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Chapter XIII

Communicable Diseases, Table of Contents

CHAPTER XIII

MUMPS

STATISTICAL CONSIDERATIONS

Table 73 shows that 230,356 cases of mumps were admitted to hospital for the total Army during the World War, giving a ratio of 55.80 per 1,000 strength. Among white enlisted men there were 179,948 primary admissions, with a ratio of 49.99 per 1,000 per annum; colored enlisted men had 38,619 primary admissions, with an admission ratio of 134.75 per 1,000 strength, three times that for the white troops.

During the World War 43 white enlisted men and 7 colored enlisted men were discharged from the service on account of disability following mumps. The discharge ratios per 1,000 strength were 0.01 and 0.02, respectively. The discharge ratio for colored enlisted men, was twice that for the white. In explanation of these discharges, it is most probable that there were factors causing disability in these cases other than mumps.

Because of the nonfatal character of mumps, its great importance to the Army is shown more particularly by the number of days lost from duty. For the total Army 3,884,147 days were lost from duty on account of this disease, giving a noneffective ratio of 2.58 per 1,000 strength. From a standpoint of noneffectiveness, mumps stood third on the list of important diseases for the Army; therefore, when compared with other diseases, and from a standpoint of noneffectiveness alone, mumps was of great importance.

aUnless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.-Ed.


452

TABLE 73.-Mumps. Admissions, discharges for disability, and days lost, by countries of occurrence, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919

 


Admissions

Discharges for disability

Days lost

Total mean annual strengths

Absolute numbers

Ratio per 1,000 strength

Absolute numbers

Ratio per 1,000 strength

Absolute numbers

Noneffective ratios per 1,000 strength

Total officers and enlisted men, including native troops

4,128,479

230,356

55.80

52

0.01

3,884,147

2.58

Total officers and enlisted men, American troops

4,092,457

229,680

56.12

52

.01

3,874,722

2.59

Total officers

206,382

2,475

11.99

---

---

37,713

.50

Total enlisted American troops:

 

 

 

 

 

 

 

    

White

3,599,527

179,948

49.99

43

.01

3,020,897

2.30

    

Colored

286,548

38,619

134.75

7

.02

656,383

6.28

    

Color not stated

---

8,638

---

2

---

159,729

---

         

Total

3,886,075

227,205

58.47

52

.01

3,837,009

2.71

Total native troops (enlisted)

36,022

676

18.76

---

---

9,425

.72

Total Army in United States including Alaska:

 

 

 

 

 

 

 

    

Officers

124,266

1,648

13.26

---

---

24,447

.54

    

White enlisted

1,965,297

117,498

59.78

35

.02

1,877,193

2.62

     

Colored enlisted

145,826

22,482

154.15

7

.05

374,904

7.04

         

Total enlisted men

2,111,123

139,980

66.31

42

.02

2,252,097

2.92

         

Total officers and men

2,235,389

141,628

63.36

42

.02

2,276,544

2.79

U.S. Army in Europe, excluding Russia:

 

 

 

 

 

 

 

    

Officers

73,728

773

10.48

---

---

12,531

.47

    

White enlisted

1,469,656

57,554

39.16

6

0

1,063,930

1.98

    

Colored enlisted

122,412

15,023

122.72

---

---

267,234

5.98

    

Color not stated

---

8,503

---

1

---

157,527

---

         

Total enlisted

1,592,068

81,080

50.93

7

0

1,488,691

2.56

         

Total officers and men

1,665,796

81,853

49.14

7

0

1,501,222

2.47

Officers other countries

8,388

54

6.44

---

---

735

.24

U.S. Army in Philippine Islands:

 

 

 

 

 

 

 

    

White enlisted

16,995

356

20.95

---

---

5,938

.96

    

Colored enlisted

4,456

65

14.59

---

---

1,025

.63

         

Total enlisted

21,451

421

19.63

---

---

6,963

.89

U.S. Army in Hawaii:

 

 

 

 

 

 

 

    

White enlisted

16,161

228

14.11

1

.06

4,482

.76

    

Colored

3,319

107

32.24

---

---

1,623

1.34

         

Total

19,480

335

17.20

1

.05

6,105

.86

U.S. Army in Panama: (White enlisted)

19,688

82

4.17

---

---

1,324

.18

U.S. Army in other countries and not stated:

 

 

 

 

 

 

 

    

White enlisted

(a)

1,850

---

---

---

32,239

---

    

Colored enlisted

(a)

107

---

---

---

2,220

---

    

Color not stated

---

107

---

---

---

2,004

---

         

Total

14,232

2,064

145.06

---

---

36,463

7.02

Transports:

 

 

 

 

 

 

 

    

White enlisted

97,498

2,380

24.41

1

.01

35,791

1.01

    

Colored enlisted

10,535

835

79.26

---

---

9,377

2.44

    

Color not stated

---

28

---

1

---

198

---

         

Total

108,033

3,243

30.02

2

.02

45,366

1.15

Native troops enlisted:

 

 

 

 

 

 

 

    

Philippine Scouts

18,576

504

27.13

---

---

7,330

1.08

    

Hawaiians

5,615

43

7.66

---

---

465

.23

    

Porto Ricans

11,831

129

10.90

---

---

1,630

.38

aSeparate strength of white and colored not available.

