The Medical Detectives Volume I

by Berton Roueche

  Except for a brief period around the beginning of this century, when several European countries refused, because of its dubious nature, to import American pork, the adoption of a less porous system of control has never been seriously contemplated here. One reason is that it would run into money. Another is that, except by a few informed authorities, it has always been considered unnecessary. Trichinosis is generally believed to be a rarity. This view, though hallucinated, is not altogether without explanation. Outbreaks of trichinosis are seldom widely publicized. They are seldom even recognized. Trichinosis is the chameleon of diseases. Nearly all diseases are anonymous at onset, and many tend to resist identification until their grip is well established, but most can eventually be identified by patient scrutiny. Trichinosis is occasionally impervious to bedside detection at any stage. Even blood counts sometimes inexplicably fail to reveal its presence at any stage in its development. As a diagnostic deadfall, it is practically unique. The number and variety of ailments with which it is more or less commonly confused approach the encyclopedic. They include arthritis, acute alcoholism, conjunctivitis, food poisoning, lead poisoning, heart disease, laryngitis, mumps, asthma, rheumatism, rheumatic fever, rheumatic myocarditis, gout, tuberculosis, angioneurotic edema, dermatomyositis, frontal sinusitis, influenza, nephritis, peptic ulcer, appendicitis, cholecystitis, malaria, scarlet fever, typhoid fever, paratyphoid fever, undulant fever, encephalitis, gastroenteritis, intercostal neuritis, tetanus, pleurisy, colitis, meningitis, syphilis, typhus, and cholera. It has even been mistaken for beriberi. With all the rich inducements to error, a sound diagnosis of trichinosis is rarely made, and the diagnostician cannot always take much credit for it. Often, as at Metropolitan Hospital that April day in 1942, it is forced upon him.

  The report of the arresting discovery at Metropolitan reached the Health Department on the morning of Friday, April 17. Its form was conventional—a postcard bearing a scribbled name, address, and diagnosis—and it was handled with conventional dispatch. Within an hour, Dr. Morris Greenberg, who was then chief epidemiologist of the Bureau of Preventable Diseases and is now its director, had put one of his fleetest agents on the case, a field epidemiologist named Lawrence Levy. Ten minutes after receiving the assignment, Dr. Levy was on his way to the hospital, intent on tracking down the source of the infection, with the idea of alerting the physicians of other persons who might have contracted the disease along with Sauer. At eleven o'clock, Dr. Levy walked into the office of the medical superintendent at Metropolitan. His immediate objective was to satisfy himself that Sauer was indeed suffering from trichinosis. He was quickly convinced. The evidence of the eosinophile count was now supported in the record by more graphic proof. Sauer, the night before, had undergone a biopsy. A sliver of muscle had been taken from one of his legs and examined under a microscope. It teemed with Trichinella spiralis. On the basis of the sample, the record noted, the pathologist who made the test estimated the total infestation of trichinae at upward of twelve million. A count of over five million is almost invariably lethal. Dr. Levy returned the dossier to the file. Then, moving on to his more general objective, he had a word with the patient. He found him bemused but conscious. Sauer appeared at times to distantly comprehend what was said to him, but his replies were faint and rambling and mostly incoherent. At the end of five minutes, Dr. Levy gave up. He hadn't learned much, but he had learned something, and he didn't have the heart to go on with his questioning. It was just possible, he let himself hope, that he had the lead he needed. Sauer had mentioned the New York Labor Temple, a German-American meeting-and-banquet hall on East Eighty-fourth Street, and he had twice uttered the word "Schlachtfest. " A Schlachtfest, in Yorkville, the Doctor knew, is a pork feast.

