Part 100

COURSE AND SYMPTOMS.--The course of the disease is susceptible of a division into three stages--a period of incubation, of invasion, and of actual attack.

The stage of incubation extends over a period variously estimated as from seven to fourteen days. It is marked by no symptoms, though sometimes a history of impaired appetite and digestion, irregular bowels, and languor during the last two or three days may be obtained.

The period of invasion is short, lasting only twelve, or at the most twenty-four, hours. The patient is pale and languid, has slight rigors, pains in the breast and head, and loss of appetite; later, local pain in the parotid region on moving the jaws or on taking acid liquids into the mouth. The surface temperature increases from hour to hour, and just before the glandular swelling appears it reaches 100° or 101° F. In some cases the invasion is characterized by the same train of symptoms that ushers in the acute exanthemata, such as repeated vomiting, diarrhoea, restlessness and anxiety, a disposition to syncope, and, in very irritable children, convulsions. Contrasted with this violent invasion other cases are met with, in which there are no prodromes whatever except a gradual rise in temperature, imperceptible without the use of the thermometer.

The first symptom of actual attack is a peculiar slight stitch-like pain in one parotid region, usually the left. This radiates toward the ear of the affected side, and is increased by movements of the jaw, as in {622} chewing or talking, and by external pressure. The pain rapidly grows more intense, and soon becomes associated with swelling. The tumor first appears in the depression between the mastoid process and the ramus of the jaw, which it fills up, and at the same time thrusts outward the lobe of the ear. As the gland alone is swollen at first, the tumor has the outline of a triangle, with the apex directed downward and forward; soon, however, the connective tissue becomes oedematous and the swelling is greatly extended, involving the cheeks and neck, in the latter region, in severe cases, running forward as far as the median line, downward nearly to the shoulder and backward toward the spine. The most prominent point is directly in front of the ear. The oedema also extends internally, involving the pharynx, the tonsils, and sometimes even the larynx. The skin covering the tumor is either perfectly natural in color or slightly reddened. The central portion is firm and elastic to the touch, the periphery doughy, and pressure here often produces pitting. There is but moderate tenderness. The swelling reaches its height in three days, remains stationary for two days longer, and then rapidly declines, the oedema first disappearing and afterward the glandular swelling, the process of resolution occupying four or five days and being attended with a slight desquamation of the cuticle.

While mumps almost uniformly begins on one side, both glands are, as a rule, affected during the attack. The second tumor begins to develop twenty-four to forty-eight hours after the first, though its appearance may be delayed much longer, even until resolution has begun on the side primarily affected. As the course of the inflammation is similar in both parotids, the whole duration of the attack will depend on the time of involvement of the second gland.

Among the other symptoms an alteration of expression is prominent. At first, the head is inclined toward the affected side; later, when both glands are involved, it is held perfectly erect, and, as the slightest movement increases the pain, it is maintained stiffly in this position. The swelling of the cheeks prevents all play of the features, and this, combined with widely-open, staring eyes and increased thickness of the neck, gives the patient a stupid, almost idiotic, expression. The swelling of the neck is sometimes so great that its diameter exceeds that of the head, and the shoulders, neck, and head, viewed together, have the outline of a truncated pyramid.

As any movement of the lower jaw greatly augments the suffering, the mouth is kept closed, often so tightly that it is impossible to see more than the tip of the tongue. All efforts at mastication are suspended, and deglutition is so painful, especially when the tonsils become enlarged, that the sufferer bears the pangs of hunger and thirst rather than endure the agony entailed in satisfying his wants. The act of speaking even augments the pain; the voice, when heard, has a nasal tone. The acuteness of hearing is impaired, there are singing noises and shooting pains in the ears, headache, and sometimes, in extreme cases, symptoms of cerebral hyperæmia due to pressure upon the cervical veins.

The tongue is heavily coated, the mouth is either dry or there is an increased flow of saliva, and the fluid dribbling from the mouth adds another element to the idiotic expression already referred to. There is loss of appetite, increased thirst, occasionally vomiting, and commonly {623} constipation. The temperature is elevated and the pulse increased in frequency, both to a moderate degree. The respiration is unaffected, except when the oedema has invaded the submucous connective tissue of the larynx; then the movements are increased in frequency and difficult.

Throughout the attack the pain, unless intensified by some extraneous influence, as pressure or the act of speaking or swallowing, is only moderately severe. In ordinary cases the patient rests quietly and sleep is undisturbed, unless the tonsils are enlarged, when it is liable to interruption from loud snoring. When the attack is severe and in nervous, excitable children there is restlessness, sleeplessness, and slight delirium at night.

The general symptoms keep pace with the local in their increase, but they commence to subside before, beginning to disappear while the swelling remains stationary. As soon as resolution sets in the general and local improvement are both rapid, and by the end of the week nothing is left but a trifling weakness and pallor, which disappear in a few days more, leaving the patient perfectly well.

Besides the ordinary symptoms, mumps in certain instances shows a peculiar tendency to metastasis, or secondary involvement, of the testicle and scrotum in males, and the mammæ, vulva, and ovaries in females. This metastasis occurs much more frequently in males than in females, and is usually met with in pubescents and adults, being very rare either in childhood or old age. It generally begins six or eight days after the appearance of the parotid tumor. The latter, as a rule, subsides on the occurrence of any of these metastatic affections, though occasionally the two run a simultaneous course. This occurrence, together with the fact of the secondary inflammation appearing at the date on which the parotitis naturally begins to disappear, tends to support Niemeyer's view, that the two affections are in reality due to the same cause, and that no true transference of inflammation takes place from one point to the other. Occasionally, the parotitis disappears a variable time before the onset of the metastatic affection; then the interval is marked by grave symptoms of depression and cerebral disturbance, but there are no proofs of actual meningeal involvement. In these cases there is, at times, an excessive elevation of temperature, which may account for the brain symptoms.

