VINCENT'S ANGINA
BY GEORGE O. CUMMINGS, M.D.*
also known
VINCENT' Sangina,
angina,
mouth, ulcero-membranous
membranous
angina, pseudo-
stomatitis,
ulcerative ul-
as
cero-membranous tonsillitis, chancriform ton-
sillitis, has increased markedly since the World
War.
It was originally described by Plaut in 18941
and by Vincent in 18962.
It is a mildly contagious disease which affects
particularly the tonsils and the tissues about the
teeth. More rarely, it attacks the larynx3 and
tracheobronchial tree4. Its organisms have been
found in middle ear diseases5,6'7; Ottoni has re-
ported a fatal case of mastoiditis due to this in-
fection8. Thompson cites a fatal case of brain
abscess due to Vincent's angina following the ex-
traction of a tooth9. Balanitis and ulcerations
about the genitals have been caused by its organ-
isms10, which have also been found among bac-
teria associated with noma and Ludwig's angina.
Vincent's infection in a finger has followed a
human bite11. Tunnicliff has reported a general
infection with multiple abscesses subsequent to
this disease12; it has also been followed by
necrosis of the jaw13.
The infective organisms, a fusiform bacillus
and a spirillum, live in symbiosis. There has
been debate as to which plays the more impor-
tant role and whether the spirillum is a degen-
erative form of the bacillus. Apparently early
in the disease the fusiform bacillus predominates,
the spirilla increasing in number as it progresses
and decreasing with convalescence.
Carpenter14, Miller and Epstein15, Reasoner
and Gill16, Tenney17 and others feel that these
organisms may be found in many normal mouths.
Carpenter reported the following examinations
of smears taken routinely from tonsils before,
and from tonsillar fossae three weeks after
operation in cases where there was no reason to
suspect Vincent's infection:
Percentage of tonsils showing Vin-
cent's spirochetes and fusiform
bacillus.„. 50%
Percentage of tonsils showing no Vin-
cent's spirochetes but fusiform
bacillus 13 %
„.
Percentage of tonsils showing no Vin-
cent's spirochetes or fusiform ba-
cillus .„._._._ 37%
100%
Smears taken three weeks after the opera-
tion showed the following results:
Fairly numerous spirochetes and fusi-
form bacilli. 13%
Very few spirochetes and fusiform ba-
cilli .-._.. 31 %
Negative for spirochetes or fusiform
bacilli._ 56 %
100%
*Cummings\p=m-\Attending Surgeon, Ear,
ice, Maine General Hospital.
Nose and Throat Serv-
For record and address of author
see "This Week's Issue", page 785.
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trench Bloodgood18 states that he has never found
the organisms of Vincent's angina in a mouth
from which all the teeth have been extracted. I
have found them as secondary invaders in an
edentulous patient having a cancer of the tonsil.
They color readily with methylene blue and
earbol-fuchsin. The spirilla are more easily seen
if Giemsa's stain has been used.
This disease most frequently affects young
adults, but may be seen in children during their
first dentition and in the aged. As Bloodgood
intimates, we should not expect to find it in those
without teeth. Cigarette smokers, whose front
gums are frequently irritated, seem more than
usually susceptible.
Clinically it should be differentiated from
diphtheria, syphilis, malignancy, and less fre-
quently from tuberculosis, scurvy, mouth mani-
festations of certain blood dyscrasias such as
pernicious anemia, aplastic anemia, acute leu-
kemia, etc., bismuth or mercurial stomatitis,
mouth manifestations of erythema multiforme
and pellagra.
Vincent's angina appears on the tonsil or
mucous membrane as an ulcerated area the edges
of which are red and irregular, having a rather
firm base and being filled with loose grayish
necrotic tissue which cannot be wiped off cleanly,
the attempt leaving the ulcerated surface oozing
blood. In contra-distinction, the membrane of
diphtheria appears painted on and is more
superficial. Chancre of the tonsil or mucous
surface presents a punched out, regular outline,
showing less necrosis- and having a firmer base.
Secondary syphilitic lesions are more slimy in
appearance, more superficial, and less indurated.
Tertiary syphilitic lesions are longer in duration
and give rise to few symptoms. Ulcerating new
growths are more sluggish and indurated.
