"I'm afraid I didn't exactly share his optimism. Quite the reverse, as a matter of fact. And for several reasons. One of them was that Dr. Saltzman had nothing to add to what we already knew. Nothing helpful, I mean. Except for what he said was a rather equivocal set of chest X-rays, his epidemic-aid request had fully covered the physical findings. I went over his pictures later, and he was right. Most of them showed some cloudiness, but nothing that wasn't generally characteristic of any respiratory infection. It looked a little like psittacosis. But it also looked like miliary tuberculosis. Or histoplasmosis. The only other information he had was a change in the number of cases. Our total of twenty-nine was out of date. Since turning in his call for help, he had checked again with the local doctors and found some cases that they hadn't got around to reporting. Also, while we were on the road, a brand-new case had turned up. The total number of cases now was thirty-six—out of a school enrollment of three hundred and eighty-six. What depressed me most of all, however, was Dr. Saltzman himself. He wasn't at all what I had hoped to find. I had pictured him as somebody dim and doddering. That had made it possible to hope that he was simply out of his depth —that the outbreak might not be as tricky as it sounded. Well, I dropped that notion in a hurry. Ten minutes' conversation was enough to convince me that I'd met a really good man. Far too good to be easily baffled. If he was stumped, there were no two ways about it. We were in for a lot of hard work.
"All that, of course, is largely by the way. Whatever Dr. Saltzman might have been or said wouldn't have made much difference. I might have settled down to work in somewhat higher spirits, but our procedure would have been the same. It isn't often that a public-health investigator can take anything for granted. The epidemiological discipline requires him to see and judge for himself. And the only place to start is at the bottom—with the victim and his environment. In this case, that meant thirty-six children, a school, and an unknown number of parakeets. The division of labor was no immediate problem. Beran's job was understood, and Paxton and I quite naturally took the children. That left the school for Mrs. Rakich. She could handle the preliminary survey there, and also give Beran any help he might need. The transportation problem was solved as soon as the matter came up. Dr. Saltzman had his own work to attend to—his practice and the health-department routine. But his nurse, Miss Whitmore, had a car, and, with his permission, she volunteered to drive Paxton and me around. So Mrs. Rakich and Beran kept ours. We all drove out to the school together. I wanted to make sure of their reception. The school was three or four blocks from the square—a one-story brick building, built since the war and in good repair, with twelve classrooms, an office, and an auditorium. The principal was expecting us. He and his staff, he said, were eager to cooperate in every possible way. That settled that. I left him to Beran and Mrs. Rakich, and Miss Whitmore and Paxton and I pulled out.
"We didn't see Beran and Mrs. Rakich again until evening. Faxton and I spent the day with the sickest children on the list. We examined all thirteen of them. Thirteen calls is a lot of calls, and they were scattered all over town, but with Miss Whitmore there to make the introductions and generally pave the way we managed. That's about all, however. I can't say we learned very much. The clinical picture we put together and the one we had had from Saltzman were practically identical. High fever. General malaise. Lassitude. Nonproductive cough. Occasional chest pains. A few complaints of nausea and vomiting. Those were the symptoms. In three or four cases, we found some enlargement of the liver and the spleen. Aside from that, the physical findings were essentially negative. The epidemiological picture also stood unchanged. No parties. No trips. No unusual group activities of any kind. The only environment common to all the children was the school—the building and the grounds. Nevertheless, it wasn't a wasted day. It was merely an unproductive one. We had done what had to be done. We had made a start.
