- Email: [email protected]
RUBELLA IN A REMOTE COMMUNITY
64 the ground that under 15 years of age boys contracted it more often than girls, and thus acquired immunity. Another explanation is that in families the infected children tend to infect the mother rather than the father (demonstrated for the common cold by Heasman Or it is possible that, as with poliomyelitis, 1955). pregnancy makes a woman more likely to contract rubella (Lundstr6m 1952). Comparison of attack-rates in pregnant and non-pregnant women is required to show whether this is so. Lastly, women may have sought medical advice more often than men ; for the symptoms were trivial and my clinics were mostly held during the men’s working hours.
RUBELLA IN A REMOTE COMMUNITY M.D. LATE
F. K. M. HILLENBRAND Restock, M.B. Berlin, L.A.H. Dubl.
MEDICAL
OFFICER,
FALKLAND
ISLANDS
THE isolated community has advantages for the study of infectious diseases (Isaacs et al. 1950, Christensen The people are relatively accessible ; their 1952). isolation makes it easier to estimate incubation periods, epidemic periodicity, and immunity ; and, as other infections are less likely to be present, the clinical picture may be observed in pure form. The Falkland Islands had outbreaks of rubella in 1911-12 (when it was almost pandemic, attacking a high proportion of adults, and even old people) and again in 1947-48 when the epidemic was overlapped by an equally extensive epidemic of measles. The further outbreak I describe here was confined to the Colony’s chief settlement, Port Stanley, whose population is entirely white and largely of British descent. It began seventeen days after the arrival of the monthly mail-cum-passenger boat from Montevideo on Sept. 7, 1952. None of the passengers reported sick, and the first case was seen in a Port Stanley schoolboy. Most of them occurred during the first two months ; but a second crop followed Christmas gatherings, and after this there were still a few scattered cases. No other infectious fever was current at the time.
Clinical Picture
Usually the illness was mild and presented no diagdifficulty. The prodromata, which were rarely
nostic
Epidemiology As in 1911-12 and 1947-48, the time of the outbreak was spring, as is usual also in the Northern Hemisphere (Paterson and Moncrieff 1949). In isolated communities infectious diseases do not, as a rule, return until a new generation of non-immune persons has grown up. This would account for the absence of rubella between 1911 and 1947 ; but the shortness of the interval between 1947 and its reappearance in 1952 is not easily explained.
Second Attacks
When, as often happened, patients with rubella in 1952-53 gave me a history of rubella in 1947-48 I was inclined to think that they had confused german measles with true measles, of which there had been an outbreak at about the same time : of 33 women who became pregnant during the epidemic of 1952-53, 15 claimed to have had rubella earlier on. However, there were 107 school-children whose medical records showed that they had both measles and rubella in 1947-48, and of these no fewer than 15 developed clinical rubella and 6 subclinical rubella, in 1952-53. and Sex The age-range was wide, with 7 infants under 6 months of age (10, 14, 21, and 23 days, 5 weeks, and 3 and 5 months) and a considerable number of adults over 40, the oldest being 57 ; in the case of the youngest infant transplaccntal infection despite maternal immunity (Schick 1949) is possible. The only substantial risk from the disease is in pregnancy, and it is noteworthy that in the age-group 15-45, when women are fertile, far more females than males contracted the disease (table i). This difference, which has been observed elsewhere (ClaytonJones 1947, Laucet 1952), cannot be fully explained on
Age
TABLE
I—144 CASES OF RUBELLA IX FALKLAND 1932-53 AGE AND SEX DISTRIBUTION Age (year-.)
Male
ISLANDS,
Female
Chart of
severe
conspicuous, took the
rubella in girl aged 17.
form of aches
and pains.
In
most cases the rash was characteristic of rubella both in site and in appearance, but in some it was rudimentary, particularly on the exposed weather-beaten parts of the body. The duration of the rash varied from an hour to
days : as a rule it lasted one or two days, often towards evening and reappearing after rest in bed or a hot bath, as observed by Rundle (1929). Following the rash, a branny desquamation was observed in several
fading 2
patients.