In the simpler eases diagnosis may be made
clinically, and confirmed by finding the charac-
teristic organisms in a stained smear. A culture
should be taken at the same time, although this
disease should be rarely confused with diph-
theria or exudates resulting from pyogenic
organisms. After a smear has been examined, if
there is still doubt of the diagnosis and the con-
dition does not yield to treatment, or, if sal-
varsan is to be used, blood for Wassermann or
Kahn tests should be taken. If doubt then
exists, the smear should be examined for tubercle
bacilli, the fungus of actinomycosis or if coc-
cidioidal granuloma, etc. If these procedures
have yielded negative information, or treatment
is resisted, a biopsy should be performed and
the tissue examined for malignancy. The blood
should then be examined for possible disease.
It would seem there should be little difficulty
in differentiating the stomatitis of Vincent's an-
gina from that of erythema multiforme, pellagra,
scurvy, or of bismuth or mercurial stomatitis.
 In the mouth Vincent's angina most com- Tincture of iodine, like silver nitrate, is of
monly occurs about the back teeth. It should be little value.
easily differentiated from pyorrhea in which Hydrogen peroxide is beneficial as a mouth
there is formation of liquid pus, little infiltra- wash and gargle as it bubbles away necrotic
tion of tissue, little or no tenderness or pain, and material.
a history of long, gradual onset; while in this
disease there is an accumulation of necrotic ma- weak Permanganate of potash has been used in
solution as a germicide. It has little to
terial about the teeth accompanied by soreness, recommend it.
foul odor to the breath with, or without, saliva-
tion and pain. Sodium perborate when applied about the
The severity of the case is determined by the gums gives off nascent oxygen and thus acts as
resistance of the individual and virulence of the a germicide, at the same time mechanically bub-
infecting organisms. When the disease attacks bles away debris.
the tonsils or gums, the distress may range from Many drugs of the phenol group give anti-
severe pain to discomfort on swallowing or chew- septic qualities to mouth washes and gargles.
ing. Lymph nodes at the angle of the jaw are There is no object in using them in strong solu-
usually swollen and may be exquisitely tender. tions for their escharotic effect.
Constitutional symptoms are usually present for Hexylresorcinol solution, S. T. 37, is a mild
a few days and may be quite severe. The tonsil antiseptic that may be employed to flush the
may be almost entirely sloughed away in neg- gingival folds in full strength and as a mouth
lected cases, while untreated disease about the wash or gargle, either in full strength or diluted
teeth generally reaches a subacute stage with with from one to three parts of warm water.
low grade ulceration usually found in the re- Trichloracetic acid as an escharotic or in solu-
dundant gingival folds about the third molars. tion has nothing to recommend it.
Vincent's angina about the larynx or in the Chromic acid has been used as an escharotic
tracheobronchial tree doubtless arises from these and in solution. It is best applied in a solution
semi-chronic cases. from 2 to 10% as a topical application to ton-
When this disease occurs elsewhere than at the sils or gums. It should not be used in excess
usual sites of election, the gums or tonsils, the as it is a poison affecting the kidneys.
diagnosis is apt to be made in the laboratory. Arsenic has been used in many forms. Fow-
Concerning treatment, the vast number of ler's solution has been made a constituent of
drugs which have been tried and are being tried mouth washes and gargles. Its use is to be con-
only go to show that there is no specific. There demned as there are equally effective mouth
follows a discussion of some drugs that have washes and gargles that are less poisonous.
been advocated for this disease. Neo-salvarsan has been applied as a powder.
Mercury has been used in various forms and Salvarsan has been used in a 10 to 15% solu-
combinations. A favored prescription contains tion in glycerine as a topical application and its
bichloride of mercury combined with peroxide of various forms have been employed intravenously.
hydrogen. There seems little excuse for using This drug in its different forms and methods
this drug when there are many less poisonous of application is the sheet anchor in the treat-
antiseptics. ment of Vincent's infection.
