A SEPTIC SORE THROAT EPIDEMIC IN CORTLAND
AND HOMER, N.Y.*

Cuar_Les E. Norrg, BENJAMIN WHITE, AND OswaLp T. AVERY.
J. HISTORICAL.

Since 1875 outbreaks of sore throat have been reported in
England. A number of large epidemics have been officially investi-
gated there, in all of which the symptoms of the disease have been
characteristic and the relationship to the milk supply either sus-
pected or confirmed.

Swithinbank and Newman' state that “in all probability these outbreaks are
comparatively common, but, as the condition is not notifiable, it is seldom that a
record is obtained of the cases occurring. We think it is safe to assume that a year
never goes by in which there are not outbreaks of sore throat or tonsillitis due to milk —
orcream. The usual symptoms are congestion of the tonsils and mucous membrane
of the throat, with sometimes ulceration, enlargement of the cervical glands, and some
pyrexia and general malaise.” The authors suggest some relation between scarlet
fever and this disease, but believe they are not identical. They tabulate 9 typical
outbreaks. Among these they mention an outbreak at Dover in 1884, affecting 205
persons, all of whom obtained milk from one dairy farm. The chief symptoms were
local inflammations of the throat and enlargement of the lymphatic glands of the neck.
In 1890 they mention an outbreak at Craigmore affecting 80 persons. As secondary
to the sore throat, a number of cases of erysipelas developed. The incubation of the
disease was 3 or 4 days. They record an outbreak in April and May, 1900, at North
Hackney, which included 151 cases, 138 of which were supplied with milk from one
dairy. The symptoms included tonsillitis, swelling of the cervical lymphatic glands,
Tise of temperature—in some cases to 105° F.—and great prostration. Secondary to
the sore throat, in 1 case septicemia developed, followed by pneumonia and death;
in 2 cases, acute nephritis. The authors state that there was a marked tendency for
multiple cases to occur in families. Another outbreak mentioned by these authors
occurred at Bedford, in June, 1902, including 42 cases. In every case milk was ob-
tained from the samedairy. The health officer reporting this outbreak states: “I think
that every case of septic sore throat should be notifiable. The difficulties of tracing
an outbreak like this to its origin in the dairy can only be successfully carried out by a
sanitary expert with the aid of a skilled bacteriologist.” He also states: “Milk which
was boiled did not produce the disease, but cream, which could not be boiled, produced
the disease.” In many of these sore-throat outbreaks the investigators found dairy
cows suffering from mastitis, and they reported this inflammation of the udder as the
probable cause. The bacteria most commonly found in the throats and udders were
streptococci.

* Received for publication November 15, ror3.

* Bacteriology of Milk, New York, 1903, p. 352.

124
A Septic SorE THROAT EPIDEMIC 125

In the United States this disease has attracted much attention in the last 3 years
owing to 3 extensive outbreaks.

The first of these, reported. by Winslow," occurred in Boston, Massachusetts,
in the winter of 1910-11. The total number of cases collected was 1,043. The epi-
demic lasted over a period of about 2 weeks in Boston, Brookline, and Cambridge.
About 70 per cent of the cases were supplied by one dairy. In the statistics reporting
these outbreaks Winslow concludes that the milk from this dairy was the means of
transmission of the disease, but that it was infected by human beings and not by dairy
cows. Altho there were no acute cases among dairy employees the author states:
“‘A carrier case presumably infected the milk.” wd

In December, 1911, and January, 1912, an extensive outbreak occurred i in Chicago:
In the report by Capps and Miller? the authors estimate that over 10,000 persons were
victims of the outbreak, the majority of whom were taking milk from the same dairy.
They state that an epidemic of mastitis occurred among the cows supplying milk to
this dairy during the winter months. Dr. D. J. Davis,3 of Chicago, reports, concern-
ing the examinations of the milk, that they found a streptococcus identical in mor-
phology, in culture, and in pathogenicity with a culture obtained from a human case
of tonsillitis and arthritis. E.C. Rosenow‘ reports further studies of this streptococcus
and other streptococci from milk. The author is not positive in his conclusions,
however, for he states: “The fact that milk so modifies streptococci is an additional
indication of the important part it may play in epidemic sore throat. It is not possible
to determine whether the streptococci in such epidemics are of exclusively bovine or
human origin; they may be both. Milk drawn in a sterile way from normal cows
may contain virulent streptococci and pneumococci; hence, “certified milk,” while
surely less contaminated than ordinary milk, may contain pathogenic bacteria, and
the advisability of pasteurization even in this case should be considered, especially
during the season when sore throat is common.”