Mumps caused more noneffectiveness among colored troops than among white troops; there were 3,020,897 days lost from duty among 3,599,527 white enlisted men and 656,383 days lost among 286,548 colored enlisted men. These figures give a ratio of 2.30 for white enlisted men and 6.28 for colored per 1,000 strength. Thus the noneffectiveness was approximately three times greater among colored troops than among white. Mumps was widely distributed over the United States and was reported from all stations, as is shown in Table 74. The camps that had the largest occurrence among white enlisted men, were, in the order named: Camp Beauregard, La.; Camp Wheeler, Ga.; Camp Bowie, Tex.; and Camp Travis, Tex. The admission ratios per 1,000 strength for the camps mentioned were all above 213 per 1,000 strength. The camps reporting the smallest number of total cases were Camp Syracuse, N. Y.: Camp Forrest, Ga.; and Camp Cody, N. Mex. The first two camps were small, with a mean strength of about 10,000 troops. Camp Cody, N. Mex., though a camp of average size, reported only 333 cases, giving a ratio of 14.71 per 1,000 strength. The average number of cases per camp in the United States was 2,650 and the average ratio per 1,000 strength was 81.40. It is seen that


453

of the 39 camps shown in Table 74, 16 reported cases above the average in number and 13 had a primary admission ratio above the average among total troops.

TABLE 74.-Mumps. Admissions, by camps of occurrence, white and colored enlisted men,United States Army, April 1, 1917, to December 31, 1919. Absolute numbers

Camps

Average strength for period


Primary admissions


White enlisted men

Colored enlisted men

Total


Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Camp Beauregard, La.

20,625

4,725

233.88

81

191.94

4,806

233.01

Camp Bowie, Tex.

26,193

5,387

213.43

104

109.13

5,491

209.63

Camp Cody, N. Mex.

22,636

333

14.71

---

---

333

14.71

Camp Custer, Mich.

37,631

1,676

46.20

141

103.98

1,817

48.28

Camp Devens, Mass.

47,921

722

15.80

557

250.90

1,279

26.68

Camp Dix., N.J.

49,786

849

18.88

408

84.74

1,257

25.24

Camp Dodge, Iowa

39,032

2,616

78.73

1,476

254.22

4,092

104.83

Camp Doniphan, Okla.

26,747

1,377

51.48

---

---

1,377

51.48

Camp Eustis, Va.

6,780

306

48.39

83

182.02

389

57.37

Camp Forrest, Ga.

8,980

40

4.45

---

---

40

4.45

Camp Fremont, Calif.

15,414

455

29.52

---

---

455

29.52

Camp Funston,  Kans.

56,222

5,874

117.35

1,092

177.05

6,966

123.90

Camp Gordon, Ga.

44,871

2,752

72.33

2,364

346.50

5,116

114.01

Camp Grant, Ill.

49,256

1,390

32.85

1,163

167.61

2,553

51.83

Camp Greene, N.C.

29,710

2,423

92.55

387

109.66

2,810

94.58

Camp Greenleaf, Ga.

11,959

243

20.32

---

---

243

20.32

Camp Hancock, Ga.

37,994

849

23.32

238

149.22

1,087

28.61

Camp Humphreys, Va.

12,836

344

35.27

613

198.78

957

74.55

Camp Jackson, S.C.

42,011

4,183

113.42

1,102

214.86

5,285

125.80

Camp Johnston, Fla.

22,267

1,162

58.52

412

170.82

1,574

70.68

Camp Kearny, Calif.

25,472

1,752

68.78

---

---

1,752

68.78

Camp Lee, Va.

57,635

3,388

66.43

875

131.96

4,263

73.96

Camp Lewis, Wash.

47,792

4,676

98.93

26

49.53

4,702

98.38

Camp Logan, Tex.

27,734

416

15.60

90

84.19

506

18.24

Camp MacArthur, Tex.

25,271

1,076

44.25

25

26.23

1,101

43.56

Camp McClellan, Ala.

28,664

723

27.25

276

129.58

999

34.85

Camp Meade, Md.

50,033

672

16.01

503

62.50

1,175

23.48

Camp Mills, N.Y.

24,197

1,079

47.04

214

170.26

1,293

53.43

Camp Pike, Ark.

49,587

5,848

143.09

1,456

167.02

7,304

147.29

Camp Sevier, S.C.

27,786

5,245

200.34

125

77.84

5,370

193.26

Camp Shelby, Miss.

