The investigation into the case of Richard Poole that Dr. Jacobziner had requested fell to a visiting nurse named Veronica Flynn. Miss Flynn received the assignment when she reported for duty at the Corona District Health Center on Thursday morning, May 5, and she set about discharging it without excitement or delay. A chronicle of her findings, which she wrote and posted late that afternoon, reached Dr. Jacobziner the following day. It made, he found, sad but familiar reading.
"I had fifteen others almost exactly like it in my files," Dr. Jacobziner said the other day. "All children, all accidents, all totally inexcusable. Only the details were different. Fifteen cases may not sound like very many. It wouldn't be today, of course. But it was then. In May, 1955, my file on acetylsalicylic-acid intoxication didn't go back very far. It only went back a couple of months—to the middle of March, in fact. That was when we established our Poison Control Center, with Harry Raybin, an extremely competent chemist, as its technical director. There wasn't any file on aspirin or any other kind of poisoning until then. The accumulation of epidemiological data is merely one phase of our work at the center. The function of the center is primarily educational. That takes two forms. One is to provide doctors and hospitals in the city with a source of accurate emergency information when they come up against some unfamiliar kind of poison. There are hundreds of potentially toxic chemical substances in daily household use. Every now and then, some child takes it into his head to sample one of them. In many instances, the doctor who gets the case has only the most general notion of what to do. He may know what it was that the child ate. That usually isn't much of a mystery. It was Johnson's Cream Furniture Wax, say, or Noxon Metal Polish, or Shinola. But he doesn't know what's in it. He doesn't know its chemistry. Our people do. When we get a call for help, we have the answer ready, and also the antidote, if any. In return for that service, however, we require something of the doctors and hospitals. They must notify us promptly of every case of chemical poisoning that comes to their attention. That's essential to the other aspect of our educational function. It gives us a chance to study the particular how and why of such outbreaks, and, often enough, to do something to prevent their recurrence. Well, the Poole case gave us something to study, all right. Not because it was unusual in any of its particulars. In that respect, as I say, Miss Flynn's report was only too familiar. It didn't tell us much of anything that we didn't already know about the causes of acetylsalicylic-acid poisoning. What made it a study was this: There was almost nothing that is known about the problem that wasn't present. It was practically a model of carelessness, bad luck, and ignorance.
"Miss Flynn's report was also something of a model. It couldn't have been more explicit. She began with a note on the boy. He was still at Whitestone Memorial, and his condition, at the moment of writing, was listed as serious. The report then took up the results of her investigation. She had paid a visit to the Poole home and talked to Mrs. Poole. The Pooles had a flat in a remodeled house —living room, kitchen, bathroom, bedroom. Richard was their only child. Mrs. Poole, however, was pregnant. She was in her fifth month, often felt unwell, and spent much of her time lying down. Mr. Poole was a subway guard, and worked an early shift. He was not at home at the time of the accident. That was somewhere between eight-thirty and nine on Wednesday morning. He had been gone since six. Mrs. Poole was at home, but in bed and asleep. She didn't know when Richard had got up. He had had a slight cold for a couple of days, and she had supposed that he would sleep late, too. 'Hoped' might be a better word. Assuming, that is, that she thought about it at all. At any rate, she was mistaken. He didn't sleep late. He was up by at least half past eight. Up and about, running loose in the apartment, for all practical purposes alone. And only three years old. That was the setting. It makes a nice picture, doesn't it? Absolutely custom-built for trouble, and absolutely standard. They all begin that way.