About a third of my cases were of non-eruptive rubella " (Paterson and Moncrieff 1949, Dods 1951). These subclinical infections were seen because I frequently examined whole families, but no doubt some of the patients had had a fleeting rash. Pyrexia was, with a few exceptions, mild or absent ; conjunctivitis was rarely seen and photophobia only once ; a mild tonsillitis was present twice (once accompanied by vomiting and a second attack of pyrexia : see chart), and in one patient the spleen was enlarged. Both in clinical and in subclinical infection the postauricular, and almost always the "
occipital, lymph-nodes were enlarged at an early stage : cases the postauricular lymph-nodes were inflamed, though they did not suppurate. Less frequently the supratrochlear, axillary, and inguinal groups were in 2
involved. for up to
In most seven
cases
the
lymph-nodes
months, and in many for
were
over a
enlarged
year.
65
relapse
TABLE
infections (Wesselhoeft 1951) ten weeks and five and seven were months after the first attack : 2 were clinical on both occasions, while in the 3rd, with an interval of five months, the first infection was subclinical. In 3
relapsing observed, occurring
Outcome
cases
III-EPIDEMICS
STANLEY
AND
BIRTHS
OF
INFECTIOUS DISEASES AT PORT YEAR AFTER THEIR ONSET
DURING
of Pregnancies
As in 1947-48, many congenital malformations followed this outbreak, though the majority of the women had shown no clinical infection. There was also a considerable number of premature births and stillbirths, as has been observed elsewhere (Swan 1948). Of the women with a history of rubella in 1947-48 who were again exposed during pregnancy, 3 had babies with defects (Bamatter 1949, 1951) (1mother subclinically infected at the third month), 1 had a premature birth and 1 had stillbirth. The outcome of pregnancy in all pregnant women in Port Stanley during the epidemics of 1947-48 and 1952-53 are shown in table 11. In years when other infectious diseases were prevalent in the town the only evidence of damage to offspring is a single miscarriage (table 111). My departure from the Colony in May, 1954, prevented my obtaining data regarding further deformities (particu-
larly congenital deafness). Rheumatism The presence of fibrositic
recognised
as
fairly
common
" trigger points " is now (Copeman 1954) ;
in rubella
TABLE IT-OUTCOME
OF PREGNANCIES
Reference : Medical and Sanitary Reports, Port Stanley. estimated that 50 % of households were affected. Surprisingly high number of middle-aged and even old people." t Listed in table 11.
* It
"
was
,
but in the 1952-53 outbreak other rheumatic symptoms 25 were prominent. patients showed muscular rheumatism, which was usually at the onset but in 7 was prodromal and in 4 came on long after the acute stage. General or localised aching in the backs and calves, and less frequently pains in the joints, were complained of. A transient. arthritis with painful swelling of the middle finger, knee, wrist, or ankles was seen in 15 patientswith clinical or subclinical rubella. 2 patients had exacerbations of prepatellar bursitis, and 1 of an old injury to the knee. Also 3 patients with osteo-arthritis of long standing had exacerbations at the height of the epidemic : they showed neither clinical nor subclinical rubella but had blood changes suggestive of this infection. Similarly, rheumatoid arthritis was observed in 5 adult women during the outbreak : of these, 2 had their exacerbation during the onset of clinical rubella, 1 had it during subclinical infection, and 2 showed no infection but had characteristic blood changes. Erythema nodosum was seen in 3 adult patients (2 with osteo-arthritis and 1 with arthralgia of the knee). In 1 of these a concurrent chest lesion might have provoked the syndrome, but all 3 showed the blood changes.
Studies After my return to England in 1954, I was able to make some observations on children with rubella in a hospital in London.
Comparative
Of 88 patients, 3 had a medically recorded history of rubella in the same hospital in 1951-52. Subclinical infections were seen in 5 and there was one relapsing infection within fifteen days of the original attack, with rash on both occasions. 2 girls showing congenital defects and a history of maternal rubella in early pregnancy (Kirman 1955) contracted rubella in 1954 : 1 of them had a sister, four years younger, similarly deformed.
It has been shown that intra-uterine infection with rubella, though potentially destructive to various organs, does not result in a generalised disease of the foetus
(Tondury 1953). Summary An outbreak of rubella observed in 1952-53 in the Falkland Islands differed in several ways from the usual
pattern. It attacked people over a wide range of age, and in the age-group 15-45 many more females than males were affected. Other outstanding features were : relapses ; presumed second attacks ; many subclinical infections ; and an unusually high incidence of a variety of rheumatic afflictions. Enlargement of lymph-nodes was found to persist for many months. Pregnancies starting during the epidemic resulted in a number of congenital defects and other sequels similar to those reported elsewhere.