"So had Beran and Mrs. Rakich. Only theirs was more than just that. They were waiting for us when we finally got back to the courthouse, and it was obvious that one or the other of them had turned up something interesting. They both had, in fact. Beran's contribution was a sick parakeet. There were six birds in all. Four of them had been bought in December and given as pets to the children in four lower-grade rooms—1-A, 1-B, 1-C, and 2-B. Just after the Christmas vacation, another bird was bought, and given to Room 2-C. The sixth parakeet was bought on January 24th. It went to Room 2-A, and that was the sick one. Its name was Liberace. The children named him that because he sang so prettily, but he wasn't singing now. According to Beran, he was a miserable sight. Ruffled feathers. Dull eyes. Listless stance. Loose green droppings all over his cage. The other parakeets, he said, were as bright and lively as crickets. Not, of course, that that meant much. An autopsy might show different. Psittacotic birds are often asymptomatic. Liberace also figured in Mrs. Rakich's report. While Beran was out gathering up the birds—they had been removed from the school, on Dr. Saltzman's orders, about a week before—she had settled down in the principal's office and checked the thirty-six known cases against the relevant classroom records. Her findings made interesting reading. The first child became sick on February 1. He was followed, at intervals of a few days, by five more. Then, between February 13 and February 24, there was an explosion. Twenty-six cases. Eight of them occurred on one day—February 17. Mrs. Rakich's report went on to break down the cases by classroom. One room—5-A—had had no children on the sick list. That room, incidentally, was the senior room. The school had only five grades. Sixth-graders went to another school—a junior high. Two rooms—1-B and 1-C—each had one case. There were two cases in each of four rooms—2-B, 2-C, 4-A, and 5-B. Rooms 1-A, 3-A, 3-B, and 4-B each had three. The Liberace room—2-A—had a total of fourteen. Mrs. Rakich ended her report with a kind of postscript. In the course of her room survey, she had talked with the various teachers. One of them, it developed, had been sick for several days at about the time of the onset peak. Nothing serious—no need to call the doctor. Just malaise. A little fever. Some coughing. I've forgotten her name, but I'll call her Miss Smith. Miss Smith taught Grade 4-A. Her room was across the hall and down a couple of doors from the Liberace room. However, for some reason or other, she had the job of supervising the children as they got into the school buses at the end of each day. And the place she found most convenient for doing that job was at a window in Room 2-A.
"I went to bed that night feeling pretty good. Of course, the picture was still confused. Miss Smith and the heavy concentration of cases in Room 2-A seemed enormously significant. Until you remembered the scattered cases in the other rooms, and the five other parakeets, and the teacher who taught 2-A. Why wasn't she sick, too? But Liberace was something else. If he turned out to be as psittacotic as he looked, we almost certainly had a lead. A post-mortem answer to that was Beran's job for Saturday. Dr. Saltzman gave him a place to work in his office, and he got started right after breakfast. The rest of us spent the day making house calls. Paxton and Mrs. Rakich tackled the twenty-three convalescent or recovered cases. I worked with Miss Whitmore. Our job was to revisit the thirteen sick children we had seen on Friday, and arrange for a number of diagnostic tests. They might or might not be illuminating, but it had to be done. It was routine. In general, the nature of the suspected disease determines the kind of test. Because of the number of possibilities in this case, we had to use two kinds. One was a series of simple skin tests for antibody reaction. Each child was injected intradermally with the antigens of four of our several suspects—tuberculosis, histoplasmosis, coccidioidomycosis, and blastomycosis. The results of such tests can be read in about forty-eight hours. A positive reaction—the appearance of a characteristic induration at the site of injection—is evidence that the patient has, or has had, the disease in question. There is no skin test for psittacosis. For that, as well as the other clinical possibilities, a blood test was required. A blood test is fairly complicated. It can be done only in a specially equipped laboratory, and it takes time. The
nearest Public Health Service serological laboratory was the Rocky Mountain Laboratory, in Hamilton, Montana. We took samples from each of the thirteen children, packed them in dry ice, and sent them off by airmail that afternoon, along with a note of explanation and instruction. They were to be tested for Q fever, influenza, psittacosis, and histoplasmosis. The last was for insurance. In histoplasmosis, a serological examination is apt to be more conclusive than the skin test. Well, with any luck, we would have the results in about a week. Meanwhile, Paxton and Mrs. Rakich had made a good start on their twenty-three convalescent or recovered boys and girls. Not that they had anything much to report. The histories they had obtained merely confirmed the data we already had. They would finish that phase of the job on Sunday, and then get started on a round of tests and samplings of their own. The report of the day was Beran's. I don't mean that it was any sensation—his findings were only tentative. The results of gross examination are rarely anything else. They have to be substantiated by laboratory test. But he did have something to tell us. Liberace was very definitely sick, and in a very provocative way. The other birds had no visible signs of abnormality, but Liberace more than made up for that. In psittacosis, the most striking clinical manifestation is enlargement of the liver and the spleen. Liberace's liver was considerably larger than normal, and his spleen was huge. A parakeet spleen is usually about the size of a small seed. His was as big as the end of my middle finger.
