RUBEOLA—MEASLES

(W. M. Welch)
Synonyms.—Morbilli; Fr., Rougeole; Ger., Masern; Ital., Rosolia.

Definition.—An acute, highly contagious disease, characterized
by fever, marked catarrhal symptoms of the respiratory tract and the
occurrence of a macular rash about the fourth day of illness, without
any abatement of the earlier symptoms.

Symptoms.—The disease usually begins as a common cold. At
first a feverish condition is noticed, and there may be slight shivering,
but rarely a decided chill. Sneezing and coryza are often the earliest
symptoms observed, and soon become very pronounced. There is slight
running at the nose, and the eyes are irritable, reddened, and watery.
More or less intolerance to light is noticed. Examination of the mouth
and throat will show a furred tongue and hyperemia of the fauces.
Toward the end of the initial stage a distinct punctiform rash may be
seen on the mucous membrane of the mouth, with the exception of the
tongue. On the buccal mucous membrane opposite the molar teeth
may also be seen in most cases minute bluish-white specks at the sum­
mits of small red spots. These are known as Koplik's spots.

Subacute laryngitis is commonly present. This is denoted by hoarse­
ness and a troublesome cough, which is dry, sonorous, and distressing.
The hyperemia may extend lower down in the respiratory tract and give
rise to symptoms of bronchitis. With these local catarrhal affections,
which may vary greatly in severity in different cases, there is usually
proportionate pyrexia, the axillary temperature varying from ioi° to 104⁰
F. The appetite is impaired or lost. There is often headache, always
debility or lassitude, and sometimes nausea and vomiting. Epistaxis
is not uncommon. Convulsions may be seen in children, but are not
of frequent occurrence. Spasm of the glottis or false croup sometimes
occurs in young children.

The average duration of the initial stage is about four days. It may
be as short as two or three days, but more frequently it is as long as five
or six days, and sometimes even longer.

The eruption first appears on the face and neck. On the neck,
behind the angle of the jaw, it often assumes its distinctive character
earlier than anywhere else. It appears as small red spots which increase

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INFLAMMATIONS

in number and size, spreading over the face first and rapidly extending
to the trunk and extremities. The redness now entirely disappears on
pressure. The eruption is macular in character, sometimes becoming
somewhat papular on some parts of the body, but never presenting to
the touch the shotty sensation peculiar to variola. When fully developed,
the eruption arranges itself into irregular outlines which are commonly
described as crescentic in shape, with here and there normal skin inter­
vening. At this stage the face is slightly swollen and the lymphatic
glands of the neck may become somewhat enlarged and sensitive, though
the latter symptom is not so prominent as in scarlet fever. The cur­
vilinear or peculiar shaped character of the eruption is usually found
best marked on the chest, abdomen, and back. The eruption reaches
its fullest development on the face on the second day, and on the trunk
on the third day, when it begins to recede on the face. On the fourth
day it is still seen on the trunk and extremities, but presents a faded
appearance. After the eruption disappears there remain for several
days innumerable yellowish-brown spots, giving to the skin a distinctly
mottled appearance.

The fever and catarrhal symptoms, so prominent in the initial stage,
do not abate with the appearance of the eruption. On the contrary,
the fever not infrequently is highest after the eruption appears, reaching
often 104⁰ to 105⁰ F. on the first and second days. On the third or fourth
day of this stage, when the eruption is fading, the temperature falls
rapidly to normal, and the catarrhal symptoms also become markedly
mitigated. The fall is usually by crisis; when by lysis it is probably
because of the persistence of the catarrhal symptoms.

After the rash has entirely disappeared a slight desquamation occurs
in the form of fine furfuraceous scales, often so fine as to be scarcely
noticeable. It is certainly not to be compared to the coarse desquama-
tion in scarlet fever. In the absence of complications all symptoms now
rapidly disappear, and convalescence is established.

