R.oyal krmy Medical Corps. - BMJ Military Health · Orchitis.-86 (21 per cent) of the Cypriots had this complication. Of these 34 (39 per cent) were, right-sided, 41 (48 per cent)

VOL. LXXXIII. .;

R.oyal

. SEPTEMBER, 1944.

·Authors are alone responsible. for the statements made and the opinions expressed in their papers.

Journal of the

krmy Medical

'Original Communications.

MUMPS IN CYPRIOT TROOPS.

By CAPTAIN R. N. HERSON,

Royal Army Medical Corps,

CAPTAIN G. P. CHRISTOPOULOS,

Royal Army Medical Corps,

AND

MAJOR N. F; COGHILL,

Royal Army Medical Corps, Medical Specialist.

No. 3.

Corps.

IN November, 1942, an epidemic of mumps broke out amongst the troops in Cyprus. There appears to be little doubt that in the past this disease has been rare among the local popUlation, and epidemics have not occurred, but information is rather inadequate as mumps is not notifiable to the civilian authorities. In ten years' of civilian practice in Cyprus one of us (G. P. C.) has never seen a case. So far as can be discovered in discussion with other

,local general practitioners and the Government Public Health Department only· a very, occasional mild sporadic case has occurred. It is significant that large numbers of Cypriot tiviliansof all ages were observed with mumps in this epidemic and the general impression. among civilian medical practitioners has been that the cases were much more severe than those observed previously. A number of such complications as meningitis have been seen,

. Civilian patients were not usually admitted to hospital or isolated in any way, many remaining ambulant for much of their illness. This lack of segregation may have influenced the spread of the infection to some extent. Until November, 1942, only a verjoccasiorial case of mumps had been seen among U.K. troops in Cyprus but, in contrast, a steady small flow of cases had come from Indian units; Amongst the U.K. and Indian troops mumps did not reach epidemic proportions, For reasons of security incidence 'figures cannot be given but, in spite of a well-marked preponderance of British and Indian troops, the' great /majority of cases came from Cypriot units among whom the incidence was high. The outbrf'ak was notable on accounts of its severity and the number of complications; nearly

. all of which affected the Cypriots only. In consequence it appears to. us worth while ... recording our experience of mumps in what amounts to virgin soil. Between November,

1942, and the end of April, 1943, 827 cases were notified to the Army medical aut.\J,orities

9

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108 Mumps in Cypriot Troops

in 'Cyprus and of these 432 were admitted to the hospital at which we were working. Of the cases notified 715 were Cypriot and 40 V.K. (the rest being Indian) and, of those seen by us, 408 were Cypriot and 24 V.K. Only ,one case (V.K.) was admitted to our

, hospital in May. There was no selection in the type of case admitted to us. Age.-All the Cypriot patients were soldiers and therefore fell broadly into the age-group

18 to 45. The average age in this series was 20·5 years. . Salivary Gland Involvement.-This is shown in Table 1. The incidence 9£ glandular

involvement in this epidemic was not greatly "different from that in a series of 5,756 cases of mumps in Army personnel in Camp Wheeler, Georgia, V.S.A., reported by Radin (1918), or that in a series of 694.cases mainly amongst Australian troops observed by Macleod (1919).

From the records of the last 136 cases of our series further facts were obtained. In 109 of these five to. eight days elapsed after admission before all the glands subsided; the average period was seven days, the extreme~ being two and fifteen., It was found that, in those cases in which the submaxillary glands were not involved on admission', if they later became so the average period between initial parotid enlargement and subm<:J.xillary spread was seven days. A striking feature in many of the cases appeared to us to be the extreme size of the salivary gland swellings, particularly of the parotids, the largest of all occurring in Cypriots. The onset of the disease was usually accompanied by a moderately severe bout of fever lasting in some up to a week. .

Treatment and Length oJ Stay in Hospital.-The average length of stay of all cases was 16·5 days' with extremes of thirty-siX and twelve. This is little different from Radin's series where the average duration of illnes,'? was fourteen days. The patients were isolated for a minimum of eight days after the salivary glands had,subsidei or fourteen days from the onset, whiChever was the longer period. Treatment was largely symptomatic and along the usual' lines.

There were no deaths. COMPLICATIONS.