In Baltimore an epidemic occurred in 1912 during the months of February and
March. This was reported by several authors, the most extensive report being made
by Frost and Stokes and Hachtel.s A total of 602 cases was reported, the majority of
which occurred from February 1 to March 20, 1912. The symptoms included sudden
onset with chill, irregular fever, inflammation of tonsils, enlargement of cervical glands,
and unusual prostration. Of these cases 65 per cent were supplied with milk from one
dairy. This dairy supplied only 3.3 per cent of the milk sold in Baltimore. There
were 28 deaths following the sore-throat attacks due to secondary infection, which
included 13 cases of peritonitis, 7 cases of septicemia, 1 case of appendicitis, 2 cases of
erysipelas, and 4 cases of pneumonia. The milk was pasteurized by the flash method.
The author states: ‘Either the pathogenic germs were introduced into the milk by
some infected person who had had to handle the milk, or were derived from the udders
of some of the cows which producedit.” The latter is believed to be the more probable
hypothesis, altho no evidence could be obtained of the epidemic among the cows, and-
the veterinary examination of the cows through March and April failed to discover
any cows with mastitis.

3 Jour. Infect. Dis., 1922, 10, Pp. 73.

» Jour. Am. Med. Assn., 1912, 58, p. r111; ibid., p. 1848.

3 [bid., p. 1852.

4 Sour. Infect. Dis., 1912, <1, P. 338.

8 Pub. Health Report 47, U.S. Public Health Service, 1912, 27, p. 1889.
126 CHartes E. Norta, BENJAMIN WHITE, OSWALD T. AVERY

Stokes and Hachtel recovered pneumococci from the milk, showing that the flash
system of pasteurization was inefficient. In the raw milk shipped to Dairy 1, they iso-
lated a streptococcus of the epidemicus type. Several gargety cows were found
among the dairy herd. The authors state: “We feel reasonably sure that the infec-
tion was caused by streptococci of the epidemicus type from cases of mastitis among
the herds supplying this dairy.”

In February, 1912, there was a sudden increase in the acute infections noted in
Boston, almost a year later than the great Baltimore outbreak préviously described. .
In this outbreak, which was investigated and reported by Coues,' 227 cases were
reported. Forty-eight and five-tenths per cent were found to be taking milk from one
dairy. Examination of the employees in the plant of this dairy showed that 16 men
had remarkably reddened throats. A visit to the dairy farm from which the milk was
obtained showed 10 farm hands with reddened throats. The milk was not pasteurized.

The author concludes: ‘The occurrence of so many cases of milk pharyngitis . . . .
in dairymen . . . . and the presence of streptococci in so many of their throats is of
great interest. . . . . It seems fair to state from clinical examination of 77 cases that

there is a condition which might be termed dairymen’s or milk handlers’ pharyngitis,
incident to the long hours of constant work on wet floors often covered with ice and
milk..... It would seem as if direct, or nearly direct, hand contact with the milk
is impossible to avoid in some stage of the preparation.” ,

From a survey of the outbreaks outlined above it is obvious
that, with the exception of those reported from Boston, there is a
tendency on the part of all observers to conclude that the source of
infection in septic sore throat is to be found in the inflamed udder
of the dairy cow and is due to the streptococcus which is discharged
from the inflamed udder into the milk, through which it is trans-
ferred to the throats of milk consumers, but that such conclusions
are based on circumstantial evidence and that positive and direct

evidence is lacking.

Il. CORTLAND-HOMER OUTBREAK.

During the months of February and March, and the first three
weeks of April, 1913, while there were a few scattered cases of sore
throat among the inhabitants of the city of Cortland and the village
of Homer, New York, no unusual conditions were noted. In the
last week of April, however, the physicians in both these com-
munities were alarmed by the sudden increase in the number
of their patients complaining of sore throat. Within 3 days
the cases multiplied rapidly into a widespread epidemic of sore
throat. The disease manifested itself by redness and swelling—a
raw beefsteak appearance—of the fauces, a rise in temperature,

t Am. Jour. Pub. Health, 1912, 2, p. 419.
A Septic Sore Turoat Epmemic . 127

enlargement of the lymphatic glands of the neck, and, in some
cases, great prostration. —

The city of Cortland has a population of 12,060 and the village
of Homer, a population of 2,700. They are 2 miles distant from
each other. As soon as the outbreak was recognized, a special
meeting of the Cortland County Medical Society was called and a
committee appointed to study the epidemic. The health officers’
of Cortland and Homer also began an official investigation of the
outbreaks in these communities. By the first week in May there
were several hundred persons in these two communities who were
suffering from the disease, altho only a few cases had-been officially
reported to those studying the outbreak. The milk supply of one
dairy soon fell under suspicion, and Doctor Ball, the health officer,
took prompt action by making an inspection of the dairy, isolating
from the main herd two cows showing physical signs of udder
inflammation, and ordering that their milk be no longer used. This
milk dealer was ordered to suspend the delivery of all milk from his
dairy until the completion of the investigation, and a supply of
pasteurized milk was secured for him from a large pasteurizing
station located in the neighborhood.

On May 7, an offer made by Doctor North to act as a special
investigator was accepted by the committee of the Cortland
County Medical Society and by the health officers of the two
communities. Every facility was furnished by the local physicians
and health officers for a complete study.

