MUMPS AND METASTASIS.

BY A. A. DAVIDSON, M.D., AUGUSTA, GA.

Mumps. Osler's definition: "An infectious disease characterized by inflammation of the parotid glands. The testes in the male and the ovaries and breast in females are sometime involved." The first sentence tersely tells of a simple epidemic disease ephemeral in nature, familiar in name and appearance to every one, of itself dreaded by no one, and demanding practically no interference in its limited course. Rarely is such not the case. Muirhead gives a definition of mumps: "An acute febrile infectious discase, attended by swelling of the salivary glands mostly of the parotids; and ending in resolution." Nor would one discover need for treatment in the mumps here defined. True, in diathetical subjects the disease might prove troublesome, even disastrous. It is not the facial manifestations of the disease, but that "the testes in the male and the ovaries and breasts in females are sometimes involved that induces me to offer this paper.

The nature of the specific germ that may cause mumps is not known. Winter seems the most favorable season for it. It is eininently a disease of youth, though by no means exclusively so. Males are its preferred subjects. It is contagious, yet when an epidemic becomes established it seems to become endemic. The period of invasion is from ten days to two weeks, during which time there is usually no prodromatal disturbances; but there may be marked precursory symptoms, such as chilly sensations, fever, malaise, etc.

Commonly pain is suddenly detected in angle of the jaw, usually the left, sometimes in both, but when in both development is mostly successive. Swelling is noticeable at site of the pain and rapidly augments for following twenty-four hours, febrile action accompanying. The peculiar and intense pain on taking an acid or sweets into the mouth is common but not constant. The third or fourth day the symptoms begin subsiding and the trouble in the parotid ends quickly in resolution; sometimes the organ continues enlarged, however.

Involvement of the reproductive glands begins insidiously, occurring most often about second day after subsidence of the parotid symptoms or about the sixth day of the disease; but the mumps may have been considered well for six to fourteen days when the so-called metastasis becomes unpleasantly manifest; then cases are recorded where orchitis and parotitis occurred synchronously (substantiated by recent personal observations); others occur prior to the facial symptoms, and still others (see reports of Kocher, and others), where the trouble neither follows, precedes or is concurrent to the swollen parotids, yet where the causative factor is epidemic influence of mumps. So it is not invariably post hoc. Why propter hoc then? There is no direct lymphatic communication between parotid and testes or ovary. There is no common nerve trunk whose branches supply both. The blood supply to these glands supply glands immune from the mump's influence as well. The factor causative enters the system and finds expression in an inflamed parotid followed by an orchitis; sometimes the converse is true. Quite commonly the parotid is alone affected, but the testes may be solely. Therefore it would appear that the involvement of the procreative glands in the disease is not consequent upon a specifically swollen parotid, but that there is in them a selective affinity, as it were, as there is in the salivary glands, for the specific morbific influence, the mumps infection, which has entered the system and circulation, and favored by the peculiar arrangement or structure of these secreting glands; but that they are not so readily nor by any means so uniformly susceptible; resisting for greater length of time and often most effectually this influence.

Angusta has had the past winter a most general epidemic of the disease; hundreds were its subjects. The surprising feature to me has been the proportion of the sostyled metastases and the extreme partiality shown for the male organ. In sixty per cent. of males, past fourteen years of age, coming under my observation for mumps, oсcurred orchitis. One party fifty-six years old was subjected to a severe case. Implication of female organs are Tar less frequent and rarely of much severity. Fortunately in majority of cases but one testicle is affected. I say fortunately, for orchitis of mumps is a serious condition, all too frequently fraught with baneful consequences. The statement is far from rashness that twenty-five per cent. of all cases of orchitis of mumps result in atrophy and impotence of the organ, or that fifteen per cent. of males with mumps at ages from fourteen to forty sustain loss of function of one or both testes. Orchitis of no other origin proves so fruitful of sterility; although in this form suppuration is seldom. The epididymis is commonly first involved and not infrequently the organ proper escapes, but the testes may be primarily affected.

This form of orchitis in its course is not peculiarly dissimilar to that consecutive to specific urethritis excepting in the intensity of the symptoms of the latter; indeed, Kocher attributes it to an extension of inflammation with which the urethra and bladder are sometime affected during mumps, which view is hardly tenable, since often no urethritis or cystitis are discoverable before or during the parotitis. Often the orchitis, sometimes the mammitis, is ushered in with a chill; the chill may occur several days after intimation of the trouble. The orchitis is attended with varying degrees of fever and intensity of pain, always its concomitant, and proportioned to the severity of the inflammation. After four to ten days parotitis ends in resolution and restitution. When the generative glands are involved such is the case with the female organs and about seventy per cent. of cases in males; resolution and atrophy terminating the remaining thirty per cent. When the physiological function of the testis is considered in the light of its anatomical structure, how that the origin of the semen and spermatozo is of the cells which line the distal portion of the tubuli seminiferi, to pass through which, their secreton is dependent, even though the caliber of these tubes be Lut 1-200 inch, the length of them fifteen feet and their course be so tortuous and intertangled as to admit of three hundred such being confined in one of the thirty lobes of the testis, all so closely invested by the unyielding tunica vaginalis, it is little wonder that an inflammation should leave thirty per cent. of these organs so affected, functionless; the real wonder is that a single organ could retain its integrity. Also when the delicacy of the seminal tubes and the stroma of the organ are considered with the products of the inflammation unremoved, that there should ensue a degenerative process and an absorption of the hyaloid lining and cellular contents of these tubes and the natural contracting upon, closing in of the spaces thus made, with the consequent atrophy so frequently a result, is not strange.

Treatment of mumps as expressed in the face and neck should be tentative and expectant; light diet and mild saline catharsis. Diathetical tendencies should be appropriately combated. But the treatment of mumps as expressed in the generative organs, and especially in the testis, should be eminently anticipatory and prophylactic. As in nearly all cases the parotid is affected some days before other developments, strict precautionary injunctions should be given. The prophylaxis consists in putting the patient to bed, at the farthest not allowing him to leave his room, continuing light diet and salts to keep bowels well open, with perhaps five or ten grains of quinine daily. But where no such precaution has been taken and there becomes noticeable a sense of discomfort about the testes aз though the clothing was not properly adjusted, the orchitis may still be averted by having patient at once assume and maintain a recumbent posture, supporting the scrotal contents over the pubes, and, if there be a uric acid or rheumatic diathesis, administering full doses of salicylate of soda. Nature will second these peremptory efforts, seeking to prevent the trouble or cut it short in its incipiency; and while the uninitiated may protest at these extreme and seemingly unreasonable measures, seeing no reason to be a patient, the end so thoroughly justifies the means, the physician's duty is clearly to be uncompromisingly insistent. When the trouble is more advanced the sufferer needs no urging. A properly adjusted sling or suspensory should be worn while in bed, within which the testicles should be enveloped in gauze or cotton saturated with some appropriate lotion. One which will be uniformly found beneficial is chloride of amm. zi, ether or alcohol 5i. to water 3xiii. But where pain is excessive, and in these cases it is not uncommonly so, some narcotizing astringent lotion applied as hot as bearable and covered with oiled silk is much to be preferred, such a one is of laudanum and hamamelis in subacetate lead solution. This will prove most grateful to the very sensitive organ. Scarifying the tunica vaginalis