Vol. 30

An Outbreak of Shiga Dysentery in

Michigan, 1938 ** N. BERNETA BLOCK, M.D., AND WILLIAM FERGUSON

Field Physician, and Bacteriologist, State Departmentof Health, Lansing, Mich.

IN the summer of 1938 an outbreakof Shiga dysentery resulting in 45

knowil cases occurred in Owosso, Mich.,and other parts of the state. The rarityof this disease in the northern statesand the comparatively large number ofpersons involved are deemed importantenough to warrant a description of theoutbreak (Map I).

Attention was focused on the firstcases in this outbreak when a physician

* Read at a Joint Session of the Laboratory andEpidemiology Sections of the American Public HealthAssociation at the Sixty-eighth Annual Meeting inPittsburgh, Pa., October 17, 1939.

t Case Numbers are listed according to dates ofonset as on Chart I.

was called on July 28, 1938, to visit 6members of the " X " family living inone of the two tenant houses on a dairyfarm 7 miles south of Owosso. The othertenant house was occupied by a middleaged man living alone who did most ofthe work in the dairy. He proved to besymptom free, and laboratory reportsof fecal specimens were negative. Theowner, " Y," lived in a third house on

the farm.

Of the 7 members of the " X " fam-ily, 6 had become suddenly ill with aviolent bloody diarrhea. The mother(case 5) t was the first to succumb to

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AMERICAN JOURNAL OF PUBLIC HEALTH

SHIGA DY3ENTE2.Yirn environs oF Qurooso. Crumpond tiesperta, Michsc3am

the distressing symptoms. Her date ofonset (July 21) was followed in rapidsuccession by the dates of onset of her5 children (cases 6, 7, 8, 9, 10). Becauseof prostrating toxic symptoms and theutter impossibility of caring for thefamily in their poverty stricken home,the doctor on his first visit ordered thatthey all be admitted immediately asemergency cases to the Owosso Me-morial Hospital. The severity of theinitial symptoms might be accounted for'in part by the fact that the family hadbeen on inadequate rations for sometime and all showed signs of poor nutri-tion. The only person not affected atthe time was the father (case 31) whosubsequently contracted the disease in amild form and remained ambulatorythroughout.The 4 year old daughter (case 11) of

" Y" the owner of the dairy farm, hada history of diarrhea which began July20. It became bloody in type on July28, but because of religious scruples aphysician was not called. The child died

in the home on July 31, which was thedate on which a 17 year old delivery boy(case 13), the first case to be reportedin the city of Owosso, entered the hos-pital with a chief complaint of bloodydiarrhea. He recalls that he delivered acatalogue to the home of " Y " on July22, and loaned his pencil to the 10 yearold son to sign for it. The 4 year oldchild, whose symptoms began 2 dayspreviously, was absent from the premisesat that time.On July 29, the first child (case 6) in

the " X " family died, after having beenin the hospital but 1 day. On July 30,the second (case 7), on July 31, thethird (case 8), and on August 2, thefourth (case 9) death occurred in thefamily. Also on August 2, an Owossochild of 6 years (case 12), sufferingfrom a bloody diarrhea, was admitted tothe hospital and died 2 days later.The symptoms common to all these

patients were: a sudden onset of violent,almost continuous diarrhea which im-mediately or very soon became bloody,

44 Jan., 1940

SHIGA DYSENTERY

accompanied by nausea, vomiting, rest-lessness, irritability, and a moderate risein temperature. Signs of dehydrationappeared very early. Excruciating ab-dominal pain and tenesmus were present,and very often, especially in the youngerchildren, a prolapse of the bowel or aconstant hemorrhage from the rectumwas noted.

DIAGNOSISA search for the causative agent was

made in the fields of toxicology, proto-zoology, and bacteriology. Reports inthe first two fields were negative.Shigella dysenteriae variety Shiga wasisolated on August 5 from cultures ofnecropsy material from case 9 (the firsttime this organism had been isolated inthe state laboratories).The findings on case 9 are recorded

in detail as a typical case, and the oneon which the diagnosis of the outbreakwas made.

