The investigator who led the sprint to Washington Heights that August morning in 1946 was Dr. Harold T. Fuerst, an epidemiologist, and he and Dr. Ottavio J. Pellitteri, another epidemiologist, handled most of the medical inquiry. One afternoon, when I was down at the Bureau, they told me about the case. Miss Gamso sat at a desk nearby, and I noticed after a moment that she was following the conversation with rapt attention. Her interest, it turned out, was entirely understandable. Typhoid-fever investigations are frequently tedious, but they are seldom protracted. It is not unusual for a team of experienced operatives to descry the source of an outbreak in a couple of days. Some cases have been riddled in an afternoon. The root of the trouble on Washington Heights eluded detection for almost two weeks, and it is probable that but for Miss Gamso it would never have been detected at all.
"I got to Presbyterian around eleven," Dr. Fuerst told me. "I found a staff man I knew, and he led me up to the patients. It was typhoid, all right. Not that I'd doubted it, but it's routine to take a look. And they were in bad shape—too miserable to talk. One —the woman—was barely conscious. I decided to let the questioning go for the time being. At least until I'd seen their histories. A clerk in the office of the medical superintendent dug them out for me. Pretty skimpy—name, age, sex, occupation, and address, and u few clinical notations. About all I got at a glance was that they weren't members of the same family. I'd hoped, naturally, that l hey would be. That would have nicely limited the scope of the investigation. Then I noticed something interesting. They weren't a family, but they had a little more in common than just typhoid. For one thing, they were by way of being neighbors. One of them lived at 502 West 180th Street, another at 501 West 178th Street, and the third at 285 Audubon Avenue, just around the corner from where it runs through the five-hundred block of West 179th Street. Another thing was their surnames. They were different, but they weren't dissimilar. All three were of Armenian origin. Well, Washington Heights has an Armenian colony—very small and very clannish. I began to feel pretty good. I didn't doubt for a minute that the three of them knew each other. Quite possibly they were friends. If so, it was reasonable to suppose that they might recently have shared a meal. It wasn't very likely, of course, that they had been the only ones to share it. Ten-year-old boys don't usually go out to meals without their parents. Maybe there had been a dozen in on it. It could even have been some sort of national feast. Or a church picnic. Picnic food is an ideal breeding ground for the typhoid organism. It can't stand cooking, but it thrives in raw stuff—ice cream and mayonnaise and so on. And if a carrier had happened to have a hand in the arrangements ... I decided we'd do well to check and see if there was an Armenian carrier on our list."
"We found one, all right," Dr. Pellitteri said. "A widow named Christos—she died a year or two ago—who lived on West 178th Street."
"To be sure, we had only three cases," Dr. Fuerst went on. "But I didn't let that bother me. I've never known an outbreak of typhoid in which everybody who was exposed got sick. There are always a certain number who escape. They either don't eat whatever it is that's contaminated or they have a natural or an acquired immunity. Moreover, the incubation period in typhoid—the time it takes for the bug to catch hold—varies with the individual. Ten days is about the average, but it can run anywhere from three to thirty. In other words, maybe we had seen only the vanguard. There might be more to come. So in the absence of anything better, the Armenian link looked pretty good. I called the Bureau and told Bill Birnkrant—he was acting director at the time—what I thought, and he seemed to think the same. He said he'd start somebody checking. I went back upstairs for another try at the patients."
"That's when the rest of us began to come into the picture," Dr. Pellitteri said. "My job was the recent social life of the Armenian colony. Ida Matthews, a public-health nurse, took the carrier angle. Neither of us had much luck. The file listed twelve carriers in Washington Heights. As I remember, the only Armenian was Mrs. Christos. At any rate, the nurse picked her first. I remember running into Miss Matthews somewhere on Audubon toward the end of that first afternoon. She told me what progress she had made. None. Mrs. Christos was old and sick, and hadn't been out of her apartment for a month. Miss Matthews said there was no reason to doubt the woman's word, as she had a good reputation at the Department—very cooperative, obeyed all the rules. Miss Matthews was feeling pretty gloomy. She'd had high hopes. Well, I knew how she felt. I'd hit nothing but dead ends myself. Our patients didn't seem to be friends. Apparently, they just knew each other. The priest at the Gregorian church in the neighborhood— Holy Cross Armenian Apostolic, on West 187th Street—knew of no recent feasts or festivals. He hadn't heard of any unusual amount of illness in the parish, either. No mysterious chills and fevers. And the Armenian doctors in the neighborhood said the same. They had seen nothing that resembled typhoid except the cases we already had. Before I gave up for the day, I even got in touch with an Armenian girl who used to work at the Department. The only thing I could think of at the moment was a check of the Armenian restaurants. When I mentioned that, she burst out laughing. It seems Armenians don't frequent Armenian restaurants. They prefer home cooking."
