment of the other complications and sequelæ of measles
the reader is referred to the appropriate sections of this work.
{582}
RÖTHELN.[1]
BY W. A. HARDAWAY, M.D.
[Footnote 1: In the preparation of this article the author has
consulted the following authorities: Emminghaus, in _Gerhardt's Handb.
der Kinderkrankh._, Zweiter Band, 1877; Thomas, in _Ziemssen's Cyclop.
Pract. Med._, vol. iii., Am. ed., 1875; Squire, in _Quain's Dict.
Med._, 1883. References to current literature will be found in
foot-notes to the text.]
SYNONYMS.--Rubeola, Rubella, Roseola, Epidemic Roseola, German
Measles, French Measles, Hybrid Measles, False Measles, Rubeola
Morbillosæ et Scarlatinosæ.
DEFINITION.--Rötheln is an acute infectious disease, presenting an
eruption of reddish macules upon the skin, accompanied by mild
catarrhal symptoms, and usually producing but slight disturbance of
the general system. It is self-protective, and occurs but once in the
same individual. It has no relationship to measles or scarlatina.
HISTORY.--A rapid glance at the interesting historical evolution of
rötheln to a specific position among the acute infectious diseases is
all that our space will allow. Some writers have attempted to show
that this affection was known to the Arabian physicians; but since it
is only in comparatively recent times that the contagious epidemic
exanthemata in general have been thoroughly differentiated, it is
quite likely that the modern conception of it was not held by them nor
by other medical men till many centuries later. Indeed, in our day,
physicians are yet to be found, though the number is rapidly
diminishing, who refuse to recognize in rötheln a distinctive specific
malady. Certain German observers in the middle of the last century (De
Bergen, 1752; Orlow, 1758) favored the idea of specificity, but these
views were soon disputed. In the years following a number of other
physicians announced their belief in the specific nature of rötheln,
while, on the other hand, various noted authorities still insisted
upon its connection with scarlet fever or measles. In 1815, Maton, an
English physician, most unequivocally declared that he had observed
cases of an eruptive disorder which resembled neither measles,
scarlatina, nor roseola, and which was worthy of a new designation.[2]
In the second and third decades of this century Hildebrand, and
afterward the celebrated Schönlein, taught that rötheln was a hybrid
of measles and scarlatina, although at this time Wagner (1834)
advocated the essential independence of rötheln. There is no doubt
that under the name of rubeola sine catarrho Willan, Bateman, and
later writers described what we now call rötheln, for they stated that
this variety of measles was not self-protective. Space will not allow
of a detailed mention of the various writers who, during the first
half of this century, {583} have contended for or against the autonomy
of rötheln. It will be well to state, however, that Hebra, from the
standpoint of the dermatologist, very properly regards the manifold
roseolæ of Willan as in many instances merely symptomatic erythemata,
or else as irregular forms of measles or scarlatina; but he also fails
to recognize the distinctive features of rötheln. Even so recent a
writer as Niemeyer declares that roseola arising from infection
consists in a modification of measles or scarlet fever. It is only in
the last twenty years that our present exact ideas of rötheln have
obtained. For example, while Trousseau[3] asserts that rubeola
(rötheln) is a perfectly distinct nosological species, he speaks of
the rash as appearing and disappearing alternately for some days, of
its frequent recurrence in the same individual, etc. American
physicians were almost entirely ignorant of rötheln till within the
last ten years, when they were made acquainted with it through the
medium of a careful paper on the subject from the pen of J. Lewis
Smith of New York.[4] Before this time, however, cases had been
described by Homans, Sr., of Boston (1845), and in 1853 and 1871 by
Cotting. Very few authorities now dispute the distinctive specific
nature of rötheln; which statement is borne out by the fact that at
the last meeting of the International Medical Congress, held at London
in 1881, there were but two dissentients to this view in the section
before which it was discussed.[5]
[Footnote 2: Squire, _Trans. Internat. Med. Congress_, London, 1881.]
[Footnote 3: _Clinical Medicine_, vol. ii.]
[Footnote 4: _Archives of Dermatology_, Oct., 1874.]
[Footnote 5: See especially Kassowitz's paper, "Die Wirkliche Stellung
der sogenannten Rubeola," etc., _Trans. Internat. Med. Cong._, 1881.]