  Before leaving the hospital, Dr. Levy telephoned Dr. Greenberg and dutifully related what he had found out. It didn't take him long. Then he had a sandwich and a cup of coffee and headed for the Labor Temple, getting there at a little past one. It was, and is, a shabby yellow-brick building of six stories, a few doors west of Second Avenue, with a high, ornately balustraded stoop and a double basement. Engraved on the facade, just above the entrance, is a maxim: "Knowledge Is Power." In 1942, the Temple was owned and operated, on a non-profit basis, by the Workmen's Educational Association; it has since been acquired by private interests and is now given over to business and light manufacturing. A porter directed Dr. Levy to the manager's office, a cubicle at the end of a dim corridor flanked by meeting rooms. The manager was in, and, after a spasm of bewilderment, keenly cooperative. He brought out his records and gave Dr. Levy all the information he had. Sauer was known at the Temple. He had been employed there off and on for a year or more as a dishwasher and general kitchen helper, the manager related. He was one of a large group of lightly skilled wanderers from which the cook was accustomed to recruit a staff whenever the need arose. Sauer had last worked at the Temple on the nights of March 27 and March 28.

  On the latter, as it happened, the occasion was a Schlachtfest.

  Dr. Levy, aware that the incubation period of trichinosis is usually from seven to fourteen days and that Sauer had presented himself at Lenox Hill on April 6, motioned to the manager to continue. The Schlachtfest had been given by the Hindenburg Pleasure Society, an informal organization whose members and their wives gathered periodically at the Temple for an evening of singing and dancing and overeating. The arrangements for the party had been made by the secretary of the society—Felix Lin- denhauser, a name which, like those of Sauer and the others I shall mention in connection with the Schlachtfest, is a fictitious one. Lindenhauser lived in St. George, on Staten Island. The manager's records did not indicate where the pork had been obtained. Probably, he said, it had been supplied by the society. That was frequently the case. The cook would know, but it was not yet time for him to come on duty. The implication of this statement was not lost on Dr. Levy. Then the cook, he asked, was well? The manager said that he appeared to be. Having absorbed this awkward piece of information, Dr. Levy inquired about the health of the others who had been employed in the kitchen on the night of March 28. The manager didn't know. His records showed, however, that, like Sauer, none of them had worked at the Temple since that night. He pointed out that it was quite possible, of course, that they hadn't been asked to. Dr. Levy noted down their names—Rudolf Nath, Henry Kuhn, Frederick Kreisler, and William Ritter—and their addresses. Nath lived in Queens, Kreisler in Brooklyn, and Kuhn and Ritter in the Bronx. Then Dr. Levy settled back to await the arrival of the cook. The cook turned up at three, and he, too, was very cooperative. He was feeling fine, he said. He remembered that Schlachtfest. The pig, he recalled, had been provided by the society. Some of it had been ground up into sausage and baked. The rest had been roasted. All of it had been thoroughly cooked. He was certain of that. The sausage, for example, had been boiled for two hours before it was baked. He had eaten his share of both. He supposed that the rest of the help had, too, but there was no knowing. He had neither seen nor talked to any of them since the night of the feast. There had been no occasion to, he said.

  Dr. Levy returned to his office, and sat there for a while in meditation. Presently, he put in a call to Felix Lindenhauser, the secretary of the society, at his home on Staten Island. Lindenhauser answered the telephone. Dr. Levy introduced himself and stated his problem. Lindenhauser was plainly flabbergasted. He said he was in excellent health, and had been for months. His wife, who had accompanied him to the Schlachtfest, was also in good health. He had heard of no illness in the society. He couldn't believe that there had been anything wrong with that pork. It had been delicious. The pig had been obtained by two members of the society, George Muller and Hans Breit, both of whom lived in the Bronx. They had bought it from a farmer of their acquaintance in New Jersey. Lindenhauser went on to say that there had been twenty-seven people at the feast, including himself and his wife. The names and addresses of the company were in his minute book. He fetched it to the phone and patiently read the
m off as Dr. Levy wrote them down. If he could be of any further help, he added as he prepared to hang up, just let him know, but he was convinced that Dr. Levy was wasting his time. At the moment, Dr. Levy was almost inclined to agree with him.

  Dr. Levy spent an increasingly uneasy weekend. He was of two antagonistic minds. He refused to believe that Sauer's illness was not in some way related to the Schlachtfest of the Hindenburg Pleasure Society. On the other hand, it didn't seem possible that it was. Late Saturday afternoon, at his home, he received a call that increased his discouragement, if not his perplexity. It was from his office. Metropolitan Hospital had called to report that Herman Sauer was dead. Dr. Levy put down the receiver with the leaden realization that, good or bad, the Schlachtfest was now the only lead he would ever have.