Orchitis.-86 (21 per cent) of the Cypriots had this complication. Of these 34 (39 per cent) were, right-sided, 41 (48 per cent) left-sided and 11 (13 per cent) bllateral. (For the V.K. troops the figures were as follows: total incidence 4 cases (18·2 per cent); one right-sided, two left-sided and one bilateral.) An average of nine days elapsed before theorchitis subsided. In most cases the orchitis was accompanied by a well-marked febrile reaction and -moderately severe constitutional disturbance. Temperatures of 104° F. were common and the febrile period was fairly often prolonged to seven days. 'It was noticed

'that cases with orchitis were more 'liable to other complicatio'ns such as meningitis or pancreatitis and that, when these were absent, headaches, mild epigastric pain and vomiting

, were frequent. The orchitis usually occurred six to seven days after the onset of the disease. If the affection became bilateral the second testis generally swelled up two or three days after the first. Stengel (1936) collected representative statistics for this complication from the literature and found that in seven series, each of over 1,000 cases reported by' various authors, the average percentage incidence was 18·2 per cent, although the figur-es' varied within very 'wide limits in different outbreaks. It is gen~rally agreed that orchitis is very uncommon in childhood and is most likely to affectyoun'g adults. In the cases iecorqed' in the literature there is usually little difference in the incidence of involvement of the right and left side. Stengel states that most authors find that unilateral orchitis is two or three times as frequent as bilateral, but here agairi there is considerable variation recorded. He also fo~nd from his review of the literature' that orchitis as a rule follows parotitis and most often appears towards the end of the first week of the illness. Exceptionally orchitis precedes' parotitis and may even occur without involvement of the saliviJ.ry glands.

Meningitis.-There were 14 cases of meningitis, an incidence of 3·4 per cent. All these patients were CyPriots and most occurred early in the epidemic. Four of them had orchitis in addition. The usual symptoms were considerable malaise and headache all(~ nausea / often with vomiting. Some of the patients were drowsy and one' was delirious. Neck


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Troops U.K. Cypriot

Numbers 16*

385*

R. alone

No. % 7 43·7

69 17·9

. Parotid

L. alone

No. 01 ,0

1 6·3 36 9·4

TABLE I.-SALIVARY GLANI) INVOLVEMENT.

Submaxillary

Both, R. .' L. Both, alone alone alone alone

No. % No. % No. % No. % 5 31·3 ,0 0 0

256 66·5 0 I, 0·3 0

One S.M. One S.M. Two S.M. All and and and four

one P. two P. one P. , glands No. % No. % No. % No. %

I ,6·3 0 I 6·3 1 6·3 4 1·0 13 3·4 0 6 1·6

S.M. = Submaxillary Gland. P. = Parotid Gland. * No detailed information available as to glandular swellings in 23 Cypriot and 8 U.K. cases:

TABLE n.-SUMMARY OF C.S,F, FINDINGS IN THE CASES OF MEN'INGITIS.

First lumbar puncture Second lumbar puncture Third lumbar puncture

Day Pres- White cells Day Pres- White cells Day Pres- White cells of sure Total Lym- of sur:e Total Lym- of sure Total Lym-

dis- mm. per Polys. phos. Protein dis- mm. per Polys. phos. Protein dis- mm. per Polys. phos, Protein Case ~ase C.S.F. C.mm. % % mgm.% ease C.S.F: c.mm. % % mgm.% ease C,S.F, c.mm. % % mgm.% . E.L 9 160 130 Mostly 10 250 3 100 G. not + 12 80 26 G. not + N.G, 6 120 38 Mostly 7 120 880 8 92 IS 60 IS 85 N.C. 12 250 33 G. not + 16 150 0 -' G. not + -M'. R. 11 185 20 G. not + 13 120 14 110 0 G. not + S.H; 8 135 60 G. * 11 150 5 G. not + K. M. 5 180 200 G. not + 8 75 60 20 80 G. not + Y:M. 8 200 800 G.not+, 10 145 50 G. t 16 165 22 G. not +

Fourth lumbar puncture = 21 120 11 25 75 . 13·2 A.O. 4 135 14 20 80 G, not + S. C. 9 130 30 G. not + 13 115 20 15 85 26·4 20 110 11 5 95 20·0 E.T. 7 110 180 G. not + 11 Very low 53 28 72 G.mod.+ 18 120 13 8 92 26,4 F,N. 9 140 16 5 95 25·0 14 110 11 4 96 25·0 M.H. e not + 35 8 92 30·0 A.D. 3 not + 14 3 97 20·0 c: G. 7 125 14 5 95 30·0

+ = lp-crease. G. ;= Globulin. * = Slight +. t = Very slight +. Mod. = Moderate.