66 I wish to thank H.M. Colonial Government of the Falkland Islands and the Senior Medical Officer, Port Stanley, for facilities for studying the epidemic, and Dr. J. H. Edwards
stained by Pappenheim’s panoptic method and differentiated by Schilling’s method, 100 cells being counted. Absolute numbers were calculated throughout. In judging whether the white cells were increased or decreased the standards of Whitby and Britton (1953) were used :
for his help during and after my stay in the Colony. I am also grateful to Dr. B. Kirman for his support and advice. REFERENCES
Bamatter, F. (1949) Cited by Töndury. (1951) Cited by Töndury. Christensen, P. E. (1952) Acta med. scand. 144, 313, 430. Clayton-Jones, E. (1947) Lancet, i, 56. Copeman, W. S. C. (1954) Textbook of Rheumatism. London. Dods, L. (1951) In Parsons’s Modern Trends in Pædiatrics. London. Heasman, H. W. (1955) J. R. stat. Soc. 17, 64. Isaacs, A., Edney, M., Donnelley, M., Ingram, M. W. (1950) Lancet, i, 64. Kirman, B. (1955) Ibid, ii, 1113. Lancet (1952) i, 1057, 1073. Lundström, R. (1952) Acta pœdiat., Stockh. 41, 583. Medical and Sanitary Reports, Port Stanley, 1906-1953. Paterson, D., Moncrieff, A. (1949) Diseases of Children. London; -
vol. ii.
Rundle, C. (1929) In Ker’s Infectious Diseases. London. Schick, B. (1949) Acta pœdiat., scand. 38, 563. Swan, C. (1948) Lancet, i, 744. Töndury, G. (1953) Études néo-natales. Zurich ; vol. ii, p. 2. Wesselboeft, C. (1951) In Banks’s Infectious Fevers. London.
THE BLOOD PICTURE IN RUBELLA ITS PLACE IN DIAGNOSIS
M.D.
F. K. M. HILLENBRAND Rostock, M.B. Berlin, L.A.H. Dubl.
LATE MEDICAL
OFFICER,
FALKLAND ISLANDS
RUBELLA in the first three months of pregnancy may
produce heart lesions, cataract (Gregg 1941), deafness, and other deformities in the offspring (Swan et al. 1943, Swan 1948). Women at this stage of pregnancy must therefore be protected from infection ; and since, owing to the long incubation period and high infectivity, segregation is seldom effective, passive immunisation may be required (British Medical Journal 1956). The usefulness of such immunisation will depend on its being undertaken in good time ; and for this reason early diagnosis of rubella can be very important. Diagnosis by clinical methods alone is not infrequently difficult.
The rash may resemble those of mild scarlet
fever, infectious mononucleosis, and abortive measles. As it may be of very short duration, it may pass unnoticed ; or there may be no rash at all. Subclinical rubella without rash is
epidemic family. an
or
a
likely to be missed unless there is concurrent typical case in the same
As an aid to diagnosis, the blood-cell changes in rubella have been considered helpful (Whitby and Britton 1953) ; but there has been no general agreement on their’difference from those seen in measles. My interest in them was aroused many years ago when I examined the blood of patients with persistent enlargement of postauricular and occipital lymph-nodes following rubella and found that it regularly showed plasmacytosis. Accordingly, when an opportunity arose during the Falkland Islands epidemic of rubella in 1952-53 I made routine white-cell and differential counts in cases both clinical and subclinical, including, of course, women who had become pregnant during the outbreak. The absence of any other infectious fever on the island at the time, and the accessibility of the cases, made conditions favourable for such observations. On my return to England these studies were extended. At that time (August, 1954, to September, 1955) there was no major epidemic in the London area, and all observations had to be made on patients in hospitalmostly children. The follow-up period was shorter, but, on the other hand, considerably larger numbers could be examined at early stages of infection. Methods
Most of the white-cell counts noon, the time being noted.
