The Medical Detectives Volume I

by Berton Roueche

  Dr. Pellitteri shook his head. "I walked right into it," he said. "It was mostly pure luck. What happened was this. On the way out, I ran into the superintendent—an elderly woman. I was feeling two ways about the son-in-law—half sympathetic and half suspicious. It occurred to me that the superintendent might have some idea where he'd been working the past few weeks. So I stopped and asked. She was a sour old girl. She didn't know and didn't care. She had her own troubles. They were the tenants, mainly. She backed me into a corner and proceeded to unload. The children were the worst, she said—especially the boys. Always thinking up some new devilment. For example, she said, just a few weeks ago, toward the end of July, there was a gang of them up on the roof playing wild Indians. Before she could chase them off, they'd stuffed some sticks down one of the plumbing vent pipes. The result was a stoppage. The soil pipe serving one whole tier of apartments blocked and sprang a leak, and the bathroom of the bottom apartment was a nice mess. I hadn't been paying much attention until then. But at that point— Well, to put it mildly, I was fascinated. Also, I began to ask some questions. I wanted to know just what bathroom had flooded. The answer was Apartment 23. What were the other apartments in that tier? They were 33, 43, and 53. What was underneath Apartment 23? A store— Tony's Market, on the corner. Then I asked for a telephone. Birnkrant's reaction was about what you'd expect. Pretty soon, a team from Sanitary Engineering arrived. They supplied the details and the proof. Tony stored his fruits and vegetables in a big wooden walk-in refrigerator at the rear of his store. When Sanitary Engineering pulled off the top, they found the soil pipe straight overhead. The leak had been repaired almost a month before, but the sawdust insulation in the refrigerator roof was still damp from the waste that had soaked through. It wasn't Tony's fault. He hadn't known. It wasn't anybody's fault. It was just one of those things. So that was that."

  "Not entirely," Dr. Fuerst said. "There was still Jones to account for. It wasn't necessary. The thing was settled. But I was curious. I had a talk with him the next day. We talked and talked. And in the end, he remembered. He was a night walker. Every evening after dinner, he went out for a walk. He walked all over Washington Heights, and usually, somewhere along the line, he stopped and bought something to eat. It was generally a piece of fruit. As I say, he finally remembered. One night, near the end of July, he was walking down Audubon and he came to a fruit stand and he bought an apple. On the way home, he ate it."

  [1952]

  CHAPTER 4

  The Incurable Wound

  On october 30, 1951, a woman I'll call Mabel Tate, the wife of a West Texas cotton planter, was admitted to the Parkland City-County Hospital, in Dallas, with a tentative diagnosis of bulbar poliomyelitis. The record also noted, as is usual in ambiguous cases, two possible variant readings. They were epidemic encephalitis and, at the suggestion of the Tate family doctor, influenza. The general nature of her trouble, however, was somewhat less uncertain. All major signs and symptoms reflected a virus invasion, and one of massive, if not overwhelming, proportions. Mrs. Tate was blazing with fever, she was wildly agitated, and she was unable to speak, unable to swallow, and unable to move her left arm. Four days later, she sank into a coma, and died. Something about the manner of her death prompted the attending physician to request a clarifying post-mortem examination. The autopsy was done, with Mr. Tate's consent, early the following day. When the attending physician reached the hospital that morning, a report of the laboratory findings was on his desk. It began, "Encephalomyelitis with demonstrable Negri bodies in central motor neurons . . ." There was no need to read any further. That emphatically answered his question. Negri bodies are distinctive clusters of cellular substance whose presence in the brain has just one denotation. Mrs. Tate was a victim of rabies.

  The attending physician once more sought out Mr. Tate. He told him what the pathologist had found and what the finding meant. That being the case, he went on to explain, two corollary conclusions were obvious. One was that Mrs. Tate had been attacked and bitten by a rabid animal. The other related to the approximate time of the attack. In view of the usual incubation period of rabies, he felt, it had probably taken place between two and six weeks earlier. The doctor spread his hands. All that remained was to establish the specific source of infection. It could have been a dog. It could have been a cat or a fox. It might even have been a skunk. There were numerous possibilities. Mr. Tate nodded. He appreciated the doctor's position. He doubted, though, if he could be of much help. It depended on what the doctor meant by an animal. His wife had been bitten, all right, and fairly recently, too. On October 9, to be exact. But it wasn't a dog or a cat or any of those. It was a bat. His wife had come across it lying in the road near their house. She had thought it was dead, and stooped down to take a look. The next thing she knew, it had jumped up and given her a nasty nip on the left arm. Then it had flown away.