Case 9. L. B., Age 4 YearsDate of onset-7-27-38. Date of death-

8-2-38. Chief complaint: Violent bloodydiarrhea. Past History: Generally under parfor some months, otherwise not essential.Family History: Father was living and well;mother ill with the complaint of violentdiarrhea; brothers, two, rn with the samecomplaint; sisters, three, two ill with thesame complaint. (One sister who was livingwith the grandmother was well, and does notenter into the picture as she had not beenliving at home for some months and had notvisited or been visited by members of thefamily.) Physical Examination: Head-noabnormalities noted except dryness of mucousmembrane; Neck-no glands enlarged; Chest-Lungs-voice sounds and breath soundsnormal, no rales. Heart-not enlarged, normalrhythm, no murmurs; Abdomen--scaphoid, nodistention, no masses or organs palpated,diffuse tenderness. Laboratory Work: BloodStudy: (7-28-38) Hemoglobin-85% (Sahli);White blood cells-27,000, 6% Lymphocytes,2% Large Mononuclear cells, 22% Neutrophils,segmented, 60%o Neutrophils, non-segmented,10% Metamyelocytes.

Signs of dehydration were present on en-trance to the hospital. The violent diarrheacontinued, became almost constant, and thechild's condition rapidly grew more serious.

Shreds of mucus, pus, fresh and occult bloodwere discharged from the bowel. On theseventh day of the disease (8-2-38) the childdied. A post-mortem examination was made6 hours after death and necropsy specimenswere sent to the Michigan Department ofHealth and the University of MichiganPathology Department.

The Autopsy Report of the Colon readsas follows: " Extremely severe necrotizingulcerative and hemorrhagic colitis. Practicallyno mucosa remaining. The hemorrhagic processextends to the muscde in practically all regionsand in some areas involves the completqthickness of the circular muscle coat. Thenecrotic surface is covered with an almostcontinuous layer of bacteria."

BACTERIOLOGY

Washings from the small and largeintestine were made and streaked onEndo, and MacConkey plates. Pouredplates of bismuth sulphite were alsomade with the washings as inoculum.From the 30-odd plates that werestreaked with dilutions of the intes-tinal contents only 2 non-lactose fer-menting colonies proved to be Shigelladysenteriae, variety Shiga.

Identification of the organism wasmade on the basis of biochemical, sero-logic, and stain reactions. The reactionon triple sugar was typical of dystenteryorganisms-alkaline slant, pink butt, nogas, no H2S produced. In single sugarsdextrose and levulose were fermented;lactose, sucrose, maltose, mannite,xylose, dulcite, and inosite were unaf-fected. Indol was not formed aftergrowth in tryptone water for 72 hours,and the organism was not motile after 4hours' and 24 hours' growth in nutrientbroth. Gelatin was not liquefied in 168hours. The staining reaction was Gram-negative.With two lots of specific Shiga anti-

sera, one lot furnished by Parke, Davis& Co. and the other bv Lederle & Co.,the organism was agglutinated in a1:1280 dilution of both sera. Flexnerpolyvalent antiserum failed to agglu-tinate the bacteria in the low dilutionof 1:80.

Vol. 30 45

AMERICAN JOURNAL OF PUBLIC HEALTH

MAPU

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Because of the failure of the centrallaboratory in Lansing to isolate anythingof significance from shipped specimens,a field laboratory of the department wasestablished in Owosso to plate specimensas soon as they were obtained. Theroutine procedure in this laboratory wasto emulsify the fecal specimen in physio-logical saline, making a heavy suspen-sion, and to inoculate a plate of bismuthsulphite. The material was furtherdiluted and 2 plates of Endo medium,and 2 plates of MacConkey mediumwere streaked serially from thisinoculum.