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110 Mumps in Cypriot Troops . '. \

rigidity was constantly present at some,stage although Kernig's sign was not often positive. High remittent temperatures sometimes lasting as long as a week and reaching as high as 105° F. were a striking feature in this series. The C.S.F. findings varied considerably from case to case as will be seen in Table n. The symptoms and signs started either concurrently with the onset of the mumps or up to ten days later (average siJ\), and they lasted for one to seven days (average 4·5).

By way of control the CSF. was examined in twelve Cypriots during the acute phase of parotitis but showing no signs of meningeal irritation. There was no increase in the pressure in any case, and in eleven the cell count and protein content were normal. In one case there were fourteen cells per c.mm. of which 94 per cent were lymphocytes. These controls were performed towards the end of the epidemic when there were a few cases shoWing meningitis reaction. .

The histories -of three cases of mumps complicated by meningitis are reproduced as illustrations.

Case L"':"-Private E. L., aged 1.9. Admitted on the third day of his illness with very tender bilateral parotid swellings and a history of fever with difficulty in swallowing. He rem<J,ined afebrile and progress was uneventful until the eighth day when he developed a left epididymo-orchitis, cons'iderable suffusion of the conjunctiva! and a temperature of 102·4° F. He was very restless and agitated during the night with fits of uncontrolled weeping and screaming. The next day the temperC).ture, which was 105° F. in the morning, remained

. high and his headache, after steadily increasing, became very se'vere by the evening when there was marked neck rigidity and a positive Kernig's sign. He remained delirious and excitable. A lumbar puncture was performed and clear fluid under a pressure of 160 mm. C.S.F. containing 130 cells per c.mm. (mostly lymphocytes) . was withdrawn. He passed a poor night in spite of receiving an injection of morphine and hyoscine. The following day he remained in much the same condition except that he now complained of an aching pain in the epigastrium. A lumbar puncture was again performed and on this occasion t1!e pressure was 250 mm. C.S.F.; about 30 c.c. of clear fluid were slowly withdrawn. The white cells now numbered only 3 per c.mm., all of which were lymphocytes ;/globulin was not increased. By .the evening he was a little quieter and showing signs of improvement. This was maintained for twenty-four hours after which there was a recrudescence of the'signs of meningeal irritation. Because of this a third lumbar puncture was performed; the fluid was clear and not under increased pressure but the white cells numbered 26 per c.mm. ; globulin was not raised. After this his condition greatly improved and in two days he was symptom-free. ' The abdominal pain which ap,peared on the tenth day lasted two days and 'was not accompanied by any physical signs in the abdomen. He was discharged from hospital thirty-two days after the onset .

. Case 2.-Private A. D., aged 25. Admitted with a history that on the previous night he had developed a head~che and pain in both sides of the face. Both parotids were swollen and his temperature was 103'2° F. with pulse-rate 120 per min. He had a severe headache, was drowsy and could not be properly roused. Then: was moderate neck rigidity and a mildly positive Kernig's sign. The following day there was an improvement, the patient being more conscious, although the neck rigidity and Kernig's sign remained unchanged. A lumbar puncture was performed. The fluid was not under increased pressure; there were 14 cells per c.mm. of which 97 per cent were lymphocytes and 3 per cent polymorphs ; the protein was 20 mgm. per cent. A steady improvement was maintained and by the fifth day-of the disease the temperature was normal and the headache had gone. Thereafter progress was uninterrupted and the patient was discharged from hospital fifteen days after the onset.' .

Case 3.--,--Driver N. G., aged 19 .. Admitted on the third day of disease with bilateral . parotitis. The onset was accompanied by shivering and a frontal and occipital headache

which had become severe. There had been 'mild vomiting. The day after admission to hospital there was moderate neck rigidity but no other abnormal physical- signs. The symptoms persisted and on performing a lumbar puncture clear fluid under a pressure of 120 mm. C.S.F. was withdrawn. It contained 38 white cells per c.mm. (mostly lymphocytes). On the following day the neck rigidity was passing off but the headache remained the same


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R. N. Herson, G. P. Christopoulos and N. F. Coghitl III

and a second lumbar puncture was carried out. There was no change in the pressure of the fluid, which was clear, but the white cells now numbered 880 per c.mm. of which 92 per cent were lymphocytes and 8 per'cent polymorphs. After this clinical improvement was rapid and sustained but a third lumbar puncture eight days later (thirteenth day of disease), when there were no symptoms or signs, produced a fluid still containing 60 white cells per c.mm. of which 85 per cent were lymphocytes and 15 per cent polymorphs. 'He was discharged from hospital eighteen days after the onset.

