The Tonsillar Manifestations in the Early Diagnosis of Measles

Abstract

What one does not look for one does not see. This is well illustrated in the case of the oral manifestations of measles. The disease is extremely common; numerous careful observers have examined innumerable patients and still the significance of certain manifestations for a long time escaped detection. I can find only three authors who have mentioned the tonsillar spots as an early manifestation of measles. Comby1 reported four cases of measles in one family and described white spots (angine pultac\l=e'\e) as being present on the tonsils of two of these cases two days before the eruption appeared. Grumann2 describes white spots or streaks about 3 mm. long which are present on the tonsils one or two days before the eruption. Miller3 reports the case of a child which, when first examined, besides a rise of temperature, had dyspnea and a reddened throat. The tonsils were swollen and on each tonsil there were a number of small bluish semitransparent elevated bodies averaging considerably less than the size of the head of an ordinary pin. The eruption appeared the following day. No Koplik's spots were observed.It is interesting to note that occasionally when these spots on the tonsils were seen, they were regarded as merely coincidental and their relation to the onset of measles not recognized. To cite one example, in von Pirquet's splendid monograph on measles two of Fried Jung's cases are quoted to illustrate an unusually long period of incubation:

Infection of lymphoid tissues in the macaque upper respiratory tract contributes to the emergence of transmissible measles virus

“…In this study, multi-nucleated giant cells of assumed lymphocyte origin were observed beneath and within tonsillar and adenoid epithelium, with elongated syncytia observed to extend between epithelial cells towards the surface of the tonsils. The pathology associated with the spread of uninfected and infected immune cells into tonsillar epithelium may be responsible for the 'spots' on the surface of the tonsil that have been reported during the prodromal stage of measles (Herrman, 1915). In more serious cases, alterations to the tonsillar epithelium have been associated with rupture and haemorrhaging during the prodromal stage (John et al, 1988;Redman & Chaney, 1959).…”

Part II. Infant Feeding in Relation to Survival, Health and Development.

“…While the incidence of measles among babies who have never been breast fed is relativcly high at all ages, it will be seen in Table XVII (which gives the incidence per 1,000 months exposure to risk) that significant differcnces between the feeding 1 Thc total incidcncc of all childish infections is lower than the sum ot the incidence of iiidiriirlual diseases because sane babies had hed two or more infei :ions of riifirrcrit type5 Herrman (1923) who showed that, at all periods during the first 12 months, the incidence of measles was lower among breast fed than among bottle fed babies.…”

“…Breast fed babies are generally considered to be healthier than babies who are bottle fed. Among the diseases which are reported to be unduly frequent among bottle fed babies are gastro-enteritis (Grulee, et d., 1934 ;Robinson, 1940), lower respiratory infections (Grulee, 1934(Grulee, , 1935Stevenson, 1941)~ measles (Herrman, 1923), eczema (Grulee and Sanford, 1936), rashes (Robinson, 1940) and all types of infection (Ebbs and Mulligan, 1942; Grulee, et al, 1934). But much of this evidence was gathered 10 to 20 years ago, before feeding with dried milk had been introduced and when standards of hygiene were lower than they are to-day.…”