The Medical Detectives Volume I

by Berton Roueche

  "I did. I did indeed. And I still do."

  [1978]

  CHAPTER 20

  Sandy

  Dr. Joel L. Nitzkin, chief of the Office of Consumer Protection, a section of the Dade County, Florida, Department of Public Health, sat crouched (he is six feet nine) at his desk in the Civic Center complex in downtown Miami, stirring a mug of coffee that his secretary had just brought in. It was around half past ten on a sunny Monday morning in May—May 13, 1974. His telephone rang. He put down his coffee and picked up the phone and heard the voice of a colleague, Martha Sonderegger, the department's assistant nursing director. Miss Sonderegger was calling to report that her Miami Beach unit had just received a call for help—for the services of a team of public-health nurses—from the Bay Harbor Elementary School. There had been a pipe break or a leak of some kind, Miss Sonderegger had been told, and the school was engulfed in a pall of poison gas. Many of the children were ill, and some had been taken to a neighborhood hospital by the rescue squad of the municipal fire department. Dr. Nitzkin listened, considered.

  He said, "What do you think, Martha?"

  "It sounds a little strange."

  "I think so, too."

  "But I'm sending a team of nurses."

  "Yes," Dr. Nitzkin said. "Of course. And I think I'd better drive out to the school and take a look myself."

  He thanked her and hung up—and then picked up the phone again. He made two quick calls. One was to an industrial hygienist named Carl DiSalvo, in the Division of Environmental Health. The other was to a staff physician named Myriam Enriquez, in the Disease Control Section. He asked Dr. Enriquez to meet him at once at his car; as for Mr. DiSalvo, he was already on his way to the school. Dr. Nitzkin untangled his legs and got up. He was out of his office in two easy, five-foot strides. His coffee cooled on his desk, untasted and forgotten.

  Dr. Nitzkin is no longer associated with the Dade County Department of Public Health. He has moved up, both professionally and geographically, to Rochester, New York, where he now serves as director of the Monroe County Department of Health, and it was there, on a winter day, that I talked with him about the summons to the Bay Harbor Elementary School. His recollection was un- dimmed, indelible.

  "I remember it was hot," he told me, standing at his office window and gazing down through the palm trees in his memory at the bare maples and last night's foot of new snow. "Warm, anyway—warm enough to make me think that the 'poison gas' at the school might have something to do with the air-conditioning system. And I remember my first sight of the school. The scene was complete pandemonium. It had the look of a disaster. We had to park half a block away, because the school parking lot was full of trucks and vans and cars of all kinds—all parked every which way. Ambulances. Fire equipment. Police cars. All with their flashers flashing. And the media—they were swarming. Newspaper reporters and photographers. Radio people with microphones. Television cameras from four local stations. And even—good God!—local dignitaries. Members of the Dade County School Board. Members of the Bay Harbor Town Council. And neighbors and passersby and parents all rushing around. I had never seen anything like it, and I had to wonder how come. But the explanation, it turned out, was simple enough. The school had called the fire department, and the fire department had called the rescue squad—and the media all monitor the fire department's radio frequency. There was one oasis of calm and order. That was the children. They had been marched out of the building in fire- drill formation and were lined up quietly in the shade of some trees at the far end of the school grounds. There were a lot of them— several hundred, it looked like. Which was reassuring. I had got the impression that most of the school had been stricken by whatever the trouble was. Dr. Enriquez and I cut through the mob, looking for someone in charge. It turned out that the school principal was away somewhere at a meeting. We asked around and were finally directed to the head secretary. She was the person nominally in charge, but you couldn't say she was in control. Nobody was in control.