In addition to the fourteen cases classed as meningitis about the same number of patients (including a U.K. Medical Officer and Sister) had a slight meningeal reaction lasting thirty-six hours or less. These cases were not confined to one part of the epidemic but were spread over the whole period. On account of the mildness of the symptoms and signs, or their short duration, lumbar puncture was not carried out and they were not classed as true cases of meningitis. ,~

The C.S.F. findings varied from case to case; chiefly in the pressures and total,cell counts. The former ranged from normal to ,250' mm.C.S.F. but in" the majority it was not greatly raised. Generally speaking, there was a tendency for the pressure to fall after the first lumbar puncture, and it was usually found that the operation considerably or almost ' completely relieved the headache, at least for a time. There was a wide variation in the C.S.F. cell totals at the first lumbar puncture, the lowest being 14 and the highest 800. In all cases the great majority of the cel~s were lymphocytes. The increase in cells lasted over fourteen days in one case (Y. M.), over twelve in two (S. C. and E. T;) and over ten in, a fourth case (N. G.). A few days after the onset of the complication the cell counts usually bore little relation to the clinical state of the patient and might remain raised for some days after the complete subsidence of the meningeal signs; furthermore, even in the early stages' some of the patients appeared to be more affected by the ID-eningitis than would have been suggested by the C.S.F. findings alone, as in Case 2. The proteins in most instances did not

J differ from normal but in one the globulin was moderately increased on one occasion. The frequency of meningitis or meningo-encephalitis varies greatly in different· mumps

epidemics. Larkin (1919) ?bserved the complication twice in 2,400 cases. Gordon' (1940) . states that, in Dopter's large French Army series of 1910 and 1911, the frequency was

9·8 per cent. In the series. of 5,756 cases of Radin (1918) the complication was seen once. Steinberg is quoted by Gordon as finding meningitis in 10 per cent of 210. cases. References could be. multiplied but the fig~res given serve to illustrate h~w widely the incidence of this complication has varied in the recorded series. It would appear that mumps meningitis has so far been rare in the M.E.F. (personal communication from Brigadier n. McAlpine, Consulting Neurologist, M.E.F.). One of us (N. F. C.) has seen one other case' in a New Zealand private soldier in Egypt in 1940. At the same time the incidence 'of mumps

• in the M.E.F. outside Cyprus has been low. It might be supposed that th.e strain responsible for the epidemic here reported was more rieurotropic than usual at least early in the outbreak. This hypothesis receives a little confirmation from the fact that the English matron of a civilian hospital on the island who had had mumps as a child contracted a second attack in this epidemic, complicated by severe meningitis immediately followed by an encephalitic phase with comatose state, there being a lymphocytic pleocytosis in the C.S.F.

As a general rule meningitis appears at a time when the salivary gland swellings are )Vell marked or when they are beginning to subsi5ie but ·it may occur early in the disease and even be the first manifestation of-mumps in which case diagnosis is difficult until a salivary gland becomes involved. The meningitis of mumps fuay be mild or severe and its duration

., is likewise variable. The usual symptoms are fever, headache and vomiting. Haden (1919) considered that encephalitis plays at least as important a part as meningitis in producing the clinical manifestations of central nervous system involvement in mumps. His reasons for this assertion are that cases may often be observed with severe headache and fever, and it may be with vomiting, but without other signs of meningitis; and further that even when there are' signs the neurological symptoms may be out of all proportion to the findings


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in the spinal fluid. -In this epidemic our experience has been similar to Haden's. This author .quotes Acher as noting convulsions, monoplegia, hemiplegia, aphasia, psychosis, stupor and c!isturbances of sensation among 31 cases of mumps meningitis. Such -signs are undoubtedly indicative of an encephalitis as were those that developed in the English matron apd in at least two Cypriots observed in the present series (Cases i and 2). Feiling (1915) in his critical review of mumps states that " cliniCal observatjonsalone raise a strong presumption in favour of the possibility of the virus of mumps attacking the nervous structures of the brain itself." Although the prognosis in meningo-encephalitis of mumps is nearly always favourable yet on rare occasions there are permanent sequelce such as hemiplegia or aphasia and in a few cases death has occurred. '

It is generally agreed that a lymphocytosis in the C.S.F. can occur'in mumps whether there is clinical evidence -of meningitis or not but reports differ as to how often it is -found without the clinical signs of this complication and recorded estimations of its frequency vary considerably. Feiling cons}dered it a consta~t finding but Gordon quotes Popkova et al. as encountering it uncommonly and Chalier et al. as finding it in 5 per cent of cases. Teissier and Eismein also quoted by Gordon discovered it in 25 per cent of their cases. In our series only one of the 12 controls had -a slight increase in the number of leucocytes in the C.S.F. It is thus clear that such an increase is not a constant finding. The C.S.F. in mumps meningitis may not return to normal for several weeks. Feiling quotes a case of Chauffard imd Boidin in which a considerable lymphocytosis persisted until the forty-sixth day of the illness. The number of cells found varies from just above normal to many thousands.