It was found that MacConkey me-dium was particularly valuable for isola-tion of Shiga organisms, since it was lessinhibitory than the Endo medium em-ployed and yet did not permit an over-growth of lactose-fermenting bacteria.Practically without exception more col-

b5IGA DYSEM1TEP.Y* coA.s

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onies of Shigella were found onMacConkey medium than on Endo, andthe colonies were larger in size. It wasalso easier to distinguish different typesof non-lactose-fermenting colonies onMacConkey medium.

It has been the experience of manystate laboratories that the recovery ofShigella dysenteriae from shipped speci-mens, with or without preservatives, isgenerally unsuccessful.* Our own ex-perience in the early cases, and subse-quent attempts at isolation, resultedin failure. At the field laboratory stoolsfrom known cases of Shiga dysenterywere divided, part placed in the usualfecal container with 30 per cent glyc-erine solution as a preservative, and theother part cultured immediately. Thepreserved specimens were sent to the

Confidential Communications.

46 Jan., 1940

SHIGA DYSENTERY

Central Laboratory and cultured about24 hours later. Out of 10 specimensfrom which Shigella dysenteriae wasisolated from the fresh stool not asingle isolation was made from the pre-served portion. The stools were teemingwith dysentery bacilli and with com-paratively few coliform organisms.The experiments with shipped speci-

mens, while few in number, agree withthe experiences of others and confirmtheir opinion that at present Shigelladysenteriae, especially the Shiga variety,must be isolated from fresh fecalspecimens.From our observation bacteriological

examination of the fresh feces wasnecessary within an hour after passagefor successful isolation of Shigelladysenteriae, although in a few instancesthe organism was isolated when thestool had been obtained 2 hours priorto plating.On August 6, a Mexican boy, age 14

(case 25), from the Mexican colony inthe northwest section of Owosso (seeMap II) was admitted to the hospitaland a diagnosis of Shiga. dysentery wasmade after isolating the organism fromfecal specimens.'

Deaths continued to occur (see ChartI), and by August 6, more than 45cases of diarrhea were reported. Shigelladysenteriae variety Shiga was isolatedfrom fecal specimens obtained fromambulatory cases presenting only mildsymptoms as well as from hospitalizedcases with severe symptoms. A descrip-tion of the more significant cases willbe brought into the text. For the com-plete list of those involved see Chart I.

Case 35, who was living outside thecity but working in the Owosso Hos-pital, was placed as an orderly in theisolation unit on July 28, when the 6patients from the "X" family wereadmitted. He became ill with bloodydiarrhea on August 10. Although theorganism was not isolated in his case,his family of 5 had similar symptoms

of varying degrees, and the organismwas isolated from stool specimens ofhis two sons.

Also, on August 10, it was reportedfrom Bay City, some 55 miles north ofOwosso, that from one family, 4 chil-dren with a complaint of severe bloodydiarrhea had been admitted to TheGeneral Hospital. The symptoms de-scribed were identical with those of thepatients with Shiga dystentery, andwithin a few days, Shigella dysenteriaevariety Shiga was isolated from fecalspecimens of 2 of the children, one ofwhom died.

These children (cases 14, 15, 20, 37)lived on a farm near Crump, about 15miles north of Bay City, 70 miles northof Owosso (see Map I). It was foundthat about 2 weeks before the onset(August 1) of these cases, " Z " (case1) and his family had come from theMexican colony in Owosso to work inthe beet fields on a farm almost directlyacross from their home. He and hisbaby daughter (case 2) had had bloodydiarrhea since early in July. On theirway from Owosso to Crump they stop-ped over night in a camp which alsosheltered a Mexican family in whichthere was a 22 months old baby (case 3)with pertussis. Within a few days thatbaby developed a bloody diarrhea anddied. Some time after they arrived inCrump a frail Mexican baby (case 26)in the home where they made a shortstay contracted a violent bloody diar-rhea and recovered only after a pro-longed illness. " Z " and his daughterand the 4 children (cases 14, 15, 20,37) frequently met at a third farm,where they went regularly for the fam-ily supply of milk and water and wereknown to use a common drinking cup.The day before the investigation wasmade in this vicinity he and his familyagain had moved to an unknowndestination.