"It was almost nine o'clock when Mrs. Poole woke up. When she finally woke up, I should say. A little earlier, around eight- thirty, she had opened her eyes for a minute, and noticed that Richard's bed was empty. Or so she decided later. At the moment, it didn't make much impression on her. She was too comfortable, too sleepy. The second time was different. She didn't just wake up —she was awakened. By a noise. It sounded like breaking glass, and came from somewhere in the flat. She rolled over and sat up, and this time there wasn't any doubt about it. Richard wasn't in his bed. She called to him, and he answered her at once and in his normal voice. He was playing in the living room. That relieved her mind, but it didn't explain the crash. She got out of bed and went to investigate. Her first stop was the bathroom, and that was it. The medicine-cabinet door was open, there was an aspirin bottle on the floor, and the basin was a litter of broken glass and vitamin pills. She stared at the mess, and then walked into the living room and asked the child what had happened. Candy, he said. He was hungry. He'd been looking for candy. In the bathroom? she said. They didn't keep candy in the bathroom. He knew that perfectly well. She told him he ought to be ashamed of himself. And so on, until he began to cry. She gave up in exasperation, went back to the bathroom, and cleaned it up. Then she put on some coffee, and returned to the bedroom to dress. She was almost dressed when it suddenly dawned on her that the aspirin bottle had been empty. Not only empty but uncapped—and no tablets on the floor or in the basin or anywhere. But it shouldn't have been empty. They had only bought it on Sunday—the day Richard caught his cold. She dug it out of the wastebasket and looked at it. It was a small bottle, but there should have been at least thirty tablets left in it.
"Miss Flynn later saw the bottle. Mrs. Poole had kept it, and showed it to her during their talk. The facts—or, rather, some of them —were on the label. It was, as expected, baby aspirin. That means colored pink for eye appeal and flavored orange for palatability. One and a half grains per tablet. There had been forty tablets in all. But, of course, no warning. Nothing about potential toxicity. Only some mumbo jumbo in fine print advising adult supervision. Nothing to frighten the customer. Nothing that frightened Mrs. Poole, anyway. At least, not at first. I don't mean that she wasn't upset. All her reactions were normal. But mostly she was simply bewildered. It was quite obvious what had happened to the rest of the aspirin pills. She realized that at once. Richard had as good as told her. He'd eaten them. What she couldn't understand was why. It seemed fantastic. What had got into him? Why had he wanted to eat a bottle of pills—a bottle of medicine? It wasn't fantastic, however. Not in the least. As she learned the minute she asked him. He didn't know it was medicine. He thought it was candy. Why? Because it tasted like candy. That was one reason. There was also another reason—just as good, or better. Mrs. Poole was like all the other mothers in our files. She had told him it was candy. She had told him so on Sunday and Monday and again on Tuesday, and probably many other times as well. It had seemed, she thought, the easiest way of getting him to take it. What Mrs. Poole did next was also painfully typical. She looked at Richard, and he looked all right. Then she asked him how he felt. He said he felt fine. I suppose she was still uneasy, but that seemed to be that. So she relaxed. It would be easy enough to blame her, but you can't. It wouldn't be fair. She didn't know that anything serious had happened. She had the universal attitude that aspirin isn't really a drug. It's something else. Because drugs are something they sell only in drugstores, and you can get a dose of aspirin anywhere—at a lunchroom or a soda fountain or on a train. It's just aspirin.
"I'm speaking for myself, of course. That's only my interpretation. Miss Flynn didn't interpret. She simply gave the facts. And one of the facts was that Mrs. Poole, understandably or not, wasn't greatly alarmed. Aspirin poisoning doesn't manifest itself in a minute. It takes a little time to catch hold. So when Richard went on playing in a perfectly normal manner, she was reassured. She calmed down. She finished dressing and helped him into his clothes, and they had breakfast. Richard didn't eat much, but there was nothing strange about that. He hadn't eaten much since Sunda
y. He never had much appetite with a cold. After breakfast, she got him settled with his toys in the living room, and went to work. There were the dishes to wash and the beds to make and the rest of the household chores. That must have been about ten o'clock. Well, around ten-thirty she stopped for a rest and a cigarette. Richard seemed still absorbed in his toys. She asked him how he was feeling. He didn't answer. Instead, he began to cry. She dropped down on the floor and put her arms around him, but he twisted away. That wasn't like him. He was almost never cranky. She pulled him back and felt his forehead. It was cool but wet. He was streaming with perspiration. Even his clothes were damp. After a moment, he stopped crying, and began to whine and whimper. His stomach hurt, he said. So did his head. He hurt all over. Then, all of a sudden, he vomited.