  "She and Dr. Enriquez and I talked for a moment at the entrance to the building. The building was standard design for contemporary Florida schools. The entrance hall ran back to a cross corridor that led to the classrooms. The other school facilities were off the entrance hall. The offices, the clinic, and the library were on the right-hand side. On the left were the teachers' lounge, the cafetorium, and the kitchen. A cafetorium is a room that doubles as an auditorium and a cafeteria. The secretary gave us all the information she had. It was her understanding that there had been a gas leak of some kind. That was what she had heard. But she had seen the first victim with her own eyes. The first victim was an eleven-year-old girl in the fifth grade. I'll call her Sandy. Sandy was a member of a chorus of around a hundred and seventy-five fourth, fifth, and sixth graders who had assembled with the music teacher in the cafetorium at nine o'clock to rehearse for a schoolwide musical program. Halfway through the hour—this, I should say, was constructed later—she began to feel sick. She slipped out of the cafetorium. She was seen by some of the students but not by the teacher. She went across the hall to the clinic and went in and collapsed on a couch. The clinic start was off duty at the moment, but the secretary happened to catch sight of her, and went in and found her lying there unconscious She tried to revive her—with smelling salts!"

  "My mother used to carry smelling salts," I said.

  "Yes. It was rather sweet, I thought. Well, anyway, Sandy didn't respond, and that very naturally alarmed the secretary. And so she very naturally called for help. She called the fire department. Sandy was still unconscious when the fire-rescue squad arrived, and they didn't waste any time. They put her on a stretcher and took her off to the hospital—North Shore Hospital. Then another child got sick, and another, and another. That's when our nursing unit was called. Seven children were sick enough to also be rushed to the hospital after Sandy went. Around twenty-five others were sick enough to be sent home. The school called their parents, and they came and picked them up. Another forty or so were being treated here at the school. They were in the cafetorium." Dr. Nitzkin raised his eyebrows. "That's what the secretary said—in the cafetorium! Myriam Enriquez and I exchanged a look. Wasn't the cafetorium where Sandy became ill, I asked. Where the poison gas must have first appeared? The secretary looked baffled. She said she didn't know anything about that. She had first seen Sandy in the clinic. All she knew was that the sick children still at the school were being treated in the cafetorium.

  "We left the secretary and went on into the school. I think we were both in the same uncomfortable state of mind. The situation still felt the way it had to Martha Sonderegger. It felt strange. There was also a strange smell in the place. We smelled it the minute we stepped into the hall. It wasn't unpleasant—just strong. We couldn't place it. Well, that was what Carl DiSalvo was here for. He would work it out. I hadn't seen him, but I knew he was somewhere in the building. We went on to the cafetorium. There was the sound of many voices. It sounded like a mammoth cocktail party. We went into a big room full of people, full of uniforms.

  Nurses. Police. Fire-rescue workers, in their white coveralls. And u lot of other people. The sick children were stretched out here and there. I could still smell the strange smell, but it was fainter— much fainter—here. Dr. Enriquez and I separated. She had her clinical tests to make. I was the epidemiologist. I walked around the room and looked, and talked to some of the children. The clinical picture was rather curious. There was an unusual variety of signs and symptoms. Headache. Dizziness. Chills. Abdominal pain. Shortness of breath. Weakness. I noticed two kids who were obviously hyperventilating, breathing very fast and very deep. That was an interesting symptom.

  "I stood and thought for a moment. I began to get a glimmer of a glimmer. I went across the hall to an office and found a telephone and called the emergency room at North Shore Hospital and talked to the doctor on duty there. He knew about the children from the Bay Harbor school. He said they were in satisfa
ctory condition. He said they seemed to be feeling better. He said he didn't have results on all of the lab tests yet, but the findings he had seen seemed to be essentially normal. My glimmer still glimmered. I started back to the cafetorium, and ran into DiSalvo. He had been looking for me. He had made a quick inspection of the physical environment of the building and he hadn't turned up any tangible factors—any gases or fumes or allergens—that could have caused any kind of illness. I mentioned the funny smell. He laughed. He had checked it out. It came from an adhesive used to secure a new carpet in the library. The adhesive was in no way toxic. Anyway, the carpet had been laid a good two weeks earlier. DiSalvo was satisfied with his preliminary findings, but he was going to settle down and do the usual full-scale comprehensive survey. I was satisfied, too. I was more than willing to drop the idea of a toxic gas. I had never really believed it. And I was also satisfied that we could rule out a bacterial or viral cause of the trouble. The incubation period—the interval between exposure and the onset of illness—was much too short. And the symptoms were also wrong.

