J A SEPTIC SORE THROAT EPIDEMIC IN CORTLAND AND HOMER, N.Y.* CHARLES E. NORTH, BENJAMIN WHITE, AND OSWALD T. AVERY. I. 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 outbr&ks are comparatively common, but, as tbe condition is not notifiable, it is seldom that a record is obtained of tbe 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 or cream. The usual symptoms are congestion of the tonsils and mucous membnrne 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, atrectlng 205 persons, all of whom obtained milk from one dairy farm. The chief symptoms were local in&unmations of the throat and enlargement of the lymphatic glands of the neck. In 189o they mention an outbreak at Craigniore 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 ISI cases, 138 of which were supplied with milk from one dairy. The symptoms included tonsillitis, swelliig of the cervical lymphatic glan+, rise of temperature-in some cases to 10s' F.-and great prostration. Secondary to the sore throat, in I 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 same dairy. The health officer reporting this outbreak states: "I think that every case of septic sore throat should be notifiable. The difliculties 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 thii inflammation of the udder as the probable cause. The bacteria most commonly found in the throats and udders were streptococci. . 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 191o-11. The tOti 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 thii 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 wthor states: "A carrier case presumably infected the milk." 1 In December, 1911, and January, 1912, an extensive outbreak occurred 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, concem- in8 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 modiies 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 or∈ they may be both. Milk drawn in a sterile way from normal cows may contain virulent streptococci and pneumococci; hence, "certi8ed milk " while surely less contaminated than ordinary milk, may contain pathogenic bactkia, and the advisabiity 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 Hachte1.s A total of 602 cases was reported, the majority of which occurred from February I to March 20,rgrz. 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 Qepticemia, I case of appendicitis, z 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 produced it." 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. 126 CHARLES E. NORTH, BENJAMIN WIIITE, OSWALD T. AVERY Stokes and Hachtel recovered pneumococci from the milk, showing that tbe flash system of pasteuriaation was inefficient. In the raw milk shipped to Dairy I, 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 dab-y." In February, 1912, there was a sudden increase in the acute infections noted in Boston, almost a year later than the great Baltimore outbreak prkviously described. In this outbreak, wbicb was investigated and reported by Co&> 227 csses 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 IO farm hands with reddened throats. The milk was not pasteurized. The author concludes: "The occurrence of so many cases of milk pbaryngitis . . . . 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, band 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. II. 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, `Am Jour. Pub. Eeulth, 1911, 1, p. 419. A SEPTIC SORE THROAT EPIDEMIC 127 enlargement of the lymphatic glands of the neck, and, in some cases, great prostration. The city of Cortland has a population of 12,cbo and the village of Homer, a population of 2,700. They are 2 miles distant from each other. As soon as &e outbreak was recognized, a special meeting of the Cortland County Medical Society wgs 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 w&s 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: I. Public Health Committee of the Cortland County Medical Society. i. 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 CHARLESE. NORTH,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 Iines of work at `the same time. The work fell into the following divisions : a) RGpwtilag of cases.-Printed blanks were prepared havfng 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 ln 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 Co&and and 5 in the village of Homer made reports in the manner indicated. 61) D&iled inocs6igation of cuses.-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. i c) Cd6wes 6&s.-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$~ec6ions.-Early in the investigation, it became evident that a much larger number of csses were the patrons of one milk dealer than hisproportion 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. e) Sedfmenl ks6s of cows &&.-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) hAxwiza6ion of &K.-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 hii 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) Inqr&es L otkcr 6owns.-To determine whether the outbreak was strictly local in character or not, inquiries were carried out in nearby towns and villages. h) Tab&6iopl 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 occur&g among the customers of one A SEPTIC SORE THROAT I~PIDEMIC! 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 MA+- do 5. IO r5 i- CEAslT 'I. the patrons of Dairy X, the figures for both Cortiand and Homer are combined in Table I, 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 I. From this chart it appears that the epidemic 130 CHARLES E. NORTE,BENJAMIN WHITE, OSWALD T. AVERY Date I TOtd Car*, 'i April I. . . , . . . . * I a . . . . . , . . . . . . . . . . J........... .