30,432

2,637

91.63

378

228.81

3,015

99.07

Camp Sheridan, Ala.

26,507

977

38.13

43

48.59

1,020

38.48

Camp Sherman, Ohio

42,750

2,224

60.17

912

157.65

3,136

73.35

Camp Syracuse, N.Y.

3,367

4

1.19

---

---

4

1.19

Camp Taylor, Ky.

46,962

2,880

67.64

338

77.06

3,218

68.52

Camp Travis, Tex.

44,264

7,998

213.22

1,073

163.24

9,071

204.92

Camp Upton, L. I., N. Y.

44,871

608

15.12

1,009

216.11

1,617

36.03

Camp Wadsworth, S.C.

31,809

415

13.77

88

52.60

503

15.81

Camp Wheeler, Ga.

25,726

5,144

215.13

248

136.64

5,392

209.59

Others

339

---

---

10

29.50

10

29.50

     


     Total

1,270,069

85,468

73.71

17,910

161.93

103,378

81.40

OCCURRENCE IN THE UNITED STATES

The seasonal occurrence of disease is well shown by mumps in the Army in the United States during the World War. The average admission ratio for mumps in the United States was 66.30 per 1,000 per annum. (Table 75.) In October, 1917, the admission ratios for white troops increased, reaching the maximum in February of the year following. Reviewing the occurrence among white troops only, we find that in October, 1917, 1,683 cases were reported as primary admissions. The ratio was 19.57 per 1,000 strength. In November of this year, 4,179 cases were reported as primary admissions, giving a ratio of 47.25 per 1,000 per annum. The following month, December, both the number of cases and the ratio were more than doubled. There were 10,368 primary admissions, giving a ratio of 110.19 per 1,000 strength. In January, 1918, again these numbers were practically doubled. There were 19,460 primary admissions and the ratio per 1,000 strength was 212.98. In February, 1918, although there was an increase, this increase was not in the same proportion as had occurred during the several preceding months. There were 21,092 primary


454

admissions, with a ratio of 231.14 per 1,000 strength. From this date the number of cases and the ratio decreased until the second seasonal occurrence, which occurred in the following November. The seasonal occurrence commencing in 1918 did not reach the same magnitude in the United States as did the seasonal occurrence which started in 1917. The seasonal occurrence of 1918 began one month later, with 2,729 primary admissions, giving an admission ratio of 26.09 per 1,000 strength. In December, twice as many cases were reported with more than double the admission ratio-that is, 4,718 primary admissions and a ratio of 60.16 per 1,000 per annum. Although there was an increase in January, 1919, it was not in the same geometrical proportion as had occurred in the previous year. For this month, 6,027 primary admissions were reported with a ratio of 107.48 per 1,000 strength. In February, 1919, the occurrence of mumps began to decrease, and continued to decrease to the end of the war. There was no seasonal occurrence in the latter part of 1919.

TABLE 75.-Mumps. Admissions, by months, white and colored enlisted men, United States Army, United States and Europe, April 1, 1917, to December 31, 1919

Year and month


White enlisted men


United States

Europe

Mean strength


Admissions

Deaths

Mean strength

Admissions

Deaths

Absolute numbers


Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

1917

 

 

 

 

 

 

 

 

 

 

April

183,758

485

31.67

---

---

---

---

---

---

---

May

245,454

634

30.99

---

---

---

---

---

---

---

June

309,205

771

29.92

---

---

a13,420

a9

8.05

---

---

July

458,817

754

19.72

---

---

28,821

256

106.58

---

---

August

562,714

578

12.33

---

---

50,882

335

79.01

---

---

September

776,466

731

11.30

---

---

70,266

288

49.18

---

---

October

1,032,244

1,683

19.57

---

---

92,139

258

33.60

---

---

November

1,061,422

4,179

47.25

1

.01

123,429

708

68.83

---

---

December

1,129,065

10,368

110.19

13

.14

160,178

1,478

110.73

1

.07

     
     Total 1917

479,929

20,183

42.05

14

.03

44,928

3,332

74.16

1

.02

1918

 

 

 

 

 

 

 

 

 

 

January

1,096,434

19,460

212.98

17

.19

193,264

2,693

167.22

1

.06

February

1,095,039

21,092

231.14

12

.13

223,130

3,087

166.02

2

.11

March

1,129,223

13,950

148.24

11

.12

283,268

3,234

137.00

---

---

April

1,168,558

7,181

73.74

4

.04

388,048

1,626

50.28

1

.03

May

1,197,757

4,136

41.44

1

.01

587,240

1,579

32.27

1

.02

June

1,303,746

2,366

21.78

---

---

796,427

1,293

19.48

2

.03

July

1,328,513

2,211

19.97

1

.01

1,063,192

1,264

14.27

1

.01

August

1,284,247

1,883

17.60

---

---

1,266,592

1,587

15.04

3

.03

September

1,321,440

1,872

17.00

6

.05

1,527,793

3,018

23.70

8

.06

October

1,343,933

1,817

16.23

5

.04

1,635,321

4,347

31.90

10

.07

November

1,255,195

2,729

26.09

2

.02

1,682,836

6,477

46.19

3

.02

December

941,219

4,718

60.16

11

.14

1,591,962

8,864

66.82

5

.04


     Total 1918

1,205,442

83,415

69.20

70

.06

936,589

39,069

41.71

37

.04

1919

 