At a special meeting of the Boards of Health of Cortland and
of Homer, regulations were passed declaring septic sore throat to
be a contagious disease, reportable and quarantinable, and state-
ments were published in the local papers urging citizens to avoid
contact with those suffering from the contagion.

_I. ORGANIZATION OF INVESTIGATION.
The investigation was greatly facilitated by the ready co-
operation which was secured from the following bodies:

1. Public Health Committee of the Cortland County Medical Society.
2. Boards of Health of Cortland and Homer.

3. New York Milk Committee.

4. Hoagland Laboratory, Brooklyn.

5. DeLaval Separator Company.

6. New York Dairy Demonstration Company.
128 CuHartes E. Nortu, BENJAMIN WHITE, OSWALD T. AVERY

Through these agencies it was possible to organize thoroughly all
branches of the investigation at once, and to carry on several paral-
lel lines of work at the same time. The work fell into the following
divisions:

a) Reporting of cases.—-Printed blanks were prepared having spaces for residence,
name, age, sex, type of disease, date of onset, date of first visit, number of adults in
the family, number of children, milk dealer, and remarks. These blanks were dis-
tributed to all of the physicians in Cortland and Homer, and they were'asked to record
in this regular manner all of the cases occurring in their practice, and to report same
promptly to the director of the investigation. Twenty-seven physicians in the
city of Cortland and 5 in the village of Homer made reports in the manner indicated.

b) Detailed investigation of cases.—Two statisticians were furnished by the New
York Milk Committee who made a house to house canvass both in Cortland and
Homer, calling on physicians and patients to check up and confirm details regarding .
each report in order that the same might be complete. ‘

c) Cultures taken.—Doctors Benjamin White and Oswald T. Avery at the Hoag-
land Laboratory in Brooklyn made bacteriological examinations of cultures, taken from
sore throats and from the sore udders of dairy cows. .

d) Dairy ins pections.—Early in the investigation, it became evident that a much |
larger number of cases were the patrons of one milk dealer than his-proportion of the
milk trade would warrant. Inspection was made of his own dairy and of another
dairy from which he occasionally purchased a small quantity of milk. Physical ex-
aminations were made of dairy cows by the local veterinarian.

¢) Sediment tests of cows’ milk—-A new form of centrifuge called the Clarifier
was furnished by the DeLaval Separator Company, with an expert operator, and
proved of the highest value in the examination of cows’ milk for inflammatory products.
The apparatus was installed in the dairy barn of the dairyman under suspicion, and the
milk of each dairy cow was examined by this means. From those cows in which the
presence of inflammatory products was obvious, cultures were sent to the laboratory
for bacteriological examination.

f) Pasteurization of miik—The New York Dairy Demonstration Company in
Homer consented to carry out the washing and sterilizing of all milk utensils of the
suspected dairyman and furnish him with pasteurized milk for his retail trade during
the progress of the investigation. All of his own milk supply was taken out of the
market and disposed of for manufacturing purposes.

g) Inquiries in other towns—To determine whether the outbreak was strictly
local in character or not, inquiries were carried out in nearby towns and villages.

h) Tabulation of results.—As fast as the detailed reports of cases were completed,
the results were tabulated at the central office by the director of the investigation, the
entire local work occupying a period of about one week.

2. CASES REPORTED.

The cases reported by the physicians of Cortland and by the
physicians of Homer were tabulated. Because of the obviously
large percentage of cases occurring among the customers of one
A Septic SorE Taroat Ermemic 129

dairy, which will be called Dairy X, the number of cases occurring
among the patrons of this dairy were separated from those occurring
among the patrons of all other dairies. Since the outbreak occurred
simultaneously in the communities of Cortland and Homer, and
in both of these a considerable number of cases was found among

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APrRiL Man
10 2 . ic is 2
s is oO 2s 30 S , os
70 | j -
Total Cases
eo m Cary X
co Alf others
6o
BO
20 J
20 a
io Mm
° oll

 

 

 

 

 

 

Carant ‘s.

the patrons of Dairy X, the figures for both Cortland and Homer
are combined in Table 1, in order to secure a comprehensive idea of
the entire outbreak.

The rise and fall of the cases in Cortland and Homer and of
the cases found among’ the patrons of Dairy X is shown graphi-
cally in Chart 1. From this chart it appears that the epidemic
130 CHARLES E. Nort#, BENJAMIN WHITE, OSWALD T. AVERY

 

 

    

 

    

TABLE :.

Total Dairy Other Date Total Dairy Other
Date x Dairies Cases x Dairies

4 3 tr

4 2 2

13 Ir 2

29 22 . 7

34 25 9

73 3 7

5 I

34 r a 59 or 3

2 r I 50 44 6

5 i 4 76 62 . 14

3 a I

2 r I 59 4t bt ae
3 3 ° 30 a4 6;.

9 4 Ss 3s 23 12

6 3 3 13° 7 6

r t ° a2 1g 7

4 x 3 5 7 8

8 5 3 7 4 3

4 x 3 I 3 rE

L (- rr 13 6 7 3 ° 3

 

 

 

 

 

 

 

 

 

 

extended over a period of about 20 days, beginning April 20 and
ending May 10, and that its crest was reached about April 30.