were
The
made in the foreblood-films were
"
"
White cells were classified as increased " or decreased " according to whether they were above or below Whitby and Britton’s maximum and minimum for the total age. Comparable observations were made in London on infections sometimes confused with rubella. Results
Rubella The initial neutropenia and lymphopenia described by Carroll (1934) and Hynes (1940) was seen in rather less than half the cases, both in London and in the Falkland Islands, but lasted longer than these authors report. At later stages lymphocytosis was infrequent and polymorphonuclear leucocytosis almost absent
(table i). In clinical and subclinical infections alike, the outstanding feature was the regular occurrence of Tiirk and plasma cells, which in uncomplicated rubella were invariably present up to the tenth day, and usually persisted for many months. The maximum percentages of these cells observed in single specimens were : Falkland Islands: 14 8
(third day) (Turk
and
plasma cells)
(sixth day). London 19
(fourth day) (Turk
and
plasma cells) (Carroll
1934). The increase in monocytes noted by Glanzmann (1929), Carroll (1934), and MacBryde and Charles (1935) was confirmed, the percentage amounting to 18 (London) and 16 (Falkland Islands) on several occasions. Bilobed monocytes (Whitby and Britton 1953), numerous in both groups, were not registered separately. Next I would draw attention to the degenerate lymphocytes occurring, independently of age, in examples of clinical and subclinical infection from both groups. These large cells, about the size of monocytes, often show an eccentric (sometimes nucleolated) nucleus : the cytoplasm stains clear, pale, and light-blue and may show vacuoles and azure-staining granules. They are quite distinct from large lymphocytes or those deformed during the film-taking or staining ; and they differ also from the abnormal monocytes of infectious mononucleosis. Though found at all stages of rubella infection they are commonly a late feature, their appearance coinciding with the diminution of the Turk and plasma cells though they show no morphological relationship with these. Usually few (Kamerbek 1949) in both London and Falkland Islands specimens, they were sometimes increased (maximum percentages : Falkland Islands 22 fifteenth day, London 16 eleventh day). They have been observed in other conditions (Schilling 1935), but not in infectious mononucleosis. Basophils, inconstant in the London series, were occasionally numerous at late stages, up to a maximum of 420 per c.mm. in the Falkland Islands group. A slight initial increase in eosinophils (Glanzmann 1929, Carroll 1934, -1facBryde and Charles 1935) was also observed in the Falkland Islands group. Metamyelocytes were found in insignificant proportions and were almost confined to blood from infants (MacBryde and Charles 1935).
RUBELLA IN A REMOTE COMMUNITY M.D. LATE
F. K. M. HILLENBRAND Restock, M.B. Berlin, L.A.H. Dubl.
MEDICAL
OFFICER,
FALKLAND
ISLANDS
THE isolated community has advantages for the study of infectious diseases (Isaacs et al. 1950, Christensen The people are relatively accessible ; their 1952). isolation makes it easier to estimate incubation periods, epidemic periodicity, and immunity ; and, as other infections are less likely to be present, the clinical picture may be observed in pure form. The Falkland Islands had outbreaks of rubella in 1911-12 (when it was almost pandemic, attacking a high proportion of adults, and even old people) and again in 1947-48 when the epidemic was overlapped by an equally extensive epidemic of measles. The further outbreak I describe here was confined to the Colony’s chief settlement, Port Stanley, whose population is entirely white and largely of British descent. It began seventeen days after the arrival of the monthly mail-cum-passenger boat from Montevideo on Sept. 7, 1952. None of the passengers reported sick, and the first case was seen in a Port Stanley schoolboy. Most of them occurred during the first two months ; but a second crop followed Christmas gatherings, and after this there were still a few scattered cases. No other infectious fever was current at the time.
Clinical Picture
Usually the illness was mild and presented no diagdifficulty. The prodromata, which were rarely
nostic
Epidemiology As in 1911-12 and 1947-48, the time of the outbreak was spring, as is usual also in the Northern Hemisphere (Paterson and Moncrieff 1949). In isolated communities infectious diseases do not, as a rule, return until a new generation of non-immune persons has grown up. This would account for the absence of rubella between 1911 and 1947 ; but the shortness of the interval between 1947 and its reappearance in 1952 is not easily explained.