- Usually the lymphocytes constitute over 90 per cent of the cells in the C.S.F., tlje remainder - being polymorphonuclears, but sometimes the proportion of the latter is larger and may

even show a predominance up to 70 per cent (Haden) .. Pancreatitis.-Like meningitis this complication was confined to Cypriots. Xhere were

9 cases giVing an incidence of 2·2 per 'cent, most of which occurred towards the end of the outbreak. Six also had orchitis.

Pancreatitis was diagnosed only when the following signs were present: _ Fever, epiga'ltric pain and tenderness; nausea and vomiting. There were a few patients with mild epigastric pain but no tenderness, only slight fever and perhaps mild na,usea, but these have not been

_ included as true cases of pancreatitis. The complication started between three and thirteen days after the onset of the mumps (average 7·7) and persisted for from one to seven days (average 3·4). Asirt the case of meningitis the febrile resppnse was often striking. Diastase estimations starting within thirty-six hours of the onset of the complication were performed on twenty-four hourly specimens of urine in 7 of the patients; the results of these tests are given in Table In. It will be seen that the diastase content of the urine was not much

TABLE IIl.-URINARY DIASTATIC INDICES IN CASES WITH PANCREATITIS.

Test Test Test Test- Test Highest Patient 1 2 3 4 5 value

1 64 32 32 64 2 32 32 32 3 16 16 32 32 4 8 16 16 16 5 A. H.· 128 64 16 16 16 128 6 M. C.t 64 32 16 64 7 64 64

Average 57 * See C~se 5. t See Case 6. I

raised, only one case giving a significant high value. In three of the five cases where the' tests were performed more than twice there was a' decline of the diastase values to no ~mal as the patients progressed to -recovery. - Controls were performed on 18 cases with uncomplicated parotid swellings; the results of these are given in Table IV. Both in the cases of pancreatitis and in the controls when more than one test was performed the interval between successive tests was twenty-four or forty-eight hours. Taking the~average of the


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TAB'LE IV.-URIXARY DIASTATIC INDICES IN THE-CONTROL CASES OF UNCOMPLICATED MUMPS.

Test Test Test Test Test Highest Patient 1 2 3, 4 5 value

1 8 16 16 2 64 32 32 64 3 32 32 128 16 32 128 4 16 32 32 5 32 16 8 32 6 32 32 32 32 7 16 8 8 16 8 8 8 16 16

'9 8 16 16 16 10 32 16 16 32, 11 64 32 32 . 64 12 16 32 16 32 13 32 16 16 32 14 " 8 16 16 16 15 32 16 32 32 16 16 16 16 16 17 8 8 18 16 8 16 16

A,!,erage 33

highest values found in the cases with pancreatitis there is a small difference compared with the average of the highest values of 52 urinary diastase estimations in the 18 controls. One control on one occasiongave a result (128 units) as high as the highest in the pancreatitis cases. Thus this complication may, occur without much' disturbance of urinary diastase excretion but this is not surprising when the relatively mild and transient nature of the condition is considered. The urines of the 9 cases of pancreatitis were examined for sugar and albumin with negative results. In several cases the stools were inspected and showed no macroscopic evidence of steatorrhcea.

The following two case histories are fairly typical of this series :-

Case S.-Private A. H., aged 30. Admitted with a three-day history of shivering and headache and with bilateral parotid swellings for the previous two days. There was mild

• fever which rose to 105'2° F. on the eighth day of the disease when left orchitis developed. rhe next day he complained of anorexia, nausea and a constant aching upper abdominal pain. He vomited once; there was constipation. The patient looked ill, his face appearing drawn and his complexion muddy;, his tongue was furred. The abdomen was mildly distended and there was considerable tenderness in the epigastrium ·with slight resistance. During that night there was constant nausea and he vomited several times.' The following morning he felt and looked better and the abdominal tenderness was improving although the other symptoms and signs were not greatly different and there was a continued mild feve'r. Urine collected during the previous twenty-four hours was found to have a diasta'tic index of 128 units. The next day he was much improved, vomiting had ceased and there was only mild anorexia, nausea, abdominal pain and tenderness. A second twenty-four-hour specimen of urine had a diastaticindex of 64 units. Thereafter he made uneventful progress although his appetite was not normal until the eighteenth day of the disease. Three further twerity-fourchour urine specimens ,each gave diastatic indices of 16 units. He was discharged from hospital twenty-one days after the onset.