The figures given show the number of persons living in houses
to which the milk of Dairy X was delivered. All of these persons
were not milk drinkers. The proportion of cases found in house-
holders receiving milk from Dairy X was so great that it was thought
to be unnecessary to make a detailed inquiry as to those persons
who did or did not drink milk. For the same reason a tabulation
of the number of persons who lived in the houses to which milk was

‘delivered who did not become victims of the disease was not under-,
taken. The facts shown in Table 1, and their relation to the milk
supply of Dairy X, are summarized in Table 2.

 

 

 

 
 
 
 

TABLE 2.
Cortland Homer. Totals

Population. 0... 2.02.6. ee ener eens £2,000 2,700 14,790
Total cases.... 0.4... . 483 186 669
Dairy X..... 360 120 480
Other dairies . 123 66 189
Milk dealers. ae 34 - § 19
Milk supply... ccc eect eee 4,200 qts. 700 ats. 4,900 qts.
Dairy X supply... 0.0.0.0 eee eee eee eee goo “. so “ 350 “

 

 

 

 

From these summaries it appears that about 72 per cent of the
cases were found among the patrons of Dairy X, while, on the other
hand, Dairy X was delivering less than 7 per cent of the total milk
A Septic SorRE THROAT EPIDEMIC 131

supply. This means, in short, that there were ro times as many
cases of septic sore throat among the patrons of Dairy X as that
dairy would be entitled to, had the cases been evenly distributed
among all milk dealers.

TABLE 3.

 

 

 

Ace Disrrreurion or Cases.

Ages Cortland Homer Ages Cortland = [ Homer
Sic esseccee 41 8 BOAO... se eee eee 93 : 31
BIO. cee eee 42 10 4O-SO.... eee eee 61 ; 24

TO“20.. 0 eee 76 29 §0-60.........., 36 19
BOWJO. eee eee or 24 St 37 42

 

 

 

 

 

 

 

The age distribution of the cases is shown in Table 3. The
occurrence of a larger number of cases between the ages of 20 and
40 than at other times of life corresponds to conditions found in
other similar outbreaks.

Sex distribution was also recorded, showing that in Cortland
there were 215 males and 268 females suffering from the disease.
In Homer 71 males and 115 females were afflicted.

3. DEATHS.

- There were 14 deaths in all reported by the local physicians as
resulting from this epidemic. In each case death was due to
complications. The date, age, and complication causing death
have been separately tabulated in Table 4. :

TABLE 4.
DEATHS.

 

 

Date Age Cause of Death

 

CorTLAND

Edema of larynx
Heart failure
Lobar pneumonia
Peritonitis
Erysipelas
Peritonitis

«

Erysipelas

 

 

 

 
132 CHARLES E. NortTH, BENJAMIN WHITE, OswaLp T. AVERY

Of the 14 deaths, 5 were due to peritonitis, 4 to erysipelas,
2 to pneumonia, 2 to heart failure, and 1 to edema of the larynx.
_ In addition to the complications shown in the list of deaths,
‘the physicians have reported that a considerable number of per-
sons contracted rheumatism which manifested itself chiefly in the
joints. In some cases the rheumatic symptoms were severe.
There were also several cases of erysipelas, in addition to those
resulting in death. Pleurisy and pericarditis have also been men-
tioned by some physicians as complications. >
Inquiries were made in the communities located nearest to Cort-
land and Homer. These were the small villages of Preble, Scott,
and McGraw, having populations of from 400 to 1,000, and located
from 3 to 5 miles distant. The health officers of each of these
villages stated that there were no cases of septic sore throat occurring
in those places during the period of this outbreak. It is of further
interest to note that no milk was supplied to these villages by
Dairy X.

4. DAIRY INSPECTION.

Before the investigation was fully organized the health officer of
Cortland, with a local veterinarian, had made physical examina-
tions of the dairy cows in the herd of Dairy X and another dairy
herd, from which the proprietor of Dairy X occasionally purchased
‘milk. As a result of this examination, Doctor Ball ordered two
of the cows in the herd of Dairy X, showing external physical signs
of inflammation, to be separated from the rest of the herd. Inspec-
tions of these two herds were again made and physical examina-
tions of the dairy cows were duplicated by the local veterinarian,
with the same result as in former examinations.