 

 

 

 

 

 

 

 

 

January

672,937

6,027

107.48

4

.07

1,488,683

6,399

51.58

3

.02

February

471,815

3,972

101.02

---

---

1,310,083

3,835

35.13

1

.01

March

406,839

2,254

66.48

1

.03

1,115,693

2,648

28.48

1

.01

April

339,836

843

29.77

---

---

853,425

1,220

17.15

---

---

May

291,810

344

14.15

---

---

569,842

539

11.35

---

---

June

246,903

172

8.36

---

---

271,633

198

8.75

---

---

July

215,104

56

3.12

---

---

111,634

153

16.45

---

---

August

156,791

56

4.29

---

---

48,006

94

23.49

---

---

September

149,360

62

4.98

---

---

30,315

24

9.50

---

---

October

139,877

31

2.66

---

---

21,055

3

1.71

---

---

November

132,403

24

2.18

---

---

18,920

1

.63

---

---

December

135,441

52

4.61

---

---

18,379

2

1.31

---

---


     Total 1919

279,926

13,893

49.63

5

.02

488,139

15,116

30.97

5

.01

Month not stated

---

7

---

---

---

---

37

---

---

---


     Total for period

1,965,297

117,498

59.78

89

.05

1,469,656

57,554

39.16

43

.03

aIncludes April and May.


455

TABLE 75.-Mumps. Admission, by months, white and colored enlisted men, United States Army, United States and Europe, April 1, 1917, to December 31, 1919-Continued

Year and month

Colored enlisted men


United States

Europe

Mean strength


Admissions

Deaths

Mean strength

Admissions

Deaths

Absolute numbers


Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

1917

 

 

 

 

 

 

 

 

 

 

April

4,870

10

24.63

1

2.46

---

---

---

---

---

May

5,826

4

8.23

---

---

---

---

---

---

---

June

5,171

4

9.28

---

---

---

---

---

---

---

July

6,675

11

19.78

---

---

---

---

---

---

---

August

8,519

5

7.04

---

---

---

---

---

---

---

September

9,409

14

17.86

---

---

---

---

---

---

---

October

21,795

29

15.97

---

---

935

1

12.82

---

---

November

39,225

82

25.09

---

---

2,392

57

286.43

---

---

December

36,851

330

107.46

---

---

5,346

357

800.45

1

2.24

     
     Total 1917

11,529

489

42.41

1

.09

723

415

574.00

1

1.38

1918

 

 

 

 

 

 

 

 

 

 

January

50,705

1,870

422.60

3

.71

8,673

1,235

1,708,16

1

1.38

February

49,955

2,406

577.95

1

.24

9,664

923

1,146,58

---

---

March

54,814

1,351

295.75

5

1.09

11,541

149

154.89

---

---

April

59,015

1,257

255.60

1

.20

12,667

287

271.78

---

---

May

87,650

2,060

282.04

3

.41

28,279

593

251.59

---

---

June

89,305

1,859

249.80

2

.27

33,208

622

224.79

1

.36

July

124,976

1,047

100.53

1

.10

47,171

942

239.63

2

.51

August

168,422

931

66.33

2

.14

78,734

1,053

160.49

2

.31

September

164,846

1,080

78.62

3

.22

91,270

1,195

157.11

4

.53

October

182,706

1,486

97.60

1

.07

138,827

1,892

163.54

3

.26

November

150,587

2,094

166.87

1

.08

148,679

2,972

239.87

2

.16

December

104,140

2,094

241.30

1

.12

148,372

1,429

115.58

1

.08


     Total 1918

107,260

19,535

182.13

24

.22

63,090

13,292

210.68

16

.25

1919

 

 

 

 

 

 

 

 

 

 