  "I left DiSalvo and went back to the cafetorium, and I remember looking at my watch. It was eleven-thirty. I had been at the school a scant twenty minutes. It felt like forever. But then, all of a sudden, things began to move. I entered the cafetorium this time- by a side door at the kitchen end of the room, and there was a woman standing there—one of the kitchen staff. The dietitian, maybe. An authoritative woman, anyway. She called me over. And—Was it some look in my eye? I don't know. But she said, 'Aren't you a doctor?' I said I was. 'Well,' she said, 'then why don't you do something? Why don't you straighten out this mess? This is all perfectly ridiculous. You know as well as I do that there's nothing the matter with these kids. Get them up on their feet! Get them out of here! They're in the way! I have to start setting up for lunch.'

  "I must have stood and gaped at her. I'd had a funny feeling—a deep-down, gut suspicion—from the very beginning of the case that there was something not quite right about it. I'd got a glimmer when I saw those two kids hyperventilating. Hyperventilation is a classic psychosomatic anxiety reaction. And now the truth finally hit me. A memory rose up in my mind. I knew what I was seeing here. Something very like this had happened just a year before in an elementary school in a little town in Alabama —Berry, Alabama. The dietician was right. But she was also wrong. She was right about there being nothing fundamentally the matter with the kids. But she was wrong in thinking that all those aches and pains and chills and nausea were illusory. They were real, all right. And this was a real epidemic. It was an epidemic of mass hysteria."

  The word "hysteria" derives from the Greek hystera, meaning "uterus." This curious name reflects Hippocrates' notion of the point of origin of the disturbance. "For hysterical maidens," he wrote, "I prescribe marriage, for they are cured by pregnancy." His view prevailed in medicine until well into the nineteenth century, and is perhaps still prevalent in the lingering lay association of women and hysteria. The term "mass hysteria" is also a lay survival. The phenomenon is now preferably known to science as "collective obsessional behavior." Collective obsessions occur throughout the animal world (the cattle stampede, the flocking of starlings on the courthouse roo0, and the human animal, despite —or maybe because of—its more finely tuned mentality, seems exquisitely susceptible to them. Manifestations among the human race take many forms. These range in social seriousness from the transient tyranny of the fad (skate-boards, Farrah Fawcett- Majors, jogging, Perrier with a twist) and the eager lockstep of fashion (blue jeans, hoopskirts, stomping boots, white kid gloves, the beard, the wig) to the delirium of the My Lai massacre and the frenzy of the race riot and the witch hunt. Epidemic obsessional behavior differs from its companion compulsions in one prominent respect. It is not, as Alan C. Kerckhoff and Kurt W. Back, both of Duke University, have noted in "The June Bug: A Study of Hysterical Contagion" (1968), "an active response to some element in the situation; it is a passive experience. The actors do not do something so much as something happens to them."

  History is rich in eruptions of mass hysteria. An outbreak was reported toward the end of the first Christian century by Plutarch. In "Mulierum Virtutes," one of his several philosophical works, he refers to a mass "mental upset and frenzy" among the young women of Miletus (a then important port on the Aegean coast of what is now Turkey), in which "there fell suddenly upon all of them a desire for death, and a mad impulse toward hanging." The toll, if any, is not recorded. More recently, in 1936, a similar desire for death fell upon the citizens of Budapest. Its victims, eighteen in all, were mesmerized admirers of a popular song called "Gloomy Sunday." Lugubrious in words and music, it is a cry of despair from a lover whose loved one has died. The lyrics, in English translation, read in part:

  Gloomy is Sunday, with shadows I spend it all.

  My heart and I have decided to end it all.

  Soon there'll be candles and pray'rs that are sad, I know.

  Let them not weep, let them know that I'm glad to go.

