MUMPS.

Synonym. Epidemic Parotitis.

Definition. An acute infectious disease characterized by inflammation
of one or both parotid glands, sometimes extending to the submaxillary
glands and rarely to the testicles, ovaries and mammary glands.

.etiology. This disease is most common in childhood and youth and
is most likely to occur in the spring and fall. The infection is uncommon
in young infants and in adults and attacks boys more frequently than girls.
Sporadic cases are generally present in cities and epidemics occur at intervals.
The disease is communicable from person to person but the specific cause of
the contagion is not known; one attack usually confers immunity.

Pathology. The morbid anatomy of this disease consists of a congestion
and oedema of the salivary glands with swelling of the walls of their ducts
resulting in obstruction of their lumen.

Symptoms. The incubation period is from two to three weeks. Pro-



MUMPS. 89

dromal symptoms are rare and in mild, cases the initial symptoms are referable
to the affected gland. In the severer types there may be such symptoms at
the invasion of the infection as headache, general bodily pains, loss of appetite,
vomiting and a rise of temperature, in mild instances rarely above 101° F.
(38.3° C), but in the severe forms the fever may reach 103° to 104° F. (39.6°
to 40° C). The first local symptom is usually pain below and in front of the
ear, pain in swallowing is often present and swelling soon becomes apparent
in both parotid glands simultaneously or more often in one, the other becoming
involved two or three days later or not at all. The swelling is in front of
and below the ear and may affect the entire neck in this vicinity. The lobe
of the ear is everted and occupies the central part of the tumor. The swelling
reaches its greatest size in from two to three days and at this time the pain
may be severe and the difi&culty in swallowing marked, opening the mouth
and mastication may be well-nigh impossible, the secretion of saliva is dimin-
ished, and there may be earache.

The disease is usually mild but in rare instances disturbing and even danger-
ous symptoms, such as delirium resulting from pressure upon the veins of the
neck and consequent cerebral congestion, may occur. Suppuration of the
glands is rare.

The fever lasts four or five days but the swelling may last a week or more.
The opposite side may become involved after the original site of the disease
has returned to normal.

Complications are rare in young children but in youths orchitis may occur
after the inflammation of the parotids has subsided. The body of the testicle
is affected rather than the epididymis and both organs may be involved.
The onset of this complication is marked by a rise in temperature, the testicle
is swollen, painful and tender; the acuity of the inflammation lasts several
days but the swelling persists for a few weeks and rarely atrophy may result.
Hydrocele of the tunica, oedema of the scrotum and a muco-purulent iu"ethral
discharge may accompany the orchitis.

Ovaritis, and inflammation of the vulva and of the mammary glands may
occur in girls.

Still rarer complications are nephritis, otitis media and deafness, pneu-
monia, pericarditis, endocarditis, meningitis and facial paralysis. Enlarge-
ment of the thyroid gland and symptoms suggestive of pancreatic inflamma-
tion have been observed. Following the disease, permanent hypertrophy of
the parotid may be noted.

The diagnosis is usuaUy easy. Mumps is most likely to be mistaken for
acute cervical lymphangitis but may be differentiated by the characteristic
shape of the parotid tumor and by the elevation of the lobe of the ear.

The prognosis is very favorable, especially in the absence of complications.

Treatment. Isolation is necessary in institutions and in families where



9© THE INFECTIOUS DISEASES.

there are other children, and the quarantine should be continued for at least
three weeks. At the onset of the disease the patient's bowels should be
opened and if there is fever he should be put to bed and kept there until all
constitutional symptoms have disappeared. Avoidance of exposure will
diminish the Hability to complications. The pain in the swollen gland may
be diminished by compresses of gauze impregnated with a mixture of
fluid extract of belladonna, /i xx (1.33) and an ounce (30.0) of glycerin,
with a 5 percent, ointment of ichthyol or a 2 percent, morphine ointment.
The compress should be covered with rubber tissue or oil-silk. Cold com-
presses may be grateful to the patient but the application of heat is usually
preferred. Should the fever give rise to anxiety an ice coil may be applied
to the precordium but this will seldom be found necessary. Other symptoms
should be treated as they arise.

If enlargement and hardness of the parotid persists after the acuity of the
infection has subsided inunctions of 6 percent, iodine-vasogen or of a potas-
sium iodide ointment are suggested.