The most constant secondary manifestation is swelling of the testicle proper, or true orchitis; less frequently there is epididymitis, and with it acute hydrocele and oedema of the scrotum. The orchitis in most cases is unilateral, the right testicle being affected, just the opposite to the parotids, of which the left is the one first involved. When the orchitis is double, both testicles do not become swollen at once, the one preceding the other by an interval of several days.

The course of the orchitis is very similar to that of the mumps, the inflammation increasing gradually for from three to six days, then undergoing rapid resolution, the gland returning to its normal condition by the end of two weeks.

The local symptoms are swelling, the testicle being enlarged to two or three times its natural size, dull pain, and moderate tenderness, while in very severe cases there is burning on micturition and a purulent discharge from the urethra. The spermatic cord does not sympathize in the {624} inflammation, and neither the swelling, pain, nor tenderness is so great as in specific orchitis.

The general symptoms are confined to a moderate elevation of temperature and increase in the frequency of the pulse, thirst, and loss of appetite. This fever is separated from that of the parotitis by an interval of two or three days.

The course of bilateral orchitis is longer by forty-eight hours than that of the unilateral form, and the attending fever is more intense.

The rapid return of the testicle to its natural size and shape shows that, as in the parotid glands, the inflammation does not extend beyond the stage of serous exudation.

THE DIAGNOSIS of mumps is easy after the disease is sufficiently developed to produce the characteristic alterations in the facial expression. In the earlier stages the position of the swelling, immediately beneath and in front of the ear, its triangular shape, and the elevation and outward displacement of the lobe of the ear of the affected side, distinguish it from the enlargement of the cervical lymph-glands so liable to occur in strumous subjects. The acute onset and course of mumps are the points of distinction between it and morbid growths, or the very rare condition of chronic hypertrophy of the parotid gland. The metastatic orchitis cannot be mistaken for gonorrhoeal orchitis if the least care is taken to investigate the history in either case.

THE PROGNOSIS is extremely favorable, there being no record of a fatal case of uncomplicated mumps. Suppuration may occur, but it is an exceedingly rare event. In scrofulous children the course may be protracted for several weeks, and in them resolution is occasionally imperfect, a degree of enlargement and induration of one or both parotids remaining for some time.

Metastatic orchitis, as a rule, leaves the testicle in a normal condition, but, according to Vogel, in some epidemics complete atrophy results.

Dogmy reports an epidemic which raged in a garrison of Mount Louis in January, 1828. Of sixty-nine bilateral and eighteen unilateral cases of parotitis, metastasis to both testicles occurred in four cases, all of which resulted in atrophy of the affected testicle.

THE TREATMENT is simple. The patient should be kept in a uniform temperature, confined to one room, or, better still, to bed, until resolution is well established. While the difficulty in swallowing and fever continue the food should consist of milk and beef-tea; later, other nutritious articles of diet may be added as the appetite demands. Water, iced carbonic acid water, or lemonade may be allowed as freely as the patient will take them, to allay the thirst. A daily evacuation of the bowels must be secured by the use of saline laxatives. During the early stage, if the fever be high, tincture of aconite-root should be cautiously administered; afterward liquor potassii citratis will sufficiently fill the indications for a febrifuge. Tonics are required during the decline of the disease; of this class of remedies, syrup of the iodide of iron, bitter wine of iron, and ferrated elixir of cinchona are most useful.

Special symptoms may demand attention. For example, headache and delirium should be relieved by hot mustard foot-baths and moist cold to the forehead; difficult deglutition from enlargement of the tonsils, by the frequent swallowing of bits of ice, or, if possible, by the application of {625} astringent lotions, as tannic acid and glycerine (one drachm to the ounce); sleeplessness, by the administration of bromide of potassium, with or without small doses of hydrate of chloral in children and of some preparation of opium in adults.

In the way of local treatment the best results and greatest relief to suffering will be obtained by gently rubbing the swollen glands with a mixture of tincture of opium and sweet oil (one drachm to the ounce), three times daily, and in the mean while keeping the parts enveloped with a moderately thick layer of cotton wadding covered by oiled silk. Water dressings or light poultices may be used with advantage. When resolution begins a more stimulating lotion will hasten the disappearance of the swelling.

In the exceptional instances in which the skin covering the tumor becomes tense and red, and suppuration is threatened, two or three leeches may be applied behind the ear of the affected side. When suppuration has actually taken place the abscess should be immediately opened to prevent further destruction of the gland-tissue and perforation into the external auditory meatus.

If, particularly in strumous subjects, resolution be incomplete and glandular enlargement and induration remain after the cessation of the acute symptoms, cod-liver oil and iodide of iron are demanded for internal administration and the compound ointment of iodine for external application. It is well to dilute the latter sufficiently to prevent its causing irritation of the skin, and to apply it twice daily.

When metastasis occurs, the return of fever calls for the same general treatment as in the early stage of parotitis. In addition, an emetic should be given, as this often cuts short the fever or causes it to disappear more rapidly. The patient must be kept at perfect rest in bed, with the scrotum elevated by a cushion and covered with warm anodyne lotions. Salines must be administered sufficiently often to secure regular and free action of the bowels.

When the mammæ or ovaries are secondarily attacked, the seat for local treatment is of course different, but in all other respects the management must be the same.