*.....*. 4 .................... 5 ........... 6 .............. ..f ... , ............ . ....... a ........... * ........... :* IO.. ......... 5 II.. ......... 3 It ........... r3 ........... 3 14. .......... 1s ........... 8 16 ........... I I, ........... Ia ........... d I* ........... 4 10. .......... 13 DgY x . . . . . . . . . . . . . . f ,....... I *..*.... * . . . . . . . I 1: f * : s I f ffJ TABLE r. Other DairiiX 0 . . . . . . . . , . . . . , . . . . . . . . . , . . . . . . . ..I.. s : I I 0 : 0 3 : I Date Total April ?I .,,.. *,*.. 11.. . . . . . . . . . . 13.....*..... *4..,........ :&`. : . . . . . . . . . . . . . . . . z,........... aa .,...: . . . . . IQ........... 30. . . . . . . . . May I,........,. ,I.........., J.,.....,... 4........... s........... 6........... ,.........., 8. . . . . . . . . . g.,.......,. 4 4 x3 29 i: c :: 59 30 3.5 23 11 1s 7 I 3 Other DSi&S I 1 , : P 4 I7 a 6 14 Ifr 6; Ia 6 i 3 I- 3 extended over a period of about 20 days, beginning April 20 and ending May IO, 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 I, and their relation to the milk supply of Dairy X, are summarized in Table 2. TABLE z. Population. . , . . . . . . . . . . . . . . , . . . . . . . . . . . Total cows. . , . . . , . . . . . . . . . . . . . . . . . . . . Dairy XL . . . . . . . . . . . .._. . . . . . . . . . . . . . . . ~~d~~~ ..,..,....,....,..........,.... ._.~.,...,.................,... Milk supply. . . . .,....,................ *... Daky X SUPPIY ,,...,..*......,.,........*. 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 SORE THROAT EPIDEMIC 131 supply. This means, in short, that there were IO 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. Acr DImmExpON 01 CASES. Ases Coctfand Homer Q-5, . . . . . . . . 41 a s-10. . . . . . . . 41 10 m-20. . . . . . . . 76 29 z-30. . . . . 91 14 Ages Cortland Homer 30-40. . . . . . . . 31 40-30........... 8: i a4 p-60........... 36 60+. . . . . . . 37 t- 19 41 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 IIS females were atllicted. 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. DltATES. Date I I Age Cause of Death My 3 ........................ (I 4 ......................... 5 ......................... u *r ......................... June14 ......................... My 3 3 .................................................. I 4 ......................... II 5 ......................... : 6 7 .................................................. 1 a ......................... II ......................... . as ......................... HCLI ii E a0 11 78 . . . . ..I... 132 CHARLES E. NORTH, BENJAMIN WHITE, OSWALD T. AVERY Of the 14 deaths, 5 were due to peritonitis, 4 to erysipelas, 2 to pneumonia, 2 to heart failure, and I 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 &I%- 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 &iilk. 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 THROAT EPIDEMIC 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 I per cent solution of chlorid of 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. I are shown typical results of these examinations. The glass bottles are 2 ounces in 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 quarts each. The 134 CHARLES E. NORTH, BENJAXIN WHITE, OSWALD 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 I quart, and in the other, I. 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 suflicient evidence for these purposes. There were, however, qualitative differences in the slime which were even more interesting, as shown by microscopic examinations. 5. 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 considerabIe 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 epithelial cells shed in the normal process of lactation from the walls of the milk glands. A SEPTIC SORE THROAT EPIDEMIC I35 Fro. 2. 136 CHARLES E.NORTH,BENJAMIN WHITE, OSWALD T. AVERY The microscopic appearance of the slime from the miIk of the 2 cows having inflamed udders shows a marked Merence in appear- ance. Fig. 3 shows a considerable variety of cells; of even greater interest are the large numbe?s 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 in&rnmation. ~ This condition was shown plainly in every smear which was made (from the slime obtained from these inflamed uc&lers. : 6. BACTERIOLOGY. A. ORGANISXS ISOLATED IN PP.EVIOUS EPIDEXICS. The bacte~olo~ca~ exam~ation 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: (I) 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 big the milk. In the Finchley epidemic in 1904 the streptococcus was first isolated from the throats of the affected patients, while Sk. @goes was first detected in the suspected milk by Pierce' in the Guildford outbreak in 1903. Since that time,' in the majority of outbreaks, *&it. Ned. low.. x003, 2, 0. 1402. A SEPTIC SORE TIIBOAT EPIDEMIC I37 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. #yegenes, but they do not have the mucoid appearance of Str. ~ucosur. The colonies are surrounded by a distinct zone of hemoly- sis, generally, but not always, narrower than the zone produced by Str. pyogenes, and exhibiting a faint greenish tint by transmitted light. Str. epidemicws 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, whiie rafllnose, 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 Ha&e1 confirm its pathogenicity for mice. The organisms isolated during the Chicago and Baltimore epidemics correspond to the above description. B. NATURE AND COLLECTION OF ~PE~NS.'