that of the unilateral form, and the attending fever is more intense.
The rapid return of the testicle to its natural size and shape shows
that, as in the parotid glands, the inflammation does not extend
beyond the stage of serous exudation.
THE DIAGNOSIS of mumps is easy after the disease is sufficiently
developed to produce the characteristic alterations in the facial
expression. In the earlier stages the position of the swelling,
immediately beneath and in front of the ear, its triangular shape, and
the elevation and outward displacement of the lobe of the ear of the
affected side, distinguish it from the enlargement of the cervical
lymph-glands so liable to occur in strumous subjects. The acute onset
and course of mumps are the points of distinction between it and
morbid growths, or the very rare condition of chronic hypertrophy of
the parotid gland. The metastatic orchitis cannot be mistaken for
gonorrhoeal orchitis if the least care is taken to investigate the
history in either case.
THE PROGNOSIS is extremely favorable, there being no record of a fatal
case of uncomplicated mumps. Suppuration may occur, but it is an
exceedingly rare event. In scrofulous children the course may be
protracted for several weeks, and in them resolution is occasionally
imperfect, a degree of enlargement and induration of one or both
parotids remaining for some time.
Metastatic orchitis, as a rule, leaves the testicle in a normal
condition, but, according to Vogel, in some epidemics complete atrophy
results.
Dogmy reports an epidemic which raged in a garrison of Mount Louis in
January, 1828. Of sixty-nine bilateral and eighteen unilateral cases
of parotitis, metastasis to both testicles occurred in four cases, all
of which resulted in atrophy of the affected testicle.
THE TREATMENT is simple. The patient should be kept in a uniform
temperature, confined to one room, or, better still, to bed, until
resolution is well established. While the difficulty in swallowing and
fever continue the food should consist of milk and beef-tea; later,
other nutritious articles of diet may be added as the appetite
demands. Water, iced carbonic acid water, or lemonade may be allowed
as freely as the patient will take them, to allay the thirst. A daily
evacuation of the bowels must be secured by the use of saline
laxatives. During the early stage, if the fever be high, tincture of
aconite-root should be cautiously administered; afterward liquor
potassii citratis will sufficiently fill the indications for a
febrifuge. Tonics are required during the decline of the disease; of
this class of remedies, syrup of the iodide of iron, bitter wine of
iron, and ferrated elixir of cinchona are most useful.
Special symptoms may demand attention. For example, headache and
delirium should be relieved by hot mustard foot-baths and moist cold
to the forehead; difficult deglutition from enlargement of the
tonsils, by the frequent swallowing of bits of ice, or, if possible,
by the application of {625} astringent lotions, as tannic acid and
glycerine (one drachm to the ounce); sleeplessness, by the
administration of bromide of potassium, with or without small doses of
hydrate of chloral in children and of some preparation of opium in
adults.
In the way of local treatment the best results and greatest relief to
suffering will be obtained by gently rubbing the swollen glands with a
mixture of tincture of opium and sweet oil (one drachm to the ounce),
three times daily, and in the mean while keeping the parts enveloped
with a moderately thick layer of cotton wadding covered by oiled silk.
Water dressings or light poultices may be used with advantage. When
resolution begins a more stimulating lotion will hasten the
disappearance of the swelling.
In the exceptional instances in which the skin covering the tumor
becomes tense and red, and suppuration is threatened, two or three
leeches may be applied behind the ear of the affected side. When
suppuration has actually taken place the abscess should be immediately
opened to prevent further destruction of the gland-tissue and
perforation into the external auditory meatus.
If, particularly in strumous subjects, resolution be incomplete and
glandular enlargement and induration remain after the cessation of the
acute symptoms, cod-liver oil and iodide of iron are demanded for
internal administration and the compound ointment of iodine for
external application. It is well to dilute the latter sufficiently to
prevent its causing irritation of the skin, and to apply it twice
daily.