Second Attacks
When, as often happened, patients with rubella in 1952-53 gave me a history of rubella in 1947-48 I was inclined to think that they had confused german measles with true measles, of which there had been an outbreak at about the same time : of 33 women who became pregnant during the epidemic of 1952-53, 15 claimed to have had rubella earlier on. However, there were 107 school-children whose medical records showed that they had both measles and rubella in 1947-48, and of these no fewer than 15 developed clinical rubella and 6 subclinical rubella, in 1952-53. and Sex The age-range was wide, with 7 infants under 6 months of age (10, 14, 21, and 23 days, 5 weeks, and 3 and 5 months) and a considerable number of adults over 40, the oldest being 57 ; in the case of the youngest infant transplaccntal infection despite maternal immunity (Schick 1949) is possible. The only substantial risk from the disease is in pregnancy, and it is noteworthy that in the age-group 15-45, when women are fertile, far more females than males contracted the disease (table i). This difference, which has been observed elsewhere (ClaytonJones 1947, Laucet 1952), cannot be fully explained on
Age
TABLE
I—144 CASES OF RUBELLA IX FALKLAND 1932-53 AGE AND SEX DISTRIBUTION Age (year-.)
Male
ISLANDS,
Female
Chart of
severe
conspicuous, took the
rubella in girl aged 17.
form of aches
and pains.
In
most cases the rash was characteristic of rubella both in site and in appearance, but in some it was rudimentary, particularly on the exposed weather-beaten parts of the body. The duration of the rash varied from an hour to
days : as a rule it lasted one or two days, often towards evening and reappearing after rest in bed or a hot bath, as observed by Rundle (1929). Following the rash, a branny desquamation was observed in several
fading 2
patients.
About a third of my cases were of non-eruptive rubella " (Paterson and Moncrieff 1949, Dods 1951). These subclinical infections were seen because I frequently examined whole families, but no doubt some of the patients had had a fleeting rash. Pyrexia was, with a few exceptions, mild or absent ; conjunctivitis was rarely seen and photophobia only once ; a mild tonsillitis was present twice (once accompanied by vomiting and a second attack of pyrexia : see chart), and in one patient the spleen was enlarged. Both in clinical and in subclinical infection the postauricular, and almost always the "
occipital, lymph-nodes were enlarged at an early stage : cases the postauricular lymph-nodes were inflamed, though they did not suppurate. Less frequently the supratrochlear, axillary, and inguinal groups were in 2
involved. for up to
In most seven
cases
the
lymph-nodes
months, and in many for
were
over a
enlarged
year.
65
relapse
TABLE
infections (Wesselhoeft 1951) ten weeks and five and seven were months after the first attack : 2 were clinical on both occasions, while in the 3rd, with an interval of five months, the first infection was subclinical. In 3
relapsing observed, occurring
Outcome
cases
III-EPIDEMICS
STANLEY
AND
BIRTHS
OF
INFECTIOUS DISEASES AT PORT YEAR AFTER THEIR ONSET
DURING
of Pregnancies
As in 1947-48, many congenital malformations followed this outbreak, though the majority of the women had shown no clinical infection. There was also a considerable number of premature births and stillbirths, as has been observed elsewhere (Swan 1948). Of the women with a history of rubella in 1947-48 who were again exposed during pregnancy, 3 had babies with defects (Bamatter 1949, 1951) (1mother subclinically infected at the third month), 1 had a premature birth and 1 had stillbirth. The outcome of pregnancy in all pregnant women in Port Stanley during the epidemics of 1947-48 and 1952-53 are shown in table 11. In years when other infectious diseases were prevalent in the town the only evidence of damage to offspring is a single miscarriage (table 111). My departure from the Colony in May, 1954, prevented my obtaining data regarding further deformities (particu-
larly congenital deafness). Rheumatism The presence of fibrositic
recognised
as
fairly
common
" trigger points " is now (Copeman 1954) ;
in rubella
TABLE IT-OUTCOME
OF PREGNANCIES
Reference : Medical and Sanitary Reports, Port Stanley. estimated that 50 % of households were affected. Surprisingly high number of middle-aged and even old people." t Listed in table 11.