  On Monday, Dr. Levy buckled heavily down to the essential but unexhilarating task of determining the health of the twenty-seven men and women who had attended the Schlachtfest. Although his attitude was half-hearted, his procedure was methodical, unhurried, and objective. He called on and closely examined each of the guests, including the Lindenhausers, and from each procured a sample of blood for analysis in the Health Department laboratories. The job, necessarily involving a good deal of leg work and many evening visits, took him the better part of two weeks. He ended up, on April 30th, about equally reassured and stumped. His findings were provocative but contradictory. Of the twenty- seven who had feasted together on the night of March 28, twenty- five were in what undeniably was their normal state of health. Two, just as surely, were not. The exceptions were George Muller and Hans Breit, the men who had provided the pig. Muller was at home and in bed, suffering sorely from what his family physician had uncertainly diagnosed as some sort of intestinal upheaval. Breit was in as bad a way, or worse, in Fordham Hospital. He had been admitted there for observation on April 10. Several diagnoses had been suggested, including rheumatic myocarditis, pleurisy, and grippe, but none had been formally retained. The nature of the two men's trouble was no mystery to Dr. Levy. Both, as he was subsequently able to demonstrate, had trichinosis.

  On Friday morning, May 1, Dr. Levy returned to the Bronx for a more searching word with Muller. Owing to Muller's debilitated condition on the occasion of Dr. Levy's first visit, their talk had been brief and clinical in character. Muller, who was now up and shakily about, received him warmly. Since their meeting several days before, he said, he had been enlivening the tedious hours of illness with reflection. A question had occurred to him. Would it be possible, he inquired, to contract trichinosis from just a few nibbles of raw pork? It would. Dr. Levy told him. He also urged him to be more explicit. Thus encouraged, Muller displayed an unexpected gift for what appeared to be total recall. He leisurely recounted to Dr. Levy that he and Breit had bought the pig from a farmer who owned a place near Midvale, New Jersey. The farmer had killed and dressed the animal, and they had delivered the carcass to the Labor Temple kitchen on the evening of March 27. That, however, had been only part of their job. Not wishing to trouble the cook and his helpers, who were otherwise occupied, Muller and Breit had then set about preparing the sausage for the feast. They were both experienced amateur sausage makers, he said, and explained the process—grinding, maccrating, and seasoning—in laborious detail. Dr. Levy began to fidget. Naturally, Muller presently went on, they had been obliged to sample their work. There was no other way to make sure that the meat was properly seasoned. He had taken perhaps two or three little nibbles. Breit, who had a heartier taste for raw pork, had probably eaten a trifle more. It was hard to believe, Muller said, that so little —just a pinch or two—could cause such misery. He had thought his head would split, and the pain in his legs had been almost beyond endurance. Dr. Levy returned him sympathetically to the night of March 27. They had finished with the sausage around midnight, Muller remembered. The cook had departed by then, but his helpers were still at work. There had been five of them. He didn't know their names, but he had seen all or most of them again the next night, during the feast. Neither he nor Breit had given them any of the sausage before they left. But it was possible, of course, since the refrigerator in which he and Breit had stored the meat was not, like some, equipped with a lock . . . Dr. Levy thanked him, and moved rapidly to the door.

  Dr. Levy spent the rest of the morning in the Bronx. After lunch, he hopped over to Queens. From there, he made his way to Brooklyn. It was past four by the time he got back to his office. He was hot and gritty from a dozen subway journeys, and his legs ached from pounding pavements and stairs and hospital corridors, but he had tracked down and had a revealing chat with each of Sauer's kitchen colleagues, and his heart was light. Three of them —William Ritter, Rudolf Nath, and Frederick Kreisler—were in hospitals. Ritter was at Fordham, Nath at Queens General, and Kreisler at the Coney Island Hospital, not far from his home in Brooklyn. The fourth member of the group, Henry Kuhn, was sick in bed at home. All were veterans of numerous reasonable but incorrect diagnoses, all were in more discomfort than danger, and all, it was obvious to Dr. Levy's unclouded eye, were suffering from trichinosis. Its source was equally obvious. They had prowled the icebox after the departure of Muller and Breit, come upon the sausage meat, and cheerfully helped themselves. They thought it was hamburger.

