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(#09-02)

About Measles

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The symptoms of Measles Encephalitis may begin either abruptly or gradually and vary from a mild delirum, a convulsion or a deep coma.

The earlist symptoms are restlessness, headache, vomiting, and convulsions which occur in about one half of all patients. Spinal Fluid shows an increase in white blood cells and an elevation of protein.

To summarize, common Measles (Rubella) is an extremely important worldwide disease. The Measles Virus could be classified as one of the common cold Viruses, characterized by cough, a runny nose, conjunctivitis and a blotchy red rash.

Measles Virus may cause serious disease without a rash. The most important consequence of Measles is Measles Encephalitis, occurring in about one in 1,000 cases.

German Measles (Rubella) is an entirely different disease and is serious for the unborn child.

The Rubella Virus may rarely cause Encephalitis but does not cause serious DeMyelination disease which is so characteristic of Multiple Sclerosis, now so clearly related to the Rubella or Measles Virus, and other Virus like agents.

Mild Or Benign Multiple Sclerosis

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On occasion MS is a mild disorder, it may be mild at the beginning, during the development of the illness, or ultimately may remain silent for years or forever. Difficulty in categorizing the degree of severity is due to the widely varied manifestations of the illness.

Because of unusual clinical findings or lack of any clear symptoms or signs, the labels "Probable" or "Possible" MS are the first terms used until symptoms or signs become more extensive.

A definite diagnosis of MS in the early stages of illness is unlikely, lacking a specific diagnostic test. Elevated AntiBodies to certain Viruses in blood Serum or Spinal Fluid lead the doctor to strongly suspect that a "Slow-Virus" may be active in the patient's body, causing symptoms of MS even though they are very mild.

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Dr. Douglas McAlpine formulated a classification system, according to the degree of disability. In MS the major cause of disability comes from the weakness in one or both lower limbs or a lack of balance or a combination of these symptoms:

  • First; "Unrestricted" which he defined as without restriction of activity for normal employment or domestic purposes but not necessarily symptom free.

  • Second; "Restricted" and defined this group as those who are able to walk unaided for short distances up to half a mile and able to get on and off public transport.

  • Third; "Markedly Restricted" and defined these patients as capable of moving outdoors without difficulty for up to a quarter of a mile usually with the aid of sticks, and often unable to use public transport.

  • Fourth; "Mobility-At-Home", and here the patient is able to move with difficulty about the home with suppport from furniture but unable to mount stairs.

  • Fifth; "Immobility-At-Home", confined to wheelchair and entirely dependent on others for moving from room to room.

  • Sixth; "Bedridden".

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Other reports in medical literature state, that any case may be considered mild if it permits a more or less normal social and occupational career after a long course under partial remission.

They conclude that the Benign forms of MS present from the early stages of the disease allow hope of a favorable outlook in 20% of all cases.

Another report of interest recorded two "clinically silent" patients discovered to have MS only at autopsy. The authors believe that one slient MS case occurs in each four definitely diagnosed.

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Recognition of the "Benign" form of MS leads to a belief that, in a certain proportion of patients where resistance is high, it seems possible that a more prolonged period of rest and aftercare in the early stages of the disease, might beneficially influence the subsequent course of the disease.

It is probable that in a few rare and exceptional cases, the disease is permanently arrested. Patients whose initial disturbance is relatively sudden may remain in perfect health for months or years at a time.

Distribution Of Multiple Sclerosis In The World

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Although MS is worldwide in distribution, there are regionswhere the disease is more common than elsewhere. The risk areas are in the temperate zones; whereas the low risk areas are nearthe tropics in both northern and southern hemispheres.

Two Viral diseases which are also worldwide share a parallelism with MS; they are regular Measles (Rubella) and PolioMyelitis. The first epidemic of PolioMyelitis was recognized in northern Sweden about 1840. In the United States the first polio epidemic occured in Vermont in 1910.

Paralytic Polio or "Infantile Paralysis" as it was originally diagnosed is rare in tropical regions of thr world. The Viruses of PolioMyelitis are present in the tropics; but the paralytic forms of the disease are very uncommon.