When metastasis occurs, the return of fever calls for the same general
treatment as in the early stage of parotitis. In addition, an emetic
should be given, as this often cuts short the fever or causes it to
disappear more rapidly. The patient must be kept at perfect rest in
bed, with the scrotum elevated by a cushion and covered with warm
anodyne lotions. Salines must be administered sufficiently often to
secure regular and free action of the bowels.
When the mammæ or ovaries are secondarily attacked, the seat for local
treatment is of course different, but in all other respects the
management must be the same.
For the uncommon cases in which the transference of the inflammation
is attended with depression stimulants are required, and for those in
which meningitis is threatened cutting off the hair and the
application of cold to the head, hot mustard foot-baths, local and
general venesection, drastics, and irritants to the cutaneous surface,
are necessary.
II. Symptomatic or Metastatic Parotitis.
Symptomatic, metastatic, malignant, or suppurative parotitis, as the
condition is variously designated, is an inflammation of the parotid
gland which occurs during the course of different grave acute
diseases, is usually unilateral, and terminates in suppuration, or
much more rarely in gangrene, of the gland involved.
ETIOLOGY.--It may occur in association with typhus, typhoid,
relapsing, puerperal, and scarlet fevers, or with the plague, measles,
dysentery, cholera, and pyæmia, springing into notice at different
periods of the {626} course of these affections, which may be regarded
as predisposing causes. The exciting cause is perhaps mechanical in
nature--namely, the excessive dryness of the mucous membrane of the
mouth so common in the severe fevers. This dryness may lead to an
occlusion of the orifice of the parotid duct, with retention of the
saliva, which fluid, undergoing decomposition, may act as an irritant,
producing inflammation, and finally suppuration, of the glandular
tissue. This is a likely enough explanation of the causation in some
cases, but dryness of the mouth is such a uniform symptom in fever,
and suppurative parotitis such a comparatively rare complication, that
it cannot be a very active or common cause. Nevertheless, it is
impossible to fix upon any other direct cause, though the altered
condition of the blood in the conditions mentioned must not be lost
sight of as an important etiological factor.
ANATOMICAL APPEARANCES.--The character of the pathological lesions
have been well established, owing to the frequent opportunities that
arise of examining the diseased gland at different stages of the
inflammatory process. When the inflammation has lasted a short time, a
day or two, the tubes and acini of the gland are seen on section to be
swollen and reddened, and the connective tissue infiltrated with serum
and yellowish-red in color; a fluid, either viscid, ropy, grayish in
color, or more purulent in character, fills the duct, and may be
forced out into the mouth by stroking it in the direction of the
orifice. If of several days' longer duration, purulent softening will
be noticed in the centre of the acini; this gradually extends until
each acinus is converted into a little sac of pus. Then the
inter-acinous connective tissue breaks down, and the multiple, minute,
purulent collections become converted into a single large abscess or
into two or more smaller ones. Next, the pus seeks an outlet. The
position of pointing may be on the cheek or in the external auditory
meatus--a very common location; again, the abscess may break into the
mouth, the pharynx, the oesophagus, or into the anterior mediastinum,
the pus burrowing its way along the sheath of the
sterno-cleido-mastoid muscle.
While the parotid abscess is forming, suppurative inflammation is apt
to be set up in the masseter, pterygoid, and temporal muscles, and
from these positions the pus forces its way upward to the temporal or
zygomatic fossæ. The periosteum of the neighboring bones, and even the
bones themselves, may become involved, and sometimes the cranial bones
are partially destroyed, and there is an extension of the inflammation
to the brain or its membranes. The middle ear may participate in the
general destruction, and the patient is left permanently deaf, if
indeed he escape with his life.
The lymphatics, veins, and nerves traversing the parotid are affected
by the suppuration in the gland. Irritation of the lymph-vessels
results in swelling, tenderness, and suppuration of the lymph-glands.
Thrombi form in the jugular vein and its branches, and by breaking
down lead to septicæmia and ichorization of the sinuses of the dura
mater. The nerves resist for a long time, but seem to act as paths of
conduction of the inflammation, the facial nerve leading it to the
ear, and the branches of the trifacial to the brain. When gangrene of
the gland takes place, the traversing nerves as well as the gland
elements are rapidly destroyed.
