Communicable Diseases, Table of Contents

CHAPTER XIII

MUMPS

STATISTICAL CONSIDERATIONS

Table 73 shows that 230,356 cases of mumps were admitted tohospital for the total Army during the World War, giving a ratio of 55.80 per1,000 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 38,619primary admissions, with an admission ratio of 134.75 per 1,000 strength, threetimes that for the white troops.

During the World War 43 white enlisted men and 7 coloredenlisted men were discharged from the service on account of disability followingmumps. 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. Inexplanation of these discharges, it is most probable that there were factorscausing disability in these cases other than mumps.

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

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TABLE 73.-Mumps. Admissions, dischargesfor disability, and days lost, by countries of occurrence, officers and enlistedmen, United States Army, April 1, 1917, to December31, 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 whiteand colored not available.

Mumps caused more noneffectiveness among colored troops thanamong white troops; there were 3,020,897 days lost from duty among 3,599,527white 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 coloredper 1,000 strength. Thus the noneffectiveness was approximately three timesgreater among colored troops than among white. Mumps was widely distributed overthe 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 theorder named: Camp Beauregard, La.; Camp Wheeler, Ga.; Camp Bowie, Tex.; and CampTravis, Tex. The admission ratios per 1,000 strength for the camps mentionedwere all above 213 per 1,000 strength. The camps reporting the smallest numberof 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 10,000troops. Camp Cody, N. Mex., though a camp of average size, reported only 333cases, giving a ratio of 14.71 per 1,000 strength. The average number of casesper camp in the United States was 2,650 and the average ratio per 1,000 strengthwas 81.40. It is seen that

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of the 39 camps shown in Table 74, 16 reported cases abovethe average in number and 13 had a primary admission ratio above the averageamong 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 inthe Army in the United States during the World War. The average admission ratiofor mumps in the United States was 66.30 per 1,000 per annum. (Table 75.) InOctober, 1917, the admission ratios for white troops increased, reaching themaximum in February of the year following. Reviewing the occurrence among whitetroops only, we find that in October, 1917, 1,683 cases were reported as primaryadmissions. 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 per1,000 per annum. The following month, December, both the number of cases and theratio were more than doubled. There were 10,368 primary admissions, giving aratio of 110.19 per 1,000 strength. In January, 1918, again these numbers werepractically doubled. There were 19,460 primary admissions and the ratio per1,000 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 severalpreceding months. There were 21,092 primary

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admissions, with a ratio of 231.14 per 1,000 strength. Fromthis date the number of cases and the ratio decreased until the second seasonaloccurrence, which occurred in the following November. The seasonal occurrencecommencing in 1918 did not reach the same magnitude in the United States as didthe seasonal occurrence which started in 1917. The seasonal occurrence of 1918began one month later, with 2,729 primary admissions, giving an admission ratioof 26.09 per 1,000 strength. In December, twice as many cases were reported withmore than double the admission ratio-that is, 4,718 primary admissions and aratio 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 theprevious year. For this month, 6,027 primary admissions were reported with aratio of 107.48 per 1,000 strength. In February, 1919, the occurrence of mumpsbegan to decrease, and continued to decrease to the end of the war. There was noseasonal occurrence in the latter part of 1919.

TABLE 75.-Mumps. Admissions, by months, white andcolored 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.

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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 theUnited States applies, in general, to the occurrence of mumps among the coloredenlisted men. Mumps was more common among colored enlisted men, but the ratiosduring the latter part of 1917 were lower than those for white enlisted men inthe respective months; however, the number of colored troops in the Army at thattime was small. By January, 1918, the number of colored troops had greatlyincreased. The mean aggregate strength for 1917 was 11,529; during 1918, themean aggregate strength was 107,260. Commencing in January, 1918, the occurrenceof mumps among colored enlisted men was greater than among white enlisted men.This occurrence continued until the spring of 1919. The highest ratio forcolored 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

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

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

It has been shown that the occurrence of mumps in the Army inthe United States was a matter of serious concern during mobilization. No menwere enlisted in the Army during the first two months of 1919 and comparativelyfew during the early spring. The admission rate, as shown by Table 75, was onthe decline at this time, and much below that of the corresponding months of thepreceding year. Large numbers of troops were returned to the United States fromEurope during the latter months of 1918, and throughout the remaining portion ofthe winter and spring of 1919. In spite of the fact that large numbers oftroops 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 ofmumps in the camps.

OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES

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

The great importance of mumps in the Army overseas, as in theUnited States, was due to the amount of time lost from duty. Table 73 shows1,501,222 days lost from this disease in the Army in Europe, giving anoneffective ratio of 2.47 per 1,000 per annum. Again the ratio was greater forcolored enlisted men. White enlisted men had a noneffective ratio of 1.98 andcolored enlisted men 5.98 per 1,000 per annum.

FACTORS INFLUENCING OCCURRENCE

Many factors enter into the occurrence of mumps. According toZinsser¹ "Our impression from Army experience is that there may becarriers." Radin² found that 95 per cent of the cases at CampWheeler, Ga., occurred during the first two months of service. A physicalcondition 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 haddistinct 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

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difference in the occurrence of this disease between whiteand colored troops, being more common among the latter. It is also probable thatcrowding had a marked influence on the occurrence of mumps; however, there is norecord of any experiments conducted along these lines during the World Warperiod.

One attack of mumps usually confers immunity, but notnecessarily so.

SYMPTOMS

The usual onset of mumps was characterized by pain, swelling,and stiffness about the angle of the jaw, made more noticeable by openingthe mouth. There was usually malaise and some fever. Likemany other diseases where the bacteriology is not known, diagnosis was oftenvery difficult. The leucocyte count was usually normal in the uncomplicatedcase; sometimes there was leucopenia. When complications occurred, especiallyorchitis, there was usually a mild leucocytosis. Radin² summarized the onset ofmumps as follows: Onset with no symptoms; onset with gastric disturbances andfeatures suggesting pancreatitis; onset with pancreatitis, orchitis, andurethral discharges; onset with features of acute laryngitis and bronchitis;griplike onset, with fever, headache, malaise, sore throat, and pain in thebones; onset with inguinal pain and backache; and the ordinary onset. The sameobserver 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 facein the parotid region; (4) doughy elasticity of the swelling; (5) discharge ofsecretion from Steno's duct on pressure over the gland externally. This authordescribes Hatchcock's sign as follows:² "The sign istenderness just beyond the angle of the jaw on running the finger toward theangle, under the mandible. If the parotid gland is at all involved, the patientwinces with pain. This occurs before any swelling can be made out."

Pouting of the orifice of Steno's duct, with a pink areolaon the mucous membrane around the mouth of this duct, has often been describedas occurring in mumps. It was reported as occurring only on the side where mumpswas present. On inserting a cannula into the mouth of Steno's duct, afluid will often be ejected if mumps is present. According to Radin, elevationof 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 durationwas from 1 to 24 days, with an average of 4 days. About 24 hours before theonset of a complication, a rise in temperature of from 1? to 3? was noticed.This was usually accompanied by leucocytosis, the polymorphonuclear leucocytesshowing a relatively higher percentage in the orchitic than in the uncomplicatedcases. In the latter the average was 51.9 per cent; in the orchitic cases thepercentage 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 inorchitic cases. Vomiting, nausea, and orchitic pain may occur without apparentcause.

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 werenot immune to mumps and placed on duty in a mumps ward. One nurse developedmumps in two weeks and the other in two and a half weeks after exposure.

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Although mumps may involve the submaxillary, sublingual, andoccasionally the lachrymal glands, as well as the parotid glands, the system ofrecording diagnoses in the Surgeon General's Office does not permit suchdetailed analysis of cases.

The average duration per case was 16.86 days for the totalArmy. The average number of days in hospital for mumps in the United States was16.07 days and in Europe 18.34 days.