Case 6.-Private M. C., aged 20. The illness started with swelling of the leftparotid gland which had subsided seven days later. The temperature rose on the seventh day and on the eighth'reached 104·2° F. (see temperature chart) with the development of right-sided orchitis and malaise, anorexia, nausea,vomiting and intermittent shooting upper abdominal pain. The face was flushed; there was moderate tenderness in. the epigastrium but no resistance. The next-day the fever, vomiting and considerable abdominal pain continued. The epigastric tenderness had become more pronounced but there was still no abdominal resistance. Urine collected during the previous twenty-four hours had a diastatic index

'of 6.4 units. The following day he started to improve. Vomiting ceased, he felt better in himself and there was less epigastric tenderness. A second twenty-four-hour specimen of, urine had a diastatic index of 32 units. Thereafte~ there was a steady improvement. By the fourteenth day the temperature was normal and a final urinary diastase estimation gave


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It t Mumps in Cypriot Troops

DAY OF DIS EASE 4 5 6 7 II

105"'

104"

103' w "" " ;;;)102.

I-~IOI' LJJ

~IOO'

'" . I- .9.9

.98"

" 97 120

100

w on ..J

,::I 0..

BO

60 Temperature and pulse chart of Case 5, Pte. A: H,

DAY OF DI!>EA5E ~ __ 7~ __ ~ __ ~8 __ ~ __ ~9 __ -r __ ~'~O __ -r __ ~I~I __ -, __ ~I~~~-. __ ~1~3~ __

104'

103'

~ 102.' :::J

!( ID" ,"' ~ lOO' z: ~ 99' 98'r-r-------~------~-+----~~----~----~~

Temperature and pulse chart of Case 6, Pte. M. C.


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'a value of 16 units. Three days later the patient was symptom-free. . He was discharged from hospital twenty-six days after the onset.

Available laboratory tests did not afford any help in establishing a diagnosis of pancreatitis which had to be made solely on clinical grounds. The findings were sufficient, however, to leave little doubt as to the nature of the condition. 'It is not known why all the cases of pancreatitis should have occurred' in the later stages of the epidemic when there were almost no cases showing evidence of meningeal reaction.

There was more often 'orchitis with pancreatitis than with menIngitis, this occurring in two-thirds of the former but only one-quarter of the latter cases. In the majority the onset of the orchitis was concurrent with the pancreatitis or within a day of it in contrast to the cases with meningitis where there was more ofteh a lap3e of three to four days between the onsets of these two complications. Meningitis and pancreatitis were ncit seen in the same patient.

As with other complications of mumps the incidence of pancreatitis has varied considerably in the published series. Among Radin's 5,756 cases this complication was encountered 14 times (0·31 per cent). Simonin is quoted by Bernard and Scheffer as having found pancreatitis in 10 of his 654 cases of mumps admitted over a four-year period to a military hospital. N~lson's" Loose Leaf Medicine" quotes Vaccara,zia as having found an incidence of 1·21 per cent in 6,923 cases of mumps reported by eleyen observers. Most critical reviews on this subject consider pancreatitis to be rare.

Farhan (1922) collected 119 cases of mumps pancreatitis from the literature and from his analysis of these he reached the following conclusions :-

(1) Urine and stool examinations have rarely been performed. Sugar was found in the urine only twice in the 23 cases;in which it was looked for. An increase in frecal fat has on occasions been noted, but the number of observations is so small that no generalizations can be made from them.

(2) The febrile reaction accompariying pancreatitis is usually slight; on only four occasions were temperatures as high as 103-104° F. recorded.

(3) ~ymptoms only persist for a' short time, usually not more than forty-eight hours. Even in severe cases the duration is rarely more than seven days. Recovery is the rule.

(4) In 7 of the 119 cases there was orchitis and in 2 there was meningitis. (5) In 28 cases the interval betweeri the onset of parotitis and that of pancreatitis was

four to seven days; in 4 it was two weeks, in 10 less than four days and in 5 pancreatitis preceded parotitis. '

(6) An abdominal mass representing the swollen pancreas was felt only 13 times. The literature subsequent to the paper by Farhan that we have had at our disposal has

little to ,add to the above summary. It would appear that the febrile reactions observed in our cases were often unusually severe, in some perhaps because of the usually concurrent orchitis which was associated with the complication much more often than generally occurs.