In the case of the other dairy, duplicate examinations failed to
reveal any animals with udder inflammation. As later facts
showed that the two cows having inflamed udders in the herd
of Dairy X were undoubtedly responsible for the epidemic of septic
sore throat, to the prompt action taken by Doctor Ball, the health
officer of Cortland, must be credited the rapid decline in the
number of new cases of sore throat which immediately followed.
‘A Septic SorE Toroat Epemic 133

For the first time in the history of the investigation of indi-
vidual cows for the existence of udder inflammation, a new form of
apparatus, the DeLaval milk clarifier, was used. The herd of Dairy
X numbered 28 cows. The milk at the night’s milking of all animals
was examined by means of this apparatus. The machine was
cleansed and sterilized between each operation by taking the
apparatus entirely apart and washing and brushing all parts with a
strong soda solution, after which they were rinsed in clean water.
They were then plunged into a 1 per cent solution of chlorid of

 

Fic. 1.

lime, and afterward thoroughly rinsed in boiling water. This
procedure was followed between the examination of each cow’s
milk. Two men were thus able to secure the sediment from the
milk of about 9 cows at one milking, and it required three after-
noons to secure sediment from every member of the herd.

In Fig. 1 are shown typical results of these examinations. The
glass bottles are 2 ouncesin capacity. The first 3 show the quantity
of sediment obtained from the milk of 3 dairy cows which were
apparently normal. The quantity of milk produced by these
animals at the night’s milking varied from 6 to 8 quartseach. The
134 CHARLES E. Nort, BENJAMIN WuiTE, Oswap T. AVERY ©

last 2 bottles contain the sediment obtained by the clarifier from
the milk of the 2 animals in which udder inflammation was sus-
pected. In one case, the quantity of milk produced was 1 quart,
and in the other, 1.5 quarts. - The difference in the quantity of sedi-
ment secured from their milk as compared with sediment found in
the milk of normal animals is too obvious to require comment.

In these examinations, the use of the clarifier made it possible
to eliminate the existence of udder inflammation from other,mem-
bers of the dairy herd, and to confirm most emphatically the exist-
ence of udder inflammation in the 2 dairy cows under suspicion.
The quantitative results alone furnished sufficient evidence for
these purposes. There were, however, qualitative differences in the
slime which were even more interesting, as shown by microscopic
examinations.

§. MICROSCOPICAL EXAMINATIONS.

Smears were made on glass slides of all samples of slime as soon
as they were obtained. Experience in examining milk sediments
has shown that considerable change takes place in appearance,
particularly of the tissue cells and bacteria, if sediments are kept
for any length of time before examinations. The multiplication
of bacteria alone is enormous. Degeneration. of leukocytes and
tissue cells is also very rapid. The best results are obtained, there-
“fore, by making smears from samples which are as fresh as possible.
In all of the sediments examined from this herd, there was shown,
microscopically, no evidence of inflammatory conditions excepting
in the cases of the 2 dairy cows already mentioned. The micro-
scopical appearance of sediment from normal cows is shown in
Fig. 2.

Here we observe a large number of cells, the majority of which
- are apparently of the same character. Many of these have multiple
nuclei. It might be inferred that the cells were leukocytes or
possibly pus cells. The’ more one studies sediments from milk
the more must one hesitate, however, to call cells having multiple
nuclei pus cells or even leukocytes. The cells shown in Fig. 2 are
probably tissue cells, being epithelia] cells shed in the normal process
of lactation from the walls of the milk glands.
A Septic SorE THRoAT EPIDEMIC 135

 

Fie. 3.
136 CuarLes E. Norra, BENJAMIN WHITE, OswaLp T. AVERY

The microscopic appearance of the slime from the milk of the
2 cows having inflamed udders shows a marked difference in appear-
ance. Fig. 3 shows a considerable variety of cells; of even greater
interest are the large numbefs of bacteria and the marked phago-
cytosis. No one would hesitate to say that cells must be pus cells
which have multiple nuclei and are engaged in collecting such large
numbers of bacteria within their bodies. The discharge.from the
udder into milk of streptococci, bacilli, and of phagocyting white
blood corpuscles, and their appearance in milk sediment, must be ac-
cepted as evidence of the existence of udder inflammation. _ This
condition was shown plainly in every smear which was made from
the slime obtained from these inflamed udders.

6. BACTERIOLOGY.
A. ORGANISMS ISOLATED IN PREVIOUS EPIDEMICS.

The bacteriological examination of cultures from throat exudates
in a number of patients and from the milk slime of gargety cows
was undertaken with three objects in view: (1) to determine, if
possible, whether any particular organism was common to all the
cases; (2) to ascertain if any organism was common both to the
throat exudates and to the slime; and (3) to study and identify
any organisms found which were believed to be of significance.

As a result of studies in previous epidemics it is now generally
held that the streptococcus is the chief etiological factor in septic
sore throat. Further, the predominance of organisms of the
streptococcus type in the inflamed udders of garget cows has
drawn attention not only to the possible significance of this organ-
ism, but has suggested the probable original source of the human
infection. In addition to this primary infection of the milk, another
possibility presents itself in the chance of an accidental introduction
into the milk of pathogenic organisms from individuals suffering
from streptococcic infection and handling the milk.

In the Finchley epidemic in 1904 the streptococcus was first
isolated from the throats of the affected patients, while Sir. pyogenes
was first detected in the suspected milk by Pierce in the Guildford
outbreak in 1903. Since that time, in the majority of outbreaks,

+ Brit. Med. Jour., 1903, 2, D. 1492.
A SEPTIC SorE Taroat EpIpEMIc 137

the streptococcus has been isolated either from the throats of
patients or from the milk supplied to the homes where infections
developed.