Cases 28 and 42 (son and fatherrespectively) who lived in the same

Vol. 30 47

AMERICAN JOURNAL OF PUBLIC HEALTH

neighborhood frequented the farm onwhich the above 4 children lived, andwere there for a threshers' dinner justprior to the onset of their illnesses.Within the next few days (August 7)the son was critically ill with a violentbloody diarrhea, became emaciated, andremained in bed for 5 weeks. Shortlyafter, his father presented similar sym-toms, though less severe. No patho-genic organisms were isolated in eithercase, but the diagnosis of Shiga dysen-tery was made on clinical and epidemio-logical evidence.The " Z " family was finally located

near the end of August in temporaryquarters at Hesperia on the far westernside of the state and the authenticity ofhis itinerary confirmed. While they werebeing interviewed 2 cases of bloodydiarrhea in a family, mother and son(cases 44 and 43 respectively), livingon the next farm were reported, andShigella dysenteriae variety Shiga wasisolated from specimens of the 4 yearold boy. The acute stage of the disease,as far as " Z's " family was concerned,had passed, and no organisms wereisolated but they gave a history ofhaving had one or more members in thefamily suffering from severe bloodydiarrhea during July and the first 2weeks of August. No deaths had oc-curred in his family, so he did notconsider it seriously.From August 10 to 25, reports of

persons ill with diarrhea continued tocome in, until a total of 159 cases wereon file. During the last 5 days of themonth only a few new cases werereported, and by September 1 mostof the 32 hospital patients had beenreleased. By September 6, the outbreakhad practically subsided.

CLASSIFICATION OF CASES ACCORDINGTO CLINICAL AND LABORATORY FINDINGSOf the 159 cases of diarrhea reported

during the outbreak, 90 had, as a chiefcomplaint, bloody diarrhea.

Forty-five of the 90 cases werediagnosed as Shiga dystentery. Thiswas confirmed in 19 instances by isolat-ing Shigella dysenteriae variety Shigafrom fecal specimens. The remaining 26were diagnosed on clinical or epidemio-logical evidence, or both. These patientswere either members of families in whichShiga dysentery was present or wherecontacts with cases of Shiga dystenteryoutside of the household were known.

Failure to recover the organisms fromfecal specimens in the above 26 casesmay be attributed, so far as one coulddetermine, to the following factors andconditions:

1. Specimens shipped to the central labo-ratory proved to be valueless.

2. Many of the cases were past the stagein which the organism was present in thefeces by the time a field laboratory had beenestablished. In some instances the patientswere transient laborers and not located untilthe acute stage had subsided.

3. Death of the patient ensued in some ofthe early cases before specimens could beobtained.

4. Laboratory technic may not as yet havereached the point where the organisms couldbe detected in all specimens.

5. A few cases, if any, may not have hadShiga dysentery.

If conditions were right for thespread of Shiga dysenteriae, it is quitepossible that they were also right forthe spread of the various types ofShigella paradysenteriae. The varietyHiss-Y was isolated in 5, and the varietySonne was recovered in 23 instances.We then were probably not dealingwith two or three simultaneous out-breaks but with one in which the caseswere caused by either dysentery orparadysentery. No mixed cases werediscovered. That is, there were no casesin which both dysentery and para-dysentery organisms were isolated fromthe same fecal specimen, and no fam-ilies in which both types were found.The remaining 17 of the 90 patients

who complained of bloody diarrheashowed negative laboratory findings and

48 Jan., 1940

SHIGA DYSENTERY

had no known contact with any of theknown cases. For that reason they werenot diagnosed Shiga dysentery. How-ever, the dates of onset ranged withinthe same time interval as those havingShiga dysentery, and many of themcomplained of symptoms which wereequally severe. The clinical diagnosisin this group ranged from " colitis " to"bloody dysentery."Of the 159 cases reported and studied,

there still remain 69 unclassified casesof diarrhea in which patients complainedof mild to severe symptoms and nobloody rectal discharge. No organismsof the bacillary group were isolated.

