Chapter XXXIV: Part II: , Showing Predominance of Malarial Element . . . . 617 (33)

The indications are to relieve the hyperæmic kidneys by diaphoresis and purgation. To produce the former the patient should be immersed in a warm bath at about the temperature of the body (98° to 100°), in which, if he be quiet and comfortable, he should remain from fifteen to twenty minutes, but if restless and frightened by the water a less time, after which he should be placed in a warm bed and well covered by blankets. If perspiration result, the bath has been useful, and it may be employed in grave cases two or three times daily. If perspiration do not result, it may be produced by surrounding the body either by hot dry or moist air. Hot dry air may be produced by burning alcohol in a thin layer upon a plate under a chair upon which the patient sits while he is surrounded by a blanket, or he may be covered in bed and the hot air introduced under the bed-clothes. In New York a convenient apparatus is used for this purpose, consisting of a small sheet-iron pipe enclosed in a small box of the same material. The box is in the form of a trunk, with a handle for convenience in carrying, and the lower end of the pipe, which extends nearly to the floor, contains an alcohol lamp. Hot moist air may be produced by placing against the patient bottles of hot water surrounded by towels wrung out of water. The steam arising from them and enveloping the body and limbs produces a prompt sudorific effect. There is in use in this city, in the treatment of these and similar cases requiring diaphoresis, a convenient apparatus for generating steam. It consists of a cylinder pierced with holes for the admission of air and containing a spirit lamp, over which is a pan or pail holding a little water. The patient, nearly naked, is placed in a chair with the apparatus underneath, and is covered by a blanket, so that the steam surrounds the body. This gives rise to free perspiration, which continues after the patient is placed in bed. This treatment should be repeated one or more times daily, according to the gravity of the case.

The sudorific effect of the treatment by external warmth described above should be aided by employing diaphoretics. Those which have been most used are the acetates of ammonium and potassium, the bitartrate and citrate of potassium, and spiritus ætheris nitrosi. If employed when the surface is cool, they act rather as diuretics than diaphoretics. {552} These agents, being simple in their action and without deleterious effects, may be given frequently and in large proportionate doses for the age.

But lately a diaphoretic which far surpasses these in efficiency has been discovered in pilocarpine, the active principle of jaborandi. Being soluble in water and tasteless, it is easily administered, and is retained when, on account of the uræmic poisoning present in scarlatinous nephritis, the stomach is irritable and other medicines, as digitalis, are rejected. Ether may be employed with it, or the amount of alcoholic stimulant may be increased at the time of its exhibition in order to guard against any depressing effect. To a child of two years one-fortieth to one-twentieth of a grain may be given every six hours by the mouth. It may also be employed hypodermically, as one-twentieth of a grain to a child of five years. It has both a diaphoretic and diuretic action, while it stimulates both the salivary and mucous secretions. According to one observer, an adult when fully under the influence of pilocarpine secretes from one pint to one quart of saliva within two hours, and Leyden reports a case of diphtheritic nephritis in which the quantity of urine rose from half a pint to five pints daily. But its most prompt and certain action is upon the sweat-glands. Hirschfelder speaks of its beneficial action in relieving various forms of dropsy, and adds: "In one morbid condition of the kidney, however, jaborandi is the remedy par excellence, and that is the acute parenchymatous nephritis which frequently follows scarlatina.... This disease heals spontaneously if the danger that threatens life from reduction of the urine and from the effusions of fluid into the cavities of the body be averted. In this disease jaborandi works wonders." I have also found it an invaluable agent when the older remedies failed and death seemed imminent. The following cases, in which the beneficial action of this agent was apparent, occurred in my practice:

_Case 8._--G----, male, aged five years and six months, sickened with scarlet fever on June 2, 1882. It began with vomiting, and was attended by a degree of febrile movement which indicated an attack of rather more than the average gravity. The fauces at one time exhibited a slight exudation like that of diphtheria. In the declining stage of the malady rheumatic pain and tenderness occurred in the wrist and finger-joints, but not in those of the lower extremities. The case, however, progressed favorably, and during the convalescence my attendance ceased. On June 24th my attention was again called to the child, when the urine was found to be scanty and very albuminous. External measures, such as are described in the foregoing pages, were employed, and the infusion of digitalis with potassium acetate ordered to be given every three hours, but this medicine was for the most part vomited. The bowels were kept open by jalap and the potassium bitartrate. The urine, however, continued scanty, and on June 28th severe convulsions occurred. At this time the quantity of urine was only fl. oz. ij in twenty-four hours. The pulse in the convulsions was quick and feeble, the skin very hot, and the axillary temperature 103°. The eclampsia continued one hour, and were controlled by large and repeated doses of bromide of potassium, aided by clysters of five grains of hydrate of chloral in water. Muriate of pilocarpine was now directed to be given in doses of one-thirty-second of a grain every three hours, dissolved in cold water. This agent was not vomited, and it must have been given by the parents in their fright and {553} anxiety in larger or more frequent doses than were directed, for on July 1st the bottle containing one grain was empty. Free diaphoresis resulted from the pilocarpine, and the quantity of urine was increased. The mother stated that the child had taken only two doses, or one-sixteenth of a grain, of pilocarpine when the diuretic effect was apparent and free diaphoresis also occurred. She also stated subsequently that the quantity of urine was larger when the pilocarpine was administered every third hour than when given at a longer interval. A flaxseed poultice on which mustard was dusted was also applied over the kidneys. On June 29th the pulse was 96, temperature 100.5°; occasional convulsive attacks occurred, which were readily controlled by enemata of hydrate of chloral. On June 30th the symptoms were all better; no more attacks of eclampsia had occurred, and the urine was more abundant and less albuminous. The mother remarked that the new medicine (pilocarpine) had settled the stomach and increased the urine. The patient continued to improve, and on July 4th the record states: "Now takes the pilocarpine, gr. 1/32, every six hours; passes urine freely since yesterday; has not vomited since he began to take the pilocarpine; pulse 106, axillary temperature 99°; is playful and takes milk freely, nearly three quarts in twenty-four hours, with some farinaceous food. Digitalis with potassium acetate is also given in occasional doses." July 6th, pulse 92, temperature 99°; perspires much, and urine nearly normal in quantity and character.

_Case 9._--Mary S----, aged five years, on Dec. 22, 1882, presented the symptoms of severe nephritis. Her brother had scarlet fever two weeks previously, and she had sore throat at about the same time, but without efflorescence; pulse 98, temperature 98.5°; her urine highly albuminous, and reduced to fl. oz. iv in twenty-four hours; bowels constipated. Ordered a single dose of

Rx. Hydrarg. Chlor. Mitis gr. iii;
Resin. Podophylli gr. 1/6. M.

The muriate of pilocarpine was also ordered, gr. 1/20, but the patient vomited soon after taking it. Another dose was retained, and was followed by considerable perspiration. Dec. 23d, had one stool from the powder of yesterday. Has taken five doses of pilocarpine, but vomited after three of them. The last dose was administered at 10 P.M., and the mother says she "sweat fearfully" during the night. The patient was kept warm in bed; stimulating poultices of mustard and flaxseed, one to sixteen, were constantly in use over the kidneys, and the pilocarpine was administered three or four times a day. The record for Dec. 26 states: "Took the pilocarpine four times since yesterday morning, and each dose is followed by perspiration lasting from one to one and a half hours; quantity of urine, from fl. oz. vj to fl. oz. viij daily; vomited twice yesterday, not to-day; pulse 104, temperature 97.75°; complains of frontal headache; bowels regular; has considerable salivation. The patient is warm in bed, and the flaxseed and mustard poultice over the kidneys is continued." Dec. 28th, specific gravity of urine 1019; urine still quite albuminous, and containing blood-corpuscles and granular casts, also crystals of oxalate of lime. Dec. 30th, takes gr. 1/20 pilocarpine twice daily, and occasional doses of infusion of digitalis; urine more abundant; its specific gravity 1014, slightly albuminous, and containing {554} very few granular casts and blood-corpuscles; has lost its smoky appearance; reaction alkaline; perspiration slight; patient convalescent.

In another instance, a child of five years, from three to four weeks after scarlet fever was noticed to have anasarca of the face and extremities, with scanty and albuminous urine. One-thirty-second of a grain of muriate of pilocarpine was administered every six hours without the desired sudorific effect. It was then administered every four hours, with an increase of perspiration and urination, so that the nephritic symptoms were relieved and the patient apparently out of danger within three or four days.

In a fourth patient, a girl of three years, having scarlatinous nephritis, with symptoms very similar to those in the last case, the administration of one-twentieth grain doses of pilocarpine in conjunction with the hot-air bath, was followed by increased perspiration and urination, and progressive and rather rapid convalescence. This child had been taking bichloride of mercury in one-fiftieth grain doses, prescribed by a homoeopathic physician, without appreciable benefit. It had been for the most part vomited.

Given, as in the above cases, in moderate doses and with sufficient interval, pilocarpine has never in my practice had any deleterious effect, and I regard it as a very important addition to the remedies for the relief of scarlatinous nephritis. It is apparently the most useful and important diaphoretic for this disease which we possess.