January

68,337

1,357

238.32

---

---

140,396

546

46.67

1

.09

February

66,104

766

139.05

2

.36

131,219

271

24.78

1

.09

March

44,634

194

52.15

---

---

123,152

232

22.61

---

---

April

29,824

93

37.42

---

---

119,801

120

12.02

---

---

May

20,780

20

11.55

---

---

108,650

112

12.37

---

---

June

18,562

16

10.34

---

---

64,166

32

5.98

---

---

July

20,058

8

4.79

---

---

12,508

1

.96

---

---

August

18,013

---

---

---

---

1,741

---

---

---

---

September

11,322

1

1.06

---

---

1,287

---

---

---

---

October

9,084

---

---

---

---

185

---

---

---

---

November

8,792

2

2.73

---

---

83

---

---

---

---

December

8,935

1

1.34

---

---

---

---

---

---

---


     Total

27,037

2,458

90.91

2

.07

58,599

1,314

22.42

2

.03

Month not stated

---

---

---

---

---

---

2

---

---

---


     Total for period

145,826

22,482

154.15

27

.19

122,412

15,023

122.72

19

.16

The above review of occurrence for white enlisted men in the United States applies, in general, to the occurrence of mumps among the colored enlisted men. Mumps was more common among colored enlisted men, but the ratios during the latter part of 1917 were lower than those for white enlisted men in the respective months; however, the number of colored troops in the Army at that time was small. By January, 1918, the number of colored troops had greatly increased. The mean aggregate strength for 1917 was 11,529; during 1918, the mean aggregate strength was 107,260. Commencing in January, 1918, the occurrence of mumps among colored enlisted men was greater than among white enlisted men. This occurrence continued until the spring of 1919. The highest ratio for colored enlisted men was in February, 1918, which was 577.95 per 1,000 per annum. From this date there was a decrease in the admission ratio until


456

the following October. As in the case of white enlisted men, the second seasonal occurrence, which commenced in October, 1918, although greater among white enlisted men, did not reach the magnitude of the preceding year. The largest number of cases of mumps reported among colored enlisted men for any one month was in February, 1918. There were 2,406 primary admissions in the United States for that month.

From all points of view mumps was more important among colored than among white troops. As has been stated above, the admission, discharge, and noneffective ratios were higher among the former. The explanation is believed to lie in the fact that a larger proportion of colored troops was drafted from rural districts.

It has been shown that the occurrence of mumps in the Army in the United States was a matter of serious concern during mobilization. No men were enlisted in the Army during the first two months of 1919 and comparatively few during the early spring. The admission rate, as shown by Table 75, was on the decline at this time, and much below that of the corresponding months of the preceding year. Large numbers of troops were returned to the United States from Europe during the latter months of 1918, and throughout the remaining portion of the winter and spring of 1919. In spite of the fact that large numbers of troops were sent into the larger camps of the United States from January, 1919, to June of that year, the admission ratio for mumps decreased. Therefore, one may say that demobilization had no influence on increasing the ratio of mumps in the camps.

OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES

Table 73 shows the part played by mumps in the Army in Europe during the World War. There was a total of 81,853 primary admissions, with an average annual ratio of 49.14 per 1,000 strength. The highest admission ratio was for colored enlisted men-122.72 per 1,000 strength. As in the United States, colored enlisted men in the American Expeditionary Forces had an admission ratio far greater than did white enlisted men.

The great importance of mumps in the Army overseas, as in the United States, was due to the amount of time lost from duty. Table 73 shows 1,501,222 days lost from this disease in the Army in Europe, giving a noneffective ratio of 2.47 per 1,000 per annum. Again the ratio was greater for colored enlisted men. White enlisted men had a noneffective ratio of 1.98 and colored enlisted men 5.98 per 1,000 per annum.

FACTORS INFLUENCING OCCURRENCE

Many factors enter into the occurrence of mumps. According to Zinsser1 "Our impression from Army experience is that there may be carriers." Radin2 found that 95 per cent of the cases at Camp Wheeler, Ga., occurred during the first two months of service. A physical condition below par was found to be a factor of some predisposing importance, and most of the cases were from rural districts. As mentioned above, mumps had distinct seasonal occurrences. From October to March, in temperate climates, mumps occurred most frequently. Racial influences were marked during the war, and there was a great


457

difference in the occurrence of this disease between white and colored troops, being more common among the latter. It is also probable that crowding had a marked influence on the occurrence of mumps; however, there is no record of any experiments conducted along these lines during the World War period.

One attack of mumps usually confers immunity, but not necessarily so.

SYMPTOMS

The usual onset of mumps was characterized by pain, swelling, and stiffness about the angle of the jaw, made more noticeable by opening the mouth. There was usually malaise and some fever. Like many other diseases where the bacteriology is not known, diagnosis was often very difficult. The leucocyte count was usually normal in the uncomplicated case; sometimes there was leucopenia. When complications occurred, especially orchitis, there was usually a mild leucocytosis. Radin2 summarized the onset of mumps as follows: Onset with no symptoms; onset with gastric disturbances and features suggesting pancreatitis; onset with pancreatitis, orchitis, and urethral discharges; onset with features of acute laryngitis and bronchitis; griplike onset, with fever, headache, malaise, sore throat, and pain in the bones; onset with inguinal pain and backache; and the ordinary onset. The same observer summarized the physical signs of mumps as (1) Hatchcock's sign; (2) pouting and pinkness of the orifices of Steno's duct; (3) swelling of the face in the parotid region; (4) doughy elasticity of the swelling; (5) discharge of secretion from Steno's duct on pressure over the gland externally. This author describes Hatchcock's sign as follows:2 "The sign is tenderness just beyond the angle of the jaw on running the finger toward the angle, under the mandible. If the parotid gland is at all involved, the patient winces with pain. This occurs before any swelling can be made out."