* It
"
was
,
but in the 1952-53 outbreak other rheumatic symptoms 25 were prominent. patients showed muscular rheumatism, which was usually at the onset but in 7 was prodromal and in 4 came on long after the acute stage. General or localised aching in the backs and calves, and less frequently pains in the joints, were complained of. A transient. arthritis with painful swelling of the middle finger, knee, wrist, or ankles was seen in 15 patientswith clinical or subclinical rubella. 2 patients had exacerbations of prepatellar bursitis, and 1 of an old injury to the knee. Also 3 patients with osteo-arthritis of long standing had exacerbations at the height of the epidemic : they showed neither clinical nor subclinical rubella but had blood changes suggestive of this infection. Similarly, rheumatoid arthritis was observed in 5 adult women during the outbreak : of these, 2 had their exacerbation during the onset of clinical rubella, 1 had it during subclinical infection, and 2 showed no infection but had characteristic blood changes. Erythema nodosum was seen in 3 adult patients (2 with osteo-arthritis and 1 with arthralgia of the knee). In 1 of these a concurrent chest lesion might have provoked the syndrome, but all 3 showed the blood changes.
Studies After my return to England in 1954, I was able to make some observations on children with rubella in a hospital in London.
Comparative
Of 88 patients, 3 had a medically recorded history of rubella in the same hospital in 1951-52. Subclinical infections were seen in 5 and there was one relapsing infection within fifteen days of the original attack, with rash on both occasions. 2 girls showing congenital defects and a history of maternal rubella in early pregnancy (Kirman 1955) contracted rubella in 1954 : 1 of them had a sister, four years younger, similarly deformed.
It has been shown that intra-uterine infection with rubella, though potentially destructive to various organs, does not result in a generalised disease of the foetus
(Tondury 1953). Summary An outbreak of rubella observed in 1952-53 in the Falkland Islands differed in several ways from the usual
pattern. It attacked people over a wide range of age, and in the age-group 15-45 many more females than males were affected. Other outstanding features were : relapses ; presumed second attacks ; many subclinical infections ; and an unusually high incidence of a variety of rheumatic afflictions. Enlargement of lymph-nodes was found to persist for many months. Pregnancies starting during the epidemic resulted in a number of congenital defects and other sequels similar to those reported elsewhere.
66 I wish to thank H.M. Colonial Government of the Falkland Islands and the Senior Medical Officer, Port Stanley, for facilities for studying the epidemic, and Dr. J. H. Edwards
stained by Pappenheim’s panoptic method and differentiated by Schilling’s method, 100 cells being counted. Absolute numbers were calculated throughout. In judging whether the white cells were increased or decreased the standards of Whitby and Britton (1953) were used :
for his help during and after my stay in the Colony. I am also grateful to Dr. B. Kirman for his support and advice. REFERENCES
Bamatter, F. (1949) Cited by Töndury. (1951) Cited by Töndury. Christensen, P. E. (1952) Acta med. scand. 144, 313, 430. Clayton-Jones, E. (1947) Lancet, i, 56. Copeman, W. S. C. (1954) Textbook of Rheumatism. London. Dods, L. (1951) In Parsons’s Modern Trends in Pædiatrics. London. Heasman, H. W. (1955) J. R. stat. Soc. 17, 64. Isaacs, A., Edney, M., Donnelley, M., Ingram, M. W. (1950) Lancet, i, 64. Kirman, B. (1955) Ibid, ii, 1113. Lancet (1952) i, 1057, 1073. Lundström, R. (1952) Acta pœdiat., Stockh. 41, 583. Medical and Sanitary Reports, Port Stanley, 1906-1953. Paterson, D., Moncrieff, A. (1949) Diseases of Children. London; -
vol. ii.
Rundle, C. (1929) In Ker’s Infectious Diseases. London. Schick, B. (1949) Acta pœdiat., scand. 38, 563. Swan, C. (1948) Lancet, i, 744. Töndury, G. (1953) Études néo-natales. Zurich ; vol. ii, p. 2. Wesselboeft, C. (1951) In Banks’s Infectious Fevers. London.
THE BLOOD PICTURE IN RUBELLA ITS PLACE IN DIAGNOSIS
M.D.