Mercurochrome in a 10% solution is of some An intravenous injection of 5 c.c. of a
avail in early mild cases affecting either the solution of antimony and potassium tartrate 1% has
tonsils or gums. been advocated, and might be worth remember-
"Metaphen" is a mild antiseptic which may ing in a stubborn case that has not
be employed in an alkalinized 1-500 solution to salvarsan and local treatment13,20,21. yielded
to
flush out the gingival folds and is also of value Ipecacuanha has been made a constituent of
as a mouth wash and
gargle in a 1-5000 solution. mouth washes and gargles as it has been thought
Silver nitrate is of surprisingly little worth to be of worth in gingivitis associated with
in Vincent's infection of the tonsil and should amoeba. It is of no value in this disease.
not to be used about the gums as it is apt to
Many analine dyes, carbol-fuchsin, methylene
stain the teeth permanently. blue, brilliant green, gentian violet, etc., have
Silver proteinates are of practically no value. been used as applications. They are unusually
Copper sulphate is apt to stain the teeth and nasty to handle and may permanently stain the
lias little place in the treatment of this malady. teeth.
Zinc sulphate, in weak solution, has nothing Solutions of acri-violet or neutral acri-flavin
to recommend it except its astringent properties. have been considered beneficial because of their
Bismuth tartrate in a 30% emulsion has been antiseptic powers.
used as a topical application19. Potassium chlorate
Various proprietary solutions containing be
was formerly thought to
specific for this condition taken either in-
a
chlorine may be employed for mouth washes and ternally or used in solution. Its astringent qual-
gargles. ities are to be considered.
Hydrochloric acid in weak solutions has been The above discussion of drugs and the follow-
used about the gums but is likely to damage
the enamel of the teeth.
ing suggested outline of treatment are based
upon some 150 cases of this disease seen in

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private, dispensary, and hospital practice and in When applied as a paste about the teeth, or
the United States Navy during the war, also on pledgets, it has a greater continuity
cotton
upon conversations with many physicians and of action than it is possible to secure from per-
dentists. oxide. It should be used as a dentifrice for
During the stage of invasion, if there are con- some time after symptoms of Vincent's angina
stitutional symptoms the patient should be kept have disappeared.
in bed and treated with laxatives, antiseptics, In subacute, or chronic cases, patients may
and bland diet, as in other acute disease. reinfect themselves from their tooth brushes.
Either hot or cold packs may be used on pain- It might be well for them to have three, which
ful swollen glands. While mouth washes and may be used in rotation, one soaking in a solu-
gargles avail the patient little, they afford com- tion of chlorazene or some other mild antiseptic
fort for the time being and it is well to pre- for sterilization, one drying, and one in use.
scribe them. They should contain some astrin- If the gums are too tender for a bristle tooth
gent for the purpose of diminishing the saliva- brush, they may be massaged with the wet finger,
tion, such as potassium chlorate, tincture of or a rubber tooth brush that fits on the
tip
myrrh, or glycerite of tannic acid, and some of the finger. After the symptoms of Vincent's
non-irritating antiseptics, as hydrogen peroxide, angina about the gums have disappeared, the
chlorazene, or, glycerite of phenol. teeth should be scaled by a dentist.
Topical applications are of value in only the When this disease affects the tonsils, the
milder cases of Vincent's angina affecting the ulcerated area should be wiped free of necrotic
gums, as they do not get down into the gingival tissue and some antiseptic applied. In my hands
sulcus about the teeth, where the diseased con- chromic acid in a 5% solution has been more
dition exists. This should be flushed out with a effective than any other drug. Most cases clear
syringe having a blunt pointed needle set at an up within a week. Mercurochrome, metaphen,
angle with the long axis of the syringe as shown hexylresorcinol and other mild antiseptics may
in the accompanying illustration. As the needle be used.
Many cases treated early will yield
to almost any regimen.
When one reads the literature on this sub-
ject, it is interesting to note that most writers
fall back on salvarsan used intravenously, al-
though, it is not a specific. I do not feel that a
patient having early signs and symptoms of
Vincent's angina should be treated with sal-
varsan intravenously until simpler local treat-
ments have been tried. I have had three cases
of this disease of some weeks' duration which
were treated with three, or four, doses of neo-
salvarsan with no beneficial results. Hillsman
and Driscoll report a case of fuso-spirillary in-
fection that developed in a patient under active
treatment with old salvarsan21. Similar reports
have been made by Sutton22 and others. Dr.