PATHOLOGY

But little is known of the pathology of mumps. Althoughtypical mumps involves the parotid glands only, the other salivary glands may beinvolved. Osler³ is the authority for the statement that the submaxillary andsublingual glands may become swollen, though not always; in a few cases theyalone may be attacked. Radin² reported that a parotid gland was removed bymistake in a case of mumps at Camp Wheeler. After its removal, advantage wastaken of the opportunity to observe the structure of the gland. This proved tobe normal. Cervical and inguinal adenitis were not infrequent. Orchitis wasfrequent and redness of the scrotum and epididymitis often occurred. The thymusgland was enlarged in some of Radin's cases. Involvement of the pancreas issupposed to occur in mumps at times, but the exact pathology has not beenreported. In mumps meningitis, according to Larkin,⁴ the meningesshowed lymphatic and edematous changes associated with some encephalitis. Thespinal fluid was clear in these cases and showed an increased cell count(lymphocytes). The fluid was sterile on bacteriological examination. Larkinreported 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 bothcases. The autopsy findings in one of Larkin's cases were as follows:⁴

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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.

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DIAGNOSIS

The ordinary case of mumps is not difficult todiagnose correctly, especially in the presence of an epidemic. There may becases, however, of a mild type, or cases involving salivary glands other thanthe parotid gland, where the diagnosis is difficult. The difficulty is increasedby the absence of any positive laboratory findings characteristic of mumps. Thefollowing clinical signs and symptoms, when present, are pathognomonic: Swellingand tenderness of the salivary gland unilateral or bilaterial; pink and poutingorifice of Steno's duct, discharge of a whitish secretion from the duct uponpressure on the gland

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involved, or by aspiration; pain or a drawing sensation inthe mouth on eating sour food; Hathcock's sign. These findings are usuallyaccompanied by some elevation of temperature and an absence of leucocytosis. Asudden rise of temperature during the course of mumps leads one to suspectcomplications. These complications are usually accompanied by leucocytosis.Orchitis, with swelling and some tenderness, is the most common complication. Itmay be bilateral or unilateral, is often accompanied by epididymitis, and may befollowed by atrophy. Pain in the ear on the side involved by mumps is notuncommon, and may be due to the swollen parotid gland or to otitis media.Headache, stiffness of the neck muscles, positive Kernig's sign, with suddenincrease in temperature and the number of leucocytes, should lead one to suspectmeningitis. Confirmation of the diagnosis is made by lumbar puncture. The spinalfluid in mumps meningitis is clear on withdrawal, has an increased cell count,and the fluid is sterile. A fine whitish sediment forms on standing. Itis important to differentiate this form of meningitis from other forms,especially the epidemic variety. Larkin gives the following differentialdiagnostic 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. influenz?.
	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 fromtonsillitis with cervical adenitis is necessary. In this form there is usuallyan epidemic of mumps present and the tonsils are normal; the swelling is underthe center of the mandible and the salivary gland is involved. On the otherhand, the confusing cervical adenitis is of inflammatory origin, not epidemic,and involves the lymphatic gland which is located somewhat farther back than isthe salivary gland.

TREATMENT

Experience during the war developed no specific treatment formumps, and none is known. It was the practice in the Army to isolate all casesand 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 thequarantine on clinical findings of the individual case-when there was nolonger swelling of the salivary glands and no complications were present, thecases were assumed to be free of infection. The presence of a temperature abovenormal was a counterindication for discharge from hospital; however, a normaltemperature did not mean that the patient was not a source of danger.

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

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being masked. There is no record of proof, however, thateither 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 someinstances uncomplicated mumps patients were allowed up and walked to theirmeals, while others were treated strictly as bed patients. A review of theavailable literature does not show any great difference in the percentage ofcomplications, especially orchitis, that developed with these two differentforms of treatment. Some patients were allowed to get up for meals and to walkabout generally, while others were required to remain in bed throughout thecourse of the disease.²

The ordinary uncomplicated case of mumps required nomedication. When medicaments were administered, these varied in different camps.Radin² reported that orchitis occurred one-third less frequently inpatients treated with hexamethylenamin than in those patients who did notreceive this form of medication. Orchitis was reported as being less common atCamp Grant where bromides were used.⁵ Particularly was this trueamong colored patients. Local applications of heat or cold were used, accordingto the preference of the patient. Radin used Dobell's gargle, hotapplications, and camphorated oil over the swollen salivary glands, and aspirinand bromides internally for pain and nervousness. The early stage of otitismedia was most commonly treated by instilling 2 drops of a 2 per cent phenolizedglycerin into the external auditory canal, and sometimes into each nostril,twice daily. Where an exudate was present, manifested by bulging of thetympanum, early incision and drainage was the procedure of election. Orchitiswas treated by support, and counterirritation in the form of ice bags, ichthyol,or guaicaol carbonate. Rest in bed was the best form of treatment. Mumpsmeningitis was treated by spinal drainage.