The orchitis necessitates rest in bed, support of the testicles by means of a
bridge across the thighs made of a strip of adhesive plaster and the application
of a 10 percent, ointment of ichthyol.

The dryness of the mouth should be relieved by washes of dilute liquor
antisepticus.

The diet should be fluid while the temperature is elevated and even if this
symptom is absent it may be impossible for the patient to take solids because
of the pain upon mastication and deglutition.

WHOOPING COUGH.

Synonym. Pertussis.

Definition. A specific infectious disease characterized by catarrhal in-
flammation of the air passages and by paroxysms of coughing accompanied
by long inspirations producing the typical "whoop."

-Etiology. This disease is endemic in cities and from time to time epi-
demics appear, especially in the winter and spring and often associated with
epidemics of measles or scarlatina. Children are most frequently attacked
and the most susceptible period is between the first and second dentitions.
Niursing infants and adults may, however, contract the infection and in old
persons it is likely to be serious. Delicate children and those prone to catar-
rhal affections are particularly liable to infection. Whooping cough is most
contagious during the catarrhal stage and is generally spread by direct con-
tact but schools, dwellings, etc., may be infected.

Various observers have described micro-organisms which they consider
responsible for the occurrence of the disease but their claims have not as
yet been substantiated.



WHOOPING COUGH. 9 1

Immunity is usually conferred by one attack, and while certain individuals
seem unable to contract the affection it must not be forgotten that the dis-
ease may occur in a mild form which may be overlooked.

Pathology. There is no constant morbid change associated with whoop-
ing cough. Complications are usually responsible for fatalities and here we
find the causative lesions such as broncho-pneumonia, bronchitis, collapse
of the lung, vesicular and interstitial emphysema and enlargement of the
tracheal and bronchial lymph nodes. After death during a paroxysm the
brain is found in a state of congestion and punctate or larger haemorrhages
may be present.

Symptoms. After a period of incubation of from 7 to 10 days the first
or catarrhal stage sets in. This is marked by slight rise in temperature, run-
ning at the nose, conjunctival injection, sore throat and cough, usually dry,
and at times paroxysmal. The characteristic whoop in certain cases may
be present from the onset but more commonly after a week or 10 days of
atypical cough the tendency to the whoop becomes gradually more and more
marked, the spasms more and more frequent and the paroxysmal stage begins.
A typical fit of coughing begins in a succession of 15 to 20 short expiratory
coughs between which there is no effort at inspiration. The face is flushed
and perhaps cyanotic, the eyes are prominent, there is lacrymation and
nasal discharge. At the termination of the paroxysm there is a deep inspi-
ration accompanied by a whoop. Such a fit of coughing may be immediately
succeeded by another, be terminated by the expectoration of more or less
mucus or followed by emesis. The paroxysms vary in number from four or
five daily, to ten times this number. The patient recognizes the imminence
of the coughing fits and endeavors as far as possible to prevent them. Fre-
quent vomiting may render the child emaciated as a result of its inability to
retain sufficient nourishment. An ulcer due to friction against the lower
incisors, may form at the fraenum of the tongue; rupture of a nasal or con-
junctival vessel and involuntary urination may occur during a paroxysm.

Physical examination of the thorax during the spasm reveals diminished
pulmonary resonance during the expiratory coughs and normal resonance
during the inspiration. During the whoop there may be absence of the
normal vesicular murmur on account of the slowness with which air enters
the lungs. Mucous rales may be present.

Paroxysms may be induced by emotion, any irritating inhalations and even
by deglutition. This stage of the disease lasts from one month to six weeks,
increasing in intensity for the first half of this period, then remaining stationary
for about a week and then gradually subsiding. The paroxysms are very
likely to recur if the patient catches cold or if his digestion becomes
disordered. This reappearance of the whoop is not to be considered a true
relapse.



92 THE INFECTIOUS DISEASES.

The stage of convalescence lasts from three to four weeks but may be much
longer than this period.

Complications are frequent and sometimes serious. The congestion
caused by the paroxysm may cause bleeding from the nose, conjunctiva or
even the ears as weU as petechial haemorrhages into the skin, haemoptysis
and intestinal haemorrhage. Intracranial extravasations of blood may occur,
causing death, various paralyses or convulsions. These haemorrhages are
seldom large and their manifestations are rarely permanent. Disturbances
of the special senses are sometimes noted.