follows around in the gingival sulcus, pressure B. B. Foster, in a personal communication, in-
is slowly applied to the plunger of the syringe formed me of a case of Vincent's angina develop-
so that not only is necrotic debris washed out ing
in a patient under treatment with sulph-
arsphenamine. In severe cases untouched
local treatment, or intravenous injections by
but mild antiseptics are applied to diseased
areas. For this purpose I have found a 1-500 of
solution of metaphen or hexylresorcinol solution salvarsan, intravenous injections of 5 c.c. of 1%
S. T. 37 efficient, and prefer them to a 15% solution of antimony and potassium tartrate may
solution of salvarsan in glycerine. This treat- be tried.
ment should be carried out daily, or every other When this disease affects the lungs, supportive
treatment
day, until the condition quiets down. Most venous treatment. should be supplemented by intra-
cases taken early will clear up within a week.
If this malady has attacked the
The above treatment should be supplemented tonsils, I feel
they should be removed at a suitable interval
by the patient, by the use at home, of sodium after the condition has subsided as the individ-
perborate, an agreeable preparation of which is ual may not only be a carrier but might infect
put out under the trade name "Vince". This his tracheobronchial tree.
may be applied about the teeth with the finger It has been said that people on a
or a soft tooth brush.
Pledgets of cotton may diet are more than usually reducing
be dampened and rolled in the sodium perborate this condition. apt to suffer from
and applied about the gums, being left in posi- seem well in
With this in mind, it would
tion for five minutes. The efficacy of this drug patient was on stubborn case to see that the
any
a well-balanced diet rich in
is due to the nascent oxygen which it liberates. vitamins.

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 REFERENCES
1 Plaut, H. C.: Studien zur bacteriellen Diagnostik der Diph-
therie und der Anginen. Deut. Med. Woch., 1894, 20:920.
2 Vincent, H.: Bull, et mem. Soc. med. d. hop. de Par., 1898,
15:244-250.
3 Monthly, 52:94-98, 1925.
Moure, E. J.: The Nose, Throat, and Ear and Their Dis-
eases, ed. by Chevalier Jackson and G. M. Coates. W. B.
Saunders Co., Phila., 1929, p. 823.
4 Jackson, Chevalier: Ulcerative Bronchitis Due to Vincent's
Organisms. J. A. M. A., 83:1815. Dec. 6, 1924.
5 Adams, J.: Infection of Middle Ear with Vincent's Organ-
isms. Brit. J. Child. Dis., 12:40, 1915.
€ Mathers, R. P.: Vincent's Complicating Chronic Suppurative
Otitis Media. Jour. Laryngol., Rhinol., and Otol., 1917,
32:145.
7 Pilot, I. and Pearlman, B.: B. Fusiform Bacilli and Spiro-
chetes ; Occurrence in Otitis Media Chronica. Jour. In-
fect. Dis., 1923, 33:139.
8 Ottoni, M.: Spread of Vincent's Angina to Ear. Boletim
da Soc. de Med. de S. Paulo; abstr. J. A. M. A., 74:1474,
May 22, 1920.
9 Thompson, L. E.: A Fatal Case of Brain Abscess from
Vincent's Angina Following Extraction of a Tooth Under
Procaine Hydrochloride. J. A. M. A., 93:1063, Oct. 5,
1929.
10 Corbus, B. C.: Erosive and Gangrenous Balanitis. J. A.
M. A., 60:1769-1774, June, 1913.
11 Fuller, C. Rex and Cottrell, John C.: Infection with Or-
ganisms of Vincent's Angina Following Human Bite.
Jour. Am. Med. Assn., 92:2017, June 15, 1929.
FACTS, FIGURES AND FICTION
HEALTH STATISTICS*
BY HOWARD WHIPPLE
been used in this title
has
I SUPPOSE
as a
Fiction
for Statistics
synonym
the word Statistics.
in order not to
repeat
I would rather reverse the order to Fiction,
and Facts in Social and Health Statis-
Figures
tics. Haven't we had Fiction long enough in
our Social and Health Statistics? As an ex-
ample of Fiction take the statement that the
length of life has been enormously increased
during the past 3 decades. When the figures
are analyzed by a statistician canny enough not
to be led astray by the crude figures, we are
shown that practically the entire increase in
length of life occurs in the younger age-groups,
especially in the group under 1 year and there-
fore the length of life as ordinarily understood,
i.e., our expectancy, has changed but little.