  The doctor hesitated. Very curious, he said. And certainly a most curious coincidence. He shrugged, and rose. But, of course, that was all it could be. The only species of bat in which rabies had ever been demonstrated was the vampire, and its range was limited to tropical Latin America. He was forced to conclude that Mr. Tate was mistaken. There must have been another animal episode. It could have happened as much as a year before. Such cases were uncommon but possible. Either Mr. Tate had forgotten or his wife had neglected to tell him. The doctor returned to his office and took out the record of the case. He dosed it with the notation "Rabies, source unknown."

  Officially, the animal responsible for the death of Mrs. Tate is still not known. There is little possibility now that its identity will ever be irrefutably established. The rules of scientific evidence are too rigid for that. Nevertheless, in the opinion of most interested epidemiologists, the case no longer presents much of a riddle. Several subsequent events, they feel, have rendered it to all practical purposes clear. The first of these occurred on a cattle ranch some thirty miles southeast of Tampa, Florida, on June 23,1953. Around ten o'clock that morning, the stockman's son, a boy of seven whom I'll name David Bonner, was playing in the back yard when a bat burst out of a nearby clump of trees. He called to his father, who was at work a short distance away, and pointed. Mr. Bonner glanced up, and stared. It was odd enough to see a bat abroad in the full light of day, but the creature's behavior was even stranger. The bat, when Mr. Bonner first caught sight of it, was circling the house. An instant later, it turned and streaked straight for the woods. Then it was back again—flying high, low, and every which way. Suddenly, from almost directly overhead, it swooped. David screamed, and tried to run. But it was too late. The bat was already upon him. Mr. Bonner crossed the yard in a bound. He caught his son and swung him about. The bat was clinging to the boy's chest, its teeth sunk deep in his flesh, and blood was staining his shirt. Mr. Bonner broke its grip with a backhand swipe. It dropped, with a strangled hiss, to the ground. He gave it a kick, for good measure. Then he picked up his son and carried him into the house.

  David was more frightened than hurt. While Mrs. Bonner held and comforted him, his father examined the bite. It was an ugly wound but a small one, and not, Mr. Bonner decided, in any sense serious. There seemed no need to call a doctor. He cleaned the bite with soap and water, dusted it with sulfanilamide, and covered it with a gauze dressing. That—for the moment, at least—appeared to be sufficient. It didn't, however, put his mind altogether at rest.

  The circumstances of the assault, he had to admit, were, if nothing else, uncomfortably queer. Mrs. Bonner agreed. They held a hurried conference and reached a prompt decision. Mr. Bonner fetched his jacket and a paper bag, and returned to the back yard. The bat was lying where he had kicked it. Its fur was sandy brown, with yellow overtones, and except for its saucer ears and its long, web-fingered forearms, it might have been a field mouse. It was also, he was relieved to find, dead. He scooped it into the bag, and went on to the garage and his car. Forty minutes later, he was in the Tampa office of the Florida State Board of H
ealth, closeted with a staff epidemiologist.