The description given applies to typical measles, but it is well known
that in epidemics atypical cases are common. Sometimes the disease
is so mild and thought to be so trivial that the family physician is not sent
for. Every patient, however, should be confined to bed. The stage
of invasion may be abnormally short, lasting only thirty-six or forty-
eight hours, and marked by mild symptoms; or, on the other hand, it
may be prolonged to five or six days and attended by severe and painful
catarrhal symptoms and extreme systemic depression. The eruption
also may be abnormal either in its mildness or intensity. The macules
may be very scanty, or even quite abundant, and disappear with re­
markable rapidity; or they may be so copious as to constitute a general
efflorescence, quite like the redness of erysipelas. A high temperature
and an adynamic condition are common in the latter form of the disease.
The severest and most dangerous type of measles is the hemorrhagic
Fortunately, these cases are not common in family practice. They are
met with occasionally in crowded institutions, in military camps, and
in bad hygienic environments. In this type of the disease the early
symptoms are severe, and the eruption never develops properly. The

RUBEOLA —MEASLES

473

spots at the beginning are livid, and soon become petechial. Hemor­
rhages occur from the nose and often from the mucous membrane of
other parts. There is profound systemic depression, and death is apt to
occur early from disorganization of the blood.

In measles complications are not infrequent, especially in certain
epidemics. Those most commonly met with are inflammations of the
respiratory tract. Bronchitis and bronchopneumonia are most frequent
and most dangerous, especially in infancy and early childhood. These
affections more often occur during the decline of the eruption. Lobar
pneumonia may occur, but is less frequent and not so dangerous. Phthi­
sis pulmonalis sometimes follows an attack of measles. Laryngitis
of mild form is not at all uncommon, and may give rise to symptoms of
spasmodic croup. In severe and fatal epidemics diphtheric laryngitis
or membranous croup not infrequently occurs, requiring for its relief
intubation or tracheotomy. Recovery from this complication is very
uncertain. Catarrhal inflammation of the middle ear is seen sometimes,
but not so frequently as in scarlet fever. The mild conjunctivitis com­
monly present may develop into the purulent form; so also it may become
chronic and persist as a sequel. Likewise iritis, blepharitis, keratitis, and
some other eye affections occasionally develop as sequels.

Complications located in the mouth and intestinal tract are some­
times met with. Aphthae and ulcerative stomatitis are not uncommon.
Gangrenous stomatitis or cancrum oris may occur. The form known as
noma usually progresses rapidly to a fatal termination. Intestinal
catarrh causing troublesome diarrhea occurs not infrequently, and it may
lead to enterocolitis, especially in very young children or debilitated
subjects.

Diagnosis.—In the diagnosis of measles it is important to bear
in mind the symptoms of the two principal stages of the disease. Usually
it is quite impossible to fully recognize its presence during the first or
initial stage. But if to such symptoms as persistent sneezing, watery
eyes, slight discharge from the nares, a hoarse, rasping cough, and rise
of temperature there can be added a history of exposure, the diagnosis
of measles may be made with a reasonable degree of certainty. Such a
history, however, can but rarely be obtained in isolated cases, and hence
the diagnosis in the majority of cases cannot positively be made until
the rash appears. It is important to remember that the rash often ap­
pears first on the mucous membrane of the mouth and fauces. The
presence of Koplik‘s spots may help one to arrive at an early diagnosis,
but these are sometimes absent.

The distinguishing feature of the disease is the rash, which appears
after a catarrhal stage of about four days. It is first seen on the face,
and rapidly spreads over the entire body. The spots are red, macular
in character, and show a tendency, when fully developed, to arrange
themselves into irregular shapes, with traces of normal skin intervening,
giving to the eruption curvilinear or crescentic outlines. The eruption
is distinguished from that of small­pox in that it is macular instead of
papular, and that it never develops into vesicles nor pustules. The
disease with which measles is more likely to be confounded is scarlet

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INFLAMMATIONS

fever. In the latter affection the initial stage is short, usually not
longer than twenty-four hours, and the rash first appears upon the trunk,
rapidly spreading to all parts of the body with the exception of the face,
which is often not perceptibly involved. It differs from the rash of
measles in that it is diffuse and punctiform in character. The exclusion
of rötheln is at times most difficult. This affection may be differentiated
by the absence of prodromal symptoms, or, if present, by their shorter
duration and by the milder fever. The rash may be discrete or confluent,
but it seldom assumes the so-called crescentic arrangement. Drug-
rashes may be excluded by the absence of fever and catarrh of the res­
piratory tract.

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