"I don't know what Mrs. Poole thought. The chances are she was too frightened to actually think. But she did what any mother would do. She picked him up and carried him in to his bed and tried to make him comfortable. Then she took his temperature. It was normal. As it always is, of course, in such cases. But it was reassuring to her, and by eleven o'clock she thought he seemed a little better. The sweating had stopped and he was resting quietly. That usually happens at about that point. Sweating and irritability are early symptoms. They soon give way to just the reverse—dryness and lethargy. Now he wasn't really resting. He was doped. In any event, he didn't seem better for long. Half an hour later, he vomited again. Then he started breathing very hard and fast—another classic symptom. That, I gathered, was when the truth began to penetrate. Hyperventilation can be a frightening sight, and it must have terrified Mrs. Poole. She couldn't call a doctor. She knew no doctor to call. The Pooles didn't have a doctor—not even an obstetrician. But I must say she kept her head. She didn't collapse or run screaming out to the neighbors. She wrapped the boy up in a blanket and took him straight to Whitestone Memorial. Also, apparently, she told them exactly what had happened. Aspirin intoxication is an extremely difficult condition to diagnose. Unless there's a clue in the history, you have to work it out by test and elimination, and even then it's very often missed. Its actual incidence is probably many times greater than any of us realize. The treatment is less complicated. It includes a prompt gastric lavage, parenteral administration of some dextrose and saline solution to restore the fluid balance, and the usual supportive measures. Richard was admitted to the hospital, according to the record, at one o'clock. That meant he would have had his lavage in reasonably good time—around twelve-thirty—since they attended to that in the emergency room, on arrival. Very satisfactory.
"Well, that was the report. It told us what we needed to know, and I could assume that Miss Flynn had given Mrs. Poole some necessary instruction in the care of drugs and children. I marked it for filing and put it aside, and went on to whatever came next. As you must. Even the saddest is only one among many. By the time I got back from lunch that day, I had practically forgotten the case. And then Miss Flynn called. She had just been talking to Whitestone. Richard Poole was dead. He had died around noon. Respiratory failure. She thought I'd want to know for the record. I thanked her and hung up. I won't pretend I was more than conventionally shocked. It happens too often for that. I was, however, very considerably startled—it didn't seem in line with the facts. My impression had been that they added up to a very good chance for recovery. Thirty tablets of the size he had taken made a total of forty-five grains. Forty- five grains of aspirin is enough to cause a lot of trouble in a child of three. Anything over ten can be dangerous. As a general thing, though, it isn't fatal. I got out the report for another look. But a glance was all I needed. It was all there. It had simply slipped my mind. One of the anomalies of acetylsalicylic acid is that illness enormously intensifies its action, especially in small children, and Richard had been more or less sick since Sunday. Also, he swallowed it on an empty stomach."
[1956]
***
author's note: The physiology of aspirin is somewhat clearer now than it was in 1955 when the above depiction was written. It is now believed, on the basis of the investigations of several researchers (including, especially, John R. Vane at the Royal College of Surgeons, in London, 1971), that aspirin achieves its incongruous collection of efficacies—the reduction of fever, the reduction of inflammation, the easing of aches and pains—by inhibiting the body's production of the hormonelike substances known as prostaglandins. Prostaglandin production is also linked to the natural formation of blood clots. It is the ability of aspirin to interfere with clotting that causes aspirin's chief drawback—its tendency to cause internal bleeding. But this very flaw has been recently turned to an advantage, and aspirin is now widely used to protect against heart attacks and strokes, by blocking clot formation.