The more careful studies of the latest outbreaks seem to
strengthen the probability that the specific organism is a strep-
tococcus resembling in many respects, but in others differing from,
the pyogenes type. On account of its variations it has been classi-
fied separately as Str. epidemicus. The salient characteristics of
Str. epidemicus, as described by Davis, Hamburger,’ and Stokes
and Hachtel, are as follows:

The organism is gram-positive and usually occurs in pairs existing separately or
in short or longer chains. When freshly isolated, the pairs show a capsule, differing
from the capsule of the pneumococcus in that it is not indented between the individuals
in the pairs. It is frequently described as a halo and is rapidly lost on cultivation, but
reappears after animal passage. On blood agar, according to Davis, the colonies are
larger and more moist than those of Sir. pyogenes, but they do not have the mucoid
appearance of Sir. mucosus. The colonies are surrounded by a distinct zone of hemoly-
sis, generally, but not always, narrower than the zone produced by Sir. pyogenes,
and exhibiting a faint greenish tint by transmitted light. Sir. epidemicus is only
partially dissolved by bile, and it acidifies. milk with frequent but not constant
coagulation. Dextrose, lactose, saccharose, and dextrin are fermented with acid
production but no gas, while raffinose, mannite, and inulin are not attacked. Broth
is uniformly clouded. Davis states that the organism is highly virulent for mice,
rabbits, and guinea-pigs. Stokes and Hachtel confirm its pathogenicity for mice.
The organisms isolated during the Chicago and Baltimore epidemics correspond to
the above description.

B. NATURE AND COLLECTION OF SPECIMENS ‘(PRESENT EPIDEMIC).

The exudate from the throats of 13 patients and the pus from a suppurating
cervical gland were removed with a sterile swab and planted on Léffler’s medium.
The tubes were incubated and shipped immediately to the Hoagland Laboratory.
The milk slime, obtained from the 2 suspected cows in Dairy X by means of the
clarifier, was drawn into sterile bottles and immediately forwarded. Ali material
was examined upon its receipt.

Cc. PROCEDURE OF EXAMINING MATERIAL.

The outlined procedure was followed with all material: The swabs were rubbed
over the surface of the culture, then shaken in a tube of serum broth which was incu-
bated over night at 37.5°C. This broth culture was then plated on rabbits’ blood
agar by the Conradi method, and the plates incubated. Colonies were fished and
those yielding suspicious diplococci or streptococci were isolated on blood agar,
nutrose agar, and in ascitic broth. The milk slime was planted in serum broth and
then plated and subcultured as above.

t Jour. Am. Med. Assn., t912, 58, p. 1109; also, Bull. 263, Johns Hopkins Hosp., 1913, 24, p. 1.
+ Jour. Am. Med. Assn., 1912, 58, DP. 773+ :
 

 

 

 

 

 

 

 

 

. TABLE 5.
CoLoNIES oN BLoop AGAR CARBOHYDRATES{
SoLv- 4
CHaIN
Cuuture | Oricin | Forma- ; Ceere BIT’! HewoLysis a 3 3 i g PATHOGENICITY
TION | Size | Color | Hemolytic Bre Z é g
A 5 ala 2
CI/a’..... Throat | Short Medium | Green | Meth.* brown| Uniform — | Meth. brown; « | x {| x | x | « | x | Rabbit, suppurative
turbidity arthritis
CII/2’ « Medium « “ « « Uniform - « “ x * xlanit en x
turbidity Group
CIV/r ‘ Short Large « . « bencr ey ' - « « @ | «|x| =| x | x | Rabbit died, 7 days A
urbidity
Jereseee 6 Vee Small ‘ “ . iniform - . 7 e]elal sla] ez
turbidity
CIIl/1 “ Medium . « “ “ Uniform ~_ “ « aj;zez{aeix211- }«
turbidity
CV/1 ‘ Short “ “ No Color Uniform - « “ z)aluje]—]e
turbidity
CV/3..... ‘ ‘ Medium ‘ Meth. brown | Granular - ‘ ‘ x)e}2[ 2] —ie « “ 28 “ | Group
sediment B
CVI/1 “ Long Large “ 7 “ Ropy, - “ “ zie] ee] —] es 7 “ 8 *
sediment
CVIII/2 .. ‘ Medium | Small Faint “ « Uniform - « “ eolewlexelej—-le
green turbidity
CIV/1.... “ . Medium | Faint | No color Uniform | — | No Color zapete pele] —
reen turbidity
CV/3..... “ Long Small aint co ¢ Granular - “ # aie |x} x] al —
green sediment
CVI/2, “ Short Medium| Green | “-  “ Uniform, - «os ze] ela] ate] —
. turbidity Group
CVII/: ... ‘ Long . Faint Meth. brown | Granul - Meth. brown| x | x | x | x | x | — “ “oo. * c
green sediment
Ko... “ Medium “ Green | Hemolysis Ropy - Hemolysis ei, a2l[ue) eta] —-—
. sediment
CVIT/1/x .| Cervical | Long “ Faint Meth. brown | Granular _ Meth. brown| « | « | x | x [| x | ~
gland green sediment

 

 

 

 

 

 

 

 

 

 

 

 

 

* Methemoglobia brown.

t There was no action in mannite, inulin, and dulcite.