Cathartics, especially those of a hydragogue nature, are also very beneficial. Their action is more certain than that of most diaphoretics and diuretics, and their employment is imperatively required in severe or dangerous cases in which it is necessary to remove as soon as possible the serum or urea which endangers life. Young children or those with delicate stomach, and those much enfeebled by the primary disease, may take magnesia, either the citrate or the calcined. A good cathartic for ordinary cases is a mixture of jalap and potassium bitartrate, the pulvis jalapæ compositus, consisting of one part of jalap and two of cream of tartar. Ten grains of the mixture may be given to a child of five years, and repeated according to circumstances. Its effect is increased by dissolving a teaspoonful of potassium bitartrate in a gobletful of water, and allowing the patient to drink from it. The following is a good cathartic in some instances, especially if the stomach be irritable, so that the more bulky and nauseating cathartics are rejected. Care should be taken to obtain a good article, as some of the podophyllin of the shops is not reliable:

Rx. Resinæ Podophylli gr. j;
Sacchari scruple j. M.
Ft. in chart. No. v.-x.

S. Give one powder, and repeat according to circumstances.

In the treatment of one of the cases reported above it will be recollected that the mild chloride of mercury mite was given with the podophyllin, with a good result.

After the use of laxative agents the kidneys, being less congested on account of the diversion that has occurred, often begin to excrete urine more freely. But if the patient be anæmic or enfeebled and the symptoms are not urgent, it is frequently better to avoid active catharsis, which {555} more or less reduces the strength, and employ remedies of a sustaining character, as in the following case, which occurred in my practice: A little boy, pallid and scrofulous, began to have anasarca after scarlet fever, chiefly in the scrotum, accompanied by a moderate degree of ascites. The urine, which was passed in nearly the normal quantity, contained albumen, but not in large amount. This patient gradually and fully recovered, with no treatment except the use of an oil-silk jacket over the kidneys and abdomen to promote diaphoresis, and the use of iron. Such a patient, treated by the powerful eliminatives which we employ for the more urgent and robust cases, would probably have been injured rather than benefited. No treatment can therefore be recommended in a treatise on scarlatinous nephritis which will be strictly applicable for all cases. Variations are demanded according to the state of the patient and the form and gravity of the disease.

Diuretics which do not stimulate the kidneys are proper at an early as well as late period of the renal malady, and digitalis is the one usually prescribed. I do not hesitate to order it from the first day in combination with the acetate of potassium. One teaspoonful of the infusion may be given every third hour to a child of five years. The following formula is for one of this age in good general condition:

Rx. Potass. Acetatis oz. ss;
Infus. Digitalis fl. oz. vi. M.

The following formulæ are recommended by Meigs and Pepper:

Rx. Potass. Bitart. drachm i;
Spt. Junip. Comp. fl. drachm ii;
Spt. Æther. Nitros. fl. drachm i;
Tr. Digitalis, minim xv;
Syrupi fl. drachm v;
Aquæ fl oz. ii. M.

Dose one teaspoonful every two hours to a child of two to four years.

Rx. Potass. Acetat. drachm i;
Tr. Digitalis fl. drachm ss;
Syr. Scillæ, fl. drachm i-ii;
Syr. Zingib. fl. drachm v;
Aquæ q. s. ad fl. oz. iii. M.

Dose, a teaspoonful every two or three hours to children two or three years old.

Local treatment is important. L. Thomas, Romberg, and others recommend the application of leeches, three or more, over the kidneys. Thomas says: "In many cases the abstraction of blood causes immediate and permanent relief; the fever and the pain in the region of the kidneys cease, the secretion of urine becomes augmented, the albuminuria lessens from day to day, and the moderate degree of dropsy that has been developed disappears." It is only in the more robust children, who have been but little reduced by the primary disease, that leeching is, in my opinion, admissible. In the majority of cases instead of depletion a poultice slightly irritating, so as to cause redness of the skin, should be applied over the kidneys, or for older children, not likely to be frightened by the process, the dry cups may be applied daily. In subacute cases, not attended by any alarming symptoms, sufficient redness may be produced by one of the irritating plasters which the shops contain, constantly worn.

