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The Sick Shriners

borne disease. The prominence of nausea and vomiting; the presence of diarrhea in some cases but the absence of fever; the short incubation period, of between two and six hours after the suspect food had been eaten; and the short duration to the illness—usually less than 12 hours: all these factors were typical of S. aureus toxin. Its constellation of symptoms can also include general malaise and, in 10% of cases, abdominal pain distressing enough to justify hospitalization.

However, the prognosis for affected individuals is excellent unless fluid loss and dehydration are extremely severe—as sometimes can be the case in the very young and the elderly. Staphylococcus aureus can also cause other, more serious infections, such as abscesses, blood poisoning, and toxic shock syndrome. The laboratories of Drs. Ambrose Cheung, Jeffrey Parsonnet, and George O'Toole in the Dartmouth Medical School Departments of Microbiology and of Medicine are currently investigating factors involved in the pathogenesis of staphylococcal infections.

The symptoms of staphylococcal food poisoning are caused by a toxin secreted by the bacteria during their rapid growth in an appropriate medium. If they grow on food that is subsequently eaten, the toxin is absorbed from the gastrointestinal tract and produces vomiting and diarrhea by interacting with the organs of the abdomen. The mechanism by which these stimuli are transmitted to the vomiting center in the brain was elucidated many years ago by the late Dr. Herbert Borison, a longtime professor of pharmacology at Dartmouth.

The original source of the organism is almost always the individual who prepared the food. Staphylococcus aureus is present in low numbers on the skin, especially in the nasal cavity, in a significant number of healthy individuals. Higher numbers of organisms can be

This Shrine band participated in the 1982 parade—but the event's flavor was similar decades before . . . and since.

Once introduced into food, the bacterium needs only a few hours at warm temperatures to multiply and generate sufficient toxin to cause illness. This is why health officials recommend that no unpreserved food be left unrefrigerated for over two hours.

found in minor staphylococcal skin infections, such as boils or abscesses.

Once introduced into food, the organism needs only a few hours at warm temperatures to multiply and generate sufficient toxin to cause illness. This is why health officials recommend that no unpreserved food be left unrefrigerated for over two hours. (Interestingly, although there is much wider recognition of the importance of refrigeration now than in 1966, this trend has been more than offset by increased consumption of meals

prepared in large volume outside the home—so food-borne staphylococcal outbreaks have increased in recent years.) Almost any food prepared without large amounts of preservatives will support staphylococcal growth, and the organism is particularly fond of high-protein fare, such as cream-filled pastries or ham, chicken, potato, and egg salads.

Those who remember the Shrine incident recall that some sort of laboratory investigation was conducted. Raymond Book, a retired lab supervisor, is quite sure that the late Dr. Philip Nice, a pathologist and director of the clinical microbiology lab, obtained one of the leftover sandwiches and succeeded in growing S. aureus from it. But no written record of such a study could be found.

And even human memory of the incident does not extend to whether further studies were done to determine if this isolate was able to produce the offending toxin. Some strains of staph do not make this toxin and so are merely harmless contaminants when they are found in food.

Yet such studies would have been almost superfluous. The final circumstantial link in the chain of evidence was that the group's box lunches—containing ham or chicken salad sandwiches, and perhaps potato salad as well—had been prepared by a caterer in western Massachusetts. Some reports indicate that the lunches were transported north in an open convertible, while others say that they were in the back of one of the buses. In either case, they would not have been refrigerated. And in that pre-interstate era, the trip from Springfield would have taken three or four hours—about the same length of time as it then took the toxin to fell the affected Shriners.

But, happily, the course of the illness for most of them was also no longer than that.

The story behind this story

For over 80 years, 22 Shriners Hospitals for Children—located throughout the United States, Canada, and Mexico—have provided care for children with orthopaedic problems, severe burns, or spinal cord injuries at no charge to patients, parents, or thirdparty payors. In 2005, nearly 125,000 children were served.

Since it was first played in 1954, the Shrine Maple Sugar Bowl Game has raised more than $5 million for that effort.

The first Maple Sugar Bowl was held in Nashua, N.H. From 1955 to 1957, the game was played in Manchester, N.H., and the event moved to Hanover in 1958. It has been played there ever since, except in 1967 and 1968, during the expansion of Dartmouth College's Memorial Field, when it was played in Burlington, Vt., one year and in Durham, N.H., the next.

Because renovations are being made to Memorial Field again this year, the 2006 Shrine parade and game will be held at Plymouth State University in Plymouth, N.H.—but they'll return to Hanover in 2007.

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The authors are both longtime members of the DMS faculty. Smith is the Irene Heinz Given Professor of Pharmacology and Toxicology Emeritus and a regular contributor to Dartmouth Medicine. Jacobs is a professor emeritus of microbiology and immunology. The August 29, 1966, issue of the local daily, the Valley News, carried extensive coverage of the stricken Shriners; some of the facts in this article were drawn from that account.

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