AUAAY “[, TIVMSOC ‘ALIBM NINVINaG ‘HLYON “ SATAVH) ger
TABLE 5.—Continued.

 

 

CV/2..... Throat | Long Large Green | Meth. brown
CVI/r « « Medium “ “ .
CIX/2.... “ Medium | Small “ “ «
Long Medium * * .
“ « « a“ «
hese eee an, * * «
Mra8/r...] Milk = {......... cee ee aes “ « «
SraB/4....) Milk oo f..... fell... « _ 8 «
slime
Mr52/4...[| Milk foo... bel. « « “
Sxg2/q....] Milk 9 f....00 pe « « we
slime
$187/3....) Milk foo... poe « « 7
slime .
Sr89/1....[ Milk = [.........f. 002. “ “ «
slime
Sx8o/4....) Milk fo... * * «
slime

 

 

 

 

 

 

 

Ropy
sediment

 

 

Meth. brown
a «
+ «
«
« a
= “"
“« «
* “«
« a“
« *
“ “
« “*
« a

 

® RR &

ew RF R HR &

8

a 8 8 # & &

 

ke H 8 8&8 &# 4

&

 

* 8 # & * & &H & H KR

8

 

® # ROR

8

a

 

 

 

Rabbit died, 7 days

mee , fuppurative
Rabe died, 8 days

Not, bathogenic for

Not | ot pathogenic for

Not ot pathogenic for

Not p ‘pathogenic for

Not mice pogenic for

Nat be pathogenic for
mice

 

Grow,
D ip

Group
E

 

Litmus milk: x=acid coagulation, a =sacid production but no coagulation.

Carbohydrate reactions: x= acid coagulation, — =no action.

OINAGIAY LVOIH], TAOS OLLaaS V

6¢x
140 CHARLES E. NORTH, BENJAMIN WHITE, OSWALD T. AVERY

1. Morphology.—Observations were made on young cultures in ascitic broth.
Both the Hiss and the Rosenow capsule stains were used.

2. Hemolysis.—One-half cubic centimeter of an 18-hour ascitic broth culture was
added to 1 c.c. of a 5 per cent suspension of washed sheep and human erythrocytes,
respectively. Readings were taken at the end of 2 hours’ incubation, and over night
at room temperature. This method is considered by the authors as yielding more
definite evidence of hemolytic action than that obtained by observing the colonies on
blood agar. , ;

3. Solubility in bile—One cubic centimeter of a.24-hour broth culture was mixed
with 0.2 c.c. of sterile ox-bile. Readings were taken after 30 minutes and 2 hours
at 37.5° C. .

4. Carbohydrates and milk.—The carbohydrates were Kahlbaum preparations
and were employed in the form of Hiss serum waters. Decreamed litmus milk and
the carbohydrate media were inoculated with approximately 0.1 c.c. of an 18-hour
ascitic broth culture. Viability of the cultures used for inoculation was tested each
time by planting on nutrose agar. Readings were taken during 7 days’ incubation.

5. Pathogenicity —One cubic centimeter of an 18-hour ascitic broth culture was
injected into the ear veins of rabbits weighing approximately 500 grams.

D. RESULTS.

Table 5 shows the general morphological, cultural, and biochemical characters of
the organisms isolated.

The colonies of all the strains of streptococci isolated on rabbits’
blood agar showed a greenish tint by transmitted light. They
varied in size from pin points to aggregations somewhat larger than
the usual Sir. pyogenes colonies. The mucoid appearance pro-
duced by Sir. mucosus was never observed. The growth in
broth varied with the presence or absence of enriching ingredients,
and experience showed the advisability of disregarding this feature
as a point of differentiation. From careful observation of the form
of the cocci when grown in ascitic broth, it would be difficult to dis-
tinguish any reliable diagnostic differences. The occurrence of the
cocci in pairs was frequent, and usually these pairs were linked
together in short and sometimes moderately long chains. The use
of the Hiss and the Rosenow stains failed to reveal a true capsule.
When freshly isolated from the body, particularly on the direct
smears made from the blood or pus of the infected rabbits, a dis-
tinct encircling zone could be seen about the paired or chained cocci,
but its appearance would scarcely warrant its being designated as a
true capsule. None of the organisms in the series was appreciably
dissolved by ox bile, and only one—and that from a cervical gland—
A Septic Sore Turoat Ermwemic I4t

produced any hemolysis when added to-a suspension of washed
sheep or human erythrocytes.