"I got Pellitteri's report the next morning," Dr. Fuerst said.
"And Miss Matthews'. I was back at the hospital, and when I called Birnkrant, he gave me the gist of them. I can't say I was greatly surprised. To tell the truth, I was relieved. The Armenian picnic I'd hypothesized the day before would have created a real mess. Because the hospital had reported two new cases. Two women. They lived at 500 West 178th Street and 611 West 180th Street, but they weren't Armenians. One was Italian. The other was plain American. So we were right back where we started. Only, now we had five cases instead of three, and nothing to tie them together but the fact that they all lived in the same neighborhood. And had the same brand of typhoid. There are around a dozen different strains, you know, which sometimes complicates matters. About the only thing Birnkrant and I could be sure of was that the feast theory—any kind of common gathering—was out. I'd had a word with the new patients. They had never even heard of each other. So the link had to be indirect. That gave us a number of possibilities. The source of infection could be water— either drinking water or a swimming pool. Or it could be commercial ice. Or milk. Or food. Drinking water was a job for Sanitary Engineering. The others, at the moment, were up to us—meaning Pellitteri and me. They were all four conceivable. Even ice. You can find a precedent for anything and everything in the literature on typhoid. But just one was probable. That was food. Some food that is sold already prepared—like potato salad or frozen custard —or one that is usually eaten raw. All we had to do was find out what it was, and where they got it, and how it got that way. Birnkrant and I figured out the area involved. It came to roughly four square blocks. I don't know if you know that part of Washington Heights. It's no prairie. Every building is a big apartment house, and the ground floors of most are stores. At least a fourth have something to do with food."
"I was in the office when Fuerst called," Dr. Pellitteri said. "Before he hung up, I got on the phone and we made the necessary arrangements about questioning the patients and their families— who was to see who. Then I took off. I wasn't too pessimistic. The odds were against a quick answer, but you never know. It was just possible that they all bought from the same store. Well, as it happened, they did. In a way. The trouble was it wasn't one store. It was practically all of them. Fuerst had the same experience. We ended up at the office that evening with a list as long as my arm —half a dozen fruit-and-vegetable stands, four or five groceries, a market that sold clams, and an assortment of ice-cream parlors and confectioneries and delicatessens. Moreover, we couldn't even be sure the list included the right store. Most people have very strange memories. They forget and they imagine. You've got to assume that most of the information they give you may be either incomplete or inaccurate, or both. But there was a right store— we knew that. Sanitary Engineering
had eliminated drinking water, and we had been able to rule out swimming and milk and ice. Only one of the group ever went swimming, all but one family had electric refrigerators, and none of them had drunk unpasteurized milk. It had to be contaminated food from a store. That much was certain."
"It was also certain that we had to have some help," Dr. Fuerst said. "Pellitteri and I could have handled a couple of stores. Or even, at a pinch, three or four. But a dozen or more—it would take us weeks. Let me give you an idea what an investigation like that involves. You don't just walk in the store and gaze around. You more or less take it apart. Every item of food that could conceivably cause trouble is examined, the physical setup is inspected for possible violations of the Sanitary Code, and all employees and their families are interviewed and specimens taken for laboratory analysis. So we needed help, and, of course, we got it. Birnkrant had a conference with the Commissioner the next morning and they talked it over, and the result was an engineer and another nurse and a fine big team from Food and Drugs. Very gratifying."
"And Miss Matthews," Dr. Pellitteri said. "We had her back again. She had finally finished with her carriers. They were all like the first. None had violated any of the rules."