CASE INCIDENCE

There were 17 families in whichShiga dysentery was diagnosed; 88persons definitely exposed. Forty-fivecases of this type of dysentery resulted,an incidence of 51.1 per cent. The

average age of those who contractedthe disease was 13 years and 3 months.

FATALITY RATE

Among the 45 cases of Shiga dysen-tery there were- 10 deaths, a fatalityrate of 22.2 per cent. The average ageof those who died was 3 years and 11months, all under the age of 8 years.

ENVIRONMENTAL FACTORS

Family Contacts - Contacts withknown cases could not be establishedin all instances; those known to haveoccurred are shown in Chart II.Housing Conditions-With very few

exceptions, the persons who contractedShiga dysentery came from under-privileged homes-45.4 per cent of thefamilies lived in rural areas; 54.6 percent lived in the City of Owosso.Approximately 93 per cent came fromhomes in which the situation with

ChQ-rt iCONTACT5 BlTWEEM FAMILIES

NATIONALITY CONlTACTSl_ Mexicanx2_ Mexican.-3-. Mexican.8.- American ,9.. Arnmrican.- 16- Mexiccor_x -

7- Germcrxn8_Arnerican - --x

9_ Amnericar-io_Americanii. American. j12_ Mexican.is.. Mexicarn ! _

14&American-- -------- -] o5s. AMerican -o--o---o--o---16- AmergcQn.--.17. Arnericcan

Vol. 30 49

AMERICAN JOURNAL OF PUBLIC HEALTH

regard to cleanliness, sanitation, andhousing conditions may be rated as pooror exceedingly poor-obviously belowthe general level of the rural districtor community in which they lived. Thefood served in the homes did not, inmany instances, meet the requirementsfor good nutrition, hence one may alsosay that most of the persons exposedto the disease, especially the children,were physically under par.Common Meeting Places-There was

found to be no common grocery storeor meat market, though many patron-ized a common chain store. There wasno common drug store, bathing beach orpool, and no common church connec-tion. There was a carnival in the out-skirts of Owosso where food was served,but only a small percentage attended(7 per cent).Milk Supply-There was no common

milk supply, though it may be of sig-nificance that a small dairy located atthe edge of the city and across thestreet from the Mexican settlement(see Map II) was patronized by severalfamilies in which Shiga dysentery wasdiagnosed. The milk was not pasteur-ized, and was sold in large quantities.Among those going regularly for milkwere several Mexican families includingcases 4 and 25; a family in which achild (case 34) died from bacillarydysentery 10 days after leaving Owossoto visit a relative in another state*;a family in which a 6 year old child(case 12) died of Shiga dysentery inthe Owosso Hospital, and a family inwhich 2 members suffered from severebloody diarrhea caused by Shigellaparadysenteriae variety Sonne. Amongmembers of the family on the dairyfarm there were no complaints thatwould suggest dysentery. Stool speci-mens submitted were negative for organ-

* Laboratory work done in Lafayette, Ind., HomeHospital. Laboratory Diagnosis: Bacillary dysen-tery, type unknown. Diagnosis based on clinicaland epidemiological evidence, Shiga dysentery.

isms of the typhoid-dysentery group.The general sanitation about the farmwas exceedingly poor. There was acommon drinking cup at the well andseveral patients remembered havingused it. The well water was reported"not dangerously contaminated."