SYMPTOMS.--Symptomatic parotitis, occurring during the course of {627}
any of the diseases already named, produces no change in the general
symptoms; if, on the other hand, it occurs during convalescence, the
onset is marked by a moderate elevation of temperature and increase in
the frequency of the pulse, by thirst, loss of appetite, and sluggish
bowels. The tumor, which occupies the same position and thrusts
outward the ear-lobe as in mumps, is hard, dense, well defined, and
the seat of considerable pain until suppuration takes place, when the
latter subsides greatly. The skin over it is red, hot, and tense, and
there is much tenderness and little or no pitting on pressure. After
the abscess has formed there is well-defined fluctuation on palpation,
and at the position of pointing the skin becomes very thin and assumes
a bluish-red hue. Gangrene of the gland is manifested by the
cadaverous odor, blackening of the skin, the formation of a cavity,
and the discharge of ichor and shreds of tissue. The alteration in the
expression, the pain in the ear, the difficulty in moving the jaw and
in swallowing, are as constantly present here as in idiopathic mumps.
It must not be forgotten, though, that when the disease arises during
the course of any of the severe infectious diseases, the brain may be
so overcome that the subjective symptoms are frequently not complained
of.
The course is usually rapid, the abscess pointing on the fourth or
fifth day after the appearance of the parotid tumor; occasionally,
however, the inflammatory process is much slower, extending over a
period of several weeks. The course is also much protracted when
secondary abscesses form in other parts of the gland or in the
surrounding tissues, when the abscess is transformed into an ichorous
cavity, and when gangrene sets in. Ordinarily, where the pus is
evacuated by spontaneous rupture or by incision the abscess heals
quickly by granulation, leaving the gland enlarged and indurated for
some time.
THE PROGNOSIS depends upon the gravity of the original disease, the
period of the disease at which the complication occurs, and whether or
no mortification sets in. When the vital processes are greatly
impaired by the primary disease, the onset of the parotitis, trifling
in itself, may prove sufficient to determine a fatal result. The
danger of such a result is much increased, too, if the inflammation
begins in the earlier stages or during the height of the disease which
it complicates, while if it commences during convalescence by far the
most frequent result is recovery. Gangrene of the gland involves great
risk of life--a risk which increases in proportion to the early date
of its onset in the course of the original disease. Even when the
gangrenous process ends in recovery, the face is much distorted, the
hearing is lost in the ear, and the facial muscles are paralyzed on
the affected side. Bilateral symptomatic parotitis has naturally a
graver prognosis than the unilateral form.
DIAGNOSIS.--The disease is readily distinguished from idiopathic mumps
by the history, the less marked degree of the enlargement and
surrounding oedema, the greater degree of pain and tenderness, the
hardness of the tumor, the red discoloration of the skin covering it,
and the termination in suppuration. Further, it never displays an
epidemic tendency.
TREATMENT.--The general treatment of this form does not differ from
that of the disease it complicates, though the employment of
stimulants in increased quantities may be indicated.
{628} Before the first appearance of tumefaction of the parotid the
introduction of a probe or canula into the duct of Steno, associated
with pressure on the gland from the outside, may, by forcing from the
duct a collection of mucus or muco-pus, abort the inflammation. If
this is unsuccessful, a poultice should be applied over the gland to
encourage suppuration and pointing externally. As soon as the abscess
points the pus must be evacuated by an incision, and, as this has a
tendency to close again, a piece of lint must be kept between the lips
of the wound.
The enlargement and induration left after the healing of the abscess
require the application of tincture of iodine or of compound iodine
ointment to the surface.
When gangrene occurs it demands the same treatment, both local and
general, as when it is seated elsewhere.
{629}
ERYSIPELAS.
BY JAMES NEVINS HYDE, M.D.
DEFINITION.--Erysipelas is an acute disorder, characterized by the
systemic symptoms common to the febrile state, and by an involvement
of the integument and deeper parts, the affected surface being tumid,
hot, reddened, painful, and often the seat of well-defined bullæ, the
process terminating either in complete resolution after cutaneous
desquamation or in a fatal result commonly due to complications of the
malady.