  Suicide is not a common component of morbid mass behavior. In fact, death of any kind is a rarity in such outbreaks. The maniacal speculation in tulip bulbs that swept ruinously through Holland in the seventeenth century was a phenomenon of more classic construction. So were the Children's Crusade of the early thirteenth century and the successive waves of the dancing mania which broke over most of Europe a century and a half later. The Children's Crusade had its beginning in the summer of 1212, when some twenty thousand German and some thirty thousand French children, exalted by a sudden and contagious conviction that Christian love would succeed where Christian arms had failed in the recovery of the Holy Land, left their homes and set out in mile-long swarms for the East. It ended about a year later in Marseilles and several Italian ports, where differently inspired Christians rounded up most of the children and turned them into cash. The girls were thrust into brothels, and the boys were sold to agents of the Egyptian slave trade. The dancing mania is usually taken to have been an overreaction to the abatement of the protracted terrors of the Black Death in the mid-fourteenth century. "As early as 1374," Ralph H. Major, in his "History of Medicine," notes, "large crowds of men and women, obsessed by a strange mania, appeared on the streets of Aachen. Forming circles, hand in hand, they danced around in wild delirium for hours and hours, quite oblivious to the jeers and taunts of the onlookers. From Aachen the malady spread to Liege, then to Utrecht, Cologne, and Metz. The bands of dancers moved from town to town, finding everywhere new recruits to swell their numbers." The nineteenth- century historian J. F. K. Hecker, in his "Epidemics of the Middle Ages," adds, "Where the disease was fully developed, the attacks were ushered in with epileptiform seizures. The afflicted fell to the ground unconscious, foaming from the mouth and struggling for breath, but after a time of rest they got up and began dancing with still greater impetus and renewed vigor. . . . Music appeared to be the sole means of combatting this strange epidemic.. . . Soft, calm harmonies, graduated from fast to slow, proved efficacious as a cure." The frenetic folk dance of southern Italy called the tarantella is widely thought to be a relic of that terpsichorean marathon.

  Eruptions of epidemic hysteria in the modern world, though numerous, have tended to be more modest in size. They have also, like the 1973 outbreak in Berry, Alabama, which led Dr. Nitzkin to suspect the nature of the episode at the Bay Harbor school, tended to occur in schools or other closed communities, and to conceal their functional origin behind a mask of organic illness.

  Dr. Nitzkin turned away from the winter window. He sat on the edge of his desk and crossed his legs. He reached down and scratched a distant ankle. He raised his head and smiled. "The trouble at Berry was a little unusual," he said. His smile widened. "It was a pruritus—an itchy rash." His smile faded. "But it was otherwise very seriously typical. It was a small disaster. It went on and on. The outbreak began on a Friday, there was a recurrence on Tuesday, and another the following Friday. At that point, the schoo
l board closed the school for the remainder of the term. A diagnosis of mass hysteria is largely a matter of exclusion. The investigators at Berry seem to have suspected hysteria pretty early, but they weren't able to convince the community that they had excluded all possibility of an organic cause. Hysteria is self- perpetuating. It doesn't just run its course. It must be promptly recognized and acted upon, or it will go on and on and get worse and worse. Well, I recognized it here. I was sure of that. I trusted DiSalvo's professionalism and plain good sense, and I was sure of my own clinical judgment. So it was up to me to act. But I was critically aware that I was taking a chance. The decision to close the school or allow it to stay open was no small thing. I looked around the room, and spotted a little group at the far end. I recognized the head secretary and two or three school-board people and somebody from the town council. That was the place to start. I went over, and they saw me coming. My height has its advantages. And I guess I looked decisive. I said I had an announcement to make, and they gave me their attention. I said that our Health Department investigation had eliminated the possibility of any toxic gas. I said there was also no evidence of any infectious disease. I called their attention to the hyperventilating kids. By that time, our little circle had grown. Some of the teachers drifted over, and some of the fire-rescue squad, and some of the police, and some parents, and some of the kids themselves. And, of course, the press. All of a sudden, I was talking into microphones, and flashbulbs were popping, and the television cameras were zooming in. I tell you, it was chilling. I had to believe I knew what I was doing. I took a deep breath, and said that it wasn't an outbreak of gas poisoning or any other kind of poisoning. It was an outbreak of hysteria—mass hysteria. I said I didn't know just how it had started, but I knew how to stop it. I said the only way to bring it under control was to get things back to normal. I asked that the cafetorium be cleared, so the kitchen staff could set it up for lunch. I asked that the children out on the school grounds be brought back into the building and sent to their classrooms. And the time to do it, I said, was now—right this minute.