Sanitary Conditions in the Parts ofOwosso Where There Was an Incidenceof Shiga Dysentery-The cases involvedin the outbreak in the City of Owossolived west of the center of the city(see Map II). In the northwest andsouthwest sections there are industrialareas as well as poorer residentialquarters. In the northwest section islocated a settlement for transient Mexi-can laborers where about 100 men,women, and children lived. Thissettlement served as temporary head-quarters from which the laborers andoften whole families went to variousparts of the state to work in beet fieldsand vegetable gardens.

Conditions in and about the settle-ment were extremely poor. The 14houses located within an area represent-ing about one-half a citv block were indisrepair, inadequately screened, andunclean. There were no sewer connec-tions and no sanitary toilet provisions.One community hydrant carrying citywater served as the water supply. Withone or two exceptions, the personalhygiene was in keeping with theenvironment.

There had been repeated reports ofbloody diarrhea among these peoplewhich dated back to the early part ofJuly. When case 25 entered the hospitalon August 6 his history showed that hehad had as a playmate a former patient(case 4), who was admitted July 10,and discharged from the hospital July17, a short time prior to the admittanceof the " X " family (July 28). At thattime no one thought the complaint" bloody diarrhea of undue concern,and a diagnosis of "severe colitis" wasmade. Since case 4 could not be located

Jan., 194050

SHIGA DYSENTERY

after the outbreak began, his historywas obtained from case 25 and it wasfound that he had lived in the samehouse with " Z " (case 1) and hadhelped care for his small daughter (case2). Clinical and epidemiological evi-dence seemed strong enough to includehim in the series.

Since Shigella dysenteriae varietyShiga had been isolated from fecalspecimens of one patient (case 25) inthe Mexican colony and since there wasclinical and epidemiological evidenceagainst 3 others, specimens were re-quested from all persons on the premises.Shigella paradysenteriae variety Hiss-Ywas recovered in 1 case. It was difficultto obtain cooperation, and those sub-mitting specimens denied having had anacute bloody diarrhea. The authenticityof the specimens was questioned sinceit was felt that many were interchanged.

Water Supply- The water supply forthe City of Owosso met the approvalof the State Department of Health andno indication could be found that therehad been a temporary lapse in thequality of the water. Many living out-side the city limits and several withinthe city limits who contracted dysenteryused water from private wells. Severalof these wells were found to be " dan-gerously contaminated."

Sewage Disposal -The Bureau ofEngineering of the Michigan Depart-ment of Health reported: " The sewageplant does not provide sufficient treat-ment for the city liquid waste duringthe summer months when the local can-nery is in operation."

Type ofDysenteryOrganismIsolated

Var. Shiga

Var. SonneVar. Hiss-Y

Total

Sewer connections are not availablein all parts of the city, especially in thenorthwest and southwest sections, thesame parts of the city in which infec-tion was most prevalent (see Map II).The Bureau of Engineering also

found: "Stream surveys have shownan increasing bacterial count throughthe city. This is probably due to sepa-rate sewer connections directly to theriver or inadequate maintenance ofstorm water overflows on the intercept-ing sewer."

COST OF THE OUTBREAKTwenty-four cases of Shiga dysentery

and 8 cases of other types of dysentery(see Table 1) were hospitalized.The actual expenditure of Shiawassee

and Bay Counties for medical care andhospital maintenance of the patientsafflicted was $6,351.54 plus $150.00 forburial expenses. All hospitalized pa-tients were indigent.A report given to the Shiawassee

County Supervisors by a local businessman shortly after the outbreak stated," A tentative estimate of financial lossto business men and farmers of thecommunity is placed at $40,000."

SUMMARY1. An outbreak of Shiga dysentery result-

ing in 45 known cases occurred in Michiganin the summer of 1938. From fecal specimensof 19 cases the organism known as Shigelladysenteriae variety Shiga was isolated. In26 cases the diagnosis of Shiga dysentery wasmade on a clinical or epidemiological basissince the patients were either members of thesame family or had had contact with bac-teriologically diagnosed cases. Shigella para-

TABLE 1

HospitalOwosso

I Bay City[ Both Hosp.