Pouting of the orifice of Steno's duct, with a pink areola on the mucous membrane around the mouth of this duct, has often been described as occurring in mumps. It was reported as occurring only on the side where mumps was present. On inserting a cannula into the mouth of Steno's duct, a fluid will often be ejected if mumps is present. According to Radin, elevation of temperature was not constant, occurring in about 80 per cent of the cases; the range of temperature was most commonly from 99° to 101° F., and duration was from 1 to 24 days, with an average of 4 days. About 24 hours before the onset of a complication, a rise in temperature of from 1° to 3° was noticed. This was usually accompanied by leucocytosis, the polymorphonuclear leucocytes showing a relatively higher percentage in the orchitic than in the uncomplicated cases. In the latter the average was 51.9 per cent; in the orchitic cases the percentage was 60.2. These findings were reversed in the case of lymphocytes; the relative percentage of lymphocytes was 38.4 in uncomplicated and 34.5 in orchitic cases. Vomiting, nausea, and orchitic pain may occur without apparent cause.

The period of incubation is from two to three weeks.3 Radin2 had occasion to report upon this subject in the case of two nurses who were not immune to mumps and placed on duty in a mumps ward. One nurse developed mumps in two weeks and the other in two and a half weeks after exposure.


458

Although mumps may involve the submaxillary, sublingual, and occasionally the lachrymal glands, as well as the parotid glands, the system of recording diagnoses in the Surgeon General's Office does not permit such detailed analysis of cases.

The average duration per case was 16.86 days for the total Army. The average number of days in hospital for mumps in the United States was 16.07 days and in Europe 18.34 days.

PATHOLOGY

But little is known of the pathology of mumps. Although typical mumps involves the parotid glands only, the other salivary glands may be involved. Osler3 is the authority for the statement that the submaxillary and sublingual glands may become swollen, though not always; in a few cases they alone may be attacked. Radin2 reported that a parotid gland was removed by mistake in a case of mumps at Camp Wheeler. After its removal, advantage was taken of the opportunity to observe the structure of the gland. This proved to be normal. Cervical and inguinal adenitis were not infrequent. Orchitis was frequent and redness of the scrotum and epididymitis often occurred. The thymus gland was enlarged in some of Radin's cases. Involvement of the pancreas is supposed to occur in mumps at times, but the exact pathology has not been reported. In mumps meningitis, according to Larkin,4 the meninges showed lymphatic and edematous changes associated with some encephalitis. The spinal fluid was clear in these cases and showed an increased cell count (lymphocytes). The fluid was sterile on bacteriological examination. Larkin reported two cases of mumps meningitis, one with a cell count of about 20 per c. mm. and the other of about 200. Leucocytosis was present in the blood in both cases. The autopsy findings in one of Larkin's cases were as follows:4

*    *    *    *    *    *    *

Autopsy

-At autopsy an early bronchopneumonia, acute diffuse splenitis, and acute parenchymatous nephritis were found. On removing the brain an extensive accumulation of slightly turbid fluid in the cisterna magna was observed. The pia-arachnoid was congested. In many places a perivascular exudate was seen in the form of grayish-yellow lines following the course of the blood vessels. The ventricles were somewhat distended. The fluid was clear. The ependyma was slightly granular. Cultures (aerobic) from the perivascular exudate and from the spinal fluid were negative. Microscopic sections showed the pia-arachnoid densely infiltrated with large and small mononuclear cells. The infiltration was definitely perivascular, but also extended into the areolar tissue and cortex. Similar cells were adherent to the arterial intima.

*    *    *    *    *    *    *

DIAGNOSIS

The ordinary case of mumps is not difficult to diagnose correctly, especially in the presence of an epidemic. There may be cases, however, of a mild type, or cases involving salivary glands other than the parotid gland, where the diagnosis is difficult. The difficulty is increased by the absence of any positive laboratory findings characteristic of mumps. The following clinical signs and symptoms, when present, are pathognomonic: Swelling and tenderness of the salivary gland unilateral or bilaterial; pink and pouting orifice of Steno's duct, discharge of a whitish secretion from the duct upon pressure on the gland


459

involved, or by aspiration; pain or a drawing sensation in the mouth on eating sour food; Hathcock's sign. These findings are usually accompanied by some elevation of temperature and an absence of leucocytosis. A sudden rise of temperature during the course of mumps leads one to suspect complications. These complications are usually accompanied by leucocytosis. Orchitis, with swelling and some tenderness, is the most common complication. It may be bilateral or unilateral, is often accompanied by epididymitis, and may be followed by atrophy. Pain in the ear on the side involved by mumps is not uncommon, and may be due to the swollen parotid gland or to otitis media. Headache, stiffness of the neck muscles, positive Kernig's sign, with sudden increase in temperature and the number of leucocytes, should lead one to suspect meningitis. Confirmation of the diagnosis is made by lumbar puncture. The spinal fluid in mumps meningitis is clear on withdrawal, has an increased cell count, and the fluid is sterile. A fine whitish sediment forms on standing. It is important to differentiate this form of meningitis from other forms, especially the epidemic variety. Larkin gives the following differential diagnostic table:4

 


Mumps

Tuberculosis

Influenza

Appearance on withdrawal

Usually clear

Usually clear

Cloudy.