  Mr. Bonner began the interview with a brief account of the incident. He then produced the bat and stated the reason for his visit. He wanted to have the creature examined. It was his understanding, he said, that bats were capable of transmitting rabies. He remembered reading in a livestock journal that they had been linked to an outbreak of the disease among cattle somewhere in South America. That was true, the doctor replied. There had, in fact, been many such cases, and not only among cattle. Several human cases were also on record. Bat rabies, as it was awkwardly called, was endemic in several Latin-American countries. They included Brazil (where the phenomenon was first reported), Honduras, Mexico, Colombia, Venezuela, Surinam, and the island of Trinidad. But, he pointed out, the bats involved were not ordinary bats. They were bats of a kind unknown outside the tropics. They were true, or bloodsucking, vampires. The bat that Mr. Bonner had brought with him was a harmless Florida yellow, a member of the species Dasypterusfloridanus. It subsisted, like all other bats in the United States, exclusively on insects. Those were the facts. They didn't, of course, explain the attack. He had no theory about that. It was his opinion, though, that the facts held no cause for alarm. The doctor paused. However, he added, it was impossible to deny that the bat had behaved very strangely, and he quite understood how Mr. Bonner felt. A certain amount of uneasiness was only natural. Consequently, in order to settle the matter, he would send the bat along to the board's local laboratory for a routine brain examination. The result, he was confident, would be completely reassuring.

  Mr. Bonner left the Board of Health at a little past one. By the time he reached home, it was almost two. At three, he was called to the telephone. It was the epidemiologist in Tampa, and he sounded stunned. He was calling, he said, from the laboratory. A bacteriologist there had just finished a microscopic examination of the bat's brain, and Mr. Bonner, incredibly, was right. The findings were positive for rabies. Arrangements were now being made for the usual confirmatory tests. They involved the inoculation of laboratory mice with bat-brain material, and would be done at the main State Board of Health laboratory, in Jacksonville. But that was largely a formality. The microscopic evidence was in every essential conclusive. Mr. Bonner's son had been bitten by a rabid animal, and it was imperative that preventive measures be taken at once. Could he bring the boy in to the Tampa office that afternoon? Mr. Bonner could, and did. The Pasteur treatment, as the immunizing procedure against rabies is called (in commemoration of its creator), requires a subcutaneous injection of antirabies vaccine every day for two weeks. David completed the course, apparently with success, on July 7, but because of the variable length of the incubation period in rabies, the summer was well over before it could be said that he was in all probability out of danger. That he had been in danger was beyond dispute by then. The Jacksonville tests had confirmed the fact, and so had an even more elaborate investigation, conducted at the request of the Florida authorities by the United States Public Health Service, at its Virus and Rickettsia Laboratory, in Montgomery, Alabama. It was also certain by then that David's experience could not be dismissed as an isolated freak of misfortune. Late in September, while he was still under regular observation, a woman I'll call Frances Roberts suffered an almost identical attack, and that was closely followed by a third. The scene of both was eastern Pennsylvania.

  The second Pennsylvania episode, though the least unequivocal of the three cases, was by far the most unsettling in its implications. Unlike the others, it happened in a city, and indoors—in a tavern in the central business section of Harrisburg. Its victim was a used-car salesman I'll identify as Carl Dayton. Shortly after midnight on Saturday, November 28, 1953, Mr. Dayton was standing with a group of friends at the tavern bar. Something brushed his face. He stumbled back, looked up, and saw a bat. It was dodging from wall to wall, just below the ceiling, and was heading toward the rear of the room. There was an open window there, but the bat made no attempt to escape. Instead, it circled back to the bar, lower now and moving fast. The bartender tried to whip it down with a towel, and one of the customers swung his hat at it. Both of them missed. Another struck out with a rolled newspaper, and caught it a staggering blow. It fell to the floor at Mr. Dayton's feet. He squatted down for a look, then sprang up with a yell and began to pound on the bar. His friends stood frozen, and stared. The bat was fixed to the back of his hand, and before he could shake it off, it had bitten his thumb to the bone. The bartender was the first to recover. He slammed the bat across the room, and this released the others. They charged the bat and stomped it to death and threw it into the street. That, to the impairment of the subsequent investigation, was the last of the bat. Then, more sensibly, they inspected Mr. Dayton's wound. It was obvious that he needed medical attention, and after bandaging his thumb with a handkerchief, they fetched a cab and sent him off to Harrisburg Polyclinic Hospital. From the hospital, where an interne (either unimpressed or unconvinced by his explanation of the accident) was satisfied to merely clean, close, and properly dress the wound, Mr. Dayton went home to bed.