"That was all that Beran could tell us at the moment. It was also as much as he could ever tell us if he stayed in Mountain Home. His next move was to try to isolate the psittacosis organism from the parakeet material, and that couldn't be done in the field. Viruses can't be cultured, like bacteria. They can only be demonstrated through transfer to a living host, so the place for him was Kansas City, where we have a virus laboratory, with the necessary tools and animals. He left by bus on Sunday morning. The rest of us saw him off, and then went back to work. There was no point in counting the hours. His job would take about as long as the blood tests at Rocky Mountain. Paxton and Mrs. Rakich spent the day with their children. My day was a series of meetings. I spent an hour or so with Saltzman reviewing our work to date. Then he took me around to meet the other local physicians. In the afternoon, at my request, we held a kind of town meeting. The group included the school board, the superintendent of schools, the mayor, the publisher of the Baxter Bulletin, the local weekly—all the leading citizens. I had several reasons for calling them together. Common courtesy was one. The town was entitled to a general progress report. Another was to calm their fears. I made it clear that the cause of the outbreak was still uncertain, but I told them what we thought. Our best guess was psittacosis. In any event, I added, there was nothing to panic about. All of the patients were doing reasonably well. They would certainly all recover. Moreover, the record showed just two new cases in almost two weeks, and none since our arrival. So the worst was probably over.
"The main reason for the meeting, however, was to broaden the scope of the investigation. I wanted to organize a school-wide testing program. A comparison study would help us interpret the results of our tests on the thirty-six clinical cases. Also, since the school—the building or the playground, if not specifically the liberace room—was obviously the focus of infection, it would be useful to have an outside group of controls. One of the grades at the junior high, for example. But none of this was something we could simply decide on and do. We're not allowed to give a child an injection or draw a sample of blood without his parents' permission. I hoped to convince the civic leaders that the program was epidemiologically essential, and persuade them to bring their influence to bear. With Saltzman's help, I did. By the time the meeting adjourned, we were practically ready to go. The necessary consent forms had been drawn up, arrangements had been made to get them mimeographed, and a company of volunteers had been recruited to handle their distribution. We even had a place to work. The school authorities would let us set up a clinic in the auditorium. I couldn't have asked for fuller cooperation. Or, as it turned out, for a more enlightened response from the parents. Only thirty withheld their consent. We got permission to test and bleed a total of three hundred and sixty-nine. That included three hundred and twenty children at the elementary school, forty-eight sixth-graders at the junior high, and Miss Smith. We started in on Monday morning, and it took us most of the week. We finished up on Friday.