F. K. M. HILLENBRAND Rostock, M.B. Berlin, L.A.H. Dubl.
LATE MEDICAL
OFFICER,
FALKLAND ISLANDS
RUBELLA in the first three months of pregnancy may
produce heart lesions, cataract (Gregg 1941), deafness, and other deformities in the offspring (Swan et al. 1943, Swan 1948). Women at this stage of pregnancy must therefore be protected from infection ; and since, owing to the long incubation period and high infectivity, segregation is seldom effective, passive immunisation may be required (British Medical Journal 1956). The usefulness of such immunisation will depend on its being undertaken in good time ; and for this reason early diagnosis of rubella can be very important. Diagnosis by clinical methods alone is not infrequently difficult.
The rash may resemble those of mild scarlet
fever, infectious mononucleosis, and abortive measles. As it may be of very short duration, it may pass unnoticed ; or there may be no rash at all. Subclinical rubella without rash is
epidemic family. an
or
a
likely to be missed unless there is concurrent typical case in the same
As an aid to diagnosis, the blood-cell changes in rubella have been considered helpful (Whitby and Britton 1953) ; but there has been no general agreement on their’difference from those seen in measles. My interest in them was aroused many years ago when I examined the blood of patients with persistent enlargement of postauricular and occipital lymph-nodes following rubella and found that it regularly showed plasmacytosis. Accordingly, when an opportunity arose during the Falkland Islands epidemic of rubella in 1952-53 I made routine white-cell and differential counts in cases both clinical and subclinical, including, of course, women who had become pregnant during the outbreak. The absence of any other infectious fever on the island at the time, and the accessibility of the cases, made conditions favourable for such observations. On my return to England these studies were extended. At that time (August, 1954, to September, 1955) there was no major epidemic in the London area, and all observations had to be made on patients in hospitalmostly children. The follow-up period was shorter, but, on the other hand, considerably larger numbers could be examined at early stages of infection. Methods
Most of the white-cell counts noon, the time being noted.
were
The
made in the foreblood-films were
"
"
White cells were classified as increased " or decreased " according to whether they were above or below Whitby and Britton’s maximum and minimum for the total age. Comparable observations were made in London on infections sometimes confused with rubella. Results
Rubella The initial neutropenia and lymphopenia described by Carroll (1934) and Hynes (1940) was seen in rather less than half the cases, both in London and in the Falkland Islands, but lasted longer than these authors report. At later stages lymphocytosis was infrequent and polymorphonuclear leucocytosis almost absent
(table i). In clinical and subclinical infections alike, the outstanding feature was the regular occurrence of Tiirk and plasma cells, which in uncomplicated rubella were invariably present up to the tenth day, and usually persisted for many months. The maximum percentages of these cells observed in single specimens were : Falkland Islands: 14 8
(third day) (Turk
and
plasma cells)
(sixth day). London 19
(fourth day) (Turk
and
plasma cells) (Carroll
1934). The increase in monocytes noted by Glanzmann (1929), Carroll (1934), and MacBryde and Charles (1935) was confirmed, the percentage amounting to 18 (London) and 16 (Falkland Islands) on several occasions. Bilobed monocytes (Whitby and Britton 1953), numerous in both groups, were not registered separately. Next I would draw attention to the degenerate lymphocytes occurring, independently of age, in examples of clinical and subclinical infection from both groups. These large cells, about the size of monocytes, often show an eccentric (sometimes nucleolated) nucleus : the cytoplasm stains clear, pale, and light-blue and may show vacuoles and azure-staining granules. They are quite distinct from large lymphocytes or those deformed during the film-taking or staining ; and they differ also from the abnormal monocytes of infectious mononucleosis. Though found at all stages of rubella infection they are commonly a late feature, their appearance coinciding with the diminution of the Turk and plasma cells though they show no morphological relationship with these. Usually few (Kamerbek 1949) in both London and Falkland Islands specimens, they were sometimes increased (maximum percentages : Falkland Islands 22 fifteenth day, London 16 eleventh day). They have been observed in other conditions (Schilling 1935), but not in infectious mononucleosis. Basophils, inconstant in the London series, were occasionally numerous at late stages, up to a maximum of 420 per c.mm. in the Falkland Islands group. A slight initial increase in eosinophils (Glanzmann 1929, Carroll 1934, -1facBryde and Charles 1935) was also observed in the Falkland Islands group. Metamyelocytes were found in insignificant proportions and were almost confined to blood from infants (MacBryde and Charles 1935).