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Measles is worldwide and like MS and Polio is recognized as involving the Nervous System more commonly in the colder regions of the world, where severe epidemics have occurred. Measles Encephalitis, the most serious form of the disease, is rare in Africa and tropical climates.

The parallelism is obvious. The best way to identify a Viral disease is by the specific AntiBodies it produces. When MSers were compared with non Msers, Dr. J. Clarke in 1965 found that AntiBodies in the MSers' blood were higher against Measles Virus, but not against the Polio Viruses.

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That high and low risk areas for MS do exist in the world is a well established fact, but the precise reason for the discrete difference is not known. In the developing countries where hygiene is frequently poor the risk of developing MS is low.

Conversely, where the level of hygiene and sanitation is high, the prevalence of MS is at medium or high incidence. It seems likely that MS originated in western Europe and spread from there to the United States, Canada, New Zealand and Australia.

It is a fact that all the high and medium risk areas are found in Europe or in regions colonized by Eoropeans.

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DeMyelination & Related Diseases

Pathology Of Multiple Sclerosis

Myelin is the material which surrounds the nerves in the Brain. Since its injury and destruction is the primary change which occurs in MS, what does DeMyelination in the Nervous System really mean?

The destruction or disappearance of Myelin sheaths from the nerve tracts may be due to injury or disease of vessels related to lack of proper nutrition, or an infectious process.

We can speak of primary DeMyelinating diseases, or when the casual agent is unknown DeMyelination might be secondary to hereditary or other causes.

It is also important to attempt and arrange DeMyelinating processes in relation to time: as Acute or SubAcute forms and finally, Chronic manifestations.

It is likewise difficult to arrange DeMyelinating Diseases on the basis of the injury or pathologic change seen in the Brain. An attempt to arrange or classify these illnesses on the basis of the symptoms and signs that the patient shows also is difficult if not impossible.

In his textbook on "Diseases Of The Nervous System", Lord Brain (1962) arranged the DeMyelinating Disorders first as acute EncephaloMyelitis following acute infections such as Measles, Chicken Pox, SmallPox, vaccination against SmallPox and Rabies.

In a further subdivision he speaks of Disseminated or Multiple Myelitis associated with Optic Neuritis. A third variety and one which is of primary concern in this chapter is Disseminated or Multiple Sclerosis.

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These subdivisions as designated above, will be discussed in the following sections.

First, Acute Disseminated EncephaloMyelitis is characterized by a loss of, or injury to, Myelin about blood vessels in the Brain and Spinal Cord. It is usually related to Virus diseases such as Measles, Rubella, SmallPox, Mumps, Chicken Pox, and Vaccination against SmallPox.

Injury to Myelin may occur spontaniously. In other words, no obvious cause is apparent. The tissue changes in the Brain and Spinal Cord are centered around the Veins, and many cells such as Lymphocytes or Plasma Cells gather in the space around the Veins.

The changes occur mostly in the White Matter of the Brain where the nerve tracts gather together and are covered with Myelin.

These changes are rarely seen in the outer part or gray matter of the Brain. The changes are referred to as inflammatory and occur throughout the Nervous System.

It is possible that the Infammatory and early destructive changes about the Veins cease and result in partial or complete recovery.

The many different Viruses which cause Encephalitis produce almost identical changes but vary in severity depending on factors such as heredity, age, and the character of the causal agent; some do produce much more severe changes than others.

Rubella or Measles Virus is one of the most devastating Viruses which attacks the Nervous System. Some Viruses produce inflammation in the Brain with very little DeMyelination.

The mechanism of injury is not always clear. The Rubella Virus causes Encephalitis but minimal evidence of DeMyelination. It is not related to MS.

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EncephaloMyelitis complicating Measles is essentially the same as a complication of Smallpox vaccination. Research studies reports have clearly implicated the Measles Virus as the cause of the injury and destructive changes in the Brain.

It was 1954 that Enders & Peebles isolated Measles Virus in tissue culture and thus established the injuring effects caused by the Virus.