Pulmonary complications are usually responsible when death takes place.
Both broncho- and lobar pneumonia ma} be observed. Inflammation of
the larger bronchi is the rule and is not especially to be feared; involvement
of the small tubes is as serious as broncho-pneumonia. Transient vesicular
emphysema is not uncommon, being caused by the severity of the paroxysm;
interstitial and even subcutaneous emphysema have been observed. En-
largement of the bronchial glands is common.

Infants suffering from pertussis in summer are very frequently affected
with diarrhoea. Malnutrition may result from the frequent emesis caused
by the paroxysms.

Albuminuria and glycosuria may occiu* but these conditions are usually
only temporary. Overstrain of the heart may result in permanent valvular
endocarditis and as sequelae hernia, prolapsus ani and a predisposition to
tuberculosis may be mentioned.

The diagnosis in typical cases may be easily made; other instances may
occur, in which there is no whoop, in which the problem is much more
difficult, but a cough occmring chiefly at night, which increases in severity
for two or three weeks, is unaccompanied by constitutional symptoms and
physical signs and which may manifest itself in paroxysms followed by vomit-
ing is probably pertussis. In the presence of epidemics the diagnosis is
greatly simplified. An increase in the number of leucocytes particularly of the
lymphocytes, is an important feature of this disease.

The prognosis is distinctly bad in children under four years of age and in
those previously delicate, broncho-pneumonia being responsible for many
of the deaths.

Treatment. The patient should be kept from association with other
children; confinement to a single room is unnecessary, consequently all indi-
viduals to whom the infection is prejudicial should be sent away. Particu-
larly should all delicate children and those with any tuberculous tendency
be kept from exposure. Quarantine is necessary until the paroxysmal stage
is past.

In the treatment of the disease itself hygienic measures are most impor-
tant.



WHOOPING COUGH. 93

The patient should, as a rule, be kept in the open air especially during the
warm months. Older children may be allowed out of doors on pleasant
days even in winter. Delicate children, however, and those in whom there
is any tendency to bronchitis should be kept in doors. Special stress should
be laid upon the thorough and frequent ventilation of the apartments occu-
pied by the patient and frequent, even daily, fumigation by means of a forma-
line candle or lamp. The bedding, clothing, etc., should be often changed.

In protracted cases a change of climate is indicated and delicate children
do better, especially in winter, if they are taken to a warm place. The sea
shore and sea voyages are often beneficial.

Internal Treatment. Of the almost numberless drugs which have been
recommended in whooping cough bromoform is, perhaps, one of the most
effectual but must be employed with great caution as cases of poisoning have
been reported from its use. It may be administered in the following formula:
Bromoform, i part; alcohol, 8 parts; glycerin, 48 parts; compound tincture of
cardamom, 8 parts. Each drachm (4.0) contains 3 minims (0.2) of bromoform
which may be given to a child of two years, three or four times daily. The
mixture should be very carefully compounded and shaken immediately
before taking. Bromoform may also be taken dropped upon lumps of sugar.

Antipyrine is a useful drug but should not be given if heart or severe pul-
monary complications are present. Its dosage for a two year old child is
two grains (0.13) 5 or 6 times a day. In cases with particularly marked
paroxysms antipyrine may be advantageously combined with sodium bromide
or heroine.

Quinine has enjoyed much vogue in the treatment of pertussis. Its dosage
for a child of two years should be about three grains (0.2) three times a day,
and it may be given either as the sulphate or the hydrochloride. It is important
that it should be prescribed in palatable form, for instance, in chocolate covered
tablets. Its great disadvantage is its liability to distiirb the stomach in
infants and young children; this fault may be obviated by giving the drug in
enemata or in suppositories. The treatment should begin early and it may
be wise to give each dose directly after a fit of coughing since at this time
it is less likely to cause gastric disturbance.

Aristochine (quinine carbonic ester) has no bitter taste and may be em-
ployed instead of quinine. Its dose is i^ to 3 grains (o.i to 0.2) three times
a day. Euquinine is another substitute for quinine.