ETIOLOGY.--The contagium of rötheln is unknown, but that the disease
is contagious has been fully demonstrated by numerous observations of
epidemics and sporadic cases. From my own experience I should judge
that unprotected persons are not so susceptible of it as is known to
be the case under similar conditions in measles;[6] yet cases are
recorded which would prove that the contagion may be conveyed through
a third person and for some distance. It is probable that the vehicles
of contagion are the same as in measles. At what period of its course
the disease is most capable of transmission has not been
satisfactorily determined. Squire is of the opinion, however, that the
disease is contagious before the appearance of the rash, and may
continue so for some days or for two or three weeks. Rötheln may be
called a disease of childhood for the same reason that the other
contagious exanthemata are--namely, that the majority of adults have
already been attacked. From an examination of available statistics I
am inclined to regard the ages between five and fifteen--the years of
school attendance--as the period of life most susceptible of the
influence of rötheln, although, of course, no time of life is entirely
exempt. The non-susceptibility of sucklings, as in measles, holds true
as a rule, although I am in a position to supply exceptions to this
from my own experience, as well as from that of others. Sex seems to
be without influence in determining liability to the disease.
[Footnote 6: In this regard it resembles scarlatina more than measles,
for I have a number of times seen the disease introduced into
families, where it would attack one or two of a number equally
exposed. J. L. Smith regards it as feebly contagious, and quotes
Chadbourne's experience to the same effect. Liveing declares that
rötheln is more distinctly epidemic in Great Britain than either
measles or scarlet fever, although probably less contagious.]
The period of incubation is not very definitely settled, and, indeed,
{584} owing to the generally trivial character of the affection,
evidence on this point is difficult to obtain. Taken as a whole, it is
probably longer than is observed in measles. According to J. Lewis
Smith, in the epidemic observed by him the incubation period varied
from seven, or less than seven, to twenty-one days; Emminghaus places
it at from two to three weeks; Thomas, from two and a half to three
weeks; Squire, mostly a fortnight, the extreme being twenty-one days;
Cheadle, from eleven to twelve days.
There is nowhere recorded a trustworthy instance of a second attack of
rötheln, although from analogy such an event is to be expected. As in
measles, true recurrences of rötheln--that is, the result of a fresh
infection--are not to be confounded with relapses. I have never
witnessed a relapse, but cases of such a nature have been recorded by
other observers (Lindwurm, Emminghaus, Körtlin, Kingsley).
Rötheln is a disease sui generis, and is in no way related to either
measles or scarlatina; that is to say, it is not an irregular form of
either of these nor a hybrid of them, nor has it ever been observed to
propagate anything but itself. That it is not connected with any of
the symptomatic skin eruptions--the so-called roseolæ--is proved by
its contagiousness and epidemic character. I quite agree with other
observers in declaring that rötheln has very little clinical
resemblance to scarlatina, and that, on the other hand, in the
greatest number of cases the points of likeness are with measles. In
the section on diagnosis the differential points between rötheln,
measles, and scarlatina will be considered; therefore in this place it
will only be necessary to call attention to certain general facts.
Thus, aside from the marked divergence in clinical
symptoms--incubation, invasion, fever, eruption, complications, and
sequelæ--we are at once met by the positive fact that epidemics of
rötheln, while always presenting identical features, prevail without
regard to the existence of similar epidemics of measles and
scarlatina--following or preceding them--and that attacks of rötheln
offer no bar to the reception of their contagions, or vice versâ.
Literature is so full of examples of this statement that it need
scarcely be dwelt upon. By way of illustration, however, the accurate
observations of J. Lewis Smith may be quoted in this connection. Of 48
cases recorded by him prior to May 1st in the New York epidemic of
1874, 19 had had measles. Rötheln in the N.Y. Foundling Hospital in
1873-74 followed an epidemic of measles. During the epidemic of
1880-81 the same fact was observed--namely, that a previous attack of
measles, as well as scarlatina, afforded no protection from rötheln. I
could multiply such examples from my own experience. A single
interesting instance may be noted here. A physician asked the writer
to examine his child, suffering, as he thought, from measles. A
careful investigation revealed a typical rötheln. A number of weeks
later an older child got measles, from which the rötheln patient
acquired a characteristic attack of the same. In the following year
both children were taken with scarlet fever.
The only escape for those who would deny the autonomy of rötheln is in
the bold assertion that both measles and scarlatina more frequently
recur in the same individual than universal experience and observation
will allow; and this leaves them in the dilemma of determining to
which group rötheln must be relegated. The hypothesis of the hybrid
nature {585} of rötheln cannot be accepted by the pathologist nor the
clinician, if for no other reason than that no one has ever seen
rötheln generate anything but rötheln, and in no case give rise to
either scarlatina or measles.
SYMPTOMS AND COURSE.--As already stated, the probable average duration
of the incubation period in rötheln is about fourteen days, varying,
however, within the limits of from six to twenty-one days. In this
respect rötheln resembles scarlatina more than measles, the period of
latency in the latter observing considerable uniformity. No deviations
from the general health are to be noted in the incubation stage.