Very occasionally jaundice has been reported as an accompaniment of pancreatitis. RadiIi encountered it in 4 of his 14 cases. It is recognized that diabetes may follow the' pancreatitis of mumps but it is very rare.

No mention of the results of estimations of urinary diastase in cases of mumps with pancreatitis could be traced in the original articles at our disposal and it would therefore appear that this test has rarely been performed in these cases. Tue only reference to diastase estimations which we were able to find was a short paper by Dunlop (1933) who performed repeated tests on 60 cases of uncomplicated mumps. He found that a rise of urinary diastase may occur from the second day of the disease and persist after t~e glandular swellings have subsided. All his re<j.dings were above 30 units, some being over 200. He expressed'the opinion that the diastase was probably derived from the parotids. '

Simple Febrile Reaction.-In four patients, all Cypriots, there was a well-marked, moderately prolonged febrile reaction, for which no cause was found. The onset was' after


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the glandular enlargements had begun to subside. The only symptoms were malaise, lack of appetite, slight nausea and mild headache. Laboratory investigations were all negative, but it is perhaps unfortunate that an examination of the C.S.F. was not made in any of the cases. There were, however, no clinical grounds for supposing the meninges to have been involved. Chronic malaria is fairly common amongst Cypriots (although becoming increasingly less so) and it might be said that these unexplained fevers were in fact relapses precipitated by the secondary disease. Repeated blood films were examined (as in all the febrile cases) but no parasites were found; the fevers were in no way like that of a chronic malaria relapse and there was no splenic enlargement in any patient (ages between 18 and 25). It was considered most unlikely that malaria- was a cause of the pyrexia in these cases. It is possible that these febrile reaction.s were the Sole manifestation of abortive or otherwise silent complications.

~ 10'· ::J

~ 100· a: ~ ss::;:

, l:' 88·

'" on

DAY_OF 01 SEAS E ... IS .6 17 18 .9 .20 .2.1

3r---------~~--~----~--~~~~;r~~~~~~--~~--~ n.

60

Temperature and pulse chart, Pte. G. P.

Radin in his paper mentions (without comment or emphasis) that the temperature may rise to 106° F. without an obvious cause. He does not state at what period in the disease in his cases such an unexplained fever occurred. We haye been unable to find more than one other author who makes any reference to this complication. From the point of view of the present epidemic the outbreak of mumps reported by Madeod (1919) is of especial interest. There were 694 cases, nearly all of which were Australian troops which, he states, " offered peculIar facilities for the spread of the disease in a virgin soil as very few of them had' previously been exposed to this infection." He records that" in 48 cases which, after a primary att~k of ordinary severity, had already entered on convalescence, the temperature rose abruptly on the seventh to tenth day to 100° or even 104° F., with a pulse-rate of 80 to 120. Apart from a feeling of .general malaise, there was no local manifestation to indicate the seat of this complication, which is apparently toxic in nature; the temperature fell by crisis in two to five days and thereafter convalescence was uninterrupted."

Upper Respiratory Tract Infection.-This was noted in 23 cases. It usually took the form of follicular tonsillitis or a painful simple intense reddening of the fauces, tonsils or pharynx. Some of the patients had nasal catarrh and epistaxis. There was one case of otitis media. In the larger books of reference attention is drawn to these manifestations' as being occasionally encountered in mumps .

. Other Complications.-Four patients complained of pain in the ear made worse on moving the jaw. in all these the qrums were normal and the pain was considered to bedue to pressure

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R. N. Herson, G. P. Christopoulos and N. F. Coghill 117

caused by a tensely swollen parotid gland. One case developed lobar pneumonia; acute bronchitis, usually mild, was not uncommon. Considerable conjunctival suffusion was seen on at least four occasions but its exact frequency was not determined; this is a wellrecognized complication of mumps.

Changes in the Blood.-White-cell counts were performed on the blood of 7 of our cases and the results are shown in Table V., In none of these cases was there a leucocytosis;

Patient, 1 2 3 4 5 6 7

TABLE V.-BLOOD VVHITE CELL COUNTS IN MUMPS.

Total W.E.C.s . per c.mm.