In belladonna we have an effectual means of diminishing the number and
severity of the paroxysms. The beginning dose should be small and gradually
increased until physiological effects are produced. Its action must be care-
fully observed for the evidence of toxic symptoms. A two year old child
may receive of the fluidextract | to ^ a drop (0.016 to 0.032) every four hotus;
atropine in doses of -j-g-jj- of a grain (0.00015) may be substituted. The



94 THE INFECTIOUS DISEASES.

above doses may be gradually increased in size or given at gradually dim-
inished intervals until their physiological effect as evidenced by an erythema
of the skin is noted.

Camphor is said to act, not only as a stimulant in the bronchitis and pneu-
monia-.of pertussis, but also upon the disease itself. It may be given internally
in appropriate doses.

The severity of the nocturnal attacks may be lessened by sodium bromide
2 to 4 grains (0.13 to 0.24), or by codeine, sulphonethylmethane or chloral; the
latter, however, must be given with care. Certain observers rely chiefly
upon paregoric to check the paroxysms.

In general it may be said of the drug treatment of whooping cough, that
since the disease is self-limited and since in all probability its coiirse cannot
be shortened, internal medication, in patients whose paroxysms are neither
distressing nor frequent, should be postponed until the cough becomes so
marked as to interfere with rest and the bodily functions. When this event
takes place medication is indicated.

Local treatment by means of sprays, inhalations, insufflations of various powders
and by direct applications to the larynx may be prescribed. Sprays and insuffla-
tions probably influence the disease but little, but may be useful in allaying the
catarrhal symptoms in the upper air passages. As sprays a solution of one
of the more soluble quinine salts, Dobell's solution, liquor antisepticus, or a
mixture containing menthol 0.3 parts, thymol iodide i part, oil of sweet almonds
25 parts may be used. Insufflations such as the following may be employed:
Benzoic acid and bismuth subsalicylate each 10 parts, quinine sulphate 2
parts, or powdered antipyrine and quinine hydrochloride each i part, boric
acid 2 parts, bismuth subnitrate 5 parts. Direct applications of 5 pejxent.
cocaine solution may be made to the larynx in older children, but with cau-
tion. One percent, solutions of phenol or of resorcinol are less dan-
gerous. The applications of a i to 2 percent, solution of formalin to the
pharynx has been advised. Inhalations to be given by impregnating the air
of the apartment with various mixtures or by means of an inhaler are some-
times beneficial. By this means we may lessen the irritation of the air
passages and combat the tendency to bronchitis. The following formulae
are applicable: ^ther, chloroform and creosote equal parts; to be used upon
the cotton or sponge of a respirator. Phenol, 3 parts, thymol, 5 parts, alcohol,
50 parts, compound tincture of lavender, 20 parts, water to 1000 parts; to be
evaporated over an alcohol lamp.

Inhalations of ethyl iodide are said to afford instant relief to the paroxysms
and to lessen the severity of the disease. •

The spasm of the glottis which may occur when the spasms of coughing
are frequent and severe may be relieved by means of laryngeal intubation.
The tube may remain in place as long as the paroxysms continue.



I



CEREBROSPINAL FEVER. 95

For the convulsions a few whiffs of chloroform may be given and as an
antispasmodic a plaster of asafoetida applied to the whole chest has been
suggested.

A 20 percent, solution of cypress oil in alcohol sprinkled upon the patient's
pillow, the upper part of the bed and upon the underclothing several times
daily is said to benefit the cough.

Lewriaux has produced an antitoxic serum by inoculating horses with
cultures of a bacillus which he has isolated from cases of whooping cough.
In his hands injections of from 75 to 150 minims (5.0 to lo.o) of this serum,
especially if given early in the disease, have acted favorably.

The tendency to vomiting may be lessened by , applying an abdominal
band to which a snugly fitting elastic bandage has been sewn. To young
children in whom this symptom is marked a few drops of the camphorated
tincture of opium or a half teaspoonful of a mixture of dilute hydrochloric
acid 2 parts, simple syrup 200 parts, lemon spirits 2 parts, may be given.

The sublingual ulcer should be kept clean by the use of mild antiseptic
mouth washes and may be touched from time to time with a 3 percent, solu-
tion of silver nitrate. Heart weakness calls for the administration of alcohol
and strychnine.

The compUcating pneumonia, bronchitis, etc., may be treated as ordinarily.