"Meanwhile, of course, the results of the skin tests were coming in. By Friday, we had readings on the thirteen actual patients, on the twenty-three recoveries, and on about two hundred of the other pupils at the elementary school. And also on Miss Smith. We had them, but that's about all. It was hard to say exactly what they meant. We read the clinical-case reactions first. Every single one of them was positive for histoplasmosis. For tuberculosis, blastomycosis, and coccidioidomycosis—all negative. I won't deny that I was a little startled. Only for a moment, however. And only on account of Liberace, because histoplasmosis was fully compatible with the clinical findings, with Saltzman's chest X- rays—with all the data we had. Then we saw Miss Smith's results. She gave the same reaction—positive for histoplasmosis, and only for histoplasmosis. In the light of the other reactions, that was hardly surprising. We had assumed that she was part of the outbreak. That's why we included her in the tests. Then the results of the general student body came in, and we began to wonder. As I say, by Friday we had seen about two hundred of them—more than enough to provide a definitive contrast to the clinical-case reactions. But they didn't. They showed the same—or practically the same—reactions as the others. All negative for tuberculosis, blastomycosis, and coccidioidomycosis. And practically all— nearly ninety per cent—positive for histoplasmosis.
"Well, that brought us up pretty short. I don't mean that we were back where we started. We could forget about tuberculosis and blastomycosis and coccidioidomycosis—they were definitely out of the picture now. And probably Q fever and influenza as well, though we couldn't actually cut them off the list—not yet. Nevertheless, the way things were shaping up, there wasn't much reason to keep them on it. So at least we had narrowed the field. We had a choice between psittacosis and histoplasmosis. It had to be one or the other. But which? Liberace and that concentration of cases in his room were certainly suggestive of psittacosis. But what about the clinical-case reactions for histoplasmosis? They were equally suggestive. Or, rather, they were and they weren't. The trouble was all those other positive reactions. They had to be explained. There was a choice of several interpretations. There always is with a positive skin test for one of the fungus infections. That's largely where it differs from a blood test. A skin test will accurately reflect the presence of specific antibodies, but it has no topical value. It doesn't distinguish between a current or recent infection and one experienced sometime in the past. A blood test, on the other hand, is a diagnostic test. It is positive only during the active stage of a disease and for the following week or so. You can see what I mean by possibilities. It was possible that all of our positive reactions referred to old infections. It was possible that they all reflected current infections. It was also possible—but at that point Paxton and I let it drop. The answer—or, at any rate, the beginning of an answer—rested with the Rocky Mountain laboratory and with Beran. It was foolish to try to guess. Instead, I put in a call to Furcolow. I told him where we stood, and said that unless he had some objection, we thought we'd come home for the weekend. He said come ahead. It was time we talked things over.
"That was four or five o'clock on Friday afternoon, and I was home by midnight. I got down to the office the next day around noon. On my way to talk with Furcolow, I dropped in on Beran. No news. He had run some preliminary tests on the parakeet material, but the results were at best inconclusive. It was still too soon to say about the isolation studies. I got the impression, though, that he wasn't very optimistic. He seemed to feel that the first run of tests told the story. They did. As it turned out, we never did de
termine what was wrong with Liberace. Except that it wasn't psittacosis. But, as it also turned out, we were morally sure of that long before Beran made it certain. I knew it almost the minute I walked into Furcolow's office. We had hardly said hello when his secretary came in with a telegram. He opened it up and read it, and passed it over to me. It was a report from Rocky Mountain on the first group of Mountain Home blood tests. It read: all precipitin histo positive, psittacosis, q fever, influenza negative."
Histoplasmosis is one of about a dozen systemic diseases now known to be caused by the venerable fungus family. It is thus, unlike the overwhelming majority of infections that afflict the human race, of vegetable rather than animal origin. All the deep mycoses, as these fungus invasions have come to be called, are relatively new to medicine (none was recognized much before the turn of this century), all are serious disorders—some are invariably fatal—and all are rapidly growing in stature. Histoplasmosis is the newest member of this upstart group, and although it most often appears in a tractable form, it can be as deadly as any of the others. It is also by far the most increasingly common. Until little more than a decade ago, histoplasmosis was universally considered a medical curiosity of almost incomparable rarity. In 1945, according to a survey published in the Archives of Internal Medicine, only seventy-one authenticated cases (almost all of them fatal) were known to medical literature. Its record is now more imposing.
The Medical Detectives Volume I Page 10