Appearance after 14 hours

Fine white sediment

 

"Spider web" or "Velum"

Yellowish-white sediment.

Cell count

200

200

500.

Type

Lymphocytes

Lymphocytes

Leucocytes.

Bacteriology

Sterile

B. tuberculosis

B. influenzę.

 


Pneumonia

Streptococcus infection

Epidemic meningitis

Appearance on withdrawal

Turbid

Turbid

Turbid.

Appearance after 14 hours

Heavy purulent

Very purulent

Heavy purulent sediment.

Cell count

500

500

500.

Type

Leucocytes

Leucocytes

Leucocytes.

Bacteriology

Pneumococcus

Streptococcus

Meningococcus.

In submaxillary mumps, differential diagnosis from tonsillitis with cervical adenitis is necessary. In this form there is usually an epidemic of mumps present and the tonsils are normal; the swelling is under the center of the mandible and the salivary gland is involved. On the other hand, the confusing cervical adenitis is of inflammatory origin, not epidemic, and involves the lymphatic gland which is located somewhat farther back than is the salivary gland.

TREATMENT

Experience during the war developed no specific treatment for mumps, and none is known. It was the practice in the Army to isolate all cases and to retain them in quarantine until they were no longer a source of danger. Some hospitals adopted the plan of a 21-day quarantine; others based the quarantine on clinical findings of the individual case-when there was no longer swelling of the salivary glands and no complications were present, the cases were assumed to be free of infection. The presence of a temperature above normal was a counterindication for discharge from hospital; however, a normal temperature did not mean that the patient was not a source of danger.

Cubicled beds and gauze masks were utilized as preventives of spread of the disease in hospitals, in some instances both the patients and the attendants


460

being masked. There is no record of proof, however, that either of these methods was of great value in preventing the spread of mumps. There was a difference of opinion as to the value of this practice. In some instances uncomplicated mumps patients were allowed up and walked to their meals, while others were treated strictly as bed patients. A review of the available literature does not show any great difference in the percentage of complications, especially orchitis, that developed with these two different forms of treatment. Some patients were allowed to get up for meals and to walk about generally, while others were required to remain in bed throughout the course of the disease.2

The ordinary uncomplicated case of mumps required no medication. When medicaments were administered, these varied in different camps. Radin2 reported that orchitis occurred one-third less frequently in patients treated with hexamethylenamin than in those patients who did not receive this form of medication. Orchitis was reported as being less common at Camp Grant where bromides were used.5 Particularly was this true among colored patients. Local applications of heat or cold were used, according to the preference of the patient. Radin used Dobell's gargle, hot applications, and camphorated oil over the swollen salivary glands, and aspirin and bromides internally for pain and nervousness. The early stage of otitis media was most commonly treated by instilling 2 drops of a 2 per cent phenolized glycerin into the external auditory canal, and sometimes into each nostril, twice daily. Where an exudate was present, manifested by bulging of the tympanum, early incision and drainage was the procedure of election. Orchitis was treated by support, and counterirritation in the form of ice bags, ichthyol, or guaicaol carbonate. Rest in bed was the best form of treatment. Mumps meningitis was treated by spinal drainage.

COMPLICATIONS AND SEQUELĘ

Of the 230,356 cases of mumps reported as primary admissions, 40,008 developed complications of some kind. In addition to the above, there were 6,107 cases reported during the World War as concurrent with other diseases. The case mortality among the primary admissions was 0.08 per cent and the case mortality among cases of mumps reported as a concurrent disease was 2.11 per cent. The most common complication in mumps was orchitis. There were 24,337 cases of mumps admitted as primary admissions which developed complications of the genitourinary system, other than venereal; that is, 10.56 per cent. It is presumable that the vast majority of these cases were orchitis, epididymitis, or both. Radin2 reported this complication in 13.91 per cent of the cases at Camp Wheeler, Ga. Orchitis, bilateral, occurred in 102 cases, and unilateral orchitis in 452 cases. Epididymitis alone was reported by Radin in 5 cases. At Camp Shelby Miss., orchitis was reported as a rather frequent complication, and principally among the colored labor battalions. Fort Riley, Kans., reported orchitis present in from 20 per cent to 25 per cent of the cases of mumps in 1917 and in about 5 per cent in 1918. Camp Lewis, Wash., reported epididymitis in 7 per cent, orchitis in 21 per cent, and epididymitis and orchitis in 4 per cent of their cases. Orchitis was a frequent and an annoying complication of mumps in the American Expeditionary Forces. Among the


461

4,500 cases reported by Camp Hospital No. 52, A. E. F., orchitis was the only complication of special note.