No. ofPatients

204

24

PatientDays360376736

Days perPatient18.094.030.7

I Owosso 8 84 10. 5

Both Hosp. 32 820 25.6

Maintenance Cost

Total Per Patient$3,096.07 $154.802,533.87 633.475,629.94 234. 58

721.60

$6,351.54

90.20

$198.48

51Vol. 30

52 AMERICAN JOURNAL OF PUBLIC HEALTH Jan., 1940

dysenteriae variety Sonne was isolated in 23cases and Shigella paradysenteriae varietyHiss-Y in 5. One hundred and fifty-ninecases of diarrhea comprised the total numberreported and studied. Ninety gave as a chiefcomplaint "bloody diarrhea."

2. Of the homes investigated 93.2 per centwere classified as "poor " or "exceedinglypoor." All hospitalized patients were in-digent. Of the families involved, 54.6 percent lived in the city of Owosso; 45.4 percent lived in rural districts. In 3 instancesrural cases in geographically widely separatedareas followed in the wake of a transientlaborer against whom epidemiological evi-dence was so strong as to warrant the diag-nosis of Shiga dysentery.

3. There is no clear evidence that the dis-ease was spread by food or water, but thereis evidence, not at all striking, that a fewof the cases may have been milk-borne.

4. Direct contact was established in sev-eral instances as the outbreak progressed, butthe " X " family on whom the diagnosis ofShiga dysentery was first made gave no his-tory of contact with known cases prior totheir dates of onset.

5. The disease was of a virulent type,causing 10 deaths among 45 patients, afatality rate of 22.2 per cent. The average

age of those who died was 3 years and 11months. -

6. Bacteriological confirmation of the dlin-ical diagnosis was obtained only when theinoculation on culture media was made withina very short time after the fecal specimenswere passed, 1 hour being approximately thetime limit to insure good results.

REFERENCES1. Park, William H., M.D., and Carey, H. W.,

M.D. The Presence of the Shiga Variety of Dysen-tery Bacillus in an Extensive Epidemic of Dysenterywith Notes Upon Serum Reaction Obtained. Am.J. Med. Res., 9:180 (Feb.-June), 1903.

2. Edford la Fe'tra, Lennesus, M.D., and Howland,John, M.D. A Clinical Study of Sixty-Two Casesof Intestinal Disturbance with the Bacillus Dysen-teriae Shiga in Infants. RockefeUer Inst. for Med.ResearcStudies, 2:137, 1904.

3. Reed, Alfred C., M.D. Bacillary Dysentery imCalifornia. Am. J. Med. Res., 187:811 (Jan.-June),1934.

4. Lapp, T. S., M.D. An Institutional Outbreakof Shiga Dysentery and Its Control. Missouri StateM. A. 1., 1936-1937, p. 90.

S. Silverman, Daniel N., M.D. Clinical Featuresof Bacillary Dysentery. New Orleans M. & S. J.,1933-34, p. 86.

6. Shiga, Kiyoshi, M.D. The Trend of Preven-tion, Therapy & Epidemiology of Dysentery Sincethe Discovery of Its Causative Organism. New Eng.J. Med., 215:1205, 1936.

7. Portes, Sidney A., M.D. Recurrent DiarrheaDue to Dysentery Organisms. J.A.M.A., 110:26(June 25), 1938.

HEALTH is much more than thefreedom or recovery from disease.

It is a way of life, a balance, a com-promise sometimes, worth sacrificingother desires or ambitions to achieve,

and the most precious possession a per-son may lose or feel compelled to giveup in exchange for other ambitions.-HAVEN EMERSON-Pub. Health Rev.,Univ. of Michigan, 9, 3 (Dec. 15), 1939.