(Read at Illinois State Medical Society.)
ARTHUR E. GAMMAGE, M. D., CHICAGO
This article is prompted by the belief that Vincent's angina, rather than being a rare condition is not uncommon, and is frequently wrongly diagnosed as diphtheria and treated as such.
With the exception of a few of the most recent text books this subject is either not referred to or is given only a few lines of mention. Most literature on the subject is foreign and the condition is variously referred to as: (1) Ulcero-membranous angina and stomatitis; (2) ulcerative angina and stomatitis; (3) angina exudativa ul-cerosa; (4) angina chancriforme; (5) pseudo-membranous angina.
Probably the most complete American article to date is that by Weaver and Tunnicliff in Journal A. M. A., February 16, 1906. About ten months ago Dr. Weaver demonstrated a case to me and since that time I have seen in Cook County Hospital eight more cases. Reports from various sources show that it is not uncommon in Chicago.
Definition: An acute febrile, pseudo-membranous, inflammation of the tonsils and pharynx, with soft yellowish green exudate, which on removal leaves a bleeding ulcer. From the exudate may be isolated two forms of bacteria, one a fusiform bacillus, the other a spirillum.
(a) The bacilli are long, slender fusiform rods six to twelve microns in length and with pointed ends. They are sometimes bent and occasionally take the form of the letter "S". Obligate anaerobes and nonmotile. They stain well with Loeffler's methylene blue and anilin gentian violet but best with carbol-fucin. They decolorize by the Gram method. Scattered uniformly and often as pairs, end-to-end, forming more or less obtuse angles.
(b) The spirilla, also spoken of as spiro-chaetae, are long and delicate. The number of convolutions varies from three to eleven. They are actively motile, and stain uniformly but less intensely than the bacilli, and in faintly stained preparations may be overlooked. They are Gram negative.
Apparently there is a symbiotic relationship between the bacilli and spirilla, as they are always found together. The organisms do not grow, to any great extent, on the medium usually employed for detection of the Klebs-Loeffler bacilli, hence are overlooked, but both forms have been cultivated and it has been found that the cultures show a very marked fetor.
Historical: This condition was described by various French and Russian clinicians, e. g. Sonne and Simanousky, but Tarassiewicz was the first to demonstrate the fusiform bacilli and spirilla in ulcero-membranous angina, in 1893. Plant described them in 1894 in five cases. Vincent in 1896 found them, both in hospital gangrene and in ulcero-membranous angina, and in 1898 reported fourteen cases of ulcero-membranous angina. It has been reported by many writers since from all countries, thus indicating the wide distribution of the organisms in question.
Young adults, (18 to 25) are usually those affected, but the cases seen by me were, with one exception, in children.
Males are said to be most frequently affected, as most cases have been observed in soldiers and medical students. Weaver and Tunnicliff reports, however, show the majority in girls.
Certain temporary states of the individual doubtless favor it. While general weakness or feeble resisting power may be one of these conditions, it is likely also that purely local states, such as uncleanliness of the mouth, teeth and fauces as well as chronic inflammatory conditions may act as predisposing causes. It is said to frequently occur in scarlatina, rubeola and pertussus. Following trauma of mucous membranes. One case seen by me followed tonsillotomy.
Eruption of wisdom teeth.
One of my cases was seen to follow mercurial stomatitis.
Pathology: This may be conveniently divided into three stages: (i) The onset, characterized by congestion and edema; (2) formation of pseudo-membrane; (3) period of ulceration.
Location: Usually primarily on the tonsil and edge of the gum and may extend to the tongue, lips, soft palate, pharyngeal wall, and cheek. Usually unilateral and following the onset, the deposits on the area affected, form a grayish, yellowish, yellowish-brown, or greenish pseudo-membrane simulating the pseudo-membrane of diphtheria. It is thick, cheesy, and friable in character and fairly readily removable. If forcibly separated, it leaves an abraded, bleeding surface on which new membrane is generally promptly deposited. The membrane proper is probably the product of coagulation-necrosis as is the membrane of diphtheria.