The various streptococci isolated appear to form general groups
when classified according to their carbohydrate reactions. Altho
any classification of streptococci according to carbohydrate fermen-
tation is acknowledged to be incomplete and unsatisfactory, yet,
lacking more valuable methods, the following grouping is tentatively
offered. All the strains acidified dextrose, lactose, and saccharose,
all acidified litmus milk, but none fermented inulin, mannite, or
dulcite; hence their behavior toward raffinose and salicin is taken as
a basis for the grouping.

Group A.—Salicin and raffinose fermented. All produced the
methemoglobin darkening when added to erythrocyte suspension,
but none gave a true hemolysis. All strains appeared as diplococci
in short or medium chains. One of the strains, ‘““CI/r,” produced
a suppurative arthritis in a rabbit, and from the lesion the organism
was recovered and proved to be identical with the strain inoculated.
Strain “CIV/1” killed a rabbit in 7 days.

Group B.—Raffinose fermented but not salicin. All except
one produced methemoglobin, but no true hemolysis. The mor-
phology was the same as in Group A. Two rabbits injected with
two of the strains died in 8 and 28 days, respectively, of coccidiosis
' with no sign of streptococcic infection. In connection with this
group there may be noted the observation of Stokes and Hachtel
that their strains of Str. epidemicus developed the ability to attack
raffinose on cultivation.

Group C.—Salicin fermented but not raffinose. There were no
significant morphological features. Three strains produced no
change in the erythrocyte suspensions, 2 gave the methemoglobin
reaction, while 1 strain, ‘‘K,”’ produced true hemolysis. It is
interesting to note that this strain was obtained from a suppurating
cervical gland, and was the only one in the whole series producing
hemolysis. From the throat of this case, 3 strains were isolated,
one, ‘‘K-2,”’ falling in Group D, while the others, “K-3” and “K-4,”
differed from all the other strains examined in their ability to
attack mannite. Strain “CVII/1’’ killed a rabbit in 2 days. The
142 CHaR LES E. Nortu, Benjamin Watre, Oswatp T. AVERY

organism was recovered from the heart’s blood and corresponded
in all respects to the original strain.

Group D.—Neither salicin nor raffinose fermented. All produce
methemoglobin but no hemolysis. All the organisms isolated from
the milk slime from the infected caws fall into this group. These
strains agree with the description of Sir. epidemicus as given by
Davis, and Stokes and Hachtel, with the single exceptich that,
altho the colonies on blood agar had a greenish tint, none of these
strains produced true hemolysis when added to red blood corpuscle
suspensions. The members of Group C, like those of D,.fail to
attack raffinose, but do attack salicin. Inasmuch as other authors
make no mention of the behavior of Sir. epidemicus toward salicin,
it is impossible to draw sharp and complete comparisons.

In connection with the present series of cultures, there attaches
a pertinent significance to some observations, made by the authors
earlier in the year, on cultures of streptococci obtained from milk
slime. At the time, a preliminary attempt was made to ascertain
the nature of the predominating organism in milk and milk slime
from several cows suffering from infected udders. The whole
milk and the milk slime obtained by the clarifier was examined
by the procedure already described. Cows No. 128 and 152 had
frank cases of garget, Cow 187 had a slight infection of one
quarter, while Cow 189 was supposed to be a normal animal,
altho the quantity and nature of the slime obtained from the milk
of this cow strongly suggested the presence of inflammation. The
organisms isolated from these 4 cows are included in Group E.
It may be pointed out that, in the case of the 2 severely infected
animals, suspicious streptococci were found in both the milk and the
slime, while, in the case of the other 2 animals, these streptococci
were present only in the slime. The great similarity between the
reactions of the members of Group E and those of Group D is
strikingly suggestive.

SUMMARY.

1. Two epidemics of septic sore-throat occurred simultaneously
in May, 1913, in Cortland and Homer, New York, the two com-
munities being 3 miles apart.
A Septic Sore Taroat Epmemic 143

2. Over 7o per cent of the cases in each community occurred
among the patrons of a dairyman who was the only dairyman
selling milk in both places, and who supplied less than 7 per cent
of the total milk supply. Adjacent towns had no cases and, further,
they received no milk from the suspected dairy.

3. Physical examination of the cows and microscopical examina-
tion of milk sediments showed the éxistence of acute udder inflam-
mation in 2 cows in the herd of the suspected dairyman.

4. Bacteriological examination showed that cultures from the
throats of 4 patients contained streptococci apparently identical -
with strains of streptococci obtained from the milk slime from the
2 cows suffering from garget. Cultures from the throats of 8
other patients contained streptococci of this same type but differ-
ing, by slight variations only, in their carbohydrate fermentations.

5. The streptococci isolated from the milk slime from the 2
garget cows and the throats of 4 patients in the present epidemic
correspond in all respects to strains of streptococci isolated previ-
ously from 3 cows of another herd known to be suffering from
garget, and from the milk slime from 1 cow supposed to be normal,
but which gave an abnormal amount of slime.