A hundred years ago: The condition of the gums in measles
During the last few years, it has gradually become more and more customary for practitioners to carefully examine the buccal mucosa for the presence of the so-called Koplik's spots, in cases in which measles is suspected, but in which, because the rash has not yet appeared, is not fully out, or is atypical, the diagnosis is, in the absence of this sign, in doubt.
In this note I wish to draw attention to another sign, which I believe to be of diagnostic value in measles, and moreover, to be free from some difficulties which are associated with the recognition of Koplik's spots, and to which I shall allude later.
When an outbreak of measles has occurred in the wards of a hospital, or in a house, one naturally investigates with extreme care any slight rise of temperature occurring in patients in the same ward or house ten days or so later, which might turn out to be the slight rise of the invasion stage of measles.
In the course of the last four or five years, observations of this nature, made on a large number of children, have convinced me that I can tell in what cases I am going to find Koplik's spots by the appearance of the gums, which I catch sight of, in the act of turning back the cheek well to look for Koplik's spots in the most typical situation, viz. : on the inside of the cheek, over the first lower molar tooth.
In this movement, as in that of depressing the lower, or raising the upper lip, one gets a good view of the gums, which, in every case of measles, are in a case of hyperaemia, redness, or injection, with slight swelling.
As a rule, the uniformly injected gum is coated here and there with a patchy whitish scum, which is easily removed, and which consists of epithelial squames and debris.
The injection of the gums has its origin as early as Koplik's spots, i.e., two to three days before the rash appears, while it persists longer than they do, even, in some cases, till the rash begins to fade.
If the gums at the onset of measles are compared with the gums of patients in the initial stages of scarlet fever, of rubella, or of influenza, the contrast is very marked. The gums in these three affections present the normal pink appearance, unless there is a complicating stomatitis, which is not common in the initial stage of any of these affections, and which, if it does occur, is patchy and not uniform.
The claim that gingival hyperaemia deserves recognition as a point of some value in the early diagnosis of measles, even in preference to Koplik's spots, may be briefly outlined under the following heads:–
(a) Ease of Observance by either Natural or Artificial Light. – It is a sign easily observed by either natural or artificial light, whereas I have frequently known cases, in which Koplik's spots were definitely present, but were not identified, owing to their being only searched for by artificial light, by which they are seen with extreme difficulty.
(b) Simplification of Method of Examination. – Apart from the light difficulty, in the examination of babies and small children, it is often almost impossible to get the child sufficiently quiet to obtain a good view of the inside of the cheek, or deep part of the lip, so as to search for Koplik's spots; but it is always possible to move the lips so as to obtain a view of the gums.
(c) Incidence. – This condition of the gums is practically constant, as are Koplik's spots, but it varies in intensity.
(d) Time of Appearance and Duration. – Gingival injection appears as early as Koplik's spots – from two to three days before the rash – and persists longer than they do, i.e., it may even persist till the rash is beginning to fade.
(e) Differential Diagnosis. – This sign does not present the difficulty in diagnosis which Koplik's spots present to some, who, not having had the real spots demonstrated to them clinically, confuse them with an aphthous stomatitis. Again, the persistence of this sign after Koplik's spots have disappeared may suffice to clinch the diagnosis in a case first seen with a well-developed, but atypical rash.
I observed in one epidemic of measles, in which all the cases, over 50 in number, came from one school, a well-marked, marginal ulcerative gingivitis as a complication in 60 per cent of the cases in the third week.
The gingival hyperaemia requires no treatment, but, in the case of those patients who are old enough to use it, a mild alkaline mouth-wash is an advantage. In the epidemic, where marginal gingivitis occurred as a complication, I obtained the best results and most rapid healing with a mouth-wash containing tincture of myrrh 1/2 an ounce, and borax 2 drachms to 12 ounces of water, used frequently; in young children the same solution was regularly dabbed on the gums.