  Before settling down at his desk to compose the final installment of his report, Dr. Levy looked in on Dr. Greenberg. He wanted, among other things, to relieve him of the agony of suspense. Dr. Greenberg gave him a chair, a cigarette, and an attentive ear. At the end of the travelogue, he groaned. "Didn't they even bother to cook it?" he asked.

  "Yes, most of them did," Dr. Levy said. "They made it up into patties and fried them. Kuhn cooked his fairly well. A few minutes, at least. The others liked theirs rare. All except Sauer. He ate his raw."

  "Oh," Dr. Greenberg said.

  "Also," Dr. Levy added, "he ate two."

  [1950]

  CHAPTER 3

  A Game of Wild Indians

  During the second week in August, 1946, an elderly man, a middle-aged woman, and a boy of ten dragged themselves, singly and painfully, into the Presbyterian Hospital, in the Washington Heights section of Manhattan, where their trouble was unhesitatingly identified as typhoid fever. This diagnosis was soon confirmed by laboratory analysis, and on Thursday morning, August 15th, a report of the outbreak was dutifully telephoned to the Department of Health. It was received and recorded there, in accordance with the routine in all alarms of an epidemiological nature, by a clerk in the Bureau of Preventable Diseases named Beatrice Gamso. Miss Gamso is a low-strung woman and she has spent some thirty callousing years in the Health Department, but the news gave her a turn. She sat for an instant with her eyes on her notes. Then, steadying herself with a practiced hand, she swung around to her typewriter and set briskly about dispatching copies of the report to all administrative officers of the Department. Within an hour, a reliable investigator from the Bureau was on his way to Washington Heights. He was presently followed by one of his colleagues, a Department public-health nurse, several agents from the Bureau of Food and Drugs, and an inspector from the Bureau of Sanitary Engineering.

  Typhoid fever was among the last of the massive pestilential fevers to yield to the probings of medical science, but its capitulation has been complete. It is wholly transparent now. Its clinical manifestations (a distinctive rash and a tender spleen, a fiery fever and a languid pulse, and nausea, diarrhea, and nosebleed), its cause (a bacillus known as Eberthella typhosa), and its means of transmission have all been clearly established. Typhoid is invariably conveyed by food or drink contaminated with the excreta of its victims. Ordinarily, it is spread by someone who is ignorant, at least momentarily, of his morbid condition. One reason for such unawareness is that for the first several days typhoid fever tends to be disarmingly mild and indistinguishable from the countless fleeting malaises that dog the human race. Another is that nearly five per cent of the cases become typhoid carriers, continuing indefinitely to harbo
r a lively colony of typhoid bacilli in their systems. The existence of typhoid carriers was discovered by a group of German hygienists in 1907. Typhoid Mary Mallon, a housemaid and cook who was the stubborn cause of a total of fifty-three cases in and around New York City a generation ago, is, of course, the most celebrated of these hapless menaces. About seventy per cent, by some unexplained physiological fortuity, are women. The names of three hundred and eighty local carriers are currently on active file in the Bureau of Preventable Diseases. They are called on regularly by public-health nurses and are permanently enjoined from any employment that involves the handling of food. More than a third of all the cases that occur here are traced to local carriers but, because of the vigilance of the Health Department, rarely to recorded carriers; new ones keep turning up. Most of the rest of the cases are of unknown or out-of-town origin. A few are attributable to the products of polluted waters (clams and oysters and various greens).

  The surveillance of carriers is one of several innovations that in little more than a generation have forced typhoid fever into an abrupt tractability throughout most of the Western world. The others include certain refinements in diagnostic technique, the institution of public-health measures requiring the chlorination of city-supplied water and proscribing the sale of unpasteurized milk, and the development of an immunizing vaccine. Since late in the nineteenth century, the local incidence of typhoid fever has dropped from five or six thousand cases a year to fewer than fifty, and it is very possible that it may soon be as rare as smallpox. Banishment has not, however, materially impaired the vigor of Eberthella typhosa. Typhoid fever is still a cruel and withering affliction. It is always rambunctious, generally prolonged, and often fatal. It is also one of the most explosive of communicable diseases. The month in which it is most volcanic is August.