chapter 6
The Liberace Room
When Tom D. Y. Chin, assistant chief of the Kansas City, Kansas, field station of the Epidemiology Branch of the United States Public Health Service, and his three associates—George B. Paxton, an epidemiologist; George W. Beran, a veterinarian; and Mrs. Jennie H. Rakich, a nurse—pulled out of the station parking lot and headed south on the afternoon of Thursday, March 3, 1955, they knew next to nothing about the job ahead of them. They knew where they were going. Their destination was a town of around two thousand population called Mountain Home, the seat of Baxter County, in northern Arkansas. They knew that Mountain Home was in the grip of an epidemic. During the previous two or three weeks, twenty-nine pupils at the Mountain Home elementary school had been stricken with what had been gingerly described as an acute febrile disease; in addition to fever, which ranged in some cases as high as 106 degrees, the symptoms were headache, cough, and prostration. They also knew that parakeets were kept as classroom pets in several of the lower grades. But that was all. It was all that anyone knew, including the Baxter County health officer, a Mountain Home physician named Benjamin Saltzman, who had requested the assistance of the Public Health Service; Alexander D. Langmuir, chief of the Epidemiology Branch, at Atlanta, who had approved the request and forwarded it to Kansas City; and Michael L. Furcolow, the Kansas City station chief, who had passed the assignment on to Dr. Chin and his team. Everything else was conjecture.
"I won't say the diagnostic possibilities were endless," Dr. Chin recalls. "They were merely numerous. The clinical picture —even the little we had of it—did narrow the field a bit. It seemed to suggest a respiratory infection. Still, quite a few diseases answer to that general description, so there was plenty of room for speculation. The trouble could have been one of the rickettsial diseases—Q fever, for example. It could have been influenza. It could have been a fungus infection—coccidioidomycosis or histoplasmosis or blastomycosis. It could have been acute miliary tuberculosis. It could have been psittacosis. It could even—at a stretch—have been typhoid fever. Those were some of the choices. They were the possibilities that the signs and symptoms brought immediately to mind. They all came in for a certain amount of discussion at the briefing conference we had with Furcolow just before we left, and, under the circumstances, one looked no more likely than the next. Except, perhaps, psittacosis. Psittacosis is a virus pneumonia transmitted to human beings by birds. Until about twenty years ago, it was generally accepted that the only birds susceptible to that particular virus were psittacines—members of the parrot family. Hence the name of the disease. Since then, we've learned the truth—all birds are vulnerable to psittacosis. Nevertheless, most cases of psittacosis in human beings are traceable to parrots. Particularly, these days, to parakeets. Well, a parakeet in a classroom is hardly evidence of psittacosis, but, taken with the clinical data we had, it was something to think about. It was certainly enough to make us very curious about the health of those birds. That, of course, was largely why we had a veterinarian on the team. It was also why Furcolow gave the assignment to me, instead of going himself. Not that I'm an authority on psittacosis, but my special field is virology.
"Mountain Home is about three hundred miles fro
m Kansas City. As I remember, we made the trip in seven hours. Our only stop was Joplin, in southwestern Missouri, for dinner and gas. We reached Mountain Home around ten o'clock, and spent the night in a motel on the outskirts of town. As it turned out, we made it our headquarters. The next morning, as soon as we'd had some breakfast, we headed for the office of the county health department. Mountain Home, like most little Southern county seats, is built around a courthouse square, so we found it without any trouble. It was barely eight o'clock, but Dr. Saltzman and his county nurse, a woman named Margaret Whitmore, were already there and waiting. They gave us a hero's welcome. The town was in an uproar, Saltzman said. Parents, teachers, school board, businessmen—everybody was clamoring for action. They wanted results. He and two other local doctors were about at the end of their rope. They had tried every drug in the wonder book. None of them —old or new—seemed to help. Some of the children were back at school, but no one could take much credit for that. They had simply got well. And there were a good many others still as sick as ever. Thirteen were flat on their backs in bed. But now—he actually heaved a sigh of relief—his troubles were over. The Marines had landed, and the situation would soon be well in hand. I knew what he meant—that we had the staff, the epidemiological experience, and the technical facilities. But that was the way he put it.
The Medical Detectives Volume I Page 9