COMPLICATIONS AND SEQUEL?

Of the 230,356 cases of mumps reported as primary admissions,40,008 developed complications of some kind. In addition to the above, therewere 6,107 cases reported during the World War as concurrent with otherdiseases. The case mortality among the primary admissions was 0.08 per cent andthe case mortality among cases of mumps reported as a concurrent disease was2.11 per cent. The most common complication in mumps was orchitis. There were24,337 cases of mumps admitted as primary admissions which developedcomplications of the genitourinary system, other than venereal; that is, 10.56per cent. It is presumable that the vast majority of these cases were orchitis,epididymitis, or both. Radin² reported this complication in 13.91 percent of the cases at Camp Wheeler, Ga. Orchitis, bilateral, occurred in 102cases, and unilateral orchitis in 452 cases. Epididymitis alone was reported byRadin in 5 cases. At Camp Shelby Miss., orchitis was reported as a ratherfrequent complication, and principally among the colored labor battalions. FortRiley, Kans., reported orchitis present in from 20 per cent to 25 per cent ofthe 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 epididymitisand orchitis in 4 per cent of their cases. Orchitis was a frequent and anannoying complication of mumps in the American Expeditionary Forces. Among the

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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 mostimportant complication occurring in mumps. Haden⁶ reported 9 cases of mumpswith cerebral complications, at Camp Lee, Va., among 476 cases of mumps. Thiscomplication usually occurred late in the disease. In the careful study of morethan 5,000 cases of mumps by Radin,² no mention was made ofmeningitis. Larkin⁴ reported 2 cases of mumps meningitis at CampTaylor, Ky., during the World War, 1 of which died. The autopsy findings in thecase which died have been quoted previously in this chapter. Several cases ofmumps with signs of meningeal irritation manifested by headache, irritability,restlessness, slight cervical rigidity, suggested Kernig's sign, hightemperature, and respiration, were reported at Camp Lewis, Wash. These signsdisappeared in from 24 to 48 hours. In 1917, 2 cases of mumps meningitis among1,800 cases of mumps were reported at Beauregard, La. One case of mumpsmeningitis was reported from Base Hospital No. 106, A. E. F. in 1917.

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

Among the total primary admissions of 230,356 cases, otitismedia was reported in 906, lobar pneumonia in 701, bronchopneumonia in 320,arthritis in 184, acute articular rheumatism in 231, measles in 436, scarletfever in 288, bronchitis in 1,223, and diphtheria carriers in 208 cases. Therecords would indicate that the death rate of the concurrent disease was notincreased by the coexistence of mumps.

The report of Radin² permits analysis of the involvement ofthe 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 percent; the right or left parotid alone was involved in 20.5 per cent; bothsubmaxillary 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 wereinvolved in 73.71 per cent, the submaxillary glands in 7.64 per cent, and thesublingual glands in 5.21 per cent.

One case of suppuration of the parotid gland was reported byRadin,² but there was a question as to whether the gland proper wasinvolved in the suppurative process or whether the process was one ofsuppurative 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 veryimportant problem; however, no satisfactory method has yet been devised forcontrolling this disease. The length of time that a patient may be a source ofinfection is

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not known. It is not known when the communicable stagestarts, or when it definitely ends; therefore quarantine was not required duringthe war, except in isolating patients. Contact cases were not quarantined. Onaccount of the high degree of contagiousness of this disease, it spread rapidlythrough the various commands soon after mobilization. At Camp Wheeler, Ga.,Radin² reports that 32 per cent of the command developed this disease. Thegeneral preventive measures used there were removal of patients from theircompanies as soon as the disease appeared, retaining them in quarantine at thehospital until they appeared no longer a source of contagion. No measures usedappeared to control, or even check, the spread. Since the virus has beenreported to be contained in the saliva, boiling of all mess equipment, such asknives, forks, spoons, cups, plates, etc., would appear to be of great value,thus preventing the spread of mumps through this medium. It was customary toboil mess equipment during the World War, but there is no report upon itsefficacy 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.