SYNONYMS.--_Eng._ St. Anthony's Fire; _Fr._ Érysipèle; _Germ._
Rothlauf; _Ital._ Risipolo.
CLASSIFICATION.--Erysipelas is properly recognized as one of the acute
infectious diseases. Though by its symptoms and career it would seem
to be properly assigned to the category of the exanthemata, it is yet
by most authors set apart from the latter--first, because its career
is less specifically defined; second, because its contagiousness is
less demonstrable in every case; third, because one attack is not
known to confer upon its victims immunity against a second; fourth,
because the occasional prevalence of the disease in apparently
epidemic form is evidently due to extrinsic causes, and does not
depend exclusively upon its sudden appearance among the unprotected;
fifth, because no definite period of incubation precedes its earliest
manifestations; and, sixth, because at times it appears in local
manifestations apparently unaccompanied by systemic phenomena.
HISTORY.--The earliest writers on medicine bear witness to the fact
that the disease was recognized at the date when men first made record
of human ailments. It has occurred in all parts of the world and at
all seasons of the year, sparing neither age nor sex in its
development. Zuelzer[1] refers to epidemic occurrences of the
disorder, described by Rayer, as visiting the Paris hospitals in 1828;
by Schönlein, as existing in Zürich in 1836; by Gintrac, as spreading
in Bordeaux in 1844-45; and by Trousseau, as prevailing in the
Maternité in Paris in 1858.
[Footnote 1: _Cyclop, of the Prac. of Med., Ziemssen_, vol. iv. p.
424.]
ETIOLOGY.--Authors have in general assigned different causes to the
forms of erysipelas hitherto regarded as either idiopathic (or
medical) or traumatic (or surgical). The modern view, however, is that
which regards all cases as alike produced by the absorption of the
toxic agent capable of exciting this peculiar inflammation of the
skin. The peculiarly well-characterized symptoms of the disease--for
example, when it affects the head and face--were long regarded as
etiologically distinct from the affection which complicates surgical
injuries and wounds. But {630} a closer study of many of the cases
first named has again and again disclosed the fact that they
originated in such traumatism, for example, as the piercing of the
lobule of the ear for the insertion of an ear-ring, a carious tooth,
an alveolar abscess, or a pathological product in the antrum of
Highmore.
The disease is equally common--apart from the puerperal state--in both
sexes and at all ages, and occurs under favorable circumstances in all
seasons of the year. It is unquestionably at times spread by direct
contagion, either from the living or dead body affected with the
disease. Such contagion may occur mediately or immediately. It is,
however, not readily shown to be producible by the media of clothing
and other articles which have been in contact with a diseased surface.
The contents of the bullous lesions which appear upon the
erysipelatous surface are inoculable; and the disease has in this way
been transferred not only to men, but also, by Orth and others, to the
lower animals, and even from one of the latter to another of the same
species.
Certain it is, however, that the disease does occur, characterized by
symptoms indistinguishable from those to be recognized in the
contagious type of the malady, where the most careful investigation
wholly fails to reveal the cause, and where the disorder rapidly
spreads if the conditions for its extension are favorable. Under these
circumstances it is wisest at present to admit that the exact etiology
of erysipelas is unknown. Its relative frequency in the puerperal
state is unquestionably to be explained by the favorable local
conditions which at such times exist in the female for the development
of all septic disorders.
As regards the circumstances which might be supposed to specially
favor its development, these the capriciousness of the disease, which
is its striking characteristic, often quite disregards. Thus, on the
one hand, it may and often does prevail, year after year, in certain
hospitals, and even in certain wards of a single hospital, especially
where these are crowded with patients. But it may also repeatedly
spare masses of men affected with disease of a different type when the
latter are gathered together in prisons or camps, and indeed even may
appear among such individuals and fail to spread to others who are in
close proximity to them.