Cells become fused together and are referred to as a giant cell. Virus inclusion bodies occur in infected cells. When these are studied under the electron microscope, dense and fuzzy tubules are seen in cells proved to be infected by Measles Virus.

The changes are intimately related to Viral inclusion bodies seen with the light microscope occurring in the inflammed tissues particularly about the blood vessels in the Brain and Spinal Cord.

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The autopsy of a patient, who had developed Encephalitis three days after the onset of Measles, showed changes which were consistent with Measles Encephalitis. Pictures showed a large area of DeMyelination referred to as "plaque".

An area of infammation was also shown as well as Viral inclusion bodies in the cytoplasm and nucleus of the cells. The changes seen in the microscope were similar to the late scarring type known to be associated with Measles Encephalitis and Multiple Sclerosis.

This patient represents a case of Acute, SubAcute or Chronic DeMyelination disease proved to be caused by the Measles Virus.

Old Dog Encephalitis (ODE) provides a model for further study of the cause and PathoGenesis of severe DeMyelinating disease in man. This disease occurs in mature dogs that develop a chronic form of Encephalitis, with difficulty in walking (Ataxia), rare convulsions, and circling.

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Pathologic findings in ODE are compared with the findings in MS. SSPE and NO (NeuroMyelitis Otica) in man. Optic Neuritis in dogs with chronic Distemper shows changes similar to those in the Optic Tract of human patients with severe DeMyelinating disease.

The pathologic changes in MS, such as perivascular infiltration with Lymphocytes, Plasma Cells and DeMyelination are similar to those seen in ODE. The findings strongly support a possible relationship of ODE to Multiple Sclerosis, Subacute Sclerosing PanEncephalitis, and NeuroMyelitis Optica.

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The classic pathologic features of a typical case of MS are so striking. No disease has more characteristic findings, than the pattern of changes observed in the Central Nervous System.

It is a combination of many kinds of alterations of the Brain and the extent of the involvement is often small, when the disability of the particular patient is considered.

Some of the scarred areas in the Brain appear to be old, whereas others are small and appear to be quite new. They are so different from the old areas of scarring as to be easily missed.

Areas of involvement are randomly scattered throughout the Central Nervous System. In the most severe cases no area of the Brain is spared. There is no question that MS is a DeMyelinating process and Myelin covering the nerve tracts represent the prime target at risk.

In most cases the area about the Veins is involved and these may join together and form what might be considered a patch of Myelin destruction or a scar, rarely bigger than a small coin or about one inch in diameter.

The appearance of the patches seen at postmortem are so characteristic and striking that the skilled pathologist has no difficulty in recognizing them as the scars of Multiple Sclerosis.

In two seperate research studies, AntiBodies in the Spinal Fluid against the Vaccinia Virus have been found in about 30% of patients with Multiple Sclerosis.

The Vaccinia Virus was implicated in the death of a thirteen-year-old girl who was vaccinated at the age of seven months.

She was quite well until the age of eleven when she had visual difficulty which was diagnosed as Optic Neuritis and this was followed by paralysis in her legs.

After her death, Brain studies showed the changes which are known to be caused by the Vaccinia Virus. This case implicates the Vaccinia Virus as the cause of NeuroMyelitis Optica or Devic's disease.

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This disease occurs more commonly in children than in adults, but it may occur from five to sixty years of age. The Spinal Cord may be involved very early, even before the Brain with the possible exception of the Optic Nerve which is an important part of the Brain.

The pathologist states that the earliest areas of involvement are those around the Veins. The optic nerve or the main nerve of the eye is highly vulnerable in this disease.

It is true that a high incidence of malnutrition and chronic infection may occur in patients with Multiple Sclerosis, but no consistent disease association has been observed. Almost without exception the Optic pathways to the Brain from the Eyes are involved in Multiple Sclerosis.

From this discussion the cause of Multiple Sclerosis cannot be determined by the pathologic changes found in the classic cases.

However, pathology is the indispensable compass by which the current experimental and epidemiological research must be steered and without which research may be meaningless.

CONTINUED IN (#09-03)




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