Ulceration: The ulcer being single and round, oval, or sigmoid with irregular borders, soon follows. The floor is uneven and has granulating points. The ulceration progresses more deeply than laterally and although usually quite superficial may even bring about destruction of the tonsil, etc. The surrounding mucous-membrane is swollen and red. The submaxillary glands are usually swollen, forming in some instances a firm mass. There is, however, no peri-adenitis and the glands rarely if ever suppurate. To date there are few changes, as far as I have learned, noted in other organs.
Symptoms: The onset is usually insidious with temperature ranging from 90° to 101° F., but may rarely be severe with all the symptoms of an ordinary febrile attack—slight chilliness, fever, and aching pains in back and limbs and difficulty in swallowing. The temperature may be as high as 103.2° F. From one to five days after the onset the local condition is apparent and the patient complains of great difficulty in swallowing. On the affected mucous membrane there appear pseudomembranous formations and as a rule ulcerations. The surrounding mucous membrane is reddened and the tonsils themselves are usually swollen. There is considerable salivation and a very fetid breath, The tongue is heavily coated. The glands of the neck are enlarged, but rarely tender.
Diagnosis: The importance of the recognition of these two parasites and the conditions which they incite is, that as a rule, the cases are considered as diphtheria from the clinical appearance of the membrane.
The diagnosis depends entirely on the bacteriological findings. The failure to recognize it is due to the failure to make direct examinations of the exudate from pseudo-membranous lesions of the mouth and throat.
Klebs-Loeffler bacilli are not readily detected in throat smears, hence the reliance on cultures. The organisms of Vincent's angina do not grow to any extent on the medium usually used for detection of the diphtheria bacillus, hence they are overlooked.
It has been noted that the diphtheria bacillus is frequently found in association with the organisms in question, in the membrane, as is true also of almost any other lesion of the mouth and throat, and it is well known that the Klebs-Loeffler bacillus has been isolated from cases which show nothing more than a simple catarrhal angina or even in a normal healthy throat. In the majority of the diphtheroid inflammations the streptococcus-pyocynes is the active organism and' can be readily detected. Hence, the diagnosis is made from smears made direct from the seat of the disease, or in stained microscopic sections of the tissue.
Prognosis: In cases of ordinary severity the outlook is good. Healing takes place slowly after six to forty days. The glands remain enlarged for some time. Cases have been reported where the ulceration was severe enough to destroy an entire tonsil.
(1) Prophylaxis: Although not considered contagious, all cases should be isolated until the bacteriological examinations show that the case in not diphtheria. Careful attention should be given to the mouths and throats of children, particularly to the teeth and tonsils.
(2) Local: Because of the anaerobic character of the organisms the most useful local remedy is hydrogen peroxid applied directly, and this should be followed by an application such as the following:
|Carbolic acid||dr. ½|
|Zinc sulphocarbolate||dr. 2|
|Aqua qs. ad.||ozs. 4|
(3) General: In the majority of cases the throat symptoms are alone prominent and very little is needed in the way of general treatment. Open the bowels freely, and give baptisia, sodium sulphite, phytolacca and rarely aconite and belladonna. These are the remedies most frequently indicated.
Dr. McDonnel said: A practitioner as a rule does not have the time, if he is ever so cultured in the use of the microscope, to make slides for every case of sore throat he is called to see, and if he waits sometimes to do it as a diagnostic point he would probably call in the undertaker before they had done. It is very true that we call the undertaker much too often in these unfortunate cases of sore throats.
The writer has made plain the difference he has observed often between a diphtheretic exudate and that of the present condition existing. Yet, I treated them all upon the hypothesis that they were diphtheritic, and I believe that the cases which got well were not diphtheritic.
In any case of sore throat where I find the exudate, I use the antitoxin. I don't wait, cannot afford to wait, for various reasons.
About eight weeks ago, along in February, when we had the big snow storm here, Dr. Jentsch had been telling me about this, and I said, "Well, I have a case now, and if you want to take the risk, I will take you in as a specialist," and I took him in. The child at that time was in a very critical condition—almost moribund. He gave his injection. The throat symptoms disappeared. The child got better so far as the throat was concerned, but had hemiphlegia following, and is still in that condition. Now, remember the action of the medicine given him had nothing to do with the hemiphlegia that followed.