(PBE~ENT 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 Liiffler's medium. The tubes were incubated and shipped immediately to the Hoagland Laboratory. The milk slime, obtained from the z suspected cows in Dairy X by means of the clarifier, was drawn into sterile bottles and immediately `forwarded. All material was examined upon its receipt. C. 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 ascltic broth. The milk slime was planted in serum broth and then plated and subcultured as above. TABLE 5. -- CI/a'. . . Throat CII/z'. . . . " CIV/r.... " J . . . . . . " CIII/r.... m CV/I..... m cv/3..... - CVI/I.... * CVIII/a . " CIV/I.... " CV/3'. . . * CVI/a.. " CVIl/r . . w K . . . ' CVII/x/x . c;*kw;dal Short Medium Short Medium Short Y Lone Medium Medium Y Larse Small ` I Medium Large Small Medlun Small Mediun . * " -- -- Meth: brown Unifom Y I turbidity Uniform turbidity a I U&Xm turbidity I " Uniform turbiditv a I Ul-&Xm turbidity No Color Uniform turbidity M&h. brown Granular sediment Y I ROPY - sediment Y Y Uniform turbidity No color Urdform I Y turbidity GtlllUdU sediment ". u Uniform Meth. brown turbidity GlUUdtU sediment H%%llOlySiS WY `M&h. brown sediment G~lUlhU sediment - - -- Meth. brown " Y # Y * a No Color " Y Y Y Metb. brow H~Olysis M&h. brow - t There was DO action in mqnnite, inulin, and dulcite. m I 3 Rabbit died, : days "`;r"" o ????????o???* brown. TABLE s.--Corrlirrned. cv.L1.... CVIIf/r.. ax/a. . as. . . . . . . a.$. . . . . K-a...... Mr28/1.. &28/4.. Mr5af4.. SI32/4.. Sr87/3.. 1 SIBp/l.. . Ssspl4.. . Throat " L Mi SlhlC Milk slime Throat Milk Milk slime Milk Milk slime Milk slime Milk slime Milk slime Medium Long . e . . . ..*..., _.....* . . . . . . . . . . . . . . . . . Large Medium Small . . . . . . . . . . . I I . . . . . . . ...`.. 1 . . . . . , . . . - 1 - R~PY sediment ROPY sediment Uniform turbfdity R"7ziiment R"Lent ROPY sediment . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...*.... . . . . . . . . . , Litmus milk: ~==acfd coagalatioa, o oacfd p~~tioo but ao coapulatfon. Carbuhydrate reacticms: z=acid coagulation. --=a~ action. - - - 1 - - - - I Rabbit died, 7 days ";btit~;wppurative ' "7~ Rabbit died, 8 days Not pathogenic for mke Not oathoaeaic for c Not pat-e&c for mice ;mUp E 140 CHARLES L NORTH, BENJAMIN WHITE, OSWALD T. AVERY I. Morphology.+bservations were made on young cultures in ascitic broth. Both the Hiss and the Rosenow capsule stains were used. z. RernoZysis.-One-half cubic centimeter of an IS-hour ascitic broth culture was added to I 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. .Solub&ty in Ms.-One cubic centimeter of a q-hour broth culture was mixed with o. 2 C.C. of sterile ox-bile. Readings we& taken after 30 minutes and 2 hours at37.soC. 4. Carbohydreles and &R.-The carbohydrates were Kahlbaum preparations and were employed in the form of Hiss serum waters. Decreamed litmus mi& and the carbohydrate media were inoculated with approximately o. I C.C. of an IS-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. Pufhogen&%y.-One cubic centimeter of an II-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 Str. pyogenes colonies. The mucoid appearance pro- duced by 2%. ~UCOSUS 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 THROAT EPIDEMIC 141 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 streptococh 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 sac&arose, all acidified litmus milk, but none fermented iuulin, mannite, or dulcite; hence their behavior toward raffinose and salicin is taken as a basis for the grouping. Croul, A.-Salicin and ra5ose fermented. All produced the methemoglob~ 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/I," 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/I " killed a rabbit in 7 days. Grwp B,-Ra5ose 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 ra5ose on cultivation. &otip C.-Salicin fermented but not rafiinose. There were no s&i&ant morphological features. Three strains produced no change in the erythrocyte suspensions, 2 gave the methemoglobin reaction, while I strain, "IL" 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, "IL-2,"fallinginGroupD, whiletheothers, "K-3"and"K-4," differed from all the other strains examined in their ability to attack mannite. Strain "CVII/~"killed a rabbit in 2 days. The 142 CHARLES E. NORTH, BENJAU WHITBZ, OSWALD T. AVEEY organism was recovered from the heart's blood and corresponded in all respects to the original strain. Grozlp D.-Neither salicin nor ra5ose fermented. All produce methemoglobin but no hemolysis. All the organisms isolated from the milk slime from the infected cows fall into this group. These Strains agree with the description of Str. e~~~~s as given by Davis, and Stokes and Hachtel, with the single excepti+ 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 ra5ose, but do attack salicin. Inasmuch as other authors make no mention of the behavior of Str. epidemiczcs toward &&in, 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 indluded 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. I. 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 `I~IROAT EPIDEMIC 143 2. Over 70 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 existence of acute udder inflam- mation in 2 cows in the herd of the suspected dairyman. 4. Bacte~o~o~ca~ examination showed that cultures frbm 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 I cow supposed to be normal, but which gave an abnormal amount of slime.