Throughout the disease the bowels should be kept freely open and the
patient should be most carefully fed. The regulation of the diet is often a
difl&cult matter since vomiting is so likely to occur, but is most important, for
digestive disturbances accentuate the severity of the whooping cough and
increase the frequency of the paroxysms. Young infants should be given
diluted milk which may if necessary be peptonized. Older children should
be allowed only fluids, chiefly milk, during the acuity of the disease. It is
essential that the patient's nourishment be thoroughly maintained, conse-
quently vomited meals should be repeated.

During convalescence the administration of tonics, especially codliver oil,
the syrup of iron iodide and arsenic, is usually necessary since even if the infec-
tion has run a seemingly uncomplicated comrse the patient's system is depre-
ciated and his powers of resistance are decreased, owing to the strain to which
he has been subjected.

CEREBROSPINAL FEVER.

Synonyms. Epidemic Cerebrospinal Meningitis; Malignant Purpuric Fever;
Petechial Fever; Spotted Fever.

Definition. An acute infectious febrile disease occurring sporadically
and in epidemics and characterized by inflammation of the membranes of the
bnin and spinal cord and frequently by an eruption upon the skin.



96 THE INFECTIOUS DISEASES.

Etiology. Epidemics of this disease have occurred from time to time
in the United States, the last being in New York City during the winter of
1904-5. The epidemics are usually localized and seem to occur rather more
often in the country than in cities and usually in the winter and spring. Unsani-
tary co|iditions, fatigue, mental and physical depression and the association
of large numbers of persons in small spaces such as army camps and barracks
predispose to the occurrence of the disease.

The specific cause of epidemic meningitis is the diplococcus intracellular is
meningitidis which is found within the bodies of the polynuciear leucocytes
of the inflammatory exudate. With this micro-organism other bacteria such
as the staphylococcus, the streptococcus, the pneiunococcus, the bacillus coli,
etc., may be associated.

Cerebrospinal fever is probably not directly contagious in that the infection
is transmitted by fomites and the excretions and it is difficult to trace the
origin of a certain case to any other, irregular distribution being a character-
istic of the affection. The contagium is, however, supposed to be air borne
and to reach the meninges through the nose by means of the cribriform plate
of the ethmoid bone.

Pathology. The sl^in may bear the remains of the petechial or herpetic
eruption in certain instances but the changes in the nervous system are more
constant. These, however, are very variable in degree and may occur as
merely slight congestion or as pronounced hypersemia of the pia-arachnoid
with fibrino-purulent deposits especially at the base of the cerebrum, resulting
in a coating of the meninges with the exudate. The upper and lateral surfaces
of the brain may also be involved in the inflammatory process. The exudate
is beneath the pia mater and is likely to be more profuse in the longitudinal
fissiires and Sylvian fissures. The substance of the brain may be congested
and even softened. In the cases of long standing the meninges are thickened
and adherent to the cortex. The ventricles are filled with sero-pus and in
prolonged instances of the disease may be greatly distended, their walls being
softened, and a condition of hydrocephalus may result.

The cranial nerves, especially the optic, the facial and the auditory are
often involved.

The spinal meninges are involved similarly to those of the brain. The
exudate is most profuse upon their dorsal surface and the lower segments
are chiefly affected. The spinal and the central canal may both contain
pus in considerable amount. The cord itself may be inflamed and the
spinal nerve root? may be the seat of a neuritis or compressed by the
exudate.

Microscopical examination shows the exudate to consist of polynuciear
leucocytes enmeshed in fibrin. The meningococci are found both within
the leucocytes and amongst the fibrin. The substance of the brain and cord



CEREBROSPINAL FEVER. 97

may be infiltrated with pus, the neurogha cells are swoUen and hsemorrhagic
foci may be present.

The lungs may be the seat of a pneumonia caused by the diplococcus pneu-
moniae or by the meningococcus. Pulmonary congestion or plevirisy may be
observed.

Endocarditis sometimes is noted and the congestion of the various viscera
occiuring as a result of an infectious disease is usually present. The spleen
may be enlarged.

Symptoms. These vary with the type of the disease. The incubation
period of the ordinary form is not known. Its onset is usually sudden, although
there may be a short prodromal period marked by dizziness, headache and
pain in the back. The invasion is often evidenced by a chill and vomiting of
the projectile type followed by headache, pain in the back of the neck and in
the lumbar region. These may be mild or very severe. The muscles of the