"As expected," Dr. Fuerst said. "The average carrier is pretty cooperative. Well, that was Saturday. By Monday, we had made a certain amount of progress. We hadn't found anything yet, but the field was narrowing down. And all of a sudden we got a little nibble. It came from a confectionery called Pop's, on 178th Street, around noon. Pop's had been well up on our list. They sold ice cream made on the premises, and the place was a neighborhood favorite. Which meant it got a very thorough going over. But we were about ready to cross it off—everything was in good shape, including the help—when it developed that the place had just changed hands. Pop had sold out a week before, and he and his wife, who'd helped him run it, were on the way to California. Needless to say, Pop's went back on the list, and at the top. Also, somebody did some quick checking. Pop and his wife were driving, and their plan was to spend a few days with friends in Indianapolis. That gave us a chance. We called Birnkrant and he called Indianapolis—the State Health Department. They were extremely interested. Naturally. They said they'd let us know."
Dr. Fuerst lighted a cigarette. "Then we got a jolt," he said. "Several, in fact. The first was a call from the hospital. Four new cases. That brought the total up to nine. But it didn't stay there long. Tuesday night, it went to ten. I don't mind saying that set us back on our heels. Ten cases of typhoid fever in less than a week in one little corner of the city is almost unheard of in this day and age. The average annual incidence for the whole of Washington Heights is hardly half a case. That wasn't the worst of it, though. The real blow was that tenth case. I'll call him Jones. Jones didn't fit in. The four Monday cases, like the three Armenians and the Italian and the American, all lived in that one four-block area. Jones didn't. He lived on 176th Street, but way over west, almost on Riverside Drive. An entirely different neighborhood. I had a word with Jones the first thing Wednesday morning. I remember he worked for the post office. That's about all I learned. He hardly knew where he was. When I left the hospital, I called on his wife. She wasn't much help, either. She did all the family marketing, she told me and she did it all within a block or two of home. That was that. She was very definite. On the other hand, there was Mr. Jones. He had typhoid, which doesn't just happen, and it was the same strain as all the rest. So either it was a very strange coincidence or she was too upset to think. My preference, until proved otherwise, was the latter. I found a phone, and called Birnkrant and gave him the latest news. He had some news for me. Indianapolis had called. They had located Pop and his wife and made the usual tests. The results were negative."
"I don't know which was the most discouraging," Dr. Pellitteri said. "Jones, I guess. He meant more work—a whole new string of stores to check. Pop had been ninety per cent hope. He merely aroused suspicion. He ran a popular place, he sold homemade ice cream, and when the epidemic broke, he pulled out. Or so it appeared from where we stood. It hurt to lose him. Unlikely or not, he had been a possibility—the first specific lead of any kind that we had been able to find in a week of mighty hard work. During the next few days, it began to look more and more like the last. Until Friday evening. Friday evening we got a very excited call from the laboratory. It was about a batch of specimens we had submitted that morning for analysis. One of them was positive for E. typhosa. The man's name doesn't matter. It didn't even then. What did matter was his occupation. He was the proprietor of a little frozen-custard shop—now extinct—that I'll call the Jupiter. The location was interesting, too. It was a trifle outside our area, but still accessible, and a nice, easy walk from the Joneses'. Food and Drugs put an embargo on the Jupiter that night. The next morning, we began to take it apart."
"I missed that," Dr. Fuerst said. "I spent Saturday at the hospital. It was quite a day. We averaged a case an hour. I'm not exaggerating. When I finally left, the count was nine. Nine brand new cases. A couple of hours later, one more turned up. That made twenty, all told. Fortunately, that was the end. Twenty was the grand total. But, of course, we didn't know that then. There was no reason to believe they wouldn't just keep coming."
"The rest of us had the same kind of day," Dr. Pellitteri said. "Very disagreeable. There was the owner of the Jupiter—poor devil. You can imagine the state he was in. All of a sudden, he was out of business and a public menace. He didn't even know what a typhoid carrier was. He had to be calmed down and instructed. That was the beginning. It got worse. First of all, the Jupiter was as clean as a whistle. We closed it up—had to, under the circumstances—and embargoed the stock, but we didn't find anything. That was peculiar. I can't explain it even now. He was either just naturally careful or lucky. While that was going on, we went back to the patients and questioned them again. Did they know the Jupiter? Were they customers? Did they ever buy anything there? We got one yes. The rest said no. Emphatically. If there had been a few more yeses—even three or four—we might have wondered. But they couldn't all be mistaken. So the Jupiter lead began to look pretty wobbly. Then the laboratory finished it off. They had a type report on the Jupiter organism. It wasn't the K typhosa we were looking for. It was one of the other strains. That may have been some consolation to Mr. Jupiter. At least, he didn't have an epidemic on his conscience. But it left us uncomfortably close to the end of our rope. We had only a handful of stores still to check. If we didn't find the answer there, we were stumped. We didn't. We crossed off the last possibility on Tuesday morning, August 27. It was Number Eighty. We'd examined eighty stores and something like a thousand people, and all we had to show for it was a new carrier."