Next to orchitis, meningitis may be taken as the most important complication occurring in mumps. Haden6 reported 9 cases of mumps with cerebral complications, at Camp Lee, Va., among 476 cases of mumps. This complication usually occurred late in the disease. In the careful study of more than 5,000 cases of mumps by Radin,2 no mention was made of meningitis. Larkin4 reported 2 cases of mumps meningitis at Camp Taylor, Ky., during the World War, 1 of which died. The autopsy findings in the case which died have been quoted previously in this chapter. Several cases of mumps with signs of meningeal irritation manifested by headache, irritability, restlessness, slight cervical rigidity, suggested Kernig's sign, high temperature, and respiration, were reported at Camp Lewis, Wash. These signs disappeared in from 24 to 48 hours. In 1917, 2 cases of mumps meningitis among 1,800 cases of mumps were reported at Beauregard, La. One case of mumps meningitis was reported from Base Hospital No. 106, A. E. F. in 1917.

Acute pancreatitis in mumps was reported during the war. The monthly sick and wounded reports of the Surgeon General's Office show 26 such cases. Radin2 reported 14 cases at Camp Wheeler, Ga., or 0.31 per cent of the cases. This complication was reported from Camp Lewis, Wash., in 0.2 per cent of the cases.

Among the total primary admissions of 230,356 cases, otitis media was reported in 906, lobar pneumonia in 701, bronchopneumonia in 320, arthritis in 184, acute articular rheumatism in 231, measles in 436, scarlet fever in 288, bronchitis in 1,223, and diphtheria carriers in 208 cases. The records would indicate that the death rate of the concurrent disease was not increased by the coexistence of mumps.

The report of Radin2 permits analysis of the involvement of the various salivary glands in a large number of mumps cases studied by him. Both parotids alone were involved in 2,747 of his 5,756 cases, that is, 47.7 per cent; the right or left parotid alone was involved in 20.5 per cent; both submaxillary glands alone were involved in 16, or 0.27 per cent, of the cases, and the submaxillary salivary gland on one side alone was involved in 18 cases, or 0.31 per cent. The sublingual salivary glands were involved in 31 cases, either conjointly with other salivary glands or alone. The parotid glands were involved in 73.71 per cent, the submaxillary glands in 7.64 per cent, and the sublingual glands in 5.21 per cent.

One case of suppuration of the parotid gland was reported by Radin,2 but there was a question as to whether the gland proper was involved in the suppurative process or whether the process was one of suppurative cellulitis. One case of parotid abscess was reported from Camp Pike, Ark., in October, 1918, following mumps. This case died.

PREVENTIVE MEASURES

From a military point of view, the control of mumps is a very important problem; however, no satisfactory method has yet been devised for controlling this disease. The length of time that a patient may be a source of infection is


462

not known. It is not known when the communicable stage starts, or when it definitely ends; therefore quarantine was not required during the war, except in isolating patients. Contact cases were not quarantined. On account of the high degree of contagiousness of this disease, it spread rapidly through the various commands soon after mobilization. At Camp Wheeler, Ga., Radin2 reports that 32 per cent of the command developed this disease. The general preventive measures used there were removal of patients from their companies as soon as the disease appeared, retaining them in quarantine at the hospital until they appeared no longer a source of contagion. No measures used appeared to control, or even check, the spread. Since the virus has been reported to be contained in the saliva, boiling of all mess equipment, such as knives, forks, spoons, cups, plates, etc., would appear to be of great value, thus preventing the spread of mumps through this medium. It was customary to boil mess equipment during the World War, but there is no report upon its efficacy in controlling the spread of mumps.

REFERENCES

(1) Zinsser, Hans: A Textbook of Bacteriology. D. Appleton & Co., New York, 1922, 5th Ed., 930.

(2) Radin, M. J.: The Epidemic of Mumps at Camp Wheeler, October, 1917-March, 1918. The Archives of Internal Medicine, Chicago, 1918, xxii, No. 3, 354.

(3) Osler, Sir William: The Principles and Practice of Medicine. D. Appleton & Co., New York, 1914, 8th Ed., 349.

(4) Larkin, Wm. R.: Mumps Meningitis-Report of Two Cases with Autopsy Findings. The Military Surgeon, Washington, 1919, xliv, No. 1, 92.

(5) Rock, John L.: Some Observations on Mumps. On file, Historical Division, S. G. O.

(6) Haden, Russell: The Cerebral Complications of Mumps with Report of Nine Cases. Archives of Internal Medicine, Chicago, 1919, xxiii, No. 6, 737.