  Mr. Dayton, like David Bonner, is still alive, and for much the same reason. In his case, too, chance decisively intervened. Within an hour after the accident, a reporter on the Harrisburg Patriot, the city's morning newspaper, emerged from his office, hailed a cab, and headed home. In the course of the trip, the driver began to talk. There was one thing about hacking, he said—anything could happen. Take tonight, for example. He had just come back from hauling a man to Polyclinic Hospital, and guess what was the matter with him. He'd been bitten on the thumb—by a bat! It was a mean-looking wound, too. His whole hand was covered with blood. But who ever heard of a bat attacking a man? He didn't know whether to believe it or not. Neither did the reporter, hut it struck him that, if true, it was a possible story. The following day, on the way to work, he stopped by the hospital. A glance at the outpatient record established the facts of the matter. He then, with providential thoroughness, dropped around to the office of Ernest J. Witte, chief of the Division of Veterinary Public Health of the Pennsylvania Department of Health, and asked him what they meant. The case they described was news to Dr. Witte, but he answered without hesitation. They meant, he said, reaching for the telephone, that his division would investigate the incident at once. One phase of the inquiry would involve a search for the bat. Another, infinitely more urgent, would be concerned with Mr. Dayton. He must be found and returned to the hospital for immediate prophylactic treatment. The bat, in all probability, had been rabid.

  Dr. Witte's hunch, though spontaneous, was anything but blind. He had good reason to associate belligerent bats with rabies. The relationship, indeed, was one with which he happened to be peculiarly familiar. His knowledge derived not only from the alerting example of the Bonner episode, a bulletin on which the Public Health Service had promptly dispatched to all state health officers, but also, more recently, from direct professional experience. That had been provided by the case of Frances Roberts. On the afternoon of September 29, as Dr. Witte later reported to the American Public Health Association, Mrs. Roberts, the wife of an amateur ornithologist of Boiling Springs, an upland resort about twenty miles west of Harrisburg, had accompanied her husband on a canoeing jaunt across a lake near their home. Toward six o'clock, deciding to stretch their legs before turning back, they beached their craft on a wooded shore, and Mr. Roberts wandered off to observe a flock of waterfowl.

  Mrs. Roberts stayed by the canoe, and she was standing there, Dr. Witte noted in his report, when "a bat suddenly landed on [her] upper arm, and bit her without warning or provocation. The woman . . . was startled by the attack and could not immediately identify the object clinging to her arm. Because of her fright, she does not recall distinct biting sensations, although she was conscious of the creature's scratching. Still not knowing what the object was, she finally grabbed the bat with her other hand and threw it against a nearby fence, where it remained stunned by the blow. [Mr. Robert
s] was attracted by the commotion and quickly identified the animal as a [hoary, or Lasiurus cinereus] bat. Being a naturalist, with considerable knowledge and background in wildlife, he quickly recognized the behavior of the bat to be abnormal. He had the presence of mind to act with swiftness and cleverly trapped the creature in a pail, which he had nearby, and covered it with a newspaper. In a matter of minutes, the party headed back by canoe ... to their home. [Mrs. Roberts] proceeded immediately to the doctor for treatment. . . . The physician reported that the patient received attention within one hour after the biting episode. He scrubbed the wound thoroughly with surgical soap and cauterized the wound, using an electric cautery. There were three distinct tooth marks on the upper arm, between the elbow and shoulder. He then called the [State] Health Department for advice on the handling of this case. Motivated to a large degree by the reports of the Florida experience, we immediately recommended antirabies prophylaxis." At the same time, Mr. Roberts was asked to deliver the bat to the Harrisburg laboratory of the department's Bureau of Animal Industry. He did so the following morning. "Touch preparations and, later, sections of the bat's brain revealed typical Negri bodies," Dr. Witte continued. "These were confirmed by the Director of Laboratories, Pennsylvania Department of Health, and by the Virus and Rickettsia Laboratory of the U. S. Public Health Service. Two rabbits were injected intracranially with the bat-brain material. Both animals developed clinical symptoms of rabies and died [within] twenty-seven days. [Meanwhile], starting October 1, [Mrs. Roberts] received fourteen injections of vaccine. [She] suffered no adverse reactions during the entire course of treatment.... As of this date [November 10, 1953], she remains in good health, but is still under her physician's care."