What we have been used to using for application to the throat was compound tincture of iron, painting the throat well with that. We have never seen any occasion for changing the treatment for local application. In late years I have been in the habit of using the antitoxin in nearly every case of throat trouble, and have no occasion to regret it.
Dr. Jentsch said: In regard to the differential diagnosis between this condition and diphtheria, I have no doubt in my mind but that I have met several of those cases described in the so-called angina. But still from a bacteriological standpoint it is quite necessary and quite proper that anybody should prepare himself so that he could differentiate in that line, but I want to caution the young doctor in practice to beware of becoming, as I term it, maniacal. If a man has to go with a microscope in his pocket, and he has got to depend on his microscope in order to treat his patients, he will more often fail than succeed. He will be in the same fix as the old sea-faring captain who learned his ship and never learned to differentiate between a storm and clear weather until he ran into it. We know that diphtheria is a dangerous and malignant disease, and any other affections, as far as we know, which simulate diphtheria, are not dangerous. The microscopical diagnosis, of course, is essential.
Dr. C. W. dark asked that the essayist tell what the effect of the antitoxin is on the throat in these cases of angina. I just had an attack of something, he said, I don't know what it was; had sore throat and large glands, and the question arose whether it was diphtheria or not, but he got antitoxin just the same. A week ago last Saturday this angina disappeared. Still there is an effect of some kind, I don't know whether it is the antitoxin or what it is. I would like to know what is the effect of the antitoxin on this angina.
Dr. Thornton: I feel this subject is exceedingly important, and we should thoroughly thrash it out. I want to cry shame on the man who decries the use of the microscope. In 120 minutes one can send and obtain a diagnosis from a thoroughly reliable diagnostician. Dr. McDonnel says the antitoxin should be used in all cases. I think he is on safe ground in injecting diphtheria antitoxin. I have used it in hundreds, yes, thousands of cases, and I believe I have saved a great many children from death from diphtheria.
Dr. Bushnell: I would like a little information as to the condition spoken of by the very able essayist we have just heard, whether the microscope will always differentiate between true diphtheria and the angina spoken of. It used to be stated that a negative result with a microscope did not necessarily prove the patient did not have diphtheria.
I will cite one case in which the clinical appearance was that of diphtheria—the entire clinical picture. The microscope failed to show the diphtheria. Failed to find diphtheria with two cultures taken with the membrane itself. The patient was finally sent to Cook County hospital, where I failed to learn the final result of the cultures, but was given large quantities of antitoxin for diphtheria, and was stated to have diphtheria, and afterward recovered; but the two cultures taken before I sent the case to the hospital failed to show diphtheria.
DR. GAMMAGE: To answer Dr. Jentsch is rather difficult. Some of his patients may not have had diphtheria. They may have had Vincent's angina. He did not take the trouble to make microscopical diagnoses. He did not use antitoxin. If he had said the case was diphtheria, he would have had to isolate the patient. That is about as big an injustice as can be done to a patient, that I can think of. The importance of microscopical diagnosis is brought out. If it is diphtheria, you must use antitoxin which is expensive; you have got to isolate the patient—the health department insists on thorough isolation.
In reply to Dr. dark. I see absolutely no reason why antitoxin has any effect on Vincent's angina Antitoxin is derived from the Klebs-Loeffler bacilli, and has a specific action on the toxin of diphtheria. The cases that I had got well; in a few cases they had antitoxin but not more than a thousand units.
Dr. Bushnell asked the question whether one can always prove whether it is Vincent's angina or diphtheria. I believe I can safely say yes for this reason: Vincent's angina germs will not grow on a culture. If you have made cultures for your diphtheria bacilli, you know very often from the membrane itself you won't get the culture, but if you lift the edge you will get a culture of Klebs-Loeffler bacilli. On the other hand Vincent's angina organisms, you will not find to any great extent on any membrane. If you make a culture and it shows it is a positive Klebs-Loeffler bacilli, you go under the margin of the membrane you do not find it, but you do find the fusiform bacilli. No matter if there be a few of the Klebs-Loeffler bacilli there, you can say surely whether it is one or the other. I believe surely the microscope will tell whether it is Vincent's angina or diphtheria. (...a very strange exchange...a bit too much camphor sniffing?—MM)