With respect to the propagation of erysipelas from infected to sound
individuals, a contrast is exhibited when the transmission of variola,
for example, is compared with it. Thus, it is well known that the
mildest cases of varioloid may be sources of malignant forms of
variola to the unprotected, while those who are partially protected
and exposed to the virus of confluent forms of the disease may exhibit
the mildest symptoms of varioloid. In erysipelas, however, it is
tolerably certain that there are different degrees of virulence to be
recognized in different cases, and that the disease at times is
transmitted in its different types. Thus, traumatic erysipelas is much
more closely related to childbed fever than the varieties of the
disease appearing upon the head and face, which cannot be attributed
to traumatism, surgical accidents, dental abscesses, or local injuries
of the antrum of Highmore. Parturient women frequently escape
infection when the erysipelatous disorder is of the so-called medical
type. Per contra, it is to be noted that women who are prone to the
relapsing and so-called chronic forms of erysipelas are {631}
particularly apt to suffer from that involvement of the genital
organs, peritoneum, spleen, and febrile movement whose sudden
occurrence after confinement is so portentous.
SYMPTOMATOLOGY.--The disease is usually announced by the occurrence of
a chill, which may precede by a day or but a few hours the appearance
of the cutaneous disorder. The rigor may be severe or mild in grade,
so that it may even be forgotten by the patient till his attention
reverts to it in connection with the resulting symptoms. There may be
simultaneously some gastric distress, rarely of severe character.
These symptoms are commonly followed by a febrile reaction. In other
cases the first recognized symptoms of the malady occur in the skin,
the patient scarcely recalling the fact of a slight preceding malaise.
The cutaneous lesions appear in the form of a circumscribed oedema and
redness of the surface, often preceded and usually accompanied by a
sensation of tension, heat, and burning pain. This macule, plaque, or
patch of diseased integument is in its typical features
characteristic. It is distinctly or irregularly circumscribed; its
oedematous condition elevates its level decidedly above that of the
adjacent integument, so that there is a somewhat sudden descent from
the former to the latter for a space of from one to two or more lines.
The redness is also of a bright crimson hue, and the reddened surface
has a sheen or glossy appearance uniformly displayed over its area. It
disappears under the pressure of the finger, leaving a yellowish-white
color in the region of impact, the erysipelatous blush rapidly
returning when the circulation at the surface is restored. This smooth
and shining condition of the reddened patch is so characteristic of
erysipelas that it arrests the attention of the diagnostician as soon
as he observes it. According to Zuelzer, it is caused simply by the
tension of the epidermis. When first observed it may occur in the form
of circular, small or large coin-sized patches, or in streaks, striæ,
and radiations, or as very irregularly disposed, rosy, and shining
marblings or mottlings of an oedematous surface.
The skin thus affected is hot to the touch, tender, firm, and smooth.
It is occasionally the seat of pruritic sensations, more commonly of a
peculiar sensation of heat and burning.
In the course of two or three days the involved area spreads uniformly
or irregularly and centrifugally from the point first involved, after
which time, in mild cases, the disease persists without apparent
change for a few days more, prior to its decadence by resolution. This
final stage of the malady is characterized by a progressively
diminishing fever, moderate desquamation, gradual disappearance of the
oedema, and a color-change to the darker shades of bluish-red or to a
light brown. In this form of the disease the erysipelatous patch,
after being fully developed, does not tend to spread from the affected
to the unaffected surfaces; and, as a consequence, the affection may
complete its entire career in less than a fortnight.
In other cases, however, a remarkable tendency is developed to the
progressive spreading of the inflammation from one point or surface of
the body to another, the parts first affected paling as the disease
passes on to involve those in the vicinity, or being yet deeply
involved while the process of peripheral extension is in progress. In
yet other cases the red blush sweeps away from its first position in
tongue-like projections over a {632} tumid and painful skin, while the
region first invaded becomes paler, though still preserving its
oedematous features. In still another class of cases the advancing
ribbon or band of elevated and reddened integument passes over to a
new area, leaving the regions it has traversed tumid, painful, and
here and there streaked with rosy lines, patches, or irregular
gyrations.