{556} Eclampsia, described in the preceding pages, is produced, as we have seen, during the course of scarlet fever by the irritating effect of the scarlatinous poison upon the nervous centres, but, occurring after the decline of scarlet fever, it is ordinarily produced by the retained urea. The same remedies are required to control the convulsive movements as when they occur under other circumstances. The bromide of potassium should be immediately administered in large and frequent doses whenever eclamptic symptoms arise. During eclampsia a child of three years should take five grains of this agent every five to ten minutes till the attack ceases, and then at longer intervals. The hydrate of chloral is a more powerful agent, and if the eclampsia be not quickly controlled, I commonly employ it per rectum, dissolved in one or two teaspoonfuls of water. For a child of three to five years five grains should be thrown into the rectum by a small glass or gutta-percha syringe, and retained by pressure. Properly administered and retained, it rarely fails to control the eclampsia within ten or fifteen minutes. Subsequently, occasional doses of the bromide should be given to prevent the occurrence of eclampsia while the measures described above are being employed to relieve the uræmic condition.

Rheumatism, endocarditis, and pericarditis, arising as complications or sequelæ, require the treatment which is appropriate when they occur under other circumstances, but the remedies should not be depressing, as the system is already enfeebled by the primary disease. The rheumatism, if mild, usually abates in a few days without medication, and the affected joints require only some soothing lotion and support by a bandage. The following liniment may be applied upon muslin and covered by cotton wadding:

Rx. Acid. Carbolici fl. drachm i;
Tinc. Belladonna fl. oz. i;
Ol. Camphorati fl. oz. ii;

If the rheumatism be severe and affect several joints, the sodium salicylate should be prescribed, as in the idiopathic disease, with an occasional opiate to procure rest.

Endocarditis and pericarditis require rest in the horizontal position, avoidance of all excitement, the use of the tincture or infusion of digitalis or of the fluid extract of convalaria to procure a slow and steady action of the heart. Three drops of the tincture of digitalis or five minims of the fluid extract of convalaria may be given every four hours to a child of five years. The same external measures should be employed as in acute pleuritis. I prefer the application of a thin poultice of flaxseed containing one-sixteenth part of mustard and covered with oiled silk. The cardiac inflammations, as well as rheumatism, require opiates in sufficient doses to procure rest and sleep.

Pleuritis, which we have stated is apt to be suppurative, demands the same treatment as the idiopathic disease when it occurs in cachectic patients.

{557}

RUBEOLA.[1]

BY W. A. HARDAWAY, M.D.

[Footnote 1: In the preparation of this article the writer has consulted the following works: Thomas, in _Ziemssen's Cyclop. Pract. Med._, vol. ii., N.Y., 1875, Am. edit.; Bohn, in _Gerhardt's Handbuch der Kinderkrankh._, Zweiter Band, Tübingen, 1877; Squire, in Quain's _Dict. Med._, N.Y., 1883; Ringer, in Reynolds's _System Med._, vol. i., Phila., 1879; Meigs and Pepper, _Dis. of Children_, Phila., 1882; J. Lewis Smith, _Dis. of Children_, Phila., 1882; Hebra, _Dis. of Skin_, London. 1866; Vogel, _Dis. of Children_, N.Y., 1871; Niemeyer, _Handbook of Pract. Med._, N.Y., 1869; Trousseau, _Clinical Med._, Phila., 1871. Other references will be found in the foot-notes to the text.]

SYNONYMS.--Rubeola, Morbilli, Measles, Masern, Flecken, Rougeole.

DEFINITION.--Measles is an acute infectious disease involving the skin and mucous membranes, characterized by successive stages and a maculo-papular eruption, which terminates in a fine branny desquamation. In normal cases it runs a definite course, which from the date of invasion to the end of desquamation occupies about fourteen days. It is highly contagious, and occurs, as a rule, but once in the same person.

HISTORY.--The word rubeola is probably of Spanish origin and was formerly written rubiola or rubiolo. The designation morbilli is the diminutive of the Italian il morbo, the plague. Although it is doubtful, as claimed by Willan, that the Greek and Roman physicians were acquainted with measles, there is no question that Rhazes was one of the first to describe the affection correctly. Rubeola is said to have been distinguished from variola by the Arabians in the twelfth century; but, nevertheless, as late as the middle of the seventeenth century we find Sennertus discussing the question "why the disease in some constitutions assumed the form of small-pox, and in others that of measles;" and in a posthumous work of Diemerbroeck, published in 1687, it is asserted that small-pox and measles are only different degrees of the same affection.[2] According to Mayr, the merit of having shown measles to be a distinct malady from scarlatina must be ascribed to Forestus and Sydenham. It is not clear, however, that the two diseases were accurately differentiated till the close of the last century, and notably by Withering in 1792.

[Footnote 2: _Cyclop. Pract. Med._, London, 1834, p. 625.]

ETIOLOGY.--The exact nature of the measles contagium has never been 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.

The most pronounced feature of this stage of the disease is, beyond 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.]