Facts are being more and more recognized
as the proper basis for planning all health and
welfare activities.
The census tract or sanitary district by which
population is analyzed and demographical data
collected is of considerable assistance in deter-
mining this fact basis for community planning,
be it for health, for social work or for commer-
cial endeavors.
"Why Census Tracts?" The composition
and characteristics of the population of each
—
Ward are given in the published volumes of the
Bureau of the Census for 1900, 1910, 1920, and
these data will shortly be published for 1930.
There were 42 wards in Cleveland in 1900, 26 in
1920, and there are 33 in 1930. However, a care-
ful scrutiny of the maps indicates that none of
*Read at the annual meeting of the Boston Health League,
February 13, 1930.
\s=d\Green\p=m-\Director of Statistics and Research and Secretary
of the Cleveland Health Council.
For record and address of
author see "This Week's Issue", page 785.
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12 Tunnicliff, Ruth: Microscopic appearances in ulceromem-
branous tonsillitis (Vincent's angina). J. Infect. Disc,
25:132-134 (Aug.), 1919.
13 Bowman, "W. M.: Vincent's Angina or Ulcero-Membra no us
Tonsillitis Diagnosis and Treatment. Virginia M.
—
14 Carpenter, E. W.: Buccal Spirochetosis. South. M. J.,
20:443-448, June, 1927.
15 Miller, H. E. and Epstein, N.: Vincent's Angina; The Sig-
nificance of Fusiform Bacilli and Spirilla in Mucous
Membrane Lesions. Calif. & West. Med., 24:633-637,
1926.
16 Reasoner, M. A. and Gill, W. D.: The Use of Soap in the
Prophylaxis of Vincent's Infections. J. A. M. A., 88:716-
719, 1927.
17 Tenney, C. F.: Systemic Manifestations of Vincent's Infec-
tion. Laryngoscope, 38 :247-249, .April, 1928.
18 Bloodgood, J. C.: Oral Lesions Due to Vincent's Angina.
J. A. M. A., 88:1142, (April 9) 1927.
19 Mangabeira-Albernaz, P.: The Etiology and the Etiological
Treatment of "Plaut Vincent's Angina". Laryngoscope,
39:1-15, Jan., 1927.
20 Mitchell, R. E.: Report of Case of Vincent's Angina—"With
Treatment. Virginia M. Month., Richmond, 1925, 52:256-
257.
21 Hillsman, J. A. and Driscoll, T. L.: Report of a Case of
Fuso-spirillary Infection Which Developed During Active
Arsphenamine Treatment. Virginia M. Monthly, 52 :312-
313, 1925.
22 Sutton, I. C: J. A. M. A., 83:1919, (Dec. 13) 1924.
IN SOCIAL AND
GREEN, S.B.\s=d\
the Wards of 1910 was the same as in 1900 and
while there were 26 wards in 1910 and the
same number in 1920, none of them was com-
parable and the 1930 wards with one exception
were different from the 1920 wards. Therefore,
in order to obtain a geographical unit constant
over the years for which population data may
be obtained and other data may be collected
the Census Tract or Sanitary District is most
valuable.
''
How originated ?" The Census Tract or
Sanitary District was originated in 1902 by the
—
Federated Churches in New York City because
they found that the Boroughs of New York,
there being no wards, were entirely too large
in both area and population to aid in solving
the neighborhood problems with which that or-
ganization was faced. The Federated Churches
obtained the interest of the Bureau of Census
and in 1910,—the 9 cities in the United States
having a population of half a million or more
were enumerated by census tracts. The State
census of New York utilized the areas in the 1915
enumeration and the Federal Government again
utilized them in 1920.
The Federation of Churches being most in-
terested in this project, published the population
data for 1910 for New York City by Census
Tracts and in 1920 other individuals and or-
ganizations shared this burden through the New
York City 1920 Census Committee, Incorporated.
Cleveland was the second city to become in-
terested in the Census Tract populations and
the Cleveland Health Council early in 1925 ap-
proved of my proceeding with this work. Chi-
cago about the same time started to obtain Cen-
sus Tract data from the Bureau of the Census
and Detroit, taking a special official census at
the expense of local organizations but super-