"Well, that was something," Dr. Fuerst said. "Even if it was beside the point. But we also had another consolation. None of the patients had died. None was going to. They were all making excellent progress."
"That's true enough," Dr. Pellitteri said. "But we couldn't claim much credit for that." He paused, and shifted around in his chair. "About all we can take any credit for is Miss Gamso, here," He smiled. "Miss Gamso saved the day. She got inspired."
Miss Gamso gave me a placid look. "I don't know about inspired," she said. "It was more like annoyed. I heard them talking —Dr. Birnkrant, and these two, and all the rest of them—and I read the reports, and the days went by and they didn't seem to be getting anywhere. That's unusual. So it was irritating. It's hard to explain, but I got to thinking about that carrier Mrs. Christos.
There were two things about her. She lived with a son-in-law who was a known food handler. He was a baker by trade. Also, where she lived was right in the middle of everything—519 West 178th Street. That's just off Audubon. And Audubon is the street where practically all our cases did most of their shopping. Well, there was one store in particular—a fruit-and-vegetable market called Tony's—on almost everybody's list. The address was 261 Audubon Avenue. Then I really got a brainstorm. It was righ
t after lunch on Tuesday, August 27.1 picked up the telephone and called the bureau that registers house numbers at the Borough President's office, and I asked them one question. Did 519 West 178th Street and 261 Audubon Avenue happen by any chance to be the same building? They asked me why I wanted to know. I wasn't talking, though. I just said was it, in a nice way, and the man finally said he'd see. When he came back, I was right. They were one and the same. I was so excited I thought I'd burst. Dr. Pellitteri was sitting right where he is now. He was the first person I saw, so I marched straight over and told him. He kind of stared at me. He had the funniest expression." Miss Gamso smiled a gentle smile. "I think he thought I'd gone crazy."
"I wouldn't say that," Dr. Pellitteri said. "I'll admit, however, that I didn't quite see the connection. We'd been all over Tony's —it was almost our first stop—and there was no earthly reason to question Miss Matthews' report on Mrs. Christos. The fact that they occupied the same building was news to me. To all of us, as I recall. But what if they did? Miss Gamso thought it was significant or suspicious or something. The point escaped me. When she mentioned the son-in-law, though, I began to get a little more interested. We knew him, of course—anybody who lives with a carrier is a potential cause of trouble—and checked on him regularly. But it was just possible that since our last checkup he had become infected. That happens. And although we hadn't found him working in any of the stores, he could have come and gone a couple of weeks before we started our investigation. At any rate, it was worth looking into. Almost anything was, by then. I went up that afternoon. I walked past Tony's on the way to 519. There wasn't any doubt about their being in the same building. Tony's is gone now, like Mrs. Christos, but the way it was then, his front door was about three steps from the corner, and around the corner about three more steps was the entrance to the apartments above. The Christos flat was on the fifth floor—Apartment 53. Mrs. Christos and her son-in-law were both at home. They let me in and that's about all. I can't say they were either one delighted to see me. Or very helpful. She couldn't add anything to what she had already told Miss Matthews. The son-in-law hardly opened his mouth. His last regular job, he said, had been in January, in a cafeteria over in Astoria. Since then, he'd done nothing but odd jobs. He wouldn't say what, when, or where. I couldn't completely blame him. He was afraid that if we got to questioning any of his former employers, they'd never take him on again. When I saw how it was, I arranged for a specimen and, for the moment, let it go at that. There was no point in getting rough until we knew for sure. I told him to sit tight. If he was positive, I'd be back in a hurry. I got the report the next day. He wasn't. He was as harmless as I am. But by then it didn't matter. By that time, it was all over. To tell the truth, I had the answer before I ever left the building."
The Medical Detectives Volume I Page 4