7,200 7,500 7;600 6,600 8,500 8,500 8,400

Lymphocytes % 44 33 41 24 31 40 29

Polymorphs % 54 62 59

. 68 66 58 68

Eosinophils Monocytes % % 2 0 1 4 o 0 2 6 o 3 1 1 o 3

3 of them showed a mild relative and absolute lymphocytosis; 2 counts were normal; 2 were borderline. Feiling, in his critical review, came to the conclusion that ther~ was a slight leucocytosis in mumps and also a relative and absolute lymphocytosis. Whitby and Brltton (1942) state that" lymphocytes are always relatively increased" in the blood in mumps, but from a study of Feiling's tabulated results and our own very small series it appears that this may not always be so.' •

Comp,arison of this with other Epidemics.-As has been shown statistics for each of the recognized complications vary very considerably so that any comparison is difficult. In addition only a limited number of the relevant references have been available to us. All that can be done therefore is to present in tabular form an analysis of those series which contain complete data as' to all the complications which occurred in each (see Table VI). It would

TABLE V1.-VARIOUS EPlDEII!ICS COMPARED.

Number of Percentage Percentage Percentage with cases zn with Percentage ,with with ' unexplained

Author the series orchitis meningitis pancreatitis fever Brooks, H. (1918) 1,059 24 0 0·28 ,0 Macleod, G. (1919) 694 20 0 0·86 6·9 Radin; M. J. (1918) 5,756 13·9 One case had· convul- 0·31 Mentions as oc-

sions. Mentions that curring but no marked ,nervous dis- figures given turbance may occur but gives no details or figures

Bernard, M. B., and Scheffer, 1. H. (1931) 252 10·7 0·79 5·2 0

Present series 408 21·1 3·4 2·2 0·98' (Cypriots)

appear ftom a study of the series given in the table that meningitis and pancreatitis are seldom associated in the same outbreak and that, in the epidemic here reported, the number of patients with-complica:tions was fairly high. Statistics for complications give an imperfect picture of the severity of an outbreak and a true comparison of mumps in different series is most difficult as it is usual to find that insufficient facts are recorded for this purpose. From a study of some of the literature, and our past limited experience, we have formed the impres§ion that even in the uncomplicated cases our patients were on the whole more ill than is usually the case.

SUMMARY AND CONCLUSIONS.

Details are g\ven of 432 cases of mumps occurring, between November, 1942, and the end of April, 1943, principally in Cypriot troops stationed in Cyprus. These patients

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represented part of an epidemic in the island at that time. The case incidence was high amongst Cypriots (troops and civilians of all ages) and very much higher among them than among U.K. troops present in. the island. Nearly all the complications were 'Confined to the former. From a comparison with other . outbreaks the infection in this epidemic would appear to have been virulent. . The evidencdor this was the high case incidence, the number and severity of the different complications, the size of the glandular swellings and the fever and general disturbance, both in the initial phases and with the complications. Some of the U.K. patients were much more ill than is usually seen with mumps in adults. These features were less prominent towards the close of the epidemic as was to be expected. It seems likely that the virus gained virulence by rapid passage through a susceptible population.

. We wish to 'thank Captain K. B. Gibson, RA.M.C., for notes on some of the cases; Major]. Clark, RA.M.C.; Brigadier D. McAlpine; the Director of Medical Services (Civil), Cyprus; Drs. ] .. H. Laurie and R B. Wilkinson for permission to refer to th.eir case of meningo-encephalitis; Lieutenant-Colonel M. ]. Malley, RA.M.C., O.c. to a General Hospital, M.E.F., for permission to forward this paper;. and Sjt. A. Corner, RA.M.C., for much valuable help~

REFERENCES .

. BERNARD, M. B., and SCHEFFER, 1. H. (1931). Am. j. Med. Sci., 181,255 BROOKS, H. (1918). Med. Clin. North America, 2, 492. DUNLoP, G. A. (1933). Lancet, 2, 183.' FElLING, A.(1915). Quart. Jour. Med., 8, 255. FARHAN, L. W. (1922). Am. j. Med. Sci., 163, 859 .. GORDON, J. E. (1940). Ibid., 200, 412. HADEN, R. L. (1919). Arch. Int. Med., 23, 737. LARKlN, W .. R. (1919). Military Surg., 44, 92. MACLEOD, G. (1919). Brit. Med. Jour., 2, 742. NELSON'S" Loose Leaf Living Medicine," 1. No. 1923, 561A. RADIN, M. J. (1918). Arch. Int. Med., 22, 354. STENGEL, A., Junior (1936). Am. j. Med. Sci.,191, 340. WHITBY, L. E. H., and BRITTON, C. J. C. (1942). .. Disorders of the Blood," London.


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Documents

R.oyal krmy Medical Corps. - BMJ Military Health · Orchitis.-86 (21 per cent) of the Cypriots had this complication. Of these 34 (39 per cent) were, right-sided, 41 (48 per cent)